By Michelle Crouch, Kaiser Health News
Denver dental hygienist Jennifer Geiselhofer often cleans the teeth of elderly patients who can’t easily get to the dentist. But until recently, if she discovered a cavity, there was little she could do.
“I can’t drill. I can’t pull teeth,” said Geiselhofer, whose mobile clinic is called Dental at your doorstep. “I would recommend that they see a dentist, but that was often out of the question due to mobility issues. So visit after visit I would come back and there was more decay.
But now Geiselhofer has a weapon to obliterate a cavity with a few brush strokes.
Silver diamine fluoride is a liquid that can be painted on teeth to stop cavities. Quick, inexpensive and painless, the treatment is quickly gaining momentum across the country as the treatment of choice for patients who cannot easily get a filling, such as the very young or very old.
“It’s been life changing for my patients,” said Geiselhofer, who has been using the treatment for about 18 months.
Geiselhofer was unable to enter nursing homes during the COVID-19 pandemic, but she uses the cash on elderly people she visits in private homes. She also uses it to treat cavities in patients at homeless shelters, prisons and Head Start programs ― now wearing more protective gear, including gloves, surgical mask, N95 mask and face shield. face.
According to dental industry experts, the topical medication is a particularly attractive option for the elderly, as dental care has remained a major gap in health insurance coverage despite poor dental hygiene being linked heart disease and other health problems like diabetes and pneumonia. Medicare does not cover most dental care, and patients on fixed incomes often cannot afford treatment. But because of the effectiveness and low cost of silver diamine fluoride, more state Medicaid programs now cover it — and seniors who pay out of pocket can afford it.
Silver diamine fluoride has been used in other countries for decades and studies have proven its safety. Its biggest drawback is that it permanently darkens the decayed area – a turnoff, especially, for people with decay on a front tooth.
Dental providers say blackheads can be covered with tooth-colored material for an additional cost. For older people, Geiselhofer said, a dark spot is a small price to pay for a treatment that stops cavities quickly, without drilling, needle sticks or visits to the dentist.
Oral care, a problem for the elderly
Silver diamine fluoride was approved by the Food and Drug Administration in 2014 to reduce tooth sensitivity. But its off-label use to treat cavities was quickly adopted. It made headlines as a trauma-free treatment for tooth decay in children under 5 years old.
Pediatric dentists have adopted it as a solution for children who cannot sit still during treatment and whose parents want to avoid general anesthesia. In 2018, then president of the American Academy of Pediatric Dentistry, James Nickmansaid that aside from fluoridated water, the topical cavity fighter “may be the the greatest innovation in pediatric dental health in the last century.
But today, with more older Americans keeping their natural teeth than in decades past, the treatment is also a boon for a different generation. Due to insurance gaps and the prohibitive cost of most dental treatments, many seniors lack preventative care to avoid tooth decay, putting them at risk for dental disease that can trigger serious dental problems. health. About 27% of Americans age 65 and older have untreated cavities, according to the Centers for Disease Control and Prevention.
Residents of long-term care facilities are at particularly high risk, studies show. Medications dry out their mouths, promoting cavities. They may also have cognitive issues that make it difficult to practice good oral care. And many are either too fragile for traditional dental treatment or too weak to be transported.
Dental hygienists lead the way
Take Ron Hanscom, 87, for example. A patient of Geiselhofer, he has been in a Denver nursing home since suffering a stroke six years ago and needs a mechanical lift to get in and out of his wheelchair.
During a visit to the Hanscom nursing home earlier this year, before the pandemic, Geiselhofer spotted a cavity under one of her crowns. After consulting with her dentist, she used a small brush to paint over the silver treatment.
“It’s a good thing she had the money, because I couldn’t get to a dentist – no way,” Hanscom said. “She did it right in my room.”
Across the country, dental hygienists provide much of the care for patients like Hanscom who otherwise might never see a dentist. They also see patients in homeless shelters, schools, prisons, and low-cost medical clinics. Since the pandemic hit, Geiselhofer said she had received a flood of home care requests from seniors who were too nervous to go to a dentist, but turned them down because she was too busy caring for underserved populations.
Many states allow hygienists to work directly with patients in public health facilities without the supervision of a dentist, and Colorado is one of the few that allows them to set up a completely independent practice.
Because silver treatment is relatively new in this country and can leave a stain, the Colorado state legislature passed a law in 2018 that states hygienists must have an agreement with a supervising dentist for the apply. The law also requires them to undergo special training on the use of the liquid, which at least 700 hygienists across the state have completed.
Other states, including Maryland and Virginia, don’t have specific requirements for performing cavity treatment but do require some supervision by a dentist, said Matt Crespin, president of the American Association of Dental Hygienists. In these places, the hygienists apply it according to the same rules that govern the application of other fluoride products.
Also prevent new cavities
Studies show silver diamine fluoride stops cavities in 60% to 70% of cases with just one application. A second application six months later brings the long-term efficacy of the treatment to over 90%.
In addition to killing the cavities-causing bacteria, the treatment hardens the tooth structure, desensitizes the tooth and even prevents new cavities from forming. Applying the liquid to the exposed root surfaces of older people once a year is “a simple, inexpensive and effective way” to prevent cavities, a 2018 study concluded.
According to dental hygienist Michelle Vacha, founder of Community dental healthwhich operates clinics in Colorado Springs and Pueblo, Colorado.
Previously, a dentist would have had to remove the crown, drill the cavity and fabricate a new crown — a traumatic and time-consuming procedure with a typical cost of $1,000 or more, Vacha said. Unable to afford the cost, many patients would instead have their tooth pulled.
The paint liquid is significantly cheaper than the traditional treatment. Estimates vary, but a private dentist may charge anywhere from $10 to $75 for an application, compared to $150 to $200 for a filling. Hygienists often have lower fees. At Vacha community clinics, the cost is $10 per tooth.
About half of state Medicaid programs now reimburse for treatment, said Steve Pardue, chief scientific officer of Improving oral care which distributes Advantage Arrest, the leading brand of topical medication used nationally. Reimbursement rates range from $5 to $75 per request.
More private insurers — about 20-30% of them — have also started covering it, Pardue said.
Soon at a dentist near you?
A small but growing number of traditional dentists have started offering the treatment to all patients, not just the youngest and oldest.
It’s a good option for those who are anxious about dental care or worried about costs, said Dr. Janet Yellowitz, director of geriatric dentistry and special care at the University’s dental school. of Maryland.
A 2017 survey by the American Dental Association found that nearly 8 in 10 dentists had never used the treatment. The ADA doesn’t have more recent statistics, but ADA spokesman Matthew Messina said anecdotal reports indicate usage is increasing significantly.
Yellowitz noted that dentists still have a financial incentive to drill and fill. She has given presentations highlighting the benefits of the silver solution at national conferences.
“We try to get everyone to use it,” she said. “It’s a slow process because we’re asking dentists who have been trained their entire careers to do things in a way that completely changes their mindset. It’s like asking them to go to another country and drive on the other side of the road.