Silver Diamine Fluoride: Science, Practice, Potential
Oral Health America Webinar Series August 30, 2018
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2018
HOUSEKEEPING INFORMATION • •
Please remember to MUTE your phone. Questions are welcome! We’ll allow 10-15 minutes after the presentation for questions. • Questions will be accepted in writing through the control panel on the upper right hand of your screen. • Submit questions at any time; we will address them at the end of the presentation. • Webinar is being recorded; for rebroadcast on OHA’s website – OralHealthAmerica.org • Your feedback is important to us. Please take our brief webinar evaluation after this session; link will be sent via email.
2018
CE Credit Available
2018
ABOUT ORAL HEALTH AMERICA America’s leading national oral health nonprofit focused on the nation’s oral and overall health for 63 years, with particular emphasis on children and youth, older adults and Americans whose voices are not wellrepresented in oral healthcare conversations. OHA employs strategic partnerships and communications to connect the dots between oral and overall health
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Addresses oral health inequities in our society and identifies possibilities for closing the oral health divide in America.
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Question and Answer Session • Questions are welcome! This session may last for 10-15 minutes. • Write your questions in your control panel on the upper right hand of your screen. • Submit questions at any time.
2018
CE Credit Available
2018
Contact Information
•
Dr. Michael Helgeson • mhelgeson@appletreedental.org
•
Dr. Ryan Quock •
•
ryan.quock@uth.tmc.edu
David Martin • David.martin@oha-chi.org
2018
THANK YOU! Let’s improve the oral and overall health of all Americans together.
2018
Silver Diamine Fluoride: Science, Practice, Potential Webinar August 30, 2018: 2pm-3pm CST
Thanks to the
Dental Trade Alliance Foundation
Thanks to
3M Oral Care
We’ll share three stories… • An 18 month old facing hospitalization for general anesthesia
• A middle aged adult struggling with limited Medicaid coverage and potential loss of his front teeth • A frail elder in hospice with multiple failing teeth, fearing another abscess
Objectives… • We want help you to understand the basic science of Silver Diamine Fluoride (SDF) - what it is and how it works. • We want you to learn about our experiences introducing SDF to our team of dentists and dental therapists and then deploying in practice. • And finally, we want to share our hopes for the promise of SDF with a focus on its benefits for patients across the lifespan
1. The Science of SDF
What is SDF? • Ag(NH3)2F – silver and fluoride ions
in colorless ammonia solution • Various concentrations – most studied is 38% SDF • 38% SDF contains ~44,800 ppm F(compare with 22,600 for NaF varnish)
Walker D, Yee R. Arrest of caries technique (ACT): appropriate technology for the clinician and for disadvantaged communities in Nepal. Accessed on August 6, 2015 at http://www.scribd.com/doc/32660152/Arrest-of-Caries-Technique#scribd
Rosenblatt A, Stamford TCM, Niederman R. Silver diamine fluoride: a caries “silver-fluoride bullet.” Journal of Dental Research 2009;88(2):116-125.
What does SDF do? • Silver diamine fluoride (SDF)
has been studied outside the United States since the late 1960s. • Ag(NH3)2F arrests existing active caries lesions and prevents future lesions.
How does SDF work? • • •
Silver-salts stimulate dentin sclerosis & calcification Silver nitrate acts to kill bacteria Fluoride aids in remineralization and prevention Rosenblatt A, Stamford TCM, Niederman R (2009) Silver diamine fluoride: a caries “silver-fluoride bullet.” Journal of Dental Research 88(2) 116-125.
2. The Practice of using SDF
A PPLE T REE D E N T A L Access • Compassion • Excellence
In our 33rd year!
Minnesota Centers for Dental Health 130 Community Sites • Low income children and their families • Adults with disabilities
• Seniors and elders in long-term care • Urban and rural communities
Total Age Distribution, 2017 13,151
31,258 individual patients treated 87,633 dental visits and screenings provided 7,386 5,222 3,183
2,250 66
Under 21
21 to 44
45 to 64
65 to 84
85 to 99
Over 100
Minnesota 32 Years
MN
CA
California
NC
2 Years
LA
Apple Tree Programs and Replications
Louisiana 16 years
NC
North Carolina 19 and 20 years
Our “Centers for Dental Health” are the “hub” for mobile delivery of care in the surrounding community
Community Collaborative Practice
Collaborating to deliver oral health services where people live, go to school, or receive other health and social services
Cloud-Based Electronic Health Record
Apple Tree’s “Multi-Site Delivery Vehicle”
Implementing SDF at Apple Tree
Relevance of SDF for Vulnerable Patients • Children
• better tolerated by very young / pre-cooperative patients • preventing the need for general anesthesia • Adults • limited benefits / treatment options in public programs • Older adults
• high risk / low access
Timeline of SDF Implementation Fall 2015 Apple Tree staff intro to SDF
2016 Apple Tree pilots, then implements SDF in Centers
2015
4/15 NOHC J Horst Presentation on SDF
2016 11/15 Medicaid Committee recommends SDF coverage
2017 Apple Tree pilots, then implements SDF in LTC
2017
2018
10/16 -10/17 DTAF funded a pilot project in Long-Term Care 1/16 MN Medicaid covers D1354
Dr. Quock educating Minnesotans on Silver Diamine Fluoride
Preparation for SDF Implementation For Apple Tree staff • Lunch and learn sessions with an Elevate Oral Health representative • Apple Tree protocol development based on UCSF • Staff SDF education sessions • Customized EHR for SDF tracking / Open Dental • Talking points for Care Coordinators
Preparation for SDF Implementation For patients • Education sheet for Patients and Responsible Parties
• Letters to Directors of Nursing • Informed Consent with photos
Staff Instructions
Care Coordinator Talking Points
Information for Directors of Nursing and long-term care staff
Information for Nursing Facility Residents
Informed Consent
Implementation Strategy - Centers • 110 clinical and administrative staff, including • 90 dentists, dental therapists, hygienists, and assistants
• 20 care coordinators • Initial pilot with select dentists and dental therapists at Centers for Dental Health. Feedback incorporated.
• Expansion to all clinic-based clinicians, beginning with dentists and dental therapists and allowing clinical teams to determine when/whether to delegate to hygienists and/or assistants.
Implementation Strategy - LTC Facilities • Pilot in LTC setting, with select dentists and facilities, feedback incorporated prior to expansion to all on-site clinicians • Eight dentists, two dental therapists, and six dental therapy students provided SDF treatments for LTC residents during the pilot. • More than 75 staff members of 35 long-term care facilities received information about SDF as new treatment option for their residents and reinforcing the importance of oral health.
Sites, Patients, SDF Treatments SITES & CENTERS
PATIENTS
SDF TX
DECLINED TX
NURSING FACILITIES (35)
216
462
20
COON RAPIDS
20
35
FERGUS FALLS
90
195
HAWLEY
48
79
MADELIA
131
180
MOUNDS VIEW
29
70
ROCHESTER
29
76
1
TOTAL
563
1,097
30
SDF Treatments through 10-31-17
8
1
25 anteriors 140 posteriors
SDF by Tooth # in Long-term Care pilot
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
21
20
19
18
17
68 anteriors 212 posteriors
32
31
30
29
28
27
26
25
24
23
22
Long-Term Care Age Distribution 15 10
216 LTC patients received 462 SDF treatments
5 0
Age 47 51 54 59 61 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 102
Center Patient Age Distribution 30 25
346 Center patients received 635 SDF treatments
20 15 10 5 0 Age 4
7
10 13 16 19 22 25 28 31 34 37 40 43 47 50 53 57 61 64 70 75 81 94
Children 81% Adults 56% Older Adults 75% Preventively 36% Suspect Caries 44% Caries 81% Occlusal Surfaces 56% Interproximal Surfaces 50% Gingival Surfaces 63% Subgingival Surfaces 56% Prior to Restoration 44% Instead of Restoration 75% Other 19%
Highly Likely 43% Likely 50% Unlikely 1% (respondents had not yet used SDF) Would Not Recommend 0%
Clinical Cases and Q&A with Dr. Quock
Apple Tree Mounds View Center Restoration after SDF August 2, 2017
Before SDF
After SDF
After SDF
After Restoration
Q&A with Dr. Quock
Is there a limit to the number of teeth treated with SDF at any one appointment?
•
One drop is about 0.05 mL and treats 5 teeth
•
SDF contains about 44.8 mg F per mL, so one drop contains about 2.2mg F
•
The acute toxic dose for a 20lb. child is about 45 mg F
Please discuss the pros/cons of applying SDF and restoring over it on the same appointment.
•
PRO: Tooth gets restored the same day
•
CON: Don’t get to clinically observe the arrest of the lesion
Evaluation of SDF Outcomes
How long after treatment should one wait to assess outcomes? •
No well-defined protocols. It’s the clinician’s expertise that comes in.
When SDF is used off-label under a restoration, how can you assess whether there is new decay?
How does an SDF treated surface look on x-rays? Do you have photos of radiographic images?
Any experience with use to arrest decay under crowns with questionable prognosis for older adults?
3. The Promise of SDF
Lessons Learned Planning • Patients/Parents are receptive - ie informed consent is important but staining less of a barrier than anticipated • Challenging to incorporate a paradigm shift into day-to-day practice • Multiple educational opportunities helpful Clinical • Evaluation of caries arrest raised questions for many clinicians • Adjacent areas also darkened beyond what was anticipated and restorations with dark margins or grey appearance • Time / experience necessary for clinicians to incorporate into their practice
SDF Medicaid coverage
• D1354 Interim Caries Arresting Medicament Application • Once per six month; • tooth number required
• cannot be formed on the same date as D1206 and D9910
Closing with three stories‌
Avoiding general anesthesia‌
Fearing the loss of front teeth‌
Note: This is not the patient
Preventing painful abscesses … • A call from a dental school classmate • His mother lost two crowns after entering hospice • She couldn’t be transported and had complications following recent oral surgery • We sent an experienced collaborative practice hygienist to do a house call Note: This is not the patient
Additional Reading…
Chibinski AC, Wambier LM, Feltrin J, Loguercio AD, Wambier DS, Reis A. Silver diamine fluoride has efficacy in controlling caries progression in primary teeth: A systematic review and metaanalysis. Caries Research 2017;51:527-541.
Oliveira BH, Rajendra A, Veltz-Keenan A, Niederman R. The effect of silver diamine fluoride in preventing caries in primary dentition: A systematic review and meta-analysis. Caries Research 2019;53:24-32.
Hendre AD, Taylor GW, Chavez EM, Hyde S. A systematic review of silver diamine fluoride: Effectiveness and application in older adults. Gerodontology 2017:1-9.
Mei ML, Lo ECM, Chu CH. Arresting dentine caries with silver diamine fluoride: What’s behind it? Journal of Dental Research 2018 (epub ahead of print)
Questions and Discussion Thank you! www.appletreedental.org
Presentation Timer Timer: 2:00 to 3:00pm
TOPIC
SPEAKER
TIME (MIN:SEC)
Introduction and thanks to DTAF and 3M
Mike
01:00
1. Science of SDF
Ryan
06:00
2. Practice of SDF -Apple Tree Background
Mike
08:00
-Implementation at Apple Tree
Mike
09:00
-Clinical Cases, Q&A with Dr. Quock
Ryan
05:00
-Evaluation of SDF Outcomes
Ryan
04:00
3. The Promise of SDF and Stories
Mike
06:00
TOTAL GOAL
39:00 40:00
DIFFERENCE
01:00
Notes from July 11…
• 5 minutes: Introductory remarks from OHA • 40 minutes: Formal presentation • 15 minutes: Q&A