January 2018 Silver Diamine Fluoride History and Use Chronic Disease Management of Caries in Children Managing Caries With Silver JournaCALIFORNIA DENTAL ASSOCIATION Nitrate: Lessons Learned

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DEPARTMENTS

5 The Editor/Why We Change: Kirk vs. Spock

8 Letters to the Editor

9 Impressions

57 RM Matters/Re-treating Patients When an Associate Leaves

61 Regulatory Compliance/Cybersecurity Tips and News 9

66 Tech Trends

FEATURES 15 Silver Diamine Fluoride — The New Old: Part I An introduction to the issue. Paul Reggiardo, DDS, and Gregory J. Sabino, DDS, PhD

19 The History and Use of Silver Diamine Fluoride in Dentistry: A Review This article provides historical information on silver diamine fluoride and how after years of use in the developing world it has emerged as a successful alternative to invasive dental treatment in the United States. Elise Sarvas, DDS, MSD, MPH

23 Chronic Disease Management of Caries in Children and the Role of Silver Diamine Fluoride This article describes how chronic disease management can be introduced into contemporary clinical dental practice in which active and engaged dental providers can work as a team to support family behavior changes. Man Wai Ng, DDS, MPH, and Rosalyn Sulyanto, DMD, MS

37 Managing Caries in the Primary Dentition With Silver Nitrate: Lessons Learned From a Clinical Trial This manuscript reports on lessons learned from a randomized clinical trial comparing the medical management of carious lesions in the primary dentition using silver nitrate to conventional restorative treatment. Michael J. Kanellis, DDS, MS; Arwa I. Owais, BDS, MS; John J. Warren, DDS, MS; Deborah V. Dawson, BA, ScM, PhD; Alberto Gasparoni, DDS, MS, PhD; Reem R. Oweis, BDS, MS; Mary Akers, RDA; Derek Blanchette, BA, MS; Matthew K. Geneser, DDS; Wei Liu, BDS, MS; Mary C. Skotowski, BS, MS; and Karin Weber-Gasparoni, DDS, MS, PhD

45 Use of Silver Diamine Fluoride for Dental Caries Management in Children and Adolescents, Including Those With Special Health Care Needs This manuscript, reprinted from the American Academy of Pediatric Dentistry, presents evidence-based guidance on the use of 38% silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Yasmi O. Crystal, DMD, MSc; Abdullah A. Marghalani, BDS, MSD, DrPH; Steven D. Ureles, DMD, MS; John Timothy Wright, DMD, MS; Rosalyn Sulyanto, DMD, MS; Kimon Divaris, DDS, PhD; Margherita Fontana, DDS, PhD; and Laurel Graham, MLS

JANUARY 2018 3 CDA JOURNAL, VOL 46, Nº1

Volume 46, Number 1 JournaCALIFORNIA DENTAL ASSOCIATION January 2018 CDA Classifieds.

Free postings. published by the Editorial Production Manuscript California Kerry K. Carney, DDS, CDE Val B. Mina Submissions EDITOR-IN-CHIEF SENIOR GRAPHIC DESIGNER Priceless results. Dental Association www.editorialmanager. 1201 K St., 14th Floor [email protected] com/jcaldentassoc Sacramento, CA 95814 Randi Taylor SENIOR GRAPHIC DESIGNER 800.232.7645 Ruchi K. Sahota, DDS, CDE ASSOCIATE EDITOR Letters to the Editor cda.org Upcoming Topics www.editorialmanager. Brian K. Shue, DDS, CDE February/Silver Diamine com/jcaldentassoc CDA Offi cers ASSOCIATE EDITOR Fluoride Part II Natasha A. Lee, DDS PRESIDENT Gayle Mathe, RDH March/School-Based Subscriptions SENIOR EDITOR [email protected] Programs Subscriptions are available April/Endodontics only to active members of R. Del Brunner, DDS Paul Reggiardo, DDS the Association. The PRESIDENT-ELECT Gregory J. Sabino, DDS, PhD subscription rate is $18 and GUEST EDITORS [email protected] Advertising is included in membership Sue Gardner dues. Nonmembers can Richard J. Nagy, DDS Andrea LaMattina, CDE ADVERTISING SALES view the publication online VICE PRESIDENT PUBLICATIONS MANAGER [email protected] at cda.org/journal. [email protected] 916.554.4952 Kristi Parker Johnson Manage your subscription EDITORIAL SPECIALIST Judee Tippett-Whyte, DDS online: go to cda.org, log in SECRETARY Permission and and update any changes to [email protected] Blake Ellington Reprints your mailing information. TECH TRENDS EDITOR Andrea LaMattina, CDE Email questions or other Steven J. Kend, DDS PUBLICATIONS MANAGER changes to membership@ TREASURER Jack F. Conley, DDS [email protected] cda.org. EDITOR EMERITUS [email protected] 916.554.5950 CDA classifiedsclassifieds wworkork harder to Craig S. Yarborough, DDS, Robert E. Horseman, DDS bbringring you resuresults.lts. SeSellinglling a practice HUMORIST EMERITUS MBA or a piece ooff equipment? Now you SPEAKER OF THE HOUSE [email protected] can include photos to help buyers Stay Connected cda.org/journal Clelan G. Ehrler, DDS see the potential. IMMEDIATE PAST PRESIDENT [email protected] And if you’re hiring, candidates Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the anywhere can apply right from Management California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. Peter A. DuBois Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal the site. Looking for a job? You can EXECUTIVE DIRECTOR of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853. post that, too. And the best part— Jennifer George The California Dental Association holds the copyright for all articles and artwork published it’s free to all CDA members. CHIEF MARKETING OFFICER herein. The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff . Neither the editorial staff , the editor, nor the association are responsible for Carrie E. Gordon any expression of opinion or statement of fact, all of which are published solely on the authority All of these features are designed to CHIEF STRATEGY OFFICER of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition help you get the results you need, Alicia Malaby that they are contributed solely to the Journal. COMMUNICATIONS faster than ever. Check it out for Copyright 2018 by the California Dental Association. All rights reserved. DIRECTOR yourself at cda.org/classifieds.

4 JANUARY 2018 Editor CDA JOURNAL, VOL 46, Nº1

Why We Change: Kirk vs. Spock Kerry K. Carney, DDS, CDE

t seems simple enough: A new diagnosis and treatment recommendation is published, In the card game of private practice, for example the American one bad outcome trumps everything. Dental Association’s guidelines How does that work? Ion sealing noncavitated carious lesions. The evidence to support the recommendation is made public. The recommendation comes from an established and respected “Personal clinical experience This rationalization of an clinical and research source. The emerged as the determining factor in emotional preference is illustrated materials are readily available. dentists’ treatment decisions …”1 This in an elegant little marketing Then … nothing happens. is not hard to understand. Having a experiment. In the experiment, The recommended changes bad outcome after trying something subjects were shown a plump chicken are not incorporated into private new has chastened every dentist and a skinny chicken. The subjects practice. Practitioners continue out there. Surely, every dentist has were given the following alternate to behave in the same way they heard that tiny internal voice say, information about the chickens: either did before the recommendation’s “Well THAT did not work. I will the skinny chicken was the healthier release. What could be the problem? never do THAT again.” One bad choice or the skinny chicken was the What keeps us from changing our clinical experience seems to exert tastier choice. The results showed the treatment planning behavior? a powerful brake on innovation. subjects liked, or preferred, the plump There is an interesting In the card game of private chicken. They reported they had made examination of dentists’ behavior practice, one bad outcome trumps their decision because health was regarding implementation of clinical everything. How does that work? more important or, if they had been practice recommendations.1 The If there is a statistical chance given the opposite fact, because taste investigation attempted to look that a bad outcome will happen was more important. The subjects at what factors are in play when a one in 100 times, why does that used the facts they had been given to dentist in private practice considers one bad outcome weigh so heavily rationalize their emotional choice. changing his or her diagnostic when it happens to us? Probably This kind of emotion/logic and therapeutic behavior. it has something to do with the push-pull is part of every decision. The study was investigating the emotional aspect of decision-making. Captain Kirk can go charging determining factors in treatment Decision-making requires both around the galaxy because Mr. planning. It was not a rigorous random emotion and logic or rational thought. Spock gives him the logical basis controlled trial. The sample was small The two play off each other sort of to justify his emotional behavior. and qualitative. It was not designed like Star Trek’s Captain Kirk and Maybe the captain and his fi rst to test what variables determine an Mr. Spock. The emotional part of offi cer can illustrate what happens outcome. The results can only serve decision-making (Captain Kirk) when we choose not to change. to make us think about how we go gives us the impetus to choose. It is Most of us learned in dental about deciding to change. “Participants the gut feeling we rely on. It is what school that carious lesions are the compared their treatment plans makes us “feel” like the decision is enemy. They should be removed and with the ADA’s recommendations right. The logical side (Mr. Spock) the tooth restored. To leave infected for sealing noncavitated carious can act as a brake on the emotional tooth structure behind is tantamount lesions and they described drive to decide, but more often to setting a time bomb. Someday, barriers to implementing these it is used to bolster or rationalize the tooth will blow up and you will recommendations in their practices.”1 taking the emotional preference. be the cause of that patient’s pain

JANUARY 2018 5 JAN. 2018 EDITOR

CDA JOURNAL, VOL 46, Nº1

and extensive restorative need. That patient awareness and acceptance The Journal welcomes letters is an emotionally charged tenet. may be a barrier. The idea of treating We reserve the right to edit all The dentists in the sealant guideline carious lesions medically instead of communications. Letters should discuss an investigation may have found this surgically fl ies in the face of the same item published in the Journal within the last emotionally compelling tenet too long-cherished tenet of our profession. two months or matters of general interest strong for the logical evidence-based A colleague recently confessed to our readership. Letters must be no more challenge. They may have “raised that she was hesitant to employ SDF than 500 words and cite no more than fi ve shields” and rationalized their refusal in her practice because she was afraid references. No illustrations will be accepted. to embrace the new sealant guidelines. she might be accused of supervised Letters should be submitted at editorialmanager. They reported that they mistrusted the neglect. She is comfortable with the com/jcaldentassoc. By sending the letter, the evidence and did not see a reason to logical facts, the evidence base for place a sealant over that “dark occlusal the use of SDF in the literature and author certifi es that neither the letter nor one groove” when they could “clean it wants to change her diagnosis and with substantially similar content under the out” fi rst. They found the failure of treatment of some carious lesions writer’s authorship has been published or is being third-party payers to reimburse for the as a result. However, her emotional considered for publication elsewhere, and the procedure a barrier and called into fear of losing the respect of her peers author acknowledges and agrees that the letter question the sealant’s value. Patient or being judged by her patients as and all rights with regard to the letter become the lack of awareness and understanding providing substandard care keeps property of CDA. contributed to the dentists’ reluctance her from embracing change. to change. Finally, they looked to In a case like this, when Captain their peers for practice norms. Is the Kirk and Mr. Spock are in confl ict, standard they are applying consistent it can help to relocate the emotional with their peers or out of step? target. If the emotional priority resides This last sentiment clearly in the patient and the patient’s oral underscores how the dentists relied health and welfare, then this confl ict on the emotional connection with can be reduced. The patient can be their peers to be able to override the informed and enlisted as a partner in emotional sway of the tenets they held. settling on the innovative treatment The study concludes by emphasizing decision. Then the patient is prepared that publishing evidence-based to advocate for the procedure and guidelines are not enough to make us the decision that he or she and the change immediately. “We are faced dentist agreed upon. In fact, if the with the challenge of overcoming dentist is able to combine the Kirk longstanding beliefs based primarily and Spock elements of decision- on personal clinical observations that making successfully, he or she just seem to contradict scientifi c evidence might fi nd that an innovative … we need to look for alternative treatment may boldly go where few ways to promote acceptance of EB clinical practice recommendations [evidenced-based] recommendations.”1 have gone before: into everyday This study was based on sealant private practice. (With apologies to guidelines but the same kinds of the memory of Gene Roddenberry barriers to acceptance are in place for and Trekkers everywhere.) ■ other innovations in oral health care. REFERENCE Silver diamine fl uoride (SDF) usage 1. O’Donnell JA, Modesto A, Oakley M, Polk DE, Valappil faces many of the same challenges. B, Spallek H. Sealants and dental caries: Insight into dentists’ behaviors regarding implementation of clinical The evidence may not be trusted. practice recommendations. J Am Dent Assoc 2013 Reimbursement may be a problem, Apr;144(4):e24–30.

6 JANUARY 2018 REASON NO.27

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November 2017

Low-Risk Mandibular Symphysis Grafts Oral Health and Nutrition Journa in Vietnam Asthmatic Therapy and Oral Health Study For the Love of Amalgam CALIFORNIA DENTAL ASSOCIATION

Dr. Shue’s editorial about dental U.S. (1833), but also to learn that it

Bradley S. Henson, DDS, PhD amalgam in the November 2017 issue was used in China in the early part of DENTAL STUDENT RESEARCH of the Journal was an informative the Tang Dynasty (AD 618–907), per and enjoyable essay. His style of Wikipedia. Gosh, paper, gunpowder, the smooth-reading prose was flavored compass, printing … and amalgam, too? by well-placed bits of humor. As to the two 40-year-old buccal pit I didn’t know there was an amalgams he still has, I’ll one-up him amalgam controversy during the with two of my existing amalgams from birth of the original California State 1952 … placed with a rubber dam.

Dental Association. I had to Google STEPHEN S . YUEN, DDS Crawcour “brother” to learn when CDA EDITOR, 1970–75 dental amalgam was introduced in the San Mateo, Calif.

More Amalgam Love I found Associate Editor Brian Shue’s editorial “How I Learned to Stop Worrying and Love Dental Amalgam” in the November Journal delightful and refreshing. I love amalgam, too, because I treated and saved many teeth with this durable material during a long professional life. I have also observed the long service life of teeth restored with amalgam by my colleagues. Despite multiple studies proving that patients are only exposed to a negligible and transient mercury vapor, to free delivery. the neurological safety of amalgam will be debated until the cows come home. In my private practice, I had a few What makes big savings on thousands of dental patients who requested amalgam over supplies even better? Zero shipping fees. Shop composite for health reasons, because the TDSC Marketplace and get your favorite they were aware of the estrogen-like products delivered right to your door. No fees, component in composites. Let’s keep no minimum order size, no hassle. remembering to educate our patients on what we learned in dental school: There is no such thing as a perfect dental material. Start shopping today at tdsc.com. DONNA B . HUROWITZ, DDS San Francisco

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8 JANUARY 2018 Impressions CDA JOURNAL, VOL 46, Nº1 Which Is Worse for Dentistry: Markets or Regulation? David W. Chambers, EdM, MBA, PhD During the past decade as dentistry has become more about appearance and cost, dentists’ incomes have stagnated and in some cases declined. If dentistry loses its unique status as a regulated professional monopoly, there is no certainty that either the free market or regulation will protect it. Here is the logic regarding markets. Even in the best of worlds, patients will never know enough about when to seek care or how to choose the best available options. Information asymmetry is part of the arrangement and it is cost-ineffective to attempt to entirely remove that barrier. Better quality care is necessarily more expensive. Put in negative terms, someone can always do it cheaper and worse. Thus there will always be a quality/price gap where patients are unable to recognize the whole value they receive for higher cost. Such The nub: gaps are not evident when buying a car or a meal in a restaurant because the consumer can see pretty much all of the benefi t. In 1. Markets are a fair means of oral health, quality is latent. Great skill may be needed in case exchanging known quantities — unanticipated complications arise and the best care reduces or price is known by patients, quality eliminates the signals of quality patients can judge for themselves. The market is a blunt instrument for reducing the quality/ of care is not. price gap. We cannot count on advertising to correct information 2. Regulation primarily benefi ts asymmetries. Because we cannot adequately evaluate quality, the gap will tend to be closed by offering lower quality at lower prices. organized special interest groups. We have home bleaching and home orthodontics. Corporate models 3. It is an open question whether of delivery emphasize volume and standardized treatment plans. The market aspect of dentistry is controlled by the Department professionalism can survive the of Consumer Affairs, not the profession. Licenses are granted changing forces of the market to construction fi rms, cosmetologists, social workers, dentists and regulation. and others to function as market entities. The standard is low on the grounds that more services are better for the public. A minimal standard is set for safety and customers are allowed to select the level of quality they can discern and afford. David W. Chambers, EdM, MBA, PhD, is a professor The alternative is regulation — a mixed blessing. It is expensive, of dental education at the University of the Pacifi c, Arthur sometimes produces unexpected or even paradoxical results and is A. Dugoni School of Dentistry, San Francisco, and the editor of the American College of Dentists. intended to benefi t one group at the expense of another. Dentistry, as a well-organized special interest group, has enjoyed monopoly status and consistently raised the minimal standard of care. Monopolistic regulation focuses on the high end of the quality/ price gap, holding up both and denying access to care for many. Historically, dentistry has balanced the market and regulatory mechanisms quite successfully. This has been possible because dentistry has been organized and the public has not. These conditions are changing. Many in the profession have started selling smiles instead of health, and that in dollar- denominated terms. New, well-organized interest groups are pushing for regulatory adjustments at exactly the time when membership in organized dentistry is dropping. ■

JANUARY 2018 9 JAN. 2018 IMPRESSIONS

CDA JOURNAL, VOL 46, Nº1

Comparison of dental X-rays from patients with and Osteocytes Are Major Source of RANKL without vitamin D deficiency. Left image shows a modern tooth with normal pulp horns; right is an A study conducted by a Tokyo Medical and Dental University research team archaeological tooth with chair-shaped pulp horns. demonstrated that osteocytes play a crucial role in orthodontic tooth movement (Credit: McMaster University) as the major source of receptor activator of nuclear factor−κB ligand (RANKL), a protein crucial to bone remodeling. The study was published in the journal Scientific Reports in November. Dental X-rays Reveal Hidden During orthodontic tooth movement, osteoclastic bone resorption is essential Vitamin D Defi ciency for alveolar bone remodeling. The differentiation of osteoclasts is regulated by RANKL, however, the source of RANKL in the periodontal tissue during Human teeth hold vital information orthodontic tooth movement was not identified. about vitamin D defi ciency, a serious The research team revealed that osteocytes mainly express RANKL and are but often hidden condition that the key to remodeling of the bone surrounding teeth during orthodontic tooth can now be identifi ed by a simple movement by first examining an orthodontic tooth movement model in which dental X-ray, according to research open coil springs were inserted between teeth of mice to move first molars. conducted by McMaster University Injection of a neutralizing antibody against RANKL reduced tooth movement. anthropologists Lori D’Ortenzio and To identify the cellular source of RANKL in periodontal tissue, they established Megan Brickley and published in the a novel method to fractionate cells in periodontal tissue. Notably, osteocytes were International Journal of Paleopathology. The researchers and their colleagues revealed to express much higher levels of RANKL compared with other had previously discovered that human periodontal tissue cells. teeth hold a detailed and permanent Physiological significance of osteocyte RANKL in vivo was confirmed record of serious vitamin D defi ciency, using osteocyte-specific RANKL deletion mice. Orthodontic tooth movement also known as rickets. That record takes was significantly suppressed in these mice with a decreased number of the form of microscopic deformities osteoclasts on the bone surface around the tooth where mechanical force was in dentin, the material that makes applied, thus demonstrating the role osteocytes up the mass of the tooth, and can be have as a major source of RANKL during extremely valuable for understanding orthodontic tooth movement. precisely when people, even those who Read more about this study in Scientific Reports lived centuries ago, were deprived of (2017); doi:10.1038/s41598-017-09326-7. sunlight, the main source of vitamin D. The record is preserved by enamel, which protects teeth from breaking down, unlike bones, which are subject to decay. The problem with looking for such helpful not only to their studies of pattern, and their examination of deformities is that a tooth must be cut archaeological teeth but to living both historic and current teeth proved open to read the patterns that form a people who may not realize they are that X-ray images are consistent and lifetime’s vitamin D record, and the suffering from vitamin D defi ciency. reliable indicators of prior defi ciency. supply of postmortem teeth available The pulp shape in a healthy Because the consequences of vitamin for study is limited. To avoid wasting person’s tooth resembles an arch D defi ciency can be severe, knowing who precious specimens, the researchers topped by two cat ears, while the has had a defi ciency can help identify looked for a way to isolate teeth for pulp shape of a person who has had people who may have ongoing issues in further study. By using X-rays to study a severe defi ciency of vitamin D is time to prevent worse damage. Learn the readily observable shapes of the asymmetrical and constricted. The more about this study in the International pulp horns, they found a consistent, anthropologists’ previous research Journal of Paleopathology (2017); doi. recognizable pattern that could prove had suggested such a recognizable org/10.1016/j.ijpp.2017.10.001.

10 JANUARY 2018 CDA JOURNAL, VOL 46, Nº1

Scanning transmission electron microscope image of Nanodiamonds Protect Root Canals, Aid Recovery detonation nanodiamond. People who undergo root canals may The fi ndings are a milestone for the use soon have a tiny but powerful ally that of nanodiamonds in humans, according could prevent infection after treatment. to a paper published in Proceedings of Researchers at the UCLA School of the National Academy of Sciences. Dentistry and the UCLA Henry Samueli Nanodiamonds are tiny particles made School of Engineering and Applied Science of carbon and are so small that millions of found in a clinical trial that nanodiamonds them could fi t on the head of a pin. They protected disinfected root canals after the resemble soccer balls but have facets like of drugs and imaging agents. Researchers nerve and pulp were removed, thereby actual diamonds. Those facets enable the found that combining nanodiamonds improving the likelihood of a full recovery. nanodiamonds to deliver a wide range with gutta percha, a material used to fi ll disinfected root canals, may enhance the gutta percha’s protective properties. “Harnessing the unique properties of nanodiamonds in the clinic may help Antimicrobial Gel Could Improve Root Canal Results scientists, doctors and dentists overcome An antimicrobial gel discovered and developed at the Indiana University key challenges that confront several School of Dentistry could improve the results of root canal treatments, according areas of health care, including improving to a study published in the Journal of Endodontics and the International lesion healing in oral health,” said Dean Endodontic Journal. Ho, MS, PhD, professor of oral biology More than 15 million root canals are done each year, according to the and medicine in the dental school and American Association of Endodontists. During the procedure, the tooth’s pulp and co-corresponding author of the study. nerve are removed before the tooth is cleaned and sealed. If bacteria, viruses or The researchers tested nanodiamond- yeasts contaminate the tooth, another root canal procedure or surgery must be done. embedded gutta percha (NDGP) in three people who were undergoing root canal Ghaeth H. Yassen, BDS, MSD, PhD, a visiting assistant professor at the procedures. Tests of the implanted material university, developed the injectable antimicrobial gel, which can disinfect a tooth confi rmed that the NDGP was more during a root canal procedure. resistant to buckling and breaking than “I wanted to create a gel that provides sustained antimicrobial properties conventional gutta percha. All three patients even when it is removed. I also wanted it to have minimal toxic effect on stem cells healed properly, without unusual pain and and not cause tooth discoloration,” Dr. Yassen said. “Creating an antimicrobial without infection. Using NDGP for the space is especially important during clinical regenerative endodontic procedures.” procedures did not require changes to any The gel has advantages over traditional medications such as calcium of the standard procedures for root canals. hydroxide, which is widely used as an antibacterial agent, and offers extended “This trial confi rms the immense promise and significantly longer residual antibacterial properties. “It is biocompatible and of using nanodiamonds to overcome it contains a low concentration of antimicrobial elements,” Dr. Yassen said. barriers for a range of procedures, from His next steps include optimizing a version of the gel that is opaque to X-rays particularly challenging endodontics cases and other radiation, which will enable dental care professionals to track it within to orthopedics, tissue engineering and the root canal system. others,” said co-corresponding author Mo Learn more about this study in the Journal of Endodontics Kang, MS, DDS, PhD, UCLA Dentistry’s (2017); dx.doi.org/10.1016/j.joen.2016.12.014. Jack Weichman professor of endodontics. “We believe nanodiamonds could ultimately Ghaeth H. Yassen’s antimicrobial gel is poured from an injectable help us sidestep drug resistance in cancer syringe onto a glass plate. (Credit: Indiana University) … and address other clinical challenges.” Learn more about this study in Proceedings of the National Academy of Sciences (2017); doi:10.1073/pnas.1711924114.

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Dental Health Can Protect Children From Obesity Talking about dental health with children and parents can be one way to prevent children from becoming overweight, according to a thesis on children’s Dental Filling Failure Linked to diet, body mass index (BMI) and well-being from Sahlgrenska Academy in Smoking, Drinking, Genetics Göteborg Sweden. “Weight can be a sensitive subject, but if you talk about eating behaviors New research shows that people alongside dental health, you’re looking at the issue from a different angle,” said who drink alcohol or men who smoke are more likely to suffer a failed Louise Arvidsson, registered dietitian, PhD student at the Institute of Medicine in dental fi lling. The research team Sweden and author of the thesis. also found that a genetic difference In one of her substudies, she reviewed eating behavior, BMI and dental health in some patients is associated with of 271 preschool and primary school children in Sweden. The children’s height, increased fi lling failure rates. weight and food intake over one day were compared with the prevalence of The study, published in the journal cariogenic microorganisms in saliva — and the link was clear: The children who had Frontiers in Medicine, also shows no major a higher amount of caries bacteria also had significantly higher BMI and worse difference in fi lling failure rates between eating habits. They ate more frequently and consumed more foods rich in sugar. traditional amalgam and newer composite In addition to better oral health, good food also increases self-esteem, better resin fi llings. The results suggest that relationships with friends and fewer emotional problems, according to a substudy genetic analysis might help dentists to conducted by Arvidsson. Children who to a higher extent followed general dietary personalize treatments for their patients, recommendations reported better mental well-being. The effects were achieved which could lead to improved outcomes. regardless of socioeconomic background and regardless of the children’s weight. Fillings can fail for a variety of reasons, Arvidsson’s thesis is based on data from a including reemergence of the initial tooth large European study, IDEFICS (with the University decay or the fi lling becoming detached. of Gothenburg having primary responsibility for Until now, the jury has been out on Sweden’s participation), the aim of which is to whether newer composite resin fi llings are document and prevent childhood obesity. as durable as traditional amalgam fi llings. Read more of this thesis at hdl.handle.net/ To investigate this, researchers 2077/52844. accessed a large repository of dental records from a dental school in Pittsburgh, which contained information on patient fi llings and rates of failure up to fi ve years after the fi lling procedure. The researchers found no major allowing the team to investigate whether The researchers hypothesize that differences overall between patients patient lifestyle and genetic factors could MMP2 might be able to degrade the receiving amalgam or composite affect the failure rate of composite fi llings. bond between the fi lling and the fi llings in terms of fi lling failure rates. The team found that within two tooth surface, potentially leading This suggests that composite fi llings years of the procedure fi llings failed to failure. However, researchers are at least as durable as amalgam more often in patients who drank have not yet confi rmed whether fi llings and offer a viable alternative alcohol and the overall fi lling failure differences in the MMP2 gene are with no toxic ingredients. rate was higher in men who smoked. responsible for failed fi llings and The repository also contained Furthermore, a difference in the will need to investigate further. information about patient lifestyles, gene for matrix metalloproteinase Read more about this study in including smoking and drinking habits, (MMP2), an enzyme found in teeth, Frontiers in Medicine (2017); doi. and a DNA sample from each patient was linked to increased fi lling failure. org/10.3389/fmed.2017.00186.

12 JANUARY 2018 CDA JOURNAL, VOL 46, Nº1

New Technique Simplifi es Dental Bone Graft Procedures Researchers from the University Termed the continuous periosteal of Minnesota, Minneapolis, have strapping suture (CPSS) technique, this introduced a technique that aims method, if implemented correctly, requires to maintain the integrity of the a less complex surgical procedure than bone graft during closure after tooth currently available techniques. This any surgical screws or tacks to help keep extractions to avoid additional simpler procedure leads to lower overall the graft in place. Instead, a series of surgeries and increased treatment treatment costs, according to the study. intricate knots made with resorbable costs. The study was published in the CPSS relies on resorbable sutures sutures surrounding the membrane Journal of Oral Implantology in 2017. and membrane and does not include are used. The knots help to maintain the strength of the sutures, creating a fi rmer hold on the wound closure area. With the use of resorbable materials, the need for a separate surgery to remove Study Shows How EPS Support Survival of “tenting” screws or tacks can be eliminated. Bacteria in Dental Plaque The researchers also found that using sutures with a higher tension rate, or Extracellular polysaccharides play a central role in the survival capabilities of tensile strength, increased the duration of caries-causing bacteria in dental plaque, according to a report published recently the suture time from 56–70 days to 91–119 in the journal PLOS ONE. Researchers from the University of Basel’s preventative days. This increased tensile strength for a dentistry and oral microbiology clinic and department of biomedical engineering longer period is expected to be a critical in Switzerland hypothesized that extracellular polysaccharides (EPS) support the part of membrane and graft stabilization, bacteria’s survival capabilities. EPS are substances that build extracellular because having longer-lasting sutures cariogenic bacteria from sugar residue. They create the biofilm’s scaffolding and will help ensure the sustainability of ensure that bacteria are able to anchor themselves in the dental plaque. the procedure, according to the study. Cariogenic bacteria live in biofilm and attack dental enamel by converting “One of the biggest challenges when sugar and starch into acids that dissolve out calcium from the enamel. This osseous grafting the ridge to widen the site process can cause caries. The dissolution of calcium increases the with particulate material is containing the concentration of calcium locally, creating an environment that is hostile to graft and avoiding lateral displacement bacterial life. In the study, the researchers investigated how bacteria manage to during healing,” researcher Gregori survive in dental plaque despite these conditions. M. Kurtzman, DDS, said. “The CPSS The study showed that the more calcium cariogenic bacteria dissolve, the technique predictably helps contain the greater their calcium tolerance and survival capability in the biofilm becomes. graft without the need for an increase in The scientists were able to prove that cariogenic bacteria develop mechanisms material costs or complicated techniques.” to help them survive the high concentrations of calcium. The researchers conclude that They demonstrated that extracellular polysaccharides possess a high although their technique is limited by the number of calcium binding sites through which they can integrate the free tensile strength and resorption rate of the calcium into the biofilm, which neutralizes the toxic specifi c suture used, they still found it to have fewer complications and predictable substance and strengthens the biofilm’s EPS structure. The outcomes. The authors also suggest EPS’ integration of calcium doesn’t just help cariogenic that future studies should be conducted bacteria to survive in dental enamel; it also causes caries, comparing the CPSS technique with according to the study. other membrane fi xation techniques Learn more about this research in PLOS ONE (2017); (i.e., “tenting” screw or tack techniques). doi.org/10.1371/journal.pone.0186256. Read more about this study in the Journal of Oral Implantaology (2017); doi.org/10.1563/aaid-joi-D-17-00060.

JANUARY 2018 13

introduction

CDA JOURNAL, VOL 46, Nº1

Silver Diamine Fluoride — The New Old

Paul Reggiardo, DDS

GUEST EDITORS

Paul Reggiardo, DDS, Gregory J. Sabino, “Hey, Doc, what’s new?” is it best applied? Although these is public policy advocate DDS, PhD, earned his How many times have we heard questions are slowly being answered by for the California Society dental degree from the that tiresome chestnut from patients, researchers and clinicians, and in spite of Pediatric Dentistry. He Stony Brook School is a past president of the of Dental Medicine relatives or neighbors we run into at of a well-developed protocol published CSPD and the American In 2010, he received the supermarket or ATM and from in this Journal in 2016 by Horst and Academy of Pediatric his doctoral degree in friends and strangers alike at dinner others at the University of California Dentistry. Dr. Reggiardo molecular and cell biology parties or similar social gatherings? The San Francisco,3 we have yet to reach practices pediatric dentistry with a concentration in answer today is something as old as the professional consensus on these issues or in Huntington Beach, Calif., immunology and conducted and is an adjunct professor his postdoctoral research description of the arrest of carious dental others such as the duration of application of clinical dentistry in the in the department of lesions by the application of silver nitrate or the ideal number and frequency of division of public health and periodontology. He was reported by Stebbins in the 1800s.1 application for optimum caries control. pediatric dentistry at the the 2015–2016 national And at the same time, it’s as new as the This issue and the next of the Journal Herman Ostrow School of American Student Dental recent FDA approval of a commercially will attempt to move that understanding Dentistry of USC. Association editor-in-chief. Confl ict of Interest Confl ict of Interest available silver diamine fl uoride (SDF) and dialogue forward with a series of Disclosure: None reported. Disclosure: None reported. product as a Class II medical device articles that begins with a background to treat dentin hypersensitivity and and history of the use of silver compounds used “off label” by dentists to treat in dentistry by Elise Sarvas, DDS, MSD,

dental decay in the paradigm shift to MPH. Dr. Sarvas discusses the mechanism the medical management of caries. by which SDF arrests the carious process, Or maybe our patients are telling suggests some of the indications for use us about SDF after reading it is “better, and places it in the context of the shift faster, cheaper” than conventional from surgical management of dental restorative treatment with the added caries to a medically managed process. benefi t of “no noise, no drilling” and Man Wai Ng, DDS, MPH, and “you don’t need an injection.”2 Rosalyn Sulyanto, DMD, MS, consider Where does silver diamine fl uoride in even greater detail the role of SDF in fi t in our armamentarium of treatment chronic disease management (CDM) options? For which conditions, under of caries, a personalized system of which situations and for which coordinated health care interventions populations is it indicated? How and patient self-management of etiologic

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CDA JOURNAL, VOL 46, Nº1

factors to restore or maintain health. The authors outline a customizable seven- component CDM protocol for effective control of early childhood caries and suggest that SDF not be offered alone but in the context of a CDM program. Taking the concept into the fi eld, Michael Kanellis, DDS, MS, and co- authors report on the initial lessons learned from the fi rst randomized clinical trial in the United States to examine the effectiveness of silver nitrate in the medical management of childhood caries. The authors highlight challenges in adopting the medical model as the sole intervention strategy for dental caries and suggest clinically relevant recommendations on appropriate case selection. Finally, to aid clinical decision-making, the fi rst evidence-based guideline on the use of silver diamine fl uoride to treat caries in pediatric and special needs patients is included. Developed by the American Academy of Pediatric Dentistry from a systematic literature review and released in October 2017, it contains practical guidance in the application of 38% SDF and an application protocol supported Give health, hope and happiness. by the best available evidence to date. In the February issue, authors will present case studies in pediatric and adult (aging and medically By contributing your time and talent, CDA Cares Anaheim complex) populations, fi ndings from April 27- 28, 2018 you relieve pain, restore dignity clinical studies and some additional and create smiles for thousands of Anaheim Convention Center recommendations for practitioners. ■ people who face barriers to care. Volunteer at CDA Cares Anaheim REFERENCES 1. Stebbins EA. What value has argenti nitras as a therapeutic to help provide essential dental care agent in dentistry? Int Dent J 1891;12:661–670. to those in need. 2. Saint Louis C. A Cavity-Fighting Liquid Lets Kids Avoid Dentist’s Drills. New York Times 2016. www.nytimes. com/2016/07/12/health/silver-diamine-fl uoride-dentist- cavities.html. Accessed July 11, 2016. 3. Horst JA, Ellenikiotis H, Milgrom PM. UCSF protocol for caries arrest using silver diamine fl uoride: Rationale, indications Join us. cdafoundation.org/cdacares and consent. J Calif Dent Assoc 2016 Jan; 44(1):16–28.

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CDA JOURNAL, VOL 46, Nº1

The History and Use of Silver Diamine Fluoride in Dentistry: A Review

Elise Sarvas, DDS, MSD, MPH

ABSTRACT Silver has a long history of use in medicine, even before its antimicrobial properties were fully understood. Dentistry’s recent paradigm shift to medical management of oral disease elevates the use of medicaments. After years of use in the developing world, silver diamine fl uoride has emerged as a successful alternative to invasive dental treatment in the United States. This medicinal option to bridge primary prevention and surgical treatment holds exciting promise for future development and research.

AUTHOR

Elise Sarvas, DDS, MSD, umans have valued silver in order to achieve an effect analogous MPH, is a board-certifi ed for thousands of years for its to the hard, dark crust observed on teeth pediatric dentist and clinical antimicrobial properties. Even whose untreated decay had fortuitously assistant professor at the 3 University of Minnesota before the advent of germ arrested naturally over time. Silver School of Dentistry Masonic theory, Alexander the Great nitrate continued to be a popular dental Children’s Hospital in Hstored water in silver containers on his medicament through the era of G.V. Minneapolis. campaigns, ancient Romans described Black and his modernization of operative Confl ict of Interest placing silver foil in wounds in their fi rst dentistry. In 1917, an ammoniacal Disclosure: None reported book of medicine and American settlers silver nitrate solution (AgNH3NO3) traveling west to California dropped was developed and marketed as an silver coins in their water barrels to slow antimicrobial product that purportedly the growth of algae and bacteria.1 As could penetrate even deeper into the microbial origin of disease became dentin. Until the 1950s, this “Howe’s better understood and antibiotics solution” was used to sterilize lesions after were developed, silver continued to preparation and was even advocated as play an important role in creating a disinfectant in root canal therapy.4 successful and safe medical devices In the 1970s, the Western Australia such as sutures, catheter parts, cardiac School Dental Service used silver fl uoride devices and other surgical appliances.2 (AgF) as the initial part of a minimally Silver was fi rst used in dentistry as invasive treatment process for a cohort early as the 1840s in the form of “nitrate of disadvantaged young children in New of silver” (known today as silver nitrate, South Wales.5 In order to systematically

AgNO3). This salt is extremely caustic decrease the large backlog of dental and early American dentists used it to cases in this rural area, AgF was seen instantaneously cauterize carious lesions as essential to inhibiting the growth of

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CDA JOURNAL, VOL 46, Nº1

existing lesions. This step was followed and Nepal.8,9 The results of these studies SDF gained clearance from the U.S. by an application of stannous fl uoride are challenging to analyze because of Food and Drug Administration (FDA)

(SnF2) to act both as a reducing agent their diverse methodology, inconsistent as a Class II medical device in August for AgF and to prevent new lesions from inclusion criteria, lack of standardized 2014. Similar to 5% sodium fl uoride occurring. This two-step “metal fl uoride” controls and dissimilar outcome criteria, varnish, its approval for use to treat approach resulted in 74 percent of the but several key themes emerged. First, a dentin hypersensitivity in adults aged 21 existing lesions remaining unchanged and concentration of 38% SDF was found to and older was grandfathered in because only 35 percent of all lesions requiring be superior at arresting caries compared it was in use before 1976. Its physical additional surgical treatment. Despite to lower concentrations of 10 or 12%.10 ability to block dentin tubules allowed this combination’s success in decreasing This was true with or without reducing it to be classifi ed as a medical device, caries, there were few studies after the agents such as potassium iodide or tannic rather than a drug, paving the way for 1990s investigating this method.4 acid found in tea.11,12 Second, SDF expedited approval. In October 2016, was superior at arresting dental caries the FDA awarded SDF the designation A Brief History of Silver Diamine and preventing new caries compared of “breakthrough therapy” based on its Fluoride in Dentistry arrest of dental decay in children and Silver diamine fl uoride (SDF) was fi rst adults, a fi rst for an oral health therapy. investigated as part of Mizuho Nishino, This distinction identifi es SDF as a drug PhD’s thesis at Osaka University in Japan In October 2016, the FDA “to treat a serious or life-threatening in 1969.6 She sought to combine the awarded SDF the designation disease or condition” and affi rms powerful antimicrobial properties of silver of “breakthrough therapy” that “preliminary clinical evidence with the benefi ts of a high dose of fl uoride. indicates that the drug may demonstrate This formulation also resulted in a based on its arrest of dental substantial improvement over existing precipitate that occluded dentinal tubules decay in children and adults, therapies.”18 This marked the fi rst time and reduced hypersensitivity.7 Soon after, a fi rst for an oral health therapy. that oral disease had been categorized as “diammine silver fl uoride” was granted a serious medical condition and elevated approval from the Central Pharmaceutical its importance as a signifi cant public Council of the Ministry of Health and health issue. As of this writing, SDF is Welfare of Japan as a cariostatic agent and to fl uoride varnish alone, interim manufactured by one company in the U.S. marketed under the name Saforide (Toyo therapeutic restorations (ITR) with Seiyaku Kasei Co. Ltd., Osaka, Japan). fl uoride-releasing glass ionomer cement Utilization of SDF 2 This compound, AgF(NH3), is commonly (GIC) or other medicaments and low- misspelled or misinterpreted as silver cost interventions such as chlorhexidine Medical Management of Caries diamine fl uoride, when in fact the proper and oral hygiene instruction.8,13,14 This The resurgence of using silver ion terminology is silver diammine fl uoride as however did not hold true when SDF products in dentistry stems from the it contains two ammine groups (NH3), not was used as a sealant over noncavitated growing movement to shift the surgical 4 two amine groups (NH2). The use of the molar grooves. In these studies, it management of dental caries to a term “diamine” is so ubiquitous, however performed worse than or equal to GIC medically managed process. In medicine, it has become the accepted form both in or resin sealants.11,15,16 Finally, multiple care exists in three broad levels: primary, the scientifi c and marketing literature. applications of SDF were found to be secondary and tertiary care. For example, In vivo and in vitro studies of SDF more successful at arresting dental caries primary care of noninsulin-dependent as an alternative dental treatment than one-time placement. There was diabetes mellitus includes preventive initially emerged from dental public no consistence evidence for what the measures such as eating a healthy diet, health researchers in the developing optimal frequency and time interval maintaining appropriate body weight world, where access to oral health care is between these applications might be and regular exercise. Secondary care extremely limited. Most of these primary or the variables that could infl uence for this disease includes intervention population studies came from teams in these protocols, but most recommend an with medications such as metformin or Argentina, Brazil, China, Cuba, Japan application every six to 12 months.8,17 sulfonylureas. If the disease continues to

20 JANUARY 2018 CDA JOURNAL, VOL 46, Nº1

progress, tertiary care in the form of surgery The two main components, fl uoride (e.g., bariatric to maintain body weight or and silver, are made soluble in water limb amputation) may be necessary. From by the addition of ammonia. While the profession’s barber-surgeon origins metallic silver is inert, silver ions are until the late 20th century, dentistry was a broad-spectrum antimicrobial that concerned primarily with tertiary treatment has high biocompatibility and low FIGURE. Black staining characteristic of treatment of oral disease sequelae. As more of the toxicity in humans. These ions act as with SDF on a 3-year-old patient. (Courtesy of Daniel G. infectious process was understood and with tiny “silver bullets” that damage and Raether, DDS, MS, private practice, Plymouth, Minn. ) recognition that surgical treatment alone degrade bacterial cell walls, disrupt was not a cure, the profession embraced bacterial DNA synthesis and replication a medical model to manage the disease. and disrupt intracellular metabolic To date, this medicament has the A 2001 consensus statement from the activity, eventually leading to cell highest concentration of fl uoride ions National Institutes of Health affi rmed death.21 These killed bacteria further available on the market. The 5% SDF that this paradigm shift involved assessing act as a carrier for silver ions and can solution contains 44,800 fl uoride parts the caries risk of a patient and providing kill living bacteria nearby in a process per million (ppm), almost twice that of preventive measures as necessary based known as the “zombie effect.”22 5% sodium fl uoride varnish containing on this risk.19 Primary care, including oral Once applied, a physical barrier 22,600 ppm. In this concentration, SDF hygiene instruction, dietary counseling precipitates out of the clear solution reacts with calcium and phosphate ions and fl uoride supplementation was formally onto the carious lesion. Two major to produce fl uorohydroxyapatite crystals, included to address specifi c patient risk products form — silver phosphate which are less susceptible to solubility and 20 25 factors. Introduction of pharmaceuticals (Ag3PO4), which acts a reservoir of crucial to tooth remineralization. Despite as secondary care was the next logical phosphate ions, and calcium fl uoride the high concentration, the small amount step in full adoption of this model. (CaF2), which is a pH-regulated fl uoride required to be effective suggests that SDF Dental chemotherapeutics (e.g., high- supply available during cariogenic is well within the margin of safety for use.26 concentration fl uorides, pellicle-inhibiting challenge.4,6 Minor products such as drugs such as chlorhexidine and silver silver-protein complexes form, but Indications for Use ion compounds) act as adjunct options their role is poorly understood. It As medicament options for the to the surgical treatment of these lesions is hypothesized that silver fi lls the treatment of dental caries expand, their as caries-inhibiting and caries-arresting microtubules, further sealing the tooth potential uses will become further defi ned medications. Currently, SDF is covered from disease.23 Free silver ions in the and perhaps more specialized. SDF is under the Current Dental Terminology lesion or other physical harbors (e.g., currently only approved in the U.S. to code D1354 as set forth by the American demineralized crevices or craze lines) treat dentin hypersensitivity and is a Dental Association. This is designated for are reduced by environmental oxygen conservative alternative to restorative a caries-arresting medicament to topically and turn the lesion black, which is treatment for individuals who experience treat an existing asymptomatic carious the major nonmedical side effect of sensitivity from gastroesophageal refl ux lesion without removal of tooth structure this medicament (FIGURE).12 A small disease (GERD) or severe bruxism. It and can be used by all properly trained decrease in discoloration is possible is also a clinically acceptable treatment dental professionals. Future research will by binding free silver ions with an alternative for individuals with hopefully continue to add secondary application of potassium iodide, however challenging behavior or whose safe care adjuncts to the dental arsenal. the darkened color remains a concern dental treatment is precluded by other in aesthetic areas. A recent study medical management complexities. Mechanism of SDF reported that parent acceptability of the Its ease of application allows it to be SDF is a uniquely powerful caries- resulting staining was low for anterior applied in offi ce without need for arresting medicament because of the teeth (29.7 percent), but acceptance sedation or other invasive measures. combined antibacterial properties of increased if the choice was between This makes it ideal for individuals who silver, the resulting precipitated barrier SDF application and treatment under are uncooperative, either because of age and the high dose of fl uoride delivered. general anesthesia (60.3 percent).24 or special health care disability. When

JANUARY 2018 21 history

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dental care cannot be completed because Conclusion 15. Braga MM, Mendes FM, De Benedetto MS, Imparato of a more urgent medical complexity, Silver diamine fl uoride represents the JCP. Eff ect of silver diamine fl uoride on incipient caries lesions in erupting permanent fi rst molars: A pilot study. J Dent Child such as the need for an organ transplant, application of a familiar medicine to a (Chic) 2009;76(1):28–33. SDF can buy time until more defi nitive modern medical control of dental caries. 16. Liu BY, Lo ECM, Chu CH, Lin HC. Randomized Trial on treatment can be accomplished.27 Its meteoric rise to popularity in the U.S. Fluorides and Sealants for Fissure Caries Prevention. J Dent Res 2012;91(8):753–758. Contraindications to the use of SDF is refl ective of the quick adoption of this 17. Zhi QH, Lo ECM, Lin HC. Randomized clinical trial on include use in individuals with a silver “medical model” for the management of eff ectiveness of silver diamine fl uoride and glass ionomer allergy, those with open oral sores and oral disease. Future research into it and in arresting dentine caries in preschool children. J Dent 2012;40(11):962–967. teeth that require pulpal therapy (i.e., other potential medicaments is needed 18. FDA. Fact Sheet: Breakthrough Therapies. www. irreversible pulpitis or necrosis). The to continue to support this shift. ■ fda.gov/RegulatoryInformation/LawsEnforcedbyFDA/ exact prevalence of individuals with a Signifi cantAmendmentstotheFDCAct/FDASIA/ucm329491. silver allergy, most commonly a Type IV htm. Accessed May 1, 2017. REFERENCES 19. Horowitz AM. A report on the NIH Consensus reaction, is unknown but believed to be 1. Barillo DJ, Marx DE. Silver in medicine: A brief history BC Development Conference on Diagnosis and Management rare. Individuals at risk for developing 335 to present. Burns 2014;40 Suppl 1:S3–8. of Dental Caries Throughout Life. J Dent Res 2004;83 Spec a silver allergy include those who 2. Lansdown ABG. Silver in health care: Antimicrobial eff ects No:C15–7. and safety in use. Curr Probl Dermatol 2006;33:17–34. 20. Fontana M, Zero DT. Assessing patients’ caries risk. J Am have been previously sensitized to the 3. Stebbens E. What value has argenti nitras as a therapeutic in Dent Assoc 2006;137(9):1231–1239. metal either from medical (e.g., burn dentistry? Int Dent J 1891;12(10):661–671. 21. Jung WK, Koo HC, Kim KW, Shin S, Kim SH, Park YH. treatment with silver sulphadiazine) 4. Peng JJY, Botelho MG, Matinlinna JP. Silver compounds Antibacterial Activity and Mechanism of Action of the Silver used in dentistry for caries management: A review. J Dent Ion in Staphylococcus aureus and Escherichia coli. Appl or industrial (e.g., metallurgical 2012;40(7):531–541. Environ Microbiol 2008;74(7):2171–2178. processing) exposure.28 SDF can 5. Craig GG, Powell KR, Cooper MH. Caries progression 22. Wakshlak RB-K, Pedahzur R, Avnir D. Antibacterial irritate already sensitive open mouth in primary molars: 24-month results from a minimal activity of silver-killed bacteria: The “zombies” eff ect. Sci Rep treatment programme. Community Dent Oral Epidemiol 2015;5(1):9555. sores (e.g., herpetic gingivastomatitis, 1981;9(6):260–265. 23. Seto J, Horst JA, Parkinson DY, Frachella JC, DeRisi JL. ulcerative gingivitis) and should be 6. Nishino M, Yoshida S, Sobue S, Kato J, Nishida M. Eff ect of Silver microwires from treating tooth decay with silver diamine used with caution until those symptoms topically applied ammoniacal silver fl uoride on dental caries in fl uoride. bioRxiv Epub ahead of print. June 2017. children. J Osaka Univ Dent Sch 1969;9:149–155. 24. Crystal YO, Janal MN, Hamilton DS, Niederman R. subside. Coverage of the irritated 7. Yamaga R, Nishino M, Yoshida S, Yokomizo I. Diammine Parental perceptions and acceptance of silver diamine fl uoride mucosa with petroleum jelly to protect silver fl uoride and its clinical application. J Osaka Univ Dent staining. J Am Dent Assoc 2017 Jul;148(7):510-518.e4. doi: it during application is an option. Sch 1972;12:1–20. 10.1016/j.adaj.2017.03.013. Epub 2017 Apr 27. 8. Gao SS, Zhang S, Mei ML, Lo EC-M, Chu CH. Caries 25. Mei ML, Nudelman F, Marzec B, et al. Formation For teeth with large carious lesions remineralisation and arresting eff ect in children by of Fluorohydroxyapatite With Silver Diamine Fluoride. approximating the pulp, adjunctive professionally applied fl uoride treatment — a systematic review. J Dent Res 2017 Sep;96(10):1122-1128. doi: treatments to SDF should be considered BMC Oral Health 2016;16(1):12. 10.1177/0022034517709738. Epub 2017 May 18. 9. Llodra JC, Rodriguez A, Ferrer B, Menardia V, Ramos 26. Horst JA, Ellenikiotis H, Milgrom PL. UCSF Protocol to maximize its effectiveness, as it does T, Morato M. Effi cacy of silver diamine fl uoride for caries for Caries Arrest Using Silver Diamine Fluoride: Rationale, not restore form and function. Placement reduction in primary teeth and fi rst permanent molars Indications and Consent. J Calif Dent Assoc 2016;44(1): of GIC over an SDF-treated lesion using of schoolchildren: 36-month clinical trial. Practitioner 16–28. 2005;249(1675):721–724. 27. Chu CH, Lee AHC, Zheng L, Mei ML, Chan GC. Arresting the silver modifi ed atraumatic restorative 10. Dos Santos VE, De Vasconcelos FMN, Ribeiro AG, rampant dental caries with silver diamine fl uoride in a young technique (SMART) is an option.29 This Rosenblatt A. Paradigm shift in the eff ective treatment of caries teenager suff ering from chronic oral graft versus host disease placement should be done several hours in schoolchildren at risk. Int Dent J 2012;62(1):47–51. post-bone marrow transplantation: A case report. BMC Res 11. Monse B, Heinrich-Weltzien R, Mulder J, Holmgren C, van Notes 2014;7:3. or days after initial SDF placement, as Palenstein Helderman WH. Caries preventive effi cacy of silver 28. Group A, Lea A. Contact dermatitis with a highlight on the ammonia in the wet medicament diamine fl uoride (SDF) and ART sealants in a school-based silver: A review. Wounds 2010;22(12):311–315. can be corrosive to glass. SDF placed daily fl uoride toothbrushing program in the Philippines. BMC 29. Alvear Fa B, Arron J, Wong A, Young D. Silver Modifi ed Oral Health 2012;12(1):52. Atraumatic Restorative Technique (SMART): An alternative as an indirect pulp cap in deep lesions 12. Yee R, Holmgren C, Mulder J, Lama D, Walker D, van caries prevention tool. StomaEduJ 2016;3(2):18–24. approximating the pulp have shown similar Palenstein Helderman W. Effi cacy of Silver Diamine Fluoride for 30. Shah N, Gupta A, Sinha N, Logani A. Remineralizing remineralizing effi cacy as GIC and calcium Arresting Caries Treatment. J Dent Res 2009;88(7):644–647. effi cacy of silver diamine fl uoride and glass ionomer type VII 13. Tan HP, Lo ECM, Dyson JE, Luo Y, Corbet EF. A for their proposed use as indirect pulp capping materials — hydroxide (Ca(OH)2) in one in vivo study, Randomized Trial on Root Caries Prevention in Elders. J Dent Part II (a clinical study). J Conserv Dent 2011;14(3):233. but the opposite was seen in an in vitro Res 2010;89(10):1086–1090. investigation.30 Further research into the 14. Nantanee R, Santiwong B, Trairatvorakul C, Hamba THE AUTHOR, Elise Sarvas, DDS, MSD, MPH, can be reached H, Tagami J. Silver diamine fl uoride and glass ionomer at [email protected]. indications of using SDF is needed and, diff erentially remineralize early caries lesions, in situ. Clin Oral given its popularity, is anticipated soon. Investig 2016;20(6):1151–1157.

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Chronic Disease Management of Caries in Children and the Role of Silver Diamine Fluoride

Man Wai Ng, DDS, MPH, and Rosalyn Sulyanto, DMD, MS

ABSTRACT Chronic disease management (CDM) is a science-based approach that has been demonstrated in early studies to be effective in preventing and controlling dental caries in children. In this article, we describe how CDM can be introduced into contemporary clinical dental practice in which active and engaged dental providers can work as a team to support family behavior changes. We also discuss the role of silver diamine fl uoride in the CDM of caries.

AUTHORS

Man Wai Ng, DDS, Rosalyn Sulyanto, ontemporary management for its introduction to the U.S. dental MPH, is dentist-in-chief DMD, MS, is assistant in of dental caries calls for market. The main advantages of SDF and DentaQuest chair pediatric dentistry at Boston assessing and understanding include its ability to kill the cariogenic in pediatric oral health Children’s Hospital and an and dentistry at Boston instructor in the department an individual’s risk of bacteria, provide caries arrest without Children’s Hospital. She is of developmental biology developing caries, applying requiring the use of local anesthesia also an associate professor at the Harvard School of Ceffective strategies to manage the disease or caries excavation and promote at the Harvard School of Dental Medicine. and supplementing with restorative remineralization.4,5 These advantages Dental Medicine. Confl ict of Interest treatment when indicated.1,2 Historically, are particularly appealing in the care of Confl ict of Interest Disclosure: None reported. Disclosure: Man Wai Ng, the dental profession has primarily relied young children and children with special DDS, MPH, has received on restorative and surgical treatment to health care needs who are not able to grant funding from the address dental caries. Young children with receive traditional restorative treatment. DentaQuest Institute and early childhood caries (ECC) who are The main concerns of SDF use pertain has served as faculty chair not cooperative often require sedation to possible over-exposure to fl uoride and in the ECC Collaborative Phases 1–3. She is also the or general anesthesia. Despite receiving objection by parents (and patients) to 6 DentaQuest endowed chair costly surgical treatment, many children the black staining of the carious lesions. in pediatric oral health develop new and recurrent caries. It is now Crystal et al. found that parents of young and dentistry at Boston known that while restorative treatment children report greater dissatisfaction to Children’s Hospital. repairs damaged tooth structure, it alone having discolored anterior teeth compared does not address the underlying disease to posterior teeth; however, many parents process.3 If the responsible risk factors are apparently more willing to accept are not adequately addressed, new and the discoloration if sedation or general recurrent decay will likely develop.3 anesthesia procedures could be avoided.7 In 2014, the U.S. Food and Drug Studies have reported on the Administration granted approval for effectiveness of SDF to arrest caries silver diamine fl uoride (SDF) to be used and its effi cacy to prevent new caries in as a desensitizing agent, paving the way primary teeth as well as fi rst permanent

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TABLE 1 ECC Chronic Disease Management Protocol*

Caries risk assessment ■ Performed in full or abbreviated format during each visit ■ Children who have at least one tooth with demineralization or cavitation lesion is an ECC patient molars.8 SDF has been found to Eff ective communication ■ With permission, explain the caries process to parent and use outperform fl uoride varnish in achieving structured communication strategies such as: caries arrest.9 Annual application ● Fixing the cavities does not fi x the problem of SDF in children prevented many ● Without a change in diet and home care, new cavities and more carious lesions than quarterly broken fi llings will result application of fl uoride varnish.9 ● Change is hard and won’t happen over night Longer-term effectiveness is greater Self-management ■ Engage and coach parent to select one or two goals to work on until if the SDF treatment is repeated.10,11 goal setting the next visit Milgrom et al. found a higher average ■ Goals may include more frequent toothbrushing, topical fl uoride use proportion of arrested carious lesions and specifi c diet modifi cation strategies in an SDF-treated group compared Caries charting ■ Use a charting system, such as ICDAS or ADA Caries Classifi cation System to: to a placebo group after 14 to 21 days ● Document caries by tooth, surface and activity postintervention.12 Additional and ● Monitor disease improvement or progression longer studies are needed to establish Fluorides and other ■ Topical fl uorides, including over-the-counter toothpaste, stannous the frequency of SDF applications to remineralization strategies fl uoride, xylitol and/or calcium phosphate products can be off ered achieve and maintain caries arrest, the ■ In-offi ce silver diamine fl uoride treatment or fl uoride varnish types and depths of carious lesions for applications can be off ered which SDF treatment can be successful Restorative treatment ■ Full range of treatment options can be presented based on each and whether caries arrest and prevention patient’s needs and parent’s desires, including: can be maintained over time. ● Conventional treatment (including use of pharmacologic management) Since becoming available in the ● Interim therapeutic restorations for caries control and sealants U.S., SDF has gained considerable Risk-based recare intervals Patients are recommended to return in: attention among U.S. dental providers ■ 1–3 months (if high risk) for its purported ability to arrest dental ■ 3–6 months (if medium risk) caries and as a potentially simple, ■ 6–12 months (if low risk) easy-to-use and inexpensive alternative At the recare/disease management visit, perform: 5,6 to restorative treatment. However, ■ Caries risk assessment despite the promising potential of SDF ■ Self-management goal setting treatment to arrest caries and to defer ■ Exam and charting or obviate the need for restorative ■ X-rays if indicated treatment, Milgrom et al. found that ■ Silver diamine fl uoride or fl uoride varnish 51.7 percent (15/29) of children who received SDF treatment had 100 percent *DentaQuest Institute of caries lesions arrested 14 to 21 days after treatment.12 This suggests that SDF Chronic disease management CDM treatment on its own may be insuffi cient (CDM) is a science-based approach CDM has been defi ned as a system to achieve arrest. As in the case after tested in clinical practice that can of coordinated health care interventions restorative treatment, if the responsible prevent and manage caries and which in which patient self-care efforts are risk factors for caries development are has been demonstrated in early studies signifi cant. Based on the assumption not adequately addressed, the disease to be effective in improving outcomes that patients have the most important may continue, resulting in new and in children.14,15 In this article, we role in the care of their chronic health recurrent carious lesions. On the describe how CDM can be introduced conditions, CDM aims to promote a other hand, with effective control of into contemporary clinical dental sense of responsibility on the part of the dietary factors and with judicious use of practice with and without the use of patient, parent or caregiver for his or her fl uorides or other remineralizing agents, SDF, in which active and engaged own health. Unlike a traditional approach reduction in caries activity can occur dental providers can work as a team whereby health care providers tell patients (manifesting as signs of caries arrest).13 to support family behavior changes. what changes to make, CDM calls for

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TABLE 2 ECC Risk-Based Chronic Disease Management Protocol

Existing New Clinical Fluoride Sample Self-Management Goals Restorative DM Other Risk Findings Varnish Treatment Return Category Interval§ Interval Low No disease indicators* of caries; or 6–12 Twice-daily brushing with F toothpaste† 6–12 months months Completely remineralized (arrested) Stannous fl uoride‡ on cavitated lesions carious lesions No disease indicators,* but has 3–6 Twice or more daily brushing with F Sealants 3–6 Xylitol gum or candies † Medium risk factors** and/or inadequate months toothpaste ITR months or wipes protective factors*** ‡ Stannous fl uoride on cavitated lesions Conventional Calcium phosphate Disease indicators present with paste Dietary changes restorative some remineralization

Active caries (disease indicators 1–3 Twice or more daily brushing with ITR 1–3 Xylitol gum or candies † High present) months F toothpaste Sealants months Calcium phosphate ‡ No remineralization occurring Stannous fl uoride on cavitated lesions Conventional paste Heavy plaque Dietary changes restorative Sedation/GA

*Examples of disease indicators include demineralization, cavitated lesions, existing restorations, enamel defects, deep pits and fi ssures. ** Examples of risk factors include patient/maternal/family history of decay, plaque on teeth, frequent snacks of sugars/cooked starch/sugared beverages. ***Examples of protective factors include fl uoride exposure (topical and/or systemic), xylitol. §May use silver diamine fl uoride instead of fl uoride varnish. †Brush with a smear of 1,000 ppm F toothpaste. ‡Apply a smear of 1,000 ppm stannous fl uoride to cavitated lesions. ITR = Interim therapeutic restoration. GA=general anesthesia.

a partnership or a close collaboration trained clinical providers and team Components 1-3: Caries Risk between an informed and engaged patient members in more than 40 dental and Assessment, Effective Communication and/or parent and a proactive health oral health care practices across the U.S and Self-Management Goal Setting care provider ideally in a culturally and to test and implement a CDM protocol Regularly assessing each patient’s linguistically appropriate manner. to address ECC.17 The authors of this risk for caries and providing support and Because dental caries is a chronic paper have been involved in the ECC coaching to control risk factors are the disease that is signifi cantly infl uenced by Collaborative as care providers, change cornerstones of the ECC CDM protocol. social and behavioral factors, effective champions in their own dental practices In clinical practice, a full or abbreviated management requires customized patient and faculty in the collaborative. CRA is performed at every visit informally self-management of etiologic factors. TABLES 1 and 2 show the most or, preferably, by using a structured tool An important role of the professional recent ECC CDM clinical protocol or form. This tool is used to guide the team is to provide coaching and support for the ECC Collaborative. The query about the patient’s diet and oral to the patient and family to make the ECC Collaborative CDM protocol hygiene habits, to assess the patient’s necessary lifestyle changes, such as in includes seven components: 1) caries changing balance of risk and protective oral hygiene practices, dietary habits and risk assessment (CRA); 2) effective factors and efforts with meeting self- fl uoride use. This personalized approach communication; 3) self-management goal management goals. Structured CRA forms to patient care is the essence of CDM. setting; 4) caries charting; 5) fl uorides are available from the American Dental and other remineralizing strategies; 6) Association,20 the American Academy of ECC Collaborative CDM Protocol restorative treatment as needed and Pediatric Dentistry,2 Caries Management Since 2008, the DentaQuest desired by patient/family; and 7) recare by Risk Assessment (CAMBRA)21,22 Institute has supported multiple phases interval based on risk. The ECC CDM and other groups. FIGURE 1 shows a of a learning collaborative modeled protocol along with its rationale and CAMBRA CRA form for ages 0–5. after the Institute for Healthcare promising results from Phases 1 and 2 With permission from the patient Improvement’s Breakthrough Series.16 of the ECC Collaborative will not be or caregiver, the etiology of the caries Using quality improvement (QI) described in great detail here as they process is explained, followed by 14,18,19 methods, the ECC Collaborative has have been published elsewhere. CONTINUES ON 28

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CAMBRA — Caries Risk Assessment Form for Age 0 to 5 Years

Patient Name: ID# Age: Date: Assessment Date:

NOTE: Any one Yes in Column 1 signifies likely “High Risk” YES = CIRCLE Comments: and an indication for bacteria tests 123 1. Risk Factors (Biological Predisposing Factors) (a) Mother/caregiver has had active dental decay in past year YES (b) Bottle with fluid other than water, plain milk and/or formula YES Type of fluid: (c) Continual bottle use YES (d) Child sleeps with a bottle, or nurses on demand YES (e) Frequent (>3 times/day) between-meal snacks of sugars/cooked starch/ YES #times/day: sugared beverages (f) Saliva-reducing factors are present, including: YES 1. medications (e.g., some for asthma [albuterol] or hyperactivity) 2. medical (cancer treatment) or genetic factors (g) Child has developmental problems/CSHCN (Child With Special Health YES Care Needs) (h) Patrent and/or caregiver has low SES (Socio-economic status) and/or low YES health literacy, WIC/Early HeadStart 2. Protective Factors (a) Child lives in a fluoridated community (note zip code) YES (b)Takes fluoride supplements YES (b) Child drinks fluoridated water (e.g., tap water) YES (c) Teeth brushed with fluoridated toothpaste (pea size) at least once daily YES (d) Teeth brushed with fluoride toothpaste (pea size) at least 2x daily YES (e) Fluoride varnish in last six months YES (f) Mother/caregiver understands use of xylitol chewing gum/lozenges YES (g) Child is given xylitol (recommended wipes, spray, gel) YES 3. Disease Indicators/Risk Factors – Clinical Examination of Child (a) Obvious white spots, decalcifications enamel defects or decay present on YES the child’s teeth (b) Existing restorations YES (c) Plaque is obvious on the teeth and/or gums bleed easily YES (d) Visually inadequate saliva flow YES (e) New remineralization since last visit (list teeth): YES Child’s Overall Caries Risk*(circle): HIGH MODERATE LOW Child: Bacteria/Saliva Test Results MS: LB: Flow Rate: ml/min: Date: Caregiver: Bacteria/Saliva Test Results MS: LB: Flow Rate: ml/min: Date: Self-management goals: 1) 2) *Assessment based on provider’s judgment of balance between risk factors/disease indicators and protective factors.

Clinician’s signature Date

FIGURE 1. CAMBRA caries risk assessment form for children aged 0–5.

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Goals for Healthy Teeth (Age 5 and Younger)

Patient Name: ______Date of Visit:______Your child has been assessed to have the following risk for caries (cavities): ❏ High ❏ Medium ❏ Low

The pictures checked are the areas you should focus on between today and your next visit.

❏ Next fl uroride visit in ❏ Healthy snacks such as ❏ No soda/energy drinks ❏ Less or no candy/junk ____ months fruit, carrot sticks, yogurt, ❏ No juice food low-fat cheese, pretzels, ❏ Juice only with meals ❏ Chew sugar-free gum whole grain crackers (e.g., Trident, Orbit, Extra)

❏ No sippy cup ❏ Drink fl uoridated water, ❏ Daily fl ossing with fl oss Brush morning and before bed ❏ Only plain milk or water tap water string or pick with fl uoride toothpaste: in cup or bottle (if bottle ❏ Thin smear (<2 years old) to bed use only water) ❏ Pea-sized amount (2–5 years old)

IMPORTANT The last thing that touches your child’s teeth before bedtime is the toothbrush ❏ Fluoride varnish was with fl uouride toothpaste. Brush morning and before bed applied in clinic today. with fl uoride toothpaste: Wait until tomorrow to ❏ Use Gel-Kam ___ a day. brush/fl oss. Avoid hard, Apply a thin smear to all crunchy and sticky foods. teeth. Wait 30 minutes before eating, drinking or rinsing.

On a scale of 1–5, how likely do you think you will help your child meet these goals? 1 2 3 4 5 Not likely Not sure Very likely

Clinician’s Comments

FIGURE 2. Sample self-management goals handout (adapted from J Calif Dent Assoc 2010 Oct; 38(10):759).

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Clinical Visual Assessment ICDAS ICDAS ICDAS Alternative Charting Alternative Charting Dental Terms Detection Activity System 1 System 2

CONTINUED FROM 25 Extensive cavity 6 +⁄– 6 A, B, C D2A D2B D2C coaching about the risk and protective with visible dentin Distinct cavity with factors and providing support with self- 5+⁄– 5 A, B, C D2A D2B D2C management goal setting. In the ECC visible dentin Underlying dentin Collaborative, visual fl ip charts and 4+⁄– 4—D2 — — handouts have been used to help guide the shadow Localized enamel conversations with patients and parents. 3+⁄– 3—D1.5 — — Effective self-management support breakdown Distinct visual uses a collaborative approach, with 2+⁄– 2—D1 — — change in enamel providers and patients working together First visual change to defi ne problems, set priorities, establish 1+⁄– 2—D1 — — in enamel goals and create treatment plans to solve Sound problems. A member of the care team 0+⁄– 0— ——— (dental hygienist, dental assistant or dentist) engages with and coaches the The codes D1, D1.5 and D2 describe enamel or The codes A, B and C describe caries activity: patient or parent on self-management dentin changes, breakdown or cavitation: A = completely arrested (inactive caries; may goal setting. FIGURE 2 shows an example D1 = enamel change appear shiny or dark brown/black; feels hard) of a self-management goals handout D1.5 = enamel breakdown B = becoming inactive (may feel leathery or harder) used in the ECC Collaborative.14 D2 = decay extending into dentin C = active caries (feels soft) Recognizing that change is hard to initiate and even more diffi cult to sustain, FIGURE 3. International Caries Detection and Assessment System (ICDAS) and alternative charting systems. no more than one or two self-management goals are typically selected to work on until the next visit. Self-management goals may important to document and follow closely with remineralization of the carious include diet modifi cation, more frequent over time. Caries activity is determined surfaces with instructions to defer eating, toothbrushing and using remineralization by visual assessment and also through drinking or rinsing for 30 minutes. strategies and topical fl uorides at home. a tactile examination using a balled Xylitol products and casein phosphate explorer or by gently sliding a sharp products are also available to assist in Component 4: Caries Charting explorer over the caries lesion (TABLE 3). controlling the caries process at home.29 Because caries may progress and arrest Professional fl uoride treatments at the same time in different locations of Component 5: Fluorides, Including should be offered based on caries risk the dentition, a clinical examination and SDF, and Other Remineralization status. Children with increased caries caries charting are important to monitor Strategies risk should receive a professional topical caries presence, progression and activity The use of fl uoride for caries prevention fl uoride treatment (fl uoride varnish) by tooth and surface. Using a system such and management is both safe and effective. at least every six months.26 High-risk as the American Dental Association All children are recommended to have children should receive fl uoride varnish charting system,23 the International their teeth brushed with a smear of 1,000 every three to six months and medium- Caries Detection and Assessment ppm of fl uoridated toothpaste two or more risk children a minimum of every six System (ICDAS)24,25 or a modifi ed times each day by an adult caregiver with months. Low-risk children may not system (FIGURE 3) allows for tracking of the eruption of the fi rst tooth until age 3. receive additional benefi t from topical information important for determining Children aged 3 to 6 should brush with a fl uoride treatments in addition to what disease diagnosis, caries risk status and pea-sized amount of fl uoride toothpaste. they receive from fl uoridated drinking appropriate clinical treatment planning. After brushing, spitting out but not water and toothpaste.30 Children with In order to properly visualize the rinsing with water is encouraged.26–28 ECC who have demineralized enamel or surfaces of the teeth, any plaque present A smear of 1,000 ppm fl uoride cavitated carious lesions may benefi t from on the surface is brushed or wiped toothpaste or 0.4% stannous fl uoride professional topical fl uoride applications away. Demineralized enamel surfaces, may be applied to cavitated or more frequently than every three months which appear as chalky white spots, are demineralized tooth surfaces to assist to assist in controlling the caries process.18

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TABLE 3 Definitions of Codes in the International Caries Detection and Assessment System (ICDAS) and Alternative Charting Systems and the Characteristics of the Carious Lesions

ICDAS Code Alternative Characteristics of Lesion Codes 1 or 2 Active Lesion Inactive Lesion 1, 2 or 3 2 or 3 Surface of enamel is whitish/yellowish opaque with loss Surface of enamel is whitish, brownish or black of luster D1 or D1.5 Enamel may be shiny and feel hard and smooth when tip of Feels rough when tip of probe is moved gently across the surface probe is moved gently across surface Lesion is in a plaque stagnation area, i.e., pits and fi ssures, For smooth areas, caries lesion is typically located at some near gingival and approximal surface below contact point distance from gingival margin 4 4 or D2 Probably active 5 or 6 5A, B or C Cavity feels soft or leathery on gently probing the dentin Cavity may be shiny and feels hard on gently probing the dentin D2A, B or C

The use of SDF may be included in the therapeutic restorations (ITR) may be However, close follow-up and risk-based CDM protocol, substituting for fl uoride performed. The ITR procedure involves preventive care are essential to safeguard varnish. Following most recently available removing the decay using hand or rotary from disease relapse. Seeing a child more evidence-based protocols and with informed instruments with caution to avoid pulp frequently for preventive care over time consent, SDF may be applied to slow down exposure. After preparation, the tooth has been found to be helpful to reduce a caries progression or to achieve caries is restored with a fl uoride-releasing child’s fears and build trust between the arrest. Return visits for additional SDF glass ionomer restorative material. It is care provider and the child, allowing for treatment can be considered recare visits important for the parent to understand restorative treatment to be completed (Component 7), during which a clinical that this approach is caries control with greater ease in the clinical setting, examination and CRA are performed and rather than permanent restoration.14 at a later time.18 On the other hand, self-management goals are revisited. When signifi cant tooth structure a cavitated lesion, although arrested, has been destroyed by the caries process, may benefi t from receiving a restoration Component 6: Restorative Treatment restorative treatment is performed to in order to prevent food impaction. If (Including Sealants, Interim Therapeutic restore function or improve aesthetics. Due caries arrest has been achieved (such as Restorations and Conventional to the high risk of recurrent decay and the through use of SDF), caries excavation is Restorative Treatment as Needed and signifi cant costs of general anesthesia, long- not required prior to placement of either Desired by Patient/Family) term success of restorative treatment for glass ionomer or another restorative In high-caries risk children, tooth ECC depends upon effective management material. Deferring restorative treatment surfaces with deep pits or fi ssures would of the disease along with appropriate use and avoiding use of local anesthesia benefi t from sealant with a bonded or glass of restorative technique and materials are signifi cant benefi ts of both SDF ionomer material.2 Typically, sealants are for the primary dentition.31 A child who treatment and the CDM protocol. placed on permanent molars, but primary shows improved caries risk status and caries molars may also benefi t from sealant activity may receive more conservative Component 7: Recare Visits placement, especially if there are already restorative treatment. However, a child Patients with increased caries risk incipient lesions present or if decay has demonstrating no improvement of caries would benefi t from more frequent recare already manifested on other primary molars risk status or continuing progression of visits than the customary interval of every with similar pit and fi ssure anatomy.2 caries activity may benefi t from a more six months. The recare interval should be If destruction of tooth structure by aggressive restorative strategy to reduce based on the patient’s caries risk status (one the caries process is minimal, achieving new and recurrent decay in susceptible to three months or more often for high risk, arrest of the decay might be possible with tooth surfaces, such as with use of three to six months for medium risk and six remineralization strategies.14 Restorative full-coverage stainless steel crowns. to 12 months for low risk) and the desires treatment may be deferred if the disease When caries arrest is achieved, of the parent or parent. During the recare can be effectively controlled. If the decay restorative treatment may be deferred, visit, a CRA and clinical examination are has progressed into dentin or caries especially in a child who is unable to performed and self-management goals are arrest has not been achieved, interim cooperate for restorative treatment. revisited. The clinical examination includes

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TABLE 4 ECC Collaborative Phase I: Comparison of Rates of New Cavitation, Pain and Referral to OR Between ECC Patients and Historical Control Patients

Boston Children’s Hospital Saint Joseph Hospital ECC Historical Control ECC Historical Control (N=403) (N=129) Improvement (N=234) (N=80) Improvement Outcomes % % % % % % New cavitation 26.1 75.2 ▼65.3 41.0 71.3 ▼57.5 Pain 13.4 21.7 ▼38.2 7.3 31.3 ▼23.3

Referral to OR 10.9 20.9 ▼47.8 14.9 25.0 ▼67.8

TABLE 5 a specifi c assessment of plaque control, new caries, caries progression and caries arrest ECC Collaborative Phase II: Comparison of Rates of New Cavitation, Pain and Referral to OR Between ECC Patients and Historical Control Patients of existing carious lesions and the need for SDF reapplication. From a conversation ECC Historical Control Percentage Improvement with the patient or parent, the effectiveness (N=344) (N=316) Improvement Range Outcomes of meeting the previously agreed upon self- % % % % management goals is assessed. Coaching New cavitation 33 46 ▼28 ▲14–▼71 is then provided to the patient and family Pain 8 11 ▼27 ▲80–▼100 to help them sustain or adjust their selected self-management goals if required. Referral to OR 14 22 ▼36 0–▼81 Fluoride varnish or SDF may be applied during these visits. ITR and restorative treatment can be provided if needed. continued with fi ve additional sites across assume. In the CDM approach, the Recare visits are excellent opportunities the U.S. found that after 18 months, dental hygienist or dental assistant to build trust and provide coaching, role fewer disease management (DM) children can play a pivotal role in providing modeling, positive reinforcement and experienced new cavitation, pain and patient education, support, coaching, social rewards. Whenever possible, the referrals to the OR for restorative self-management goal setting and CDM activities are coordinated with treatment compared to baseline historical documentation of fi ndings from CRA. return visit intervals based on the most controls (TABLE 5). The fi ve participating CDM of caries requires all members of the recent caries risk status in conjunction sites found that quality improvement care team to work collaboratively with with the restorative care needed (TABLE 2). methods facilitated adoption of the DM the patient or family to address specifi c CASE STUDIES 132 and 2 and approach and resulted in improved care to risk factors and provide education, but FIGURES 4 and 5 describe examples of patients and better outcomes overall.14,15 really focus on behavioral change (using successful CDM interactions between effective communication techniques the dental health care team and Collaborative Team-Based Care such as motivational interviewing), patients with ECC and their parents. The typical dental health care team introducing fl uorides, including SDF includes dentists, dental hygienists and and other remineralizing agents, and Evidence Supporting Chronic Disease dental assistants. Although any member recommending patients to return for DM Management of ECC of the clinical care team may facilitate visits and fl uoride varnish applications Phase 1 of the ECC Collaborative, team-based CDM care, dental hygienists more often based on the patient’s caries which took place at two hospital-based may be ideally suited to lead this care. risk. At the same time, a patient may dental care practices, found that after Dental hygienists are already in position to present for restorative treatment, but 30 months children with ECC in the provide patient education and oral health the dentist or another staff should intervention group experienced lower promotion while facilitating continuity of revisit caries risk factors and provide rates of new cavitated carious lesions, pain patient care and fostering relationships and continued self-management support. and referrals for restorative treatment in trust building with patients and parents. The collaborative care team the OR compared to baseline historical FIGURE 6 shows a fl ow diagram of approach should extend to the controls with ECC (TABLE 4). A follow- the CDM protocol outlining the role administrative staff, such as front up Phase 2 of the ECC Collaborative that members of the dental team may desk/reception and billing staff, who

30 JANUARY 2018 CDA JOURNAL, VOL 46, Nº1

CASE STUDY 1

An Example of a Successful CDM Patient Visit 1: Two-year-old Abby presents with her mother for a new infant oral health visit with Logan, a dental hygienist. Logan performs a CRA and a knee-to-knee examination with Abby’s mom. Pertinent fi ndings from the CRA include: history of active caries in her mom, patient sleeps with a nursing bottle containing milk, patient brushes with a training nonfl uoride toothpaste, patient drinks apple juice three times per day and no reported pain. Pertinent clinical examination fi ndings include heavy plaque biofi lm presence on buccal cervical gingival margins of the maxillary incisors, demineralized enamel on the maxillary incisors and extensive breakdown of the maxillary left lateral incisor and a cavitated carious lesion just into dentin on a mandibular primary fi rst molar. With parental permission, Logan explains the etiology of the caries process and lets Abby’s mom know that cavities can be prevented and stopped. But without a change in the diet and/or oral hygiene, the cavities will get worse. Logan asks Abby’s mom what is most important to her, such as avoiding pain and infection, preventing the cavities from getting worse or the appearance of the teeth. Logan discusses with Abby’s mom possible restorative treatment options including restorative treatment with sedation or general anesthesia and interim therapeutic restoration (ITR) treatment of the lower left fi rst molar at an upcoming visit, explaining to Abby’s mom that because the decay is just extended into dentin, restorative treatment can be deferred in order to avoid infl icting psychological trauma to Abby. Logan helps Abby’s mom select one or two self-management activities to implement in the next month and asks if she would be willing and able to return with her child in one month for another visit and fl uoride varnish application. Abby’s mom agrees to return in one month. Her two goals are to begin brushing with a smear of 0.4% stannous fl uoride toothpaste (as demonstrated after breakfast and before bed and to wait 30 minutes before eating, drinking or rinsing after) and to switch completely to water in the bottle for bed. Abby’s mom is advised to expect a couple of sleepless nights. Visit 2: In one month, Abby and her mom return for a follow-up CDM with Logan. Mom reports brushing with a smear of stannous fl uoride toothpaste after breakfast and before bed and has switched to water in the bottle for bed. A knee-to-knee exam performed shows improved good plaque control and demineralized surfaces and cavitated lesions manifesting remineralization. Logan congratulates Abby’s mom on her eff orts and asks what other strategies she could consider implementing next. Abby’s mom is willing to try to reduce juice intake to one to two times and will give more water or milk. She agrees to defer restorative treatment and to return in three months. Because Abby has no pain and the caries lesions have not progressed, ITR for the molar is discussed as possible treatment at the next visit and to defer restorative treatment for the maxillary incisors. Fluoride varnish is applied. Visit 3: In three months, Abby and her mom return for a follow-up CDM visit with Logan. A knee-to-knee examination fi nds good oral hygiene. The carious lesions on the maxillary incisors are arrested. The cavitated lesion on Abby’s lower left fi rst molar has become larger and feels soft to the explorer. Abby’s mom reports that she has been brushing Abby’s teeth with a smear of stannous fl uoride toothpaste before bed and sometimes in the morning. She has stopped the bottle to bed completely and is giving a cup of juice each day with more water and milk. She is giving Abby fruit snacks occasionally. Abby’s mom gives consent to ITR treatment for the lower left fi rst molar. She agrees to defer restorative treatment on the maxillary incisors. Because Abby has been returning for frequent visits, she has become more comfortable with the practice and the providers. Abby has become less anxious and the ITR procedure was completed quickly and easily by the dentist. Glass ionomer restoration is placed on the molar. Fluoride varnish is applied. Logan coaches Abby’s mom to avoid fruit snacks. She agrees to give more fruit and to try to brush Abby’s teeth after breakfast and to return in three months for another follow-up visit. Abby returns every three months for CDM visits. With no additional new caries, she is deemed to be medium risk. At age 4, Abby becomes cooperative to have her maxillary incisors with the arrested decay restored with composite strip crowns. Abby’s mom and Logan agree to recare visits every six months.

FIGURE 4A. FIGURE 4B. FIGURE 4C. FIGURE 4D.

FIGURE 4A. Abby at her third visit, with improved oral hygiene and signs of caries arrest. FIGURE 4B. Abby’s lower left primary fi rst molar with occlusal decay. FIGURE 4C. Interim therapeutic restorative treatment of mandibular left primary fi rst molar; decay excavated without local anesthesia. FIGURE 4D. Glass ionomer restoration on mandibular left primary fi rst molar. FIGURE 4E. Abby at her fourth visit, three months after restoration was placed, with no new carious lesions.

FIGURE 4E.

JANUARY 2018 31 disease management

CDA JOURNAL, VOL 46, Nº1

CASE STUDY 2

Example of a Successful CDM Patient Treated With SDF Visit 1: Three-year-old Dominic presents with his mother for a recall visit. Dominic’s medical history is signifi cant for Down syndrome. He has been followed in the clinic since age 2. At the time of his initial visit one year ago, demineralization and cavitations on his maxillary incisors and deep pits and fi ssures on his molars were noted. An initial CRA was performed with pertinent fi ndings including history of active caries in Dominic’s mom, patient breast-feeds throughout the night, patient brushes with a training nonfl uoride toothpaste and no reported pain. Since his initial visit, Dominic has discontinued breast-feeding and has been brushing with 0.4% stannous fl uoride twice daily, which has allowed remineralization of his maxillary incisors. On knee-to-knee exam, a new cavitated carious lesion on a maxillary primary fi rst molar (tooth I) is observed. Plaque is noted in the grooves of his molars and along the gingival margin. The carious lesions on Dominic’s maxillary incisors are arrested. His mom reports that Dominic has started wanting to brush his teeth more on his own and has started eating fruit snacks at school. Possible restorative treatment options are presented, including restorative treatment with sedation or general anesthesia, interim therapeutic restoration (ITR) treatment of tooth I or silver diamine fl uoride (SDF) treatment of tooth I. Based on Dominic’s limited cooperation during dental visits, his mom opts for application of SDF with the understanding that restorative treatment may be needed in the future. The risks and benefi ts of SDF are discussed with Dominic’s mom, and she consents to its application. SDF is applied to tooth I during the recall visit. Dominic tolerates the procedure well. Dominic’s mom agrees to return in three months for another visit. She also sets the goal of brushing Dominic’s teeth after he brushes them himself and replacing fruit snacks with nonsticky alternatives. Visit 2: In three months, Dominic and his mom return for a follow- up visit. Mom reports that she has been brushing Dominic’s teeth twice daily with a pea-sized amount of stannous fl uoride toothpaste and that she has replaced his fruit snacks with fresh fruit. A knee-to knee-exam performed shows improved good plaque control, continued remineralization of the maxillary incisors and a dark arrested cavitation with some small areas of unarrested caries on tooth I. SDF is reapplied. Dominic’s mom is reassured that the temporary FIGURE 5A. Dominic’s maxillary FIGURE 5B. Dominic’s maxillary discoloration of the soft tissues will resolve after approximately one left primary fi rst molar with left primary fi rst molar with occlusal week. She agrees to continue to maintain Dominic’s good oral hygiene occlusal decay prior to SDF. decay three months after SDF and limit cariogenic snacks and to return in three months for another application and immediately after a follow-up visit. At the three-month visit, SDF may be reapplied if needed second SDF reapplication. and an ITR may be placed at the same visit or a subsequent visit.

can help provide clarifi cation and SDF in the Context of CDM The use of SDF may help to tip the reinforcement of oral health educational SDF is gaining interest in dentistry caries balance in favor of remineralization messages and self-management support. and among the public as an alternative in some patients. In other patients, SDF use In a broader sense, the collaborative to restorative treatment. Its use is alone may be insuffi cient to achieve caries care team may also include primary particularly attractive for patients arrest without further amelioration of risk medical care providers or specialty who are unable to tolerate traditional factors or the addition of more protective care providers for those patients surgical treatment. These patients factors. SDF treatment in the context of with special health care needs.33 include young children or individuals a CDM protocol can be expected to help Working in a collaborative partnership with special health care needs who facilitate caries arrest or at least slow caries with parents and children with ECC, would otherwise require pharmacologic progression. The return recare visits enable dental professionals and staff are able management in order to receive monitoring of the clinical effectiveness to increase the motivation to set self- traditional restorative treatment. of the SDF treatment, while at the same management goals and make seemingly SDF has the promising potential to time allowing for assessing of caries risk and simple but diffi cult behavioral changes, arrest caries without drilling and reviewing and supporting self-management such as increased brushing frequency, without the need for local anesthesia. goal setting. If SDF treatment is found to use of fl uoride toothpaste, reducing However, anecdotal reports and be ineffective for a patient or a particular carbohydrate and/or sugar intake and studies8,12,34 fi nd varying clinical success tooth, restorative treatment would be more frequent return recare visits. of SDF to achieving caries arrest. required to protect the pulp. Patients

32 JANUARY 2018 CDA JOURNAL, VOL 46, Nº1

Initial or Recare Visit Inclusion Criteria ■ Review medical and dental history (DA/H/D) ■ At least one tooth with caries (cavitation and/or ■ Perform abbreviated CRA (DA/H/D) demineralization) ■ Perform clinical exam (D) ■ Or a history of caries ■ Perform caries charting (DA/H/D) ■ Take radiographs if indicated and possible (DA/H) ■ Assess cooperation (DA/H/D) Eff ective Communication and ■ Apply SDF (D) or FV (H) Self-Management Goal Setting ■ Explain caries process and causes of ECC (DA/H/D) ■ Coaching and SM goal setting (DA/H/D) ■ Use handouts and fl ipcharts (H) Chronic Disease Management Visits** ■ Perform abbreviated CRA (DA/H/D) Restorative/Surgical Treatment as Indicated ■ Perform clinical exam (D) and Desired ■ Perform caries charting (DA/H/D) ■ Take radiographs if indicated and possible (DA/H) ■ Restorative treatment (D) ■ Revisit SM goals (DA/H/D) ■ ITR (D) ■ Assess cooperation (DA/H/D) ■ Sealants (H or D) ■ Apply SDF (D) or FV (H) ■ GA/OR or sedation (D)

**For Children at High Risk **For Children at Medium Risk **For Children at Low Risk Next DM visit in 1–3 months Next DM visit in 3–6 months Next DM visit in 6–12 months

(H) = hygienist’s role (D) = dentist’s role (DA) = dental assistant’s role ECC = early childhood caries ITR = interim therapeutic restoration GA/OR = general anesthesia/operating room DM = disease management CRA = caries risk assessment SM = self management SDF = silver diamine fl uoride FV = fl uoride varnish

FIGURE 6. Flow diagram of the ECC chronic disease management protocol and the potential roles of dental team members.

and their families should be educated CDM is not a new concept. into day-to-day clinical care with and coached to understand the potential Featherstone introduced the caries patients can be challenging. In benefi ts and limitations of SDF treatment balance in 200035 and CRA tools addition, current dental information and the importance of dietary and plaque have been available, such as through systems (electronic dental records) control along with use of home-based CAMBRA21 and the American do not easily allow population dental fl uorides and/or other remineralizing agents. Academy of Pediatric Dentistry.2 health management and tracking of Barriers to routinely adopting CDM the oral health status of patients.36 Opportunities, Barriers and Limitations of caries into clinical dental practice While dental providers are of SDF and CDM include insurance reimbursement increasingly incorporating CRA Despite its recent introduction to the that traditionally favors surgical into patient care, many providers U.S. market, SDF is actually not new management of dental caries,36 lack are not offering risk-based treatment to dentistry. More research is needed of provider training36 and lack of recommendations in a systematic to better understand the full potential knowledge by and incentives for manner. Testing and implementing a benefi ts and limitations of SDF for use the public to seek risk-based disease CDM protocol on a small scale among in clinical practice. Due to its varying prevention and management care a limited group of clinical providers and degree of success to arrest dental caries, strategies.36 Although providers may clinical and administrative staff may the authors believe that SDF should be be familiar with CRA and CDM help gain greater long-term acceptance offered in the context of a CDM protocol. approaches, operationalizing them by practitioners and patients/parents.

JANUARY 2018 33 disease management

CDA JOURNAL, VOL 46, Nº1

Payment reform is needed to account on the caries balance. Pediatr Dent 2006;28(2):128-32; Member Center/FIles/topics_caries_under6.ashx. Accessed for the additional time needed for risk discussion 92–8. Jan. 4, 2016. 4. Chu CH, Lo EC. Promoting caries arrest in children with 21. Mei ML, Li QL, Chu CH, Yiu CK, Lo EC. The inhibitory assessment, effective communication silver diamine fl uoride: A review. Oral Health Prev Dent eff ects of silver diamine fl uoride at diff erent concentrations on and goal setting and professional 2008;6(4):315–21. matrix metalloproteinases. Dent Mater 2012;28(8):903–8. fl uoride treatments. SDF use may 5. Horst JA, Ellenikiotis H, Milgrom PL. UCSF Protocol 22. Ramos-Gomez FJ, Crall J, Gansky SA, Slayton RL, for Caries Arrest Using Silver Diamine Fluoride: Featherstone JD. Caries risk assessment appropriate for help to promote greater acceptance Rationale, Indications and Consent. J Calif Dent Assoc the age 1 visit (infants and toddlers). J Calif Dent Assoc of CDM of caries by providers and 2016;44(1):16–28. 2007;35(10):687–702. patients and families. Some insurance 6. Crystal YO, Niederman R. Silver Diamine Fluoride 23. Young DA, Novy BB, Zeller GG, et al. The American Treatment Considerations in Children’s Caries Management. Dental Association Caries Classifi cation System for plans have already begun reimbursing Pediatr Dent 2016;38(7):466–71. clinical practice: A report of the American Dental for SDF treatment, which can provide 7. Crystal YO, Janal MN, Hamilton DS, Niederman R. Association Council on Scientifi c Aff airs. J Am Dent Assoc some payments to offset costs. With Parental perceptions and acceptance of silver diamine 2015;146(2):79–86. fl uoride staining. J Am Dent Assoc 2017. 24. International Caries Detection and Assessment System more evidence demonstrating the 8. Llodra JC, Rodriguez A, Ferrer B, et al. Effi cacy of silver Coordinating Committee. Rationale and Evidence for the effectiveness and cost effectiveness of diamine fl uoride for caries reduction in primary teeth and fi rst International Caries Detection and Assessment System (ICDAS the risk-based CDM approach and SDF permanent molars of schoolchildren: 36-month clinical trial. J II). Reviewed 2011 (unchanged from 2005). www.icdas. Dent Res 2005;84(8):721–4. org/uploads/Rationale%20and%20Evidence%20ICDAS%20 treatment, along with movement by 9. Chu CH, Lo EC, Lin HC. Eff ectiveness of silver II%20September%2011-1.pdf. Accessed Sept. 20, 2017. payers to reimburse providers via pay diamine fl uoride and sodium fl uoride varnish in arresting 25. International Caries Detection and Assessment System. for performance payment methods, dentin caries in Chinese preschool children. J Dent Res What Is ICDAS? www.icdas.org/what-is-icdas ICDAS 2002;81(11):767–70. Foundation. Accessed Sept. 20, 2017. adoption of CDM may be accelerated 10. Duangthip D, Chu CH, Lo EC. A randomized clinical trial 26. Guideline on Fluoride Therapy. Pediatr Dent to become the future standard of care. on arresting dentine caries in preschool children by topical 2016;38(6):181–84. fl uorides — 18-month results. J Dent 2016;44:57–63. 27. Sjogren K, Birkhed D. Factors related to fl uoride retention 11. Yee R, Holmgren C, Mulder J, et al. Effi cacy of silver after toothbrushing and possible connection to caries activity. Conclusions diamine fl uoride for arresting caries treatment. J Dent Res Caries Res 1993;27(6):474–7. Chronic disease management 2009;88(7):644–7. 28. dos Santos AP, Nadanovsky P, de Oliveira BH. A of dental caries is grounded in an 12. Milgrom P, Horst JA, Ludwig S, et al. Topical systematic review and meta-analysis of the eff ects of fl uoride Silver Diamine Fluoride for Dental Caries Arrest in toothpastes on the prevention of dental caries in the primary understanding of caries as a chronic Preschool Children: A Randomized Controlled Trial and dentition of preschool children. Community Dent Oral biobehavioral disease. Disease control Microbiological Analysis of Caries Associated Microbes and Epidemiol 2013;41(1):1–12. requires meaningful engagement of Resistance Gene Expression. J Dent 2017. 29. American Academy on Pediatric Dentistry Council 13. Edelstein BL, Ng MW. Chronic Disease Management on Clinical Aff airs. Policy on the use of xylitol in caries patients and parents by the oral health Strategies of Early Childhood Caries: Support From prevention. Pediatr Dent 2008;30(7 Suppl):36–7. care team in a collaborative partnership the Medical and Dental Literature. Pediatr Dent 30. American Dental Association Council on Scientifi c in order to provide coaching toward 2015;37(3):281–7. Aff airs. Professionally applied topical fl uoride: Evidence- 14. Ng MW, Ramos-Gomez F, Lieberman M, et al. Disease based clinical recommendations. J Am Dent Assoc making and sustaining behavioral Management of Early Childhood Caries: ECC Collaborative 2006;137(8):1151–9. changes in the unique context of Project. Int J Dent 2014;2014:327801. 31. Slayton RL. Clinical Decision-Making for Caries their families and communities. The 15. Ng MW. Quality Improvement Eff orts in Pediatric Oral Management in Children: An Update. Pediatr Dent Health. J Calif Dent Assoc 2016;44(4):223–32. 2015;37(2):106–10. traditional dental delivery model 16. Institute for Healthcare Improvement. The Breakthrough 32. McKnight RA, Yost CC, Zinkhan EK, et al. Intrauterine needs to evolve to focus on systematic Series: IHI’s collaborative model for achieving breakthrough growth restriction inhibits expression of eukaryotic elongation risk assessment and risk-based improvement. IHI Innovation Series white paper. 2003. www. factor 2 kinase, a regulator of protein translation. Physiol ihi.org/resources/Pages/IHIWhitePapers/TheBreakthrough- Genomics 2016;48(8):616–25. management of the disease itself. SeriesIHIsCollaborativeModelforAchievingBreakthroughIm- 33. Section on Pediatric Dentistry and Oral Health. SDF should be considered as a tool in provement.aspx. Accessed Sept. 20, 2017. Preventive oral health intervention for pediatricians. the CDM toolbox; SDF can be used 17. Mei ML, Ito L, Cao Y, et al. The inhibitory eff ects of Pediatrics 2008;122(6):1387–94. silver diamine fl uorides on cysteine cathepsins. J Dent 34. Zhi QH, Lo EC, Lin HC. Randomized clinical trial on as a part of a CDM protocol with or 2014;42(3):329–35. eff ectiveness of silver diamine fl uoride and glass ionomer without restorative treatment. ■ 18. Ng MW, Torresyap G, White A, et al. Disease in arresting dentine caries in preschool children. J Dent management of early childhood caries: Results of a 2012;40(11):962–7. pilot quality improvement project. J Health Care Poor 35. Featherstone JD. The science and practice of caries REFERENCES Underserved 2012;23(3 Suppl):193–209. prevention. J Am Dent Assoc 2000;131(7):887–99. 1. Guideline on Restorative Dentistry. Pediatr Dent 19. Samnaliev M, Wijeratne R, Kwon EG, Ohiomoba H, 36. Fontana M, Wolff M. Translating the caries management 2016;38(6):250–62. Ng MW. Cost-eff ectiveness of a disease management paradigm into practice: Challenges and opportunities. J Calif 2. Guideline on Caries-Risk Assessment and Management program for early childhood caries. J Public Health Dent Dent Assoc 2011;39(10):702–8. for Infants, Children and Adolescents. Pediatr Dent 2015;75(1):24–33. 2016;38(6):142–49. 20. American Dental Association. Caries risk assessment THE CORRESPONDING AUTHOR, Man Wai Ng, DDS, MPH, can be 3. Featherstone JD. Caries prevention and reversal based form (age 0–6). 2011. www.ada.org/~/media/ADA/ reached at [email protected].

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CDA JOURNAL, VOL 46, Nº1 Managing Caries in the Primary Dentition With Silver Nitrate: Lessons Learned From a Clinical Trial

Michael J. Kanellis, DDS, MS; Arwa I. Owais, BDS, MS; John J. Warren, DDS, MS; Deborah V. Dawson, BA, ScM, PhD; Alberto Gasparoni, DDS, MS, PhD; Reem R. Oweis, BDS, MS; Mary Akers, RDA; Derek Blanchette, BA, MS; Matthew K. Geneser, DDS; Wei Liu, BDS, MS; Mary C. Skotowski, BS, MS; and Karin Weber-Gasparoni, DDS, MS, PhD

ABSTRACT “Lessons learned” are reported from a clinical trial comparing conventional restorative treatment to management of caries in the primary dentition using silver nitrate. Key fi ndings include: Silver nitrate provides an effective means for arresting caries in the primary dentition; some lesions progress and new lesions appear despite silver nitrate application; radiographs are important; there can be collateral benefi t with silver nitrate application; and interproximal application of silver nitrate can be a challenge.

AUTHORS

Michael J. Kanellis, Deborah V. Dawson, BA, Mary Akers, RDA, is a Wei Liu, BDS, MS, was ilver nitrate’s ability to arrest the DDS, MS, is associate ScM, PhD, is a professor in certifi ed dental assistant in a biostatistician at the caries process and simultaneously dean for patient care and biostatistics at the University pediatric dentistry at the University of Iowa College of prevent the formation of new a professor in pediatric of Iowa College of Dentistry University of Iowa College of Dentistry and Dental Clinics. dentistry at the University of and Dental Clinics. Dentistry and Dental Clinics. carious lesions has long been 1–6 Iowa College of Dentistry Cathy C. Skotowski, reported in the dental literature. and Dental Clinics. Alberto Gasparoni, DDS, Derek Blanchette, BA, BS, MS, is an assistant SThis ability is thought to derive from the MS, PhD, is the director of MS, is a biostatistician professor in pediatric combined effects of silver-salt-stimulated Arwa I. Owais, BDS, MS, the Admissions Clinic at the at the University of Iowa dentistry at the University of sclerotic or calcifi ed dentin formation is an associate professor University of Iowa College of College of Dentistry and Iowa College of Dentistry and silver nitrate’s potent germicidal in pediatric dentistry at the Dentistry and Dental Clinics. Dental Clinics. and Dental Clinics. 2,5,7 University of Iowa College of effect. As early as 1906, G.V. Black, the Dentistry and Dental Clinics. Reem R. Oweis, BDS, Matthew K. Geneser, Karin Weber-Gasparoni, father of modern dentistry, developed a MS, is a pediatric dentistry DDS, is an associate DDS, MS, PhD, is an protocol using multiple applications of John J. Warren, DDS, resident at the University of professor in pediatric associate professor and chair silver nitrate directly to carious lesions MS, is a professor in Iowa College of Dentistry dentistry at the University of in pediatric dentistry at the until they became hard and totally preventive and community and Dental Clinics. Iowa College of Dentistry University of Iowa College of 1 dentistry at the University of and Dental Clinics. Dentistry and Dental Clinics. arrested. The clinical use of silver nitrate Iowa College of Dentistry in dentistry fell out of favor by the early and Dental Clinics. Applies to all authors: 1960s.8 Recently however, there has been Confl ict of Interest Disclosure: renewed interest, especially as a means for None reported. managing caries in high-risk populations.9

JANUARY 2018 37 silver nitrate

CDA JOURNAL, VOL 46, Nº1

While multiple publications exist touting (no clear band of dentin on radiograph in the Kalona vicinity. The majority the effi cacy of silver nitrate in arresting between decay and pulp) were excluded of Amish living near Kalona are “old and preventing dental caries,3,4,10,11 to date from the study. Subject recruitment order,” with no electricity, no telephones no randomized clinical trials comparing began in November 2014 and ended in and relying on horse and buggies for silver nitrate to conventional treatment December 2016. Recruitment was largely transportation. When they need to have been reported in the literature. dependent on “word-of-mouth” contact travel further distances (e.g., for medical This manuscript reports on lessons between families in the Kalona area. Most or dental care), they typically hire a learned from a randomized clinical trial families contacted the study investigators driver from the community. Family size comparing the medical management of by phone and appointment times were is typically large, with an average of carious lesions in the primary dentition offered. Parents gave written consent for approximately eight children per family. using silver nitrate to conventional children to participate. Eligible subjects This population was selected for restorative treatment. Designed as a were randomly assigned (computer- the current study for several reasons. two-year clinical trial, at the time of this generated random-number list) to one Study investigators were looking for a manuscript preparation data collection of two treatment groups: conventional population of children with high caries was near completion but not fi nalized. rates who would also be dependable for Final data analysis will take place and follow-up care and visits throughout be reported following completion of the the duration of the study. Based on trial. This manuscript focuses on clinically To date no randomized previous experiences working with relevant lessons learned to date from this this population at the University of clinical trial that the authors believe will clinical trials comparing Iowa College of Dentistry and Dental be immediately helpful to clinicians and silver nitrate to conventional Clinics, the investigators believed the researchers alike. The authors hope to treatment have been Kalona Amish would provide ideal highlight some challenges in adopting study subjects. The Kalona Amish’s a medical model as the sole model for reported in the literature. high caries rates can be attributed to managing dental caries and suggest some lack of fl uoride (no fl uoridated drinking clinically relevant recommendations on water, relatively low use of fl uoridated appropriate case selection for this model toothpaste, infrequent dental visits), and the expectations from implementing restorative treatment (CON) including infrequent oral hygiene and frequent such interventions in children. composites, glass ionomers and stainless consumption of carbohydrates.12,13 steel crowns or treatment with silver nitrate The College of Dentistry and Dental Study Design and fl uoride varnish (SN). The ratio of Clinics’ experience with Amish This randomized clinical trial was random assignment was two SN for every patients has been that they are carried out by faculty and staff from the one CON based on the presumption reliable patients and family life is University of Iowa College of Dentistry and that more is known and understood typically stable with families remaining Dental Clinics in a privately owned dental about conventional treatment. Subject at the same address over time. clinic in Kalona, Iowa. The University of recruitment and follow-up are shown in The Amish community was Iowa’s Human Subjects Committee gave the consolidated standards of reporting approached about this study through a study approval (IRB # 201406792) and trials (CONSORT) diagram (FIGURE 1). letter to one of their church district’s the study was registered at clinicaltrials.gov bishops (Kalona has nine church (identifi er #: NCT02604134). Subjects Study Population districts). This bishop shared the in this study were Amish children living The study population consisted investigators’ written invitation to in the vicinity of Kalona, Iowa. Inclusion of Amish children from Kalona, Iowa. participate in this study at a meeting of criteria were: between the ages of 2 and 11, Kalona is a small rural community 20 the other bishops and responded in a no signifi cant health problems (ASA I or miles south of the University of Iowa. handwritten letter stating “… we were II) and caries into dentin in one or more The Amish settlement in Kalona agreed to announce the suggestion primary teeth. Teeth close to exfoliation began in the 1840s and today there that you made, but how the people will or with caries encroaching on the pulp are approximately 1,200 Amish living respond, we do not know, as it seems

38 JANUARY 2018 CDA JOURNAL, VOL 46, Nº1

Assessed for eligibility (n=103)

Enrollment Excluded (n=28) ■ Not meeting inclusion criteria (n=28) ■ Declined to participate (n=0) ■ Other reasons (n=0)

Randomized (n=85)

Allocation Allocated to silver nitrate group (n=59) Allocated to conventional group (n=26) ■ Received allocated intervention (n=59) ■ Received allocated intervention (n=23) ■ ■ Did not receive allocated intervention (n=0) Did not receive allocated intervention (parent request to receive silver nitrate) (n=3)

Follow-Up

Lost to follow-up (give reasons) (n=0) Lost to follow-up (give reasons) (n=0) Discontinued intervention (give reasons) (n=0) Discontinued intervention (give reasons) (n=0)

Analysis

Analyzed for baseline demographics (n=60) Analyzed for baseline demographics (n=25) Excluded from analysis (give reasons) (n=0) Excluded from analysis (give reasons) (n=0)

Analysis

Analyzed for 24-month follow-up (n=42) Analyzed for 24-month follow-up (n=22) ■ Excluded from analysis (not due for the ■ Excluded from analysis (not due for the 24-month recall) (n=18) 24-month recall) (n=3)

FIGURE 1. CONSORT 2010 fl ow diagram of Kalona silver nitrate study.

if our children do not complain of a Study Signifi cance control trial investigators proposed to toothache, we rarely see a dentist.” To In 2014, study investigators proposed compare the effectiveness of medical incentivize study participation, all dental the fi rst randomized clinical trial in management of caries using silver nitrate care was provided at a private local dental the U.S. to examine the feasibility and and fl uoride varnish to the conventional offi ce in Kalona (so patients could travel the effectiveness of silver nitrate in the restorative treatment in caries to appointments by horse and buggy) and medical management of dental caries in management among a cohort of Amish all treatment was provided free of charge. children. Through this pilot, randomized children. One of the primary outcomes of

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TABLE 1 Outcome Criteria for Procedures: Clinical Assessment in the Two Treatment Arms Conventional Restorative Group Silver Nitrate Group Primary Outcome: Successful

■ Restoration appears satisfactory (intact tooth surface adjacent to restoration, ■ Caries arrested (hardness/softness; lesion feels hard on gently probing stained margins consistent with noncarious lesions), the dentin), ■ No clinical signs or symptoms of pulpal pathology or ■ No clinical signs or symptoms of pulpal pathology or ■ Tooth exfoliated without minor or major failure ■ Tooth exfoliated without minor or major failure Primary Outcome: Minor Failure

■ Secondary caries (visible dentin in the interfacial space with signs of caries ■ Caries progression that required abandonment of SN protocol and requiring intervention) placement of a restoration ■ Restoration fracture or wear requiring intervention ■ Signs or symptoms of reversible pulpitis treated without requiring ■ Restoration loss pulpotomy or extraction ■ Signs or symptoms of reversible pulpitis treated without requiring pulpotomy or extraction Secondary Outcome: Major Failure

■ ■ Signs or symptoms of reversible pulpitis (no spontaneous pain) requiring Irreversible pulpitis (history of spontaneous pain or precipitated pain pulpotomy caused by thermal or other stimuli) or dental abscess requiring pulpotomy or extraction ■ Signs or symptoms of irreversible pulpitis (history of spontaneous pain or precipitated pain caused by thermal or other stimuli) or dental abscess ■ Restoration loss and tooth is unrestorable

interest was the major and minor failures carious lesions encroaching on the pulp and placement of a restoration. Due in both groups reported over the two-year or where a pulpotomy, pulpectomy or to generalized preferences of this study period. In other words, “will primary extraction were deemed necessary were population, amalgam restorations were teeth with carious lesions that are treated excluded from the study and treated not utilized during the study. Restorative with silver nitrate remain functional accordingly. Following determination materials that were utilized included and asymptomatic throughout the study of patient eligibility for the study, composite resins, resin-modifi ed glass period compared to conventionally informed consent was obtained from ionomers and stainless steel crowns. treated teeth?” TABLE 1 summarizes the the patient’s parent(s) and random major/minor failure outcome criteria assignment was made to either the CON Silver Nitrate Group for both study groups. Other outcomes or the SN group. Study participants The protocol promoted and used of interest included incidence of caries, then received a calibrated dental by Duffi n et al. (2012) was modifi ed patient quality of life, cost effectiveness examination using criteria developed for use in this management arm and and acceptability of treatment strategies. for the NIH-funded Early Childhood included the following: 1) Teeth to Caries Collaborating Centers.14 be treated were isolated with cotton Treatment Procedures rolls or Iso-shield isolation; 2) teeth Conventional Group were dried with compressed air; 3) 25% Treatment Providers Children in the CON group received silver nitrate solution (Silver Nitrate Treatment providers for this restorative dental care in alignment with Solution 25%, Gordon Laboratories, study consisted of three board- guidelines from the American Academy Upper Darby, Pa.) was placed directly certifi ed pediatric dentistry faculty of Pediatric Dentistry and local practice on the carious lesion using a microbrush members who were calibrated. within the department of pediatric applicator with a dabbing motion — At baseline examination, prior to dentistry at the University of Iowa. fi ve seconds per lesion; and 4) 5% group assignment, all children received This treatment typically included local sodium fl uoride (NaF) varnish was a conventional dental exam and anesthesia, caries removal using rotary immediately placed over the carious appropriate radiographs (bitewings and/ instruments (dental handpieces) or hand lesion to prevent the silver nitrate or occlusal radiographs). Teeth with excavation (using hand instruments) from being washed away by saliva.

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TABLE 2 Major and Minor Failures at 24 Months*

Silver Nitrate Group Conventional Group Total

Major Failure Minor Failure Major Failure Minor Failure Major Failure Minor Failure

17 / 237 5 / 237 3 / 93 0 / 93 20 / 330 5 / 330 to interact with modern society. The unit 7.2% 2.1% 3.2% 0% 6.1% 1.5% of an Amish society is the church district ruled by bishops.17 The current study was *Reported at the tooth level. able to successfully recruit children and their families because of support received Each carious lesion was treated in this parents expressed disappointment from the bishops of Kalona’s nine church way at monthly intervals for a total of because they were hoping for the silver districts. Further, in appreciation of three applications. At each six-month nitrate treatment. These subjects limited access to transportation, the study recall, all study teeth received a single were then offered the silver nitrate was conducted in a private dental offi ce additional application of silver nitrate. protocol and all four accepted and in Kalona that was readily accessible to Any new carious lesions diagnosed remained in the study and received this population by horse and buggy. at subsequent six-month recalls were the silver nitrate treatment protocol. Silver nitrate and fl uoride varnish provide treated with the baseline protocol, The results of these four subjects are an effective means for medically managing three applications of silver nitrate and included with CON group results due dental caries in the primary dentition. At fl uoride varnish one month apart. to “intention to treat analysis.”15,16 this preliminary stage, it seems that silver At the time of this manuscript nitrate works to arrest caries. After two Prevention (Both Groups) preparation, all 85 subjects remained years of follow-up, the majority of study Preventive procedures were in the study and 75 percent (64/85) lesions treated with SN were arrested. provided to both treatment groups of study subjects had completed their Caries activity (active versus arrested) was at six-month intervals in accordance 24-month recall examination. determined by visual and tactile sensation with AAPD guidelines including recall using a periodontal probe following examination, prophylaxis, oral hygiene Major and Minor Failures criteria described by Nyvad et al.18 Despite instruction, dietary counseling, fi ssure Major and minor failures are reported a small number of failures, most teeth sealant placement on permanent teeth by tooth in TABLE 2. In every case, are doing well (TABLE 2). At the time and fl uoride varnish application. All major failures were study teeth that of this manuscript preparation, 90.7 subjects were given a toothbrush. required extraction. Minor failures in percent of the SN group carious teeth are the conventional group included lost satisfactory (maintained in the mouth and Recall Examination fi llings or crowns, broken fi llings and symptomatic) compared to 96.8 percent Both groups were recalled at six-month recurrent caries that required replacement. of the CON group’s carious teeth. FIGURE intervals. At each six-month interval, new Minor failures in the silver nitrate group 2 provides a case example of a 6-year-7- radiographs were obtained (bitewings and/ included caries progression encroaching month-old (at baseline) female subject or occlusal radiographs as appropriate), on the pulp where silver nitrate was no from the SN group with radiographic calibrated examination took place and longer considered appropriate treatment. caries into dentine diagnosed on the distal preventive procedures were applied. These teeth received excavation of of tooth I, the mesial of tooth J and the caries and placement of a restoration. distal of tooth S. Following adherence to Results the silver nitrate protocol, these carious The study enrolled 85 children (mean Lessons Learned lesions did not progress throughout the age 7.16 ± 2.13 years) including 51 males Community engagement in planning study period, and teeth I and J actually (mean age 7.29 ± 2.28 years) and 34 and implementing research constitutes a appear to have reversed in progression. females (mean age 6.98 ± 1.19 years). cornerstone in the success of recruitment and A second case example of lack of caries Twenty-fi ve children were assigned to retention of a study population. The Amish progression following adherence to the the CON group (18 males, 7 females) population is a unique one; a culturally SN protocol is found in FIGURE 3. This and 60 children to the SN group (33 appropriate approach was crucial to the 9-year-4-month-old (at baseline) male males and 27 females). Following group successful recruitment and retention of subject is of special interest because the assignment, four children assigned to the study patients in this pilot clinical trial. carious lesions were deep and capable of CON group were immediately withdrawn This is due primarily to the conservative “packing food” at baseline and throughout from the study. In all four cases, their lifestyle of the Amish and their hesitation the study. Despite the extent of the decay,

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Baseline Baseline

6 months 6 months

12 months 12 months

24 months 18 months

FIGURE 2. Lack of caries progression over 24 months following SN treatment. 24 months

FIGURE 3. Deep carious lesions at baseline. Lack of caries progression over 24 months following SN treatment. this subject showed no signs or symptoms Silver nitrate doesn’t always prevent new Location and size of lesion matters. It is of caries progression or irreversible pulpitis caries. Contrary to what has previously worth noting that all major failures in this throughout the course of the study. been reported in the literature, silver study thus far have occurred in posterior Silver nitrate doesn’t always arrest all nitrate did not prevent new caries teeth. It could be that anterior teeth fare caries progression. Despite evidence that development in our study subjects. better than posterior teeth because they silver nitrate was successful in managing New carious lesions were found in 47.5 are more readily cleansable and do not approximately 90 percent of the lesions percent of the SN subjects throughout typically pack food. Posterior teeth on in the SN group, some lesions progressed the 24-month study period (TABLE 3). the other hand can pack food in either rapidly during the study period. FIGURE This is similar to the percent of the occlusal or interproximal open lesions and 4 provides a case example of a 4-year- CON group (52.0 percent) who also this creates an additional challenge for 8-month-old (at baseline) male subject experienced new carious lesions. caries arrest and prevention. An example with interproximal caries that progressed Radiographs are important. The of interproximal lesions packing food in a rapidly during the fi rst 12 months of majority of new carious lesions detected subject assigned to the silver nitrate group the study period, despite adherence to in this study were interproximal and is found in FIGURE 5. Food packing can also the silver nitrate protocol. It is unclear diagnosed by radiographs (TABLE 4). be uncomfortable and irritating to patients. at this time why some patients reacted In the SN group, 70.5 percent of the Collateral benefi t is present with the differently than others. The authors are new carious lesions were interproximal. silver nitrate intervention. When silver optimistic that some of the variability The percent was even higher for the nitrate is applied to carious lesions, can be explained following statistical CON group (90.9 percent). Of note is adjacent teeth can benefi t. FIGURE 6 analysis of all variables following the the previously discussed case (FIGURE provides a case example where tooth conclusion of the study. Key variables 2) where all of the carious lesions K had received the SN protocol for that may be explanatory could include were interproximal and none were distal caries and upon exfoliation it was diet and oral hygiene practices. detectable without radiographs. noted that the mesial surface of tooth

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Baseline

Interproximal application of SN can be a challenge. When this study was 6 months initiated, a decision was made to use a microfi ber brush to apply SN directly to accessible carious lesions. However, for interproximal carious lesions without direct access, SN was applied 12 months using either unwaxed dental fl oss or interproximal picks. Both of these interproximal applications methods can be problematic. With both of FIGURE 4. Rapid caries progression over 12 months following SN treatment. these delivery methods, a microfi ber brush saturated with SN was applied to

TABLE 3 either the unwaxed fl oss or picks as the devices were moved interproximally. New Carious Lesions Detected by 24 Months* Unwaxed fl oss can be unwieldy to use Silver Nitrate Group Conventional Group Total and therefore the risk of contamination N=59 N=25 N=84 of the fl oss with saliva is high, as is Subjects w/ Subjects no Subjects w/ Subjects no Subjects w/ Subjects no the inadvertent application of SN to new lesions new lesions new lesions new lesions new lesions new lesions unintended surfaces (lip, cheek, etc.). It is diffi cult to keep the carious lesion N (%) N (%) N (%) N (%) N (%) N (%) free from saliva contamination during 23 (47.5) 31 (52.5) 13 (52.0) 12 (48.0) 41 (48.8) 43 (51.2) application. To minimize this risk, a separate string of unwaxed fl oss was *Reported at the child level used for each interproximal lesion. With the picks, the risk of gingival TABLE 4 bleeding is high, which contaminates Location of New Carious Lesions by 24 months the SN solution. Because SN needs Interproximal NOT Interproximal Total to remain in contact with a carious (M,D) (O,F,B,L) lesion for an extended period of time to be effective,1 and because SN is a Silver Nitrate Group 43 (70.5%) 18 (29.5%) 61 (100%) water soluble solution that can be easily Conventional Group 20 (90.9%) 2 (9.1%) 22 (100%) washed away,19 it is important that the carious lesions being treated are dry and table 4 Location of New Carious Lesions by 24 months Total 63 (75.9%) 20 (24.1%) 83 (100%) remain dry throughout SN application.

Study Limitations No. 19 had hard black staining with no anterior teeth that may have visible or In considering fi ndings to date, radiographic evidence of caries. The preclinical white spot lesions. Silver bear in mind this was a small pilot application of SN to the carious primary nitrate is a clear liquid that easily study in a unique population, which molar K had arrested an undetected leaches onto other surfaces and can impacts the generalizability of our white spot lesion on the mesial surface unintentionally discolor teeth. An fi ndings. Moreover, the study is not of the adjacent permanent fi rst molar. example can be found in FIGURE 7 yet complete and the follow-up period Silver nitrate “leaches” and stains where a decalcifi ed permanent tooth was relatively brief. Nevertheless, the decalcifi ed lesions. Caution must be was inadvertently stained black when study has provided valuable insight taken when applying silver nitrate on silver nitrate was applied to the carious into the medical management of primary teeth adjacent to permanent interproximal (mesial) surface of tooth H. caries using silver nitrate. While

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FIGURE 5. Interproximal lesions packing food. FIGURE 6. Collateral benefi t of SN on mesial FIGURE 7. Example of SN “leaching” onto DF surface of permanent molar. surface of permanent lateral incisor.

patients in this study were assigned REFERENCES 17. McKusick VA. The Amish. Endeavour 1980;4(2):52–7. to an “either/or” treatment approach, 1. Black G. Application of silver nitrate. Dental Review 18. Nyvad B, Machiulskiene V and Baelum V. Reliability 1906;20:856. of a new caries diagnostic system differentiating this would not necessarily be the 2. Miller WD. Preventive effect of silver nitrate. D Cosmos between active and inactive caries lesions. Caries Res recommended treatment approach in 1905;47:901–13. 1999;33:252–260. clinical dentistry. Depending on the 3. Hyde EJ. Caries-inhibiting action of three different 19. Rosenblatt A, Stamford TC, Niederman R. Silver topically applied agents on incipient lesions in newly diamine fluoride: A caries “silver-fluoride bullet.” J Dent Res age and cooperation of the patient, erupted teeth: Results after 24 months. J Can Dent Assoc 2009;88(2):116–25. the size and location of the lesions 1973;39(3):189–93. and patient/parent preferences, it is 4. Englander HR, James VE, Massler M. Histologic effects THE CORRESPONDING AUTHOR, Michael J. Kanellis, DDS, MS, of silver nitrate of human dentin and pulp. J Am Dent Assoc can be reached at [email protected]. likely that a combined approach (SN 1958;57(5):621–30. and CON) may be more appropriate. 5. Howe P. A method of sterilizing and at the same time Finally, it is important to understand impregnating with a metal affected dentinal tissue. D Cosmos 1917;59:891–904. that at the time this study was initiated, 6. Arrington B. Nitrate of silver and its application. Ohio silver diamine fl uoride was not yet Dent J 1893;13:328–29. available for use in the U.S. While there 7. Klein H KJ. Studies on dental caries XIII: Effects of ammoniac silver nitrate on caries in the first permanent are many similarities between silver nitrate molars. J Am Dent Assoc 1942;29:420–27. followed by fl uoride varnish and silver 8. Duffi n S. Back to the future: The medical management of diamine fl uoride, there are also differences caries introduction. J Calif Dent Assoc 2012;40(11):852–8. 9. Dos Santos VE Jr., de Vasconcelos FM, Ribeiro AG, that could affect treatment outcomes. Rosenblatt A. Paradigm shift in the eff ective treatment of caries in schoolchildren at risk. Int Dent J 2012;62(1):47–51. Conclusion 10. Klein U, Kanellis MJ, Drake D. Effects of four anticaries agents on lesion depth progression in an in vitro caries The authors plan to publish fi nal model. Pediatr Dent 1999;21(3):176–80. results from this pilot clinical trial 11. Besinis A, De Peralta T, Handy RD. Inhibition of following study completion. Final biofilm formation and antibacterial properties of a silver nano-coating on human dentine. Nanotoxicology reporting will include statistical analysis 2014;8(7):745–54. of differences between treatment groups, 12. Heima M, Harrison MA, Milgrom P. Oral health and more in-depth analysis of effect of tooth medical conditions among Amish children. J Clin Exp Dent 2017;9(3):e338–e43. and surface on treatment outcomes, 13. Bagramian RA, Narendran S, Khavari AM. Oral health more in-depth analysis on radiographic status, knowledge and practices in an Amish population. J progression of carious lesions, reporting Public Health Dent 1988;48(3):147–51. 14. Warren JJ, Weber-Gasparoni K, Tinanoff N, et on outcome measures including patient/ al. Examination criteria and calibration procedures parent satisfaction and comparison of for prevention trials of the Early Childhood Caries time and cost by treatment group. ■ Collaborating Centers. J Public Health Dent 2015;75(4):317–26. 15. Hollis S, Campbell F. What is meant by intention to ACKNOWLEDGMENT treat analysis? Survey of published randomised controlled The authors acknowledge the Delta Dental of Iowa Foundation trials. BMJ 1999;319(7211):670–4. and the University of Iowa College of Dentistry and Dental 16. Hua F, Deng L, Kau CH, et al. Reporting quality Clinics for their support of this project. Research reported in this of randomized controlled trial abstracts: Survey of article was supported by the National Center for Advancing leading general dental journals. J Am Dent Assoc Translational Sciences of the National Institutes of Health under 2015;146(9):669–78.e1. Award Number U54TR001356.

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Use of Silver Diamine Fluoride for Dental Caries Management in Children and Adolescents, Including Those With Special Health Care Needs

Yasmi O. Crystal, DMD, MSc; Abdullah A. Marghalani, BDS, MSD, DrPH; Steven D. Ureles, DMD, MS; John Timothy Wright, DMD, MS; Rosalyn Sulyanto, DMD, MS; Kimon Divaris, DDS, PhD; Margherita Fontana, DDS, PhD; and Laurel Graham, MLS

AUTHORS

Yasmi O. Crystal, DMD, John Timothy Wright, Kimon Divaris, DDS, Laurel Graham, MLS, Abstract MSc, is the SDF workgroup DMD, MS, is the Bawden PhD, is an associate is a senior evidence-based chair. She is a clinical Distinguished Professor in professor in the department dentistry manager at Background associate professor of the department of pediatric of pediatric dentistry at the American Academy pediatric dentistry at New dentistry the University of the University of North of Pediatric Dentistry in This manuscript presents evidence- York University College of North Carolina School of Carolina School of Dentistry Chicago. based guidance on the use of 38% silver Dentistry. Dentistry at Chapel Hill in at Chapel Hill in Chapel diamine fl uoride (SDF) for dental caries Chapel Hill, N.C. Hill, N.C. All authors are fellows of management in children and adolescents, Abdullah A. Marghalani, the American Academy of including those with special health care BDS, MSD, DrPH, is a Rosalyn Sulyanto, DMD, Margherita Fontana, Pediatric Dentistry. pediatric dental fellow in the MS, is an instructor in DDS, PhD, is a professor needs. A guideline workgroup formed division of pediatric dentistry developmental biology at the in the department of To cite: Crystal YO, by the American Academy of Pediatric at the University of Maryland Harvard School of Dental cariology, restorative Marghalani AA, Ureles SD, Dentistry developed guidance and an Dental School in Baltimore. Medicine/Boston Children’s sciences and endodontics at et al. Use of silver diamine evidence-based recommendation regard- Hospital in Boston. the University of Michigan fl uoride for dental caries ing the application of 38% SDF to arrest Steven D. Ureles, DMD, School of Dentistry in Ann management in children MS, is an instructor in Arbor, Mich. and adolescents, including cavitated caries lesions in primary teeth. developmental biology at the those with special health Harvard School of Dental care needs. Pediatr Dent Types of studies reviewed Medicine/Boston Children’s 2017;39(5):E135-E145. The basis of the guideline’s Hospital in Boston. Copyright © 2017 American recommendation is evidence from an Academy of Pediatric Dentistry. All rights reserved. existing systematic review “Clinical trials of silver diamine fl uoride in arresting caries among children: A systematic review.” (JDR Clin Transl Res 2016;1[3]:201–10). A systematic search was conducted in PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials and gray literature databases to identify

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randomized controlled trials and systematic with special health care needs. Silver Health intents and expected benefi ts reviews reporting on the effect of silver diamine fl uoride in this guideline’s or outcomes. diamine fl uoride and address peripheral recommendation refers to 38% SDF, The guideline is based on analysis of issues such as adverse effects and cost. The the only formula available in the data included in a recent systematic review Grading of Recommendations Assessment, United States. These recommended and meta-analysis1 and summarizes evidence Development and Evaluation (GRADE) practices are based upon the best of the benefi ts and safety of SDF application approach was used to assess the quality of available evidence to date. However, in the context of dental caries management, the evidence and the evidence-to-decision the ultimate decisions regarding disease mainly its effectiveness in arresting framework was employed to formulate a management and specifi c treatment cavitated caries lesions†2 in the primary recommendation. modalities are to be made by the dental dentition. Its intent is to provide the best professional and the patient or his/ available information for practitioners Results her representative, acknowledging and patients or their representatives The panel made a conditional individuals’ differences in disease to determine the risks, benefi ts and recommendation regarding the use of 38% propensity, lifestyle and environment. alternatives of SDF application as part of SDF for the arrest of cavitated caries lesions a caries management program. Prevention in primary teeth as part of a comprehensive of new caries lesion development and caries management program. After The panel made a conditional outcomes in permanent teeth, such as root taking into consideration the low cost recommendation regarding caries lesion arrest, were not the focus of of the treatment and the disease burden this guideline; however, because they are of of caries, panel members were confi dent the use of 38% SDF for the interest and relevant to caries management that the benefi ts of SDF application arrest of cavitated caries within the scope of pediatric dentistry, in the target populations outweigh its lesions in primary teeth as they are mentioned and will be included possible undesirable effects. Per GRADE, part of a comprehensive in future iterations of the guideline as this is a conditional recommendation the supporting evidence base increases. based on low-quality evidence. caries management program. Clinical questions addressed. Conclusions and practical implications The panel members used the The guideline intends to inform the The guideline provides practitioners Population, Intervention, Control clinical practices involving the application with easy to understand evidence- and Outcome (PICO)3 formulation to of 38% SDF to enhance dental caries based recommendations. The develop the clinical questions that will management outcomes in children and American Academy of Pediatric aid practitioners in the use of SDF in adolescents, including those with special Dentistry’s (AAPD) evidence-based primary teeth with caries lesions. Does health care needs. These recommended guidelines are being produced in the application of SDF arrest cavitated practices are based upon the best available accordance with standards created by caries lesions as effectively as other evidence to-date. A 38% SDF protocol the National Academy of Medicine treatment modalities in primary teeth? is included in Appendix II (Pediatr Dent (formerly known as the Institute 2017;39(5):E135–E145). of Medicine) and mandated by the Methods National Guideline Clearinghouse This guideline adheres to the National Scope and Purpose (NGC), a database of evidence-based Academy of Medicine’s guideline standards4 The guideline intends to inform clinical practice guidelines and related and the recommendations of the Appraisal the clinical practices involving the documents maintained as a public of Guidelines Research and Evaluation application of silver diamine fl uoride resource by the Agency for Healthcare (AGREE) instrument.5 The guidance (SDF) to enhance dental caries Research and Quality (AHRQ) of presented is based on an evaluation of the management outcomes in children the U.S. Department of Health and evidence presented in a 2016 systematic and adolescents, including those Human Services (USDHHS). review published by Gao and colleagues.1

† A caries lesion is a detectable change in the tooth structure that results from the biofi lm-tooth interactions occurring due to the disease caries. It is the clinical manifestation (sign) of the caries process.

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TABLE 1 Quality of Evidence Grades‡ Grade Defi nition High We are very confi dent that the true eff ect lies close to that of the estimate of the eff ect.

Moderate We are moderately confi dent in the eff ect estimate: The true eff ect is likely to be close Search strategy. to the estimate of the eff ect, but there is a possibility that it is substantially diff erent. Literature searches were used to identify systematic reviews that would serve as the Low Our confi dence in the eff ect estimate is limited: The true eff ect may be substantially basis of the guideline. Secondly, the results diff erent from the estimate of the eff ect. of the searches served as sources of evidence Very Low We have very little confi dence in the eff ect estimate: The true eff ect is likely to be or information on issues related to, but substantially diff erent from the estimate of eff ect. outside the context of, the PICO, such as ‡ Quality of evidence is a continuum; any discrete categorization involves some degree of arbitrariness. Nevertheless, advantages cost, adverse effects and patient preferences. of simplicity, transparency and vividness outweigh these limitations. Literature searches were conducted Reprinted with permission. Quality of evidence and strength of recommendations. GRADE Handbook: Handbook for grading the in PubMed/MEDLINE, Embase, quality of evidence and the strength of recommendations using the GRADE approach. Update October 2013. Available at: http://gdt.guidelinedevelopment.org/app/handbook/handbook.html. Cochrane Central Register of Controlled Trials, gray literature and trial databases to identify systematic via the Grading of Recommendations bias is possible, especially because clinicians reviews and randomized controlled Assessment, Development and cannot be blinded with regard to SDF trials of SDF. Search results were Evaluation (GRADE) approach,6 a application (due to the dark staining).9,10 reviewed in duplicate at both the title widely adopted and peer reviewed system The absence of rigorous caries detection and abstract and the full-text level of evaluating study quality (TABLE 1). and activity measurement criteria in when warranted. Disagreements were The guideline recommendation is based the reviewed literature can decrease the resolved by consensus; if agreement on the meta-analysis of four controlled validity of the reported results.9,10 Other could not be reached, the AAPD trials (three randomized), extracted reviewers of the systematic review1 noted Evidence-Based Dentistry Committee in duplicate, from a systematic review similar and additional limitations.9,10 (EBDC) overseeing the workgroup of SDF.1 Randomized (RCTs) and was consulted to settle the question. controlled clinical trials (CCTs) offer Formulation of the recommendations. A detailed description of the search the highest level of clinical evidence; The panel formulated this guideline strategies is presented in Appendix I. therefore, a recommendation based on collectively via surveys, teleconferences a systematic review and meta-analysis and electronic communications from Inclusion and exclusion criteria. of graded RCTs/CCTs provides more January 2017–August 2017. The panel The criteria used to identify reliable and accurate conclusions that used the evidence-to-decision framework publications for use in the guideline were can be applied toward patient care. in an iterative manner to formulate determined by the clinical PICO question. This guideline is limited by the the recommendations. Specifi cally, the See Appendix I for search strategies. small number of RCTs evaluating SDF, main methods used were discussion, Publications which addressed the use of the heterogeneity of the included trials debate and consensus seeking.11 To reach SDF to arrest caries lesions in primary and selection bias that may have been consensus, the panel voted anonymously teeth, regardless of language, merited full- introduced by possibly poor sequence on all contentious issues and on the fi nal text review; in vitro studies and studies of generation7,8 and selective reporting by recommendation. GRADE was used to the use of SDF outside of the guideline’s one study.7 Weaknesses of this guideline determine the strength of the evidence.12 stated outcomes were excluded. No new are inherent to the limitations found in randomized controlled trials were identifi ed the systematic review1 upon which this Understanding the recommendations. that warranted updating the meta- guideline is based. Major limitations of GRADE rates the strength analysis found in the systematic review1 the supporting literature include lack of of a recommendation as either selected as the basis for this guideline. calibration and/or evidence of agreement strong or conditional. A strong for examiners assessing clinical outcomes recommendation “is one for which Assessment of the evidence. and unclear defi nitions or inconsistent guideline panel is confi dent that the The main strength of this guideline is criteria for caries lesion activity.9,10 desirable effects of an intervention that it is based on a systematic review of Arguably, without a valid and reliable outweigh its undesirable effects (strong prospective randomized and controlled method to determine lesion activity at recommendation for an intervention) trials of SDF.1 Evidence was assessed baseline and follow-up, misclassifi cation or that the undesirable effects of an

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TABLE 2 Implications of Strong and Conditional Recommendations for Different Users of Guidelines

Strong recommendation Conditional recommendation For patients Most individuals in this situation would want the The majority of individuals in this situation would want the suggested course of recommended course of action and only a small action, but many would not. proportion would not. For clinicians Most individuals should receive the recommended Recognize that diff erent choices will be appropriate for diff erent patients, and that course of action. Adherence to this recommendation you must help each patient arrive at a management decision consistent with her or according to the guideline could be used as a his values and preferences. Decision aids may well be useful helping individuals quality criterion or performance indicator. Formal making decisions consistent with their values and preferences. Clinicians should decision aids are not likely to be needed to help expect to spend more time with patients when working toward a decision. individuals make decisions consistent with their values and preferences. For policymakers The recommendation can be adapted as policy in Policymaking will require substantial debates and involvement of many most situations including for the use as performance stakeholders. Policies are also more likely to vary between regions. Performance indicators. indicators would have to focus on the fact that adequate deliberation about the management options has taken place.

Reprinted with permission. GRADE Handbook: Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. Update October 2013. Available at: http://gdt.guidelinedevelopment.org/app/handbook/handbook.html.

intervention outweigh its desirable suitability of the recommendation to (95% CI = 32 to 66) success rate in effects (strong recommendation individual patients. The strength of caries lesion arrest compared to the against an intervention).”6 A strong a recommendation presents different controls (76 percent versus 51 percent recommendation implies most implications for patients, clinicians arrested lesions, in absolute terms). In patients would benefi t from the and policymakers (TABLE 2). other words, 248 more cavitated caries suggested course of action (i.e., either lesions would be expected to arrest by for or against the intervention). A Recommendations treatment with SDF compared to control conditional recommendation “is one The SDF panel supports the use of 38% treatments, per 1,000 surfaces after at for which the desirable effects probably SDF for the arrest of cavitated caries lesions least 30 months follow-up. Considering outweigh the undesirable effects in primary teeth as part of a comprehensive the stratum with most data (n = 3,313 (conditional recommendation for an caries management program. (Conditional surfaces from three RCTs and one intervention) or undesirable effects recommendation, low-quality evidence) CCT, with follow-up of 24 months or probably outweigh the desirable effects more), similar estimates of relative and (conditional recommendation against Summary of Findings absolute effi cacy were produced (i.e., an intervention), but appreciable The recommendation is based RR 1.42 [95% CI = 1.17 to 1.72]) and uncertainty exists.”6 A conditional on data from a meta-analysis of data 72 percent versus 50 percent arrested recommendation implies that not extracted from RCTs and CCTs of lesions, in absolute terms. Other follow- all patients would benefi t from the SDF effi cacy with various follow-up up and application frequency strata intervention. The individual patient’s times and controls (TABLE 3). Based are listed in the summary of fi ndings circumstances, preferences and values on the pooled estimates of SDF group, (TABLE 3). The range of estimates of SDF need to be assessed more than usual. approximately 68 percent (95 percent effi cacy between the included trials was Practitioners need to allocate more confi dence interval [95% CI] = 9.7 categorically wide. Rates of arrest on time for consultation along with to 97.7) of cavitated caries lesions in untreated groups may seem unusually explanation of the potential benefi ts primary teeth would be expected to be high, and this may be due to background and harms to the patients and their arrested two years after SDF application fl uoride exposure. In one of the trials,7 caregivers when recommendations (with once or twice a year application). all participants (i.e., both the SDF- are rated as conditional. Practitioners’ Using data with longest follow-up treated and control children) received expertise and judgment as well time (at least 30 months follow-up; 0.2% sodium fl uoride (NaF) rinse every as patients’ and their caregivers’ n = 2,567 surfaces from one RCT7 and other week in school, while in other needs and preferences establish the one CCT8), SDF had 48 percent higher trials, children were either given fl uoride

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TABLE 3 Summary of Findings: Evidence for the Relative and Absolute Efficacy of SDF Application Compared to No SDF for the Arrest of Cavitated Caries Lesions on Primary Teeth* Patient or population: Children and adolescents with cavitated caries lesions on primary teeth Intervention: SDF (various periodicities) Comparison: No SDF (various controls, including active agents and treatment) Outcome: Caries arrest in primary teeth Follow-up time; Relative effi cacy, Absolute estimates, % arrested lesions Quality N surfaces (studies) RR (95% CI) (95% CI) Ω assessment No SDF SDF (other active controls or no treatment) 24 months; RR 1.45 47.9% 68.0% ⊕ΟΟΟ 746 surfaces (2 RCTs: Yee et al., 2009 & Zhi et al., 2012) ∨ (0.79 to 2.66) (3.8 to 95.6) A (9.7 to 97.7) VERY LOW a,b,c ≥ 24 months; 3313 surfaces (3 RCTs: Llodra et al., 2005, Yee et RR 1.42 49.6% 72.4% ⊕ΟΟΟ al., 2009 & Zhi et al., 2012., 1 CCT: Chu et al., 2002) ς (1.17 to 1.72) (28.8 to 70.5)C (48.0 to 88.1) VERY LOW a,d,e ≥ 30 months; RR 1.48 50.8% 76.4% ⊕⊕ΟΟ 2567 surfaces (1 CCT: Chu et al., 2002 & 1 RCT: Llodra et al., (1.32 to 1.66) (32.5 to 69.0)B (52.1 to 90.6) LOW a,b 2005.) Ξ semi-annual application RR 1.25 72.4 % 87.7% ⊕ΟΟΟ ≥ 24 months; (0.99 to 1.58) (47.2 to 88.5) A (80.9 to 92.4) VERY LOW a,d,e 1784 surfaces (2 RCTs: Llodra et al., 2005 & Zhi et al., 2012)

CCT= Controlled clinical trials; CI= Confi dence interval; RCTs= Randomized control trials; RR= Relative risks. * Rates of arrest on untreated groups may seem unusually high, ∨ Yee is once a year application of SDF, and Zhi is once a year A Comparisons included glass ionomer and no treatment. and this may be due to background fl uoride exposure. In one versus twice a year. B Comparisons included no treatment. C of the trials7, all participants (i.e., both the SDF-treated and ς Chu is once a year application of SDF, Llodra is twice a year, Comparisons included both A and B. control children) received 0.2 percent NaF rinse every other Yee is once a year, and Zhi is once a year versus twice a year. a At least one domain had ‘unclear’ risk of bias assessment. week in school, while in other trials, children were either given Ξ Chu is once a year application of SDF, Llodra is twice a year. b High heterogeneity. fl uoride toothpaste13 or reported use of fl uoride toothpaste.8 Ω The pooled eff ect estimates and confi dence intervals for the c Wide confi dence interval of the relative risk. relative risk and absolute percentages were derived from d Very high heterogeneity. random eff ect modeling. e Wide confi dence interval. toothpaste13 or reported use of fl uoride taking in consideration the low cost of sedation, general anesthesia). toothpaste.8 The panel determined the the treatment and the disease burden of These pathways of care have overall quality of the evidence for this caries, panel members were confi dent additional health risks and comparison was low or very low, owing that the benefi ts of SDF application limitations (e.g., possible effects to serious issues of risk of bias (unclear in the target populations outweigh its on brain development in young method for randomization, selective possible undesirable effects. Specifi cally: children, mortality risks16), and reporting and high heterogeneity) in 1. Untreated decay in young children often are not accessible, at all or the included studies. No studies were remains a challenge, from clinical in a timely manner.17–19 The U.S. identifi ed regarding the arresting effect and public health standpoints, Food and Drug Administration of SDF on cavitated caries lesions in in the U.S. and worldwide.14 It has issued a warning “that adult patients. The panel suggests that confers signifi cant health and repeated or lengthy use of general similar treatment effects may be expected quality of life impacts to children anesthetic and sedation drugs for other age groups, but the lack of and their families, and it is marked during surgeries or procedures evidence informing this recommendation by pronounced disparities.15 in children younger than three restrained the panel from providing 2. Surgical-restorative work in young may affect the development an evidence-based recommendation. children and those with special of children’s brains.”20 The panel made a conditional management considerations 3. The cost of managing severe early recommendation regarding the use of SDF (e.g., individuals with special childhood caries is disproportionally for the arrest of cavitated caries lesions in health care needs) often requires high, especially when hospitaliza- primary teeth as part of a comprehensive advanced pharmacologic behavior tion is necessary. The need to treat caries management program. After guidance modalities (e.g., children in a hospital setting with

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general anesthesia is a common Potential adverse effects. creates a temporary henna-appearing scenario in the U.S. and other Silver diamine fl uoride contains tattoo if allowed to come in contact with countries.21 Studies report that approximately 24–28% (weight/volume) skin). Skin pigmentation is temporary children from the less-affl uent silver and 5–6% fl uoride (weight/volume).23 because the silver does not penetrate the regions have higher dental surgery Exposure to one drop of SDF orally would dermis. Desquamation of the skin with rates than those from more affl uent result in less fl uoride ion content than is pigmentation occurs when keratinocytes communities (25.7 versus 6.9 present in a 0.25 mL topical treatment are shed over a period of 14 days.25 Silver per 1,000),17 which results in an of fl uoride varnish. The exact amount of diamine fl uoride also permanently stains economic burden for communities silver and fl uoride present in one drop of most surfaces (e.g., counters, clothing) already impacted by the effects of SDF is determined by the specifi c gravity with which it comes into contact. poverty-related health problems.19,22 of the liquid and the dropper used. More 4. With caries lesion arrest rates studies are required to determine that Guideline implementation. upwards of 70 percent (i.e., amount, given the stability of the product This guideline will be published in higher than other comparable manufactured and packaged in the U.S. the AAPD’s Reference Manual and interventions), SDF presents as an the journal, Pediatric Dentistry. Social advantageous modality. Besides its media, news items and presentations effi cacy, SDF is favored by its less The main disadvantage of will be used to notify AAPD invasive (clinically and in terms of SDF is its aesthetic result (i.e., members about the new guideline. behavior guidance requirements) This guideline will be available as an nature and its inexpensiveness. permanently blackens enamel open access publication on the AAPD’s 5. The undesirable effects of SDF and dentinal caries lesions and website. Patient education materials are (mainly aesthetic concerns due to creates a temporary henna- being developed and will be offered in the dark discoloration of carious SDF- AAPD’s online bookstore. See Appendix treated dentin) are outweighed appearing tattoo if allowed to II for practical SDF guidance and the by its desirable properties in come in contact with skin). Resource Section of the AAPD Reference most cases, while no toxicity or Manual for a SDF chairside guide.26 adverse events associated with its use have been reported. In published clinical trials Cost considerations. In sum, the panel felt confi dent encompassing more than 4,000 young Silver diamine fl uoride is an effective that a conditional recommendation children worldwide, exposure to and inexpensive means of arresting was merited because, although a manufacturer’s recommended amounts cavitated caries lesions in primary majority of patients would benefi t of SDF has not resulted in any reported teeth.27 It is inexpensive due to the from the intervention, individual deaths or systemic adverse effects. low cost of materials and supplies and circumstances, preferences and Oral absorption can include absorption relatively short chair time required for values need to be assessed by the in mucous membranes in the mouth and application. Nevertheless, an empirical practitioner after explanation and the nasal cavity. The short-term health cost analysis discussion for SDF would consultation with the caregiver. effects in humans as a result of exposure to need to address the several additional water or food containing specifi c levels of considerations and parameters. First, Research considerations. silver are unknown. The Environmental given the wide array of surgical and Research is needed on the use of Protection Agency (EPA) suggests levels nonsurgical management approaches for SDF to arrest caries lesions in both of silver in drinking water not to exceed cavitated caries lesions in the primary primary and permanent teeth. The 1.142 mg/L (1.42 ppm). Silver diamine dentition, agreement on consensus panel urges researchers to conduct fl uoride should not be used in patients endpoints and, therefore, total cost is well-designed randomized clinical trials with an allergy to silver compounds.24 challenging and controversial. Second, comparing the outcomes of SDF to The main disadvantage of SDF is its cost should include patient/family and other treatments for the arrest of caries aesthetic result (i.e., permanently blackens practitioner time, health care services lesions in primary and permanent teeth. enamel and dentinal caries lesions and utilized and cost of nonhealth impacts,

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if any. Third, SDF economic analyses Workgroup. Guideline updating process. are likely best approached via a cost- In December 2016, the AAPD’s The AAPD’s EBDC will monitor utility framework, wherein expenditures Board of Trustees approved a panel the biomedical literature to identify are juxtaposed to quality-adjusted or nominated by the EBDC to develop a new evidence that may impact the disease-free years. To illustrate the new evidence-based clinical practice current recommendations. These importance of defi ning a consensus guideline on SDF. The panel consisted recommendations will be updated fi ve treatment endpoint, in this scenario of general and pediatric dentists in years from the time the last systematic disease-free years can be interpreted as public and private practice involved search, unless the EBDC determines that caries inactive, no surgical intervention in research and education; the stake- an earlier revision or update is warranted. needed or pain-free years. Finally, the holders consisted of representatives FUNDING economic benefi ts of SDF application from general dentistry, dental hygiene, The preparation of this guideline was funded by the American must be considered in the context of governmental and nongovernmental Academy of Pediatric Dentistry, a dental specialty organization pathways of clinical care (i.e., disease agencies and international and with more than 10,000 members. management) and account, among specialty dental organizations. AUTHOR CONTRIBUTIONS other factors, for the risks and costs All authors contributed to the formation and drafting of associated with advanced behavior Stakeholders and external review. the guideline recommendations and the manuscript. Dr. Crystal served as chair of the workgroup and provided management techniques (e.g., indicated This guideline was reviewed by expert oversight. Dr. Marghalani provided statistical surgical-restorative work may require external and internal stakeholders support and created the GRADE tables. Ms. Graham sedation or general anesthesia in continuously from the beginning of the provided methodical support for the development of the guideline, including search strategy development. All authors some cases), families’ preferences process until the formulation of the contributed to the critical revision of the manuscript and and opportunity costs (e.g., time guideline. Stakeholders were invited approved the guideline. investment beyond the direct costs). to take part in anonymous surveys to DECLARATION OF INTEREST determine the scope and outcomes of Dr. Crystal is a member of the AAPD Editorial Board. Recommendation Adherence Criteria the guideline, bringing in points of view Dr. Divaris is a member of the AAPD Editorial Board. Dr. Guidelines are used by insurers, from different geographical regions, Marghalani is an ad hoc reviewer for Pediatric Dentistry. Dr. Sulyanto is an ad hoc reviewer for Pediatric Dentistry. Dr. patients and health care practitioners to dental specialties and patient advocates. Wright is a member of the AAPD Editorial Board. No other determine quality of care. In principle, Comments also were sought on the draft of confl icts of interested were reported. following best practices and guidelines the guideline. All stakeholder comments ACKNOWLEDGMENTS is believed to improve outcomes and were taken into consideration, addressed The authors wish to thank the American Academy of reduce inappropriate care.28 Therefore, and acted upon as appropriate per group Pediatric Dentistry, Chicago, Ill., USA, for their fi nancial measuring adherence to oral health- deliberation. Additional feedback from and administrative support, as well as the following for their assistance in the development of this guideline: related guidelines is key and can serve as stakeholders is expected after publication Mr. Brandon Buchholtz, AAPD EBD intern; Dr. Patricia manifestation of the dental community’s and dissemination of the guideline. Braun, American Academy of Pediatrics; Matt Crespin, role as a “responsible steward of oral MPH, RDH, American Dental Hygienists’ Association; 29 Ms. Mary Foley, Medicaid SCHIP Dental Association; Dr. health.” Though measurement of Intended users. Norman Tinanoff, American Dental Association; Dr. Jaana oral health outcomes is in its early The target audience for this guideline Gold, American Public Health Association, Oral Health days at both system and practice is general dentists, pediatric dentists, Section; Dr. Anne O’Connell, International Association of Pediatric Dentistry; Dr. Jack Toumba, European Academy of levels, system-level performance pediatricians and family practice Paediatric Dentistry; Dr. Allen Wong, American Academy of measures for some oral health areas physicians. Public and private payers will Developmental Medicine and Dentistry; Council on Clinical have been developed by the Dental benefi t from reviewing the evidence for Affairs, AAPD; Council on Scientific Affairs, AAPD; and Evidence-Based Dentistry Committee, AAPD. Quality Alliance of the American coverage decisions regarding SDF use, and Dental Association in partnership patients and patient advocates may fi nd it TRANSLATION AND CLINICAL REVIEW SERVICE with the AAPD and other dental useful as a reference for current available Yihong Li, DDS, MPH, DrPH, is a professor and director in the department of basic science and craniofacial biology at New organizations. The goals of professional treatments for caries management. The York University College of Dentistry. Kuniko Saeki, DDS, PhD, accountability, transparency and target populations include children is an associate adjunct professor, department of preventive oral health care quality can be and adolescents, including those and restorative sciences, UCSF School of Dentistry. furthered through these measures. with special health care needs.

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APPENDICES analy*[tw] OR metanaly*[tw] OR Appendix II — Practical Guidance* metaanaly*[tw] OR met analy*[tw] * Silver diamine fl uoride in this guideline’s Appendix I—Search strategies OR research overview*[tiab] OR recommendation refers to 38% SDF, the PubMed (MEDLINE) — no date limit collaborative review*[tiab] OR only formula available in the United States. collaborative overview*[tiab] Search 1. 145 results OR systematic review*[tiab] OR Setting cariestop OR “silver diamine comparative effi cacy[tiab] OR Practitioners must fi rst consider the fl uoride”[Supplementary Concept] OR comparative effectiveness[tiab] OR current standard of care of the setting “silver diamine” OR “silver diammine” outcomes research[tiab] OR systematic where SDF therapy is intended for use. OR “diamine fl uoride” OR “diammine overview*[tiab] OR methodological Silver diamine fl uoride is optimally fl uoride” OR saforide OR “Riva star” overview*[tiab] OR methodologic utilized in the context of a chronic overview* [tiab] OR methodological disease management protocol, one Search 2. 6,589,771 results review*[tiab] OR methodologic that allows for the monitoring of the (randomized controlled trial[pt] review*[tiab] OR quantitative clinical effectiveness of SDF treatment, OR controlled clinical trial [pt] OR review*[tiab] OR quantitative disease control and risk assessment. randomi*[tiab] OR randomization[tiab] overview*[tiab] OR quantitative Practical recommendation: Know OR randomisation[tiab] OR placebo[tiab] synthes*[tiab] OR pooled analy*[tiab] the setting where SDF is to be used to OR drug therapy[sh] OR randomly[tiab] OR Cochrane[tiab] OR Medline[tiab] be consistent with goals of patient- OR trial[tiab] OR groups[tiab] OR OR Pubmed [tiab] OR Medlars[tiab] centered care. Clinical trial[pt] OR “clinical trial”[tw] OR handsearch*[tiab] OR hand search* OR “clinical trials”[tw] OR “evaluation [tiab] OR meta-regression*[tiab] Indications and usage studies”[Publication Type] OR OR metaregression*[tiab] OR data The following scenarios may be “evaluation studies as topic”[MeSH synthes*[tiab] OR data extraction[tiab] well-suited for the use of SDF: Terms] OR “evaluation study”[tw] OR OR data abstraction*[tiab] OR mantel ■ High caries-risk patients evaluation studies[tw] OR “intervention haenszel[tiab] OR peto[tiab] OR with anterior or posterior studies”[MeSH Terms] OR “intervention dersimonian[tiab] OR dersimonian[tiab] active cavitated lesions. study”[tw] OR “intervention studies”[tw] OR fi xed effect* [tiab] OR “Cochrane ■ Cavitated caries lesions OR “cohort studies”[MeSH Terms] OR Database Syst Rev”[Journal]) in individuals presenting cohort[tw] OR “longitudinal studies”[MeSH with behavioral or medical Terms] OR “longitudinal”[tw] OR Search 5. 14 results management challenges. longitudinally[tw] OR “prospective”[tw] 1 and 4* ■ Patients with multiple cavitated OR prospectively[tw] OR “follow up”[tw] caries lesions that may not OR “comparative study”[Publication Search 6. 890,576 results all be treated in one visit. Type] OR “comparative study”[tw] (“Economics”[Mesh] OR “Cost of ■ Diffi cult to treat cavitated OR systematic[subset] OR “meta- Illness”[Mesh] OR “Cost Savings”[Mesh] dental caries lesions. analysis”[Publication Type] OR “meta- OR “Cost Control”[Mesh] OR ■ Patients without access to or with analysis as topic” [MeSH Terms] OR “meta- “Cost-Benefi t Analysis”[Mesh] OR diffi culty accessing dental care. analysis”[tw] OR “meta-analyses” [tw]) “Health Care Costs”[Mesh] OR ■ Active cavitated caries NOT (animals [mh] NOT humans [mh]) “Direct Service Costs”[Mesh] OR lesions with no clinical signs “economics”[Subheading] OR cost)) of pulp involvement. Search 3. 14 results 1 and 2 Search 7. Eight results Practical recommendation: SDF is a 1 AND 6 valuable caries lesion–arresting tool Search 4. 410,530 results * Search results vetted in duplicate that can be used in the context of caries (systematic[sb] OR meta-analysis[pt] using an evidence-based minimum set management. Evaluate carefully which OR meta-analysis as topic[mh] of items for reporting in systematic patients/teeth will benefi t from SDF OR meta-analysis[mh] OR meta reviews and meta-analyses checklist. application.

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Preparation of patients and practitioners ■ Dry with a gentle fl ow Postoperative instructions Informed consent, particularly of compressed air (or use No postoperative limitations are listed highlighting expected staining of treated cotton rolls/gauze to dry by the manufacturer. Eating and drinking lesions, potential staining of skin and affected tooth surfaces.) immediately following application is clothes and need for reapplication for ■ Bend micro sponge brush, dip acceptable. Patients may brush with disease control, is recommended. and dab on the side of the fl uoridated toothpaste as per regular The following practices are dappen dish to remove excess routine following SDF application. presented to support patient safety liquid before application;24 Several SDF clinical trials and effectively use SDF: apply SDF directly to only recommended no eating or drinking for ■ Universal precautions. the affected tooth surface. 30 minutes to one hour.13,31,32 As patients ■ No operative intervention (e.g., ■ Dry with a gentle fl ow are used to these recommendations for affected or infected dentin removal) of compressed air for at in-offi ce topical fl uoride applications, the is necessary to achieve caries arrest.8 least one minute. recommendation may not be unreasonable ■ Protect patient with plastic-lined ■ Remove excess SDF with gauze, to patients and it may allow for better bib and glasses. cotton roll or cotton pellet to arrest results. More clinical studies are ■ Cotton roll or other minimize systemic absorption.4 needed to establish best practices. isolation as appropriate. Continue to isolate site for up to ■ Use a plastic dappen dish as three minutes when possible. Application frequency SDF corrodes glass and metal. The effectiveness of one-time SDF ■ Carefully dispose of gloves, Practical recommendation: No need application in arresting dental caries cotton rolls and micro brush for surgical intervention (e.g., dentin lesions ranges from 47 percent to into plastic waste bag. excavation). SDF application is 90 percent, depending on the lesion minimally invasive and easy for the size and the location of the tooth Application patient and the practitioner. It may and the lesion. One study showed Carious dentin excavation prior be desirable for the caries lesion to be that anterior teeth had higher rates to SDF application is not necessary.8 free of gross debris for SDF to have of caries lesion arrest than posterior Caries dentin excavation may reduce maximum contact with the affected teeth.33 The effectiveness of caries proportion of arrested caries lesions dentin surface. lesion arrest, however, decreases over that become black, and may be time. After a single application of considered for aesthetic purposes.30 Application time 38% SDF, 50 percent of the arrested Functional indicator of effectiveness An application time of one minute, surfaces at six months had reverted (i.e., caries arrest) is when staining on drying with a gentle fl ow of compressed to active lesions at 24 months.13 dentinal carious surfaces is visible. air, is recommended. Clinical studies Reapplication may be necessary to The following steps may vary report application times range from 10 sustain arrest.8,31–33 Annual application depending on differing practices, seconds to three minutes. A current of SDF is more effective in arresting settings and patients: review states that application time in caries lesions than application of 5% ■ Remove gross debris from clinical studies does not correlate to sodium fl uoride varnish four times cavitation to allow better SDF outcome.24 More studies are needed per year.30 Increasing frequency of contact with denatured dentin. to confi rm an ideal protocol. application can increase caries arrest ■ Minimize contact with gingiva rate. Biannual application of SDF and mucous membranes to avoid Practical recommendation: Ideal time of increased the rate of caries lesion arrest potential pigmentation or irritation; application should be one minute, using a compared to annual application.33 consider applying cocoa butter gentle fl ow of compressed air until liquid Studies that had three times per year or use cotton rolls to protect is dry. When using shorter application applications showed higher arrest surrounding gingival tissues, with periods, monitor carefully at postop and rates.7,31,33,34 Frequency of application care to not inadvertently coat the recare to evaluate arrest and consider after baseline has been suggested surfaces of the carious lesion. reapplication. at three-month follow up and then

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semiannual recall visits over two years.24 The following adverse effects ■ Caries arrest is more likely on the One option is to place SDF on active have been noted in the literature: maxillary anterior teeth8,31 and lesions in conjunction with fl uoride ■ Metallic/bitter taste.24 buccal/lingual smooth surfaces.31 varnish (FV) on the rest of the dentition ■ Temporary staining to skin, which ■ Pretreatment of dentin with or alternate SDF on caries lesions and resolves in two to 14 days.24 SDF does not adversely FV on the rest of the dentition at three ■ Mucosal irritation/lesions resulting affect bond strength of resin months interval to achieve arrest and from inadvertent contact with composite to dentin.41,42 ■ prevention in high-risk individuals.35 SDF, resolved within 48 hours.7 REFERENCES Another study recommends one-month 1. Gao S, Zhao I, Hiraishi N, et al. Clinical trials of silver postoperative evaluation of treated Aesthetics diamine fluoride in arresting caries among children: A lesions with optional reapplication The hallmark of SDF is a visible dark systematic review. JDR Clin Transl Res 2016;1(3):201– 10. as required to achieve arrest of all staining that is a sign of caries arrest 2. Longbottom C, Huysmans M-C, Pitts N, Fontana M. targeted lesions.35 Individuals with on treated dentin lesions. This dark Glossary of key terms. In: Detection, Assessment, Diagnosis high plaque index and lesions with discoloration is permanent unless restored. and Monitoring of Caries. vol 21. Karger. Basel, N.Y.; 2009:209–16. Cited by Fontana M, Young DA, Wolff MS, plaque present display lower rates of A recent study that assessed parental Pitts NB, Longbottom C. Defining dental caries for 2010 arrest. Addressing other risk factors like perceptions and acceptance of SDF based and beyond. Dent Clin North Am 2010;54(3):423–40. presence of plaque may increase the rate on the staining found that staining on 3. Richardson WS, Wilson MC, Nishikawa J, Hayward RS. 33 The well-built clinical question: A key to evidence-based of successful treatment outcomes. posterior teeth was more acceptable than decisions. ACP J Club 1995;123(3):A12–13. Practical recommendation: If the on anterior teeth.40 Although staining on 4. Institute of Medicine. Clinical Practice Guidelines We setting allows, monitor caries lesion anterior teeth was perceived as undesirable, Can Trust. 2011. www.nationalacademies.org/hmd/ Reports/2011/Clinical-Practice-Guidelines-We-Can- arrest after two to four week period most parents preferred this option to avoid Trust.aspx. Accessed July 10, 2017 (archived at www. and consider reapplication as necessary the use of advanced behavioral guidance webcitation.org/6tSSpIh8C). to achieve arrest of all targeted techniques such as sedation or general 5. Brouwers MC, Kerkvliet K, Spithoff K. The AGREE Reporting Checklist: A tool to improve reporting of clinical lesions. Provide recare monitoring anesthesia to deliver traditional restorative practice guidelines. BMJ 2016;352:i1152. based on patient’s disease activity care. It was also found that about one- 6. Schünemann H, Brożek J, Guyatt G, Oxman A. Quality and caries risk level (every three, four third of parents found SDF treatment of evidence. GRADE Handbook: Handbook for grading the quality of evidence and the strength of recommendations or six months). Careful monitoring unacceptable under any circumstance using the GRADE approach. Update October 2013. and behavioral intervention to due to aesthetic concerns. To identify The GRADE Working Group. gdt.gradepro.org/app/ reduce individual risk factors should those patients, a thorough in-formed handbook/handbook.html#h.9rdbelsnu4iy. Accessed July 10, 2017 (archived at www.webcitation.org/6tzYunbTc). be part of a comprehensive caries consent, preferably with photographs that 7. Llodra JC, Rodriguez A, Ferrer B, Menardia V, Ramos management program that aims not show typical staining, is imperative.40 To T, Morato M. Efficacy of silver diamine fluoride for caries only to sustain arrest of existing improve aesthetics, once the disease is reduction in primary teeth and first permanent molars of schoolchildren: 36-month clinical trial. J Dent Res 2005; caries lesions, but also to prevent controlled and patient’s circumstances 84(8):721–4. new caries lesion development. allow, treated and now-arrested cavitated 8. Chu CH, Lo ECM, Lin HC. Effectiveness of silver caries lesions can be restored.35 diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese preschool children. J Dent Res Adverse reactions 2002;81(11):767–70. No severe pulpal damage or Other considerations 9. Cheng LL. Limited evidence suggesting silver diamine reaction to SDF has been reported.7,36–38 ■ Coding — D1354. fluoride may arrest dental caries in children. Br Dent J 2017;222(7):516. However, SDF should not be placed on Reimbursement for this 10. Gold J. Limited evidence links silver diamine fluoride exposed pulps. Teeth with deep caries procedure varies among states and caries arrest in children. J Evid Based Dent Pract lesions should be closely monitored and carriers. Third-party payers’ 2017;17(3):265–7. 11. Alonso-Coello P, Oxman AD, Moberg J, et al. GRADE clinically and radiographically. coverage is not consistent on Evidence to Decision (EtD) frameworks: A systematic and Serum concentration of fl uoride the use of this code per tooth transparent approach to making well informed healthcare following SDF application per or per visit. Practitioners are choices. 2: Clinical practice guidelines. BMJ 2016;353: i2089. manufacturer recommendations posed cautioned to check insurance 12. Atkins D, Best D, Briss PA, et al. Grading quality little toxicity risk and was below EPA coverage for this code as it is of evidence and strength of recommendations. BMJ oral reference dose in adults.39 transitioning in most areas. 2004;328 (7454):1490.

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13. Yee R, Holmgren C, Mulder J, Lama D, Walker D, van and evaluation in health care. Can Med Assoc J Palenstein Helderman W. Efficacy of silver diamine fluoride 2010;182(18):E839–E842. for arresting caries treatment. J Dent Res 2009;88(7): 29. Dental Quality Alliance. Quality measurement in 644–7. dentistry: A guidebook. June 2016. www.ada.org/~/ 14. Listl S, Galloway J, Mossey P, Marcenes W. media/ADA/Science%20and%20Research/Files/ Global economic impact of dental diseases. J Dent Res DQA_2016_Quality_Measurement_in_Dentistry_ 2015;94(10):1355–61. Guidebook.pdf?la=en. Accessed July 17, 2017 (archived 15. Chaffee BW, Rodrigues PH, Kramer PF, Vítolo MR, at www.webcitation.org/6tSTwCrac). Feldens CA. Oral health-related quality-of-life scores 30. Lo EC, Chu CH, Lin HC. A community-based differ by socioeconomic status and caries experience. caries control program for preschool children using Community Dent Oral Epidemiol 2017;45(3):216–24. topical fluorides: 18-month results. J Dent Res 16. Owings L. Toothache Leads to Boy’s Death. ABC 2001;80(12):2071–4. News. March 5, 2007. www.abcnews.go.com/Health/ 31. Zhi QH, Lo ECM, Lin HC. Randomized clinical trial on Dental/story?id=2925584&page=1. Accessed July 10, effectiveness of silver diamine fluoride and glass ionomer 2017 (archived at www.webcitation.org/6tSTH5RQa). in arresting dentine caries in preschool children. J Dent 17. Schroth RJ, Quiñonez C, Shwart L, Wagar B. Treating 2012;40(11):962–7. early childhood caries under general anesthesia: A 32. Dos Santos VEJ, de Vasconcelos FMN, Ribeiro AG, national review of Canadian data. J Can Dent Assoc Rosenblatt A. Paradigm shift in the eff ective treatment of 2016;82(g20):1488–2159. caries in schoolchildren at risk. Int Dent J 2012;62(1):47–51. 18. Griffin SO, Gooch BF, Beltrán E, Sutherland JN, Barsley 33. Fung M, Duangthip D, Wong M, Lo E, Chu C. R. Dental services, costs and factors associated with Arresting dentine caries with different concentration and hospitalization for Medicaid-eligible children, Louisiana periodicity of silver diamine fluoride. JDR Clin Transl Res 1996–97. J Public Health Dent 2000;60(1):21–7. 2016;1(2):143–52. 19. Nagarkar SR, Kumar JV, Moss ME. Early childhood 34. Duangthip D, Chu CH, Lo ECM. A randomized clinical caries-related visits to emergency departments and trial on arresting dentine caries in preschool children by ambulatory surgery facilities and associated charges in topical fl uorides — 18 month results. J Dent 2016;44:57–63. New York state. J Am Dent Assoc 2012;143(1):59–65. 35. Crystal YO, Niederman R. Silver diamine fluoride 20. U.S. Food and Drug Administration. FDA Drug Safety treatment considerations in children’s caries management. Communication: FDA review results in new warnings about Pediatr Dent 2016;38(7):466–71. using general anesthetics and sedation drugs in young 36. Nishino M, Yoshida S, Sobue S, Kato J, Nishida M. children and pregnant women. Dec.14, 2016. www.fda. Effect of topically applied ammoniacal silver fluoride gov/Drugs/DrugSafety/ucm532356.htm. Accessed Aug. on dental caries in children. J Osaka Univ Dent Sch 21, 2017 (archived at www.webcitation.org/6tSTX1twl). 1969;9:149–55. 21. Hicks CG, Jones JE, Saxen MA, et al. Demand in 37. Okuyama T. [On the penetration of diammine silver pediatric dentistry for sedation and general anesthesia by fluoride into the carious dentin of deciduous teeth (author’s dentist anesthesiologists: A survey of directors of dentist transl)]. Shigaku Odontol J Nihon Dent Coll 1974;61(6): anesthesiologist and pediatric dentistry residencies. Anesth 1048–71. Prog 2012;59(1):3–11. 38. Gotjamanos T. Pulp response in primary teeth with 22. Liu J, Probst JC, Martin AB, Wang J-Y, Salinas CF. deep residual caries treated with silver fluoride and glass Disparities in dental insurance coverage and dental care ionomer cement (‘atraumatic’ technique). Aust Dent J among U.S. children: The National Survey of Children’s 1996;41(5):328–34. Health. Pediatrics 2007;119(Supplement 1):S12–S21. 39. Vasquez E, Zegarra G, Chirinos E, et al. Short-term 23. Mei ML, Chu CH, Lo ECM, Samaranayake LP. Fluoride serum pharmacokinetics of diammine silver fluoride after and silver concentrations of silver diammine fluoride oral application. BMC Oral Health 2012;12:60. solutions for dental use. Int J Paediatr Dent 2013;23(4): 40. Crystal YO, Janal MN, Hamilton DS, Niederman R. 279–85. Parental perceptions and acceptance of silver diamine 24. Horst JA, Ellenikiotis H, Milgrom PL. UCSF protocol fluoride staining. J Am Dent Assoc 2017;148(7):510–8. for caries arrest using silver diamine fluoride: Rationale, 41. Quock RL, Barros JA, Yang SW, Patel SA. Effect of indications and consent. J Calif Dent Assoc 2016;44(1): silver diamine fluoride on microtensile bond strength to 16–28. dentin. Oper Dent 2012;37(6):610–6. 25. Jackson SM, Williams ML, Feingold KR, Elias PM. 42. Selvaraj K, Sampath V, Sujatha V, Mahalaxmi S. Pathobiology of the stratum corneum. West J Med Evaluation of microshear bond strength and nanoleakage 1993;158(3):279. of etch-and-rinse and self-etch adhesives to dentin 26. American Academy of Pediatric Dentistry. Chairside pretreated with silver diamine fluoride/potassium iodide: guide: Silver diamine fluoride in the management of dental An in vitro study. Indian J Dent Res 2016;27(4):421–5. caries lesions. Pediatr Dent 2017;39(6)478–9. 27. Alliance for Cavity Free Future. Silver fluoride and THE CORRESPONDING AUTHOR, Laurel Graham, MLS, can be silver diamine fluoride. www.allianceforacavityfreefuture. reached at [email protected]. org/en/us/technologies/silver-diamine. Accessed July 10, 2017 (archived at www.webcitation.org/6tSTiB5p8). 28. Brouwers MC, Kho ME, Browman GP, et al. AGREE II: Advancing guideline development, reporting

JANUARY 2018 55 Specializing in selling and appraising dental practices for over 40 years!

LOS ANGELES COUNTY ORANGE COUNTY RIVERSIDE & SAN BERNARDINO COUNTIES CARSON— Long established GP in a small shopping ANAHEIM— Established in 1960’s this pracce is BEAUMONT—GP + Real Estate. Modern GP w/ 6 eq center. Grossed $234K in 2016. Has 5 eq ops. Rer- on a single story bldgSOLD w/ 4 eq ops. Grossed $735K ops in 2,400 sq offiSOLDce. Could be two suites. Grossed ing seller work 3 days/wk. Property ID #5181. in 2016. Net $308K. Property ID #5187. $960K in 2016. Property ID #5182. LA MIRADA - GP established circa 1963 located in a BREA— Beauful well established pracce located CHINO—Real Estate Only! This a rare opportunity to 2 story med prof bldg. Consists of 5 eq ops. Grossed on a corner locaon. Has 8 equipped ops and 3 approx. $408K in 2016. Property #5119. chairs in open bay. Grossed $1.5M. On a busy purchase a condo located in a single story strip mall. major street of the city. Property ID #5190. Has been a dental pracce for 40 years. Property ID LA VERNE— Est. in 1980 w/ 4 eq op in a 1, 250 sq . 5076. Grossing approx. $64K/mo. Net of $195K. PPO & BREA— GP + Bldg. Well established pracce w/4 Cash Only! Property ID #5196. eq ops & 2 plmbd not eq. PPO & Cash Only. DESERT HOT SPRINGS— GP + Real Estate! Two Grossed $683K in 2016. Property ID #5197. LOS ANGELES - Price Adjustment! GP w/ 40 years of partners one office. Consists of 4 eq ops / 1 plmbd goodwill. In a 10 story medical/dental bldg. Has 4 eq COSTA MESA - COMING SOON!! not eq. Est. in 1986. Proj. approx. $802K for 2017. ops with views to theSOLD mountains. PPO/Cash/Medi- Property ID #5198. cal/CAP. Grossed $670K in 2016. Net of $166K. FOUNTAIN VALLEY—GP in busy strip mall. Has Property ID #5107. approx. 27 years of goodwill. Grossed $344K in FONTANA— GP + Real Estate!! Premier office with 2016. Net of $136K. Property ID #5165. 50 years of goodwill. In a 3,000 sq bldg with 8 eq LOS ANGELES - GP established in 1968 in a 6 story ops. Has the latest technology. Grossed approx. bldg. NO HMO. Has 4 eq ops in a 1,211 sq suite. LAGUNA HILLS— With over 30 yrs of goodwill this SOLD Grossed approx. $531K in 2016. Property ID #5163. GP is located in a 2 story med bldg. Has 5 eq ops in $2.3M in 2016. Net of $968K. Property ID #5140. a 1,600 sq suite.SOLD Grossed approx. $304K for HEMET GP + Condo Suite Has over 40 years of MONTEREY PARK— COMING SOON! 2016. Property ID #5127. goodwill to officer. Icon in the community. Located in MOTEBELLO—Grossed approx. $1.1M in 2016, MISSION VIEJO (TURN-KEY) Modern designed GP a single story tri-plex condo bldg. Has 4 eq ops . No located in a free standing bldg w/ 5 eq ops. Estab- located in a 2 story med/dent bldg. Has 3 eq / 3 Den-cal. Net of $143K. Property ID #5152. lished in 2002. Property ID #5168 plmbd for expansion. Property ID #5138. PASADENA - Located in the heart of Pasadena w/ 60 PALM SPRINGS – General pracce with 3 equipped TUSTIN— Beauful GP NET OF $159K. Prop. #5199. years of goodwill. GrossedSOLD approx. $616K in 2016. ops located in a free standing bldg. Established in Has 3 eqs ops in a 1,150 sq suite. Property ID WESTMINSTER— GP established in 1983 in a 2 2005. Suite is approx. 1,200. Seller work 5 days/wk. #5147. story building. Has 3 eq ops in 1,300 sq suite. BUYER’S NET OF $153K. Property ID #4487. VALENCIA — GP + Spec office with 9 eq ops in a busy Next to residenal area on a busy street. Grossed RANCHO CUCAMONGA— GP established in 2004 in single shopping center. Grossed $1.6M in 2016. $183K IN 2016. Net $61K. Property ID # 5194. Property ID #5171. SOLD busy shopping center. Consists of 3 eq ops in a 1,200 sq suite. Grossed $747K in 2016. Net $251K. Prop- WALNUT PARK - Established in 1968 GP in free erty ID #5169. standing bldg. Opon to buy bldg. Grossed $531K in 2016. Net $166K. Has 4 eq ops. Property ID #5176. RIVERSIDE—GP + Real Estate!! Established in 1975 in free standing historic bldg. Has 4 eq ops in a 2,000 sq SAN DIEGO COUNTY office. Projecng approx.SOLD $284K for 2016. Property KERN, VENTURA, & SAN LUIS OBISPO COUNTIES ID #5146. CARLSBAD—Well established GP w/ 3 eq ops CAMARILLO—GP + Real Estate. Well established and 2 plmbd not eq near residenal are. Buyer’s TEMECULA—Modern designed pracce w/ 3 eq ops. pracce w/3 eq ops / 1 plmbd not eq. NET OF net of $121K. Property ID #5191. Projecng approx. $1.2MSOLD . Net of $444K. Property ID $179K. Property ID #5150. #5155. ESCONDIDO—Perio pracce w/ 40 yrs of gdwll in SIMI VALLEY— GP + Bldgs. Well established prac- a single story bldg. Has 4 eq ops. Grossed $683K UPLAND—Pediatric dental pracce located in a ce 4 eq ops & 2 plmbd not eq ops. Net of $92K. in 2016. Property ID #5173. medical bldg with 40 years of goodwill. Consists of 4 Extra income generang from rent. Property ID chairs in open with Alpha-DentSOLD soware. Grossed #5185. SAN DIEGO —COMING SOON! $271K in 2016. Property ID #5188.

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CONTACT US FOR A FREE CONSULTATION WWW.CALPRACTICESALES.COM Phone: (800) 697-5656 CA BRE #00283209 RM Matters CDA JOURNAL, VOL 46, Nº1

Re-treating Patients When an Associate Leaves TDIC Risk Management Staff

iring an associate brings with both dentists if they believe treatment (i.e., through a neutral third- the opportunity to lighten they are getting the runaround or party dentist) and establish a fi nancial workloads and potentially perceive there are arguments in regards agreement if re-treatment is required. drive in new business. But to who pays for re-treatment. One associate dentist involved in a re- as with any relationship, One way to prevent this from treatment dispute reported that he did not Hboth parties may eventually agree to happening is to have a Business Associate have a contract agreement with his former part ways. In worst-case scenarios, the Agreement in place with a re-treatment employer and was only paid a percentage split may not be amicable and your clause when bringing on an associate. of the total patient payments the practice patients and practice as a whole may Re-treatment clauses usually address received. When another dentist found an suffer unwelcome consequences. how re-treatment issues will be handled open margin on a restoration the associate As a practice owner, dealing with re- for a specifi c period of time. These had performed while still with the practice, treatment can be one of the most diffi cult clauses set the terms for objectively the patient demanded a full refund from issues and may be especially challenging validating the need for patient re- the owner to cover re-treatment. The when the dentist who originally treated the patient is no longer with the practice. The Dentists Insurance Company reports a case in which a practice owner heard from multiple patients who were unhappy with the treatment they received from an associate who was no longer with the practice. The owner referred the patients to the former associate to You are not resolve their issues, while the associate a sales goal. referred the patients back to the owner. Frustrated by a lack of resolution, some of the patients called the practice and demanded refunds. They threatened to take legal action and fi le a report with the dental board if their money was not refunded. While the practice owner believed it was the associate’s responsibility to address the situation, the patients You are a dentist deserving of an insurance company relentless actually belonged to the practice and in its pursuit to keep you protected. At least that’s how we see not to the treating dentist. Therefore, it at The Dentists Insurance Company, TDIC. Take our Risk it was the owner’s responsibility to Management program. Be it seminars, online resources or our respond to the patients’ concerns and Advice Line, we’re in your corner every day. With TDIC, ensure continuity of care, either by you are not a sales goal or a statistic. You are a dentist. completing the treatment himself, having or hiring another associate within the practice to treat them or ® referring them to another dentist or Protecting dentists. It’s all we do. specialist for treatment completion. 800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783 As demonstrated by the case above, patients may become disgruntled

JANUARY 2018 57 JAN. 2018 RM MATTERS

CDA JOURNAL, VOL 46, Nº1

owner provided the patient with the details with the former associate separately your risk by mutually agreeing on associate’s contact information and on the side. Remember, a few hundred a clear-cut, well-drafted associate advised her to reach out to him directly dollars upfront in patient care is cheaper agreement. The agreement to resolve her concern. However, the in the long run than the cost of a damaged should include a re-treatment associate dentist felt it unfair to have to reputation. By putting the patient fi rst, clause to provide seamless absorb the entire cost of re-treatment as you demonstrate the quality of care others continuity of care for patients. he only received a percentage of the profi t. can expect when visiting your practice. ■ Consult with a professional attorney When handling re-treatment disputes, Keep the following tips in mind for assistance drafting your contract practice owners are encouraged to take to minimize your practice’s risk and for review prior to signing it. into account the percentage an associate when dealing with re-treatment: ■ At the beginning of the business received to more easily reach a resolution. ■ Patients belong to the practice; relationship, clearly establish If you do fi nd yourself caught in a therefore, it is the practice who is responsible for re-treating re-treatment dispute, remember that owner’s responsibility to patients if the associate leaves. the patient always comes fi rst. Treat the ensure continuity of care. ■ If a patient is in midtreatment patient without delay and work out the ■ Before hiring an associate, manage and the treating dentist leaves the practice, complete the treatment in progress yourself or refer the patient to another dentist or specialist for completion to ensure patient care is not compromised. ■ Avoid criticizing the original treating dentist’s work. Simply state your observations based upon clinical fi ndings. If the patient questions the quality of the previous work, state that you cannot speak for the other dentist or the direction he or she took. Adhering to these guidelines can help safeguard compliance with contractual obligations and state dental boards. For more information on how to protect your practice when hiring an associate or how to protect yourself when separating from a practice, visit tdicinsurance.com/reference-guides. ■

TDIC’s Risk Management Advice Line at 800.733.0633 is staffed with trained analysts who can provide guidance on re-treatment protocols and other questions related to a dental practice.

58 JANUARY 2018 CARROLL “Matching the Right Dentist to the Right Practice” V &COMPANY 4101 SAN FRANCISCO GP 4133 NAPA GP Vibrant downtown location in historic high-rise bldg. Retiring Napa County GP in newly furnished, fully equipped 2 op facility doctor offering 30+ years of goodwill. 4.5 days of hygiene, with digital x-ray. 4 doctor day/week with 3 hygiene days. 1,500+ active patients, 20-25 new patients/mo. Gorgeous, Average annual Gross Receipts $420K+. Seller willing to help spacious facility in approx. 2,500 sq. ft. 2017 annualized GR for a smooth transition. Asking $331K. $885K. Adjusted net income $295K+ Seller will assist for smooth transition. Asking $599K 4190 SAN JOSE GP Excellent location on west side of SJ in the Blossom Hill area. 4151 MARIN COUNTY GP Easy access to Hwy 85 & 87 and light rail. Offering 17+ years Well established and respected, quality general practice located of goodwill. Beautifully appointed 3 op office in 950 sq. ft. in desirable Marin CountyD location. Office has convenient ample OL Plentiful on-siteLD parking. 730 active patients with 1.5 days of parking, overlookingS a beautiful park like setting adjacent to a hygiene.SO Average two years gross receipts $389K with peaceful creek. Office contains 5 ops in ~1,300 sq. ft. Gross adjusted net of $154K. receipts average $1.2M annually with 3 doctor days/week. 4150 SANTA CRUZ COUNTY GP 4178 SONOMA COUNTY PERIO Seller retiring from successful 33 year general practice. Fee-for- Seller retiring from 21 year practice with trained, seasoned staff service only practice. Fully-equipped 4 op facility in beautiful, D and great location. Exceptional 2,100 sq. ft. ample office with 6 remodeledO SellerL owned building. Located in desirable fully equipped ops. Majority of equipment purchased in 2002. 4 residentialS and commercial neighborhood. Buliding also for sale. doctor-days & 3 hygiene days per week. Average gross receipts $1M+. Asking $677K. 4123 CAMPBELL GP Seller transitioning 32 year general practice with an emphasis 4198 NORTH BAY PERIO on Restorative and Preventative care. Well-trained and loyal staff. Approximately 37% hygiene production. 3.5 doctor days Established Periodontic practice with loyal referral sources in LD 1,564 square foot office with 5 fully-equipped operatories per weekSO & 3 hygiene days per week. Average gross receipts conveniently located close to Petaluma Valley Hospital. Average $625K+ with average adjusted overhead of 62%. Asking Gross Receipts $480K. Seller is offering the condominiumized $464K. office for sale or lease to the buyer of the practice. Asking price for practice $284K. UPCOMING: Endodontic practice on the Peninsula 4191 SONOMA COUNTY ENDO General practices in Fremont, Concord, Walnut Creek, Seller retiring from 38 year endodontic practice located in Foster City, Mid-Peninsula, San Francisco & Solano County attractive ground floor office (remodeled in 2011) with updated modern equipment and cabinetry. Close to several regular North Bay Prosthodontic practice referral sources. Doctor sees an average of 7-8 patients per day. 5 year average Gross Receipts $700K+. Asking $447K.

4202 SANTA CRUZ COUNTY GP Retiring seller offering 40+ years of goodwill with emphasis on restorative care. Located on major thoroughfare within walking distance to the ocean. 1,600 square foot office with 4 fully equipped operatories. Average annual gross receipts approx. $500K with adj net of $170K+. Owner/doctor works on average 3 days per week with average of 5 hygiene days/week. Asking $300K. Mike Carroll Pamela Carroll-Gardiner Mary McEvoy Carroll 4193 SAN BRUNO GP Carroll & Company Well established practice in prime, high-traffic location. 670 sq. ft. office with (3) fully-equipped operatories set up for rear 2055 Woodside Road, Suite 160 D Redwood City, CA 94061 delivery. Approx.OL 650-700 active patients with an average of 5 new patientsS per month. Approx. 3.5 doctor days per week. BRE #00777682 2016 Gross receipts $516K+. Average adjusted overhead 56%. Seller transitioning into retirement. Asking $378K.

carroll.company [email protected] (650) 362-7004 (650) 362-7007 DENTAL PRACTICE BROKERAGE Making your transition a reality.

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PRACTICE SALES • PARTNERSHIPS • MERGERS • VALUATIONS/APPRAISALS • ASSOCIATESHIPS • CONTINUING EDUCATION

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Cybersecurity Tips and News CDA Practice Support Staff

ybersecurity awareness out for or ensure your IT advisor 3. Maintain good computer habits. must be an almost daily apprises you on newly identifi ed Uninstall nonessential software responsibility for a dental IT issues. For example, your IT that may be included with the practice owner. New advisor should have discussed purchase of hardware or other cybersecurity threats recently how the so-called “Krack” devices. Do not automatically Cdevelop every day and a dentist cannot Wi-Fi vulnerability2 may affect accept default settings when afford to believe that cyber criminals your system or mentioned the confi guring software. Understand will not target small businesses. “digital hurricane”3 information the options before selecting a According to a news story published security experts predict. setting. Ensure external access to in mid-2017, one hacker entity known 2. Protect mobile devices. Their small the system is secure when needed as The Dark Overlord has had “a far size make them easy to steal or and is disabled when not in use (for greater impact in the United States than lose. Encrypt when possible and example, remote access by software the (WannaCry) ransomware attack, utilize password protection. Use technicians). Automate software infl icting heavy — even crippling — a secure communication method updates and apply security patches costs on small clinics across America.”1 if electronically transmitting as soon as available. Disable user The Dark Overlord’s many targets in protected health information accounts for former employees as the past year include dental practices from devices. Maintain a log of soon as possible. Perform malware, in New York, Virginia and California. these devices and their users. vulnerability, confi guration and Ransomware attacks are not 100 percent preventable because hackers adapt to new security settings. However, it is possible to reduce the likelihood of falling victim to a hacker. Top 10 Tips for Cybersecurity in Health Care describes key steps to protect your valuable information assets and is published by the U.S. Department of Health and Human Services (HHS). HHS has focused resources to assist small health care practices align business practices with You have goals. cybersecurity and risk management principles. The tips and other resources PARAGON can help you reach them. can be found online at healthit.gov/ providers-professionals/cybersecurity- Are you thinking of buying a dental practice, merging, or selling shared-responsibility. The 10 tips are: your practice? The future you want is closer than you think. 1. Establish a security culture. Your Our guidance makes all the difference. security system is only as strong as your weakest user. Information 7DNH\RXUQH[WVWHSZLWKFRQ´GHQFH security should occupy the &DOO3$5$*21WRGD\ same plane of consciousness as workplace safety among all Your local PARAGON health care workers. Provide dental transition consultant Trish Farrell ongoing training and security reminders. A practice owner

should model behavior that Approved PACE Program Provider 866.898.1867 FAGD/MAGD Credit promotes information security, for Approval does not imply acceptance [email protected] by a state or provincial board of dentistry or AGD endorsement example, don’t share passwords. paragon.us.com 4/1/2016 to 3/31/2020 Provider ID# 302387. Hold workers accountable. Look

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CDA JOURNAL, VOL 46, Nº1

other security audits regularly. birthdate or the name of a favored little-slip-ups-can-have-huge-consequences. 5. Digital Identity Guidelines, NIST Special Publication 800- Use professional IT advisors when team. Be aware, however, that 63B, Oct. 24, 2017, pages.nist.gov/800-63-3/sp800-63b. practice owner or staff are uncertain security experts are moving to html and NIST tweaks advice on passwords, says make them about their ability to secure or change this recommendation. The easier to remember, Healthcare IT News, Aug. 16, 2017, www. healthcareitnews.com/news/nist-tweaks-advice-passwords-says- monitor security of the information National Institute of Standards make-them-easier-remember. system. A simple misconfi guration and Technology (NIST) recently 6. Security Rule Guidance Material, www.hhs.gov/hipaa/for- can lead to a data breach.4 published digital identity professionals/security/guidance/index.html. 4. Use a fi rewall. A fi rewall is essential. guidelines5 that call for less Regulatory Compliance appears Software fi rewalls typically are complex passwords, use of longer monthly and features resources about laws included with popular operating passwords or passphrases and less that impact dental practices. Visit cda.org/ systems. A dental practice that frequent changing of passwords. practicesupport for more than 600 practice uses a local area network should 9. Limit network access. Prohibit staff support resources, including practice consider a hardware fi rewall or vendors from installing software management, employment practices, dental because it provides centralized or devices without prior approval. benefi ts plans and regulatory compliance. management of fi rewall settings. Secure wireless routers and ensure 5. Install and maintain antivirus they operate only in encrypted software. Use an antivirus product mode. Remove peer-to-peer that provides continuously updated applications such as fi le sharing. protection. Ensure confi guration 10. Control physical access. Make it allows for automated updating. diffi cult to steal or lose devices with 6. Plan for the unexpected. Regularly PHI. Store servers in locked rooms backup data. Consider doing or locked cages. Adopt policy that multiple backups stored in different restricts the physical movement locations, for example, on site, of devices/media with PHI. removable and in the “cloud.” A PDF document that provides more Regularly restore data to ensure detailed information on these tips, plus backup process works. Develop maintenance, fi rewall, antivirus, backup a business recovery plan. and recovery and other checklists, can be 7. Control access to protected downloaded from the HealthIT website. A health information (PHI). Set collection of information security resources, access permissions in the regulatory guidance, NIST publications operating system and software and cyber awareness newsletters can for individual workforce be found on the HHS Security Rule members so each may only Guidance Material website.6 ■ view or use patient information REFERENCES necessary to do their work. 1. How the Dark Overlord is costing U.S. clinics big time with 8. Use strong passwords and change ransom demands, McClatchy DC Bureau, May 15, 2017, them regularly. The current www.mcclatchydc.com/news/nation-world/national/national- security/article150678617.html. recommendation is to have a 2. Krack Wi-Fi Security Fixes Are Coming, but You Need password that is at least eight To Take Control, Consumer Reports, Oct. 17, 2017, www. characters in length, uses a consumerreports.org/wireless-routers/krack-wifi -security-fi xes- coming-but-you-need-to-take-control. combination of upper-case and 3. New digital ‘hurricane’ churns, gathering strength to land lower-case letters, one number blow on the internet, Sacramento Bee, Oct. 23, 2017, www. and one special character. The sacbee.com/latest-news/article180462486.html. 4. Beware misconfi guration errors: Little slip-ups can have huge password should not include consequences, Healthcare IT News, Aug. 11, 2017, www. personal information such as a healthcareitnews.com/news/beware-misconfi guration-errors-

62 JANUARY 2018 Specialists in the Sale and Appraisal of Dental Practices PracticesPr Serving California Dentists since 1966 How much is your practice worth?? WantedW Selling or Buying, Call PPS today! Best wishes from PPS for a Prosperous and Healthy New Year! NORTHERNNORRTHERT RN CCALIFORNIAALIFORNIA SOUTHERNSOUTHERN CALCALIFORNIAIFORN (415) 899-8580 – (800) 422-2818 (714) 832-0230 – (800) 695-2732 Raymond and Edna Irving Thomas Fitterer and Dean George [email protected] [email protected] www.PPSsellsDDS.com www.PPSDental.com California DRE License 1422122 California DRE License 324962 6135 SAN FRANCISCO’SFRANCISCO’S NORTH BAY 2017 collected $1.4 Million, ENDODONTIC PRACTICE Central California Beach City. reflecting nice growth over 2016 which collected $1.1 Million. The Established 20+ years. Grosses $1,200,000 & Nets $800,000. foundation here is 6-days of hygiene. There shall be no change in fees ANAHEIM Korean clientele. Part-time grossing $200,000+. for the successor. 3-Ops, some ortho. Rent $2,300. Close to Harbor Freeway exit. 6134 SANTA CLARA On part-time basis due to time constraints, Full Price $110,000. collections shall top $400,000 in 2017. With more time in recent past, ANTELOPE VALLEY / SANTA CLARITA VALLEY Two practice has topped $900,000. Strong profits. Long term tenancy. Great separate Million Dollar Opportunities. Absentee Owners. location. BELLFLOWER Female owned Hispanic practice. Part-time. Low 6133 SAN RAMON’S BISHOP RANCH Beautiful 4-op, computerized overhead opportunity. and digital office. Located in the Bishop Ranch Medical Center. Bring DIAMOND BAR Absentee Owned. Grosses $500,000. Gorgeous Business Plan. Great addition to existing network. Full Price $115,000 high identity shopping center. State-of-art facility. Million Dollar 6132 NORTH FREMONT AREA $420,000+ invested here. Very potential. 5-Ops. Chinese / Korean / Hispanic. highend for great patient experience. 3-ops equipped (4th available), EAST LOS ANGELES Part time senior female grossing Panorex, completely networked and digital. $600,000+ in revenues. $20-to-$35,000/month. Established many years, Low overhead. Full time will do $600,000. 6131 SAN RAFAELPart-time practice. 2016 collected $243,000. Profits totaled $146,000. 2017SOLD trending $265,000. No Delta Premier hit INLAND EMPIRE Long time Union Patient Practice. Part-time here! 3-ops. Owner lives out of area. Seller works 3 days. Grossing $650,000. Patients are available to go to 6-days. Great union benefits. 6129 PROSTHODONTIC PRACTICE – SAN MATEO 2016 INLAND EMPIRE Shopping center. Great Lease. 3-ops in 1,650 collected $775,000 on 3.5 day week. Beautiful 5-op office. Excellent sq.ft. Absentee Owner. Grosses $30,000/month. Working Seller candidate for acquisition by nearby practice. Seller shall work back to used to do $50,000/month. 20-to-30 new patients/month. Full Price assist in orderly transition. Acquire here or move into nearby practice. $285,000. Choice is yours. INTERSTATE 405 & ARTESIA Established many years. 2-Ops. 6128 LOS GATOS AREA Capitation & PPO. 3-Adec equipped ops, Full Price $150,000. Pano, Digital charting. Collects $420,000+ year. Available Profits of IRVINE LOCATION 6-Ops, Beautiful state-of-the-art office. $190,000 in 2016. Full Price $225,000 Full Price $150,000. 6127 SAN RAFAEL’S NORTHGATE Collected $210,000 in 2016 on IRVINE Professional Building. Chinese clientele. Grosses part-time schedule. AvailableSOLD Profits of $106,000. $500,000-to-600,000 6-Ops in 2,000 sq.ft. Rent only $5,000. Seller 6125 OAKLAND AREA Collections average $735,000 per year. High here 2 days per week. income zip code with well employedSOLD Millennials next door. 10+ new IRVINE Lady DDS Grossing $1,2 Million. Professional Building. patients per month. Digital and paperless. 5-Ops. Only Dentist in building. Full Price $885,000 6124 SAN RAMON 100% Out-of-Network. 5-Ops. 6-days of LA PUENTE Established 20-years. Small shopping center. 3-Ops. Hygiene. $700,000 per year performer.SOLD Full Price $150,000 6122 SANTA CLARA - STARBUCKS "LIKE" LOCATION! Best LAKE ELSINORE Great second location for DDS working exposure in beautiful strip center. Office just remodeled. 5-Ops. 2017 part-time. 6-Ops. Rent $2,700. Grossing $500,000-to-$600,000. trending $1+ Million in Collections on 4-days. Perfect platform to Some HMO. operate 6-days a week. Wants to do $1.5-to-$2 Million. NEVADA DENTURE PRACTICE Add Implants. Will do $2 6121 NAPA VALLEY FAMILY PRACTICE Highly respected Million. 4,000 sq.ft. rents for $4,000. Full Price $850,000. community asset. Collections last 5-years have averaged $1.28 Million NEWPORT BEACH’S FASHION ISLAND Grossing per year. Beautiful facility. CondoSOLD optional purchase. $400,000-to-$500,000. 6120 OAKLAND’S PIEDMONT AREA Highly coveted area. Right ORANGE COUNTY BEACH CITY Location, location! off Highway 13. 3-days of Hygiene.SOLD 4-Ops with 5th available. 2016 Previous Gross One Million. Facility only. 6-Ops with collected $650,000+. computerized monitors, TV's and Dentrix. Full Price $150,000. 6118 SAN FRANCISCO’S EAST BAY Forty percent partnership in ORANGE COUNTY BEACH HMO Absentee owned. Grosses $1.6 Million. High identity shopping center. 10-Ops. Full Price well positioned and branded practice. 2016 collected $2.53 Million. $1.3 Million. 2017 trending $3.2+ Million in collections. Full complement of specialties. 6-month Trial Association wherein interested Candidate shall PEDO Chinese / Hispanic. Grosses $450,000. 4-Ops, low rent. Digitized office. Lots of options to grow to Million Dollar practice. see ability to make $350,000+ per year. REDLANDS Great Location. Rent $1,100/month. 3-ops. Nice 6114 LINCOLN $1.1+ Million year performer. Profits tracking patient base. Full Price $150,000. $425,000+. Beautiful and extensive facility leases for $1.60 sq.ft. PPO SOLD WEST LOS ANGELES High Identity Location. 3-Ops. Room to Practice. grow. Free parking. Grossing $450,000. Full Price $500,000.

BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA NORTHERN CALIFORNIA CONTINUED

AC-566 SAN FRANCISCO: Spectacular views of BG-765 FREMONT: This quality pracce is the true EC-729 GREATER SACRAMENTO AREA: HN-280 NORTHEAST CA: $60k Largest Washington Square. 3 ops +2 add’l, 1400sf $170k definion of a “Family Pracce”. 1000sf w/ 2 ops. HN-618 SIERRA FOOTHILLS: AC-624 SAN FRANCISCO: Wonderful patients, $295k EG-722 ROSEVILLE: $95k solid income in great stand-alone bldg $475k BN-777 OAKLAND: Providing a full spectrum of quali- HN-740 SHASTA CO: Broker in AC-649 SAN FRANCISCO Facility: Richmond Dis- ty denstry to a wide range of paents. 1,297sf w/ 3 $1.05M $475k trict, 3 ops+1 add’l, Equipment less than 5yrs old ops. $295k EN-628 ORANGEVALE: HN-773 SUTTER CREEK: $120k CC-661 SAN RAFAEL: Starter practice in beautiful 375k $195k Northern AG-562 SAN FRANCISCO: Strategically located with location w/ like-new equipment. 3 ops, 900sf $190k EN-660 ROSEVILLE: huge growth potential. 2 ops + 1 add’l, 600sf $175k CC-720 SONOMA COUNTY: Well-established practice $995k CENTRAL VALLEY AN-513 REDWOOD CITY: Pracce of your dreams! w/stable pts base. Excellent signage, 3 ops, 940sf w/ EN-664 SACRAMENTO Facility: California 900sf w/ 4 ops + 2 add’l $350k newer high-end Equip $375k Now Only: $30k IC-468 SAN JOAQUIN VALLEY AN-686 SAN FRANCISCO: Office designed w/ paent CG-616 NAPA: State-of-the-Art practice. Seller mov- EN-702 SACRAMENTO: $425k flow & maximum office efficiency. 1000sf w/ 4 ops ing out of state! $425k $450k Real Estate $325k IG-687 TURLOCK: $825k DC-671 SAN JOSE: Starter pracce. Desirable area. EN-708 SACRAMENTO: $298k AN-712 SAN FRANCISCO: Easy accessibility, excep- 6 npts/mo, 3 ops in 900sf $150k $150k IN-761 MODESTO: Extensive Buyer onal visibility, free parking & extremely low rent! DC-738 WATSONVILLE: 6ops in beauful remodeled EN-747 CITRUS HEIGHTS Facility: 1000sf w/ 2 ops + 2 add’l $89.5k 2,600sf office, visibly located in aracve shopping $100k $150k AN-752 SAN FRANCISCO Facility: 3 months Free complex $480k EN-749 LINCOLN: IN-764 STOCKTON: Database & Rent! Opportunies like this one are few and far DC-786 LIVERMORE Facility: Move In ready & recent- $320k $267.5k between! 1007sf w/ 4ops. $125k ly updated! 2380 sf w/ 3 fully equipped ops. EN-755 FOLSOM: IN-776 STOCKTON: Unsurpassed BC-682 CONCORD: Located in desirable, bustling Plumbed for 3 add’l $190k $175k $25k community w/ seasoned, caring staff. 836sf w/ 3 DG-635 CASTRO VALLEY: Excellent locaon & stellar EN-768 WEST SACRAMENTO: JG-753 VISALIA: ops $224k reputaon! Solo Group Pracce $650k $275k Call for Details! Exposure allows BC-710 WALNUT CREEK: Desirable location in DG-756 LOS GATOS: Rare & Remarkable Oppor- FC-650 FORT BRAGG: JG-778 FRESNO: stand-alone, single-story bldg. 1313sf w/ 3 ops tunity in affluent community! 920 sf w/ 3 ops $350k for the Pracce & $400k for the Real Estate $328k us to offer you $150k / RE $850k $275k FC-677 FORT BRAGG: BC-741 DANVILLE (FACILITY): Move in Ready facility DG-767 CUPERTINO: “Dream Pracce” near Apple $500k SOUTHERN CALIFORNIA to build the practice of your dreams! ~ 1600sf w/ Headquarters! Real Estate also available. 3 ops FN-754 SOUTHERN HUMBOLDT: 3 fully equipped ops $195k 1284 sf $438k KC-678 LOMPOC & SANTA MARIA:

BC-758 PLEASANT HILL (FACILITY): Gorgeous décor DN-665 SANTA CRUZ AREA: Loyal, stable, mul- $195k $240k & remarkable location! 768 sf w/ 2 ops $42,500 generaonal paent base. FFS. 1460sf w/ 4 ops GC-472 ORLAND: BC-780 RICHMOND: Contemporary design, warm $540k $160k SPECIALTY PRACTICES environment, large windows. 1300 sf w/ 3 ops DN-693 SAN JOSE Facility: Aracve & spacious! GG-454 PARADISE: $675k Faces one of the city’s major thoroughfares. 1080sf $450k AC-748 SAN FRANCISCO Perio: BC-781 LAFAYETTE: Located in Dental Professional w/4 ops $95k GN-656 NO. TEHAMA CO: Great Locaon! $800k bldg complex. 1400 sf w/ 3 ops. Desirable Locale! DN-713 CASTRO VALLEY Lease: Well maintained, Now Only $225k AC-759 SAN FRANCISCO Endo: $275k attractive, “Move-In Ready” dental office. 1500sf w/ GN-667 OROVILLE: Great place to work & play! $495k BG-724 RICHMOND: Spacious office w/ enormous 5ops Call for details! $195k BC-784 CENTRAL CONTRA COSTA CO Perio: growth potential! 2000sf w/ 4 ops Practice DG-723 SAN JOSE: The pracce exceeds $1.2mil in GN-668 BUTTE COUNTY: $450k $138k / Real Estate $700k collecons annually! 1,450 sf w/ 5ops. $850k $95k IC-543 CENTRAL VALLEY Ortho: BG-731 LAFAYETTE: Well-educated, health con- DN-771 SOQUEL Facility: The perfect place to sink GN-717 YUBA CITY: Build- $125k scious paent base. 1,000 sf w/ 3 ops 35+ years down roots, raise a family & build an empire! ing available for purchase! $475k HG-763 GRASS VALLEY Ortho: goodwill $229k 1100sf w/2 ops + 1 add’l. $50k GN-746 YUBA CITY: Includes the latest technol- $210k BG-762 EAST BAY: Stellar, high Quality practice DN-774 FREMONT: This opportunity has it all and ogy in CBCT Imaging. JG-757 VISALIA Perio: consistently generates ~ $3M annually. 3000 sf w/ awaits your talent and skill! 1,150sf w/3 ops + 1 Pracce $480k/ Real Estate TBD. 6 ops $1.99M add’l $150k GG-769 REDDING AREA: $395k BG-734 ANTIOCH: The perfect place to work, live DG-785 SANTA CRUZ: Known for its amusement park Pracce $390k Real Estate $540k and play! Located in desirable professional neigh- & beach boardwalk, this community has much to HG-732 GRASS VALLEY: borhood. 1,323 sf w/ 4 ops. $315k offer! 1000sf w/ 4 ops. $245k $215k

800.641.4179 [email protected] Timothy Giroux, DDS Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD

BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA NORTHERN CALIFORNIA CONTINUED

AC-566 SAN FRANCISCO: BG-765 FREMONT: EC-729 GREATER SACRAMENTO AREA: Seller rering! FFS Pracce and Real HN-280 NORTHEAST CA: Only Practice in Town! 900sf w/ 2 ops $60k Largest $170k Estate Available! HN-618 SIERRA FOOTHILLS: Seller Retiring! Huge opportunity for growth by AC-624 SAN FRANCISCO: $295k EG-722 ROSEVILLE: On track to collect $1.5M in 2017 with increased profit increasing office hours! 750sf w/ 2 ops $95k $475k BN-777 OAKLAND: compared to last year! Price Reduced even though collecons are increas- HN-740 SHASTA CO: Warm, caring atmosphere that is magnified by the Broker in AC-649 SAN FRANCISCO Facility: ing! 1919sf w/ 4 ops $1.05M exceponal, long-term staff. 2400+sf w/ 5 ops + 1 add’l $475k $295k EN-628 ORANGEVALE: Great place to work, play & live. HMO 1310sf w/ 4 HN-773 SUTTER CREEK: Located in an area known for beauful scenery, $120k CC-661 SAN RAFAEL: ops + 1 add’l $3375k excellent wine and rich history! 1536sf w/4 ops + 1 add’l $195k Northern AG-562 SAN FRANCISCO: $190k EN-660 ROSEVILLE: Highly-esteemed, well-respected, fee-for-service prac- $175k CC-720 SONOMA COUNTY: ce w/ loyal paent base. 2950sf w/ 5 ops $995k CENTRAL VALLEY AN-513 REDWOOD CITY: EN-664 SACRAMENTO Facility: Great corner locaon, excellent visibility & California $350k $375k easy access! 2300sf w/ 4 ops. Now Only: $30k IC-468 SAN JOAQUIN VALLEY: High-end restorave pracce! 6 ops in AN-686 SAN FRANCISCO: CG-616 NAPA: EN-702 SACRAMENTO: Long-established pracce w/ emphasis on preven- 2500+sf office. Call for Details! $425k $425k tave denstry! 1600sf w 4 ops + 1add’l. $450k Real Estate $325k IG-687 TURLOCK: Established quality pracce - remarkable opportunity! $825k DC-671 SAN JOSE: EN-708 SACRAMENTO: Family-oriented pracce with appreciave & loyal 2000sf w/ 5 ops $298k AN-712 SAN FRANCISCO: $150k paent base. 1600sf w 4 ops + 1add’l. $150k IN-761 MODESTO: Pracce philosophy: “Paent First Care” quality care in Extensive Buyer extremely low rent DC-738 WATSONVILLE: EN-747 CITRUS HEIGHTS Facility: Be the only dental office in this aracve, a warm, comfortable, and yet professional environment. 5,395 SF W/ 12 + 1 $89.5k popular Retail Shopping Center! 2200sf w/5 ops + 6 add’l. $100k add’l. $150k AN-752 SAN FRANCISCO Facility: 3 months Free $480k EN-749 LINCOLN: Come sink your roots down and enjoy a fantasc life- IN-764 STOCKTON: Well-established, fully computerized, paperless, digital- Database & Rent! DC-786 LIVERMORE Facility: style which can’t be beat! 1877sf w/4 ops + 1 add’l. $320k ized pracce just waing for your talent & skill! 5,000sf w/10 ops $267.5k $125k EN-755 FOLSOM: A perfect locaon, envied by all! Enjoy an amazing IN-776 STOCKTON: Step right in and you won’t miss a beat in this long- Unsurpassed BC-682 CONCORD: $190k quality lifestyle in this thriving city. 1200sf w/ 4 ops. $175k established, quality pracce! 1046sf w/2 ops add’l. $25k DG-635 CASTRO VALLEY: EN-768 WEST SACRAMENTO: family-oriented pracce, equipped with up- JG-753 VISALIA: Pedo/GP Pracce AND Real Estate Available! Stellar repu- $224k $650k dated technology! 1612sf w/4 ops. $275k taon, 30 pts w/ 15 hyg pts daily! Spacious 2600 sf office! Call for Details! Exposure allows BC-710 WALNUT CREEK: DG-756 LOS GATOS: FC-650 FORT BRAGG: Family-oriented pracce. 5 ops in 2000sf, 6 npts/ JG-778 FRESNO: What a steal. Consistent collecons over $600k with cash mo $350k for the Pracce & $400k for the Real Estate flow over $300k!! 1452 sf w/ 4 ops $328k us to offer you $150k / RE $850k $275k FC-677 FORT BRAGG: Beauful, FFS Pracce, 4 ops +1 add’l, in 2375sf, BC-741 DANVILLE (FACILITY): DG-767 CUPERTINO: Gross $1M+/yr $500k SOUTHERN CALIFORNIA FN-754 SOUTHERN HUMBOLDT: If you love the lure of sea air, a relaxed $195k $438k lifestyle & charm of coastal living, then look no further! 1500sf w/ 3 ops KC-678 LOMPOC & SANTA MARIA: Live & practice along the central coast.

BC-758 PLEASANT HILL (FACILITY): DN-665 SANTA CRUZ AREA: + 1 add’l. $195k Plenty of room for growth, Call for Details! $240k $42,500 GC-472 ORLAND: Live & practice in charming small town community. 1000sf BC-780 RICHMOND: $540k w/ 2 ops. Seller Retiring $160k SPECIALTY PRACTICES DN-693 SAN JOSE Facility: GG-454 PARADISE: 2550sf w/ 9 ops. 40 yrs goodwill! Amazing Opportunity! $675k $450k AC-748 SAN FRANCISCO Perio: Pracce in this presgious building in de- BC-781 LAFAYETTE: $95k GN-656 NO. TEHAMA CO: Great Locaon! Ideal place to work, live & raise a sirable central locaon. 3 ops, 980sf $800k DN-713 CASTRO VALLEY Lease: family! 2468sf w/ 5 ops Now Only $225k AC-759 SAN FRANCISCO Endo: Union Square. 1190 sf w/3 ops (plumbed for 1 $275k GN-667 OROVILLE: Great place to work & play! Constant growth aracng add’l) $495k BG-724 RICHMOND: Call for details! an influx of residents! 1000sf w/ 3 ops $195k BC-784 CENTRAL CONTRA COSTA CO Perio: Seasoned Staff. Office runs like Practice DG-723 SAN JOSE: GN-668 BUTTE COUNTY: Remodeled in 2010! Well-maintained, long- well oiled machine! 3 ops $450k $138k / Real Estate $700k $850k established professional complex. 1200sf w/ 2 ops $95k IC-543 CENTRAL VALLEY Ortho: 1650sf w/ 5 chairs in open bay & plumbed BG-731 LAFAYETTE: DN-771 SOQUEL Facility: GN-717 YUBA CITY: Seller Rering. All reasonable offers considered. Build- for 2 add’l. Strong referrals and PT base $125k ing available for purchase! 2400sf w/ 5 ops $475k HG-763 GRASS VALLEY Ortho: Avg 30+ pts per day. Newer retail Shopping $229k $50k GN-746 YUBA CITY: State-of-the-Art Equipped! Includes the latest technol- Center $210k BG-762 EAST BAY: DN-774 FREMONT: ogy in CBCT Imaging. Real Estate also available! 1600sf w/ 3 ops +1 add’l. JG-757 VISALIA Perio: Keep implants in house and imagine the growth Pracce $480k/ Real Estate TBD. possibilities! 9 hygiene days per week! Rare Gem! 2,000 sf w/ 5 ops $1.99M $150k GG-769 REDDING AREA: Offering a full spectrum of general denstry and $395k BG-734 ANTIOCH: DG-785 SANTA CRUZ: total care! 2700sf w/ 6ops. Pracce $390k, Real Estate $540k HG-732 GRASS VALLEY: Seller retiring. Well established practice. 1250sf w/ 3 $315k $245k ops. Real Estate also available. $215k

“ASK THE BROKER” CAN NOW BE FOUND AT WWW.WESTERNPRACTICESALES.COM Tech Trends CDA JOURNAL, VOL 46, Nº1

A look into the latest dental and general technology on the market

iPhone X (Starting at $999, Apple) Sickweather (Free, Sickweather Inc.) Apple released the high-end model of its line of iPhones, the iPhone Getting sick is not fun; getting others sick is worse. Any means of X, in November. Boasting a full edge-to-edge OLED screen, Face ID proactively preventing illness has the potential to save countless technology and numerous other improvements, Apple boasts that hours of time and money. Sickweather is an app and service that this model is as revolutionary a leap as the original iPhone was 10 collects reports and information from a variety of sources to create years ago. “personalized sickness forecasts.” Awareness of sicknesses in an area empowers people to take more active preventative measures. The most noticeable change with the iPhone X is the screen itself — while the form factor of the phone is nearly identical to the non- Sickweather is a service that works by scanning an area for available Plus models, the viewable area of the screen takes up nearly the sickness data and, through an algorithm, calculates the likelihood entire front face of the phone. Gone are the top and bottom bezels of getting sick from specifi c illnesses. Signing up for an account (including the home button), leaving only a small chunk of the upper or logging in using Facebook and enabling location services are screen containing the front-facing camera and sensors. The OLED required. The service listens to social media (Twitter, Facebook, etc.) screen delivers much more detailed and brighter resolution. While posts of thousands of individuals along with their location data Apple touts the strength of the all-glass enclosure, reports indicate whenever they mention themselves or others getting sick. Users can that this phone is especially susceptible to cracking when dropped, self-report their sickness directly on the app by choosing from a list so a case is defi nitely recommended. of sicknesses ranging from simple allergies to whooping cough. People can also post messages of their illness in user-created forums, FaceID is the most notable new feature of the iPhone X, replacing or “Sickweather Groups,” that they follow. All these reports are the need to hold your fi ngerprint over the home button for then combined with other third-party partner reports to create a authentication. Instead, FaceID uses the camera and sensors to scan crowdsourcing database that tracks sickness trends. The service also your face while holding and looking at the phone, authenticating correlates data from the Centers for Disease Control and the sale and unlocking the phone as fast (if not faster) than the previous of over-the-counter medications. This entire set of extensive data is fi ngerprint scan. Even more impressive is that FaceID will still work processed through machine learning and a patent-pending algorithm regardless of hair style, haircut, glasses, facial hair, etc. to display a simple forecast over a map of the local area with the top As is the norm with new iPhones, Apple has made improvements to three illnesses going around in the region. the onboard cameras as well. The dual rear cameras still include As with many services that rely on the aggregation of data, optical image stabilization and portrait mode, while the front Sickweather is only as good as the data it collects. Although the camera has been upgraded to 7MP and also features portrait mode app and service cannot predict that a specifi c person will or will not allowing for even better selfi es with more styling options. get sick, the awareness of an increase in sickness trends is valuable The battery life has been improved to add longer usage times on in promoting proactive defensive measures to prevent the spread of a single charge. With the iPhone X (as well as iPhone 8), wireless contagious diseases. charging via the Qi standard is now an option, making it quick and —Hubert Chan, DDS easy to charge the phone simply by resting it on a Qi-compatible charging pad. Worth noting is that upcoming iOS software updates promise even faster wireless charging times. Would you like to write about technology? Dentists interested in contributing to this section should contact — Blaine Wasylkiw, CDA director of online services Andrea LaMattina, CDE, at [email protected].

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