Margherita Fontana, DDS, PhD

Transcription

1 Chu et al., 2014 Margherita Fontana, DDS, PhD University of Michigan School of Dentistry Department of Cariology, Restorative Sciences and Endodontics

2 Objectives Attendees will be able to compare and contrast the mechanism of action of silver diamine fluoride (SDF) for caries control vs. other topical fluoride strategies Discuss evidence supporting use of SDF to control coronal caries lesions (primary and permanent teeth) Understand side-effects and contraindications with use of SDF Duffin, 2012

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4 Mei et al., 2016 Canada recently approved SDF under the natural health product category

5 38% SDF 2014 Breakthrough Therapy Status in 2016 Thus, use for caries control is off label (FV use in the US is also off label, but indications are different)

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7 Silver Compounds Peng et al., 2012

8 After about only one year on the market, it was being used by approximately 25% of U.S. pediatric dentistry programs, albeit with great variation (Nelson et al., 2016) Crystal and Niederman, 2016

9 38% (~44,800 ppm F) Silver Diamine Fluoride-SDF F (CaF 2 ): Helps with caries control Rosenblatt et al., 2009 Silver (Ag 3 PO 4 ): When in contact with dentin: Ag 3 PO 4 (weakly soluble; turns black with sunlight or reducing agents)= Black, hard layer ~20-25mm deep enamel, Suzuki et al., 1974; mm in dentin; Chu and Lo, 2008) Silver is antimicrobial (denatures bacterial enzymes, etc.), but also affects dentin metalloproteinases, cathepsins, etc. (involved in dentin degradation) To counter stain: KI (forms yellow-white AgI; in vitro suggests same effect on biofilm, Knight et al., 2005; clinical data questions long-term effect on color-masking; Li et al., 2015)

10 Higher Similar With SDF Within outer mm SDF arrested lesions are harder (5 teeth) Chu and Lo, 2008

11 Mei et al., 2016 Mei et al., 2014

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

13 1) Most of the studies on primary teeth have focused on arrest of cavitated caries lesions with dentin exposed clinically

14 Meta-analysis of studies using 38% SDF to arrest dentin caries Every 12 mon (for 30 mon) Every 6 mon (for 36 mon) Once (for 24 mon) Every 3 or 6 mon (for 36 mon) Systematic search was [(fluoride) AND (remineralisation OR remineralization OR arresting) AND (children caries OR early childhood caries)] Meta-analysis (5 papers) using 38 % SDF= overall proportion of arrested dentin caries was 65.9 % (95 % CI: 41.2 % %; p < 0.001) Gao et al., 2016

15 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

16 Chu et al., 2014 Case report: Done 3 times weekly to arrest caries and relieve sensitivity

17 Systematic Review on Noninvasive Treatment of Root Caries Lesions (Wierichs & Meyer-Lueckel, 2015) Moderate Effect - Very Low Level of Evidence

18 Recommended Technique 1. Discuss with your patient the process of SDF application, and its side-effects. Be sure to mention the staining side-effect. Obtain faculty approval for SDF usage and patient consent. 2. Open uni-dose 38% SDF. 3. Isolate the carious tooth and dry the area (to avoid diluting the SDF). 4. Remove any food debris (there is no need to remove carious tissue). Be careful if using vaseline on gingiva to avoid getting it inside the cavity. 5. Dip the provided microbrush into the SDF and paint the liquid onto the carious lesion and leave for about sec (not EBD!).

19 6. With an air-water syringe and high-vacuum suction, remove excess SDF (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-on a separate appointment-, and at home!!!)

20 Note: Reducing agent (10% SnF 2 or tannic acid or light) has not shown clinically any additional benefit in effect of SDF (very limited data) Do not to touch soft tissues (tongue, cheek, etc.) or clothes, dental operatory, as they will stain

21 The combination of SDF and FV remains an open question. FV is used to prevent smooth surface caries and remineralize NC lesions. Conversely, SDF is used primarily for caviated lesions. Therefore, their combination may be additive or synergistic and remains to be determined. One potential solution is alternating their use at threemonth intervals. Crystal and Niederman, 2016

22 Color changes expected within 1 week Castillo et al., 2011 Within 2 weeks the lesions should be hard (Milgrom et al., IADR 2017) Billing Michigan Medicaid (Starting Jan 2017): D1354-Interim Caries Arresting Medicament Application is billable once per date of service regardless of the number of teeth treated up to a maximum of 5 teeth per visit. D1354 has a maximum lifetime limit of 6 applications as medically necessary in the treatment of active caries when traditional treatments are not available or are contraindicated. SDF cannot be billed on the same date of service as other fluoride applications.

23 Holt et al., 2016

24 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

25 In vitro literature suggests no effect on bonding to non-carious dentin (if done on same appointment, rinse it; Quock et al., 2012) If cementing a crown, bonding might be reduced, thus excavation of the SDF treated dentin might be necessary prior to cementing a crown (Soeno et al., 2001) In vitro SDF data suggest inhibition of sec caries (Mei et al., 2015). KI might reduce effectiveness a bit, but reduces margin discoloration in vitro (Zhao et al., 2017). SDF under amalgam in 3-6 year old children followed over 26 months for secondary caries prevention: 26% of amalgam group had sec. caries vs. 0 in the SDF/amalgam group (Shimizu and Kawagoe, 1976) A study in the UK (not random) including 52 children found no difference in caries progression of cavitated lesions including SDF/SnF 2 and resin vs. resin alone (McDonald and Sheiham, 1994) Close to the pulp: 55 primary teeth to be extracted for orthodontic reasons were treated with 40% AgF on deep caries lesion next to pulp + GI; after 16 months all restorations ok, and 91% of teeth had favorable pulpal response histologically (Gotjamanos, 1996)

26 New code in the 2016 CDT: D Interim caries arresting medicament application "Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure." SDF could can also be billed under: D1208 -Topical application of fluoride D Application of a desensitizing medicament, per visit D Unspecified preventive procedure by report

27 CONCLUSIONS Remember caries lesion can arrest with F alone as long as the biofilm can be controlled, but this is hard to do especially in coronal surfaces

28 But SDF is a useful alternative: Low cost Easy to use Patient still has to manage their caries risk by known EBD means (F toothpaste, diet, FV, sealants, etc.). Evidence limited, but some studies of moderate quality suggest this is an important alternative for some lesions, in some patients, to help control dental caries at the tooth level: Arrest cavitated lesions (not all lesions arrest, some require more than 1 application) Maybe helps with prevention in other sites of the mouth not directly treated? Thank you!