Fluoride Prescribing Behaviors for Medicaid-Enrolled Children in Oregon

Published:September 30, 2021DOI:


      This study aims to examine physician and dentist fluoride prescription patterns and identify the factors associated with fluoride prescriptions for Medicaid-enrolled children. The hypothesis is that dentists will be the primary prescribers of fluoride and that caries risk factors will be associated with fluoride prescriptions.


      Data were analyzed for Oregon children aged 0–17 years enrolled in Medicaid for ≥300 days in both 2016 and 2017. The outcome variable was receiving a fluoride prescription in 2017. A 2-tailed chi-square test was used to assess fluoride prescribing differences between physicians and dentists. Multivariable logistic regression models were used to examine the likelihood of receiving a fluoride prescription in 2017 and to generate ORs. Model covariates included child's age, sex, race, ethnicity, Medicaid plan type, previous fluoride prescription, previous restorative dental treatment, and water fluoridation status.


      Of 200,169 Medicaid-enrolled children, 6.7% (n=13,337) received fluoride prescriptions. Physicians were >3 times as likely to prescribe fluoride as dentists (73.4% vs 23.0%, p<0.001). Children with a history of fluoride prescriptions (OR=14.30, p<0.001) and any restorative dental treatment (OR=1.58, p<0.001) were significantly more likely to receive a fluoride prescription, whereas children living in areas with water fluoridation were significantly less likely (OR=0.50, p=0.01).


      Physicians play an important role in prescribing fluoride to Medicaid-enrolled children, especially those at increased dental caries risk. Additional research is needed on strategies to ensure that all high-risk children have an opportunity to benefit from prescription fluoride.
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        • Bernabe E
        • Marcenes W
        • et al.
        • GBD 2017 Oral Disorders Collaborators
        Global, regional, and national levels and trends in burden of oral conditions from 1990 to 2017: a systematic analysis for the Global Burden of Disease 2017 Study.
        J Dent Res. 2020; 99: 362-373
        • Herzog K
        • Scott J
        • Chi DL
        • Treadwell HM
        • Evans CA
        3. Children's Oral Health inequalities: intersectionality of race, ethnicity, and income.
        in: Treadwell HM Evans CA Oral Health in America: Removing the Stain of Disparity. APHA Press, Washington, DC2019: 15-24
        • Colak H
        • Dülgergil CT
        • Dalli M
        • Hamidi MM.
        Early childhood caries update: a review of causes, diagnoses, and treatments.
        J Nat Sci Biol Med. 2013; 4: 29-38
        • Chi DL
        • Masterson EE
        • Carle AC
        • Mancl LA
        • Coldwell SE.
        Socioeconomic status, food security, and dental Caries in U.S. children: mediation analyses of data from the National Health and Nutrition Examination Survey, 2007-2008.
        Am J Public Health. 2014; 104: 860-864
        • Muñoz-Millán P
        • Zaror C
        • Espinoza-Espinoza G
        • et al.
        Effectiveness of fluoride varnish in preventing early childhood caries in rural areas without access to fluoridated drinking water: a randomized control trial.
        Community Dent Oral Epidemiol. 2018; 46: 63-69
        • Kelly SE
        • Binkley CJ
        • Neace WP
        • Gale BS.
        Barriers to care-seeking for children's oral health among low-income caregivers.
        Am J Public Health. 2005; 95: 1345-1351
        • Badri P
        • Saltaji H
        • Flores-Mir C
        • Amin M.
        Factors affecting children's adherence to regular dental attendance: a systematic review.
        J Am Dent Assoc. 2014; 145: 817-828
        • Rozier RG
        • White BA
        • Slade GD.
        Trends in oral diseases in the U.S. population.
        J Dent Educ. 2017; 81: eS97-eS109
        • Rozier RG
        • Sutton BK
        • Bawden JW
        • Haupt K
        • Slade GD
        • King RS.
        Prevention of early childhood caries in North Carolina medical practices: implications for research and practice.
        J Dent Educ. 2003; 67: 876-885
        • Lewis C
        • Teeple E
        • Robertson A
        • Williams A.
        Preventive dental care for young, Medicaid-insured children in Washington State.
        Pediatrics. 2009; 124: e120-e127
        • Stearns SC
        • Rozier RG
        • Kranz AM
        • Pahel BT
        • Quiñonez RB.
        Cost-effectiveness of preventive oral health care in medical offices for young Medicaid enrollees.
        Arch Pediatr Adolesc Med. 2012; 166: 945-951
        • Kranz AM
        • Rozier RG
        • Preisser JS
        • Stearns SC
        • Weinberger M
        • Lee JY.
        Preventive services by medical and dental providers and treatment outcomes.
        J Dent Res. 2014; 93: 633-638
        • Lewis CW
        • Boulter S
        • Keels MA
        • et al.
        Oral health and pediatricians: results of a national survey.
        Acad Pediatr. 2009; 9: 457-461
        • 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: e83-e90
        • Weyant RJ
        • Tracy SL
        • Anselmo TT
        • et al.
        Topical fluoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic review.
        J Am Dent Assoc. 2013; 144 ([published correction appears in J Am Dent Assoc. 2013;144(12):1335]): 1279-1291
        • Rozier RG
        • Adair S
        • Graham F
        • et al.
        Evidence-based clinical recommendations on the prescription of dietary fluoride supplements for caries prevention: a report of the American Dental Association Council on Scientific Affairs.
        J Am Dent Assoc. 2010; 141: 1480-1489
      1. Screening and interventions to prevent dental caries in children younger than age 5 years. U.S. Preventive Services Task Force.
        Updated January 2, 2020
        • Clark MB
        • Slayton RL
        Section on Oral Health. Fluoride use in caries prevention in the primary care setting.
        Pediatr. 2014; 134: 626-633
        • Silk H
        • McCallum W
        Fluoride: the family physician's role.
        Am Fam Physician. 2015; 92: 174-179
        • Ly P
        • Hayes DK
        • Yamashiroya V
        • Turnure MM
        • Iwaishi LK.
        Knowledge and attitudes towards fluoride supplementation: a survey of pediatric medical and dental providers in the state of Hawai'i.
        Hawaii J Med Public Health. 2018; 77: 275-282
        • Roberts MW
        • Keels MA
        • Sharp MC
        • Lewis JL.
        Fluoride supplement prescribing and dental referral patterns among academic pediatricians.
        Pediatrics. 1998; 101: E6
        • Kuthy RA
        • McTigue DJ.
        Fluoride prescription practices of Ohio physicians.
        J Public Health Dent. 1987; 47: 172-176
        • Herndon JB
        • Tomar SL
        • Lossius MN
        • Catalanotto FA.
        Preventive oral health care in early childhood: knowledge, confidence, and practices of pediatricians and family physicians in Florida.
        J Pediatr. 2010; 157 (e10242): 1018-1024
      2. 2018 Fluoridation statistics. Centers for Disease Control and Prevention. Updated September 8, 2020. Accessed August 28, 2020.

        • Damiano P
        • Momany ET
        • Crall JJ.
        Determining dental utilization rates for children: an analysis of data from the Iowa Medicaid and SCHIP programs.
        J Public Health Dent. 2006; 66: 97-103
      3. NPPES NPI Registry. Centers for Medicare and Medicaid Services. Accessed July 21, 2020.

        • Fisher-Owens SA
        • Gansky SA
        • Platt LJ
        • et al.
        Influences on children's oral health: a conceptual model.
        Pediatrics. 2007; 120: e510-e520
        • DeVoe JE
        • Graham AS
        • Angier H
        • Baez A
        • Krois L.
        Obtaining health care services for low-income children: a hierarchy of needs.
        J Health Care Poor Underserved. 2008; 19: 1192-1211
      4. State ‘accountable care’ activity map. National Academy for State Health Policy. Accessed December 23, 2020.

      5. Coordinated care organizations (CCO). Oregon Health Authority, Oregon Health Plan. Accessed December 23, 2020.

      6. Coordinated care: the Oregon difference. Oregon Health Authority, Health Policy and Analytics. Accessed December 23, 2020.

        • Chi DL
        • Momany ET
        • Neff J
        • et al.
        Impact of chronic condition status and severity on dental utilization for Iowa Medicaid-enrolled children.
        Med Care. 2011; 49: 180-192
      7. My water's fluoride. Centers for Disease Control and Prevention. Accessed July 21, 2020.

      8. Oregon ZIP codes. Accessed July 21, 2020.

        • Barnard J
        • Meng XL.
        Applications of multiple imputation in medical studies: from AIDS to NHANES.
        Stat Methods Med Res. 1999; 8: 17-36
        • Bounthavong M
        • Watanabe JH
        • Sullivan KM.
        Approach to addressing missing data for electronic medical records and pharmacy claims data research.
        Pharmacotherapy. 2015; 35: 380-387
        • Janssen KJ
        • Donders AR
        • Harrell Jr, FE
        • et al.
        Missing covariate data in medical research: to impute is better than to ignore.
        J Clin Epidemiol. 2010; 63: 721-727
        • Jakobsen JC
        • Gluud C
        • Wetterslev J
        • Winkel P.
        When and how should multiple imputation be used for handling missing data in randomised clinical trials - a practical guide with flowcharts.
        BMC Med Res Methodol. 2017; 17: 162
        • Madley-Dowd P
        • Hughes R
        • Tilling K
        • Heron J.
        The proportion of missing data should not be used to guide decisions on multiple imputation.
        J Clin Epidemiol. 2019; 110: 63-73
        • Kranz AM
        • Preisser JS
        • Rozier RG.
        Effects of physician-based preventive oral health services on dental caries.
        Pediatrics. 2015; 136: 107-114
        • Narendran S
        • Chan JT
        • Turner SD
        • Keene HJ.
        Fluoride knowledge and prescription practices among dentists.
        J Dent Educ. 2006; 70: 956-964
        • Silk H
        • Kwok A.
        Addressing adolescent oral health: a review.
        Pediatr Rev. 2017; 38: 61-68
        • Sohn W
        • Ismail AI
        • Taichman LS.
        Caries risk-based fluoride supplementation for children.
        Pediatr Dent. 2007; 29: 23-31
        • Lynch RJ.
        The primary and mixed dentition, post-eruptive enamel maturation and dental caries: a review.
        Int Dent J. 2013; 63: 3-13
        • Pahel BT
        • Rozier RG
        • Stearns SC
        • Quiñonez RB.
        Effectiveness of preventive dental treatments by physicians for young Medicaid enrollees.
        Pediatrics. 2011; 127: e682-e689
        • Kobayashi M
        • Chi DL
        • Coldwell SE
        • Domoto P
        • Milgrom P.
        The effectiveness and estimated costs of the access to baby and child dentistry program in Washington State.
        J Am Dent Assoc. 2005; 136: 1257-1263
        • Irvine J
        • Holve S
        • Krol D
        • Schroth R.
        Early childhood caries in Indigenous communities: a joint statement with the American Academy of Pediatrics.
        Paediatr Child Health. 2011; 16: 351-364
      9. Caries-risk assessment and management for infants, children, and adolescents.
        Pediatr Dent. 2017; 39: 197-204
        • Chi DL.
        Parent refusal of topical fluoride for their children: clinical strategies and future research priorities to improve evidence-based pediatric dental practice.
        Dent Clin North Am. 2017; 61: 607-617
        • Curiel JA
        • Slade GD
        • Christian TL
        • Lafferty-Hess S
        • Carsey TM
        • Sanders AE.
        Referendum opposition to fluoridation and health literacy: a cross-sectional analysis conducted in three large U.S. cities.
        BMJ Open. 2019; 9e022580
        • Kalenderian E
        • Ramoni RL
        • White JM
        • et al.
        The development of a dental diagnostic terminology.
        J Dent Educ. 2011; 75: 68-76