SDF and ITR Considerations - PowerPoint Presentation

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SDF and ITR Considerationsfor Tri-County SMILES

Bill Maas

April 2, 2020

Supplemented with slides from

Jeremy Horst, Elevate Oral Care Webinar, March 26, 2020

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“The actual depth of penetration of a carious lesion is greater than it appears on the radiograph.”

What does this mean?

The radiograph shows loss of mineral content.

Some mineral content can be lost before it is apparent on radiograph.

That is what is meant by “greater penetration” of the lesion.

But, does that mean the dentin is

infected

with bacteria?

If no bacteria, then decay will not progress. Demineralized dentin is not fatal to pulp vitality.

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Minimally Invasive Control of Caries

Remove biofilm.

Use SDF to kill bacteria infecting dentin and to

hypermineralize

affected dentin and enamel.

Seal infected dentin off from the biofilm and sources of nutrition for the bacteria infecting the dentin.

This can be done by resin, resin-composite, or glass ionomer.

Thickness of restorative material does not matter; integrity of seal matters.

Removal of sound tissue is justified when necessary to assure integrity of seal.

Glass ionomer material fuses with enamel and dentin to separate remain infected dentin from source of nutrition.

Isolated, dormant bacteria in carious dentin do not demineralize further.

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Secondary Prevention Goals of SMILES DHs

Preserve primary teeth

Are best space maintainer

Function is relatively unimportant

Form is not important at all

Esthetics can motivate visit to dentist, but is not concern of remote DH

Preserve healthy tissue of permanent teeth

Preserve pulps of both primary and permanent teeth

Distinguish reversible from irreversible pulpitis

Recognize no Dx, Tx or Prognosis is perfect

Accept some toothaches to prevent many others –referral % unknown

Symptoms have more Dx value than Signs (radiographs, photographs)

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Irreversible Pulpitis

Primary tooth pulp may die without symptoms – fistula tract

Permanent pulp death consequences are much greater

Pain – which will provide incentive to go to dentist

Infection – potentially very serious

If irreversible Dx is clear, DH should emphasize referral

Includes case management when possible

If Dx is not clear, low intensity heroics may be appropriate

SDF has immediate desensitizing effectiveness

Dentist and patient must accept risks that

tx

may increase symptoms

Referral is still appropriate, but SDF may reduce consequences of delay

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SDF

Safety – max dose = 8 drops of 38% SDF

Based on US FDA approval of multicenter trial for children as young as 12 months old: 260 µL, two 130 µL unit doses, or eight 32.5 µL drops.

Several

microbrush

applications of SDF per drop

Rarely will need more than one unit dose for entire mouth?

Deep lesions – pulp response is very localized; success is good

Direct pulp exposure – Not recommended

Therefore, do NOT remove deepest carious dentin

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SDF Technique

Penetrate biofilm

“Scrub” SDF onto caries with

microbrush

Use PAA to dissolve biofilm if using one-day SMART technique

Allow time to penetrate – at least 1 minute

May work in as short as 10 seconds in some lesions

Cover with FV,

vaseline

, glass ionomer,

etc

to mask taste and retain for optimal penetration.

2 applications is protocol. More than 2 applications rarely needed.

All should be monitored – texture and appearance

Success may be related to saliva flow and self-cleansing lesion

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Restoring SDF Treated Tooth

LT Success of restoration will be most affected by:

Respect of pulp

Good marginal seal of restoration to starve remaining bacteria

When should hard dentin be removed?

To provide space for thicker, stronger restoration? Yes, if in occlusion.

Because we don’t like to leave arrested decay under a filling? No

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Interim Therapeutic Restoration (ITR)

Will ITRs fail if less than 2 mm of dentin exists to pulp?

NO. Dentists successfully restore teeth with less dentin all the time.

Basis? Glassman VDH Pilot wanted 100% success rate for ITRs

Result: 1000 ITRs placed, no toothaches.

# of toothaches for kids who did not receive ITR and also did not go to dentist? > 0

Can DH be as respectful of pulp as dentists?

Are we willing to accept same success rate from DH as Dentist?

Why? Why not?

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How to avoid pulp death?

Respect the pulp

Trust the seal of our restoration

By the time you wonder if you should go deeper in removing carious tissue, you probably have already gone too far.

Glass ionomer is as biocompatible with deep lesion as

CaOH

(

Brignardello

-Petersen, JADA, May 2019)

But, what if pulp exposure?

Primary tooth – document bleeding (vitality), place GI, referral w urgency

Permanent tooth – document bleeding, place MTA or

CaOH

and/or glass ionomer, referral

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SMART – SDF plus ART

One step or Two step

Even when some “principles” are violated, results are similar

Principles that must be followed:

Selective caries removal

Get SDF to dentin (remove biofilm by PAA or scrubbing)

Adhere GI to tooth crystal, not smear layer, by using PPA conditioner

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If Fissure Caries, even into Dentin, is Sealed, Should Child be Referred to Dentist

for Follow-up?

Evidence (

Qvist

, 2016) suggest that even lesions treatment planned for restorations can be controlled by sealing.

Annual recall, enabling visual-tactile examination by DH and radiographic examination by dentist, should identify lesions not controlled by the sealant.

Repair of sealant or referral to the dentist for restoration (approximately 1/3 of cases over 7 years) can be done at the annual recall.

While there is nothing wrong with restoring such teeth, it is misguided to imply that parents

need

to take child to dentist rather than rely on annual monitoring via SMILES programs.

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Consequences of Sealing Deep Caries

--

Qvist

, JDR

Clin

Trans Res, 2016

Over 8 years, only 31% of sealants were replaced by restorations.

Median survival time for sealants not replaced by restorations was 7.3 years.

This study shows the possibility of treating occlusal

dentin

caries lesions with non-invasive resin sealants instead of conventional composite restorations in children and adolescents.

A restoration may not be the final treatment, but the start of an ongoing treatment with still more loss of tooth substance.

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Infection Control with Portable Equipment

Previous special guidance for school programs has been replaced by simplified version of CDC’s comprehensive 2003 guidance.

Current materials, including

DentalCheck

Mobile App are available:

https://www.cdc.gov/oralhealth/infectioncontrol/index.html

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The Future of Elective Dental Care

Will we distinguish between procedures that generate aerosols from those that don’t?

Might remote sites to control caries justify operations even before traditional comprehensive care practices?

Will operatory turnover and PPE be less extensive and less expensive for non-aerosolizing procedure?

Eliminate 3-way syringe in community based care?

SDF and ITRs have been used in remote austere settings

Provide water in paper cups, expectorate in paper cups, and cotton rolls to dry

Some folks are asking questions, but answers may not come soon.

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