Clinician Characteristics Associated With Fluoride Varnish Applications During Well-Child Visits

ABSTRACT

Objectives: To identify factors associated with clinicians’ likelihood and intensity of applying fluoride varnish (FV) overall and for visits paid by Medicaid and private insurers.

Study Design: Observational study using claims data.

Methods: Using the Massachusetts All-Payer Claims Database (2016-2018), we conducted a repeated cross-sectional study of 2911 clinicians (7277 clinician-year observations) providing well-child visits to children aged 1 to 5 years. Zero-inflated negative binomial models estimated the probability of a clinician applying FV and the number of visits with FV applications, overall and separately for visits paid by Medicaid and private insurers.

Results: A total of 30.9% of clinician-years applied FV at least once, and overall, an average of 8.4% of a clinician’s well-child visits included FV annually. Controlling for all covariates, having a higher percentage of patients insured by Medicaid was associated with applying FV (OR, 1.35; 95% CI, 1.23-1.45) and a higher expected number of applications (OR, 1.05; 95% CI, 1.02-1.09). Additionally, having a higher percentage of patients aged 1 to 5 years was associated with applying FV (OR, 1.20; 95% CI, 1.01-1.43), but not the number of applications. Similar associations were observed among visits paid by private insurers.

Conclusions: Despite clinical recommendations and mandated insurance reimbursements, the likelihood and intensity of FV applications was low for most pediatric primary care clinicians. Clinician behavior was associated with patient-panel characteristics, suggesting the need for interventions that account for these differences.

Am J Manag Care. 2024;30(7):e203-e209. https://doi.org/10.37765/ajmc.2024.89582

Takeaway Points

• Fewer than 1 in 3 primary care clinicians applied fluoride varnish (FV) during well-child visits in a year, despite clinical recommendation and reimbursement by Medicaid and private insurers.
• Clinicians treating a higher percentage of Medicaid patients and a higher percentage of patients younger than 5 years were more likely to apply FV.
• Our findings provide evidence for policy makers that strategies to increase FV applications in medical offices need to be attentive to clinician-level patient-panel characteristics, which would expand access to preventive oral health services among young children.

In 2014, the US Preventive Services Task Force (USPSTF) recommended that primary care clinicians apply fluoride varnish (FV) to the teeth of all children 5 years and younger.¹ FV applied in medical offices may help to increase young children’s receipt of preventive oral health services because children are more likely to receive medical care than dental care,² including during 10 well-child visits (WCVs) from aged 6 months through 5 years.³ Despite this, few children receive FV during WCVs. A study of children in Massachusetts during 2016-2018 showed rates of WCVs with FV for children aged 1 to 5 years were 14% for Medicaid enrollees and 7% for children with private insurance.⁴ In a 2018 survey, only 47% of pediatricians reported they should apply FV and only 17% reported applying FV to most of their patients 3 years or younger.⁵

Many factors, such as clinical training, practice size, and patient characteristics, may affect a primary care clinician’s decision to apply FV. One study from a Midwestern tertiary teaching hospital and its affiliated clinics during 2009-2019 found FV was applied only by pediatricians, not family practice physicians, although fewer than 100 FV applications were observed overall.^6,7 Studies conducted nearly 20 years ago in North Carolina and Washington state found higher rates of FV among pediatric practices, large practices, and clinicians treating only Medicaid patients.^7,8 A 2012 American Academy of Pediatrics (AAP) survey found clinicians were more likely to apply and bill for FV if they had a higher penetration of publicly insured patients.⁹ Much of this evidence, however, was collected before 2015, when financial incentives regarding FV differed by insurance type. Most state Medicaid agencies have covered FV for more than a decade,¹⁰ yet most private health insurers have covered it only since May 2015 to comply with the Affordable Care Act provision that required coverage of USPSTF-recommended preventive services, including FV application.¹¹ Little is known about clinician characteristics associated with the provision of FV in medical offices in this current context.

Identifying clinician-level factors associated with FV application is important for tailoring and targeting interventions. Using all-payer medical claims data from Massachusetts, this study extends prior work by identifying factors associated with clinicians’ likelihood and intensity of applying FV during well-child medical visits in 2016-2018, a period when both Medicaid and private insurers covered it. Based on prior literature, we hypothesized that pediatricians and clinicians serving a larger share of Medicaid-insured children would be more likely to apply FV.

METHODS

This observational study was approved by the RAND institutional review board, and a waiver of informed consent was granted.

Data Sources

We analyzed data from the Massachusetts All-Payer Claims Database (APCD; Release 8.0), acquired from the Center for Health Information and Analysis.¹² This database included information on health insurance enrollment, claims, and clinician data for MassHealth (Massachusetts’ combined Medicaid and state Children’s Health Insurance Program) and commercial payers, including employer-sponsored insurance, some self-insured employers, health insurance marketplaces, and individually purchased plans. The Massachusetts APCD contains National Provider Identifiers (NPIs), which are unique provider IDs that we linked to annual National Plan and Provider Enumeration System (NPPES) files.¹³ The NPPES contains provider information, allowing us to identify individual clinicians, clinician sex, clinician specialty, and training; these items are unlikely to change over time, alleviating concerns about infrequent updates to the NPPES.^14,15

Study Population

We studied medical clinicians providing WCVs to children aged 1 to 5 years during 2016-2018 because FV applications are mostly applied during WCVs.³ Although teeth typically erupt around age 6 months, we excluded visits for children younger than 1 year because our dataset did not include information about child age in months. A clinician’s provision of a WCV was identified using Current Procedural Terminology (CPT) codes 99382, 99383, 99392, 99393. We limited the sample to include medical clinicians whose primary practice location was Massachusetts and who saw at least 5 unique children aged 1 to 5 years for WCVs in a year, as these clinicians commonly treat the population for which FV is recommended. The analytic sample included 7277 clinician-year observations for 2911 unique clinicians (eAppendix Figure [eAppendix available at ajmc.com]).

Outcomes

We examined the number of FV applications during WCVs for each clinician-year, including for those with zero FV applications. We defined FV being applied when observing an FV application and a WCV for a child provided on the same day by the same clinician. FV applications were identified using CPT code 99188 and Current Dental Terminology code D1206. Both codes are used for billing the application of FV in medical offices.¹⁶ We constructed this outcome for all WCVs for patients aged 1 to 5 years attributed to a clinician, only visits paid by Medicaid, and only visits paid by private insurers.

Clinician and Patient-Panel Characteristics

We obtained clinician sex and primary taxonomy from the NPPES. Based on the distribution in our sample, we categorized each clinician as a pediatrician, family medicine physician, other physician (eg, internal medicine), or other medical clinician (eg, nurse practitioner, physician assistant). Clinician age, from the APCD, was constructed using the clinician’s year of birth. We divided clinician age by its SD to normalize the variable. Using all paid medical claims in a year, we constructed 2 variables to describe the patients treated by each clinician in each year. We calculated the percentage of a clinician’s patients insured by Medicaid and the percentage of patients aged 1 to 5 years. We determined primary practice location based on the plurality zip code listed on all paid medical claims.

Statistical Analysis

We reported unadjusted means and proportions for outcomes and clinician characteristics overall and by whether a clinician applied FV during a year. We estimated zero-inflated negative binomial (ZINB) regressions to model clinicians’ number of FV applications in a year. In the logit parts of the ZINB models, ORs indicate the odds of not applying FV during any visits. We calculated and reported the inverse ORs that indicate the odds of applying FV. For the negative binomial parts of the ZINB models, the outcome is the number of FV applications, conditional on the clinician having applied FV, interpreted as incidence rate ratios (IRRs). Models were estimated using all of a clinician’s WCVs for children aged 1 to 5 years and separately for only visits paid by Medicaid and only visits paid by private insurers. We used a clinician’s total number of WCVs during a calendar year as the offset variable to account for heterogenous practice volume. Models controlled for the aforementioned variables as well as 3-digit service zip code and calendar year fixed effects to account for unobserved time-invariant geographic heterogeneity and time trends that could affect the delivery of FV^.17,18 Standard errors were clustered at the 5-digit service zip code level to account for the potential correlation across observations. We used estimates from the ZINB model to calculate regression-adjusted predictions for clinicians’ probability of any FV applications, number of applications, and number of applications among clinicians who provided FV in a calendar year. For example, we computed average predicted outcomes for the entire sample after setting the percentage of patients insured by Medicaid during a year first to the 25th percentile, then to the 50th percentile, and finally to the 75th percentile, while keeping the number of WCVs at 100 and all other covariates at observed values. For these predictions, we used a sample of clinicians who provided WCVs to both young children with Medicaid and young children with private insurance in a year (N = 6592) to ensure comparability across all models. The δ method was used to calculate SEs for predicted probabilities. Analyses were performed by using Stata/MP version 16.1 (StataCorp LLC). A 2-sided P value less than .05 was considered statistically significant.

Because controlling for the percentage of a clinician’s patients aged 1 to 5 years could mask differences across clinician training, we examined the sensitivity of our results to the exclusion of this variable.

RESULTS

Sample Characteristics

Among 7277 clinician-year observations, 30.9% applied FV at least once during a year, 68.0% were female clinicians, and 53.2% were pediatricians (Table 1). Compared with those without FV applications, clinician-years with FV applications had more WCVs on average (155 vs 103 without FV; P < .001), a higher mean percentage of Medicaid-insured patients (59.9% vs 40.2% without FV; P < .001), and a higher mean percentage of patients aged 1 to 5 years (22.6% vs 16.8% without FV; P < .001).

Provision of FV

Among 2911 unique clinicians, 1129 (38.8%) ever applied FV during the study period. Overall, a mean (SD) of 8.4% (17.4%) of a clinician’s WCVs included annual FV. Among 2250 clinician-years with at least 1 FV application, an average of 27.1% (21.7%) of WCVs included FV applications (Table 1). Figure 1 shows the distribution of each clinician-year’s rate of FV applications during WCVs, among those that ever applied FV. Most clinicians applied FV during few visits, with only 348 clinician-years (15.5%) applying it during more than 50% of visits (Figure 1, panel A). Among clinician-years ever-applied FV during visits paid by Medicaid, 15.3% applied it during more than 50% of these visits. Among clinician-years ever-applied FV during visits paid by private insurers, 16.2% applied it during more than 50% of these visits (Figure 1, panel B).

Factors Associated With FV Application

Regardless of the payer, clinician-level patient-panel characteristics were associated with differences in the odds that a clinician applied FV during a year (Table 2). Having an additional 10 percentage points more patients insured by Medicaid was significantly associated with an increased likelihood of applying FV overall (OR, 1.35; 95% CI, 1.23-1.45), for visits paid by Medicaid (OR, 1.41; 95% CI, 1.30-1.52), and for visits paid by private insurers (OR, 1.30; 95% CI, 1.20-1.41). As shown in Figure 2, panel A, the predicted probabilities of applying FV during a visit paid by Medicaid were 16.44% for a clinician with the 25th percentile of the share of Medicaid-insured patients and 46.43% for a clinician with the 75th percentile of the share of Medicaid-insured patients (75th vs 25th, P < .001). Similarly, the predicted probabilities of applying FV during a visit paid by private insurance were 20.38% for a clinician with the 25th percentile of the share of Medicaid-insured patients and 43.81% for a clinician with the 75th percentile of the share of Medicaid-insured patients (75th vs 25th, P < .001). Additionally, a higher percentage of patients aged 1 to 5 years was associated with a greater likelihood of applying FV overall (OR,1.20; 95% CI, 1.01-1.43) and for visits paid by private insurers (OR, 1.33; 95% CI, 1.06-1.66), with no significant association observed for visits paid by Medicaid (Table 2).

Factors Associated With FV Application Intensity

Among clinicians who applied FV in a year, having an additional 10 percentage points more patients insured by Medicaid was significantly associated with a greater expected number of FV applications overall (IRR, 1.05; 95% CI, 1.02-1.09) and for visits paid by private insurance (IRR, 1.05; 95% CI, 1.01-1.09), with no significant association observed for visits paid by Medicaid (Figure 2, panel B).

Compared with pediatricians, family practice physicians had a lower expected number of FV applications per year for visits paid by private insurers (IRR, 0.64; 95% CI, 0.41-1.00), with no significant association observed overall or for visits paid by Medicaid. Female clinicians had a higher expected number of FV applications per year than male clinicians when examining all visits (IRR, 1.15; 95% CI, 1.04-1.28) and visits paid by Medicaid (IRR, 1.12; 95% CI, 1.01-1.25), with no significant association observed for visits paid by private insurance.

Among all clinicians, including those who did not apply FV in a year, the overall predicted number of FV applications per 100 WCVs paid by private insurance was 4.08 for a clinician with the 25th percentile of the share of Medicaid-insured patients and 12.17 for a clinician with the 75th percentile of the share of Medicaid-insured patients (75th vs 25th, P < .001). In the model restricted to visits paid by Medicaid, the predicted number of FV applications per 100 WCVs was 4.07 for a clinician with the 25th percentile of the share of Medicaid-insured patients and 12.50 for a clinician with the 75th percentile of the share of Medicaid-insured patients (75th vs 25th, P < .001). In the model restricted to visits paid by private insurance, the predicted number of FV applications per 100 WCVs was 3.69 for a clinician with the 25th percentile of the share of Medicaid-insured patients and 9.69 for a clinician with the 75th percentile of the share of Medicaid-insured patients (75th vs 25th, P < .001) (Figure 2, panel C).

Sensitivity Analysis

We conducted additional analyses without controlling for the percentage of a clinician’s patients aged 1 to 5 years (eAppendix Table). Findings were similar to the main analysis, with additional findings that family practice physicians and other physicians had significantly lower probabilities of applying FV and lower numbers of applications than pediatricians.

DISCUSSION

Applying FV during WCVs is critical for expanding access to preventive oral health services and improving children’s oral health.² Using medical claims from public and private payers in Massachusetts from 2016 to 2018, we found that pediatric primary care clinicians’ likelihood and intensity of FV applications were low in primary care settings. We also found clinicians’ patient-panel characteristics were strong predictors of a clinician’s application of FV.

Across all visits, regardless of payer, having a larger share of patients insured by Medicaid was associated with greater odds of applying FV. This finding is akin to evidence in the years before private insurers were required to cover FV applications in medical settings without patient cost sharing^7,10 and is similar to findings showing that children insured by Medicaid have higher rates of receiving FV applications during WCVs than children with private insurance.^4,18,19 The positive association observed between share of Medicaid-insured patients and FV applications may be explained by the duration of state Medicaid programs paying for FV and efforts toward expanding FV in medical offices primarily focused on children insured by Medicaid.^10,20,21 Thus, clinicians with more patients insured by Medicaid may have established infrastructure for this service. Further, some clinical guidelines suggest FV applications during medical visits for children at high risk of dental caries,²² which typically includes children insured by Medicaid due to their comparatively low rates of dental visits and high rates of unmet needs.²³

Additionally, we found that having a larger share of patients aged 1 to 5 years was associated with greater odds of a clinician applying FV. Clinicians with a larger share of patients aged 1 to 5 years may be more likely to be aware of this recommended service and be more willing to integrate FV into their routine practice. In the sensitivity analysis, which did not control for the share of a clinician’s patients aged 1 to 5 years, we observed differences by training in the odds of applying FV and intensity. Because we did not observe associations related to training when controlling for a clinician’s share of patients aged 1 to 5 years, this suggests clinician behavior is more likely explained by patient-panel characteristics (ie, share of patients recommended to receive FV) than differences in training.

Although recent studies have shown increasing trends in both children’s receipt of and medical clinicians’ provision of FV over time,^4,24 the overall low likelihood and intensity of FV application among pediatric primary care clinicians remains a public health challenge. Only 30.9% of medical clinicians provided FV at least once, and only about 8 in 100 WCVs included FV applications in a year. Given these low rates, identifying clinician and patient-panel characteristics associated with FV application is critical to the development and implementation of solutions. A 2018 AAP survey reported similarly low rates of FV applications, reporting that only 17% of surveyed pediatricians applied or had their staff apply FV during most visits for children 3 years or younger.⁷ Findings from that survey and other recent research suggest that lack of professional training in oral health care and inadequate time during health supervision visits may explain the low rates of FV application even though it is recommended by clinical guidelines and covered by most health insurers.^5,25-27 Additionally, clinical guidelines differ in periodicity and eligibility of receiving FV in medical settings,²² which may contribute to low FV application rates. For example, the AAP’s clinical report and visit guide recommend considering whether a child has a usual source of dental care; other guidelines do not.^22,28,29 Primary care clinicians may not apply FV to children who visit dentists, lowering overall rates of providing FV.

Limitations

This study has several limitations. First, we examined only FV applications in medical offices. Other patient-panel characteristics (eg, percentage of patients receiving FV in dental settings) may also affect clinicians’ decisions about applying FV. Future research is needed to examine the provision of FV for children with usual sources of dental care. Second, we did not examine FV applications during other types of visits (eg, sick visits). However, few FV claims occurred outside WCVs (4.6%, authors’ analysis). Third, our analysis focused on characteristics of the clinician who provided the WCV. It is possible that different clinicians provide WCVs and FV for a child on the same day; nevertheless, we observed and excluded only 2.4% of FV claims that had a different NPI from the clinician who provided the WCV. Fourth, we focused on the behavior of individual clinicians and thus excluded claims with an organization NPI, such as federally qualified health centers—significant providers of FV.^25,30 Future research should explore factors associated with FV applications by organizations. Fifth, our study is specific to Massachusetts and caution should be taken when attempting to generalize these results to other states. Finally, starting in 2016, self-insured plans were not required to submit data to the APCD due to a Supreme Court ruling.¹² Hence, visits paid by private insurers are underrepresented in our sample. We addressed this concern by examining visits by payer.

CONCLUSIONS

Despite clinical recommendations and mandated insurance coverage, fewer than 1 in 3 primary care pediatric clinicians applied FV. Clinicians who provided this service rarely applied it during a large proportion of WCVs for young children. Characteristics of a clinician’s patient panel were associated with both the likelihood of ever applying FV and the intensity of providing this service. Our study findings highlight the need for targeted interventions to address children’s oral health in medical settings.

Author Affiliations: RAND Corporation (KL, AMK), Arlington, VA; George Washington University Milken Institute School of Public Health (KL), Washington, DC; Duke Margolis Institute for Health Policy (KL), Washington, DC; RAND Corporation (AYAC, AWD), Boston, MA; University of Massachusetts Chan Medical School (KHG), Springfield, MA.

Source of Funding: This research was supported by the National Institute of Dental and Craniofacial Research (NIDCR; grant No. R01 DE028530-03).

Author Disclosures: Drs Li and Geissler report payment from the NIDCR grant. Dr Kranz reports grants from Agency for Healthcare Research and Quality and NIDCR and a pending grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (KL, KHG, AWD, AMK); acquisition of data (AWD, AMK); analysis and interpretation of data (KL, AYAC, KHG, AWD, AMK); drafting of the manuscript (KL); critical revision of the manuscript for important intellectual content (AYAC, KHG, AWD, AMK); statistical analysis (KL, AWD); obtaining funding (KHG, AWD); administrative, technical, or logistic support (AYAC); and supervision (AMK).

Address Correspondence to: Kun Li, PhD, RAND Corporation, 1200 S Hayes St, Arlington, VA 22202. Email: kun.li@duke.edu.

REFERENCES

1. Moyer VA; US Preventive Services Task Force. Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement. Pediatrics. 2014;133(6):1102-1111. doi:10.1542/peds.2014-0483

2. Manski R, Rohde F, Ricks T, Chalmers NI. Statistical brief 544: number and percentage of the population with any dental or medical visits by insurance coverage and geographic area, 2019. Agency for Healthcare Research and Quality. October 2022. Accessed January 27, 2023. https://www.meps.ahrq.gov/data_files/publications/st544/stat544.shtml

3. Recommendations for preventive pediatric health care: periodicity schedule. American Academy of Pediatrics. Updated April 2023. Accessed October 25, 2022. https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf

4. Chen AY, Geissler KH, Dick AW, Goff S, Kranz AM. Association between insurance type and fluoride varnish application during well-child visits in Massachusetts. Acad Pediatr. 2023;23(6):1213-1219. doi:10.1016/j.acap.2023.05.003

5. Lewis C, Quinonez R, Sisk B, et al. Incorporating oral health into pediatric practice: national trends 2008, 2012, 2018. Acad Pediatr. 2022;22(8):1443-1451. doi:10.1016/j.acap.2022.06.008

6. Kim P, Daly JM, Berkowitz S, Levy BT. Use of the fluoride varnish billing code in a tertiary care center setting. J Prim Care Community Health. 2020;11:2150132720913736. doi:10.1177/2150132720913736

7. Lewis C, Lynch H, Richardson L. Fluoride varnish use in primary care: what do providers think? Pediatrics. 2005;115(1):e69-e76. doi:10.1542/peds.2004-1330

8. Slade GD, Rozier RG, Zeldin LP, Margolis PA. Training pediatric health care providers in prevention of dental decay: results from a randomized controlled trial. BMC Health Serv Res. 2007;7:176. doi:10.1186/1472-6963-7-176

9. Quinonez RB, Kranz AM, Lewis CW, et al. Oral health opinions and practices of pediatricians: updated results from a national survey. Acad Pediatr. 2014;14(6):616-623. doi:10.1016/j.acap.2014.07.001

10. Sams LD, Rozier RG, Wilder RS, Quinonez RB. Adoption and implementation of policies to support preventive dentistry initiatives for physicians: a national survey of Medicaid programs. Am J Public Health. 2013;103(8):e83-e90. doi:10.2105/AJPH.2012.301138

11. Preventive care benefits for children. CMS. Accessed October 4, 2021. https://www.healthcare.gov/preventive-care-children/

12. Massachusetts All-Payer Claims Database (MA APCD) Release 8.0: 2014-2018 Documentation Guide. Center for Health Information Analysis. February 2020. Accessed July 18, 2022. https://www.chiamass.gov/assets/docs/p/apcd/apcd-8.0/APCD-Release-8-Documentation-Guide.pdf

13. National Plan and Provider Enumeration System NPI Files. CMS. https://download.cms.gov/nppes/NPI_Files.html

14. Bindman AB. Using the National Provider Identifier for health care workforce evaluation. Medicare Medicaid Res Rev. 2013;3(3):mmrr.003.03.b03. doi:10.5600/mmrr.003.03.b03

15. Bell N, Lòpez-DeFede A, Wilkerson RC, Mayfield-Smith K. Precision of provider licensure data for mapping member accessibility to Medicaid managed care provider networks. BMC Health Serv Res. 2018;18(1):974. doi:10.1186/s12913-018-3776-4

16. Oral health coding fact sheet for primary care physicians. American Academy of Pediatrics. October 25, 2022. Accessed October 25, 2022. https://downloads.aap.org/AAP/PDF/coding_factsheet_oral_health.pdf

17. Kranz AM, Goff SL, Dick AW, Whaley C, Geissler KH. Delivery of fluoride varnish during pediatric medical visits by rurality. J Public Health Dent. 2022;82(3):271-279. doi:10.1111/jphd.12518

18. Geiger CK, Kranz AM, Dick AW, Duffy E, Sorbero M, Stein BD. Delivery of preventive oral health services by rurality: a cross-sectional analysis. J Rural Health. 2019;35(1):3-11. doi:10.1111/jrh.12340

19. Geissler KH, Dick AW, Goff SL, Whaley C, Kranz AM. Dental fluoride varnish application during medical visits among children who are privately insured. JAMA Netw Open. 2021;4(8):e2122953. doi:10.1001/jamanetworkopen.2021.22953

20. Advancing prevention and reducing childhood caries in Medicaid and CHIP affinity group. CMS. Accessed January 23, 2023. https://www.medicaid.gov/medicaid/quality-of-care/downloads/oral-health-AG-factsheet.pdf

21. Silk H, Sachs Leicher E, Alvarado V, Cote E, Cote S. A multi-state initiative to implement pediatric oral health in primary care practice and clinical education. J Public Health Dent. 2018;78(1):25-31. doi:10.1111/jphd.12225

22. Goff SL, Gahlon G, Geissler KH, Dick AW, Kranz AM. Variation in current guidelines for fluoride varnish application for young children in medical settings in the United States. Front Public Health. 2022:10:785296. doi:10.3389/fpubh.2022.785296

23. Shariff JA, Edelstein BL. Medicaid meets its equal access requirement for dental care, but oral health disparities remain. Health Aff (Millwood). 2016;35(12):2259-2267. doi:10.1377/hlthaff.2016.0583

24. Gracner T, Kranz AM, Li K, Dick AW, Geissler K. The Patient Protection and Affordable Care Act and pediatric medical clinicians’ application of fluoride varnish. JAMA Netw Open. 2023;6(11):e2343087. doi:10.1001/jamanetworkopen.2023.43087

25. Bernstein J, Gebel C, Vargas C, et al. Integration of oral health into the well-child visit at federally qualified health centers: study of 6 clinics, August 2014-March 2015. Prev Chronic Dis. 2016;13:E58. doi:10.5888/pcd13.160066

26. Goff SL, Gilson CF, Decou E, et al. Barriers and facilitators to optimal fluoride varnish application. Acad Pediatr. 2023;S1876-2859(23)00371-6. doi:10.1016/j.acap.2023.09.018

27. Herndon JB, Tomar SL, Catalanotto FA. Effect of training pediatricians and family physicians in early childhood caries prevention. J Pediatr. 2015;166(4):1055-1061.e1. doi:10.1016/j.jpeds.2014.12.040

28. Clark MB, Keels MA, Slayton RL; Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2020;146(6): e2020034637. doi:10.1542/peds.2020-034637

29. Bright Futures: guidelines for health supervision of infants, children and adolescents, 4th edition. American Academy of Pediatrics. Accessed April 9, 2023. https://www.aap.org/en/practice-management/bright-futures/bright-futures-materials-and-tools/bright-futures-guidelines-and-pocket-guide/

30. Zea A, Henshaw M. Promoting children’s health equity with medical-dental integration. AMA J Ethics. 2022;24(1):E33-40. doi:10.1001/amajethics.2022.33