Margherita Fontana, DDS, PhD. University of Michigan School of Dentistry Department of Cariology, Restorative Sciences and Endodontics

Transcription

1 Margherita Fontana, DDS, PhD University of Michigan School of Dentistry Department of Cariology, Restorative Sciences and Endodontics

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

3 Dental caries is a: 1) chronic, 2) site-specific, 3) multifactorial, What is Dental Caries? 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

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

5 Dental Caries is a Result of a Dysbiosis in the Biofilm Gross et al PLOS-One 10:e47722

6 A necessary and sufficient cause SES MEDIATED VARIABLES Moderating Variables Food Policy OH Culture (Parent) Behavior Child Diet Dietary Sugars Biofilm changes Decayed Tooth Sealants Fluoride Geography Genetics Dental Caries Sugar Dr. Weyant

7 Strategies with the strongest, consistent, highest quality evidence now-a-days are: Fluoride Sealants Use other strategies to supplement well known interventions, rather than substituting them

8 Caries Risk Assessment Caries Management Medical, Dental, Social History 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 DIAGNOSIS No Treatment Remineralize Arrest Sealant Minimal Surgical Traditional Surgical Endodontic Treatment Extraction Non-Surgical Surgical

9 Many protocols are available.

10 Enhances Remineralization * Reduces Demineralization Antimicrobial The Cochrane Database of Systematic Reviews, 2003, 2006, 2008

11 Fluoride Mechanisms of Action

12 VARNISHES GELS/FOAMS DENTIFRICE S MOUTHRINS ES 0.01% F 100 ppm F or 0.02% NaF SELF-APPLIED PRODUCTS 0.02% F 226 ppm F or 0.05% NaF 0.09% F 0.10% F 905 ppm F or 0.2 % NaF 1,000 ppm F or 0.76% SMFP Over-the-counter Needs prescription 0.11% F 1,100 ppm F or 0.243% NaF 0.11% F 0.5% F 1,100 ppm F or 0.454% SnF 2 5,000 ppm F or 1.1% NaF 0.9% F PROFESSIONALLY-APPLIED PRODUCTS 9,050 ppm F or 2% NaF 1.23% APF 12,300 ppm F or 1.23% APF 2.26% F 22,600 ppm F or 5% NaF 1.13% F 0.77% F 11,300 ppm F or 2.5% NaF 7,700 ppm F or 1.5% NH 4 F 0.1% F 1,000 ppm F 38% SDF , , , , ,000 Concentration in ppm F (~44,800 ppm*) *Up to 55,800 ppm; Mei et al., 2012 Fernandez and Gonzalez-Cabezas, 2015

13 CDC Recommendations

14 Baseline am Brushing 15 min 30 min 45 min 1 h 2 h 8 h pm Brushing Upon Rising ppm F Dentifrices (toothpastes)

15 % Inhibition of Demineralization Fluoride and Dentin Fluoride Concentration (ppm) Enamel Dentin ten Cate et al., 1998

16 Mouthrinses

17 Fluoride In- Office Risk Group < 6 Years 6 18 Years > 18 Years Root Caries Low Moderate/High 2.26 % Fluoride Varnish every 3-6 months May not receive additional benefit from topical fluoride 2.26% Fluoride Varnish every 3-6 months or 1.23% APF fluoride gel application for 4 min every 3-6 months JADA, Nov 2013 The Cochrane Database of Systematic Reviews, 2003, 2006, 2998 Marinho et al., 2013

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. 18 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.

19 F Levels Fluoride Dilemmas Frequency vs. Concentration Time We need to find the ideal balance for each patient

20 An Update on Dental Sealants (and Sealing Caries) Margherita Fontana, DDS, PhD

21 CDC, 2016

22 Sealants for Caries Prevention

23 Summary Evidence (Efficacy of sealants): Median Caries Reduction: 81% at 2 year follow-up (Ahovuo-Saloranta et al. 2013) 2013

24 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 occurred where this was reported. Ahovuo-Saloranta et al., 2017

25 What about sealing caries lesions? (Non cavitated lesions) Effective Seal A Sealant is NOT a Preventive Resin Restoration

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

27 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

28 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%

29 % Reduction in Mean Bacteria Counts Reduction in Bacteria Counts by Time since Sealant Placement (Oong et al., % 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% Months since Sealant Placement Bacterial reductions (4 studies) ranged from 50.8% to 99.9% and appeared to increase as time since sealant placement increased

30 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

31 How to assess teeth for sealant placement (Gooch et al., 2009; Fontana et al., 2010; Wright et al., 2016) Non-Cavitated J Pub Health Dent, 1995 Cavitated

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

33 Wright et al., 2016 (ADA) 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 longterm 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)

34 Placement Techniques Routine mechanical preparation of enamel before acid etching is not recommended Sealant Failure - With Enameloplasty Beneath Dr. 34 Fiegal Wright et al., 2016

35 Four-handed sealant placement is associated with higher retention rates. Griffin SO, Jones K, Gray SK, Malvitz DM, Gooch BF Exploring four-handed delivery and retention of resin-based sealants. Journal of the American Dental Association 139(3): 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 A comparison of the effects of toothbrushing and handpiece prophylaxis on retention of sealants. Journal of the American Dental Association 140(1):38 46.

36 Evidence synthesis: The median one-time SSP cost per tooth sealed was $ 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 highrisk children 2016

37 Sealants vs. SDF on Occlusal Surfaces? Liu et al. (2012) Studies on Permanent Teeth Only (Occlusal surfaces) 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 on 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.

38 Infiltration (ICON)

39

40 Sealing Caries In Primary Molars: Randomized Control Trial, 5-year Results. (Innes et al., 2011)

41

42 38% SDF 2014 Breakthrough Therapy Status in 2016 Mei et al., 2014 Thus, use for caries control is off label (FV use in the US is also off label, but indications are different)

43 38% (~44,800 ppm F) Silver Diamine Fluoride-SDF Ammonia and AgF combined to form a diamine silver ion complex Ag(NH 3 ) 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. ** + AgO Yamaga et al., 1972; Chu and Lo, 2008

44 Indications Teeth: Cavitated accessible lesions (coronal or root caries) No signs of symptoms of irreversible pulpitis Sensitivity Patients Michigan Medicaid, Jan 2017

45 No consensus on # of applications, but 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) Gao et al., 2016b

46 Tan et al. (2010) Zhang et al. (2013) Li et al. (2016) Studies on Root Caries 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) 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) 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

47 Jeanette MacLean

48 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 onto the carious lesion and leave for about sec (not EBD!).

49 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 office; e.g. FV and at home!!!)

50 Color changes expected within 1 week Castillo et al., 2011 Within 2 weeks the lesions should be hard (Milgrom et al., 2017) THAT IS HOW YOU KNOW IT WORKED

51 Contraindications Heavy metal (Silver) allergy Side Effects 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

52

53 Thank you