Answers to 12 of Your Questions About Caries Management

Avoiding a “one-size-fits-all” approach to caries management is critical as new evidence, new treatments, and new innovations continue to develop and shape the way dental teams manage the disease.

CareQuest Institute, in collaboration with Kansas City University and the American Association of Public Health Dentistry, held a webinar, “Managing Dental Caries: Evolving Strategies and Proven Techniques,” where experts shared various strategies for managing dental caries and provided guidance on nonsurgical and nonrestorative protocols and implementation.

But because the webinar was only 60 minutes, those experts — Sandra Guzman-Armstrong, DDS, MS, clinical professor and advanced education program director at the University of Iowa College of Dentistry and Dental Clinics; John Frachella, DMD, a pediatric dental consultant; and Erinne Kennedy, DMD, MPH, MMSc, assistant dean for curriculum and integrated learning, College of Dental Medicine, Kansas City University — didn’t have time to answer all the questions surrounding the topic.

As a bonus for webinar participants and a resource for anyone interested in caries management, the speakers took the time to answer those questions after the event:

1. Is there a concern about occlusion when using the Hall technique on children?
   
   No, there is no concern. The Hall technique is designed for children. There are plenty of studies showing that the occlusion self-resolves, and that children, parents, and dental teams prefer the experience over traditional restorations. The Hall technique temporarily opens the bite. Some dental teams advise that the child should have soft foods for about three to four weeks afterward and pay attention to their diet. Kids get used to it while the high occlusion of Hall self-resolves, but the bite will not self-resolve in adults. To be clear, on kids, even into the mixed detention, not just in a 100% primary dentition, it self-resolves.
    
2. Is the Hall technique (and similar techniques) considered a procedure that registered dental hygienists (RDH) can do?
   
   Dental hygienists should consult their state’s dental practice act to determine which procedures are allowed within their scope of practice. While some states permit dental hygienists to place certain types of restorations, it's essential to note that regulations vary by state. For instance, while the Hall technique may not necessitate the removal of tooth structure, guidelines regarding its application by dental hygienists may vary by state.
    
3. Are hygienists permitted to place glass ionomer sealants if they are permitted to place resin sealants?
   
   Absolutely, yes. Hygienists are permitted because the CDT code book identifies glass ionomer as “composite” because glass ionomer is a “composite of materials.” Thus, glass ionomer sealants (whether pure glass ionomer cement or resin-modified glass ionomers) are equal to resin sealants, according to the American Dental Association (ADA). The Centers for Disease Control and Prevention (CDC) sealant programs recently opened to use glass ionomer as well.
    
4. For glass ionomer sealants, we know this releases fluoride but for how long? Is it days, weeks, months, years?
   
   Glass ionomer sealants are like a car battery. They leech out their energy, and they need to be recharged. Using fluoride toothpaste is always a good idea for a lot of reasons, but one is that it recharges the glass ionomer sealants. It’s going to get in there, the glass ionomer recharges, and then it releases and continues to release. Studies show this fluoride reabsorption and release continues for years.
    
5. When we place glass ionomer sealants, should we disinfect the occlusals before sealing?
   
   Use povidone-iodine as opposed to SDF as a disinfectant before glass ionomer sealants because it won’t stain.
    
6. Should SDF be followed with fluoride varnish? Or is this not necessary?
   
   Combination therapy with caries arresting and preventive treatments like SDF and fluoride varnish work better than single-agent therapies used alone in all the current trials. Reported outcomes in studies of SDF and fluoride varnish together have better outcomes than when SDF is used alone. Most notably, studies by Steve Duffin, DDS (Journal of the California Dental Association, 2012), and Margherita Fontana, DDS, PhD, and colleagues (Journal of the Canadian Dental Association, 2020) show 96% of caries arrest with SDF and fluoride varnish, which is much higher than in trials with SDF used alone (though they were not compared to SDF-only or fluoride varnish-only groups). To be clear, we do not need the fluoride varnish for “more fluoride,” but it seems very useful to 1) protect the SDF from immediate dilution by saliva because SDF arrest has been shown in trials to be directly related to Ag+ ion concentration. And, as a bonus, 2) fluoride varnish helps mask the taste of SDF. Trials on toxicity show no danger of fluoride toxicity with SDF and fluoride varnish in children or adults.
    
7. What about applying povidone-iodine before sealing?
   
   Why not, and why not all the way upstream for infants? Remember though, it’s not just povidone-iodine that does the magic, it’s iodine and fluoride prevention combination therapy that has the best outcomes for prevention. But don’t use fluoride varnish after povidone-iodine if using the povidone-iodine to disinfect before the glass ionomer sealants because the fluoride varnish will adversely affect glass ionomer sealant adhesion.
    
8. Can you discuss the application of SDF on adults in more detail?
   
   You can use SDF in root caries and areas that are cleansable. I would not recommend use in cavitations under crown margins because the patient cannot keep the surface clean, and SDF would not have the same efficiency. You can apply SDF to root surfaces of teeth that you cannot restore for many reasons (the patient is medically and/or mentally compromised, has financial concerns, is having an interim restoration while waiting to go back for further restorations, etc.).
    
9. Why are we still promoting resin-sealing white spot lesions (WSL)? Is there any research on the ability of the tooth to be remineralized years after the infusion?
   
   There does not appear to be any health benefit for using resin over glass ionomer for sealing WSL (initial caries lesions). One large clinical trial (Cagetti and colleagues, 2014) shows one-third fewer new cavities on nearby teeth when using glass ionomer instead of resin. We do not know of studies assessing remineralization under resin sealants, but there are plenty of studies showing that sealing initial lesions with glass ionomer cement or resin-modified glass ionomer (RMGI) prevents cavitation.
   
   To be able to remineralize a WSL, we need time and compliance from the patient. If we seal an occlusal WSL, it will arrest without the need to depend on the compliance of the patient. Even if SDF is used to remineralize, the patient needs to remove plaque and be compliant with hygiene and biofilm removal, so sealants are a very good material to arrest the lesion.|
    
10. Are there any good patient education videos that we could show on a tablet or phone that are brief? Because this is new, sometimes there’s inconsistent messaging from various team members, and having something standardized and well-made would be super helpful.

    

    
    This is a helpful resource related to SDF.
    
    If you're looking to learn more about Silver Modified Atraumatic Restorative Treatment (SMART), this resource can help. And check out this resource on the Hall technique if you'd like to learn more about that.
    
    Lastly, we should highlight the resource (for providers) that we mentioned several times during the webinar: The Non-Invasive Caries Therapy Guide.
     
11. What about payment for these treatments? Does Medicare/Medicaid pay? Or is that a hurdle, too?
    
    It’s a hurdle, too. We need to advocate on all fronts, including private insurance and Medicaid. Keep in mind that state-to-state differences in payment are hugely varied. The new CPT code for use of SDF by medical teams opens a new dimension for reimbursement.
     
12. It's challenging to get my practice to buy-in and deliver minimally invasive care. Do you have any tips?
    
    Guess who it is not hard to get buy-in from? Patients. It is not hard to get buy-in from the parents who watch you treat their children and then say, “Wait a minute. I know you’re a children’s dentist, but won’t you treat me? And won’t you treat my neighbors?” The buy-in that we’re not getting is from dentists. Well, that’s the problem.
    
    The patients are the ones who end up paying if there’s any extra payments. And when you educate the patient, and when there is clear information on what the benefits are of prevention, the patients will go for it. I think you need to take the time to not only educate the patients but also educate your entire team. It’s your hygienist, it’s your assistants, it’s your manager; they should be in tune with the whole philosophy more than anyone else.
    
    So, you’re losing time because you need to do that education, which is critical. But you gain that time in spades on the other end by being able to treat so many more patients, adults, and children, in the same amount of time because you’re not waiting for teeth to get numb, you’re not behavior managing the kid that’s crying, you’re not having to make the decision to send them to the hospital. No, you’re putting a person in the office because you’re going to have to hire somebody to cancel all those dental general anesthesia appointments. I’m not saying you’re going to eliminate them. We aren’t taking anything out of the toolbox. But what we’re trying to do is use the right tools for the right jobs.
    
    Editor’s Note: To view the full recording of the webinar, “Managing Dental Caries: Evolving Strategies and Proven Techniques,” visit the CareQuest Institute webinar library.