Barriers and Facilitators to Topical Fluoride Varnish Application in Well-Child Visits

Dental caries is the most common chronic childhood disease in the United States. Topical fluoride varnish (TFV) is a simple evidence-based preventive procedure shown to reduce early childhood caries and is approved for the primary care setting; however, rates of TFV application nationally are low. Less than 10% of eligible children received TFV at 1 academic family medicine group during well-child visits. This study assessed the clinician-reported barriers and facilitators to TFV application in that group to inform quality improvement efforts.

Using an exploratory sequential design, we developed a 29-item survey assessing knowledge, attitudes, and perceived barriers and facilitators to TFV application. The survey was distributed to outpatient family medicine practice clinicians in a mid-Atlantic academic health center in July 2020. Data were analyzed by univariate descriptive statistics.

Of 163 eligible clinicians, 93 (57%) completed the survey, including 60 MD/DO attending physicians, 12 advanced practice clinicians (5 physician assistants, 7 nurse practitioners), and 21 resident physicians. The most frequently reported facilitator was having TFV supplies preplaced in the examination room (92%), followed by nursing staff providing patient education (84%). The most frequently reported barrier was time constraints (61%), followed by the belief that dentists already provide TFV (47%). Advanced practice clinicians expressed a greater need for hands-on training, while residents prioritized refreshers on eligibility and billing. Attending physicians were more likely to report insufficient time for parent education as a barrier.

The study highlights key workflow and education-related barriers affecting TFV application in family medicine. Strategies such as interprofessional workflow optimization, previsit planning, and enhanced EHR documentation may address these barriers. Findings support the need for quality improvement initiatives to integrate TFV more effectively into routine pediatric preventive care, ultimately improving early childhood caries prevention.Knowledge Transfer Statement:Despite recommendations for topical fluoride varnish in primary medical care, application rates remain low due to time constraints, workflow inefficiencies, and unclear clinician roles. This study identifies key barriers and facilitators, highlighting the need for team-based workflows, previsit planning, electronic health record enhancements, and targeted training. Findings can inform quality improvement initiatives to streamline topical fluoride varnish application, optimize interprofessional collaboration, and enhance early childhood caries prevention in primary medical care settings.