Oral Health: School Fluoride Varnish Delivery Programs

Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends school fluoride varnish delivery programs to prevent dental caries (tooth decay) among school-aged children (preschool through high school). Evidence shows that these programs, implemented primarily in communities with lower incomes and high rates of tooth decay among children, achieve meaningful rates of student participation, increase the number of treatments received, reduce dental caries, and reduce disparities in onset of tooth decay by income and other social determinants of health.

The full CPSTF Finding and Rationale Statement and supporting documents for Oral Health: School Fluoride Varnish Delivery Programs are available in The Community Guide Collection on CDC Stacks.

Intervention

School fluoride varnish delivery programs apply fluoride varnish to the teeth of children attending preschools and schools (from tooth eruption at age 6 months through high school) either at school or at offsite locations. Depending on state regulations, fluoride varnish applications may be administered by:

Dental professionals: dentists, dental hygienists, dental therapists
Trained non-dental health professionals: physicians, nurses, medical assistants, community health workers
Trained lay workers: teachers, administrative staff, counselors, volunteers

Programs may also provide one or more of the following additional services:

Risk assessment for tooth decay
Oral hygiene instruction and supplies
Oral health education
Dental sealants
Referrals to dental care

Programs may prioritize schools in communities with a large number of students at elevated risk for tooth decay (e.g., with lower incomes).

About The Systematic Review

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

Study Characteristics

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)

Summary of Results

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).

Summary of Economic Evidence

A systematic review of economic evidence has not been conducted.

Applicability

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.

Evidence Gaps

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?

Implementation Considerations and Resources

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
Medicaid reimbursement policy regarding who can bill for preventive dental services and who can deliver them may pose greater barriers for non-dental providers
In most states, Medicaid reimbursement policy for non-dental health professionals only allows providers who are physicians or nurses with advanced degrees to bill for fluoride varnish application and typically does not reimburse for fluoride varnish delivered to children older than age 6 years

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
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

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
Minimizing student time out of class by ensuring efficient delivery of services could increase school acceptance

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—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.

Crosswalks

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