SDF/SMART TRAINING FOR DENTAL OFFICES

Review science behind S.D.F. - Silver Diamine Fluoride

S.M.A.R.T.- Silver Modified Atraumatic Restorative Technique.

History of chemotherapeutic agents for treating decay.

Science review about SDF, the tooth, and bacteria.

Helpful information about CDT coding and educating.

COURSE OBJECTIVES

Give a brief history of silver nitrate and SDF.

Provide evidence of its efficacy.

Detail the science, both chemistry and microbiology, of the interaction between SDF and tooth structure.

Enforce importance of a complete and thorough understanding of SDF by all staff members in order to implement a successful SDF program.

Detail specific SDF and SDF related protocols including but not limited to combining with fluoride varnish and glass ionomer materials.

Review informed consent and how it piggybacks with SDF education.

Review all related CDT codes for SDF use and success.

DISCLAIMER

Research on SDF (Silver Diamine Fluoride) and SMART (Silver Modified Atraumatic Restorative Technique) is ongoing.

This information is current up to approximately May of 2018.

DISCLOSUREI have no financial connection to anyone or any business entity related to this subject and I am not an expert. I’m just a cranky old dentist

FIVE COMMON MYTHS1) It’s going to ruin your practice financially. IT WILL ENHANCE IT!

2) Patients reject it due to poor aesthetics.

3) It’s only for children.

4) Patients will not get treatment completed.

5) You cannot bond to it.

THANK YOU Dr. Jeanette MacLean.

IT CAN BE HELPFUL, EFFECTIVE, AND PROFITABLE

FOUNDING FATHERS

Dr. W.D. Miller: DDS, MD, PhD. In 1890 he published The Microorganisms of the Human Mouth discussing bacteria and metabolism of sugars/carbohydrates creating acid that demineralizes tooth structure.

Dr. G.V. Black, in 1906, published a 4 volume set on Dental Science. He discussed the role bacteria played in caries and the use of Silver Nitrate (AgNO3) to arrest these caries.

Dr. Percy Howe, founder of The Forsythe Institute in Boston. In 1917, Dr. Howe became an advocate for treating caries with Silver Nitrate (AgNO3). The “Howe’s Solution” protocol remained an ongoing treatment modality until the early 1950s.

A Quick History of Chemotherapy in Dentistry

Prior to the 1920’s decay was treated almost exclusively with chemical agents.

Many chemical agents came and went- too caustic or not effective.

Silver Nitrate (Ag NO3) won out as most effective and safe.

Very Important to note that the rotary belt driven handpiece came into common use in the 1920s.

WHAT HAPPENED? Past the 1920s

“JUST PASS ME THE DRILL”. The belt driven rotary handpiece arrived in the 1920s. Then in the 1950s we got the high speed H.P. remember my father telling me he got his first high speed H.P. in 1954.

Using antimicrobial agents did not fit the new paradigm of “surgical removal” for caries.

TRADITIONAL SURGICAL APPROACH TO DECAY REMOVAL

Physically remove all visible signs of decay either by hand and/or powered handpiece. Did we miss any microscopic areas?

Restore the void with conventional filling materials.

This requires local anesthesia, I.V. sedation, or general anesthesia.

My anecdotal question after 40 years of clinical dentistry. “Is this reducing the incidence of decay for the patient or, collectively, the general population?”

Also, what are the clinical parameters to defining “adequate caries removal?” How does a caries arrest agent fit into these parameters?

BUT IS SDF REALLY NEW?

Mizuho Nishino received her PhD in 1969 after doing 4 years of research using silver nitrate combined with fluoride to prevent caries. The SDF formulation resulted from this research.

SDF was meant to be a preventive agent.

Over 2 million bottles have been sold in more than 6 countries in the last 50 years. A conservative estimate of more than 100 million teeth have been treated.

NO ADVERSE AFFECTS REPORTED.

THE FLAT EARTH SOCIETY (?)

“New opinions are always suspect and usually opposed, without any other reason but because they are not common.”

John Locke

Provide Evidence of itsEfficacy and Safety

EFFICACY OF SDF/FLUORIDEVARNISH COMBO

There are many studies, over more than a 10 year period, showing the efficacy of SDF. Please see www.mmclibrary.com Go to “articles”…… Peruse at your leisure.

One such study: One application per year of SDF has shown to be more effective in preventing decay than using fluoride varnish 4 times per year. (Chu et al., 2002). Note the date.

Combining SDF with fluoride varnish has an even greater decay preventive effect than SDF alone. There is an even greater remineralizing capability with this combination.

Actually anywhere you have decay or want to prevent decay, you can use SDF.

http://www.mmclibrary.com/http://journals.sagepub.com/doi/pdf/10.1177/0810767

SDF SIDE EFFECTS: STAIN ONLY

Area of decay will be stained black, NOT the healthy tooth structure.

The stain will show through most composites. To a lesser extent with

glass ionomer restorations. This is exacerbated with light cured composites.

ALERT- it can permanently stain clothing and counter tops.

If it comes in contact with the gingiva it will stain but not be permanent

A salt/water slurry mix will remove/reduce stain on skin/gingiva.

No adverse pulpal response ever reported.

Detail the Science, Chemistry and Microbiology Aspects

REMEMBER: Caries is a Bacterial Infection

Streptococcus mutans (facultative anaerobic gram + cocci)

Lactobacillus (facultative anaerobic gram + rods)

Actinomyces ( facultative anaerobic gram + filaments)

DENTAL CARIES IS A COMMUNICABLE DISEASE

“Oh, look, Mommy likes it!” YUM, YUM!!

Any obvious mouth to mouth contact.

Window of infectivity is 19-31 months for children.

Preventive measures to reduce transfer and colonization of bacteria:

-Diet most effective preventive measure. Diet analysis.

-For expectant mothers; xylitol to reduce bacteria.

-Use of fluoride products, xylitol.

-EDUCATE, EDUCATE, EDUCATE!!!!!

DEPTH OF KNOWLEDGE•In order to EDUCATE people, at the very least, you need adequate knowledge

•The greater your own level of understanding, the easier it is to explain to the general public.

•Explaining any scientific concept to the general public, we must make it clear and easy to understand. Assume an 8th grade level of comprehension.

•We all have had experience explaining treatment to patients and know it can be frustrating. At times, it is hard to simplify without omitting important information.

“It all depends on your “Depth of Knowledge.”

DIET: SOOOO OVERLOOKED

Even if you brush and floss consistently every day, if you eat/drink unhealthfully, you will still be in a high decay category.

“SIP ALL DAY AND GET DECAY”. Sugar in coffee, juice boxes, sport drinks, orange juice (any fruit juice), soda, etc.,. These have “negative” nutritional value and destroy your teeth. (Thank you Pam!)

Do Health Care Providers help to educate/change our American Diet paradigm?

More emphasis on NOT JUST WHAT we eat but WHEN we eat and HOW LONG teeth are exposed to carbohydrates. Too much snacking will negate good homecare.

ONE out of every THREE American children is overweight.

LET’S TALK ABOUT BIOFILMS

The caries pathogens (bacteria) are part of a pathologic BIOFILM.

A detailed analysis of BIOFILMS: Biofilm Dispersal: Mechanisms, Clinical Implication, and Potential Therapeutic Uses. Dr. J.B. Kaplan, Journ. Dent. Res. 2010: 89: 205. Go to www.mmclibrary.com. Under “Articles”, “Oral Microbiolgy”, “#8”.

We can change BIOFILMS in a negative manner. Example: after doing a prophy what small amounts of the BIOFILM that remains is likely to change/mutate to better survive and adapt in an acidic environment. Host modulation.

http://www.mmclibrary.com/

ORAL BIOFILMS 101For the most part, biofilms exists symbiotically within the body both externally and internally.

Biofilms are made of bacteria and an extracellular polymeric substance (EPS.)

This EPS include proteins, polysaccharides, mucins, etc.,.

The host and bacteria contribute to this EPS. This EPS is the glue that holds it all together.

Add pathologic microbes and the mass itself becomes pathologic. As the bacteria reproduce, the mass gets thicker.

This more dense mass becomes more diverse with a mix of bacteria. The layering continues and becomes more chemically and molecularly mixed. This diversity makes for a more virulent and aggressive mass.

And acids go right through it to the tooth! AND SO DOES SDF.

BIOFILMS 101 continuedThe thicker it gets the more anaerobic it becomes. Thus more Streptococcus, Lactobacillus, and Actinomyces (Increased colonization).

The more dense it becomes, the more resistant it is to antibiotics because the antibiotics cannot physically penetrate the mass.

This increased colonization further contributes to a lower pH.

IONIC Ag (silver ion- SILVER BULLET) DOES PENETRATE this mass and kills the bacteria.

There are numerous articles on biofilms found at www.mmclibrary.com.

Go to “Articles”, “General Microbiology” #s10-14 and “Oral Microbiology” #1 and #s6-10. These are just a start.

http://www.mmclibrary.com/

SOME BORING CHEMISTRY

➢SILVER DIAMINE FLUORIDE: Ag (NH3)2 F

Hydroxyapatite (Calcium Hydroxy Phosphate)

Ca5 (PO4)3 OH

Fluorapatite (Calcium Fluoro Phosphate)

Ca5 (PO4)3 F

➢SILVER PHOSPHATE: Ag3 (PO4)

➢CALCIUM FLUORIDE: Ca F2

Silver Nitrate: Ag (NO3)

Sodium Fluoride: Na F

Ammonium Hydroxide: (NH4)OH

Potassium Iodide: KI

Silver Iodide: AgI

BACK TO SDF AND TOOTH DECAY

Enamel- 95% Hydroxyapatite and 5% other minerals

(Calcium Hydroxyphosphate-Ca5 (PO4)3 OH)

Dentin- 70% Hydroxyapatite and 30% Collagen

(Calcium Hydroxyphosphate-Ca5 (PO4)3 OH)

IMPORTANT- The Hydroxyapatite is damaged by ACID and Collagen damaged by ENZYME RELEASE from the bacteria/carbohydrate metabolism.

COLLAGEN BREAKDOWN

Remember the dentin is 30% Collagen (structural protein in the extracellular space).

COLLAGEN is sort of like the JELLO in a fruit/jello ring and the Hydroxyapatite (Calcium Hydroxy Phosphate) is the FRUIT. Lots of fruit! 70% FRUIT.

The bacteria, streptococcus mutans, (when it “eats” sugar and/or simple carbohydrates) produce acid AND Collagenase and other “ASES” that breakdown the peptide links of the proteins in Collagen.

These “ASES” come from the cytoplasm matrix within the bacterial cell.

Continued…

Some of those “ASES” are “protease”, and "collagenase” produced during the bacteria/carbohydrate metabolism.

The Ca5 (PO4)3 OH is damaged by the ACID PRODUCTION during the bacteria/carbohydrate metabolism.

BOTH the Ca5 (PO4)3 OH and COLLAGEN are REPAIRED/STABILIZED by the silver ion (“Ag” ion) and/or the fluoride ion (“F” ion). These are both part of SDF.

Ag (NH3)2 F + Ca10 (PO4)6 (OH)2 = CaF2 + Ag3 (PO4) + NH4 OH

IN SUMMARY, SDF DOES:Look at the right side of the equation.

= CaF2 + Ag3 (PO4)

These two compounds do the magic.

•Ag3 (PO4): kills the bacteria and deposits phosphate into damaged dentin.

•CaF2: deposits calcium and fluoride into damaged dentin

Continued…

Ag3 (PO4)- a “silver salt.” Embeds itself into damaged dentin.

Ag ion does 3 things:➢Breaks through the cell wall of bacteria➢Breaks down mitochondria ( respiration and Kreb’s cycle)➢.Breaks down DNA within the bacterial cell.

BUT WAIT, THERE’S MORE!

With a dead bacterial cell, there is no more enzyme production to break down collagen in the dentin and no more acid production.SDF destroys the pathogenicity of the Biofilm.Food for thought: Could we use SDF as a comprehensive preventive agent?

WILL I DIE??!!Yes, someday you will die BUT not from SDF.

There is a lot of confusing math and mg/kg and microgram (uL) dosage information but the bottom line is you would need to take 400 TIMES the average dose and then there is a 50/50 chance you would die.

SDF has been used safely for more than 40 years in more than six developed countries.

Understanding SDF by all staff

THE SDF/SMART NARRATIVE

Why have a narrative? The general public and many dental professionals know very little, if anything, about SDF/SMART.

To Whom is it being directed? Patients, parents, caregivers, 3rd party dental benefit groups, and other groups/organizations.

How does this educational effort differ from explaining other conventional dental procedures? This treatment approach has not been used for almost 2 generations and is considered “brand new!” “A New Paradigm!”

THIS MEANS THE WHOLEDENTAL TEAM

That’s why I bored you all to death with all the chemistry and microbiology!

Everyone must understand how SDF works in order to answer questions from patients. Yes, even the Front Desk Personnel.

Choose a point person to educate patients. I firmly believe it should start with the Dental Assistant and Dental Hygienist. Let’s face it, after the dentist discusses treatment and then leaves the room who does the patient turn to and start asking questions?

EVERYONE!

EVERYONE on the staff must be able to answer basic questions about SDF.

It is very important that you DO NOT overlook the front desk.

When people call to ask questions, the “Front Line” is the front desk.

Everyone should be completely familiar with Informed Consent form and basic SDF Facts.

Get a “SDF Fact Sheet.” with 8th grade reading level and understanding. Pictures speak a 1,000 words!

Have script cards at front desk.

SCRIPTING AND ROLE PLAYING:WHY?

Unknown and brand new ideas need easily understood explanations. Think “8th grade level.”

Close the knowledge gap, remove myths and inaccuracies fomented by non-scientific sources.

SCRIPTING WILL:

➢Bolster your credibility.

➢Increase patient confidence.

➢Increase likelihood of patient acceptance.

➢Reduce post operative misunderstandings.

SOME IDEAS TO BUILD SCRIPTS AROUND

➢Behavior difficulties with children due to previous history and traumatic experience.

➢Emphasize the positive of SDF protocol NOT the negative of traditional protocol.

➢Use questions to determine whether information is absorbed.

➢Get agreement on important points you are emphasizing.

➢Discuss their home care.

➢Financial issues are always on the table so do not ignore them. With SDF this is in your favor.

MORE ON SCRIPTING

When face to face USE PICTURES AND MORE PICTURES!

Make sure they understand the “Black color.” remember, AND EMPHASIZE THIS, the black is good. It shows that the SDF is working on the decay in the tooth and will continue to inhibit decay.

Don’t forget to get in some information on diet and homecare.

ROLE PLAY……ROLE PLAY……ROLE PLAY……

WHO DO WE TREAT WITHSDF/SMART?

ANYBODY/EVERYBODY!!! Children and adults of all ages at high risk for decay.

Your elderly patients who start getting a high caries rate due to age related factors (poor homecare, change in diet, mobility issues, being placed in different environment, etc.,.)

Patients with disabilities.

Patients with immunodeficiency conditions.

SDF protocols

THE FIRST ACCEPTED USE

Remember the first recognized and approved use was as a desensitizing agent.

How many phone calls do you get after a crown prep or a deep restoration from a patient complaining about sensitivity?

Also desensitize after deep restorative procedure?

EARLY INTERVENTION,DAILY USES

IN THE HYGIENE ROOM. Use on those incipient interproximal “divits.”

NEW SEALANT PARADIGM; If you have those questionable occlusal areas, use SDF and then “seal” with a high viscosity glass ionomer but don’t waste leftover G.I. Smear it over all available occlusal areas on adjacent teeth.

Restoring tooth with DEEP DECAY. Did you get it all out?

Use SDF after crown prep. A great desensitizer!

Caries detection. Must wait 4-5 minutes for adequate color change.

METHODS/PROTOCOLSApply SDF/FV twice a year (every 6 months). Most common method.

Apply SDF/FV once a month for 3 months

SMART: One time application SDF and Glass ionomer.

SMART- An acronym: Silver Modified Atraumatic Restorative Technique.

OKAY…..HOW DO WE DO THIS?

Materials (For both SDF/FV and SMART)

• Mirror, explorer, tweezers.

• Cotton rolls. Cotton roll holder optional.

• Small (NOT regular size) microbrushes.

(Dentin Conditioner: Polyacrylic Acid) SMART TECHNIQUE ONLY.

• SDF liquid (Advantage Arrest) ElevateOralCare.com.

• Fluoride varnish (or glass ionomer cement/material- SMART)

Equipment: (this can be optional)

Air/H2O syringe.

Evacuation system.

Light source.

APPLICATION Protocol: SDF/FV➢Clean area of any food debris or foreign material.

➢Isolate using cotton rolls. Cotton roll holder helpful.

➢Blow reasonably dry. A little moisture is okay

➢Apply SDF and keep isolated for 1 to 2 minutes.

➢Apply Fluoride varnish. Same post-op directions.

APPLICATION PROTOCOL FOR SMART

•Clean area of any food debris or foreign material.

•Blow dry. Apply conditioner (polyacrylic acid) 10-15 seconds.

•Wash thoroughly and, then, dry thoroughly.

•Isolate using cotton rolls: cotton roll holder optional.

•Apply SDF and keep isolated for 1 to 2 minutes.

•Apply glass ionomer (G.I.) over SDF and squash into tooth. If necessary/possible put

matrix band on tooth first.

DON’T WASTE REMAINING G.I. Squash into occlusal surfaces of adjacent teeth.

REMEMBER Glass ionomer (A) ionically bonds with tooth structure and (B) has

similar expansion/contraction coefficient as tooth.

SDF APPLICATION TIME (?)Let’s not get confused at this point.

You will see varying recommendations for application time of SDF on Caries.

The “Group” seem to think 1-2 minutes is adequate. Dr. Jeremy Horst does 2-3 minutes. I usually do 2 plus minutes.

DO NOT get thrown off by Dr. Doug Young’s article in the August JADA. He does 4 applications for 5 minutes each. This was done at U of P DugoniSchool of Dentistry.

TWO VISIT SMART: WHY???

Dr. Jeanette MacLean, a pediatric dentist in Arizona does her smart restorations in two visits.

If you have the possibility of utilizing two visits for your SMART Technique you can avoid all the stain.

Following conventional restorative techniques with partial decay removal at the 2nd appointment and high viscosity glass ionomers allows your end result to be very aesthetically pleasing but still have a SMART restoration.

INTERPROXIMAL APPLICATION

Interproximal areas (PAY ATTENTION HYGIENISTS!)

Follow the first 4 steps of the SDF application protocol shown in the previous slides.

Apply SDF using Superfloss.

Drop superfloss through contact.

Saturate superfloss (buccal/lingual) and slide it back and forth interproximally.

keep in place for 1-1.5 minutes.

“Slide out side “ or “pull through contact?” Varying opinions.

Lastly, squish Fluoride varnish interproximally from both buccal and lingual.

INITIAL COLOR CHANGE

Apply SDF to decayed area. Make sure all of the caries are covered.

Keep area isolated.

Wait 1 to 1.5 minutes if possible before applying fluoride varnish or G.I.

You will not see black at this initial application. The black appears after 24-36 hours.

You may only see slight staining on the edges of decay/tooth interface and very slight appearance change on the caries. You DO NOT need to see much change in order to apply varnish or G.I.

LET’S REVIEWGLASS IONOMERS

How does G.I interface with tooth? There is a CHEMICAL/IONIC BONDbetween both healthy dentin and affected dentin NOT mechanical/physical bond. This is due to hydrophilic nature of the G.I.

The COEFFICIENT OF EXPANSION/CONTRACTION is VERY SIMILAR to tooth structure.

Because of these 2 characteristics the literature tells us that the margins remain closed and continue to leach fluoride, calcium, and phosphate into the tooth and is recharged with fluoride sources. (thank you Drs. Doug Young and John Featherstone)

Maintaining crosslink strength improves compressive strength.

MORE ON GLASS IONOMERSCrosslink strength continues to increase over time (up to 6 months) due to uptake of saliva. To optimize this cross link strength:

1) After placing G.I. DO NOT DISTURB IT (30 seconds from titrator start)

2) Moisten when frosty surface begins to appear.

3) Use copious water when finishing/polishing. Use coating to prevent moisture loss.

4) NO CHEWING FOR 2 DAYS. Then, soft foods for 2 days.

5) Does thermal curing enhance crosslink strength?

6) Compressive strength: Equia- 218 Mpa ( 31,000 psi )

RINSING IS NOT RECOMMENDED!

DESPITE the UCSF January, 2016 committee advisory, DO NOT RINSE SDF AFTER APPLICATION!

This recommendation to rinse was a typical recommendation made at a time when there was alleged insufficient (?!!) data about the safety of SDF. Dr. Jeremy Horst fought tooth and nail over this in January, 2016. Rinsing has since been deleted from protocol.

Based on over 40 years of use in more than 6 developed countries and the research to date, there are no significant safety concerns.

SDF STAINING FROM SILVER ION

REMEMBER, the only part of the tooth that stains is decayed tooth structure. Healthy enamel and dentin DO NOT stain.

Temporary stain on the gingiva and other soft tissue can occur from 2 days up to 2 weeks.

The Ag (silver) ion can also stain composite and glass ionomer materials and cements.

Clothing and countertops will also stain permanently. A slurry of salt and water can reduce staining on these surfaces.

MINIMIZE STAINING ON RESTORATIVE MATERIALS

Shofu makes a product, Beautifil Opaquer, that is effective in masking the stain. It is not 100% but can make anterior restorations much more aesthetic.

Light cured composite will show stain more than non- light cured materials.

The use of Potassium Iodide (KI) to prevent stain has been shown to NOT be permanent. The stain will come back within 1-2 months. DO NOT USE KI ON PREGNANT WOMEN.

Do a 2 visit SMART to optimize aesthetics.

Billing Codes and Informed Consent

LET’S TALK BILLING CODESCode: D1354: Pays $15 per tooth (Vermont), can apply 2 times per life of tooth. Must wait 120 days before second application. This makes NO sense!

Code: D2940: “Protective restoration.” Pays $60. This is the SMART part. Use Glass Ionomer. Most research indicates use of Fuji Nine or Fuji Forte. I always used Fuji one. You want to talk Fluoride amounts?

Code: D1352 (TWO): Pays $70 Preventive resin restoration. Only for moderate to high caries risk permanent teeth.

Code: D1206: Pays $18 Fluoride varnish for moderate to high risk patients. More frequent than 6 months.

But wait there’s more!

OKAY, LET’S TALK BOTTOM LINENew Hampshire is still working out exact guidelines on their Medicaid protocol. Right now they pay $20 per tooth up to 8 teeth per visit and you can re-apply every 6 months.

D1354 is the code. A 2016 CDT code, “a caries arresting medicant.”It is approved by FDA for “off-label use” to treat decay.

Delta. They are big time on board BUT it depends on the employer whether it is a covered procedure. You must check with other carriers.

D2940. This is a “protective restoration.” This is the SMART part. N.H. Medicaid pays $55

D9910- Application of desensitizing medicant.

“Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicant without mechanical removal of sound tooth structure”.

Elevate Oral Care

But wait there’s more!!

BUT WAIT, THERE’S MORE……

D2941- Interim therapeutic restoration (primary dentition); SDF/G.I. with intent to place a future restoration (not covered by VT Medicaid).

D3120- Indirect pulp cap. SDF first then G.I. on top. Deep caries situation.

D1351- Sealant. Try this new idea. Use SDF first, then use G.I. sealant material.

DETAILS ON SDF ACTION

There are more details to the action of SDF on the carious lesion than outlined in the previous slides.

Immerse yourself in the articles at the website, “ www.mmclibrary.com “

You need to do a thorough search of the literature for these details.

PLEASE READ DR. DOUG YOUNG’S AUGUST JADA ARTICLE!

http://www.mmclibrary.com/

BEST RESOURCESwww.mmclibrary.com

http://www.mmclibrary.com/ (Medical management of Caries-MMC).

Go to “HOME” PAGE.

Go to “ARTICLES”.

Also: www.silverdf.org Good resources/videos for Dentists/general public.

Go to “For Dental Professionals” for:

A) This complete power point presentation.

B) Excellent videos by Dr. Jeanette MacLean on SDF and SMART

applications.

http://www.mmclibrary.com/http://www.silverdf.org/

Contact information; Q&A timeJohn S. Echternach, D.D.S. P.O. Box 258, South Strafford, VT., 05070.

Email: jeje14470@outlook.com Website: www.silverdf.org

Phone: (H) 802 765 9648

IT’S MILLER TIME !!!!!!!

mailto:jeje14470@outlook.comhttp://www.silverdf.org/