Oral Health: School Fluoride Varnish Delivery Programs

The CPSTF recommendation is based on evidence from a systematic review of 31 studies (search period from database inception to December 2023).

The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to oral health.

Untreated tooth decay, one of the most prevalent diseases among children, reduces a child’s ability to eat, speak, learn, and play (U.S. Department of Health and Human Services 2000). Prevalence is significantly higher among children from families with lower incomes as well as racial and ethnic minority groups (Centers for Disease Control and Prevention 2019). Although there is strong evidence that topical fluoride treatments prevent decay in all teeth (Marinho et al. 2013; Weyant et al. 2013), less than 18% of children from families with lower incomes received a treatment during an annual dental visit in 2013-2014 (Wei et al. 2018). Significant disparities in fluoride treatment receipt also exist by race and ethnicity (Wei et al. 2018). Fluoride varnish is a commonly used form of topical fluoride treatment for children and can be applied periodically to all teeth (Clark et al. 2020). Fluoride varnish was approved by the U.S. Food and Drug Administration (FDA) as a cavity liner and tooth desensitizer in 1994 (Clark et al. 2020). Although use of fluoride varnish for caries prevention is off-label in the U.S., fluoride varnish has been used widely to prevent caries in Europe and Canada since 1960s and in the U.S. since 1994 (Marinho et al. 2013). There has been strong evidence that fluoride varnish is safe and effective in preventing caries even among young children (Marinho et al. 2013; Weyant et al. 2013; Clark et al. 2020; Chou et al. 2021). ) Fluoride varnish does not require specialized dental equipment and can be applied quickly by both dental and non-dental professionals in a variety of settings (Chou et al. 2021; Chou et al. 2023).

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

School fluoride varnish delivery programs reduced initiation of caries by 32% in permanent teeth (19 studies) and by 25% in primary teeth (12 studies). When applied to teeth with existing caries, these programs reduced the progression of caries to more advanced stages by 10% (6 studies) and increased remineralization or arrestment of caries by 18% (4 studies).

Student participation in school fluoride varnish delivery programs was estimated at 68% (14 studies). This was substantially higher than the annual percentage of United States children from families with lower incomes who received either fluoride varnish or dental sealants in a clinical setting in 2013–2014 (<18%; Wei et al. 2018).

A systematic review of economic evidence has not been conducted.

Based on results for interventions in different settings and populations, the finding should be applicable to fluoride varnish delivery programs provided to school-aged children (preschool through high school) and implemented in schools in both rural and urban areas in the United States.

Most of the effectiveness data were for students at elevated caries risk living in low socioeconomic areas, indicating applicability of findings to U.S. programs that prioritize these populations.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base.

CPSTF identified the following questions as priorities for research and evaluation:

• How effective are school programs in reducing disparities in the United States for historically disadvantaged racial and ethnic groups and for rural areas?
• How can programs maximize school engagement and student participation?
• What can programs do to minimize delivery time and costs?

Remaining questions for research and evaluation identified in this review include the following:

• How effective are school programs when delivered by non-dental providers in the United States?
• How effective are school programs which deliver a single fluoride varnish application per year?
• How effective are school programs for students of low and moderate caries risk?
• How effective are school programs serving children in communities with higher social economic status?
• How effective are school programs in preventing caries in chewing surfaces of teeth in adolescents?
• Do school programs improve quality of life, school performance, and other health outcomes including harms?

• Studies were conducted in high (20 studies) or upper-middle (11 studies) income countries.
• Studies were conducted in communities with lower incomes (18 studies) and in communities that serve historically disadvantaged racial and ethnic populations (3 studies).
• Studies examined the effectiveness of school fluoride varnish delivery programs in preventing caries initiation (27 studies).
• Studies examined the effectiveness of applying fluoride varnish to teeth with existing caries (8 studies).
• Studies examined whether the reduction in caries initiation varied by income and other social determinants of health (2 studies).
• Studies applied fluoride varnish at least twice annually (31 studies).
• Studies estimated school fluoride varnish delivery program participation (14 studies).

Effectiveness Review

• Logic Model – Effectiveness Review (Print Only) [PDF – 161 KB]
• Text Description – Effectiveness Review [PDF – 68 KB]

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

• Summary Evidence Table – Effectiveness Review [PDF – 386 KB]

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Abreu-Placeres N, Garrido LE, Castillo Jaquez I, et al. Does applying fluoride varnish every three months better prevent caries lesions in erupting first permanent molars? A randomised clinical trial. Oral Health Prev Dent. 2019;17:541-546.

Arruda AO, Senthamarai Kannan R, Inglehart MR, et al. Effect of 5% fluoride varnish application on caries among school children in rural Brazil: a randomized controlled trial. Community Dent Oral Epidemiol. 2012;40(3):267-76.

Autio-Gold JT and Courts F. Assessing the effect of fluoride varnish on early enamel carious lesions in the primary dentition. J Am Dent Assoc. 2001;32(9):1247-53.

Bergstrom EK, Birkhed D, Granlund C, et al. Approximal caries increment in adolescents in a low caries prevalence area in Sweden after a 3.5-year school-based fluoride varnish programme with Bifluorid 12 and Duraphat. Community Dent Oral Epidemiol. 2014;42(5):404-11 2014.

Bergstrom EK, Lingstrom P, Hakeberg M, et al. Caries and costs: an evaluation of a school-based fluoride varnish programme for adolescents in a Swedish region. Swed Dent J. 2016;40(2):181-190.

Braun PA, Quissell DO, Henderson WG, et al. A cluster-randomized, community-based, tribally delivered oral health promotion trial in Navajo Head Start children. J Dent Res. 2016;95(11):1237-44.

Bravo M, Garcia-Anllo I, Baca P, et al. A 48-month survival analysis comparing sealant (Delton) with fluoride varnish (Duraphat) in 6- to 8-year-old children. Community Dent Oral Epidemiol. 1997;25(3):247-50.

Chu CH, Lo EC and Lin HC. Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children. J Dent Res. 2002;81(11):767-70.

Clark DC, Stamm JW, Robert G, et al. Results of a 32-month fluoride varnish study in Sherbrooke and Lac Megantic. J Am Dent Assoc. 1985;111(6):949-53.

Dudovitz RN, Valiente JE, Espinosa G, et al. A school-based public health model to reduce oral health disparities. J Public Health Dent. 2018;78(1):9-16.

Effenberger S, Greenwall L, Cebula M, et al. Cost-effectiveness and efficacy of fluoride varnish for caries prevention in South African children: A cluster-randomized controlled community trial. Community Dent Oral Epidemiol. 2021;50(5):453-460.

Florio FM, Pereira AC, Meneghim Mde C. et al. Evaluation of non-invasive treatment applied to occlusal surfaces. ASDC J Dent Child. 2001;68(5-6):326-31.

Grodzka K, Augustyniak L, Budny J, et al. Caries increment in primary teeth after application of Duraphat fluoride varnish. Community Dent Oral Epidemiol. 1982;10(2):55-9.

Hardman MC, Davies GM, Duxbury JT, et al. A cluster randomised controlled trial to evaluate the effectiveness of fluoride varnish as a public health measure to reduce caries in children. Caries Res. 2007;41(5):371-6.

Hedman E, Gabre P and Birkhed D. Dental hygienists working in schools – a two-year oral health intervention programme in Swedish secondary schools. Oral Health Prev Dent. 2015;13(2):177-88.

Jiang EM, Lo EC, Chu CH, et al. Prevention of early childhood caries (ECC) through parental toothbrushing training and fluoride varnish application: a 24-month randomized controlled trial. J Dent. 2014;42(12):1543-50.

Kidd JB, McMahon AD, Sherriff A, et al. Evaluation of a national complex oral health improvement programme: a population data linkage cohort study in Scotland. BMJ Open. 2020;10(11):e038116.

Liu BY, Lo EC, Chu CH, et al. Randomized trial on fluorides and sealants for fissure caries prevention. J Dent Res. 2012;91(8):753-8.

McMahon AD, Wright W, Anopa Y, et al. Fluoride varnish in nursery schools: A randomised controlled trial – protecting teeth @3. Caries Res. 2020;54(3):274-282.

Milsom KM, Blinkhorn AS, Walsh T, et al. A cluster-randomized controlled trial: fluoride varnish in school children. J Dent Res. 2011;90(11):1306-11.

Moberg Skold U, Petersson LG, Lith A, et al. Effect of school-based fluoride varnish programmes on approximal caries in adolescents from different caries risk areas. Caries Res. 2005;39(4):273-9.

Modeer T, Twetman S, Bergstrand F. Three-year study of the effect of fluoride varnish (Duraphat) on proximal caries progression in teenagers. Scand J Dent Res. 1984;92 (5):400-7.

Munoz-Millan P, Zaror C, Espinoza-Espinoza G, et al. Effectiveness of fluoride varnish in preventing early childhood caries in rural areas without access to fluoridated drinking. Community Dent Oral Epidemiol. 2018;46(1):63-69.

Pitchika V, Kokel CJ, Andreeva J, et al. Effectiveness of a new fluoride varnish for caries prevention in pre-school children. J Pediatr Dent. 2013;38(1):7-12.

Sirivichayakul P, Jirarattanasopha V, Phonghanyudh A, et al. The effectiveness of topical fluoride agents on preventing development of approximal caries in primary teeth: a randomized clinical trial. BMC Oral Health. 2023; 23: 349.

Souza BM, Silva MS, Braga AS, et al. Acceptability and effect of TiF4 on dental caries: a randomized controlled clinical trial. Braz Oral Res. 2021;35:e121.

Tagliaferro EP, Pardi V, Ambrosano GM, et al. Occlusal caries prevention in high and low risk schoolchildren. A clinical trial. Am J Dent. 2011;24(2):109-14.

Turska-Szybka A, Gozdowski D, Twetman S. et al. Clinical effect of two fluoride varnishes in caries-active preschool children: A randomized controlled trial. Caries Res. 2021;55(2):137-143.

Wang Z, Rong W, Xu T. et al. Effect of fluoride varnish in caries prevention on permanent first molars: A 36-month cluster randomized controlled trial. Pediatr Dent. 2021;43(2):82-87.

Wu S, Zhang T, Liu Q, et al. Effectiveness of fluoride varnish on caries in the first molars of primary schoolchildren: a 3-year longitudinal study in Guangxi Province, China. Int Dent J. 2020;70(2):108-115.

Zimmer S, Robke FJ and Roulet JF. Caries prevention with fluoride varnish in a socially deprived community. Community Dent Oral Epidemiol. 1999;27(2):103-8.

Effectiveness Review

The following databases were searched from database inception through December 31, 2023: PubMed (OVID), Embase (OVID), Global Health (OVID), Cochrane Central, Cochrane Oral Health Trial Registry, Scopus, ERIC (ProQuest), and CINAHL (EBSCO). The types of documents searched in the databases included journal articles, books, book chapters, reports, conference papers, and dissertations in English.

The strategy was intentionally broad to search for all studies with MeSH terms for fluoride varnish and children and to enable locating studies conducted among children in any school setting including preschool settings (e.g., nursery, Head Start programs), Kindergarten, and through high schools. Through deduplication, the search yields 1,049 citations including 1,040 journal articles. The search strategy also identified all fluoride varnish effectiveness trials conducted in schools and published in English that were included in the Cochrane (Marinho et al. 2013) and the U.S. Preventive Services Task Force (Chou et al. 2021; Chou et al. 2023) systematic reviews of fluoride varnish delivered in multiple setting types.

Teams of two reviewers independently screened search results and abstracted qualifying studies. Differences were reconciled first by the two abstractors, with unresolved differences brought to all review team members to reach consensus. Members of the review team also scanned the bibliographies of all reviewed studies to identify any additional relevant literature. The CPSTF finding included 31 unique studies.

The search strategy is specified below.

MEDLINE (OVID) 1946-

(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations and Daily

1 exp Tooth Demineralization/
2 (caries or carious).mp.
3 (teeth adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab,kw.
4 (tooth adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab,kw.
5 (dental adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab,kw.
6 (enamel adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab,kw.
7 (dentin$ adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab,kw.
8 (root$ adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab,kw.
9 Dental plaque/
10 ((teeth or tooth or dental or enamel or dentin) and plaque).ti,ab,kw.
11 Dental Health Surveys/
12 (“DMF Index” or “Dental Plaque Index”).mp.
13 Mass screening/
14 exp Stomatognathic diseases/
15 13 and 14
16 or/1-12
17 15 or 16
18 Fluorides, Topical/
19 (fluoride* or fluor or “PPM F” or PPMF or APF or NAF or “Sodium F” or “Amine F” or SNF2 or “Stannous F” or “phosphat* F” or “acidulat* F” or “acidulat* fluor*” or “phosphat* fluor*” or fluorphosphat* or “amin$ fluor*or sodium* fluor*” or “stannous* fluor*” or SMFP or MFP or monofluor*).mp.
20 18 or 19
21 (varnish* or lacquer* or laquer* or lacker* or lakk* or polyurethane*).ti,ab,kw.
22 20 and 21
23 (duraphat or “fluor protector” or “bifluorid 12” or “cavity shield” or cavityshield or duraflor or Flulak or “omni varnish” or “prevident varnish” or clearshield or “clear shield” or allsolutions).mp.
24 22 or 23
25 (preschool* or pre-school* or kindergarten or prekindergarten or pre-kindergarten or nursery or nurseries or “head start” or “early head start”).ti,ab,kw.
26 exp *adolescent/ or exp *child/ or (adolescen* or child* or juvenil* or teen* or youth*).ti,ab.
27 (childhood or “early childhood” or “elementary school*” or (primary adj (education or school)) or “K-12” or “K12” or “middle school*” or “junior high” or “high school*” or “secondary school*” or pupil* or school* or student* or schoolchildren or “school-based services”).ti,ab,kw.
28 Schools, Nursery/
29 Child, Preschool/
30 Child Care/
31 Child Day Care Centers/
32 Students/
33 Schools/
34 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33
35 17 and 24 and 34
36 24 and 34
37 35 or 36
38 37 not (animals not humans).sh.
39 38 not (exp adult/ not (exp child/ or adolescent/))
40 (editorial or letter or comment).pt.
41 39 not 40
42 limit 41 to english language

Embase (OVID) 1947-

1 exp Tooth Demineralization/
2 (caries or carious).mp.
3 (teeth adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab,kw.
4 (tooth adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab,kw.
5 (dental adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab,kw.
6 (enamel adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab,kw.
7 (dentin$ adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab,kw.
8 (root$ adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab,kw.
9 Dental plaque/
10 ((teeth or tooth or dental or enamel or dentin) and plaque).ti,ab,kw.
11 Dental Health Surveys/
12 (“DMF Index” or “Dental Plaque Index”).mp.
13 Mass screening/
14 exp Stomatognathic diseases/
15 13 and 14
16 or/1-12
17 15 or 16
18 Fluorides, Topical/
19 (fluoride* or fluor or “PPM F” or PPMF or APF or NAF or “Sodium F” or “Amine F” or SNF2 or “Stannous F” or “phosphat* F” or “acidulat* F” or “acidulat* fluor*” or “phosphat* fluor*” or fluorphosphat* or “amin$ fluor*or sodium* fluor*” or “stannous* fluor*” or SMFP or MFP or monofluor*).mp.
20 18 or 19
21 (varnish* or lacquer* or laquer* or lacker* or lakk* or polyurethane*).ti,ab,kw.
22 20 and 21
23 (duraphat or “fluor protector” or “bifluorid 12” or “cavity shield” or cavityshield or duraflor or Flulak or “omni varnish” or “prevident varnish” or clearshield or “clear shield” or allsolutions).mp.
24 22 or 23
25 (preschool* or pre-school* or kindergarten or prekindergarten or pre-kindergarten or nursery or nurseries or “head start” or “early head start”).ti,ab,kw.
26 exp *adolescent/ or exp *child/ or (adolescen* or child* or juvenil* or teen* or youth*).ti,ab.
27 (childhood or “early childhood” or “elementary school*” or (primary adj (education or school)) or “K-12” or “K12” or “middle school*” or “junior high” or “high school*” or “secondary school*” or pupil* or school* or student* or schoolchildren or “school-based services”).ti,ab,kw.
28 Schools, Nursery/
29 Child, Preschool/
30 Child Care/
31 Child Day Care Centers/
32 Students/
33 Schools/
34 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33
35 17 and 24 and 34
36 24 and 34
37 35 or 36
38 37 not (animals not humans).sh.
39 38 not (exp adult/ not (exp child/ or adolescent/))
40 (editorial or letter or comment).pt.
41 39 not 40
42 limit 41 to english language
43 limit 42 to exclude medline journals

Global Health (OVID) 1910-

1 tooth demineralization.ti,ab.
2 (caries or carious).mp.
3 (teeth adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab.
4 (tooth adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab.
5 (dental adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab.
6 (enamel adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab.
7 (dentin$ adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab.
8 (root$ adj5 (cavit$ or decay$ or lesion$ or deminerali$ or reminerali$ or white spot$)).ti,ab.
9 Dental plaque/
10 ((teeth or tooth or dental or enamel or dentin) and plaque).ti,ab.
11 Dental Health Surveys.ti,ab.
12 (“DMF Index” or “Dental Plaque Index”).mp.
13 Mass screening.mp.
14 stomatognathic*.mp.
15 13 and 14
16 or/1-12
17 15 or 16
18 Fluorides, Topical/
19 (fluoride* or fluor or “PPM F” or PPMF or APF or NAF or “Sodium F” or “Amine F” or SNF2 or “Stannous F” or “phosphat* F” or “acidulat* F” or “acidulat* fluor*” or “phosphat* fluor*” or fluorphosphat* or “amin$ fluor*or sodium* fluor*” or “stannous* fluor*” or SMFP or MFP or monofluor*).mp.
20 18 or 19
21 (varnish* or lacquer* or laquer* or lacker* or lakk* or polyurethane*).ti,ab.
22 20 and 21
23 (duraphat or “fluor protector” or “bifluorid 12” or “cavity shield” or cavityshield or duraflor or Flulak or “omni varnish” or “prevident varnish” or clearshield or “clear shield” or allsolutions).mp.
24 (preschool* or pre-school* or kindergarten or prekindergarten or pre-kindergarten or nursery or nurseries or “head start” or “early head start”).ti,ab.
25 exp *adolescent/ or exp *child/ or (adolescen* or child* or juvenil* or teen* or youth*).ti,ab.
26 (childhood or “early childhood” or “elementary school*” or (primary adj (education or school)) or “K-12” or “K12” or “middle school*” or “junior high” or “high school*” or “secondary school*” or pupil* or school* or student* or schoolchildren or “school-based services”).ti,ab.
27 Child Care.ti,ab.
28 day?care.ti,ab.
29 Students/
30 Schools/
31 24 or 25 or 26 or 27 or 28 or 29 or 30
32 17 and 22 and 31
33 22 and 31
34 32 or 33
35 34 not (exp adults/ not (exp child/ or adolescent/))
36 (editorial or letter or comment).pt.
37 35 not 36
38 limit 37 to (abstracts and english language)

ERIC (ProQuest) 1966-

noft((fluoride* or fluor or “PPM F” or PPMF or APF or NAF or “Sodium F” or “Amine F” or SNF2 or “Stannous F” or “phosphat* F” or “acidulat* F” or “acidulat* fluor*” or “phosphat* fluor*” or fluorphosphat* or “amin$ fluor*or sodium* fluor*” or “stannous* fluor*” or SMFP or MFP or monofluor*)) AND noft((varnish* or lacquer* or laquer* or lacker* or lakk* or polyurethane*))

Scopus (1960-)

( ( TITLE-ABS ( preschool* OR pre-school* OR kindergarten OR prekindergarten OR pre-kindergarten OR nursery OR nurseries OR “head start” OR “early head start” ) ) OR ( TITLE-ABS ( adolescen* OR child* OR juvenil* OR teen* OR youth* ) ) OR ( TITLE-ABS ( childhood OR “early childhood” OR “elementary school*” OR “primary education” OR “primary school” OR “K-12” OR “K12” OR “middle school*” OR “junior high” OR “high school*” OR “secondary school*” OR pupil* OR school* OR student* OR “school children” OR “school-based services” ) ) ) AND ( ( TITLE-ABS ( duraphat OR “fluor protector” OR “bifluorid 12” OR “cavity shield” OR cavityshield OR duraflor OR flulak OR “omni varnish” OR “prevident varnish” OR clearshield OR “clear shield” OR allsolutions ) ) OR ( ( TITLE-ABS ( fluoride* OR fluor OR “PPM F” OR ppmf OR apf OR naf OR “Sodium F” OR “Amine F” OR snf2 OR “Stannous F” OR “phosphat* F” OR “acidulat* F” OR “acidulat* fluor*” OR “phosphat* fluor*” OR fluorphosphat* OR “amin$ fluor*or sodium* fluor*” OR “stannous* fluor*” OR smfp OR mfp OR monofluor* ) ) AND ( TITLE-ABS ( varnish* OR lacquer* OR laquer* OR lacker* OR lakk* OR polyurethane* ) ) ) ) AND ( LIMIT-TO ( LANGUAGE , “English” ) )

‘Oral Health’ in Cochrane Groups – Reviews and Trials

1 ( preschool* OR pre-school* OR kindergarten OR prekindergarten OR pre-kindergarten OR nursery OR nurseries OR “head start” OR “early head start” ):ti,ab
#2 ( adolescen* OR child* OR juvenil* OR teen* OR youth*):ti,ab
#3 (childhood OR “early childhood” OR “elementary school*” OR “primary education” OR “primary school” OR “K-12” OR “K12” OR “middle school*” OR “junior high” OR “high school*” OR “secondary school*” OR pupil* OR school* OR student* OR “school children” OR “school-based services”):ti,ab
#4 #1 OR #2 OR #3
#5 ( duraphat OR “fluor protector” OR “bifluorid 12” OR “cavity shield” OR cavityshield OR duraflor OR flulak OR “omni varnish” OR “prevident varnish” OR clearshield OR “clear shield” OR allsolutions):ti,ab
#6 (fluoride* OR fluor OR “PPM F” OR ppmf OR apf OR naf OR “Sodium F” OR “Amine F” OR snf2 OR “Stannous F” OR “phosphat* F” OR “acidulat* F” OR “acidulat* fluor*” OR “phosphat* fluor*” OR fluorphosphat* OR “amin$ fluor*or sodium* fluor*” OR “stannous* fluor*” OR smfp OR mfp OR monofluor*):ti,ab
#7 (varnish* OR lacquer* OR laquer* OR lacker* OR lakk* OR polyurethane* ):ti,ab
#8 #6 AND #7
#9 #5 OR #8
#10 #4 AND #9 with ‘Oral Health’ in Cochrane Groups – Reviews and Trials

CINAHL (Ebsco)

S1 TI ( (preschool* OR pre-school* OR kindergarten OR prekindergarten OR pre-kindergarten OR nursery OR nurseries OR “head start” OR “early head start”) ) OR AB ( (preschool* OR pre-school* OR kindergarten OR prekindergarten OR pre-kindergarten OR nursery OR nurseries OR “head start” OR “early head start”) )
S2 AB ( (adolescen* OR child* OR juvenil* OR teen* OR youth*) ) OR TI ( (adolescen* OR child* OR juvenil* OR teen* OR youth*) )
S3 AB ( (childhood OR “early childhood” OR “elementary school*” OR “primary education” OR “primary school” OR “K-12” OR “K12” OR “middle school*” OR “junior high” OR “high school*” OR “secondary school*” OR pupil* OR school* OR student* OR “school children” OR “school-based services”) ) OR TI ( (childhood OR “early childhood” OR “elementary school*” OR “primary education” OR “primary school” OR “K-12” OR “K12” OR “middle school*” OR “junior high” OR “high school*” OR “secondary school*” OR pupil* OR school* OR student* OR “school children” OR “school-based services”) )
S4 S1 OR S2 OR S3
S5 TI ( ( duraphat OR “fluor protector” OR “bifluorid 12” OR “cavity shield” OR cavityshield OR duraflor OR flulak OR “omni varnish” OR “prevident varnish” OR clearshield OR “clear shield” OR allsolutions) ) OR AB ( ( duraphat OR “fluor protector” OR “bifluorid 12” OR “cavity shield” OR cavityshield OR duraflor OR flulak OR “omni varnish” OR “prevident varnish” OR clearshield OR “clear shield” OR allsolutions) )
S6 TI ( (fluoride* OR fluor OR “PPM F” OR ppmf OR apf OR naf OR “Sodium F” OR “Amine F” OR snf2 OR “Stannous F” OR “phosphat* F” OR “acidulat* F” OR “acidulat* fluor*” OR “phosphat* fluor*” OR fluorphosphat* OR “amin$ fluor*or sodium* fluor*” OR “stannous* fluor*” OR smfp OR mfp OR monofluor*) ) OR AB ( (fluoride* OR fluor OR “PPM F” OR ppmf OR apf OR naf OR “Sodium F” OR “Amine F” OR snf2 OR “Stannous F” OR “phosphat* F” OR “acidulat* F” OR “acidulat* fluor*” OR “phosphat* fluor*” OR fluorphosphat* OR “amin$ fluor*or sodium* fluor*” OR “stannous* fluor*” OR smfp OR mfp OR monofluor*) )
S7 TI ( (varnish* OR lacquer* OR laquer* OR lacker* OR lakk* OR polyurethane* ) ) OR AB ( (varnish* OR lacquer* OR laquer* OR lacker* OR lakk* OR polyurethane* ) )
S8 S6 AND S7
S9 S5 OR S8
S10 S4 AND S9
S11 S4 AND S9 Limiters – English Language; Peer Reviewed

American Academy of Pediatrics. 2024. Medicaid payment of preventive oral health services. [accessed May 9, 2024]. Available at: https://www.aap.org/en/patient-care/oral-health/payment-for-oral-health-services/.

American Dental Association. 2024. Current Policies. American Dental Association, Chicago. P57. [accessed May 13, 2024]. Available at: https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/about/governance/current_policies.pdf?rev=f8a6561f9da4421387a6c8c982a118f8&hash=9DED0F70F6E09C155240BBF6007A4B70.

Braun PA, Quissell DO, Henderson WG, Bryant LL, Gregorich SE, George C, Toledo N, Cudeii D, Smith V, Johs N et al. 2016. A Cluster-Randomized, Community-Based, Tribally Delivered Oral Health Promotion Trial in Navajo Head Start Children. Journal of Dental Research. 95(11):1237-1244.

Centers for Disease Control and Prevention. 2019. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016. [accessed March 21, 2022]. Available at: https://www.cdc.gov/oralhealth/publications/OHSR-2019-index.html.

Chou R, Pappas M, Dana T, Selph S, Hart E, Fu RF, Schwarz E. 2021. U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews. Screening and Interventions to Prevent Dental Caries in Children Younger Than Age Five Years: A Systematic Review for the US Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US).

Chou R, Bougatsos C, Griffin J, Selph SS, Ahmed A, Fu R, Nix C, Schwarz E. 2023. Screening, Referral, Behavioral Counseling, and Preventive Interventions for Oral Health in Children and Adolescents Aged 5 to 17 Years A Systematic Review for the US Preventive Services Task Force. Am J Prev Med. 64(4):579−594.

Clark MB, Keels MA, Slayton RL, Section on Oral Health, Braun PA, Fisher-Owens SA, Huff QA, Karp JM, Tate AR. 2020. Fluoride Use in Caries Prevention in the Primary Care Setting. Pediatrics. 146 (6): e2020034637.

Dudovitz RN, Valiente JE, Espinosa G, et al. A school-based public health model to reduce oral health disparities. J Public Health Dent. 2018;78(1):9-16.

Indian Health Service. 2010. Head Start’s Role in ECC Prevention & Early Intervention [accessed March 29, 2024]. Available at:
https://www.ihs.gov/doh/documents/ecc/CommunityDocs/HeadStartRoleECCPreventionAndIntervention.pdf.

Marinho VC, Worthington HV, Walsh T, Clarkson JE. 2013. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2013(7):Cd002279.

Patel N, Griffin SO, Linabarger M, Lesaja S. 2022. Impact of school sealant programs on oral health among youth and identification of potential barriers to implementation. J Am Dent Assoc. 153(10):970-978.e974.

Scherrer CR, Griffin PM, Swann JL. 2007. Public health sealant delivery programs: optimal delivery and the cost of practice acts. Med Decis Making. 27(6):762-771.

US Department of Health and Human Services. 2000. Oral Health in America: A Report of the Surgeon General. [accessed March 29, 2024]. Available at: https://www.nidcr.nih.gov/research/data-statistics/surgeon-general.

Wei L, Griffin SO, Robison VA. 2018. Disparities in Receipt of Preventive Dental Services in Children From Low-Income Families. Am J Prev Med. 55(3):e53–e60 e53.

Weyant RJ, Tracy SL, Anselmo TT, Beltrán-Aguilar ED, Donly KJ, Frese WA, Hujoel PP, Iafolla T, Kohn W, Kumar J et al. 2013. Topical fluoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic review. J Am Dent Assoc. 144(11):1279-1291

The following considerations for implementation are drawn from studies included in the existing evidence review, the broader literature, and expert opinion.
Strategies to support school fluoride varnish delivery programs include:

• School sealant programs not already providing fluoride varnish could add this intervention, which requires no additional equipment and takes advantage of the program’s current access to schools.
• Programs may be administered by the school (e.g., school health center) or by outside entities (e.g., Federally Qualified Health Centers, State Oral Health Programs, dental schools).

State Medicaid policies and billing considerations:

• Low Medicaid reimbursement rates and care that is not reimbursed can hinder program implementation and sustainability (Patel et al. 2022; Dudovitz et al. 2018).
• Medicaid reimbursement policy regarding who can bill for preventive dental services and who can deliver them may pose greater barriers for non-dental providers. (Dudovitz et al. 2018; Scherrer et al. 2007)
• In most states, Medicaid reimbursement policy for non-dental health professionals only allows providers who are physicians or nurses with advanced degrees (e.g., nurse practitioners) to bill for fluoride varnish application and typically does not reimburse for fluoride varnish delivered to children older than age 6 years (AAP 2024; Dudovitz et al. 2018).

Considerations for who can apply fluoride varnish:

• Although the majority of states allow physicians and nurses with advanced degrees to delegate delivery to other types of non-dental health professionals (e.g., medical assistants, registered nurses), in a few states, other types of non-dental providers are not allowed to apply fluoride varnish, even without seeking reimbursement (AAP 2024).
• The Indian Health Service allows different types of non-dental providers to apply fluoride varnish in preschool programs including trained lay health workers and Head Start staff including directors, health coordinators, and teachers (Indian Health Service 2010; Braun et al. 2016).

Other factors affecting school adoption and student participation:

• Changing approaches to seeking consent.
• Socio-demographic, cultural, and linguistic factors affecting demand and ability to participate.
• Involving a local champion, such as a school nurse, who understands the value of the program and is trusted by both parents and school personnel to increase school acceptance and student participation (Dudovitz et al. 2018).
• Minimizing student time out of class by ensuring efficient delivery of services could increase school acceptance of school fluoride varnish delivery programs (Dudovitz et al. 2018).

When implementing programs, it is important to note that the greatest caries reductions will likely result from implementing programs as soon as the first tooth erupts—preschool (e.g., Early Head Start) for primary teeth beginning eruption at age 6 months and kindergarten for permanent teeth beginning eruption at age 6 years; (Braun et al. 2016)—and applying fluoride varnish at least twice annually.

Resources for Implementation

Several publicly available resources provide guidance on the implementation of school fluoride varnish delivery programs.

• Preventing Tooth Decay | State Strategies | Policy, Performance, and Evaluation | CDC
• Advancing Prevention and Reducing Childhood Caries in Medicaid and CHIP Learning Collaborative | Medicaid
• Fluoride Varnish (astdd.org) [PDF – 234 KB]
• Fluoride Varnish | California Oral Health Technical Assistance Center (ucsf.edu)
• Dental Portal | Indian Health Service (ihs.gov)
• Local Oral Health Program (LOHP) Resource Guide (ucsf.edu) [PDF – 667 KB]
• School-Based Fluoride Varnish & Sealant Program | Health and Human Services North Dakota
• Washington State School-based Sealant and Fluoride Varnish Program Guidelines [PDF – 838 KB]

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the proportion of children and adolescents with lifetime tooth decay — OH 01
• Reduce the proportion of children and adolescents with active and untreated tooth decay — OH 02
• Increase use of the oral health care system — OH 08
• Increase the proportion of low-income youth who have a preventive dental visit — OH 09
• Increase the proportion of children and adolescents who have dental sealants on 1 or more molars — OH 10
• Reduce the proportion of people who can’t get the dental care they need when they need it — AHS 05