Fluoride varnish use in primary care: what do providers think?

OBJECTIVE A number of state Medicaid programs, including Washington, reimburse pediatricians and other pediatric health care providers to apply fluoride varnish, a caries preventive agent, to eligible patients' teeth. Little is known about the factors that encourage or impede diffusion of fluoride varnish into primary care physicians' (PCPs') offices. The objective of this study was to perform an in-depth case study of fluoride varnish diffusion in 12 pediatric, family medicine, and nurse practitioner offices that underwent fluoride varnish training. METHODS We conducted focus groups with providers and staff in 12 community-based medical practices that had undergone fluoride varnish training within the previous 18 months. Topics of discussion included how the office staff learned about and sought fluoride varnish training, the perceived role of PCPs in oral health, oral health problems within the practice, specific details about the training, and organizational and logistic factors that promoted or impeded adoption. Focus groups were audiotaped and professionally transcribed; content analyses of the transcripts were conducted by the 3 authors. RESULTS Three major themes emerged about the fluoride varnish diffusion process; these were preexisting factors, communication, and logistics. Within preexisting factors, PCPs learned about fluoride varnish through their involvement in public health-related activities and were influenced to participate in the training by their concerns for their patients' oral health and difficulty gaining access to professional dental care. Among communication factors identified as important were qualities of the training session and the communication that occurred within the practice about fluoride varnish. When staff were included in the fluoride varnish decision-making and planning process, the practice was more likely to be successful in implementing fluoride varnish. Logistic factors included systems used to identify and capture eligible patients for fluoride varnish application. Other important logistic factors that were considered included division of labor and timing of the fluoride varnish application during the visit. Access to dental care was a persistent theme throughout the focus group discussions that had an impact on the other 3 major themes. CONCLUSIONS Fluoride varnish can be adopted successfully into medical practice given PCP and staff commitment and openness, training that leaves participants motivated, appropriate systems, and resources for professional dental care referral. In addition, PCP involvement with fluoride varnish provided opportunities to discuss preventive oral health with families. Specific recommendations to encourage fluoride varnish diffusion in other settings are offered for program planners and PCP offices.