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JADA Specialty Scan - Orthodontics
Orthodontics - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

The efficacy and uses of silver diamine fluoride in older adults

An estimated 19% of the U.S. population will be 65 years or older by 2030. Untreated coronal tooth caries is present in 19% of community dwelling seniors in the United States. Silver diamine fluoride (SDF) is an emerging caries preventive management strategy that is cost-effective, safe, and readily available. Although SDF has been shown to be efficacious in caries prevention and arrest in children, few randomized controlled clinical trials have been published regarding its effectiveness in older populations. The primary objective of this study was to conduct a systematic review to evaluate the use of SDF for root caries prevention and arrest in older adults. The results were published in the July 2017 issue of Gerodontology.

To conduct this systematic review, the researchers used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. “Silver diamine fluoride” and “caries in older adults” were the broad umbrella terms under which the literature search was conducted. Inclusion criteria included English-language, randomized controlled clinical trials or cohort studies involving permanent dentition in community dwelling or institutionalized adults 18 years or older that evaluated the treatment outcomes of caries prevention, arrest, or remineralization. The authors excluded systematic reviews, meta-analyses, case reports, in vitro studies, comments on articles, reports on caries in seniors that excluded SDF, reports on primary dentition, animal studies, and non–English-language articles.

After applying inclusion and exclusion criteria, 18 articles were selected for full review, and 3 were chosen for final inclusion in this systematic review. The authors used summary tables to organize study characteristics and results. They calculated prevented fraction (PF), number needed to treat, and relative risk. The quantity and risk of bias of the chosen articles were assessed using the critical appraisal worksheet for randomized controlled trials from the Oxford Centre for Evidence-Based Medicine (Center for Evidence-Based Medicine. CEBM critical appraisal tools. University of Oxford. Published 2005.). The initial literature search under the 2 umbrella terms yielded 2,931 articles.

The 3 randomized controlled clinical trials all reported a significant effect of SDF use on the prevention or arrest of root caries. In a 3-year study, the PF for SDF, sodium fluoride varnish, and chlorhexidine varnish was 71%, 64%, and 57%, respectively (P < .001) compared with placebo and oral hygiene instruction (OHI). In a 2-year study, the PF for arrested caries was 600% greater in the SDF/OHI group and 725% greater in the SDF/OHI and oral hygiene education group than in the OHI and placebo group. In a 30-month study, the caries arrest rate was 90% for SDF compared with 45% in the placebo group.

The authors found no studies reporting the effects of SDF on coronal caries in adults. However, they noted the literature was replete with studies supporting the effectiveness of SDF in both prevention and arrest of coronal caries in children 18 through 36 months of age. Hypersensitivity is a sentinel herald of demineralization, reversible using SDF. Studies in children, young adults, and middle-aged adults suggest that SDF could be effective at halting and preventing coronal caries in senior adults. This could lead to retention of natural teeth in older adults challenged by chronic illnesses and dysfunctional physiological processes.

The authors concluded that the clinical trials studying SDF in older adults demonstrated its efficacy in prevention and arrest of root caries in this group. They postulate that further clinical trials investigating SDF efficacy in diverse groups of older adults would provide further information on a broad range of ideal uses.

Read the original article.


Consulting Editor: Linda C. Niessen, DMD, MPH
Dean and Professor
Nova Southeastern University College of Dental Medicine

Necessity of and options for access to oral health care for Medicare beneficiaries

Oral health has been linked repeatedly to overall physical health. In spite of this, Medicare explicitly excludes dental care services from its covered benefits. This dearth of coverage leaves older adults at risk of developing problems that could have been prevented or intercepted at an earlier stage with regular oral health care. Data from the 2011 and 2012 National Health and Nutrition Examination Survey revealed that 19% of adults 65 years or older had untreated caries and almost 19% were edentulous.

Researchers conducted a study to review data from the 2012 Medicare Current Beneficiary Survey (MCBS) Cost and Use Files to assess the extent of unmet dental need. Their second goal was to sketch out 2 illustrative policies that include dental coverage for Medicare beneficiaries, while also providing cost estimates for enhancing Medicare to provide those services. The results were published in the December 2016 issue of Health Affairs.

The MCBS queries recipients about dental care received during the previous year, what health insurance or supplemental dental insurance they carried, and dental expenses incurred during that time frame. Weighted population numbers with access to oral health care and weighted costs were inflated to 2016 amounts. Beneficiaries were stratified into 5 categories based on their income level per the federal poverty level (FPL). A beneficiary was classified as being at 100% of the FPL with a 2016 annual income of $11,407.

MCBS findings were sobering. Only 26% of beneficiaries with incomes below 100% of the FPL visited a dentist, while 73% of those with incomes of at least 400% of the FPL did. A mere 12% indicated having some dental insurance. Those with insurance received dental care at twice the rate of those without. Total spending and out-of-pocket spending for dental care was linked to having dental insurance and higher incomes.

Two illustrative policies for expanding dental coverage were presented. Both offered the same standard dental benefit package. This covered the full cost of 1 preventive care visit annually and 50% of allowable costs for care, capped at $1,500 annually, for additional preventive care, acute periodontitis, or dental caries. Policy 1 was a premium-financed, voluntary one, similar to Medicare’s current Part D prescription drug program. The estimated premium was calculated at $29 per month, with the federal government’s subsidy costs estimated at $4.38 billion per year. In Policy 2, the dental care package was included as a core benefit and covered all beneficiaries. Premiums would be set at $7 or $15 per month, depending on whether 25% or 50% of costs were covered. General revenues to pay noncovered expenses were estimated as either $14.7 billion or $9.8 billion per year, depending on the level of coverage chosen.

Reviewing the data from MCBS shed light on the positive impact that having at least some dental insurance had on dental health. It is critical that preventive care is covered. Adding some dental benefits to Medicare would mirror most employer-sponsored insurance plans. The added costs would be partly mitigated by lower hospital and emergency department costs for patients whose disease had progressed and would improve rates for early detection of oral cancer and other diseases. The authors conclude that this study demonstrated concrete alternatives for expanding Medicare to include dental care, which should help inform policy makers and provide the information vital to keeping the conversation moving forward.

Read the original article.


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Seattle Care Pathway offers a novel approach to promoting good oral health in older patients

The concept of frailty refers to the “state of increased vulnerability to stressors due to age related decline in physiological reserve across neuromuscular, metabolic and immune systems.” Frail elders will comprise an increasing component of the demographic going forward. This presents challenges as well as opportunities for both the dental team and the larger health care work force in the provision of good and effective oral health care to patients across a spectrum of dependency. The authors of an article published in a supplement to the January 2014 issue of Gerodontology summarize the proceedings of a 3-day workshop held in Seattle, Washington, in March 2013 to review, analyze, and update existing evidence for the maintenance of oral health in the geriatric population.

The goal of the workshop was to categorize the spectrum of the older population so as to create meaningful categories of physical and cognitive dependency. These established categories, then, would provide a framework with predictive capability for provision of optimal oral health care.

The Seattle Care Pathway, which emerged from this workshop, describes 7 levels of frailty that categorize the state of dependency of an individual patient. These categories, which share some descriptors of the Canadian Study of Health and Aging (CSHA) Frailty Scores, range from CSHA level 1 (no dependency) to CSHA level 7 (high dependency). CSHA level 1 patients are robust and fit and should be on standard periodic oral recall schedules. CSHA level 7 patients have complex health care issues, which prevent them from receiving dental care outside the home.

The Seattle Care Pathway addressed assessment, preventive oral health care strategies, recommended treatment approaches, and suggested topics for communication with the patient, family, caregivers, and other health care professionals.

Level of dependency rather than chronological age was the defining characteristic of the pathway. That being said, the oral care concerns were largely focused on older patients. Clinical scenarios were developed for each level of the pathway to illustrate its utility in designing effective oral health care across the spectrum of dependency.

The authors highlighted the import of communicating with physicians and other health care providers as well as policy makers about the public health crisis of poor oral health in the geriatric population. It is paramount that the dangers of sugars in medications and impaired nutritional status, as well as the detrimental oral effects of pharmaceuticals, be communicated to other members of the patient’s health care team to better inform their therapeutic choices. The authors stressed that interprofessional education can help ensure provision of more holistic oral health care for older adults. They concluded that the Seattle Care Pathway is a sound first step in the development of an evidence-based practical, outcome-driven strategy for providing effective oral health care for older adults that is designed to be global, yet flexible enough to allow for local and regional customs and regulations.

Read the original article.

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JADA publishes new article on silver diamine fluoride

Silver diamine fluoride is not just for children. Applying 38% SDF on the exposed root surfaces of older adults once a year is a simple, inexpensive, and effective way to prevent root caries and their progression, according to a team of researchers from the Faculty of Dentistry, Rio de Janeiro State University, and the College of Dentistry, New York University. These findings are reported in an article published online ahead of print in The Journal of the American Dental Association. The article will be the cover story of the August issue JADA, which will be available online July 25.


Antibiotic prophylaxis: For whom is it recommended … or not?

The clarifying brochure, “Antibiotics and Dental Treatment” helps your patients understand who should take antibiotics before dental treatment and who should not. It takes into account the current American Heart Association recommendations, and it also addresses antibiotic prophylaxis for patients with orthopedic implants. Patients are asked to consider the downsides of antibiotics as well as possible benefits, and they are encouraged to discuss antibiotics with their dentist and physician. 

The 6-panel brochure is available in packs of 50 from the ADA Catalog. A sample can be viewed here. To order, call 1-800-947-4746 or go to Readers who use the 18435W code before July 20 can save 15 percent on all ADA Catalog products. 


ADA CE Online offers course on Aging and Dental Health

Visit ADA CE Online where our Science Institute dives into the oral health topic  Aging and Dental Health. This course discusses dental conditions associated with aging and what to expect as the number of senior aged patients continues to grow. Earn 1 CE hour upon completion.

Check out this course and other helpful topics at


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JADA+ Specialty Scans and JADA+ Scans

JADA+ Specialty Scans and JADA+ Scans are quarterly newsletters updating dentists on the latest research in selected specialties and disciplines in dentistry. ADA Publishing and the consulting editors from the represented specialties and disciplines aggregate and summarize research from previously published materials, each item attributed to its publication of origin. JADA+ Scan specialties and disciplines include endodontics, oral pathology, orthodontics, pediatric dentistry, periodontics, prosthodontics, radiology, cosmetic/esthetic and osseointegration. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. View past issues here.

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Any statements of opinion or fact are those of the authors and do not necessarily reflect the views of the American Dental Association. Neither the ADA nor any of its subsidiaries have any financial interest in any products mentioned in this publication. Any reference to a product or service, whether in advertisements or otherwise, is not intended as an endorsement or as approval by the ADA or any of its affiliated organizations unless accompanied by an authorized statement that such approval or endorsement has been granted.

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