to the editor: We were delighted to read the editorial in American Family Physician high-lighting the importance of early childhood caries as a transmissible but preventable chronic disease.¹ As noted in the editorial, family physicians can provide screening examinations, parent education, and early dental referral. Education should include promoting regular oral hygiene, appropriate exposure to fluoride, the importance of early and routine dental care, and balanced nutrition. Such services are particularly important for the economically disadvantaged who have high risks of developing caries, but limited access to dental care. The authors note that lack of clinical time and reimbursement are obstacles to the provision of oral health care in family medicine.¹ Oral health guidelines were added to the well-child visit, but another option is to establish an oral health screening and prevention program.

To address the barriers of time and reimbursement, we piloted an early childhood oral health-screening clinic embedded in our federally qualified health center. We serve an ethnically diverse urban community at a county teaching hospital. The oral health clinic operates bimonthly and screens children within six months of tooth eruption and at five years of age. The visit takes about 20 to 30 minutes, including individualized risk assessment, screening examination, fluoride varnish application (if necessary), anticipatory guidance, individualized action plan, and appropriate dental referrals. It takes a trained, licensed medical provider less than five minutes to conduct the oral examination.

Fluoride varnish reduces caries in permanent dentition by 38 percent for those at high risk of decay² and reverses early caries lesions.³ Fluoride varnish is an attractive option for the primary care setting because it can be easily painted on by ancillary staff in less than five minutes.⁴ Although Medicaid policies vary by state, nurse practitioners, physician assistants, and other nonspecified medical personnel are often legally permitted to apply the varnish when the attending physician prescribes the procedure and establishes a protocol.⁵ In a community practice, a trained medical assistant could fill the role that the resident or medical student performs in our clinic. Other visit components may be completed by nursing staff, a nutritionist, or a social worker.

A number of state Medicaid programs, including California's, reimburse for fluoride varnish applications by medical staff. Clinics can bill using current procedural terminology (CPT) code D01203 (Topical application of Fluoride [Prophylaxis not included]) and International Classification of Diseases, 9th rev. (ICD-9) code V07.31 (Need for prophylactic fluoride administration) under principal diagnosis. Our model is financially viable and has improved access to needed preventive and screening oral health services. Family physicians play a pivotal role in all aspects of family health and disease prevention, particularly for children who do not receive regular dental care. Family physicians are well positioned to impact oral health disparities in children in ways that will yield long-term benefits.