2/14/18
3 years of SDF & SM-ART
Jeremy Horst DDS,PhD UCSF
disclosures
My research is funded by gifts & grants from:
Chan-Zuckerburg BioHub
Advantage Silver Arrest
Howard Hughes Medical Institute
National Institutes of Health
Jeremy Horst
https://sites.google.com/site/
JeremyAHorst/SanGabriel201802
1 2/14/18
3 year outcome – severely fragile 3 to 7 year old
1 year 3 years
No excavation SDF + GIC
2 years
Outline _ 1. SDF – what is it? 2. SDF adoption 3. SDF clinical evidence 4. SDF clinical use 5. SDF mechanisms 6. SDF treatment failure 7. SDF x-ray follow up 8. SMART
2 2/14/18
SDF - what is it?
Colorless liquid 25% silver: antimicrobial 8% ammonia: solvent 5% fluoride: remineralization
SDF vs SN + FV
SDF SN + FV 25% silver 16% silver 8% ammonia 9% nitrate 5% fluoride 2.5% fluoride > effect data > safety data
BOTH are safe & effective.
SDF - what does it do?
- Arrests dental caries
- Prevents dental caries • directly & indirectly
- Decreases dentin hypersensitivity
3 2/14/18
How do you use it?
Accessible 1. Isolate with cotton. Arrested cavities cavity. 2. Air dry. after 1 year 3. Apply with microbrush.
Where did this come from?
• Silver Nitrate used globally for >1000 years. – Caries arrest case series & protocols in 1800s. – 1891: 87 of 142 treated lesions were arrested. – Founding fathers of dentistry had protocols.
• AgF used in Japan for ~900 years. – Cosmetic blackening of teeth – Known to prevent caries.
+ • NH3 added in 1960s = SDF. – Approved & monitored by Japan.
• Available in Japan, Australia, Brazil, Argentina, Cuba, China since 1980s or before…
Rosenblatt et al, J Dent Res 2009
4 2/14/18
SDF is now available in the U.S.
~60¢/drop D1354 caries arrest CDT code active January 2016.
FDA clearance = hypersensitivity. Off label use = caries treatment. This is the same as BREAKTHROUGH THERAPY fluoride varnish.
Outline _ 1. SDF – what is it? 2. SDF adoption 3. SDF clinical evidence 4. SDF clinical use 5. SDF mechanisms 6. SDF treatment failure 7. SDF x-ray follow up 8. SMART
What do parents think about SDF? SDF
uncoop. semi- coop. coop
n=33 Tesoriero & Lee 2016 boys girls
5 2/14/18
Oregon: 30 2-5 year olds, 102 cavities, SDF 30s+, FV @3 mon, 100 stopped, no ∝ application time.
Esthetics? SSC or SDF
Dr. Jason Hirsch
6 2/14/18
NIDCR, January 2017
sales of SDF bottles per dentist
bottles.per.dentist 50% 30% 20% 10% 5% 3% 2% 1%
SDF is here to stay.
January 2016
Periodontics and Oral-Systemic Relationships Atypical Presentation of Zoster Leadership Trajectories of U.S. Dentists JournaCALIFORNIA DENTAL ASSOCIATION
7 2/14/18
Outline _ 1. SDF – what is it? 2. SDF adoption 3. SDF clinical evidence 4. SDF clinical use 5. SDF mechanisms 6. SDF treatment failure 7. SDF x-ray follow up 8. SMART inkids Arrest Caries Caries
10 0% Llodra et al., 2005 373 6 year olds 50 % SDF q6mon control: 2.5 new lesions (only applied to lesions) 100% SDF q1year Liu et al., 2012 50 % Sealant once 482 9.1 year olds NaF q6 mon control: 4.6 new lesions 100% SDF q1year Chu et al., 2002 exc SDF q1 year 308 3-5 year olds 50 % exc N aF q3mon control: 1.6 new lesions NaF q3 mon (only applied to lesions) revented caries 100% p SDF once Monse et al., 2012 50 % GIC se alant once 708 6-8 year olds control: 0.44 new lesions 0% 0.5 1 1.5 2 2.5 3 time (years)
8 2/14/18
Older adults 100%# SDF#q1year# Li et al., 2016 50%# SDF,#KI#q1year# 67 72 year olds 1.9 lesions at start control## 100%#0%# SDF#q1year# Zhang et al., 2013 Arrest 50%# +#OHI#q6mon# 227 60-89 year olds control## 0.91 lesions at start 0%# 0.5# 1# 1.5# 2# 2.5# 3#
100%# SDF#q1year# Tan et al., 2010 50%# NaF#q3mon# 203 79 year olds Chlorhex#q3mon# control: 2.5 new lesions 100%#0%# Zhang et al., 2013 SDF#q1year# 50%# 227 60-89 year olds +#OHI#q6mon# control: 1.3 new lesions Prevention 0%# 0.5# 1# 1.5# 2# 2.5# 3# time (years)
Learned from clinical trials?
• 12 RCTs with 1,816 patients tx SDF = safe. • 9 on caries arrest. 80-90% arrest with 2/year application. 40-80% arrest with 1/year application.
• 6 on caries prevention (3 overlap). 70-80% prevention in kids by application only to lesions. 25-70% prevention, outperforms everything by far.
Stopping Cavities Trial purpose: Safety & Arrest Effectiveness
n arrested (SD) 95% CI adverse events flu, nausea, SDF 30 .72 (.38) .55 to .85 redness, spot diarrhea x 2, placebo 36 .05 (.18) .00 to .16 tummy ache, toothache + diarrhea
Advantage, UW, UCSF
9 2/14/18
Microbiology by “sequencing”
∆ species after SDF
6 unc Tannerella Gemella morbillorum Roseburia intestinalis Proteus mirabilis No unc Lachnospiraceae Clostridium piliforme 4 decreases 10 −log p 2
FDR<.01 FDR<.05 0 logFC|>2 −8 −4 0 4 8 ∆ relative abundance SDF log ( ) 2 ∆ relative abundance placebo
Trial Summary
No harms observed. No foreseeable threats to safety. Higher effect @2 weeks vs 6 months.
10 2/14/18
IHS Pilot
• “If I had anything that worked, do you think I would be introducing an unknown drug that is not standard of care into my community?”
• 5x Silver nitrate + Fluoride varnish
• 3 years: 85% arrest, 75% no new lesions. • 2 years: 93% arrest.
• After 1 year: “Finally, after 30+ years of clinical experience, I have something that works.”
Outline _ 1. SDF – what is it? 2. SDF adoption 3. SDF clinical evidence 4. SDF clinical use 5. SDF mechanisms 6. SDF treatment failure 7. SDF x-ray follow up 8. SMART
11 2/14/18
When would you use it?
UCSF Indications: 1. Extreme caries risk (Xerostomia, S-ECC) 2. Behavior or medical challenges. 3. More lesions than treatable at 1 visit. 4. Difficult to treat lesions. 5. Patients without access to care.
How do you use it?
Accessible 1. Isolate with cotton. Arrested cavities cavity. 2. Air dry. after 1 year 3. Apply with microbrush.
How much do you use?
– microliters per lesion. – 1 drop (20μL) can treat 5+ lesions.
12 2/14/18
How much can you use? – FDA rat & mouse LD50 studies: • Oral LD50 = 520 mg/kg • Subcutaneous LD50 = 380 mg/kg
– 20uL drop in 10kg child (100% absorption) ~15 month old = 0.76 mg/kg • 500-fold LD50 safety margin. – NOAEL level for 14 days of daily exposure = 1.3 mg/kg • 13 mg/kg resulted in mild gastric inflammation. UCSF limit: 1 drop per 10kg of weight per visit.
SDF, how safe is it? • No adverse reports in >80 years of use in Japan. • Contraindication – Silver allergy. • Relative contraindication: – Significant desquamative processes e.g. ulcerative gingivitis, stomatitis. → Protect by petroleum jelly • Side effects: – Stains the lesion black. – Small, white mucosal lesions • disappears in 48 hours.
1 L 1 ppm F
20 µL 50,000 ppm F =
13 2/14/18
SDF staining
Duffin, J Cal Dent Assoc 2012
time 0 1 day 1 week
Castillo et al, J Dent Res 2011
567px-Singapore_Road_Signs_-_Temporary_Sign_-_Caution.s... http://3.bp.blogspot.com/-VJvRwbauAzo/TxAnwGkM1aI/A... 567px-Singapore_Road_Signs_-_Temporary_Sign_-_Caution.s... http://3.bp.blogspot.com/-VJvRwbauAzo/TxAnwGkM1aI/A... Person and Clinic Protection
Permanent staining of clinic surfaces & clothes. 1 of 1 6/3/15, 8:10 PM 1 of 1 6/3/15, 8:10 PM – Does not come out after setting. – Clean immediately with copious water, ethanol, or high pH solvents such as ammonia.
Temporary staining of skin – Rinse. – Will go away in days. – No harm.
Outline _ 1. SDF – what is it? 2. SDF adoption 3. SDF clinical evidence 4. SDF clinical use 5. SDF mechanisms 6. SDF treatment failure 7. SDF x-ray follow up 8. SMART
14 2/14/18
SDF: how does it work?
• Bactericidal • Prevents bacterial growth • Deactivates enzymes
• Remineralizes to fluoroapatite • Increases lesion hardness • Prevents demineralization
• Occludes dentinal tubules • Penetrates far into dentin
silver ion = wrecking ball
Antimicrobial: - denatures all proteins. - breaks cell walls. - inhibits DNA replication.
Coagulant - denatures exposed dentin proteins.
SDF: sustained antimicrobial effects – Treated dentin resists plaque formation. – demineralized dentin resists more.
– Zombie Effect: Silver-killed bugs kill active bugs. • Ideal substantivity.
15 2/14/18
Silver chases bugs down into tubules
Hamama, Aust Dent J 2015
SDF penetration testing
SDF: penetration
SDF casts silver rebar millimeters into dentin, reinforcing the lesion and sustaining kill.
16 2/14/18
kinetics of SDF penetration
1 hour 10 minutes Before
Outline _ 1. SDF – what is it? 2. SDF adoption 3. SDF clinical evidence 4. SDF clinical use 5. SDF mechanisms 6. SDF treatment failure 7. SDF x-ray follow up 8. SMART
Some cavities keep growing after SDF treatment, because of differences in the:
Answer Options % response Ability to get SDF into the lesion 72.0 (cavity location, cooperation) Severity / size of cavity 59.0 Diet 54 Depth of SDF penetration 51 Hygiene 51 Cavity cleansability 45 Time of SDF contact with the lesion 44 Bacteria 43 Salivary flow through the cavity 37 Patient physiology 27 Curing light or other precipitant 5 Lack of curing light or other 3 None of the above 0
Write ins: Application frequency, protocol, Subgroup of patients, Fluoride exposure, Bacteria levels vs composition, Tooth location, Cavity location, and Stage of remineralization
17 2/14/18
Ghana Ag+F pilot
SDF treatment failure 5 Propionibacterium Streptococcus mutans 4 3 2 −log10 p-value 1
0 FDR<.05
−1 0 1 2 log2 Fold Difference SDF treatment FAILURE
Faster
Outline _ 1. SDF – what is it? 2. SDF adoption 3. SDF clinical evidence 4. SDF clinical use 5. SDF mechanisms 6. SDF treatment failure 7. SDF x-ray follow up 8. SMART
18 2/14/18
baseline
1 year
2 years
@ 2 years: 0 new cavities
start: 2y11m
2 treatments 6 months +6 months
2 treatments
12 months +7 months
@ 1y4m: 0 new cavities
3y8m lesions: A,B,I,J,S,F,H,C
2 treatments
+6 months
2 treatments
+8 months
A disappeared M,R appeared
@ 1y2m: 2 new cavities
19 2/14/18
3y10m Topical arrest @ 2years: 0 new cavities
3 treatments +9 months
+2 treatments +6 months +1 treatment +6 months
5y10m
Topical arrest 3y10m @ 2years: 0 new cavities
3 treatments +9 months
+2 treatments +6 months +1 treatment +6 months
5y10m
Topical arrest
3y10m @ 2years: 0 new cavities
3 treatments +9 months 5y10m
20 2/14/18
Topical arrest
3y10m @ 2years: 0 new cavities
3 treatments +9 months 5y10m
Outline _ 1. SDF – what is it? 2. SDF adoption 3. SDF clinical evidence 4. SDF clinical use 5. SDF mechanisms 6. SDF treatment failure 7. SDF x-ray follow up 8. SMART
21 2/14/18
Billing Consent
Patient Name: Date of Birth: • ! Medical Record Number: D1354 caries arrest. ! San!Francisco!Department!of!Public!Health!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Dental!Services! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! INFORMED!CONSENT!FOR!SILVER!DIAMINE!FLUORIDE! ! Facts!for!consideration:! • Silver!diamine!fluoride!(SDF)!is!a!liquid!that!helps!stop!tooth! • D1208 topical fluoride. decay.!SDF!is!applied!every!3,!6!or!12!months.! • A!small!amount!of!SDF!is!applied!to!the!decayed!tooth!area.! • After!SDF!application!no!eating!or!drinking!for!60!minutes! and!no!tooth!brushing!until!the!following!morning.! • The!decayed!area!will!stain!black!permanently.!Healthy! tooth!structure!will!not!stain.!! • I!should!not!be!treated!with!SDF!if:!1)!I!am!allergic!to!silver.!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 2)!There!are!painful!sores!or!raw!areas!on!my!gums!or!anywhere!in!my!mouth.! • D9910 desensitization. !!! Benefits!of!receiving!SDF:! • Helps!stop!tooth!decay.! • Fast.! • Do!not!need!to!numb!teeth.! • Does!not!hurt.! ! Risks!of!receiving!SDF:! • The!affected!area!will!stain!black!permanently.!This!means!SDF!is!working.! • ToothJcolored!fillings!and!crowns!may!discolor!if!SDF!is!applied!to!them.!! • After SDF treatment, a filling or crown might still be needed.! • If!accidentally!applied!to!the!skin!or!gums,!a!brown!or!white!stain!may!appear!that!causes!no! harm,!cannot!be!washed!off!and!will!disappear!in!one!to!three!weeks.! • Permanent dark spots if spilled on clothing.! • Allergic reaction.! • Risk!that!the!procedure!will!not!stop!the!decay.! • Not every cavity can be treated with SDF! ! Alternatives!to!SDF,!not!limited!to!the!following:! • No!treatment,!which!may!lead!to!continued!break!down!of!the!tooth.!Symptoms!may!get!worse.! • Placement!of!fillings!or!crowns,!extractions!or!referral!to!a!specialist.! ! I have read this form. I understand the treatment and have had the chance to ask questions. I have seen the photo of how teeth may look after SDF discolors the cavities. I understand that I may refuse treatment with SDF. I understand that I can decide to have no treatment or I can have fillings, crowns, or extractions done at this or another dental office.
I consent and authorize SFDPH Dental Services to use Silver Diamine Fluoride to help stop tooth decay.
Signature!of!patient/parent/guardian!!______!Date______! ! ! Signature!of!witness______Date!______!!
sites.google.com/site/jeremyahorst
SDF take-homes
1. SDF arrests >90% caries when used 2/year. 2. Powerful indirect prevention. 3. Dry before use. 4. Safe. 5. SDF stains the crap out of everything.
SDF pro tips
1. 3x in 2 weeks. - Dr. Steve Duffin 2. Cover immediately with varnish. - Dr. Steve Duffin 3. Light-cure to precipitate. - Prof. GV Black 4. Superfloss to soak posterior interproximals. - Dr. Jason Hirsch 5. Ortho separators to access interproximals. - Dr. Neel Satpute
22 2/14/18
Dr. Jeanette McLean
• Increased treatment follow through. • Parents don't want their children sedated. • Parents happily sign on to SDF, to avoid massive out of pocket expense. • The word of mouth is incredible. • Many new patients find us through SDF. • The ease and speed of placement allows us to make up in volume what we "miss."
Outline _ 1. SDF – what is it? 2. SDF adoption 3. SDF clinical evidence 4. SDF clinical use 5. SDF mechanisms 6. SDF treatment failure 7. SDF x-ray follow up 8. SMART
SDF + GIC: silver modified ART SMART • Glass Ionomer Cements (GICs) add the benefit of sustained fluoride release and a seal! • Protocol: SDF, then standard GIC protocol.
(they darken over time)
Drs. John Frachella & Cate Quas
23 2/14/18
SMART armamentarium
SMART retention
24 2/14/18
GIC stain by SDF
SDF + GIC SDF + GIC 3x SDF Fuji 2LC Fuji 9 no-prep GIC 1 month 1 month Shofu Beautifil 2 weeks
Dr. John Frachella
SMART
Dr. Jason Hirsch
25 2/14/18
SDF + GIC/ART = SMART
Dr. Steve Duffin
SDF + GIC/ART = SMART
26 2/14/18
Kitchen SMARTs
Drs. Steve Duffin & John Frachella
The paradox of covering
Lesion (GIC) Mouth (SDF) • seal stops progression - SDF prevents lesions • seal may seal in SDF throughout • GIC prevents lesions - SDF needs more nearby applications • GIC needs less frequent - SDF is cheaper reapplication - SDF is less technique • Small lesions may not sensitive retain GIC - Deep lesions may progress
Outline _ 1. SDF – what is it? 2. SDF adoption 3. SDF clinical evidence 4. SDF clinical use 5. SDF mechanisms 6. SDF treatment failure 7. SDF x-ray follow up 8. SMART
27 2/14/18
Hall crown technique
BMC Oral Health 7:18
Hall technique no preparation SSCs
BMC Oral Health 2007, 7:18 http://www.biomedcentral.com/1472-6831/7/18
Table 5: Teeth where Hall PMC was unable to be fitted and reason recorded by GDP.
Reason recorded why crown not fitted Tooth Number
"extra cusp on maxillary Ds, couldn't get crown to fit without major adjustments" 64 1 "patient unable to cooperate, very nervous" 64 1 "couldn't get crown to fit" 54 1 "all (crowns) were too big" 54 1 Total 4
Subjective assessment of discomfort, if any, experienced by for either technique expressed by the child, their parent or the child their dentist. When the Control restoration and Hall PMC For 89% of Hall PMCs, procedures were rated by the were provided during the same appointment, the chil- GDPs as causing "no apparent discomfort" to "mild, not dren's preferences were not dependent on which restora- significant", while for Control restorations, the figure was tion was carried out first (Chi square analysis; P = 0.203). 78%, and the difference was statistically significant (Chi square test, p = 0.012). The distribution of this data is Consequences of increasing the occlusal vertical dimension shown in Figure 4. As the Hall Technique does not involve any occlusal reduction of teeth, it is inevitable that the placing of a Hall Preference for either procedure PMC will increase the occlusal vertical dimension (OVD). Following completion of both procedures, the dentists GDPs measured this increase at the incisors immediately recorded which procedure (Hall PMC or Control restora- after placement of the Hall PMC. The mean reported value tion) they, the child and their carers had preferred. Over for all teeth was 2.4 mm (SD 0.13, range 0–4 mm). For nine out of 10 children and dentists, and three-quarters of first primary molars this was 2.3 mm and for second pri- carers, expressed a treatment preference (Figure 13). For mary molars the mean value was a little higher at 2.5 mm. 77% of the children, 83% of carers and 81% of dentists, Even occlusal contact was recorded on both sides of the the preference was for the Hall PMC, and this was statisti- arch for all 129 children at the one year recall appoint- cally significant (one sample Chi square goodness of fit ment. An example of a patient treated with Hall PMCs test; P < 0.0001) for all three groups. Therefore, the null demonstrating re-established even occlusal contact is hypothesis that children, carers and dentists would not shown in Figure 14. have a preference was rejected. Indicators ofHistory success of TMJ pain The use of separators did not influence either the level of There was no history of TMJ pain, and no difficulty with discomfort experienced by the child when having a Hall eating reported by either the child or their parent for all PMC fitted, as assessed by their dentist, or the preference 129 children assessed at one year recall.
RadiographisfactoryFigure 11 fit of Hall PMC on tooth 74 (LLD) recorded as sat- RadiographunsatisfactoryFigure 12 of fitHall PMC on tooth 54 (URD) recorded as Radiograph of Hall PMCsuccess on tooth 74 (LLD) recorded as sat- Radiograph of Hall PMCfailure on tooth 54 (URD) recorded as isfactory fit. Patient randomisation number 7. unsatisfactory fit. Patient randomisation number 34.
Page 11 of 21 (page number not for citation purposes)
28 2/14/18
Hall crown Clinical Trial in UK General dentists, 4 year follow up
1
0.8
0.6
0.4 proportion 0.2
0 Hall Conventional no failures minor failures major failure 130 kids
Innes, J Dent Res 2011
Hall crown Clinical Trial in Germany treatment by Pediatric dentists, 1 year f/u
100
80
60
40
proportion (%) 20
0 Hall NRCT Conventional NRCT no failures minor failures major failure Non-restorative caries therapy 148 kids
Craig & Powell, 2013 Santamaria et al., 2014
ORIGINAL CONTRIBUTIONS
Halls in the USA of many of the studies reviewed 1.00 showed that sealing caries 0.98 results in clinical and radio- graphic signs of inactivation of 0.96 the caries lesion with tertiary 0.94 dentin formation.15 The use of 0.92 glass ionomer cement placed 0.90 directly over carious dentin during indirect pulp therapy in 0.88 primary teeth has been shown 0.86 to be 93 percent successful 0.84 after four years of follow-up.16 SURVIVAL PROBABILITY 0.82 Investigators in another study found the use of resin-modified 0.80 glass ionomer for indirect pulp 1 67 11 0 2 117 98 69 26 12 0 therapy in primary molars 0 246 810 to have a survival rate of 96 percent over three years.17 One TIME, IN YEARS Years study in which researchers Hall Technique Traditional Preparation Censored followed up permanent teeth JADA 2014 with remaining deep dentinal Figure 5. Kaplan-Meier survival curves and 95 percent confidence intervals, showing the number caries and a sealed restoration of patients at risk. The blue-shaded and red-shaded areas around the survival curves represent the showed no lesion progression 95 percent pointwise confidence interval. Row 1 shows the crowns placed according to the Hall after 10 years.18 Similar success technique (n = 67); Row 2 shows the crowns placed with traditional preparation (n = 117). of sealed caries in primary teeth would allow for these teeth to 96.2 percent after a minimum of 23 months of follow-up8 be restored successfully until exfoliation. and 92 percent at a minimum of 48 months of follow- Although it is impossible to evaluate the success of up.11 The survival rate seen in this study after 15 months the seal provided by an SSC in vivo, studies of extracted is in accord with these previous results, and it equals or primary molars have shown that SSCs luted with resin- exceeds the success of all other materials used for restor- modified glass ionomer cement have displayed little 29 ing primary molars at one to two years of follow-up.12-14 microleakage, and there is no significant difference in Investigators conducting a review of Class II restoration microleakage between intact and extensively carious pri- longevity found mean annual failure rates of 7.6 percent mary molars restored with SSCs by means of a tradition- for alloys, 13.9 percent for glass ionomer cement, 4.2 al preparation.19 Investigators in one study reported that percent for resin-modified glass ionomer and 5.9 percent SSCs placed in vitro with either the Hall technique or a for resin-based composite restorations.12 Some caution traditional preparation all displayed microleakage, with should be used in comparing these results with those of statistically significantly greater microleakage values in previous studies involving the Hall technique, because the Hall-technique SSC group. However, the study’s au- in the private practice setting in our study, in the event thors noted that it was challenging to fit Hall-technique of tight contacts, the clinician would provide a proximal SSCs in vitro without the aid of the patient’s biting force slice to permit easier seating of the SSC. In contrast, to seat the crown, which may have affected adaptation.20 the published Hall technique recommends use of an Additional studies are needed to explore the differences orthodontic separator to allow for physiological move- on microleakage between these two techniques further. ment of the teeth to permit crown seating without any This study had several limitations. First, it is retro- proximal reduction.8 However, even accounting for this spective, and the group of traditionally placed SSCs is change, the clinician was able to render treatment in one not an ideal control group, because the majority of these appointment, without the need for local anesthetic, and crowns were placed during an earlier period than those with no apparent change in overall success. in the Hall technique group and patients did not receive Although the Hall technique shows promise as an random assignment to a treatment modality. In addition, alternative treatment modality, the question remains the difference in patients’ ages at time of treatment may whether the caries lesions restored according to this have played a factor in this study’s results and should technique will be sealed successfully and remain ar- be considered, because an SSC’s success decreases with rested until the tooth exfoliates naturally. The results of increasing age at time of placement.21 A majority of a 2013 systematic review showed that incomplete caries SSCs placed in the Hall-technique group were provided removal can be considered advantageous, and findings to children aged 5 through 7 years, whereas a major-
1252 JADA 145(12) http://jada.ada.org December 2014
1248_1253_Dean.indd 1252 11/13/14 1:19 PM BMC Oral Health 2007, 7:18 http://www.biomedcentral.com/1472-6831/7/18
Table 6: Use of separators and subsequent satisfactory fit of Hall PMC where a PMC was fitted (n = 128 teeth).
Hall PMC fit satisfactory Hall PMC fit not satisfactory Total
Separator used 15 2 17 Separator not used 95 16 111 Total 110 18 128
Time taken for placement of restoration Radiographic assessment of outcomes For 84 patients (64%), the treatments took place at the For the period of 0 to 36 months, there were a total of 422 same appointments and for 48 (36%), at separate follow-up radiographs (211 Control and 211 Hall) avail- appointments. The time taken to explain and complete able for the 124 patients meeting the inclusion criteria, as each procedure was reported for 129 Hall PMC proce- there was more than one set of radiographs for some dures and 128 Control restoration procedures. For the patients. There was radiographic information for 117 Control restorations, a mean time of 11.3 minutes (range patients out of 124 (94%) where this might have influ- 4 to 32 minutes; SD 5.5) was reported, with a mean time enced the assessment of success or failure (one patient's of 12.2 minutes (range 2 to 40 minutes; SD 8.3) for the teeth exfoliated before the one year recall and six had no Hall PMCs. Table 7 shows a breakdown of the times for follow-up radiographs for unknown reasons). The results each procedure. for radiograph quality assessment are shown in Table 8. The presence or absence of new caries or caries progres- 2/14/18 Follow-up period sion could be determined (codes 0 and 1 for exposure/ The minimum period of 23 months (rather than 24 developing; codes 0 and 1 for visibility of study tooth months) was chosen to take account of minor variation in crown) for 114 Control restoration allocated teeth (88%) dental practices arranging yearly recalls. Data were ana- and 117 Hall PMC teeth (91%). Information on the pres- lysed for all patients with follow-up data at a minimum of ence or absence of inter-radicular radiolucencies (codes 0 23 months (mean 28 months), for the period 0 – 36 and 1 for exposure/developing; codes 0 and 1 for furca- months following enrolment into the trial. Patients with tion visibility) could be determined for 110 teeth allo- data only at less than 23 months were not included in the cated to Control restorations (85%) and 81 Hall PMC follow-up data analyses. Of the 132 patients enrolled in teeth (63%). The reduction in visibility of the furcation the study, there were 124 patients (94% follow-up rate) area for Hall PMC teeth compared with the Control resto- who met these criteria. Table 1 details the outcome criteria ration teeth can be explained as the PMCs are fitted with for the clinical and radiographic assessment of the resto- no occlusal reduction, and so lengthen crown height, rations and teeth. reducing the area of film adjacent to the furcation area. The high bite self-adjusts
120 Control restoration 97 100 95 Hall Technique restoration 83 80 No preference expressed
60
40 number of individuals of number 32 48 kids 28 23 20 17 12 3 9
0 2.5 child (patient) parent/carer dentist ClinicaltheFigure6 Hall Hall photograph14Technique crowns atof separatea patient appointments with six PMCs fitted using 2 Patient/carer/dentisttreatmentFigure 13 events) treatment preference (n = 396 for 132 Clinical photograph of a patient with six PMCs fitted using1.5 Patient/carer/dentist treatment preference (n = 396 for 132 the Hall Technique at separate appointments. The occlusion treatment events). has adjusted to give even contact between the arches. 1 0.5 canine overlap (mm) 0 Page 12 of 21-1 7 15 23 (page number not for citation purposes) days post-treatment vanderZee & vanAmerongen 2010
preference
Innes, J Dent Res 2011
wikipedia.org/wiki/Hall_Technique
The Hall Technique A minimal intervention, child centred approach to managing the carious primary molar
A Users Manual Version 4
Text copyright Nicola Innes, Dafydd Evans, Matthew Stewart, Alex Keightley
30 2/14/18
Joe DeRisi Peter Milgrom Steve Duffin Jason Hirsch John Frachella Douglas Young Jeanette MacLean Martin MacInytre John Featherstone THANK YOU Pam DenBesten Thuan Le Jong Seto Eleni Ellenikiotis Helen Yuan Alex Yamana
31