Abstract
Background
Nonsurgical caries management, particularly silver diamine fluoride (SDF) and Hall-style crowns, present alternative options for populations that have barriers to traditional treatment. The authors aimed to assess changes in the teaching and utilization of these modalities in pediatric dental residency programs.
Methods
The authors e-mailed a 29-question electronic survey regarding the utilization and teaching of nonsurgical caries management agents to US pediatric dentistry residency program directors. Data were compared with results from a similar survey conducted in 2015 to analyze trends, report protocols, barriers for utilization, and possible reasons for changes.
Results
Respondents from 82 programs completed the surveys (89% response rate). Although only 26% of respondents reported using SDF in 2015, 100% reported its utilization in 2020 (P < .001). The Hall-style crown technique is taught didactically in 90% of programs, and 69.5% of respondents use it at least sporadically in their clinics. Long wait times for the operating room (4 weeks-14 months) and sedation (1 week-12 months) motivate increased utilization of SDF, interim therapeutic restorations, and Hall-style crowns. Guidelines supporting off-label utilization of SDF have also resulted in its increased utilization.
Conclusions
US pediatric residency programs have universally adopted SDF for caries arrest in the primary dentition, and this trend seems to extend to other nonsurgical caries management agents. These changes are likely driven by diverse barriers to delivery of traditional restorative care.
Practical Implications
The rapid increases in teaching and utilization of minimal intervention techniques provide clinicians with more options for caries management in patients with barriers to traditional treatment.
Key Words
Abbreviation Key:
APF (Acidulated phosphate fluoride), CHX (Chlorhexidine), F (Fluoride), FV (Fluoride varnish), ITR (Interim therapeutic restoration), NR (Not reported), OR (Operating room), SDF (Silver diamine fluoride), SSC (Stainless steel crown)
- Marcenes W.
- Kassebaum N.J.
- Bernabe E.
- et al.
,
- Meyer B.D.
- Lee J.Y.
- Lampiris L.N.
- Mihas P.
- Vossers S.
- Divaris K.
Young children and patients with special needs with limited cooperation for restorative treatment often require sedation or general anesthesia to receive restorative treatment. This results in additional costs and risk and can create treatment delays and additional barriers.
- Crystal Y.O.
- Niederman R.
Nonsurgical methods for caries management offer a viable alternative to treat vulnerable populations who are unable to receive traditional oral health care,
- Slayton R.L.
- Urquhart O.
- Araujo M.W.B.
- et al.
and they include the utilization of silver diamine fluoride (SDF), interim therapeutic restorations (ITR), atraumatic restorative treatment (ART), and Hall-style crowns, usually in conjunction with other methods of caries prevention, such as fluoride products and antibacterial agents.
- Frencken J.E.
- Peters M.C.
- Manton D.J.
- Leal S.C.
- Gordan V.V.
- Eden E.
- Gao S.S.
- Zhao I.S.
- Hiraishi N.
- et al.
with arrest rates ranging from 54% through 90%, depending on tooth location, size of the cavity, and presence of plaque.
- Fung M.H.T.
- Duangthip D.
- Wong M.C.M.
- Lo E.C.M.
- Chu C.H.
These results are achieved without caries removal
- Chu C.H.
- Lo E.C.
- Lin H.C.
and without the need for local anesthetic, which makes it easy to use and minimally invasive.
- Crystal Y.O.
- Niederman R.
In 2014, the US Food and Drug Administration approved SDF as a device to treat dentinal sensitivity in adults older than 21 years. Its main drawback is the dark staining of arrested lesions. Because it is also an affordable therapy with minimal adverse effects and relative safety, it is now used off-label for treating young patients, those with behavioral problems, and patients who experience barriers to conventional restorative care.
- Innes N.P.
- Evans D.J.
- Bonifacio C.C.
- et al.
It was developed for utilization when delivery of ideal treatment was not feasible, and it has gained some popularity in the United Kingdom and Germany, where use of traditionally placed SSCs is infrequent.
- Threlfall A.G.
- Pilkington L.
- Milsom K.M.
- Blinkhorn A.S.
- Tickle M.
This technique relies on the principle that sealing existing caries will stop caries progression. It might also require a separate visit for placement of a separator to create interproximal space when there are closed contacts.
- Innes N.P.
- Evans D.J.
- Stirrups D.R.
Some researchers have reported modifications of the technique that include partial caries removal, proximal tooth slicing, or both.
- Hussein I.
- Al Halabi M.
- Kowash M.
- et al.
,
- Midani R.
- Splieth C.H.
- Mustafa Ali M.
- Schmoeckel J.
- Mourad S.M.
- Santamaria R.M.
In our study, we used the term Hall-style crowns to allow modifications of the technique to be included in the responses.
- Nelson T.
- Scott J.M.
- Crystal Y.O.
- Berg J.H.
- Milgrom P.
- Nelson T.
- Scott J.M.
- Crystal Y.O.
- Berg J.H.
- Milgrom P.
assessed the utilization and teaching of SDF and other caries-control techniques. It found that although only 26% of the programs utilized or taught SDF in their clinics, 69% expected an increase in implementation. The main barrier cited for utilization was parental acceptance. Since then, the American Academy of Pediatric Dentistry has created a guideline for the use of SDF and numerous other studies have been published on this topic.
- Slayton R.L.
- Urquhart O.
- Araujo M.W.B.
- et al.
,
- Crystal Y.O.
- Marghalani A.A.
- Ureles S.D.
- Schmoeckel J.
- Mourad S.M.
- Santamaria R.M.
The purpose of our study was to assess the current utilization and teaching of SDF, Hall-style crowns, and other caries-control methods in postgraduate pediatric dentistry programs and compare our results with those obtained in the 2015 survey. In addition, we determined factors associated with implementation, protocols for use, and potential barriers.
Methods
Our study’s protocol for a Web-based questionnaire was determined to be exempt from federal policy by the New York University Institutional Review Board under IRB-FY2020-4061.
Participants
Survey instrument
To allow for direct comparison, we used the same questions asked in the 2015 survey, which was composed of Likert-style, multiple-choice, and fill-in responses. Questions about the teaching and utilization of Hall-style crowns were appended to the original survey instrument. Additional questions covered indications for utilization, actual protocols, consent forms, follow-up for SDF, and perceived barriers to its utilization. In addition, we inquired about the wait times for general anesthesia and sedation in each program and whether long wait times had affected use of nonsurgical methods. Directors were queried regarding their own practice experiences and years in the director position, and they had a choice to sign their name and provide contact information or submit the survey anonymously. The total number of questions was 29, and the survey was designed to be completed in approximately 10 minutes.
Survey methods
The survey was administered via SurveyMonkey, with a cover invitation from the principal investigator to the program directors with a description of the study and a link to the survey. Participating in the survey implied consent. The first mailing was sent on January 20, 2020, with an e-mail reminder sent to program directors who had not responded 1 week later. A third e-mail was sent 1 week after that. The end date of the survey was February 17, 2020.
Data analysis
Survey responses were exported to and analysis was completed using IBM SPSS software, Version 26. Frequencies and percentages were calculated for each survey item. Comparison of those frequencies between the 2015 and 2020 survey responses was accomplished with the χ2– statistic. Analysis of variance was used to compare reported wait times between groups. In general, exact P levels are provided, except when less than .001. A P value < .05 implies significance.
Results
The response rate was 89%. Surveys were completed by 64 residency directors, 10 associate directors, and 6 faculty designees. Two surveys were completed anonymously.
Table 1Characteristics of pediatric dentistry residency programs.
Table 2Reports of utilization and teaching caries control in US pediatric residency programs in 2015∗ (n = 74) and in 2020 (n = 82).
Universal utilization of fluoride varnish (FV) was unchanged from 2015, as was the minimal utilization of povidone iodine. The utilization of silver nitrate and acidulated phosphate fluoride foam trended lower but was statistically similar over time (from 9.5% to 2.5% and from 49% to 28%; P = .10 and P = .06, respectively).
Table 3Perceived indication and barriers to the utilization of silver diamine fluoride in US pediatric dentistry residency programs in 2020 (n = 82).
Almost all respondents (99%) report using the 2017 American Academy of Pediatric Dentistry guideline for SDF as a resource when teaching, and 86% said that this guideline has resulted in increased utilization of SDF in their clinics. Most (98%) were familiar with the Current Dental Terminology dental procedure code to bill for SDF.
Table 4Reported protocols for silver diamine fluoride utilization.
Almost all respondents (95%) reported using SDF as an interim treatment, 91% agreed that a consent form should be obtained, and 83% use a specific consent form in their programs.
Discussion
Historically, dental providers treating early childhood caries had few alternatives to conventional restorative treatment, and behavioral limitations in young children often necessitated use of sedation and anesthesia. We present evidence that the paradigm is shifting, with nearly all pediatric dentistry residencies now teaching caries management with techniques like SDF, IRT, and Hall-style crowns. Availability of professional guidelines on minimal intervention and nonrestorative treatment has also likely increased understanding, justification for off-label utilization, and clinical implementation.
- Patel M.
- McTigue D.J.
- Thikkurissy S.
- Fields H.W.
,
- Eaton J.J.
- McTigue D.J.
- Fields Jr., H.W.
- Beck M.
Accordingly, in the US and Canada, we have seen an increase in use of pharmacologic behavior guidance for pediatric oral health care.
- Meyer B.D.
- Lee J.Y.
- Lampiris L.N.
- Mihas P.
- Vossers S.
- Divaris K.
,
- Schroth R.J.
- Pang J.L.
- Levi J.A.
- Martens P.J.
- Brownell M.D.
Although relatively well accepted by many parents, these procedures carry risk, especially in children younger than 3 years and those with comorbidities.
- Chicka M.C.
- Dembo J.B.
- Mathu-Muju K.R.
- Nash D.A.
- Bush H.M.
,
- Paterson N.
- Waterhouse P.
These concerns have affected the way parents and oral health care providers view treatment of caries in young children, influencing pediatric dentistry training programs to rapidly adopt new minimal intervention treatments.
- Hussein I.
- Al Halabi M.
- Kowash M.
- et al.
The conventional procedure can be completed in 1 visit and it avoids problems like transient open bite and traumatic occlusion. Teaching of the conventional SSC technique has changed considerably over time, as modern preformed crowns require minimal tooth preparation, and most programs have embraced the concept of partial caries removal with indirect pulp therapy, which has reduced the need for pulpotomies before SSC placement.
- Dhar V.
- Marghalani A.A.
- Crystal Y.O.
- et al.
This is not only the case in the United States. Investigators studied the practices of 709 pediatric dentists from 65 different countries and found that although 54% reported using Hall-style crowns, practitioners largely consider this technique a treatment option, not the reference standard.
- Hussein I.
- Al Halabi M.
- Kowash M.
- et al.
The authors also reported that for a cooperative 6-year-old patient, 75% of respondents would choose a conventional SSC over a Hall-style crown.
- Hussein I.
- Al Halabi M.
- Kowash M.
- et al.
This is consistent with our findings, in which most programs teach the technique didactically and utilization it clinically in a limited number of patients.
Most directors credited the long waiting times for ORs and sedation with increasing their utilization of SDF. This comes as no surprise, as wait times as long as 12 and 14 months for sedation and general anesthesia, respectively, allow plenty of time for emergency situations to emerge in children who have substantial disease burden. Written comments from respondents cited that they utilize SDF on very young children (< 24 months) “to delay treatment that requires use of sedation or [general anesthesia].” Others reported utilizing SDF routinely on patients scheduled for sedation or general anesthesia “to decrease the risk of irreversible/necrotic pulpal status while they wait.”
Others reflected that minimal intervention techniques give them the time to implement other behavioral interventions to manage caries: “We notice that in the absence of compliance and diet modification, our success rate (with SDF) has not been stellar.” The desensitizing actions of SDF can allow a patient to implement the necessary hygiene practices that slow lesion progression and prevent emergency flare-ups while waiting for definitive treatment. Others commented that SDF and Hall-style crowns also provide an alternative to manage a limited number of lesions in precooperative patients instead of opting for general anesthesia.
- Slayton R.L.
- Urquhart O.
- Araujo M.W.B.
- et al.
,
- Crystal Y.O.
- Marghalani A.A.
- Ureles S.D.
- Schmoeckel J.
- Mourad S.M.
- Santamaria R.M.
However, as seen in Table 4, most programs apply FV on the same visit as the SDF, a protocol that was not utilized in any of the clinical trials that are cited as the basis for expected arrest rates.
- Crystal Y.O.
- Niederman R.
The effect on arrest rates (or caries prevention) when SDF is immediately covered with FV has not been investigated or reported.
Caries-risk assessment and management for infants, children and adolescents.
,
- Featherstone J.
- Crystal Y.
- Chaffee B.
- Zhan L.
- Ramos-Gomez F.
- Crystal Y.O.
- Janal M.N.
- Hamilton D.S.
- Niederman R.
In that study, although many parents were willing to compromise esthetics to avoid general anesthesia, one-third of parents found the staining unacceptable under any circumstance. The effect was mediated by parent education, income, and ethnicity. Program directors throughout the country have found that many parents prefer tooth-colored restorations and esthetic crowns over the utilization of SDF.
Interim Infection Prevention Guidance for Dental Settings During the COVID-19 Response.
Although it is still uncertain how the public health crisis will change dental practice, it is apparent that it is not possible to simply put a pause on oral health care. Every day at our institutions we see patients seeking treatment for true dental emergencies. Wait times for procedural sedation and general anesthesia will get even longer, as the current situation in hospitals throughout the country has forced all programs to defer “nonurgent” treatment for 3 months and perhaps much longer. Minimal intervention approaches, such as SDF, ITR, and Hall-style crowns, can be implemented to address these needs, while limiting generation of aerosol and combining with procedural sedation to provide extractions and other urgent procedures for young patients. This experience highlights the importance of maintaining a broad skill set to safely and compassionately address the patient needs in the context of an ever-changing practice climate.
Conclusions
Pediatric dentistry residency programs in the US seem to be moving toward increased utilization of nonsurgical approaches like SDF, ITR, and Hall-style crowns as essential components of a comprehensive caries management plan based on risk assessment that is tailored to address patient needs. The simplicity and utility of these treatment options makes them an attractive component of both pre- and postdoctoral training. Accordingly, this trend in specialty programs may also be an indication of curriculum trajectory in undergraduate dental education.
Increased utilization and teaching of minimal intervention techniques in specialty education programs will eventually result in more practicing dentists embracing those approaches. This paradigm change provides clinicians with additional options for caries management, offering flexibility to tailor treatment to suit patient needs and the constraints of practice in the modern era.
Supplemental Data
References
Global burden of oral conditions in 1990-2010: a systematic analysis.
J Dent Res. 2013; 92: 592-597
“They told me to take him somewhere else”: caregivers’ experiences seeking emergency dental care for their children.
Pediatr Dent. 2017; 39: 209-214
Silver diamine fluoride treatment considerations in children’s caries management.
Pediatr Dent. 2016; 38: 466-471
Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: a report from the American Dental Association.
JADA. 2018; 149: 837-849.e19
Minimal intervention dentistry for managing dental caries: a review—report of a FDI task group.
Int Dent J. 2012; 62: 223-243
Clinical trials of silver diamine fluoride in arresting caries among children: a systematic review.
JDR Clin Trans Res. 2016; 1: 201-210
Randomized clinical trial of 12% and 38% silver diamine fluoride treatment.
J Dent Res. 2018; 97: 171-178
Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children.
J Dent Res. 2002; 81: 767-770
The Hall technique 10 years on: questions and answers.
Br Dent J. 2017; 222: 478-483
General dental practitioners’ views on the use of stainless steel crowns to restore primary molars.
Br Dent J. 2005; 199 ()
The Hall technique: a randomized controlled clinical trial of a novel method of managing carious primary molars in general dental practice—acceptability of the technique and outcomes at 23 months.
BMC Oral Health. 2007; 7: 18
Use of the Hall technique by specialist paediatric dentists: a global perspective.
Br Dent J. 2020; 228: 33-38
Success rates of preformed metal crowns placed with the modified standard Hall technique in a paediatric dentistry setting.
Int J Paediatr Dent. 2019; 29: 550-556
Silver diamine fluoride in pediatric dentistry training programs: survey of graduate program directors.
Pediatr Dent. 2016; 38: 212-217
Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs.
Pediatr Dent. 2017; 39: 135-145
Parental attitudes toward advanced behavior guidance techniques used in pediatric dentistry.
Pediatr Dent. 2016; 38: 30-36
Attitudes of contemporary parents toward behavior management techniques used in pediatric dentistry.
Pediatr Dent. 2005; 27: 107-113
Trends in pediatric dental surgery for severe early childhood caries in Manitoba, Canada.
J Can Dent Assoc. 2014; 80: e65
Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims.
Pediatr Dent. 2012; 34: 231-238
Risk in pediatric anesthesia.
Paediatr Anaesth. 2011; 21: 848-857
Use of vital pulp therapies in primary teeth with deep caries lesions.
Pediatr Dent. 2017; 39: 146-159
Caries-risk assessment and management for infants, children and adolescents.
in: The Reference Manual Pediatric Dentistry: Best Practice Documents 2019-2020. American Academy of Pediatric Dentistry,
Chicago, IL2019: 220-224An updated CAMBRA caries risk assessment tool for ages 0 to 5 years.
CDA J. 2019; 47: 37-47
Parental perceptions and acceptance of silver diamine fluoride staining.
JADA. 2017; 148: 510-518.e4
Interim Infection Prevention Guidance for Dental Settings During the COVID-19 Response.
Centers for Disease Control and Prevention,
Atlanta, GA2020
Biography
Dr. Crystal is a clinical professor of pediatric dentistry, New York University College of Dentistry, Floor 9W Dental Center, 421 First Ave, New York, NY 10010.
Biography
Dr. Janal is a senior research scientist and an adjunct professor, Department of Epidemiology and Health Promotion, New York University College of Dentistry, New York, NY.
Biography
Dr. Yim is a pediatric dental resident, New York University College of Dentistry, New York, NY.
Biography
Dr. Nelson is a clinical associate professor and an acting chair, Department of Pediatric Dentistry, University of Washington, Seattle, WA.
Article Info
Publication History
Footnotes
Disclosure. Dr. Nelson is a consultant to Sprig Oral Health Technologies, manufacturer of zirconia crowns for primary teeth. None of the other authors reported any disclosures.
Identification
DOI: https://doi.org/10.1016/j.adaj.2020.06.022
Copyright
© 2020 American Dental Association.
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