Guest Editorial: A Strategic Approach to Addressing Dental Caries
In addition to establishing a dental home and developing a comprehensive treatment plan, the introduction of silver diamine fluoride may be a game changer in the effort to reduce the prevalence of dental caries.
Dental caries remains one of the most common chronic preventable diseases of childhood. By age 5, 23% of United States children have a cavity in a primary tooth.1 This increases to six of 10 children by their 8th birthday. When it comes to permanent teeth, 14% of Americans will be affected by caries by age 8, with this rate increasing to 29% by age 11.1 Low income and minority populations tend to bear the brunt of the disease.2 The cost to the child includes potential pain, infection, lost school time, and, in rare cases, death. Families and society also incur losses due to lost productivity and treatment costs.
To avoid caries or catch the process at an early and easy-to-treat stage, the American Academy of Pediatric Dentistry (AAPD), American Academy of Pediatrics, and American Dental Association all recommend establishing a dental home by age 1.3 Every child deserves a great start in life, and oral health is an essential component of this. A dental home is defined by the AAPD as “the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated and family centered way.”3
ESTABLISHING A DENTAL HOME
One of the easiest ways to help patients and families establish an early dental home is to perform infant examinations. These can be one of the most rewarding parts of the day for the dental team. During the initial visit, it is common to perform a lap-to-lap examination to examine the dentition and oral structures. The lap-to-lap position ensures good visibility for the oral health professional, and also allows the parent/caregiver to see and comfort the child in a supportive manner. It is also important to review with parents/caregivers preventive information about at-home oral hygiene, as well as diet and inappropriate feeding habits.
INTERVENTIONS ACCORDING TO RISK LEVEL
Unfortunately, it is not uncommon to observe early decay—or worse—in an infant’s dentition. Depending on disease severity, a range of interventions is available. With minimal disease levels, the intervention might vary from improved hygiene and diet to more frequent fluoride applications. With more severe disease, the intervention typically involves some type of surgical intervention. Both will require changes at home to maintain low disease levels, and are dependent on the motivated, ongoing compliance of parents and caregivers.
Infants, young children, and individuals with special health care needs may be unable to tolerate treatment in normal clinic settings. For these populations, treatment potentially involves an advanced behavior management technique, such as sedation or general anesthesia. Generally, sedation and general anesthesia are safe procedures, but risks increase for children younger than age 2 and individuals with underlying medical concerns. As part of the informed consent process, the risks and benefits for all options, including appropriate treatment settings— from least to most invasive—must be discussed with the family. Oral health professionals should also enlist parents/caregivers as partners with the treatment team in modifying behaviors that contribute to disease in the home setting.
NEW ADDITION TO THE CARIES ARMAMENTARIUM
One option that may allow deferral of definitive treatment until a child is able to tolerate it in a normal clinic setting is silver diamine fluoride (SDF). Although various formulations have been used in other parts of the world for more than 70 years, 38% SDF has been approved for use in the US by the federal Food and Drug Administration (FDA) for treating dentinal hypersensitivity. In addition, SDF is used “off label” for managing caries. However, the FDA has granted “breakthrough therapy designation” to SDF 38% for the arrest of dental caries. It is the first such drug to receive designation for the purpose of arresting caries and is the first oral care medicine to be distinguished by the FDA as a breakthrough therapy. The breakthrough therapy designation represents the FDA’s effort to expedite the development and review of drugs that are intended to treat a serious condition; it is granted when preliminary clinical evidence indicates the drug may demonstrate substantial improvement over available therapies.
In September 2017, the AAPD published its first evidenced-based dentistry guideline on the use of SDF.4 The AAPD’s evidence-based dentistry workgroup was extremely thorough in its evaluation of published literature, and research studies were required to meet high standards in order to be included. Due to the limited number of evidenced-based dentistryquality studies available, the AAPD’s SDF guideline was issued as a conditional recommendation for use. As the body of evidenced-based dentistry-quality research grows, the guideline’s recommendations are expected to strengthen.
The guideline determined that the evidence indicates SDF works, and that its benefits outweigh the possible side effects. In the available studies, SDF was shown to arrest active decay with a 76% success rate. This is a painless, relatively inexpensive material that halts the disease process and does not require a great deal of patient cooperation to apply. That noted, SDF requires reevaluation and reapplication in nonrestored teeth at set intervals to maintain an arrested state of decay.
No significant adverse effects or toxicity were noted in the studies that met evidence-based dentistry criteria. By its nature, SDF turns cavitated and decalcified portions of teeth hard and black as the lesions arrest and the silver oxidizes. Although unesthetic, the arrested areas can be restored to improve appearance when appropriate. As SDF has a bitter metallic taste, there is no contraindication for patients to resume normal diets after application. Adjacent tissues may discolor, but the tissue stain is temporary and usually returns to normal appearance within 2 days to 14 days. Spills on countertops or clothing may be permanent if not cleaned immediately.
This agent is not appropriate for all teeth with caries, and should only be used for caries management as part of a comprehensive treatment plan. In a minimally cooperative child or individual with special health care needs, SDF may be used to delay treatment until definitive care is appropriate. This may mean delaying treatment for an infant or toddler until the patient matures such that he or she can receive care in a conventional clinic setting. For a child who has medically complex or special health care needs, SDF may halt the decay process until definitive care can be delivered in a hospital setting under general anesthesia. Contra indications for SDF include teeth that are abscessed, have pulp exposures, or otherwise present a poor prognosis. In addition, SDF should not be used in patients with an allergy to silver compounds.
Since the creation of CDT Code D1354 (Interim Caries Arresting Medicament Application), 19 states5 have approved SDF coverage as part of their medical assistance dental programs. Additional states are now evaluating coverage, and it is likely reimbursement by commercial insurance carriers will also grow with increased research and practitioner adoption. Providers should check with their state dental boards to determine who may apply SDF (eg, a dental hygienist under general supervision).
Establishing a dental home is an important step in promoting lifelong oral health. In addition, SDF has the potential to significantly impact caries management and treatment. Traditional approaches to caries control can be frustrating and rely on patient compliance and behavior modification. While not appropriate for all situations, SDF is a tool that can halt the caries process and provide another therapeutic option as part of the dental home and a comprehensive treatment plan.
To read the American Academy of Pediatric Dentistry’s silver diamine fluoride usage guidelines and for information on additional clinical guidelines, best practices, and other policies, visit aapd.org.
- National Center for Health Statistics. Dental Caries and Sealant Prevalence in Children and Adolescents in the United States, 2011–2012. Available at: cdc.gov/nchs/data/databriefs/db191.htm. Accessed January 3, 2018.
- Welcome to America’s Children: Key National Indicators of Well-Being. Available at: childstats.gov. Accessed January 3, 2018.
- American Academy of Pediatric Dentistry. Definition of Dental Home. Available at: aapd.org/media/Policies_Guidelines/D_DentalHome.pdf. Accessed January 3, 2018.
- Crystal YO, Marghalani AA, Ureles SD, et al. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Pediatr Dent. 2017;39:E135–E145.
- American Academy of Pediatric Dentistry Pediatric Oral Health Research and Policy Center. Are Your Kids Covered? Medicaid Coverage for the Essential Oral Health Benefits, September 2017. Available at: aapd.org/policy_center/technical_briefs/. Accessed January 3, 2018.
From Dimensions of Dental Hygiene. February 2018;16(2):16-17.