Starting July 1, certified medical assistants will now be allowed to apply fluoride varnish to young children at well-child doctors’ visits, thanks to a collaboration between physicians, dentists, nurses, and a Virginia advocacy group.

In 2018, the Delta Dental of Virginia Foundation awarded the Virginia Tech Carilion School of Medicine $100,000 to start a new pilot program to promote integrated oral health care exams and fluoride varnishing for young children in local doctors’ offices.

“Many people don't realize that early childhood caries is the number one chronic disease in kids,” said Tarin Schmidt-Dalton, associate dean for clinical science years 1-2 and family medicine physician with Carilion Clinic. Caries are tooth decay, also known as cavities. Guidelines advise for children to have fluoride applied at regular intervals starting at the onset of their first tooth eruption to help prevent caries.

Schmidt-Dalton teamed up with Brooke Crouch, who was the Virginia Department of Health’s oral health dental hygienist educator for Southwest Virginia. “We know that children are more likely to see a physician, before seeing a dentist, at that critical age of 1-3 years old, so it is imperative to have our medical staff integrate an oral exam and fluoride varnish into their well child visits,” Crouch said.

Schmidt-Dalton added, “Those providers are the ones that need to be educated and empowered to be able to prevent early childhood caries because many of our dental colleagues are not seeing children until they already have advanced disease.”

They developed a presentation and fluoride application training for other health care providers. The team not only trained medical students at VTCSOM and nursing students at Radford University Carilion, but also resident physicians, nursing staff, and health care providers at 19 practices in family medicine and pediatrics in the Carilion Clinic network.

Tarin Schmidt-Dalton and Brooke Crouch lead fluoride varnish application training
Tarin Schmidt-Dalton (left) and Brooke Crouch (right) lead a fluoride varnish training session with residents in the Department of Pediatrics at Carilion Clinic.

One thing that became apparent during training is that many practices used certified medical assistants in addition to nurses to support clinical care of patients. Mary Colette Carver, senior director of ambulatory nursing practice for Carilion Clinic’s Department of Family and Community Medicine, knew this would be a hurdle for implementation.

“We knew that medical assistants were not legally able to apply fluoride varnish,” Carver said. “That was a problem because they are about half of our clinical support staff in family medicine practices. We needed to bridge the gap.”

“The providers told us if their medical assistant that was hired to work with them is not able to do the varnishing, that would be the main barrier to be able to implement the procedure,” Schmidt-Dalton said.

The group decided to try to solve the problem and contacted the Virginia Health Catalyst, an advocacy group centered around promoting oral health, for help. “We reached out to Sarah Holland in Richmond, as she is well-connected and highly focused on dental health access issues. Sarah immediately took up the cause,” said Lee Jones, section chief of Carilion Clinic Dental Care and assistant professor of surgery at VTCSOM.

Holland, the organization’s CEO, worked with Del. Mark Sickles and Sen. George Barker to put legislation forth in the 2019 General Assembly to enable medical assistants to apply fluoride to children. The Virginia Dental Association and Virginia Dental Hygienist Association also supported the bill. It passed with broad support. “The fact that they recognized a barrier and, rather than try to work around it, they decided to try to change the barrier, is going to help a lot of people,” Holland said.

While the effort was based on a collaboration of health care and dental providers in Southwest Virginia, the new law has positive benefits for family medicine and pediatric clinics across the commonwealth.

“This was real nursing and physician advocacy at the grassroots,” said Carver. “We really did advocate for this important member of our workforce, it was the right thing to do in terms of professional support for the medical assistants and it was also in the best interest of our patients.”

“This was a one-of-a-kind example of collaboration and medical-dental integration, and I am proud to have been a part of it,” Crouch added.

Beyond the new law, Schmidt-Dalton said the interdisciplinary team has built a model of collaboration and training that other practices across Virginia and even the nation can implement to better serve their patients. “I believe we are leading the way with this, having developed a model that other communities can use and adapt,” Schmidt-Dalton said. The team was supposed to present their model and findings at the Virginia Academy of Family Physicians’ Annual Meeting this summer, but due to the pandemic, will now present at the 2021 annual meeting.