	With an endodontic-periodontic practice in West Los Angeles, Dr. Bernice Ko is well aware of the importance of having the best endodontic tools at her fingertips. That’s why she incorporated the KaVo Kerr Traverse™ Orifice and Glide Path File solution into her practice in the spring of 2019.

	Designed to make forming the glide path easier, the nickel titanium rotary file is said to reduce time and manual labor while improving the efficiency of endodontic procedures. There are often challenges when establishing the glide path using stainless steel hand files, but Dr. Ko lists the sizes of the Traverse files among the product’s many benefits.

	“They’re uniquely sized .13/06 for small canals and .18/06 for large canals,” she says. “This allows an uncomplicated, effortless transition from a #10 hand file to a rotary shaping file.”

	The Traverse files streamline the process of glide path creation, enabling Dr. Ko to deliver successful endodontic treatments more efficiently. A triangular cross section allows for greater cutting efficiency.

	“The non-cutting tip with variable heat treatment enhances superior flexibility with stable torsional strength,” says Dr. Ko, who first implemented the Traverse files into her practice in April 2019. “This allows smooth navigation through tight constraints and curved canals while minimizing transportation. Also, the maximum flute diameter minimizes excessive removal of coronal dentin during glide path creation.”

	Additional features noted by Dr. Ko include:

		Allows preservation of sound tooth structure

		The triangular cross-section retains file cutting efficiency to improve the clinician’s efficiency and allows less procedure time

	The Traverse files allow reduced risk of cross-contamination with single-use recommendation only, and are readily available, says Dr. Ko, who received her DDS and her postgraduate training in Hospital Dentistry and Endodontics at UCLA.

	As previously stated, using the Traverse files benefits the practice by increasing efficiency in endodontic procedures. This reduces procedure time and manual labor, which is a plus for both the clinician and the patient.

	“The Traverse Glide Path Files allow significantly less file inventory and manual labor. This allows less procedure time and improved patient comfort,” adds Dr. Ko, who is a Diplomate of the American Board of Endodontics and is a lecturer with the Section of Endodontics and Special Patient Care at UCLA. “Traverse Glide Path Files are well-designed, user-friendly and engineered with all the safety features to enable a very smooth transition to a rotary shaping file while eliminating the manual labor of traditional hand filing using multiple files.”

	Dr. Bernice Ko is a paid consultant for KaVo Kerr. The opinions expressed in this interview are those of Dr. Ko. 

	KaVo Kerr is a medical device manufacturer and does not dispense medical advice. Clinicians should use their own professional judgement in treatment of their patients. 

	Additionally, Dr. Ko was interviewed by Dental Products Report for a Closer Look article on the elements™ e-motion endodontic motor that was published in September. The above discloser was inadvertently left out of that article. To read this article online, go to 

http://www.dentalproductsreport.com/view/power-provide-quality-treatment

	Traverse is a rotary glide path file designed to simplify the process of establishing the glide path in root canal treatment. Its advanced technology helps enhance the procedural technique by creating a more tapered glide path that reduces the workload of the shaping files. In addition, Traverse reduces procedure time and manual labor when compared to traditional hand filing, resulting in improved efficiency. The nickel titanium file is engineered with a triangular cross-section for better cutting efficiency and Variable Heat Treatment technology for greater flexibility and strength. 

Articles

Quicker, efficient glide path forming for dentists

	With the Osstell Beacon, clinicians can measure implant stability and know exactly when an implant is suitably osseointegrated to support the planned restoration.

	Determining when to restore an implant can be a guessing game. It is difficult to know when an implant is integrated and stable enough to support the load of a restoration.

		Designed to help objectively and non-invasively determine implant stability in a matter of seconds

		The RFA (Resonance Frequency Analysis) technology used to determine the Implant Stability Quotient (ISQ) has been validated in more than 1,000 studies

		Provides a numerical and color-coded assessment of stability for a quick assessment of when the implant is ready to support a restoration

		Measuring implant stability can shorten treatment times and help drive more predictable treatment success

		ISQ can be used to determine when to place a temporary restoration and when to replace that with the final restoration

Solve My Problem: Know when implants are ready to be restored with Osstell Beacon

	The STATCLAVE G4 from SciCan aims to provide the room to sterilize the instruments of a busy practice, the efficiency to process them quickly, and the connectivity to provide practices with peace of mind. 

	Sterilization takes too long and doesn’t completely dry instruments  

	Dental sterilizers can operate with long process cycles and even longer drying cycles that can keep instruments out of service when they are needed.

		A Class B vacuum sterilizer, it features pre-sterilization vacuum for enhanced steam penetration and post-sterilization vacuum for enhanced drying Designed for fast processing, the STATCLAVE G4 can sterilize and dry wrapped instruments in as little as 38 minutes

		Closed-door drying and vacuum technology work to ensure every load is dried completely

		The unit can sterilize up to four full-size cassettes, four exam cassettes or up to 20 pouches in its 11-inch chamber

		A part of SciCan’s G4 line, the sterilizer can connect to the internet and send cycle data and notifications to smart devices

		The system is designed to use fresh water every cycle to reduce oil and debris buildup

		The unit is designed to be versatile to fit into any practice’s stericenter with a variety of filling and draining set up options

Solve My Problem: SciCan's STATCLAVE G4 – A sterilizer with speed, capacity, and connectivity

 it is an exciting time to be a dentist. Upon graduating from dental school, I had the advantage of joining a state-of-the-art, high tech dental office that emphasized quality of work, which in turn made me into the continuing education and technology aficionado I am today.

	One focus of my first orthodontics class was to discover the types of information patients would be seeking regarding orthodontics and how to properly address their concerns. Ten years later, I believe understanding the “why” of orthodontics helped to establish my career. I evolved into being a restorative dentist who ensures I am working with a solid infrastructure. Foundation first, then build the rest of the house. 

	The majority of my downtown Denver patient population is comprised of busy professionals who have both high demands and very little time. They want their Instagram-ready smile makeover by “tomorrow” and have usually shopped around by the time I actually see them for a consult. I start each consult by stating “I want you to make decisions knowing what I know.” I want them to make the best choices that fit their lifestyle, while having as much information about options and treatments as possible.

	When I say, “I want to ensure you get the best possible result,” even in the light of my “informational talk,” they immediately ask, “How long?” The bottom line is they have already done their research on dentists who will provide a reasonable price, modern technology, and fastest completion time, so I must provide all three. 

	Two technologies that allow me to fulfill their wish for faster treatment are Propel’s combination of micro-osteoperforations (MOPs

) and high frequency vibration. The concept of MOPs is fascinating, and the research makes sense. Micro-osteoperforations are tiny perforations along the patient’s gumline made with a Propel Excellerator

 series driver. These MOPs activate a cytokine cascade which increases osteoclast activity and accelerates bone remodeling. As orthodontic forces are applied, teeth can move more easily through remodeling areas. The result is faster, more predictable movements. 

	While the MOPs accelerate the bone remodeling, the VPro High Frequency Vibration (HFV) device activates the biology causing a reduction in treatment time by up to 64%,

 obtunds pain and assures ultimate aligner seating. The sum of these advantages also increases predictability. I personally use VPro to help accelerate treatment as well as to facilitate seating of aligner trays.

	In my experience, the high frequency vibration also increases comfort for patients-my patients who use VPro report less discomfort as they progress through aligner tray changes. As for the retention, studies showing the effects on the alveolar bone in retention make it a tool they can utilize from start to finish. 

	For treatment options I use with these techniques, I offer options of brackets versus clear aligners as well as extraction versus non-extraction. During the consultation, I explain the pros and cons of each. I explain rubber bands and IPR, and the possibility of doing treatment with and without these procedures. I want patients to choose an option they would commit to so we can achieve good results. Of course, I always give patients the option to see an orthodontist first, especially for more complex cases.

	In my practice, the combination of MOPs and VPro allows patients to switch their aligners every 3-7 days, depending on specific needs and to ensure that aligners are tracking consistently. MOPs has been very effective at facilitating the more difficult movements and jump-starting struggling cases all in a short office visit with minimal pain being reported by patients afterwards.

	The VPro ensures proper seating of the aligner, which allows for fewer office visits due to better tracking. It also serves as a pain reducer so my sensitive patients are not relying on pain relievers to get them through the discomfort of advancing trays.

	Some studies note the simultaneous sensory effect of vibration on nerves can cause reduced pain. Personally, I believe the blood flow to the area caused by high frequency vibration is mainly what contributes to this, which is the reason we tell patients not to take anti-inflammatories for pain reduction.

	When I first discovered Propel’s products, I thought solely of acceleration because as mentioned previously, patient demands were all about time. Since incorporating these techniques into my cases, the treatment of complex cases has become more predictable, and that makes me more confident in treating those types of cases. Specifically, I personally think intrusion and crossbite cases are so much more predictable than just using Invisalign

without Propel treatment options. Realizing how predictable some results are can help general dentists be able to more carefully choose the cases they are able to treat and which cases they should refer out to an orthodontist. The value added by incorporating both products into my practice has me looking at orthodontics in a whole new light.  

	This 28-year-old patient presented to our office in April 2018 stating he would be getting married in a year, and he wanted his teeth straightened and whitened prior to the wedding. He had very narrow upper and lower arches with an anterior and premolar cross bite, slightly Class III occlusion bilaterally by 1 mm.

	After evaluating diagnostic models, options were given to the patient with pros and cons. The patient decided to proceed with the extraction of tooth #24. We decided to expand both the upper and lower jaw for a rounder appearance and align as much as possible prior to the wedding, then take attachments off about three weeks before the wedding and refinement after the event. 

	We delivered the first set of trays the end of May and extracted tooth #24 the same day. The patient wore Class III rubber bands for four months, and we completed MOPs at month five to expedite treatment.

	I completed perforations premolar to premolar on maxillary and mandibular areas with one perforation between all teeth at about 3 mm deep, and two perforations mesial and distal of maxillary canines and premolars. We started MOPs and VPro halfway through his treatment because his teeth were not moving as fast as we needed them to if we were to meet his treatment timeline.

	We removed all attachments for the wedding in April and whitened his teeth, using take-home whitening trays and Venus

 products from Kulzer Dental.  At this time, he was Class I bilaterally and had no cross bites. After the wedding, we rescanned his teeth and devised a round of refinements to improve on his overjet and upright anterior teeth, improving on the faciolingual angulations of his anterior teeth and improving on the overjet.

	The patient was very happy about the results for wedding photos and especially impressed with progress of tooth #7. Previously, this tooth was positioned so far palatally that it was hardly visible in a facial view. Prior to the wedding, we did one round of trays, so the total treatment involved 40 trays and one refinement. Figs. 1 to 8 show the before and afters for Juan’s treatment. 

	Daniel, a 23-year-old patient, presented to our office with chief complaint of wanting to align his teeth. He had a Class I occlusion on the right and Class III on the left by 3 mm. He had an overbite of 90 percent; tooth #27 was in cross bite, and tooth #7 was very palatally positioned. His upper midline was 
	2 mm to the left. He had 8 mm crowding on the mandibular and 
	10 mm on the maxillary.

	After evaluating diagnostic models and measuring the jaw size discrepancies, we give patients options of extraction versus no extraction, discussing the pros and cons. After the consultation, the patient decided to extract the premolars. We decided to extract tooth #5 and tooth #28 because his midline was already off, and that would provide enough space for the treatment plan as well as help with aligning the midline. 

	I completed MOPs two weeks after the first aligner delivery, one perforation premolar to premolar, and maxillary and mandibular. That is my protocol, so the patient can become accustomed to the aligners first and then we can add more to process. At that point, I also asked him to start VPro vibration.

	After starting treatment at the beginning of April, Daniel progressed through 40 trays in six months at the time of first refinement. After his 40 trays, he showed great improvement. At that time, we planned to align his midline and fine tune his occlusion. At that point, he still showed crowding and spaces that need to be aligned, and we are correcting those issues while keeping the midline in mind and moving teeth to help us align the midline as well. 

 show the before and afters for Daniel’s treatment.

	This patient, a 32-year-old female, presented to our office in January 2019 stating she might be moving in the summer and wanted to take care of spaces that resulted from congenitally missing laterals before she moved.  She had a molar Class II occlusion bilaterally, 2 mm of crowding on the mandible, and 5 mm of spacing on maxillary.

	After discussing options, we decided to retain the posterior occlusion at Class II and close the anterior spacing and place veneers on tooth #7 and tooth #10. The veneers were purely to make canines look like laterals because the patient expressed her want for this to happen.

	We prepared one round of 18 aligners with MOPs changing trays every five days. We did MOPs on the maxillary mesial and distal of tooth #5 and #3 and tooth #11 and #12 on mandible 23-26. The two perforations on the maxillary and one perforation of the mandible were 3 mm deep. This was followed by whitening and veneers just on time for her to move in July. 

	This patient also used VPro high frequency vibration to ensure the aligners were seating well. Because of the time constraint, she was changing aligners every three days, and they tracked every time.

	Kara specifically wanted me to finish treatment on her timeframe. Due to trust we had built throughout her treatment in the past, timing was very important because the goal was to finish all teeth movement, whitening, and veneers prior to her departure (

	This 30-year-old female patient presented with the chief complaint of crowded teeth but also wanted an implant to replace her missing tooth #19 on her lower left. She had a Class III on the right, and Class II on her left molars. She also had a posterior right crossbite as well as tooth #12 and tooth #14 in cross bite, a 30 percent overbite and overjet of 4 mm. She needed her upper midline centered and lower midline moved 2 mm to the left. Her lower left molars had shifted with very limited space for implant.

	We did MOPs two weeks after the first aligner was delivered, and recommended use of the VPro. I did MOPs on the first premolar to first premolar, all were one perforation. I usually don’t do any perforations on midlines so there were no perforations between tooth #8 and #9 and tooth #24 and #25. She started using VPro at the same time as the MOPs, two weeks after the first aligner.

	After completing her first set of 34 aligners, we planned to do the first refinement. The refinement entailed adding IPR on upper left and lower anteriors to align the midline and to improve on overjet and close posterior occlusion.

	We are at the refinement stage right now after six months, and there is no crossbite on the left, the right-side teeth are end-to-end with slight crowding still present (

	Someone once told me they were amazed by how much I postpone pleasures in life for the sake of doing something “right.” As someone who endured two rounds of braces, I know the end cannot come fast enough! It is extremely satisfying to be able to comfortably tell someone, “Yes, you will have the smile you’ve always dreamed of in time for your wedding.” Or, “Yes, we will have your veneers done right before your upcoming move.” Nothing beats the feeling when I’ve delivered on my promise, and they express their gratitude for changing their life. It’s the reason I became a dentist. 

	1. Alansari S, et al., The Effects Of Brief Daily Vibration On Clear Aligner Orthodontic Treatment, Journal of the World Federation of Orthodontists, Volume 7, Issue 4, December 2018, Pages 134-140 https://doi.org/10.1016/j.ejwf.2018.10.002 

		FDA-cleared high frequency vibration product line proven to accelerate orthodontic tooth movement and increase predictability 
		

		First and only line cleared by the FDA for use in micro-osteoperforation 

		Simple in-office treatment executes challenging movements efficiently 
		
		 

How to increase predictability for faster tooth movement

	I recently had the pleasure of speaking for a practice management software company’s annual meeting in Nashville and the title of that course was “Cybersecurity: What You Don’t Know CAN Hurt You” and I thought that would be an excellent tie-in for this month’s article. 

	Security holes. Unauthorized or outdated users. Unknown devices. Unlicensed software. Ports on your firewall that are open to the internet. These are just a few of the big liability issues that I see on at least 90 percent of the networks that I evaluate. And, this is true even for dental offices that are supposedly monitoring their networks on a regular basis. When is the last time you had a third-party individual or company come into your practice (or remotely) and take an objective look at how your network is configured?

	Many of us in the IT world have switched away from the older break-fix model (you call us when there’s a problem) to the more modern managed services model, where you pay monthly for ongoing services. Break-fix is inherently more costly in the long run for both service and repairs, not to mention putting a dollar value on any downtime that you suffer. But, more importantly, with that older model, there’s nobody that is monitoring your critical network settings that control access to your patient data.

	If you’re one of the many offices that have made the switch to a managed services model, that’s a great first step. But, it still never hurts to have someone who is an expert in HIPAA and cybersecurity take another look. Often, that second set of “eyes and ears” will find things that your regular IT providers might have missed, or at the very least, they can validate if your current IT is using best practices for protecting your data. This is not to suggest your current IT doesn’t know what they are doing-far from it. But, given how complex modern dental networks are and the multitude of things you need to monitor for HIPAA compliance, even the best local IT people can occasionally miss something important.

	The good news is most Office Managers and HIPAA Compliance officers welcome these types of evaluations. In my experience, the local IT company will also normally be receptive to this, if you phrase it in such a way that you’re not looking to replace the services they provide for you but rather, to supplement what they are offering. At the end of the day, you, as the Covered Entity, are ultimately responsible for your entire IT systems-you can’t point the finger at your IT folks if the HIPAA auditors ever come calling.

	The other good news is these scans can often be quick and painless. When we do this for an office, we call it a “tech audit”, it normally takes no more than 20 to 30 minutes and when done, it will give you a treatment plan of where your office isn’t meeting accepted standards for data protection and security. It’s done remotely, we simply run some software on a few computers and ask your staff a few questions to get a clear picture of where you are at. You should not confuse this tech audit, though, with a full-blown risk assessment. Risk assessments normally take at least 4 to 5 hours, not to mention the time needed to then develop a HIPAA Management plan. 

	As HIPAA audits are becoming more common and the fines and penalties rising on a regular basis, you should ask yourself when is the last time you did a network evaluation, and if it’s been longer than six months, what are you waiting for?

Don’t put off your dental practice network evaluation

	Comfort plays a major role in the success of any dental appointment and this is as true for clinicians as it is for patients. While many important pieces of dental equipment help make things more comfortable for patients, and others make things more comfortable for clinicians, it is the patient chair that is (often literally) at the center of the operatory, and it is these chairs that can provide that critical comfort to both clinicians and patients.

	Specialized chairs for dental treatment date back as far as the late 1700s. Features such as integrated instrument trays, and head and foot rests for patients were common on chairs dentists used, and designs allowed chairs to tip backwards to provide easier oral access. Still, the modern dental chair that is so well-known today is actually a 20th century development, as the first chair with a split in the seat and a full recline was invented by Dr. John Naughton in 1958.

	Today dental chairs offer a range of functions and features, as well as an endless selection of upholstery materials and finishes to match any operatory décor or clinician’s sense of style. Today’s dental chairs are designed to provide both patient comfort and ergonomic clinician positioning and access.

	Features can include automated movements and pre-set positions, massage and heat functions for patients, and even integrated delivery systems with connections to clinical software and other systems.

	Numerous chair options are available, but here is a roundup of some of the current models ready to help enhance patient and clinicians comfort.

		An affordable ambidextrous Left/Right Swing Mount package that can be converted easily in the operatory without the use of any tools

		A Hybrid Chair, it features a hydraulic lift for the base movement and electromechanical movement for the backrest

		Designed for versatility and comfort, it features a smooth and ergonomic memory foam upholstery cushion

		The thin backrest and seat are designed for both patient and clinician comfort

			The first U.S. dental chair with built-in Wi-Fi, USB access, and cloud based remote diagnostics

			The chair was designed to provide durability, efficiency, and modern technology at an affordable price

			Features include a thin backrest, simple controls, and time saving features such as four programmable positions, last position, and auto exit functions

			The Marathon chair is available with traditional post mounted or swing operatory packages

A portable dental chair with a foot-activated hydraulic base which provides many of the functions of a fixed chair

				It can be adjusted up and down, as well as swiveling 360 degrees

				Supportive side bolsters and arm slings provide patient comfort and the double articulating headrest allows for optimal patient positioning

				The backrest folds onto the seat and the chair separates into two parts for easier transportation 

				Positionable deluxe plus touchpad dynamically displays only the function being used, for uncomplicated ease of use

				Ambidextrous delivery with the center located handle and screen reachable and visible from either side

				Signature ultra-thin back allows clinicians to work with legs under the patient, elbows at their sides

				Perfect position headrest adjusts with the press of a lever for an optimal view of the oral cavity

				Well-suited for orthodontic and surgical treatments, the Planmeca Chair™ is designed with ergonomic features to provide patients with optimal comfort

				Equipped with a 180-degree swivel function, it can be swiveled 90 degrees to the left and right, ideal for use while capturing X-rays or in small operatories

				Available in two different upholstery options-the Ultra Relax™ with memory foam that adapts to the patient’s body shape or the Comfy™ with thin shape and seamless design that is easy to clean

				Engineered to fit into small spaces, the Traverse Chair is designed to accommodate a rear delivery style with 10 inches of extra space behind the patient

				Designed for ergonomics and comfort, even during long procedures, the chair is fully programmable

				Advanced hydraulic controls provide smooth movements for optimal patient comfort

				The chair is manufactured, assembled, and serviced in the United States and is backed by a 5-year warranty 

				Designed to provide a spa-like experience with plush Ultraleather

				Comes with programmable chair controls and a hydraulic drive system for smooth, quiet operation

				While requiring minimal floor space, the chair offers clinicians an optimal range of motion whether working seated or standing

				Ergonomic features such as the electronic chair lock which prevents the need to repeatedly bend over to lock and unlock the chair are designed to make it as comfortable for clinicians as it is for patients 

A seat at the center of everything – A roundup of dental patient chairs

	Whether you’re a practice owner or dental associate, managing business debt on top of other responsibilities can only add to your stress. If you carry credit card balances or have outstanding business loans, having to deal with multiple balances, payments, and due dates can be time-consuming and costly. Here are five reasons why consolidation could be an easier way to manage your debt. 

	By reducing your monthly liabilities, you may end up with a lower cumulative monthly payment, which means more money stays with you. Having extra cash can help you stay focused on the big picture without worrying about delayed insurance reimbursements, co-pays and deductibles. It can also help you plan better for taxes or rising or unexpected operational costs. Calculate what your potential savings could be and set it aside for another purposes, like practice investments or taxes. With a debt consolidation loan, borrowers know exactly what they’re paying every month, which can enable better financial forecasting. 

	One of the benefits of consolidating your debt is the opportunity to potentially get a better-fixed-interest rate. Compared to having to pay multiple APRs, this can be an additional cost savings. If you’re carrying multiple smaller loans with high interest rates, consolidating your debt into a single loan with a lower interest rate can free up cash for more immediate needs at your practice. You can then take these savings to reinvest back into your practice or profession.

	With consolidation, you no longer have to track multiple due dates. This frees you from having to remember to make several different payments from multiple creditors. With a debt consolidation loan, borrowers only need to make one single payment per month to one account. Merging multiple debts into a single monthly payment also reduces the likelihood of missed payments. This simplicity can make your books easier to keep and help lower your stress.

	Consolidating your debt can potentially help you improve both your personal and business credit score by decreasing your revolving debt and helping you pay down all of your debts in a consistent manner. Credit utilization-the ratio of your balances versus the combined limit across all of your accounts-represents up to 30 percent of your credit score. The cumulative effect of debt consolidation is a lower utilization ratio that lenders prefer-and a potential boost to your score.  

	Multiple debts can mean multiple collateral assignments and restrictions assigned to the business. You can cut that down (and maybe even eliminate it) by consolidating your debt with one lender.  

	As a dental professional, you already have a lot on your mind-and your schedule. If you’re finding it challenging to juggle multiple payments, multiple due dates, and a lack of cash, then debt consolidation might be a good solution for you.

Top 5 Reasons to consolidate your dental business debt

	The incremental layering technique can be very time-consuming, especially when dealing with large cavities

	Additionally, problems can arise when the clinician experiences application errors and insufficient curing of esthetic posterior restorations.

		 Dentists can reduce their treatment time by more than half while achieving the same esthetics and function of traditional 2 mm layered composites

		 The system is comprised of products that are optimally coordinated for direct restorative procedures and designed to enable esthetic, high-quality posterior restorations to be produced with extreme efficiency 

		When light-cured from the occlusal surface with Bluephase PowerCure, the adhesive will polymerize in 3 seconds and each 4 mm layer of composite can be cured in just 3 seconds

 Universal (single-component adhesive), Bluephase

 PowerFlow (sculptable and flowable composites which can be placed in increments up to 4 mm) 

		Bluephase PowerCure is an intelligent curing light that detects unintentional movement of the handpiece during the light-curing procedure

 and AFTC) allow for the efficiency of the composite
		

Solve My Problem: An esthetic, quality, and efficient composite solution

	The FDA cleared Silver Diamine Fluoride (SDF) in 2014 for treating hypersensitivity. However, research shows SDF is also useful for its off-label use of dental caries management. 

	Jeremy Horst, DDS, Ph.D., and the UCSF School of Dentistry in their paper “UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications, and Consent,” described SDF as a powerful new tool in the fight against dental caries. The UCSF study in 2016 found application every six months was the best performing minimally invasive option for decay management. In addition, the researchers said SDF served as a preventative material for teeth without decay as well, although, in this use, dental sealants outperformed SDF. 

	Since then, research on SDF has continued. Dr. Horst says that more trials around the world and in the US have produced data that supports SDF’s efficacy and safety. Currently, he says there is a clinical trial going on in New York, Iowa, and Michigan that could be influential in SDF getting the FDA’s approval to be the first drug approved for treating cavities. Meanwhile, it is already approved for caries use in other countries such as Canada and Japan.

	“Perhaps most importantly, we have now completed safety trials. After application of SDF to large cavities in three to five-year-old children, in ours and another independent study, all the kids were fine,” Dr. Horst says. 

	Dr. Horst described SDF’s fluoride and silver components as producing a double-whammy effect of fighting decay. The combination of silver’s antibacterial properties and fluoride’s remineralization effects make the tooth harder by incorporating into the tooth structure and making the tooth more resilient to decay. SDF then slows or stops decay altogether, although patients and providers may choose to restore the tooth as well. With regular SDF retreatment, no further therapeutic work is necessary in approximately 80 percent of cases. 

	Dr. Horst says his team has been doing a lot of basic science, taking patient samples and analyzing them in the lab to try to understand the mechanisms of how Silver Diamine Fluoride works. The team learned that while there are fewer bacteria overall, the relative amount of each type of bacteria stays the same	 

	“There’s a lot less of all the bacteria, but the amounts of each kind all go down evenly, which was surprising to us,” Dr. Horst says. “Changes in the microbiome can be dangerous, so this actually speaks to the safety of SDF.”

	As awareness of SDF’s off-label use spreads, dental professionals discover another option for caries management that is the best possible option for treatment for some patients. From schools to nursing homes to community outreach events, SDF provides a conservative approach to treating dental decay for patients who might not be candidates for traditional restorative care because of severity of decay, economic conditions, age, behavioral issues, or medical conditions.

	Steven Parrett, DDS, FAGD, has a private practice in Chambersburg, Pa., and works with his community at a local church at an event called Diaper Depot. The event is all-volunteer and run by Dottie Bush, along with more than 50 community volunteers who give their time and resources. The program provides diapers and a hot breakfast, as well as food and other essentials, to around 200 to 300 people in the community who need them. Dr. Parrett does a dental screening clinic there, as well. 

	“Anyone who has concerns about their teeth, I’ll look at them and tell them what I think and make some recommendations as far as whether they should get a cleaning, a tooth extracted, or if they need to have some X-rays for a diagnosis,” Dr. Parrett says. “If I see decay, I apply Silver Diamine Fluoride.”

	Dr. Parrett sees using SDF as a disclosing solution as an essential aspect of the SDF conversation. It has changed the way he diagnoses in areas where the decay isn’t apparent. 

	“We have this infamous term we used to use: We’re going to watch it. My question is, watch it what? Get worse? Get better? Stay the same? I don’t know,” Dr. Parrett says. “Any watch areas we have, we put SDF on it. If it is active, it will turn black, and then we can decide if we’re going to retreat it with SDF or restore it.”

	Betty Kabel, RDH, BS and past president of the American Dental Hygienists Association, says SDF has been a help in her school-based program that treats children from ages three to 12 years old. Working in Northwest Florida, she and the dental hygiene team have seen an increase in primary decay, and, in some kids, decay in the permanent teeth as well. 

	Many times Kabel’s patients are on a waiting list for treatment from a Medicaid provider, which she says could be a wait anywhere from three to five weeks. They use SDF as a stop-gap measure to arrest the decay while they wait for restorative care. In her program, they see patients in the fall months, and then again in the spring, which is a good schedule for retreatment. 

	“We pull those same children again and reapply it if they have not had it restored,” Kabel says. 

	Also, because the program does not include radiographs, they diagnose what they can see. When they see something that might indicate decay but is not 100 percent clear, Kabel and the team will apply SDF and recheck it the next time they see the patient for visual changes. An additional benefit here is the SDF protects against decay in the area where it was applied. 

	“Since we were already providing other preventative treatment, this has been a great supplement to be able to provide the service,” Kabel says of using SDF in the school-based program.

	Using SDF has been particularly helpful when treating patients who move a lot, especially for the transient Hispanic population that uses Kabel’s program for dental care. When applied to their permanent molars, SDF helps protect the patients against future decay.

	“We’re able to put SDF on there and arrest that decay. At least we know that it stopped because we don’t know if we will see them again,” Kabel explains. “Sometimes we see them in September, and then, when we go back in January, they’ve already moved. So, that’s been an added benefit for them.”

	In his private practice, Dr. Horst uses SDF at the examination for nearly all cavities, particularly those he will restore. He describes this as the first step in the two-day SMART (Silver Modified Atraumatic Restorative Technique) protocol for small or large Class I restorations-at the second visit he merely cleans the tooth with pumice, applies conditioner, rinses, then places a glass ionomer filling. This method has enabled him to treat countless toddlers and fearful patients without use of numbing or rubber dams. His first fillings using this simple approach were placed in 2014 and are still in the baby teeth that will exfoliate within the next year.

	“It would not be possible without using SDF to harden the cavity first. The SDF-arrested area is twice as hard as healthy dentin, so why put a drill on it?” Dr. Horst says.

	SDF can help patients on the other end of the age spectrum, as well. Geriatric patients with difficult-to-treat cavities on the root or under another dental prosthesis can use SDF to delay treatment but arrest caries in the meantime. Also, it can help for patients who are unable or unwilling to treat the decay. 

	Cindy Yanora, RDH at Stuart Periodontics in Florida, uses SDF with her elderly patients. Many times she describes it as buying time while they work through whatever is preventing them from moving forward with the restorative work they need. 

	“I always try to get them back to the general dentist to do the restorative work,” Yanora says, regarding patients where she uses SDF to arrest decay. 

	Yanora describes a case where a woman in her late 70s was having restorative work on an existing crown and having a new implant placed at the same time, but not for a few months. Near the margin, the dentist had repaired the crown already. The patient complained of sensitivity around that repair. 

	“I could feel it was soft around that repair,” Yanora says. “So, I put SDF there because she’s probably months out before she does the crown on that one.”

	Also, SDF can provide another option for removal and restoration therapy for caries management. However, retreatment is necessary to maintain its effects. 

	Yanora says SDF comes in handy with patients suffering from Xerostomia. The dry conditions contribute to early decay around crown margins. After cleaning the plaque, she applies SDF to protect against further decay.

	“Nursing homes are using it now,” Yanora says. “It would make total sense for patients that can’t be transported. A lot of people, it’s just too much to be able to go through a procedure, but SDF would prevent them from being in pain.”

	There are some drawbacks to using SDF. The most notable disadvantage is the staining that occurs. After application, decay turns black. 

	SDF can also stain inflamed gingiva. As a result, SDF is not applied to broken or ulcerated tissue areas because the staining could be permanent. 

	SDF is not for everybody. You should not apply it to patients with allergies to silver. Also, patients who are fluoride-treatment averse would not like the high concentration of fluoride present. 

	You should discuss all of these disadvantages in a pretreatment interview. With minors, parents should sign a waiver that acknowledges these risks to avoid problems later. 

	Yanora says the staining scares some people away from using it, even other hygienists. However, she thinks that fear is unnecessary. Often, she says, you are using it in areas that most people can’t see. Many times, she uses her explorer to see if it worked because she can’t see the area where she applied it.

	“It doesn’t turn the tooth black; it turns the caries black,” Yanora says. “Just don’t be afraid of it. Patients are very willing to use it.”

	In Kabel’s school-based program, they have seen almost 1,100 children for more than a year and a half and haven’t had any negative consequences from its use. 

	“As far as any side effects or parental concern about the discoloration or not having consent forms signed, that has not been a problem,” Kabel says, adding they have about a 50 percent return rate on consent forms to use SDF.

	Dr. Horst agrees that staining is not a significant deterrent from treatment. He estimates that two out of 600 patients have declined SDF in the past year, and that wasn’t because of the staining. 

	“We find that patients don’t care about staining nearly as much as dentists,” Dr. Horst says. 

	Kabel especially appreciates how SDF helps some kids who otherwise might have to be hospitalized and put under general anesthesia to have their teeth restored. It also benefits kids who are afraid of the dentist. Furthermore, by arresting the decay in the primary teeth, SDF helps them reduce the incidences of decay in their permanent teeth.

	“I don’t know why anyone would not want to use SDF because it’s probably the best thing we’ve done in our schools.”

	Dr. Parrett explains the risks of staining with SDF and has the patients or their legal guardians sign consent forms. He also encourages them to come back the next month for retreatment if they haven’t had the restorative work done yet. 

	One of his patients is a six-year-old girl named Macie, whom he describes as a real happy kid that he has been treating with SDF since she was two. Macie was facing surgery under general anesthesia and chrome crowns as a toddler. Instead, Dr. Parrett arrested the decay with SDF. Soon, her permanents will come in, which will give her a chance to “learn to cut out the gummy bears,” Dr. Parrett says. 

	“That’s a whole other area that SDF is going to help with; eliminating the trauma that patients would have experienced with the old drill and fill,” Dr. Parrett says. 

	Dr. Parrett is also actively campaigning for the use of SDF in community screenings. In particular, he wants to use SDF to buy time for patients that attend a local FQHC (federally qualified health center), which has a six-month wait time for routine care. 

	“These patients could receive immediate applications of Silver Diamine Fluoride and schedule for return visits to the Screening Clinic to retreat,” Dr. Parrett writes in his proposal to the CEO of Keystone Health. 

	“It is the best thing that has been added to our regimen to help kids or help anyone at high risk for decay. I would recommend anyone who can use it, whether you are private practice or public health, nursing homes, or anything else, I would use it,” Kabel says. 

	“It’s a social justice product because it’s so easy to do and so easy to receive as a treatment,” Dr. Horst says, “and to make a huge difference in the trajectory of the disease.”

	1. Horst, Jeremy A et al. “UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications and Consent.” Journal of the California Dental Association vol. 44,1 (2016): 16-28. Accessed via web. 17 October 2019. < https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4778976/>.

	4. “American Academy of Pediatric Dentistry Fact Sheet Silver Diamine Fluoride.” Elevateoralcare.com. Web. 18 October 2019. < http://www.elevateoralcare.com/site/images/AAPDSDFmedicaid.pdf?promocode=&promocodeaction=overwrite>

	As of now, there are no standard-of-care guidelines and protocols for SDF. However, many practices will apply two consecutive months followed by a third six months later, and then periodically from there. Some dentists also apply a fluoride varnish over the SDF to keep it on the lesion longer and optimize its effects.

	Elevate Oral Care, LLC, in West Palm Beach, Fla., makes the SDF solution available in the US called Advantage Arrest™. The one-step system is a blue topical agent that is tinted to improve placement visualization and comes in a small bottle with a brush. 

	The UCSF Study recommends isolating the area with cotton rolls or gauze to dry the lesion before you apply the solution. After application of a couple of drops of the solution to the lesion, you should allow from one to three minutes for the SDF to absorb into the tooth is ideal. However, in some cases, particularly with unruly patients in the chair, a few seconds seems to be enough to arrest caries. 

	Since the 2016 study, Dr. Horst and his research team have learned you do not have to rinse the SDF as was initially suggested. At the time of the original study in 2015, there was not enough safety data for children, and the research team didn’t want to endanger the children in the study, which is why a rinse was suggested. Now, however, there have been enough safety studies that everyone feels comfortable eliminating the rinse step. 

	“It was kind of silly that we suggested the rinse because you were putting medicine in and then taking it away a little bit,” Dr. Horst explains. “Now, there are multiple studies of safety data for young children, so we all fine about not having the rinse.”

	Dr. Horst says studies show frequent reapplication at the beginning of the SDF protocol, followed by annual or bi-annual retreatments, has shown the best results. But for how long?

	“We don’t have any information on that just yet,” Dr. Horst says. “Pediatric dentists would say once the teeth fall out, but that could be a long time.”

	Our experts have a couple of tips on how to use SDF in the tight spaces of the oral environment. Kabel uses the microtip to get the SDF into small areas. Dr. Parrett uses the natural capillary action in close contact areas to allows the SDF to flow in many cases. However, in a few instances, Dr. Parrett and his team will apply on the buccal side of the tooth and use high-volume suction on the lingual to pull the solution through. 

	“You might use a little bit more than you would have. But it’s still a lot better than cutting into the tooth that may not need it, and the cost is minimal,” Dr. Parrett explains.

	Dr. Horst says SDF can be the first part of a two-step SMART (Silver Modified Atraumatic Restorative Technique) filling. First, you use the SDF on the lesion and allow it to absorb and stain, then, at a second appointment a week later, you use the drill on the margin without any local anesthetic and then place an opaque glass ionomer cement over it to manage the stain.

	The billing for SDF is established already. Per a fact sheet from the American Academy of Pediatric Dentists, the CDT code is D1354-interim caries arresting medicament application.  As of January 2018, you record it as a per tooth application. 

	Dr. Parrett sometimes applies SDF three times within a two-week period. He says D1354 covers all three of those applications and the charge is $23. By comparison, when they apply SDF to the full mouth to decrease sensitivity, Dr. Parrett’s office uses code 9910 and the charge is $64. 

	Elevate Oral Care conducted a study this summer that revealed 32 state Medicaid dental plans currently reimburse this code and procedure. However, California, Texas, and New York, three of the top four states by population, are not among them. Dr. Horst says more private insurances cover D1354 than state Medicaid programs. 

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