4/30/19 medical models of caries forthemoderndentalpractice

4/30/19

1

Jeremy Horst

DDS,PhD

UCSF+UW

Medical Models of Caries

for the Modern Dental Practice

• At the conclusion of the session, the participant will be able to:

• 1. Explain the history, clinical evidence, safety, indications, and protocol for using SDF to treat dental caries.

• 2. Explain the indications, benefits, and risks for SDF, SMART, and Hall crowns to patients.

• 3. Guide patients through deciding whether to start with surgical versus topical caries management.

• 4. Demonstrate the technique for applying high viscosity glass ionomer cement as a sealant.

• 5. Propose to patients simple and effective strategies beyond brushing and flossing to prevent caries.

THANK YOU

Peter Milgrom

Joe DeRisi

Jong Seto

John Frachella

Steve Duffin

Douglas Young

Jeanette MacLean

Jason Hirsch

Martin MacInytre

Thuan Le

Pam DenBesten

Ling Zhan

John Featherstone

Eleni Ellenikiotis

Helen Yuan

Alex Yamana

4/30/19

2

3 year outcome – severely fragile 3 to 7 year old

1 year later

3 years later

No excavation SDF + GIC

3 years post-SDF

2 years post-GIC

MMC is good enough for anyone

4/30/19

3

SDF Outline _

1. SDF – status & basics

2. SDF clinical evidence & use

3. SDF mechanisms

4. Glass ionomer

5. Hall crowns

SDF - what is it?

Colorless liquid

25% silver: antimicrobial

8% ammonia: solvent

5% fluoride: remineralization

SDF vs SN + FV

SDF

25% silver

8% ammonia

5% fluoride

> effect data

SN + FV

16% silver

9% nitrate

2.5% fluoride

> safety data

BOTH are safe & effective.

4/30/19

4

SDF - what does it do?

- Arrests dental caries

- Prevents dental caries

• directly & indirectly

- Decreases dentin hypersensitivity

Accessible

cavity.

1. Isolate with cotton.

2. Air dry.

3. Apply with microbrush.

Arrested cavities

after 1 year

How do you use it?

4/30/19

5

US acceptance

FDA clearance

UCSF protocol & guidelines

FDA “breakthrough status”

Advantage, Willamette protocols

Medicaid funding

IHS protocol & recommendation

ADA resolution

AAPD policy & guidelines

CDA Journal 2018 Jan & Feb

~20% of dentists, ~all pedodontists.

FDA/NIDCR/UMich/NYU/UIowa pivitol trialADA recommendation

October 2018, the ADA

“Clinicians are encouraged to prioritize use of

[nonrestorative treatments] based on

effectiveness, safety, and feasibility." - JDR

"38% silver diamine fluoride solution applied

biannually [is] effective for arresting advanced

cavitated carious lesions on any coronal surface

(moderate to high certainty).” - JADA

Dr. Jason Hirsch

Esthetics? SSC or SDF

4/30/19

6

Dr. John Frachella

Esthetics? Handled.

SMART

Dr. Jason Hirsch

4/30/19

7

Issues à prompts

• What are your goals for your oral health?

• Which matters more to you:

looks or comfort?

• Do you prefer:

multiple easy visits, or

fewer visits that are more intense?

Patient Name:

Date of Birth:

Medical Record Number: !

!

San!Francisco!Department!of!Public!Health!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Dental!Services!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!INFORMED!CONSENT!FOR!SILVER!DIAMINE!FLUORIDE!

!Facts!for!consideration:!

• Silver!diamine!fluoride!(SDF)!is!a!liquid!that!helps!stop!tooth!

decay.!SDF!is!applied!every!3,!6!or!12!months.!

• A!small!amount!of!SDF!is!applied!to!the!decayed!tooth!area.!

• After!SDF!application!no!eating!or!drinking!for!60!minutes!

and!no!tooth!brushing!until!the!following!morning.!

• The!decayed!area!will!stain!black!permanently.!Healthy!

tooth!structure!will!not!stain.!!

• I!should!not!be!treated!with!SDF!if:!1)!I!am!allergic!to!silver.!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

2)!There!are!painful!sores!or!raw!areas!on!my!gums!or!anywhere!in!my!mouth.!

!!!

Benefits!of!receiving!SDF:!

• Helps!stop!tooth!decay.!

• Fast.!

• Do!not!need!to!numb!teeth.!

• Does!not!hurt.!

!

Risks!of!receiving!SDF:!

• The!affected!area!will!stain!black!permanently.!This!means!SDF!is!working.!

• ToothJcolored!fillings!and!crowns!may!discolor!if!SDF!is!applied!to!them.!!

• After SDF treatment, a filling or crown might still be needed.!

• If!accidentally!applied!to!the!skin!or!gums,!a!brown!or!white!stain!may!appear!that!causes!no!

harm,!cannot!be!washed!off!and!will!disappear!in!one!to!three!weeks.!

• Permanent dark spots if spilled on clothing.!

• Allergic reaction.!

• Risk!that!the!procedure!will!not!stop!the!decay.!

• Not every cavity can be treated with SDF!

!

Alternatives!to!SDF,!not!limited!to!the!following:!

• No!treatment,!which!may!lead!to!continued!break!down!of!the!tooth.!Symptoms!may!get!worse.!

• Placement!of!fillings!or!crowns,!extractions!or!referral!to!a!specialist.!

!

I have read this form. I understand the treatment and have had the chance to ask questions. I have seen the photo

of how teeth may look after SDF discolors the cavities. I understand that I may refuse treatment with SDF. I

understand that I can decide to have no treatment or I can have fillings, crowns, or extractions done at this or

another dental office.

I consent and authorize SFDPH Dental Services to use Silver Diamine Fluoride to help stop tooth decay.

Signature!of!patient/parent/guardian!!______________________________________________________!Date____________!

!

!

Signature!of!witness____________________________________________________________________________Date!____________!!

Consent = Conversation

This is a consent document.

Risks?

Benefits?

Alternatives?

Simple language.

Show pictures!

sites.google.com/site/jeremyahorst/SDFconsents

Tesoriero & Lee 2016

4/30/19

8

Billing

• D1354 caries arrest.

• D1208 topical fluoride.

• D9910 desensitization.

As of Jan 2018: Per tooth

How much do you use?

– microliters per lesion.

– 1 drop (20μL) can treat 5+ lesions.

How much can you use?

– FDA rat & mouse LD50 studies:

• Oral LD50 = 520 mg/kg

• Subcutaneous LD50 = 380 mg/kg

– 32.5uL drop in 10kg child (100% absorption)

~15 month old = 1.23 mg/kg

• >300-fold LD50 safety margin.

– NOAEL level for 14 days of daily exposure = 1.3 mg/kg

• 13 mg/kg resulted in mild gastric inflammation.

UCSF limit: 1 drop per 10kg of weight per visit.

SMART Tribe max used: 4 drops…

4/30/19

9

=

32.5 µL

50,000 ppm F

2.3 L

0.7 ppm FHow much Fluoride?

6 1=

SDF, how safe is it?

• No adverse reports in >80 years of use in Japan.

• Contraindication

– Silver allergy.

• Relative contraindication:

– Significant desquamative processes

e.g. ulcerative gingivitis, stomatitis

→ Protect by petroleum jelly

• Side effects:

– Small, white mucosal lesions

• disappear in 48 hours.

– It will stain the lesion black.

– 14 days: mild gastric inflammation.

n arrested (SD) 95% CI adverse events

SDF 30 .72 (.38) .55 to .85flu, nausea,

redness, spot

placebo 36 .05 (.18) .00 to .16

diarrhea x 2,

tummy ache,

toothache + diarrhea

Stopping Cavities Trial

purpose: Safety & Arrest Effectiveness

4/30/19

10

The US safety study in

Person and Clinic Protection

Permanent staining of clinic surfaces & clothes.

– Does not come out after setting.

– Clean immediately with copious water,

ethanol, or high pH solvents such as ammonia.

Temporary staining of skin

– Rinse.

–Will go away in days.

– No harm.

SDF staining

time 0 1 day 1 week

Castillo et al, J Dent Res 2011

Duffin, J Cal Dent Assoc 2012

4/30/19

11

pH 13!!!!

When would you NOT use it?

1. Pulp exposure

2. Irreversible pulpitis

3. Allergy to Silver, Fluoride, or Ammonia

4. ~~~ open muco/gingival lesions

5. ~~~ simultaneous to resin, if avoiding stain

4/30/19

12

SDF Outline _



3. SDF mechanisms

4. Glass ionomer

5. Hall crowns

Ca

rie

s A

rre

stin

kid

s

Horst, Adv Dent Res 2018

9%

9%

4/30/19

13

Ca

rie

s A

rre

st

in k

ids

no caries removal before SDF!!!

Ca

rie

s A

rre

stin

kid

s 2x > 1x / year

keep applying!!!

Ca

rie

s A

rre

stin

kid

s

Horst, Adv Dent Res 2018

9%

9%

loading doses help

4/30/19

14

Ca

rie

s A

rre

st

in k

ids

similar effect vs ART

Suggested frequency protocol

• For mild caries:

q6mo

baseline

2-6 wk

3 mo

6 mo

12 mo

18 mo

• For moderate caries:

q6mo + 2-6 week loading dose

• For severe caries:

q6mo + two 2-6 week loading doses + 3mo

0%#

50%#

100%#

0.5# 1# 1.5# 2# 2.5# 3#

SDF#q1year#

+#OHI#q6mon#

control##

Zhang et al., 2013 227 60-89 year olds

0.91 lesions at start

0%#

50%#

100%#

SDF#q1year#

SDF,#KI#q1year#

control##

Li et al., 2016 67 72 year olds


0%#

50%#

100%#

SDF#q1year#

NaF#q3mon#

Chlorhex#q3mon#

0%#

50%#

100%#

0.5# 1# 1.5# 2# 2.5# 3#

SDF#q1year#

+#OHI#q6mon#

Tan et al., 2010 203 79 year olds

control: 2.5 new lesions



Arr

est

Older adults

Pre

ve

ntio

n

time (years)

4/30/19

15

Kanellis. CDAJ, 2018

SN+FV trial

@Amish U.Iowa

TABLE 2

Major and Minor Failures at 24 Months*

Silver Nitrate Group Conventional Group

Major Failure Minor Failure Major Failure Minor Failure

17 / 237 5 / 237 3 / 93 0 / 93

7.2% 2.1% 3.2% 0%

*Reported at the tooth level.

Baseline

6 months

12 months

18 months

24 months

Ca

rie

s P

reve

nti

on

in k

ids

pre

vente

d fra

ction o

f caries lesio

ns

0%

0.5 1 1.5 2 2.5 3

time (years)

50%

100%

50%

100%

50%

100%

50%

100%

50%

100%

50%

100%

50%

100%

50%

100%

SDF q1year

Resin Sealant

NaF q6mos

Liu et al., 2012

482 9.1 year olds


SDF q1year

exc SDF q1year

exc NaF q3mos

NaF q3mos

Chu et al., 2002

308 3-5 year olds


SDF once

GIC Sealant

Monse et al., 2012

708 6-8 year olds


40% AgF once

849 5-8 year olds


background: 10% SnF2

Green, 1989

50%

100%

SDF q1year

SDF q6mos

Nguyen et al., 2017

295 2-3 year olds


SDF 3x/1week

25 6-8 year olds


Sato & Saito, 1970

SDF q6mos

Llodra et al., 2005

373 6 year olds


50%

100%

SDF q3mosTsutsumi et al., 1981

58 5-7 year olds

mean (61%)

weighted average

SDF q3mos

Yoshida et al., 1976

26 1-2 year olds


Horst & Heima, Compendium 2019

4/30/19

16

0%#

50%#

100%#

0.5# 1# 1.5# 2# 2.5# 3#

SDF#q1year#

+#OHI#q6mon#

control##



0%#

50%#

100%#

SDF#q1year#

SDF,#KI#q1year#

control##

Li et al., 2016 67 72 year olds


0%#

50%#

100%#

SDF#q1year#

NaF#q3mon#

Chlorhex#q3mon#

0%#

50%#

100%#

0.5# 1# 1.5# 2# 2.5# 3#

SDF#q1year#

+#OHI#q6mon#

Tan et al., 2010 203 79 year olds




Arr

est

Older adults P

reve

ntio

n

time (years)

Learned from clinical trials?

• 12 RCTs with 1,816 patients tx SDF = safe.

• 9 on caries arrest.

81% (68-89%) arrest with 1-2/year application.

• 11 on caries prevention.

70-80% prevention in kids by application only to lesions.

61% direct prevention, outperforms everything by far.

? OR ?

Interproximals?

Hirsch Horst

84% after 1 year!!!

- MacLean et al, in press

4/30/19

17

Horst, Duffin et al CDAJ 2018

Some cavities continue to grow

arrested

What to watch for:

active growing

@ 6 months.

45% 35% 20%

3y10m

3 treatments

+9 months

+2 treatments

+6 months+1 treatment

+6 months

5y10m

Topical arrest@ 2years: 0 new cavities

4/30/19

18

3y10m

3 treatments

+9 months

+2 treatments

+6 months+1 treatment

+6 months

5y10m

Topical arrest@ 2years: 0 new cavities

3 treatments

+9 months

@ 2years: 0 new cavities

Topical arrest

3y10m

5y10m

3y10m

3 treatments

+9 months

Topical arrest

5y10m

@ 2years: 0 new cavities

4/30/19

19

arrested

What to watch for:

active growing

@ 6 months.

45% 35% 20%

Ca

rie

s A

rre

st

in k

ids

6mo 18mo

SDF Outline _



3. SDF mechanisms

4. Glass ionomer

5. Hall crowns

4/30/19

20

Hamama, Aust Dent J 2015

SDF chases bugs

down into tubules

SDF: sustained antimicrobial effects

– Treated dentin resists plaque formation.

– demineralized dentin resists more.

– Zombie Effect: Silver-killed bugs kill active bugs.

• Ideal substantivity.

0

1

2

−2 −1 0 1 2

log2(groupB

groupA)

−lo

g1

0(p

.va

lue

)

FDR<0.05

|logFC|>2

both

Caries legions after treatment

resistance genes

No changes

metagenomic

NextGen Sequencing

Milgrom + Horst et al. J Dent, 2018

●

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●

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● ●

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●●●● ●●●● ●● ●●● ●● ●

●●●● ● ●●● ● ●● ●● ●●

●●

● ●●

●●

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●

●

●

●

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●

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●

●

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●●● ● ●●●●

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●

●●

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●

●● ●● ● ●● ●● ●●● ●●● ● ●● ●●●●●● ●● ●●● ●●●●● ●●●●●●● ●●● ●●●●● ●● ●● ●●●● ●●●● ●●● ● ●●● ●●● ●●●●●● ●● ●●●●●●●●● ●●● ●●●● ●●● ● ●● ●●● ●●● ●●● ●●●● ●●● ●●● ●●●●● ●●●●●●●● ●●●● ●●● ●●●● ●●● ●●●●●●●●●●●●●●●●●●●●●

● ●●●●●●●●●●●●● ●●

●●●●●

●●●●●●●●●

●●●●●●● ●●●●●●●●●●●●●●●●●●

−15 −10 −5 0 5 10 15

02

46

log2FoldChange

−lo

g1

0(p

va

lue

)

●

●

●

●

●

●

●

●●

●

●

●●

●●

●

●●

●●●

●

●●

●●

●●● ●●

●●● ●●●●

●

●

●Lactobacillus reuteri

Acidithiobacillus caldus

Sulfuriferula sp. AH1

●

●

●

FDR<0.01

|LogFC|>2

both

Lactobacillus

reuteri

Sulfuriferula sp. AH1

Acidithiobacillus caldus

failure

-1 0 1 2 3

log2FoldChange

PropionibacteriumStreptococcus mutans

FDR<0.05

|LogFC|>1

3

Streptococcus

mutans

microbes

4/30/19

21

SDF microstructures

SDF casts silver rebar millimeters into dentin,

reinforcing the lesion and sustaining kill.

Seto, Horst, Frachella, Duffin, MacLean

Silver wires in

dentinal tubules

Seto, Horst,

Frachella, Duffin

SDF penetration testing

Seto, Horst

4/30/19

22

Before10 minutes1 hour

kinetics of SDF penetration

Seto, Horst, Frachella, Duffin

Kitchen SMARTs

with Drs. Steve Duffin & John Frachella

Horst, Seto, Frachella, Duffin

4/30/19

23

SDF Outline _

1. SDF – history & status

2. SDF clinical evidence

3. SDF mechanisms

SDF pro tips

1. 3x in 2 weeks.- Dr. Steve Duffin

2. Cover immediately with varnish.- Dr. Steve Duffin

3. Superfloss to soak posterior interproximals.- Dr. Jason Hirsch

4. Vaseline on lips & skin, toothpaste on tongue,

scented lip balm under nose.

- Dr. Jeanette MacLean

5. Cover it with GIC

- Drs. John Frachella & Cate Quas

SDF take-homes

1. Arrests 81% of lesions when used 1+/year.

2. Prevents 62% of new lesions.

3. Dry before use.

4. Safe.

5. Stains the crap out of everything.

4/30/19

24

When would you use it?

UCSF Indications:

1. Extreme caries risk (Xerostomia, S-ECC)

2. Behavior or Medical management

challenges.

3. More lesions than treatable at 1 visit.

4. Difficult to treat lesions.

5. Patients without access to care.

SDF Outline _



3. SDF mechanisms

4. Glass ionomer

5. Hall crowns

Locker...Kay, Br Dent J 195:375

What about Sealants?

71% prevention on treated surfaces

4/30/19

25

Mickenautsch & Yengopal PLoS One 2016

2 years

3 years

4 years

5 years

Beiruti 2006 n=315

Chen 2012 n=867

Liu 2014 n=357

Hilgert 2015 n=203

Beiruti 2006 n=292

Oba 2009 n=137

Hilgert 2015 n=171

Beiruti 2006 n=266

Zhang 2014 n=741

Beiruti 2006 n=156

Barja 2009 n=49

GIC sealants vs Resin sealants???

Does a sealant here prevent caries here?

2,557 7yo,

2.5 years in Italy

Cagetti J Dent Res 2014

0.610.72

0.94

0

1

2

GIC Flu oride Res in Re sin

Ne

w c

ari

es

on

dis

tal

of

2n

d p

rim

ari

es

**

Choice of HV-GIC.

Fuji Equia = Fuji IX. Working time: 2 min. Set time: 4:20 min (total).

Tap, plunge, click once in gun, mix 10s.

Fuji Equia Forte (GC). Working time: 1:15 min. Set time 3:45 min.

Riva self-cure HV (SDI). Working time: 1:30 min. Set time: 5:00 min. Tap, depress, DO NOT CLICK, mix 10s.

Ketac Universal / Molar (3M ESPE). Working time: 3:00 min. Set time: 7:00 min.

Tap, depress, click in activator for 3s, mix 10s.

4/30/19

26

Choice of HV-GIC.

NO!!!

You’ve got 45s to stop messing with it.

Control the moisture.

Then after the SETTING time, drill with

copious water IFF necessary.

Where’s the margin?

Courtesy of Rella Christensen

4/30/19

27

Amalgam

Original Magnification 300x

[Powerpoint and projectors affect magnification]

Courtesy of Brian Novy

Results

composite




Glass ionomer




4/30/19

28


Glass ionomer





4/30/19

29

GI margin

Glass Ionomer Critical pH

~5.6

Hydroxyapatite Critical pH

~5.5


Seal over caries with GIC

“sealants can prevent the progression of early noncavitated

carious lesions.”

“These clinical recommendations... include use of a glass

ionomer cement material”


4/30/19

30

pre-operative 6 years 10 years

JADA 1998, 129:55

10 year follow up of 170 paired molars(n=312 at start)

0

1

2

3

4

5

0 1 2 3 4 5 6

F R

ele

ase

(p

pm

)

Months

RelyX Luting Plus (RMGI)

Fuji Cem 2 (RMGI)

CX-Plus (GI)

Fuji Plus (RMGI)

Ketac CEM Maxicap (GI)

Fuji I (GI)

F Release – Cements November 2014 - April 2015

Courtesy Rella Christensen, PhD

TRAC Research; Provo, UT

4/30/19

31

0

1

2

3

4

5

0 1 2 3 4 5 6

F R

ele

ase

(p

pm

)

Months

RelyX Luting Plus (RMGI)

Fuji Cem 2 (RMGI)

CX-Plus (GI)

Fuji Plus (RMGI)

Ketac CEM Maxicap (GI)

Fuji I (GI)

F Release – Cements November 2014 - April 2015

Courtesy Rella Christensen, PhD

TRAC Research; Provo, UT

SDF + GIC: silver modified ART

SMART

• Glass Ionomer Cements (GICs) add the benefit of

sustained fluoride release and a seal!

• Protocol: SDF, then standard GIC protocol.

Drs. John Frachella & Cate Quas

(they darken over time)

SMART armamentarium

4/30/19

32

SDF + GIC/ART = SMART

Dr. Steve Duffin

SDF + GIC/ART = SMART

SMART retention

Drs. John Frachella & Steve Duffin

4/30/19

33

GIC stain by SDF

SDF + GIC

Fuji 2LC

1 month

SDF + GIC

Fuji 9

1 month

3x SDF

no-prep GIC

Shofu Beautifil

2 weeks

Dr. John Frachella

SMART

Dr. Jason Hirsch

Elizabeth Ng, me, Stefan Habelitz, & Karen Shultze

4/30/19

34

SDF Outline _



3. SDF mechanisms

4. Glass ionomer

5. Hall crowns

4/30/19

35

Hall crown technique

BMC Oral Health 7:18

Hall technique

no preparation SSCs

4/30/19

36

success

Indicators of success

failure

Innes, J Dent Res 2011

Hall crown Clinical Trial in UK

General dentists, 4 year follow up

0

0.2

0.4

0.6

0.8

1

Hall Conventional

proportion

nofailures minorfailures majorfailure130 kids

4/30/19

37

Hall crown Clinical Trial in Germany

treatment by Pediatric dentists, 2.5 year f/u

Santamaria et al., 2017

148 kids

Craig & Powell, 2013

NRCT

Non-restorative

caries therapy

0%

20%

40%

60%

80%

100 %

Hall NR CT Co nvent ion al

pro

po

rtio

n (

%)

no fai lur es minor failures major failu re

1.00

0.98

0.96

0.94

0.92

0.90

0.88

0.86

0.84

0.82

0.80

0

1

2

2 4

117 98

1167

SU

RV

IVA

L P

RO

BA

BIL

ITY

Years

JADA 2014

Halls in the USA

6 Hall crowns

vanderZee & vanAmerongen 2010

0

0.5

1

1.5

2

2.5

3

-1 7 15 23

canineoverlap(mm)

dayspost-treatment

48 kids

The high bite self-adjusts

4/30/19

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preference

Innes, J Dent Res 2011

The Hall Technique A minimal intervention, child centred approach to managing the carious primary molar

A Users Manual Version 4

Text copyright Nicola Innes, Dafydd Evans, Matthew Stewart, Alex Keightley

wikipedia.org/wiki/Hall_Technique

4/30/19

39

SDF Outline _



3. SDF mechanisms

4. Glass ionomer

5. Hall crowns

THANK YOU

You can get these slides and more at:

http:// bit.ly / DrJeremy

Watch the SDF video any time:

youtube.com/watch?v=zUAJkqcItco

My email:

jahorst @ gmail.com

4/30/19

40

Chu et al, BMC Res Notes 2014

Restoration stain by SDF

SDF + GIC

Fuji 2LC

1 month

SDF + GIC

Fuji 9

1 month

3x SDF

no-prep GIC

Shofu Beautifil

2 weeks

Dr. John Frachella

The paradox of covering

Lesion (GIC)

• seal stops progression

• seal may seal in SDF

• GIC prevents lesions

nearby

• GIC needs less frequent

reapplication

• Small lesions may not

retain GIC

Mouth (SDF)

- SDF prevents lesions

throughout

- SDF needs more

applications

- SDF is cheaper

- SDF is less technique

sensitive

- Deep lesions may

progress

4/30/19

41

1 1 2 1 1, E.C.M. Lo1 1

Gao et al., JDR Clin 2016

Personnel

• The only safety study in children used RDH-EPs.

• Dental boards ruled to let Hygienists place SDF:

AK, CO, FL, GA, HI, ID, NM, MD, ME, MT, NH, NV, OR, WA.

• Dental boards ruled to let Assistants place SDF:

Yes: ID, NV. No: CO.

• Most states are proceeding without a formal ruling,

treating SDF as a topical fluoride.

• Some states require CE.

• In my 6 years of private practice use, I commonly

have properly trained RDAs place SDF.

4/30/19 medical models of caries forthemoderndentalpractice

Documents