WIC Fluoride Varnish Program

State: FL Type: Promising Practice Year: 2019

Broward County is the second most populous county in Florida, 17th most populous in the United States, with almost 1.9 million people and 10% of Florida's residents. We are home to an international airport, ranked 19th in the U.S. in total passenger traffic and a sea port, which is the cruise ship capital of the world. 15.4 million visitors visit our beautiful beaches each year. However, there is more to Broward County. We are a majority/minority community. Our population is 37% White, 30% Black, and 30% Hispanic of any race (U.S. Census). One-third of our residents are foreign born. Nearly 15% of the residents are living below the poverty level; and 20 % of children under age 18 are living in poverty. South Florida continues to be the most cost-burdened metro region in the nation, with over half of Broward residents spending more than 30% of their monthly income on housing expenses. Fort Lauderdale, the county-seat, ranks 10th nationwide on a list of most cost-burden communities. Broward County Public Schools (BCPS) is the sixth largest public-school system in the United States. Students are from 204 different countries and speak 191 different languages.

The Florida Department of Health in Broward County (DOH-Broward) is the primary providers for Women, Infants, and Children (WIC) services in the county. The DOH-Broward Dental Program operates a Fluoride Varnish Program at each of the seven WIC sites in Broward County, Florida. Each site has a registered dental hygienist to perform an assessment, oral hygiene instructions, and fluoride varnish on any individual under the age of twenty-one in conjunction with WIC services. The program promotes a single point of access for nutrition and dental care. Implementing the Fluoride Varnish Program at WIC increases access to dental care and offers a dental home for those in need. DOH-Broward's goal is to educate the caregiver on proper oral health care, good nutrition plus provide the resources necessary to prevent dental caries in young children. The goal is to provide early intervention in preventing early childhood caries (ECC) and to provide early access to oral health care to families served by the WIC Program.

This program is a community based initiative that is geared to preventing dental disease along with identifying high risk patients in the population that may not have access to dental care. Early childhood caries is one of the most common preventable chronic childhood diseases among the underserved community. Our goal is to assist the underserved population in the community by offering high risk patients a dental home. Our objectives are to provide early access to oral health care, conduct an oral health assessments, offer oral health and nutritional education, apply fluoride varnish, identify high risk patients and provide dental referrals when needed. For children, tooth decay is an infectious disease that is preventable. Healthy primary baby teeth are essential for overall development and quality of life.

The WIC Fluoride Varnish Program began as a pilot program in early 2017. In April 2017, a five-day trial was completed at one WIC location. During the trial, the dental hygienist provided services to 236 children in conjunction with the WIC visit. Due to the overwhelming success of the program, the program was expanded to all seven WIC sites in Broward county. Each site has a full time registered dental hygienist providing community with dental assessments, oral hygiene instructions, and fluoride varnish. WIC staff play a crucial role in making the fluoride program successful by incorporating fluoride varnish as an added service to the WIC appointment. WIC's support in promoting the program is an instrumental factor for the growth of the program.

Since the start of the program in April 2017 through November 6, 2018, 46,244 children have seen a dental hygienist during their WIC appointment. This program seeks to promote awareness for the importance of oral health along with finding a dental home for those in need. As the program continues to serve more children the objectives grow as well. The dental hygienists want to serve as many children as possible and provide guidance to the parents and those in need of a dental home. Finding a dental home is one of the most important aspects of the program. By providing a dental home, our hope is to decrease the number of children with dental caries and dental emergencies in the community which will increase their overall quality of life.

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There is an increasing number of children who have tooth decay which leads to dental caries; a preventable infectious disease. DOH-Broward WIC-Fluoride Program goals are to identify the high-risk clients, provide early intervention, and provide a dental home to those in need.

The target population is anyone under the age of twenty-one who is part of the WIC program. We strive to give Broward County families easier access to care and a dental home to prevent any future dental emergencies. 

The estimated eligible WIC population in Broward County is 58,751 individuals. From July 2017 through June 2018, Broward County WIC program served 35,656 infants and children. Of these infants and children, the Fluoride Varnish Program has served 17,315 infants and children in the same year or 48% of WIC population served. Our objectives is to continue to provide fluoride varnish as part of the WIC process which will help increase access to care and oral health awareness to children served by the WIC program.

When scheduling a WIC services appointment, parents are encouraged to bring their children so dental care may be incorporated with the WIC visit. With this program, the dental hygienists can focus on families that come to WIC for services. This relationship with WIC is significant regarding the patients that we see. The WIC staff are trained to promote the services dental hygienists offer clients. With the WIC program staff's assistance, staff can promote the program to the parents and children that come in for their regular WIC appointments.

Many parents are unaware of the dental services offered by the Department of Health. By serving this community, the WIC staff and the dental hygienists provide early intervention with a dental assessment and education. This relationship connects the families that are part of the WIC program, Fluoride Varnish program, and the children's dental clinics. By being part of the WIC process the dental hygienists can reach many parents and children to offer dental assessments, fluoride varnish, oral hygiene instructions, and dental referrals when needed.

This program is not new to public health or to Florida, however due to the size of our population the Fluoride Varnish Program can serve a large community. The fluoride varnish program is being done in other states as well as other counties in the state of Florida. Currently, this program can serve a population that was not being met before.

This practice is evidence based and addresses Healthy People 2020 goal, Prevent and control oral and craniofacial diseases, conditions, and injuries, and improve access to preventive services and dental care.” in 2018 through the Broward County Community Health Assessment, the Priorities identified for the Community Health Improvement Plan, include:  1) Increase Access to Health Services, 2) Reduce the Incidence of Communicable and Infectious Diseases, 3) Improve Maternal, Infant and Child Health, and 4) Enhance Preventive Care Activities.  Significant challenges for Broward County include access to primary care, racism and health equity, safe and affordable housing and our senior population.  Our cultural diversity is both a strength and a challenge.  To address these issues, we partner across the public and private sector to improve our community and view challenges and solutions through a health equity lens. 

The DOH-Broward WIC Fluoride Varnish Program is geared to serve all the clients at WIC sites under the age of twenty-one. Currently, there are seven WIC sites in Broward County with an assigned full time dental hygienist. Children with early childhood caries and dental disease is a concern in the community. Our goal is to reduce the number of children with dental caries, offer a dental home to those in need, and provide them with the necessary resources, education, and information on how to prevent dental caries. Providing early intervention is a key factor in reaching our goal. Also, the dental hygienists provide the parent or legal guardian with information on access to care and a dental home.

The support of the WIC staff has played an instrumental role in helping the fluoride program.  To implement the program at seven WIC sites, the administration of Dental and WIC needed to create a team effort in bringing the program to all seven sites. A site assessment was completed for each site needed to ensure adequate space for equipment, supplies, and storage available for the dental hygienists.  Once space was allocated, supplies and equipment were set up prior to the dental hygienist starting. The dental hygienists and the WIC staff were training on the new process of having WIC clients see a dental hygienist.  Each WIC site holds a monthly meeting with dental hygienists and WIC staff sharing information to improve performance and capacity. The ongoing support of the WIC staff is continuously needed for the dental hygienists to serve as many children as possible. Both the dental hygienists and the WIC staff keep open line of communication to ensure a successful team effort.

As the program developed, administration needed to assess the cost of the program. The dental hygienists receive an hourly rate of $30 per hour along with health insurance benefits. The cost of supplies per child is an average of three dollars, this includes a goody bag filled with a toothbrush, toothpaste, floss, a dental practice flyer, and a sticker. Some of the other supplies include fluoride varnish, personal protective equipment, and forms.  Startup costs were minimal as existing space was utilized and dental hygienists from other programs staffed the WIC Fluoride program. Community stakeholder involvement includes promoting the program at Community Outreach events and community meetings.

The objectives of the WIC fluoride program include early intervention for oral health care, provide a dental home for those in need, access to oral health care, identify high risk clients with dental assessments, and provide oral health education to the child's caregiver. Many of the children that are seen in the Fluoride Varnish program do not have access to routine dental care. Our priority is educating the parent on routine dental visits to prevent dental disease. The program is set out to create an awareness of the importance of oral health care. The dental hygienists are the primary source for collecting data on the clients that are served. Each WIC site has productivity targets to ensure the maximum number of clients are served.

Evaluation of the process has resulted in program improvements. When the program began in 2017, the fluoride program was offered as an optional service to the child and/or parent. Today, the fluoride program is incorporated into the WIC visit if the parent has a child with them to ensure every child can be seen by the dental hygienist. This provides the opportunity to educate the parent or legal guardian on healthy habits, proper brushing and flossing, and offer guidance the parent and child may need, even if they do not want to do the fluoride service. In addition, each dental hygienist attends WIC monthly meeting to provide the WIC staff with data on their monthly number of children seen and the daily average of children seen per day. This time also allows for any questions or sharing of best practices from the WIC staff to be answered by the dental hygienist. Another modification implemented in the fluoride varnish program is giving the dental hygienists the opportunity to work on a Saturday that WIC is open since many of the sites are very busy during this time.

By implementing these changes, the fluoride varnish program strives to increase the number of children seen by a dental hygienist. This creates an awareness for the significance of oral health care along with providing a dental home for the families without one. The program is set out to provide access to care to these families. As the fluoride varnish program continues to grow, modifications will happen in order for the program to be successful.

There have been many lessons learned regarding sustainability. One of the most important factors is support by the WIC staff. Without the help and promotion by the WIC staff the dental hygienists would not see as many children as they are. There is always room for improvement. Creating the fluoride varnish program as part of the WIC process as opposed to an optional” service has increased the number of children seen. Even if some parents do not want to give the child the fluoride treatment, they still see the dental hygienist. This gives the parent a reminder of proper oral health instructions to follow along with creating a positive relationship between the client and the dental hygienist. Fluoride varnish application will help decrease the prevalence of dental caries in young children, however, we also want to remind the parent or legal guardian to keep oral health care as a priority.

Currently, the fluoride varnish program is sustainable due to the number of clients with Medicaid. With this program, Medicaid can be billed for an assessment, oral health instructions, and fluoride varnish.  By doing this, the program can pay for its expenses.  Roughly 80% of the clients served have Medicaid. Of this population, there is a 20%-25% denial rate. Also, there are many families who do not have any form of insurance. With the non-insured clients and the denied clients, the fluoride varnish program will never charge the family or send a bill home and will still provide the service for free.  Due to the low costs for program implementation and Senior Leadership support, the program is fully sustainable.

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