Tim Wright, DDS, MS Bawden Distinguished Professor Department of Pediatric Dentistry School of Dentistry University of North Carolina Chapel Hill, NC Catherine Hayes, DMD, SM, DrMedSC Public Health Consultant Better Oral Health for Massachusetts Coalition Boston, MA Robert J. Weyant, MS, DMD, DrPh Professor, Chair, and Associate Dean for Dental Public Health and Community Outreach University of Pittsburgh School of Dental Medicine Pittsburgh, PA Julie Frantsve Hawley, RDH, PhD Executive Director American Association of Public Health Dentistry Springfield, IL Copyright ª 2015 American Dental Association. All rights reserved.

1. Wright JT, Graham F, Hayes C, et al. A systematic review of oral health outcomes produced by dental teams incorporating midlevel providers. JADA. 2013;144(1):75-91.

Author’s response: My thanks to Dr. Wright and his colleagues for their letter regarding my systematic review on midlevel providers. I agree with their assessment that the available evidence shows that in populations served by teams including midlevel providers, there is a reduction in untreated caries. As they summarize in their letter, the quality of the evidence supporting all their systematic review’s conclusions was poor. Their main point seems to be that I stated that the effect of midlevel providers on overall oral health remains unclear. I reached the conclusion based on their assessment of the quality of the studies included in their review. However, I think we all agree that higher-quality studies are needed to have a better level of certainty in our conclusions. Rebecca Schaffer, DDS, FAPD Adjunct Faculty Member

Arizona School of Dentistry and Oral Health Mesa, AZ Copyright ª 2015 American Dental Association. All rights reserved.


I read Dr. Ludwig and colleague’s December JADA retrospective study, “The Success of Stainless Steel Crowns Placed With the Hall Technique” (Ludwig KH, Fontana M, Vinson LA, Platt JA, Dean JA. JADA. 2014;145[12]:1248-1253), with much interest. The authors conducted a retrospective chart review of teeth treated with stainless steel crowns (SSCs) between 2003 and 2013 (exclusively using the Hall technique starting in 2010). They found that 97% of SSCs treated with the Hall technique were successful when compared with 94% of SSCs that were placed conventionally. Also, of the SSCs placed with the Hall technique, none resulted in harmful symptoms, whereas 5 of the SSCs placed by conventional means failed due to infection. The authors also mention the proven effectiveness of glass ionomer cement (GIC) placed directly over carious dentin. It is well known that large amounts of fluoride are released from certain formulations of GIC into teeth.1 That is why GIC over caries without excavation has been endorsed by the American Academy of Pediatric Dentistry (AAPD) and given the name of Interim Therapeutic Restoration (ITR).2 I have been modifying the AAPD ITR protocol by applying silver diamine fluoride (SDF) to decayed enamel and dentin before applying high fluoride–releasing GIC because SDF has been shown in vitro to inhibit Streptococcus mutans growth as well as the metabolic activity of plaque as well as caries depth progression. In vivo, SDF has been shown to inhibit the lateral spread of caries as well as occlusal and interproximal caries.3,4

Thus, it occurred to me that combining the calcifying effect of fluoride-releasing GICs with the microbe-deterring effect of SDF might prove to be additively beneficial. For instance, modifying the Hall technique by applying SDF to decayed dentin first, before placing SSCs with GIC, could possibly result in even greater successes than those experienced with the use of GIC alone. Presently, I am part of pilot studies being conducted by microbiologists to determine if the combination of silver solutions with GIC restorations can slow or even stop the progression of caries. If it is proven that it can, we may be able to rescue hundreds of thousands of decayed teeth from being lost to infection and pain for pennies on the dollar for whole populations of children in America and around the world who need our help the most. There’s only a certain amount of money available to treat tooth decay in Medicaid children. Because we cannot afford to do everything for everyone, perhaps silver solutions used together with GIC in restorative protocols can help change outcomes for the better with the potentially increased effectiveness achieved by combining 2 low-cost preventive materials and protocols. Also of note, the US Food and Drug Administration approved the sale and use of SDF in the United States in 2014.5,6 The Oregon Dental Board ruled in 2014 that Expanded Function Dental Assistant–certified dental auxiliaries can apply SDF as a “fluoride” under the supervision of dentists.7 Furthermore, the ADA and other Code Maintenance Committee members recently met to consider a new topical fluoride procedure code for inclusion in the Code on Dental Procedures and Nomenclature. The committee’s discussion noted use of silver nitrate and SDF as components of this procedure. Discussion concluded with the committee approving a CDT Code addition that would be effective in

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2016 (Peter Milgrom, DDS, University at Washington, e-mail communication, March 2015). We could be on the verge of witnessing big changes in our ability to slow the epidemic of caries observed in the overseas Third World as well the epidemic of caries seen in the Third World of “Medicaid reality” that exists in our own backyards. John C. Frachella, DMD Fossil, OR Copyright ª 2015 American Dental Association. All rights reserved.

1. Berg JH. Glass ionomer cements. Pediatr Dent. 2002;24(5):430-438. 2. Council on Clinical Affairs, American Academy of Pediatric Dentistry. Policy on Interim Therapeutic Restorations (ITR). Adopted 2001, revised 2004, 2008, 2013. AAPD Reference Manual. 36(6):48-49. Available at: P_ITR.pdf. Accessed May 8, 2015. 3. Mei ML, Li QL, Chu CH, Lo EC, Samaranayake LP. Antibacterial effects of silver diamine fluoride on multi-species cariogenic biofilm on caries. Ann Clin Microbial Antimicrob. 2013;12:4. 4. Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: a caries “silver-fluoride bullet”. J Dent Res. 2009;88(2):116-125. 5. Domino M. FDA’s reclassification of SDF as a fluoride could mean new treatment options. Available at: http://www.¼ser&sub¼def& pag¼dis&ItemID¼317026. Accessed May 8, 2015. 6. Department of Health and Human Services, Food and Drug Administration. Indications For Use, Silver Dental Arrest. July 31, 2014. Available at: http://www.accessdata.fda. gov/cdrh_docs/pdf10/K102973.pdf. Accessed May 8, 2015. 7. Oregon Board of Dentistry. Minutes, December 19, 2014. Available at: http://www.oregon. gov/dentistry/docs/Minutes/BrdMtgMinutes2 0141219.pdf. Accessed April 3, 2015.

Kevin H. Ludwig, DDS Pediatric Dentist South Bend, IN

Authors’ response: We would like to thank Dr. Frachella for his letter regarding our article on stainless steel crowns placed with the Hall technique, and we’re pleased with his interest in our article. Most of his letter discusses the work that he has done with silver diamine fluoride, but he does suggest that silver diamine fluoride might enhance the success rate of the Hall technique. Certainly

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this might be possible, and it could be added to the list of other questions needing to be answered regarding the use of the Hall technique. Having said that, the use of silver diamine fluoride could also be used with the traditional stainless steel crown preparation technique, as well as other restorative techniques, to see if it will enhance success rates. Although the success rate of stainless steel crowns is very high as it is, whether they are placed with the traditional or the Hall technique, anything that might increase the success rate further would be welcomed. The impact of silver diamine fluoride on the performance of restorative materials such as glass ionomer cements is not fully understood, and of course that raises other questions to be answered by research. His concluding comments that “We could be on the verge of witnessing big changes in our ability to slow the epidemic of caries .” is an interesting statement. We hope that is true, but we do not believe that restorative techniques will do much in the way of slowing the epidemic of caries. Restorations do little to prevent or cure the disease of caries. We must focus on stronger methods to address the social determinants on oral disease in children before we actually see a worldwide change in caries prevalence.1 Until then, continuing to refine our restorative techniques and preserving tooth structure will be of value.

Margherita Fontana, DDS, PhD Professor Department of Cariology Restorative Sciences and Endodontics School of Dentistry University of Michigan Ann Arbor, MI LaQuia A. Vinson, DDS, MPH Clinical Assistant Professor Department of Pediatric Dentistry School of Dentistry Indiana University Indianapolis, IN

July 2015

Jeffrey A. Platt, DDS, MS Associate Professor of Dental Materials and Ralph W. Phillips Scholar in Dental Materials School of Dentistry Indiana University Indianapolis, IN Jeffrey A. Dean, DDS, MSD Ralph E. McDonald Professor of Pediatric Dentistry and Professor of Orthodontics School of Dentistry Indiana University and Riley Hospital for Children Indianapolis, IN Copyright ª 2015 American Dental Association. All rights reserved.

1. Casamassimo PS, Lee JY, Marazita ML, Milgrom P, Chi DL, Divaris K. Improving children’s oral health: an interdisciplinary research framework [published online ahead of print Aug. 13, 2014]. J Dent Res. 2014;93(10):938-942. http://


In January JADA’s Ethical Moment, “Dealing With Good Intentions That Go Bad” (JADA. 2015;146[1]:70, 72), Dr. Darryll Beard described a dentist concerned about several patients who recently transferred from the same dental facility. The patients’ stories were similar, and evidently all were unsatisfied with their treatment. An example given was a patient who made many visits over an 18-month period for a particular tooth that was finally extracted. Dr. Beard cited several sections of the American Dental Association Principles of Ethics and Code of Professional Conduct related this patient’s predicament: l.A, Patient Autonomy (“self-govemance”), 2.B, Nonmaleficence (“do no harm”), 3, Beneficence (“do good”), and 5.A, Veracity (“truthfulness”).1 Another principle to consider is 4.C, Justice (“fairness”). Justifiable Criticism. Dentists shall be obliged to report to the appropriate reviewing agency as determined by the local component or constituent society instances of gross or continual faulty treatment by other dentists.1

Stainless steel crowns.

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