Dental caries, the most common disease of childhood and most prevalent health condition worldwide, persists despite concerted clinical and public health efforts to eliminate it over the last half-century [1, 2]. Untreated caries contributes to health problems including pain, poor quality of life, and psychosocial suffering, as well as societal burdens that include reduced productivity at work and school [1, 3, 4]. Preventing dental caries through oral health education, home hygiene, the avoidance of fermentable carbohydrates, consumption of fluoridated water, and access to and utilization of routine dental screenings, examinations, and care is essential in reducing disease incidence and burden, meeting population-level oral health goals, and addressing patient concerns [1, 4]. Because dental caries is a progressive disease, treating it as early as possible can halt extant disease, prevent or forestall subsequent cases, improve the longevity of teeth and their supporting structures, and, when possible, help patients avoid more invasive procedures and associated risks [4, 5]. As in primary prevention, secondary approaches that leverage treatment-as-prevention are particularly valuable when implemented at the population level [1, 5, 6]. Dental public health and oral health stakeholders seek to maximize caries prevention and treatment approaches that are safe, simple, effective, low-cost, minimally invasive, and amenable to delivery in a variety of community settings and by multiple members of dental treatment teams.
Silver diamine fluoride (SDF) has been approved for dental use in numerous countries including, since 2014, the United States, where its off-label use for the secondary prevention of caries beginning in 2016 has been subsequently formalized through clinical guidelines released in 2018 [7,8,9]. SDF has gained prominence among other non-invasive treatments in arresting established caries, though effectiveness varies by frequency of application (e.g., annually vs. biannually), preparation of concentrations, tooth type (e.g. permanent versus primary), and tooth surface (e.g., coronal vs. root surfaces) [6, 10,11,12,13,14,15,16,17]. SDF has also been demonstrated to prevent new carious lesions on root surfaces among older adults, while limited evidence indicates its potential to prevent caries in primary teeth for at least 24 months following initial application [15, 18, 19]. Numerous characteristics of SDF reflect those valued in dental public health interventions, including being minimally invasive, affordable, portable, and appropriate for use at scale in community settings by various multiple dental and medical team members, outside of clinical applications. In addition, amidst the proliferation of the SARS-CoV-2 virus (COVID19), SDF has been recommended as an appropriate, non-surgical, non-aerosolizing caries management procedure that complies with guidance from public health officials, regulatory bodies, and professional associations to limit the risk of exposure to airborne pathogens [18,19,20,21]. Concerns regarding the staining effects of SDF potentially limit its desirability for use on anterior dentition [22, 23]. However, recent evidence also documents its acceptability among dentally underserved patient groups for use on posterior dentition, and when posited to parents as a safe, minimally invasive, and effective alternative to procedures that could be painful or for which their children might otherwise be sedated, with particular suitability for children with behavioral challenges, often surpassing provider preference for using SDF [24,25,26,27,28,29].
The existing literature on SDF focuses primarily on young children who still have primary dentition [10, 13, 15, 22,23,24,25,26,27,28] and older adults [16, 30], often omitting older children, adolescents, and working-age adults. The strongest evidence on SDF derives from randomized controlled trials whether individual or aggregated into evidence reviews, which compare SDF with placebo or other treatments, limit the intervention to SDF alone versus when used in combination with restorative procedures, and generate findings from samples treated under ideal clinical conditions and from analyses that control for covariates [6, 10,11,12,13,14,15,16,17]. While this evidence supports SDF effectiveness in arresting caries lesion development and progression, accounts or analyses of “real world” concerns such as the settings in which treatments are delivered, patient volume at scale, and clinical decision-making when multiple treatment options are available, are limited in literature, as is evidence of the potential for SDF to prevent caries.
This study aims to address some of these limitations, with particular concern for dentally underserved patients who obtain care in community settings and who are also historically excluded from clinical trials due to geographic and other barriers. It describes survival outcomes of SDF applied independently or concurrently with a sedative or restorative procedure among a population receiving care in community settings over the course of 1 year. Utilizing a retrospective analysis of patient claims filed with the largest dental accountable care organization in Oregon, this study explores variations in health service delivery to document SDF survival in a real-world community-based practice setting. To our knowledge, it is the first study to assess SDF survival among a population sample treated in a real-world practice setting, both when used alone and in combination with a sedative filling or restoration.