Background
This analysis evaluated the time to first sedation or general anesthesia (GA) encounter for children treated with and without silver diamine fluoride (SDF).
Methods
This retrospective cohort study used dental claims of privately insured children from birth through age 71 months with a sedation or GA claim from 2016 through 2020. The exposure was SDF use (yes, no). The outcome was time to first sedation or GA. Descriptive and multivariable negative binomial analysis was performed. The analysis tested the hypothesis that among children who received sedation or GA for their caries treatment, those who received SDF would show a longer time to first sedation or GA than children who did not.
Results
Among 175,824 children included, SDF use increased the time to first sedation or GA encounter by 63 days when treated by different dentists (405 days vs 342 days; P < .001) and by 91 days when treated by the same dentist (337 days vs 246 days; P < .001), after controlling for the effects of age at first encounter, sex, and region of the country.
Conclusion
Children treated with SDF had a longer time to first sedation or GA, which was magnified when treatment was performed by the same dentist.
Practical Implications
Within an individualized caries management plan, SDF could provide benefits for patients, dental offices, and health systems.
Key Words
Abbreviation Key:
AAPD (American Academy of Pediatric Dentistry), CDT (Current Dental Terminology), GA (General anesthesia), SDF (Silver diamine fluoride), S-ECC (Severe early childhood caries)
These methods of advanced behavior management are costly and invasive.
- Green L.K.
- Lee J.Y.
- Roberts M.W.
- Anderson J.A.
- Vann Jr., W.F.
,
- Bruen B.K.
- Steinmetz E.
- Bysshe T.
- Glassman P.
- Ku L.
National statistics underscore that preschool-aged children frequently are treated under dental GA, with an estimated total expenditure amounting to more than $450 million annually.
- Bruen B.K.
- Steinmetz E.
- Bysshe T.
- Glassman P.
- Ku L.
Even though GA treatment may improve a child’s oral health–related quality of life,
- Yawary R.
- Anthonappa R.P.
- Ekambaram M.
- McGrath C.
- King N.M.
,
- Grant C.G.
- Daymont C.
- Rodd C.
- et al.
it has emerged as a health policy issue because of increasing demand
- Patel M.
- McTigue D.J.
- Thikkurissy S.
- Fields H.W.
and expense
- Green L.K.
- Lee J.Y.
- Roberts M.W.
- Anderson J.A.
- Vann Jr., W.F.
,
- Bruen B.K.
- Steinmetz E.
- Bysshe T.
- Glassman P.
- Ku L.
and the potential health risks of anesthetics, particularly in ambulatory settings outside of the hospital.
- Lee H.
- Milgrom P.
- Huebner C.E.
- et al.
Moreover, hospital-based operating room access to treat young children with S-ECC is limited.
- Vo A.T.
- Casamassimo P.S.
- Peng J.
- Amini H.
- Litch C.S.
- Hammersmith K.
An alternative is dental office–based GA, which typically involves an itinerant anesthesiologist, but it is still expensive and poses additional safety risks with respect to immediate access to emergency supports and services.
- Pham L.
- Tanbonliong T.
- Dizon M.B.
- Huang A.
- Cooke M.
,
- Hicks C.G.
- Jones J.E.
- Saxen M.A.
- et al.
- Crystal Y.O.
- Marghalani A.A.
- Ureles S.D.
- et al.
Silver diamine fluoride (SDF) is a safe and effective way to arrest caries lesions and provides an interim treatment until the child can be treated conventionally or the teeth with caries lesions exfoliate.
- Crystal Y.O.
- Marghalani A.A.
- Ureles S.D.
- et al.
,
- Gao S.
- Zhao I.
- Hiraishi N.
- et al.
In 2016, a procedure code (Current Dental Terminology [CDT] D1354—interim caries arresting medicament) was introduced to facilitate reimbursement for treatments intended to arrest caries lesion progression. A claims analysis from 2016 through 2019 showed that more than 25% of pediatric dentists and 5% of general dentists had incorporated SDF into their practices. SDF also has been adopted in new treatment guidelines by professional dental societies and residency programs.
- Crystal Y.O.
- Marghalani A.A.
- Ureles S.D.
- et al.
,
- Scully A.C.
- Yepes J.F.
- Tang Q.
- Downey T.
- Maupome G.
As a caries control measure, SDF has been shown to reduce incidence of dental emergencies in children on GA waiting lists by 80%.
- Thomas M.L.
- Magher K.
- Mugayar L.
- Dávila M.
- Tomar S.L.
- Johhnson B.
- Serban N.
- Griffin P.M.
- Tomar S.L.
Yet, in many instances, children who received SDF ultimately had their SDF-treated teeth restored, often under GA.
- Hansen R.N.
- Shirtcliff R.M.
- Dysert J.
- Milgrom P.M.
,
- Davis M.R.
- Johnson E.L.
- Meyer B.D.
,
Knowing whether and for how long SDF delays the first sedation or GA event could lead to more informed reimbursement policies that translate into improved population oral health.
It is difficult to use claims data to identify children for which sedation or GA was avoided via the use of SDF. To properly answer that question would require parent and provider preference data, as well as knowledge about which children were originally destined for sedation or GA. Therefore, the primary objective of our research was to compare the time to first sedation or GA encounter between children who did and did not receive SDF treatment. We hypothesized that among children who received sedation or GA for their S-ECC treatment, those who received SDF would have a longer time to first sedation or GA than children who did not.
Methods
The Ohio State University Institutional Review Board reviewed and approved this study under expedited review (2021H0197) with a waiver of parental permission, a waiver of consent process, and a full waiver of Health Insurance Portability and Accountability Act research authorization.
In this retrospective cohort study, we used deidentified enrollment and claims files from P&R Dental Strategies. Briefly, P&R Dental Strategies is a commercial dental claims clearinghouse with data from multiple dental insurance carriers containing more than 40% of all US dental claims for privately insured people. These claims files included patient-level data such as age and sex and encounter-level data such as all CDT procedure codes, date of service, provider identification number, provider specialty type, provider state, and provider ZIP Code. A child was included if he or she was aged 0 through 71 months, with a sedation or GA claim from January 1, 2016, through December 31, 2020, and the first encounter was either a diagnostic, preventive, or SDF encounter with a general dentist or pediatric dentist. To minimize the impact of outliers, we excluded 1,006 children, or 0.6% of the original query, if they had any claim for which the number of procedures exceeded a clinically realistic number for a specific encounter (for example, > 20 restorative codes during a single GA encounter).
Study variables
- Scully A.C.
- Yepes J.F.
- Tang Q.
- Downey T.
- Maupome G.
,
- Hansen R.N.
- Shirtcliff R.M.
- Dysert J.
- Milgrom P.M.
,
- Davis M.R.
- Johnson E.L.
- Meyer B.D.
In the study period, 2 commercial products were available in the United States, both of which were 38% SDF.
Statistical analysis
We presented descriptive statistics as median (25th-75th percentiles [interquartile range {IQR}]) and frequency (relative frequency, %) for continuous and categorical measures, respectively. To obtain adjusted estimates for the mean and variability for the count of days from first diagnostic encounter to first sedation or GA encounter, we used a multivariable negative binomial regression with a log link. Covariates included age at first diagnostic encounter, sex, and AAPD region. Differences between variable categories were made using the aforementioned regression model and characterized using incidence rate ratios (IRR, 95% CI), in which a value of 1 indicated that the number of days to first sedation or GA encounter was the same, a value less than 1 indicated that the comparison group had a smaller count of days, and a value greater than 1 indicated a longer count of days to first sedation or GA encounter. We then repeated the model on the number of encounters from the first diagnostic encounter to the first sedation or GA encounter. To understand the impact of SDF use and having the same dentist at the diagnostic and sedation or GA encounter, we included an interaction term between SDF use and same vs different dentist in both models. Likewise, to understand the impact of age and SDF use, we included an interaction term between SDF use and age in both models. We performed 2 sensitivity analyses to ensure the fidelity of the findings associated with SDF on time to and number of encounters before the first sedation or GA encounter, using the same multivariable model framework as the primary analysis. In the first, we determined if the inclusion of fluoride varnish as an additional treatment attenuated or increased the effect of SDF, and in the second, we assessed the possible dose-response of SDF on outcomes. We conducted all analyses using SAS Version 9.4.
Results
SDF: Silver diamine fluoride.
group (N = 175,824).
Oral sedation in a dental office was the most common route and venue of administration (n = 116,238), followed by hospital-based GA (n = 48,375), intravenous sedation (n = 10,115), and office-based GA (n = 1,869). Pediatric dentists provided 74.6% of the oral sedation encounters (n = 86,679), 54.7% of the intravenous sedation encounters (n = 5,529), 53.2% of the office-based GA encounters (n = 995), and 74.8% of the hospital-based GA encounters (n = 36,184). Among the 83,643 children who saw the same provider at their first diagnostic encounter and their first sedation or GA encounter, 76.0% saw a pediatric dentist.
Number of days from first diagnostic encounter to first sedation or GA encounter
All estimates were calculated within a negative binomial regression model using a log link.
(N = 175,824).
Ratios and 95% CIs were derived within a negative binomial regression model using a log link.
SDF: Silver diamine fluoride.
use (N = 175,824)
Estimates were calculated within a negative binomial regression model using a log link.
FigureDot plot showing regional differences in the number of days from first diagnostic encounter to the first sedation or general anesthesia encounter according to exposure status (silver diamine fluoride use). Regions were defined by American Academy of Pediatric Dentistry district chapter membership.
Number of encounters from first diagnostic encounter to first sedation or GA encounter
All estimates were calculated within a negative binomial regression model using a log link.
Ratios and 95% CIs were derived within a negative binomial regression model using a log link.
Discussion
- Crystal Y.O.
- Janal M.N.
- Hamilton D.
- Niederman R.
feelings of guilt,
- Carvalho T.S.
- Abanto J.
- Pinheiro E.C.M.
- Lussi A.
- Bönecker M.
or patient symptoms dictate the decision on timing the first sedation or GA encounter.
A number of developmental changes in coping skills can occur in 2- and 3-year-old children, potentially equipping them to receive treatment in the dental chair. The result showing a 2- through 3-month delayed time to sedation or GA for children treated with SDF failed to capture examples in which a sedation or GA encounter was delayed by a longer period for some children. As third-party payers consider SDF policies, a 2- through 3-month extended time to sedation or GA ultimately may delay the inevitable restorative care for some children, but the delay could provide important developmental time that improves quality and delivers value for some families.
- Crystal Y.O.
- Marghalani A.A.
- Ureles S.D.
- et al.
Receiving SDF from the same dentist rather than a different dentist who restored the teeth under sedation or GA increased the time to first sedation or GA. Cautiously, receiving SDF from the same dentist restoring the teeth could be interpreted as continuity of care or an individualized care plan. Our analysis reflects the existing best practice guideline for when to use SDF, which is within the context of an individualized, comprehensive caries management plan.
- Crystal Y.O.
- Marghalani A.A.
- Ureles S.D.
- et al.
- Scully A.C.
- Yepes J.F.
- Tang Q.
- Downey T.
- Maupome G.
our results also show regional variation both in the frequency of children treated with SDF as well as the delay to first sedation or GA encounter. Children treated in the Western region were treated more frequently with SDF than children in other regions. They also had the largest difference in time to first sedation or GA encounter between the SDF and no SDF groups. Oregon was an early adopting state where CDT code D1354 was initially reimbursed.,
- Hansen R.N.
- Shirtcliff R.M.
- Ludwig S.
- Dysert J.
- Allen G.
- Milgrom P.
Although difficult to pin to any 1 explanation, the longer time to first sedation or GA encounter in the Western region could be due to payers testing value-based care,
- Conrad D.A.
- Milgrom P.
- Shirtcliff R.M.
- et al.
more progressive state regulations about who can apply SDF, the original SDF protocol being developed in that region,
- Horst J.A.
- Ellenikiods H.
- Milgrom P.
or other confounding variables. Regional differences in dental practice administration and dentist treatment preferences could influence or be influenced by insurance coverage policies, a notion first suggested decades ago but one that likely still holds true today to some extent.
- Morrisey M.A.
- Jensen G.A.
Regional variation also could be a function of the plans that reimburse for SDF and report to the data clearinghouse used in this study, which may not reflect all insurance plans and carriers.
- Thomas M.L.
- Magher K.
- Mugayar L.
- Dávila M.
- Tomar S.L.
,
- Davis M.R.
- Johnson E.L.
- Meyer B.D.
,
The data clearinghouse used in our study assigned provider type by National Provider Identification number, which may not always be accurate or up to date.
- Bell N.
- Lòpez-DeFede A.
- Wilkerson R.C.
- Mayfield-Smith K.
- Bruen B.K.
- Steinmetz E.
- Bysshe T.
- Glassman P.
- Ku L.
, The data source did not capture medical procedural codes. Related to the study question, 1 limitation in interpreting our results is that we did not evaluate avoided sedation or GA encounters. It is nearly impossible to capture these types of avoided encounters in dental claims because claims only capture what was performed. Instead of trying to calculate the number or probability of avoided sedation or GA encounters, our study quantified how long SDF delayed a sedation or GA encounter.
Despite these limitations, our study had important strengths. First, the data set captured nearly 200,000 children across the United States with representation from all 5 AAPD regions. Second, we focused our analysis on children from birth through age 71 months, an age group captured in the early childhood caries definition. Our results reflect best practice guidelines for SDF treatment within a comprehensive early childhood caries disease management plan or as interim treatment before dental rehabilitation under sedation or GA.
Conclusions
Among privately insured children from birth through age 71 months in the United States, SDF was associated with a delayed time to first sedation or GA encounter. Age and regional variation in SDF use may lead to differential delays in time to first sedation or GA encounter. A delayed time to first sedation or GA encounter for ECC treatment allows important child developmental time in the early life periods (< 3 years). Increasing the time to first sedation or GA encounter at a usual source of care provides children more developmental time before treatment, gives dental offices more flexibility to deliver individualized and comprehensive care, and offers health systems an opportunity to deliver person-centered care.
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Biography
Dr. Meyer is an assistant professor, Division of Pediatric Dentistry, The Ohio State University College of Dentistry, Columbus, OH.
Mr. Hyer is a senior biostatistician, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
Dr. Milgrom is a professor emeritus, Department of Oral Health Sciences, University of Washington School of Dentistry, Seattle, WA.
Mr. Downey is chief analytics officer, P&R Dental Strategies, Hamilton, NJ.
Dr. Chi is a professor and Lloyd and Kay Chapman Endowed Chair, Department of Oral Health Sciences, University of Washington School of Dentistry; and professor, Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA.
Article info
Publication history
Published online: February 03, 2023
Accepted:
December 20,
2022
Received in revised form:
November 15,
2022
Received:
September 2,
2022
Publication stage
In Press Corrected Proof
Footnotes
Disclosures. Dr. Milgrom is a member of Advantage Silver Dental Arrest. None of the other authors reported any disclosures.
The data analysis was supported by Clinical and Translational Science Awards grant UL1TR002733 from the National Center for Advancing Translational Sciences.
Identification
DOI: https://doi.org/10.1016/j.adaj.2022.12.008
Copyright
© 2022 American Dental Association.
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