The Silver Bullet to Prevention — Transcript
[00:00:15] Welcome and the Elevate Oral Care portfolio
Well, hello everyone. Thank you for joining us this evening, and a big thank you to Sprig for inviting Elevate Oral Care tonight to share some exciting information on silver diamine fluoride.
My name is Hayley Buckner, and I am a registered dental hygienist and also the professional relations manager for Elevate Oral Care. If Elevate Oral Care is new to you, we are a prevention-focused company who prides ourselves in not only delivering unique preventive dental products that are a step ahead of conventional products, but also in delivering the support and education that dental offices require.
We have a team of preventive care consultants throughout the country who are dedicated to providing education to offices nationwide on preventive protocols, techniques, patient-centered communication and products. We work with offices to help build a preventive plan for your practice from start to finish, and we provide free AGD PACE continuing education hours to your team as we educate.
As you may have seen, we have an incredibly unique portfolio of preventive care products. From Advantage Arrest, the first silver diamine fluoride available in the United States, which we will be discussing in great detail tonight, to our patented FluoriMax varnish. It’s a very unique fluoride varnish. It is a shellac-based varnish, which means it’s about 40 times thinner than a traditional fluoride varnish. So it does not have that thick, sticky feel that you’re used to with a traditional fluoride varnish. It’s also completely hypoallergenic, so there are no allergies to be concerned about. And it can be as little as 16 cents for an in-office fluoride varnish treatment with FluoriMax. So that’s a really great option.
We also have a prescription toothpaste line. One of our newer ones is the Just Right 5000, which provides a six-month supply of at-home prescription toothpaste for your moderate- to high-risk pediatric patients, in a safe metered-dose pump to dispense the proper pea-sized dose to that child’s toothbrush head.
And one of the latest additions to our portfolio is the DenteShield line of products, which contains a pit and fissure sealant, a primer and a surface sealant. The entire DenteShield line contains SelDox technology, which is a specific form of selenium that either reduces or prevents plaque growth on treated materials. So imagine a pit and fissure sealant that reduces bacterial growth, especially along the margins. That selenium works as a catalyst, and it does not leach out, so it never needs recharging.
Those are a few of the preventive care products that we offer at Elevate Oral Care. I’ll also share some tools that we offer that can help with communication with your patients and get everyone on the staff on the same page when it comes to prevention. I’ll show you some of those throughout. But we are going to spend a great deal of time discussing silver diamine fluoride.
Please feel free to type questions into the question tab, and we’ll be sure to get to some questions at the end. And a reminder that within about an hour after the completion of the program, you will be automatically emailed a CE certificate for this evening. I’m going to go ahead and remove my webcam so that we can focus on the slides.
[00:03:52] Disclosure and the caries risk assessment tools
As I just mentioned, I am an employee of Elevate Oral Care, so I do have a vested interest in some of the products that we are discussing during today’s presentation.
We’re going to kick off the discussion with one of the many tools that we have created to help offices. This is our in-office caries risk assessment tool. It can be used chairside, or the patient can fill it out in the waiting room, or we’ve made it electronic, since we know a lot of offices are doing some teledentistry now due to the pandemic. It can be emailed out to patients, and they can fill in this information and email it right back to the office. You can even conduct a caries risk assessment with these patients through teledentistry and then get them set up with a prescription toothpaste or other things that patient may benefit from.
It is very important to conduct a formalized caries risk assessment through a questionnaire and your intraoral exam. On the left side of the screen, you will see a questionnaire with a title that reads, “Let’s work together to achieve good oral health.” That’s what makes this form so unique. We not only uncover those necessary yes-and-no, close-ended questions to quickly identify if the patient is at an increased risk for decay, but we also included four simple open-ended questions, which allow the patient to elaborate and the clinician to get more information from that patient. So we like to say that this helps move the caries risk assessment to more of a caries risk conversation.
The right side of the screen is the back of this tool, which can be used as a patient menu for the clinician and patient to work together to develop that treatment plan.
Here is another tool from Elevate. This is our oral health meter. Once the clinician has identified that patient’s risk level, you can use this chairside to help the patient understand where they fall on this spectrum. The bullet points scattered throughout help identify different reasons patients may have an increased risk for developing decay, whether that be dry mouth, or they’re undergoing ortho, poor oral hygiene, excessive plaque. Some are no-brainers that patients can probably figure out, but with some, like dry mouth, patients may not realize that it can be putting them at an increased risk for developing decay.
Down here, we see some percentages. There was a six-year retrospective study published in the California Dental Association journal back in October of 2011, and it found that 84.5% of the population is considered to be moderate to high caries risk. So think about that for a second. It’s safe to assume that about 84.5% of the patients we treat on a daily basis are at an increased risk for developing decay.
Those are the patients that are going to greatly benefit from silver diamine fluoride. We’re going to talk through all the different ways you can utilize silver diamine fluoride, whether it’s treating active decay to arrest those lesions or using it for prevention, and a couple of other ways as well. So keep this caries risk, and how many patients are at risk, in mind as we go through the conversation today, so you can see just how many patients are going to benefit from silver diamine fluoride.
[00:07:20] Advantage Arrest: history, safety and uses
Without further ado, let’s jump right into it. The brand name of our product is Advantage Arrest, and it’s available direct from Elevate Oral Care. This was the first silver diamine fluoride available here in the United States. Silver diamine fluoride is still pretty new here. It launched in April of 2015. What you’re seeing on the screen is just a handful of the different covers that silver diamine fluoride has made since it’s been available in the United States.
Even though it’s new here, other countries have been using silver diamine fluoride for several decades. Japan, for example, has been using it for over 50 years, and in that time there has not been a single adverse event reported. So it’s also an extremely safe product to use.
As I was alluding to a minute ago, there are a lot of different ways this can be used. First and foremost, it’s FDA-cleared as a dental hypersensitivity treatment. So you can use this for any patients in any areas of their mouth where they may be suffering from hypersensitivity. It’s a great desensitizer.
It can be used to arrest decay, which is the most common way to use silver diamine fluoride. It can also be placed around existing restorations. So if you have a patient that’s developed some recurrent decay, you can apply this right around the margins of those existing restorations to arrest that recurrent decay. It can be used as a liner under new restorations. You can use it as an occlusal barrier, like a sealant. And it can also be used for prevention. That’s one of the exciting updates today: there is a new billing code for using silver diamine fluoride for prevention, which we will go through in a moment. So those are all the different ways that silver diamine fluoride can be used.
[00:09:09] The ADA guideline on non-restorative treatment
There are a couple of different articles on the screen to point out. This one, hopefully you can see my mouse, is the top row, the second one in. This was from the California Dental Association Journal. It’s a little bit older now; it came out in January 2016. But there’s a lot of great information in there around silver diamine fluoride, and it helped to develop the initial protocol on how silver diamine fluoride is used here in the United States. So I’ll probably quote this article a few times throughout the presentation.
I also want to go through the article right next to it, the upper third one over. I’m going to click on this article. This was the cover of JADA back in October of 2018, and you can see that this was a report from the American Dental Association titled “Evidence-Based Clinical Practice Guideline for Nonrestorative Treatments for Carious Lesions.”
This article was huge for silver diamine fluoride, because this is the first time the ADA has ever come out and said that you do not need to restore over a carious lesion. There’s a lot of great information packed into this article.
There are two flowcharts that were created to summarize the information in this article. Here’s the first flowchart; the first one is for primary teeth, and the second flowchart, as you can imagine, is for permanent teeth. What these flowcharts do, and how the article is written, is break it down by whatever surface that carious lesion is on. Then, for each of those surfaces, if you’re dealing with a non-cavitated lesion or a cavitated lesion, it walks you through what the ADA’s non-restorative treatment recommendation would be for that patient.
What’s important to point out on the permanent teeth is that if it’s cavitated, the only non-restorative treatment recommendation for these teeth is silver diamine fluoride. Jumping back to the primary teeth, it’s the same thing. For those larger cavitated lesions, it works very effectively, and it’s the only non-restorative treatment option that the ADA recommends. So great information in this article.
[00:11:31] Product forms and what’s in the formula
Here’s what our Advantage Arrest product looks like. It’s available in three different forms. Originally, we launched with our eight-milliliter bottle that you can see on the left side of the screen. This bottle has about 250 drops, and each drop will treat about five teeth. So a little goes a very long way.
On the right side of the screen, we have our single-use unit-dose ampoules, which come in a kit of 30, and there are typically about three to four drops of silver diamine fluoride in each ampoule.
In the center is our newest form. This launched a little over a month ago. This is really cool; it came about during the pandemic. We had a lot of offices requesting smaller bottles so you can keep a bottle in each operatory. Having separate bottles improves asepsis, keeps everything clean, and each clinician can have their own bottle in their operatory. So you’re not running around chasing bottles and cleaning them in between patients. This comes in a three-bottle kit with three three-milliliter bottles. So that’s the newest form.
All of these have a blue tint to the formula. That helps when you’re applying it, so you can see exactly where you’re applying it. If you’ve never used silver diamine fluoride before, the consistency is very thin, like water. You may notice a bit of a Windex smell from the ammonia in it, but you use such a small amount that patients don’t typically notice it. The only thing they will notice is a little bit of a metallic taste, and that’s from the silver component. We’ll go through the application in a moment and discuss how you can mask that metallic flavor for them.
As you can see up top on the screen, this is a 38% solution, so the rest of it is water. That 38% breaks down to 25% silver, 8% ammonia, 5% fluoride, and less than 1% is the blue dye that’s used to tint it.
The silver is the antimicrobial agent. That’s what’s killing off the bacteria in those lesions, and it also helps prevent the formation of new biofilm throughout the entire dentition. The fluoride’s job is to promote remineralization in the tooth that you’re applying it to, and it too helps prevent demineralization throughout the entire dentition. And the ammonia is in there to stabilize the silver and fluoride in the concentration together.
[00:14:11] FDA clearance, breakthrough therapy designation and safety margins
As I mentioned before, this is FDA-cleared as a dental hypersensitivity treatment, which is the same way fluoride varnishes are cleared. With that being said, there are a couple of things on the package insert that may contradict what you will read in research. One of those is that, right on the package insert, it says this is for use in adults over the age of 21. But it is completely safe and acceptable to use this in a patient of any age. We’ll go through some great information on that on the next slide. And the bullet point down below gives the Canadian claims; they are able to claim a lot more in Canada.
This next slide has some great information. Back in October of 2016, the FDA awarded Advantage Arrest what’s known as a breakthrough therapy designation, which is a pretty big deal. This is the first oral product to ever receive that. You can see here that it says, “Advantage Arrest. It was announced today that the US Food and Drug Administration has granted breakthrough therapy designation to Advantage Arrest silver diamine fluoride for the arrest of tooth decay in children and adults.” So that goes on to explain how you can safely use this in patients of any age, and also for that off-label use of arresting decay.
To highlight just how safe this product is, this table paints a really nice picture. On the left side of the screen we have Advantage Arrest, the 38%, then 5% fluoride varnishes and 2.5% fluoride varnishes. The most common varnish that you’ll see on the market is a 5% varnish packaged in a 0.5-milliliter dose. If you keep that in mind, you can see that one drop of Advantage Arrest silver diamine fluoride, as shown on the right, has about a tenth of the amount of fluoride that a traditional fluoride varnish has. So it’s very safe to use. Like I said, each drop will treat about five teeth, and there’s about a tenth of the amount of fluoride in there that your traditional fluoride varnish has.
Also, it’s 400 times under the EPA’s ingestible limit on silver. And this also shows that one drop of Advantage Arrest has the same amount of fluoride as one liter of properly fluoridated water.
[00:16:42] Billing codes: D1354, D1355 and D9910
As I told you in the beginning, there’s an exciting update that recently came out for silver diamine fluoride when it comes to billing codes. I’m going to start in the center, with the second bullet point. If you’ve used silver diamine fluoride to arrest decay, you’ve probably seen this code. D1354 is the code you would use any time you’re using silver diamine fluoride to arrest active decay. And that’s been great. It became available in 2016, so not everyone’s covering it yet, but we estimate that about a third of private insurance plans are covering it, and over half the state Medicaid programs are covering it now as well.
This can be used in conjunction with your 1206 fluoride varnish code. If you were using this to arrest an active lesion or a few, you can site-specifically apply silver diamine fluoride to those active lesions, arrest them, and code 1354 per tooth that you apply it to. That patient can still receive their full-mouth fluoride varnish treatment on the same day, and you can still bill and code for that.
If you were using this as a desensitizer, you can use the D9910 code.
Up top, we’ll talk about the new code. Effective January 1st of this year, so just recently, there is a brand-new code available when you’re using silver diamine fluoride specifically for prevention. Don’t worry, we’ll talk more about that. But if you are using silver diamine fluoride for prevention, you can code D1355.
Just like with caries arrest, 1355 is a per-tooth code, because silver diamine fluoride is always a site-specific application only. What you would do is site-specifically apply the silver diamine fluoride to those high-risk sites in the patient’s mouth. And you would want to be sure to still do the fluoride varnish treatment for that patient that day as well, since they are at risk. You would apply the SDF to those higher-risk sites, followed by the full-mouth fluoride varnish treatment, and you can bill and code that 1206 in conjunction with the 1355 code.
Keep that in mind as we go through the presentation; we will talk more about the preventive uses and the benefits of that. In your handout section, there are a few handouts you can download. This one is obviously very hard to see on the screen, but be sure to download it. It’s the ADA guide to reporting the caries preventive medicament application. It goes through some questions and answers and explains exactly how you can use that code. All the questions are answered on there for you.
[00:19:30] Application protocol and the varnish step
As far as application goes, the application for silver diamine fluoride is pretty much the same no matter how you’re using it. Whether it’s to arrest decay, for sensitivity or for prevention, your application is going to be the same.
You want to clean the site, and that’s as simple as removing any plaque or food debris. With Advantage Arrest, one of the huge advantages is that you only need to cotton-roll isolate the area. You want to dry the site really well, apply your silver diamine fluoride specifically to the site or sites you’re treating, and ideally let it sit there and soak in for about a minute. After the minute’s up, you’re going to cover it with fluoride varnish.
That fluoride varnish treatment is the latest addition to the application process. The key opinion leaders who recommend that step feel that it helps leave the area undisturbed for a longer period of time, and it helps those silver and fluoride ions penetrate even deeper into the lesion. And I’ll tell you, that’s a step your patients are going to greatly appreciate, because the varnish is what’s going to mask that strong metallic flavor that silver diamine fluoride gives off. So your patients will certainly appreciate it, but it does have that clinical benefit as well.
I popped a picture in here of our FluoriMax varnish. You can see we have a unit dose available, but this is a picture of our bottle system. This is really nice. As I mentioned, it’s as little as 16 cents for your in-office fluoride varnish applications with our bottle system. It’s great because you can dispense what you need. So if for some reason you’re not doing a full-mouth fluoride varnish treatment on that patient, you can dispense a drop of this to cover the site, or the few sites, that you treated with silver diamine fluoride. One drop is enough to treat an entire primary dentition, and about two to three drops for a permanent dentition.
[00:21:30] What stains and what doesn’t
This is a great slide to go through what you should expect to stain and what won’t stain, because if you’ve heard anything about silver diamine fluoride, you’ve definitely heard about the staining that can take place.
Silver diamine fluoride does not stain sound, healthy tooth structure, and that goes for enamel, cementum or dentin. So it will not stain when you’re using it to treat sensitivity on sound, healthy tooth structure. It will stain when you’re applying it to demineralization or decay. So it’s almost like a caries-disclosing solution in a sense: it’s only going to stain where that active decay is, and that stain is permanent. We’ll talk through some ways you can cover that stain if it becomes an issue for the patient, but know that the dark black stain on that tooth surface will be permanent.
It can also temporarily discolor soft tissue. It looks like a little henna tattoo, but it usually goes away very quickly. Intraorally, it goes away in about a day. Extraorally, it can linger a few days longer, but again, it causes no issues to that soft tissue other than the temporary discoloration. That’s one of the benefits of Advantage Arrest silver diamine fluoride, which we’ll talk more about towards the end of the presentation: it has a pH of 10, so there are no issues to that soft tissue other than the temporary discoloration.
Also be aware that it can stain some of your operatory surfaces if you happen to drip or spill it. If you notice that you’ve dripped some and you catch it while it’s still wet, quickly clean it up with an ammonia-based cleaner, like Windex or Lysol wipes. If it has dried and you’ve got a stain on the countertop, you can use bleach, or a Mr. Clean Magic Eraser can sometimes help remove those stains. And be sure to cover the patient’s clothing with a bib, because it definitely stains clothing as well, and we have not found anything to get it out of clothing yet. So be very careful when you’re working with it.
This is a great image to show you before and after. If you’ve never seen what this looks like, these top teeth are before they have been treated with silver diamine fluoride, and afterwards you can see the staining that takes place. So you can see exactly what to expect.
That doesn’t always take place right away. I would say about 60% of the time you can expect some of that staining to take place chairside, but a good 40% of the time you won’t. So the good rule of thumb is when you see that patient back, if it’s been at least a week, there are two things you want to check for. One, did that stain take place? And two, has that area completely hardened and remineralized? If you were to take an explorer or a probe to that area, it should be completely hardened and remineralized. If it’s not, that’s telling you it is not yet arrested and it needs another application.
[00:24:36] How SDF prevents decay: penetration, the CDA evidence and the two-step treatment
This is a great image. It’s a micro-CT scan showing the dentinal penetration of silver. All of these little silver lines are where the silver has formed little silver rods through those tubules. So you can imagine what that does for sensitivity relief for a patient. It works very well as a desensitizer.
I also like to point out, as you can see in the second bullet point, that the outer 10 microns of an SDF-arrested lesion is intensely hard, condensed necrotic dentin. So if you were planning on building any kind of restoration over this, you’ve got a very strong foundation prior to building up that restoration. Keep that in mind as well.
But I want to switch gears a little and talk about the preventive benefits of silver diamine fluoride. We talked about the penetration through the tubules and how this would greatly help with sensitivity. For a lot of adult patients, the areas where they suffer from sensitivity are going to be exposed root surfaces. Well, an exposed root surface is a high caries risk area. So by applying this, you’re not only going to treat their sensitivity, you’re also going to offer prevention to that area.
I’m going to read you a quote from the California Dental Association Journal article that I pointed out at the very beginning of the presentation. There’s a whole section of that article dedicated to the caries prevention that’s seen. So listen to this. It says, “Annual application of silver diamine fluoride prevented many more carious lesions than four times per year fluoride varnish in both children and the elderly.”
So think about that for a second. Fluoride varnish has been our gold standard for prevention, and we now know that silver diamine fluoride offers greater prevention than if you were to treat a patient with four fluoride varnish treatments in one year. The prevention that’s seen from this is just incredible, and that’s why that new code came about. So many people had been asking for a code to be used in that manner, because there’s such a benefit to using this not only for arresting decay but also for prevention.
This is another great article that highlights the preventive benefits of silver diamine fluoride. As you can see, it’s titled “Prevention of Dental Caries by Silver Diamine Fluoride,” and it originally came out in March of 2019. Here are a couple of the key takeaways from the article. I won’t read through them all, but you can browse them. I like to point out the bottom bullet point, which says, “SDF should be placed on the highest risk surfaces as a priority.”
And it’s interesting: as you read through this article, it explains what the silver diamine fluoride is doing. It says the silver is creating antimicrobial tooth structure, so bacteria cannot colonize or demineralize. So by applying this, you’re turning the highest-risk sites in the patient’s mouth into the safest sites in that patient’s mouth.
So again, it’s recommended that this become a two-step application. When we see these patients, do the caries risk assessment, and identify them as moderate to high risk, the benefit for that patient would be to site-specifically apply silver diamine fluoride to any areas where we think the patient may have a higher risk of developing decay. That could be unsealed occlusals, buccal pits, root surfaces, furcations; any of those high-risk sites, we would site-specifically apply the silver diamine fluoride. And then you can still do the full-mouth fluoride varnish treatment as well. And now you’re able to bill and code for both: D1355 for prevention with SDF, and D1206 for your fluoride varnish. So it’s a great treatment for these patients.
[00:28:46] Gingival benefits and SDF as an occlusal barrier
Here is another great study, a recent one. As you can see up top, it says, “SDF significantly decreased gingivitis in geriatric patients in three weeks.” So this is some upcoming research. I’m going to read you the conclusion, which says, “Our results provide tangible evidence that SDF application is associated with better gingival health. SDF has the potential to be a new adjunctive, cost-effective and non-invasive tool for treating gingivitis.” So we’re not only seeing the hard-tissue benefits, but also a big soft-tissue benefit with silver diamine fluoride.
Along those lines of prevention, one of the other uses mentioned at the beginning is as an occlusal barrier, like a sealant. This is some exciting information to share. A traditional sealant goes in as a restorative material covering those pits and fissures, so nothing can penetrate down in there. That’s not what silver diamine fluoride does. This is a liquid, but it penetrates and creates that antimicrobial tooth structure we talked about, so bacteria are not colonizing there or demineralizing the tooth surface.
What we’re seeing here are 3D CT scans. The left is before silver diamine fluoride was applied, and the right picture is after. You can see the penetration you get with silver diamine fluoride deep down into these little pits and fissures, creating that antimicrobial tooth structure. Now, for this to be effective as an occlusal barrier, it does need to be reapplied every six months.
But think about all those patients with a primary dentition, where we don’t discuss sealants, but they’re getting decay in these deep pits and fissures. There are so many sugary snacks out there, gummy vitamins, all of those sticking in those little pits and fissures, but it’s a primary tooth, so we’re maybe not offering a sealant to that patient. So this is a great alternative.
Again, sealants are very technique-sensitive, and for those really young patients it’s very hard to sit through a sealant. This is not nearly as technique-sensitive. You isolate, dry, apply, let it soak in, cover with varnish, and the patient is finished. So this can be a great, quick, easy application to those occlusal surfaces to offer extra prevention for these patients. Just keep up with reapplying it every six months until you either move forward with a traditional sealant, or it can serve as that occlusal barrier for the patient.
As far as what you should expect to see clinically, here’s a before and after. SDF application is non-staining unless there’s already decay present in the walls of a fissure that is not detectable visually, in which case there may be some stain in the grooves. You can see some of these have a little darkening, but the decay will be arrested and the fissure sealed. So it’s a great option for using this preventively on these occlusal surfaces.
[00:32:02] Covering the stain, reapplication and bond strength
We talked about how, when you’re using this to arrest decay, that’s when you’ll get the stain. If the stain is an issue, it can be covered with glass ionomer, composite, any restorative. So you’ve got all sorts of different options.
Now, if you’re not restoring over it right away, or ever, then there are some reapplication steps to discuss. You can see the fourth bullet point here says that this can be reapplied at intervals of greater than one week, and one application is normally sufficient. The research tells us that about 75% of lesions are arrested with a single application, but it also tells us that 95% of lesions are arrested with two applications separated by a week.
Based on that, it’s become protocol that you do the initial application, and you don’t see that patient back until it’s been at least a week. From there, you can see the patient back, check for the staining, check for the remineralization, and reapply if need be. Moving forward, it’s recommended that you keep reapplying about every six months to a year, depending on how at-risk that patient is, until you either decide to restore over it or until that tooth exfoliates.
As far as restoring over it, bond strength is something we get asked about a lot. For some reason, silver diamine fluoride actually improves the bond strength with glass ionomer, and it does not affect composite bond strength one way or the other. So either one is fine to use over it. As we talked about, you can restore over it as early as the same day, and we’ll talk through some different ways of restoring over it, including the SMART technique, which you may have heard of.
One other thing to point out: the Advantage Arrest product has a three-year shelf life.
[00:34:08] The full-mouth “zombie effect” and what to expect on radiographs
This is a great quote too. If you went in and arrested some lesions with silver diamine fluoride and they were not covered with a restoration, we see a pretty incredible full-mouth benefit from that application. I’m going to read this quote. It says, “After two and a half to three years, 70% fewer lesions are observed on untreated surfaces of patients whose lesions were treated with SDF.”
I want to jump back to the California Dental Association article that I quoted a moment ago and read you another quote that explains this full-mouth benefit. So listen to this. This is talking about when you have arrested a lesion with silver diamine fluoride and you’re not restoring over it immediately. The article says, “When bacteria killed by silver ions are added to living bacteria, the silver is reactivated so that effectively the dead bacteria kill the living bacteria in a zombie effect. This reservoir effect helps explain why silver deposited on bacteria and dentin proteins within a cavity have sustained antimicrobial effects.”
So we see prevention if you’re site-specifically applying this to high-risk sites, but we also see prevention when you arrest a lesion and don’t necessarily cover it with a restoration right away. We see that full-mouth benefit because this will greatly reduce the bacterial load throughout the rest of the patient’s dentition.
This slide is nice for discussing what to expect radiographically. You can see some radiographs on the right. Radiographically, it will appear like a scar. You might notice a slight increase in radiopacity, but for the most part it still appears pretty radiolucent. So that’s where documentation is key. You want to make sure you’re documenting that you’ve arrested those lesions with silver diamine fluoride, and that you’re continuing to monitor and reapply when needed.
[00:36:20] Interproximal application and SMART restorations
As far as interproximal application goes, we often get asked how to apply this interproximally. If there is some kind of embrasure space and you can fit an applicator brush in there, then certainly you can wiggle that applicator brush right between those teeth. But this video is going to show you a great way to apply this to tight contacts.
What they’re using is SuperFloss, or some kind of tufted floss that has a thicker, spongy portion. You want to dry the interproximal area as best you can, thread the floss through, and leave that spongy portion on the lingual aspect. There’s what the Advantage Arrest looks like, with that blue tint, and they’re applying it right to the thicker part of the floss. You want to soak about a quarter-inch area. Once that’s soaked, he slides it through the interproximal, leaves it between those teeth, and lets it soak into those lesions, again for about a minute if you can. After the minute’s up, you remove the floss, and that’s it. So it makes for a very quick, easy application to that interproximal area with the SuperFloss technique. We’ve found that to be very handy for tight contacts.
As I mentioned before, SMART. You may have heard of what’s called a SMART restoration. SMART stands for Silver Modified Atraumatic Restorative Treatment. What’s so great about a SMART restoration is that it allows clinicians to apply silver diamine fluoride to the active decay to arrest the lesion, and then, either the same day or at a later visit, cover it with glass ionomer, typically. That eliminates the need for any local anesthetic or drilling.
So it’s a very quick, easy, painless procedure. No needle or drilling involved, which is great, especially with the pediatric patient. And during this time that we’re dealing with COVID, it’s also a non-aerosol-producing procedure, since there is no drilling involved. I’ve got the steps broken down here on how you do a SMART restoration. It’s pretty simple and straightforward, and it’s a great option, not just for eliminating the needle and drill pain-wise, but also because it is a non-aerosol-producing procedure.
To show you what that looks like, these three pictures at the bottom of the screen are a quick glimpse of how a SMART restoration works. This is tooth number 30 prior to any treatment being done. The center picture is after they’ve applied the silver diamine fluoride and arrested that lesion, and then it’s been covered with glass ionomer to restore over it. And again, no needle or drilling involved.
[00:39:18] Reducing aerosols, and clinical cases
Again, focusing on reducing aerosol production. This was from the British Dental Journal from October of 2020, and it’s titled, as you can see on the screen, “Managing Dental Caries Against the Backdrop of COVID-19: Approaches to Reduce Aerosol Generation.” Due to the mounting evidence of airborne transmission of SARS-CoV-2, a team of worldwide prevention collaborators quickly provided oral health practitioners worldwide the logic and a roadmap to safely navigate what was our new reality. So this is the roadmap for practitioners to create a safer experience for themselves, their patients and their staff.
There are a couple of tables from the article that I’ll share with you: high, low and non-AGP, meaning aerosol-generating procedure. So it gives you some alternatives. If you focus on the bottom of the table, you can see the lower portion discusses carious lesions extending into the dentin or on the root surface, and under the non-aerosol-generating procedures, SDF is an option listed for all the surfaces. This too, I believe, is in the handout for you.
On this table, for the non-aerosol caries management options, you can see SDF listed as an option in both primary and permanent teeth throughout. So Advantage Arrest is a great option if you are looking to reduce or eliminate aerosol production in your practice.
What better than to show some great examples? Here are some images courtesy of Dr. Croll and Dr. Nelson. In the picture on the left, there are some teeth that have been arrested with silver diamine fluoride, as well as SDF being applied to some of the teeth on the upper left. On the right side of the screen is a photo that shows the four maxillary anterior teeth treated with zirconia crowns. That does a great job of covering up and completely hiding the silver diamine fluoride stain.
For these next couple of series of images, I want to thank Dr. Janssen, a pediatric dentist out of Lubbock, Texas, for sharing some really great examples on the next few slides. He’s done some great casework on patients using Advantage Arrest silver diamine fluoride followed by zirconia crowns. These are incredible to see, kind of like the Sprig video that was playing at the beginning. Just the change in these patients’ lives, from these little stubs of rotten teeth, arrested with silver diamine fluoride, and then these beautiful zirconia crowns placed on top. So thanks to Dr. Janssen for sharing these photos.
Here’s another example from him as well. You can see the before at top left, then the two-week follow-up with some radiographs, and then the four-year follow-up with that patient. Pretty fascinating. And here’s another great case: the tooth decay, the arrested decay, and then repaired with crowns. So a definite change in quality of life for those patients.
[00:42:57] Pricing for each Advantage Arrest form
I’ll give you the breakdown of Advantage Arrest in the different forms it’s available in, to give you an idea. This is our new three-milliliter, three-bottle kit, and there’s the price point. Depending on how many kits you purchase, there are some cost savings. As I mentioned, with both our bottle systems, the three-milliliter bottle kit and the eight-milliliter bottle, you dispense it by the drop, and each drop will treat about five sites. This kit has a total of about 277 drops, so it’s estimated to be just under 93 drops per bottle. That breaks down to a one-drop application being about 86 cents with our three-bottle kit. So it’s equal to or less than most fluoride varnish treatments.
That’s where the FluoriMax varnish pairs very nicely with Advantage Arrest, with our bottle system of varnish. Like I said, it’s about 16 cents for an in-office fluoride varnish treatment. So 16 cents and your 86 cents together, to do that powerful two-step combination we talked about, is going to be less than most fluoride varnish treatments alone.
As far as the unit dose goes, these come in kits of 30. The unit dose comes with applicator brushes included, and depending, again, on how many kits you’re purchasing, these are anywhere from $4.67 down to about $4.33 for each ampoule. Reminder: those have about three to four drops of silver diamine fluoride in each ampoule.
And lastly, the original eight-milliliter bottle. You can see that there are about 250 drops in it. At $185, it breaks out to about 74 cents for a one-drop application.
[00:44:56] Advantage Arrest versus Riva Star, and the potassium iodide question
To do a little comparison, we often get asked about the difference between Advantage Arrest and Riva Star, and there are actually quite a few differences, especially when dealing with a pediatric patient. This table compares the two, and I want to start with what I think is most important, which is the pH and the barrier.
As discussed, Advantage Arrest has a pH of 10, so it requires only simple cotton-roll isolation. With soft tissue, you can get that temporary discoloration, but no burning or anything like that when the silver diamine fluoride gets on the soft tissue. So just simple cotton-roll isolation. Riva Star is different. It has a pH of 13, which requires you to use some kind of gingival barrier, like a rubber dam. Otherwise, in addition to soft tissue discoloration, you can also get some pretty serious soft tissue burns. So it’s a totally different application.
Some less important differences: Advantage Arrest is tinted blue, has a slightly longer shelf life, and is a lot more affordable, as you can see in the breakdown here.
Riva Star is also packaged slightly differently. It comes with silver diamine fluoride and is also packaged with potassium iodide, which we often get asked about, because potassium iodide is believed to eliminate the silver diamine fluoride stain. That is not the case. Potassium iodide will temporarily lighten the silver diamine fluoride stain, but over time it will turn back to that dark black stain. And there’s been a lot of research showing that potassium iodide causes silver diamine fluoride to not be as effective, and I’ve got some great information on that here.
This is a handout in the handout section for you to download. To highlight this study, which is small to see, but that’s why you can download it: it included 421 children with 4,496 treated lesions, which is a pretty eye-opening ratio in itself. Groups one and two received Riva Star silver diamine fluoride. The other groups received an aqueous silver fluoride solution. Two of those groups received an additional application of potassium iodide immediately after the silver diamine fluoride. Differences in caries arrest and lesion appearance were examined at both six and 12 months using two-level logistic regression modeling.
You can see the conclusion on the screen, which stated, “This study demonstrated that both silver fluoride and silver diamine fluoride can effectively arrest carious lesions on primary teeth, as consistent with other reported literature. The use of potassium iodide reduced the staining; however, it also reduced the chance of caries arrest. The potassium iodide had a positive impact on the appearance of the lesions after a year, but the potassium iodide negatively impacted the action of the therapeutic, causing a higher caries rate in teeth treated with the additional potassium iodide scrub step.” The conclusion went on to state that potassium iodide should only be considered for anterior teeth. So keep that in mind. It helps paint the picture of the differences between the products.
[00:48:33] Smart Advantage: an opaque glass ionomer to mask the stain
I want to share this product because it’s great for a couple of reasons. It’s Smart Advantage, which is Elevate Oral Care’s glass ionomer restorative. We launched it because we had a lot of requests for a restorative material that masks the black stain associated with silver diamine fluoride, and that’s exactly what this does. You can see in the description on the box that this is an opaque glass ionomer used to mask discolored surfaces and SDF-treated sites.
So it can be used as your end-all restorative. You can use it in a sandwich technique, which we hear of offices doing a lot, where they treat the teeth with silver diamine fluoride, and then when they’re restoring, they do a layer of the Smart Advantage glass ionomer to completely block that stain. Then they cover that with whatever glass ionomer or composite they use on a regular basis, to make the most aesthetically pleasing restoration. If you’re doing zirconia crowns, you can use this as the cement for those crowns as well. So that’s another perk.
I’ll quickly go through some images. One of the neat things about the tooth conditioner for this is that we tinted it yellow, because our Advantage Arrest is blue, so it won’t be confused with your traditional polyacrylic acid. You can see here’s Advantage Arrest with a traditional tooth conditioner, so you can see we’ve differentiated them nicely.
To show you what I mean by very opaque: there’s little translucency to this, and that’s how it blocks that black stain. Here are a couple of examples of different glass ionomers on the market, all over a black surface. You can see the translucency of some versus the opacity of others. The experimental A1 and A2 here are the Smart Advantage glass ionomer, and you can see it virtually completely blocks out the black color underneath. So you can imagine what that does for SDF-treated sites specifically.
Here’s what you can see intraorally and what to expect. This was not shade-matched, but it shows the patient’s teeth after they were arrested with silver diamine fluoride. And this is the glass ionomer restorative placed over that, and it completely blocked the stain.
[00:51:14] The varnish: shellac base, uptake and delivery
We’ve got a couple of extra minutes, and then we’re going to get to some questions. Since we have the time, I’ll quickly highlight the FluoriMax varnish again. As I mentioned, it pairs so nicely with Advantage Arrest, and it’s also a great everyday fluoride varnish for offices.
It is different from traditional fluoride varnish. Most fluoride varnishes that are available are 5% sodium fluoride varnishes, and they are made from a colophony base, or pine resin base. That’s where fluoride varnish typically gets the very thick, sticky feel we’re used to. It’s from that pine resin colophony base, and that’s where FluoriMax is different. We’ve eliminated that. Ours is a patented formula with a shellac base; essentially it’s a liquid-based varnish. It’s very thin, as I mentioned, about 40 times thinner than traditional fluoride varnish. And because it’s so much thinner, the fluoride particles are much more bioavailable, which leads to much better fluoride uptake. That’s why, if you’re wondering why we have a 2.5% sodium fluoride varnish: we’re much more effective at half the concentration with this shellac delivery system.
The other great thing about FluoriMax is that, since we eliminated the colophony: a lot of patients have pine and tree nut allergies, and if they do, they can certainly have an allergy to colophony-based varnishes. This one is completely hypoallergenic. There are absolutely no allergies to be concerned about.
You can see just how effective it is here. There was a study that compared FluoriMax to Vanish and PreviDent. Remember, Vanish and PreviDent are colophony-based 5% sodium fluoride varnishes. What you can see from this graph is that FluoriMax delivers better fluoride uptake after one hour than the leading brands do after four hours. And that’s at half the concentration. So it’s very effective, very comfortable, very safe and very patient-friendly, as it doesn’t have that thick, sticky feel we talked about.
Here are the different delivery systems we have available. As I mentioned, we have a unit dose, which is the option on the right side of the screen. It’s a pretty cool way to apply it: these are bristles, and you squeeze it out and paint it on the patient’s teeth. But the bottle system is the one that’s great with pediatrics, and it’s great with Advantage Arrest. You simply dispense what you need: one drop to cover those SDF-treated sites, one drop for a primary dentition, and two to three drops for a permanent dentition.
It comes with everything you see here: the varnish, these brushes and the wells. These wells have two dispensing spots, so you can put a drop of the FluoriMax varnish on one side and a drop of your Advantage Arrest silver diamine fluoride on the other. It’s all right there for you to go back to back with the application, as is recommended. So it’s a really great combination, at as little as 16 cents for a fluoride varnish application with this bottle system. It pairs very nicely and allows you to do that two-step application that is recommended for moderate- to high-caries-risk patients.
[00:54:46] Staff meetings and wrap-up
That’s pretty much what I’ve got. We’re going to go into some questions. One of the last handouts in the handout section is a handout for a staff meeting. As I mentioned before, we have a team of preventive care consultants throughout the country. If you would like to schedule either an in-person meeting or a virtual meeting, just like we’re doing today, we’d love to get that scheduled for your office and go through silver diamine fluoride with the entire team, along with any of our other preventive care products.
We can also share the tools that I showed you at the beginning and teach the whole team how to do a proper caries risk assessment, how to have that caries risk conversation with patients, and how to use patient-centered communication to increase acceptance of all the different products discussed tonight.
Thank you so much for listening. You can see our website up here, as well as our phone number. You can visit the website to request a staff meeting by filling out a little information, or you can call our customer care during normal business hours, and we’d be happy to get you set up with a meeting. I’m going to go to the questions section now. Let me pop this out.
[00:56:15] Q&A: Medicaid coverage, fees and the new code
There’s a question about SDF and Medicaid coverage. As I mentioned, over half the state Medicaid programs do cover silver diamine fluoride right now, with the D1354 code.
As far as what offices are charging patients, if they’re using it to arrest decay, we typically hear about $40 per tooth. As far as prevention goes, we’re hearing that offices are typically charging about $10 per tooth. Medicaid reimbursement, or even private insurance reimbursement, has been all over the map.
One of the things Elevate has worked hard on is that we’ve worked with every state Medicaid program to figure out what coverage we’re seeing across the country: which states are covering it, what the reimbursement is, and what the requirements are. That’s one of the tools we’d be happy to share if you reach out to Elevate, through the website or the phone number. We can get you information and resources on your specific state so you have a better understanding of the state Medicaid coverage for 1354, and hopefully we’ll see that coverage pick up very quickly with 1355 as well.
As I told you, the 1354 caries arrest code became available in 2016, and within about six months we started seeing coverage on it. So we hope to see the same kind of coverage pick up quickly with this new 1355 code. Any time you’re using it that way, be sure to bill for it so these plans are seeing it and can start covering it, because the more they see it, the more likely they are to cover it.
[00:57:57] Q&A: checking for arrest, and SDF before sealants
Another question. This person has never used silver diamine fluoride: “When you check the surface with the explorer, if it feels solid, is it safe to assume that the entire lesion is arrested? Is there any chance that the surface may be arrested with the active lesion underneath?” That’s a really good question.
Yes, that’s the general rule of thumb. The two things you want to look for are: did that stain take place, and has the area completely hardened and remineralized? With that being said, yes, you can have the surface of the lesion arrested, and there could still be a little active decay underneath. That happens sometimes with deeper, larger lesions.
In these larger lesions, it works as a combination of two ways. You apply the silver diamine fluoride, and usually within a couple of days to a week it will get that stain and be completely hardened and remineralized. Over time, the rest of that lesion will become arrested, because the bacteria deep down in the lesion no longer have their nutrition source. So that may be an issue for a while, but over time whatever remains active deep in that lesion will die off, because those bacteria no longer have a nutrition source once the most superficial layer of the lesion has been arrested. Good question.
Another great question. This person asked, “Would you recommend applying silver diamine fluoride before sealants? And if so, would you apply them the same day?” That’s a great question. We often get feedback that offices apply this prior to doing sealants because of the antimicrobial benefit. That way you’re applying the silver diamine fluoride and getting that great antimicrobial effect; if anything was active there, it is now arrested.
You can do the sealant on the same day, but you would alter your application slightly. Any time you’re placing anything light-cured over silver diamine fluoride, whether that’s your sealant material, a composite or any other light-cured material, if it’s being placed over silver diamine fluoride on the same day, then you need to light-cure the silver diamine fluoride first. That’s the only time we recommend light-curing silver diamine fluoride.
What the light-cure step does is speed up the reaction time of the silver diamine fluoride. It causes the stain to take place instantly, which helps ensure that none of those silver ions get mixed into the restorative or sealant material and cause the whole sealant or restoration to stain.
So you would apply the silver diamine fluoride like we talked about: isolate, dry, apply. If you are going to light-cure it, you definitely want to let the silver diamine fluoride soak in for at least a minute first. After the minute’s up, you quickly light-cure for two to three seconds, then you skip the varnish step we talked about and move forward with the restoration or sealant. If you’re doing the sealant or restoration on a later day, you don’t need to worry about the light-cure step; you only want to do that if you’re placing a light-cured material over it on the same day.
[01:01:31] Q&A: insurance limits, caries removal, sensitivity, rinsing and restoring
Another good question came in about insurance coverage and how many sites insurance typically covers. Again, that’s all over the map. Every insurance plan is different, and every Medicaid program is different. With Medicaid, we can give you a breakdown of what we’ve heard from states if you reach out to us, but every insurance plan is completely different.
“Have you seen recommendations for caries removal prior to application? Sounds like you’re recommending no removal. Guidelines for asymptomatic versus…” Great question again. You do not have to do any caries removal, because the silver diamine fluoride will arrest and remineralize. If there’s a lot of gross, mushy decay, a lot of people will spoon-excavate that gross decay out first, but you do not have to.
Another good question; you guys are great at this. “What is the technique with hypomineralized permanent molars that are very sensitive?” This could be great for that. It’s going to greatly help with the sensitivity. It will stain those hypomineralized teeth, but it will definitely help with their sensitivity, and it will help harden that area as well. But it will stain the surface.
Another question came in about removing that leathery, gross decay. Again, it’s certainly okay to spoon-excavate that out, but you do not have to. I’m reading through some of these questions, making sure I’m deleting the ones I’ve read. Again, yes, if there is an outer leathery layer of decay prior to placing the SDF, and it’s thick and loose, it’s a good idea to spoon-excavate that. If you don’t, that’s okay, but bring the patient back in within a week or two to check and reapply, because those are typically the ones that will need an additional application to fully arrest and remineralize the area.
“Due to the bitter taste, we usually rinse after. Should we be rinsing after application?” The answer is no. That’s where the varnish step has come in to help, for a couple of reasons. Let the silver diamine fluoride soak in for as long as the patient will let you. Up to about a minute is ideal, even longer if they’ll let you, but in some instances, with pediatric patients, you may only get a couple of seconds. So let it soak as long as they’ll let you, then cover it with the fluoride varnish, and that acts as a protective layer or seal. From there, the patient can eat and drink. You can rinse, but you don’t want to rinse until you’ve covered it with fluoride varnish to act as that protective shield over the application you just did.
“How symptomatic can teeth be before they are too far along and should move toward pulpotomy or other?” This is really going to be recommended for asymptomatic teeth.
“Once the lesion is arrested, do you just place the restoration on top?” Yes. Whether it’s a crown or a filling, you can move forward with the restoration like normal. Whatever you would typically do, you can restore over it like normal. As I mentioned, if on the same day you’re applying a material that will be light-cured over it, that’s where you would want to consider light-curing the SDF first. Otherwise, you just move forward with your restoration like normal.
I think we’ve gone through the questions. Unless I see another question pop up, I want to thank you again for joining in. I hope we provided some information and updates that you can take back to your practice. Again, we’d be happy to provide anybody with additional training on silver diamine fluoride prevention or any of our other products, so be sure to get in contact with Elevate Oral Care if you’re interested. And thank you again to Sprig for hosting tonight. This has been a really fun webinar. Thank you so much, and I hope everyone has a great evening.
