Margherita Fontana, DDS, PhD University of Michigan School of - - PowerPoint PPT Presentation

Margherita Fontana, DDS, PhD

University of Michigan School of Dentistry Department of Cariology, Restorative Sciences and Endodontics

Agenda

• What is Dental Caries?
• Do we need to remove carious tissue to control disease?
• Fluoride
• Sealants and Hall crowns
• SDF

What is Dental Caries?

Dental caries is a: 1) chronic, 2) site-specific, 3) multifactorial, 4) dynamic (but not necessarily continuous) 5) disease process that involves the shift of the balance

between protective factors (that aid in remineralization) and destructive factors (that aid in demineralization) to favor demineralization of the tooth structure over time.

6) The disease can be arrested at any point in time.

D Bratthall

Fisher-Owens SA et al. Pediatrics 2007;120:e510-e520

Dental Caries is a Result of a Dysbiosis in the Biofilm

Gross et al. 2012. PLOS-One 10:e47722

Child Diet (Parent) Behavior

SES

Food Policy

Culture

Geography

Genetics

MEDIATED VARIABLES

Decayed Tooth

OH

Fluoride Sealants

Moderating Variables

Dietary Sugars

Biofilm

changes

Sugar Dental Caries

• Dr. Weyant

A necessary and sufficient cause

Strategies with the strongest, consistent, highest quality evidence now-a-days are: Fluoride

• Use other strategies to supplement well

known interventions, rather than substituting them Sealants

Non-Surgical Surgical No Treatment Remineralize Arrest Sealant Minimal Surgical Traditional Surgical Endodontic Treatment Extraction

Caries Management

DIAGNOSIS

No Disease ICDAS 0 Initial Lesion ICDAS 1 Initial Lesion ICDAS 2 Moderate Lesion ICDAS 3 Moderate Lesion ICDAS 4 Extensive Lesion ICDAS 5 Extensive Lesion ICDAS 6

Caries Lesion Activity Assessment

Radiographs and Other Diagnostic Aids Medical, Dental, Social History

Caries Risk Assessment

9

Many protocols are available….

• Enhances Remineralization *
• Reduces Demineralization
• Antimicrobial

The Cochrane Database of Systematic Reviews, 2003, 2006, 2008

Fluoride Mechanisms of Action

5000 10000 15000 20000 25000 0.1% F 0.77% F 1.13% F 2.26% F 1.23% APF 0.9% F 0.5% F 0.11% F 0.11% F 0.10% F 0.09% F 0.02% F 0.01% F 100 ppm F or 0.02% NaF 226 ppm F or 0.05% NaF 905 ppm F or 0.2 % NaF 1,100 ppm F or 0.243% NaF 1,100 ppm F or 0.454% SnF2 5,000 ppm F or 1.1% NaF 9,050 ppm F or 2% NaF 12,300 ppm F or 1.23% APF 22,600 ppm F or 5% NaF

DENTIFRICE S MOUTHRINS ES

GELS/FOAMS

VARNISHES

SELF-APPLIED PRODUCTS

PROFESSIONALLY-APPLIED PRODUCTS

Over-the-counter Needs prescription 11,300 ppm F or 2.5% NaF 1,000 ppm F Concentration in ppm F 1,000 ppm F or 0.76% SMFP 0 5,000 10,000 15,000 20,000 25,000 7,700 ppm F or 1.5% NH4F

Fernandez and Gonzalez-Cabezas, 2015 38% SDF

(~44,800 ppm*) *Up to 55,800 ppm; Mei et al., 2012

CDC Recommendations

Dentifrices (toothpastes)

2 4 6 8 10 Baseline am Brushing 15 min 30 min 45 min 1 h 2 h 8 h pm Brushing Upon Rising ppm F

Fluoride and Dentin

10 20 30 40 50 60 70 80 90 100 0.01 0.1 1 10 % Inhibition of Demineralization Fluoride Concentration (ppm) Enamel Dentin

ten Cate et al., 1998

Mouthrinses

Fluoride In- Office

The Cochrane Database of Systematic Reviews, 2003, 2006, 2998 Marinho et al., 2013 JADA, Nov 2013

Risk Group < 6 Years 6 – 18 Years > 18 Years Root Caries Low May not receive additional benefit from topical fluoride Moderate/High 2.26 % Fluoride Varnish every 3-6 months 2.26% Fluoride Varnish every 3-6 months or 1.23% APF fluoride gel application for 4 min every 3-6 months

18

• National recommendations around children’s oral health (i.e., AAP,

AAPD, USPTF, etc.) include that every child have an age 1 dental visit, conducting an oral health screening at every well child visit starting at age 6 months and at every well-child visit thereafter, and applying fluoride varnish every 3-6 months starting when the first tooth erupts with the most benefit being received with application every 3 months.

• Reimbursement for Medicaid eligible children in ALL 50 states. There

are a number of states that include additional funding for oral examinations and other services.

Fluoride Dilemmas

We need to find the ideal balance for each patient

F Levels Time

Frequency vs. Concentration

An Update on Dental Sealants (and Sealing Caries)

Margherita Fontana, DDS, PhD mfontan@umich.edu

CDC, 2016

Sealants for Caries Prevention

Summary Evidence (Efficacy of sealants): Median Caries Reduction: 81% at 2 year follow-up

(Ahovuo-Saloranta et al. 2013) 2013

• Resin-based sealants are effective for preventing caries

in children and adolescents.

• Moderate-quality evidence that they reduce caries by

11-51% compared to no sealant.

• Similar benefit up to 48 months; after longer follow-up,

the quantity and quality of evidence is reduced (need longer follow-up studies).

• Insufficient evidence to judge the effectiveness of GI

sealant or other types of sealants.

• Information on adverse effects is limited, but none
• ccurred where this was reported.

Ahovuo-Saloranta et al., 2017

What about sealing caries lesions? (Non cavitated lesions)

A Sealant is NOT a Preventive Resin Restoration

Effective Seal

NIH Consensus Development Conference: Dental Sealants in the Prevention of Tooth Decay (1983)

Diagnosis and Management of Dental Caries Throughout Life (2001)

National Institutes of Health Consensus Development Conference Statement; March 26-28, 2001

• Effective in the primary prevention of caries
• Their effectiveness remains strong as long

as the sealants are maintained

• The evidence for caries arrest supports its

use

The Effectiveness of Sealants in Managing Caries Lesions

• Sealed non-cavitated lesions

consistently had better outcomes than not sealed lesions

• Caries reduction was about 71%

Reduction in Bacteria Counts by Time since Sealant Placement

(Oong et al., 2008

40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% . 3 . 1 5 . 2 3 . 3 5 . 5 1 . 1 . 2 . 2 . 4 . 4 . 6 . 6 . 7 . 1 2 . 1 2 . 2 4 . 6 . 6 . 6 . Months since Sealant Placement % Reduction in Mean Bacteria Counts

• Bacterial reductions

(4 studies) ranged from 50.8% to 99.9% and appeared to increase as time since sealant placement increased

Caries Prevention Sealants should be placed in pits and fissures of primary and permanent teeth when it is determined that the tooth, or the patient, is at risk of developing caries Noncavitated Carious Lesions Sealants should be placed on early (noncavitated) carious lesions, in children, adolescents and adults to reduce the percentage of lesions that progress

How to assess teeth for sealant placement

(Gooch et al., 2009; Fontana et al., 2010; Wright et al., 2016)

J Pub Health Dent, 1995 Non-Cavitated Cavitated

Sealants vs. nothing Sealants (sound and non-cavitated lesions) Sealants

• vs. FV

Sealants (sound and non-cavitated lesions) Sealants vs. nothing Unable to determine which is superior

• Unclear if one sealant material is superior to another
• Take into account the likelihood of experiencing lack of retention

when choosing the type of material

• If dry isolation is difficult, such as a tooth that is not fully

erupted, then a material that is more hydrophilic (e.g., GI) would be preferable

• If the tooth can be isolated to ensure a dry site and long-

term retention is desired, then a resin-based sealant is preferable.

• Monitor sealants over time, especially sealants showing a higher

risk of experiencing retention loss (i.e., GI)

Wright et al., 2016 (ADA)

Placement Techniques

• Routine mechanical preparation of enamel

before acid etching is not recommended

34 Sealant Failure - With Enameloplasty Beneath

• Dr. Fiegal

Wright et al., 2016

• Four-handed sealant placement is associated with

higher retention rates.

Griffin SO, Jones K, Gray SK, Malvitz DM, Gooch BF. 2008. Exploring four-handed delivery and retention of resin-based sealants. Journal of the American Dental Association 139(3):281–289.

• Sealant retention rates for teeth cleaned with a

toothbrush are at least as high as for teeth cleaned with a handpiece.

Kolavic Gray S, Griffin SO, Malvitz DM, Gooch BF.

• 2009. A comparison of the effects of toothbrushing and

handpiece prophylaxis on retention of sealants. Journal of the American Dental Association 140(1):38–46.

Evidence synthesis:

• The median one-time SSP cost per tooth sealed was

$11.64.

• Labor accounted for two thirds of costs, and time to

provide sealants was a major cost driver.

• benefits of SSPs exceed their costs when SSPs

target schools attended by a large number of high- risk children

2016

Studies on Permanent Teeth Only (Occlusal surfaces)

Liu et al. (2012) After 2 years, treatment of ICDAS 2 lesions in fissures: 38% SDF 1X/year equally effective to FV 2X/year and resin sealant (all better than control) on “prevention” (really arrest NC lesion) Proportions of fissures with dentin caries (ICDAS 4-6): Sealant 1.6%, (PF: 65%) ; FV 2.4% (PF: 48%), SDF 2.2% (PF 52%), control 4.6% Monse et al. (2012) 1X 38% SDF (for 1 min ;+tannic acid; excess removed; vaseline on top) on sound/NC lesions

• n first molars not an effective method to “prevent” dentinal (D3) caries lesions (similar to

control- not randomized). 1) ART sealants (“finger press”) significantly reduced the onset of caries over a period of 18 months.

Sealants vs. SDF on Occlusal Surfaces?

Infiltration (ICON)

Sealing Caries In Primary Molars: Randomized Control Trial, 5-year Results.

(Innes et al., 2011)

Thus, use for caries control is “off label” (FV use in the US is also “off label”, but indications are different)

38% SDF

2014

Breakthrough Therapy Status in 2016

Mei et al., 2014

38% (~44,800 ppm F) Silver Diamine Fluoride-SDF

• Ammonia and AgF combined to form a diamine silver

ion complex Ag(NH3)2+; more stable than AgF, and can be kept at constant concentration for a longer time (in dark/opaque container)

• pH=8-10
• The solution contains 5-6% (w/v) fluoride (~44,800 ppm

F) and 24-27% (w/v) silver. Thus the F concentration is almost double than that of traditional fluoride varnish

• products. **

Yamaga et al., 1972; Chu and Lo, 2008

+ AgO

Indications

Teeth:

• Cavitated accessible lesions (coronal or root caries)
• No signs of symptoms of irreversible pulpitis
• Sensitivity

Patients

Michigan Medicaid, Jan 2017

Gao et al., 2016b

• Meta-analysis (8 papers) using 38 % SDF on primary teeth= overall proportion of

arrested dentin caries was 81 % (95 % CI: 68 % - 89 %; p < 0.001) No consensus on # of applications, but…

Studies on Root Caries

Tan et al. (2010) Focus is root caries prevention Over 3 years, elders receiving applications of CHX varnish, sodium fluoride varnish, or SDF developed fewer new root caries surfaces than the elders in the control group who received OHI only (respective reductions of 57%, 64%, and 71% in root caries development) Zhang et al. (2013) Focus on root caries arrest, but also measures prevention

• OHI+SDF+EDUC had fewer root surfaces with new caries than OHI. (PF: 25%)
• OHI+ SDF and OHI+SDF+EDUC had a greater number of active root caries surfaces which

became arrested than OHI.

• SDF groups: 90% lesions arrested (arrest fraction 9.24)

Li et al. (2016) One year follow-up with 38% SDF Focuses on arrest Caries arrested fraction= 2.0 (64% of lesions arrested) Potassium Iodine did not significantly increase effectiveness, and was ineffective in reducing the characteristic black staining

Jeanette MacLean

Recommended UoM Technique

• 1. Discuss with your patient and obtain consent.
• 1. Open uni-dose 38% SDF.
• 2. Isolate the carious tooth and dry the area (to avoid diluting the

SDF).

• 3. Remove any food debris (there is no need to remove carious

tissue). If using vaseline on gingiva, avoid getting it inside the cavity.

• 4. Dip the provided microbrush into the SDF and paint the liquid
• nto the carious lesion and leave for about 30-60 sec (not

EBD!).

• 6. Remove excess: with an air-water syringe and high-vacuum

suction, or blot dry excess

• 7. Avoid eating for ½ h (needed?)
• 8. Reapply every 6 months if possible, if not repeat annually (or

reapply sooner if lesion is still soft and patient is in)

• 9. Patient should be instructed to continue to manage their

caries risk at home with EBD strategies, and every effort should be made to keep the cavity clean. (Moderate and high risk patients should be receiving other F recommendations in

• ffice; e.g. FV and at home!!!)

Castillo et al., 2011

Color changes expected within 1 week… Within 2 weeks the lesions should be hard (Milgrom et al.,

2017)

THAT IS HOW YOU KNOW IT WORKED

Contraindications

• Heavy metal (Silver) allergy
• Metallic taste
• Transient gingival and mucosal irritation on

very few reported cases (Llodra et al., 2005; Castillo et al.,

2011)

• Treated lesions turn black
• Can stain the skin, mucosa, clothes…

Side Effects

Thank you…