Faculty Bibliography

INTRODUCTION/UNASSIGNED:Current economic evaluations of school-based caries prevention programs (SCPPs) do not compare multiple types of SCPPs against each other and do not consider teeth beyond permanent first molars. OBJECTIVES/UNASSIGNED:To assess the cost-effectiveness of a comprehensive SCPP relative to an SCPP focused on delivering sealants for permanent first molars only and to a default of no SCPP. Based on a societal perspective, a simulation model was used that compared the health and cost impacts on 1) permanent first molars only and 2) all posterior teeth. METHODS/UNASSIGNED:To calibrate the model, we used data from CariedAway, a comprehensive SCPP that used glass ionomer to prevent and arrest active decay among children. We then evaluated the incremental cost-effectiveness of implementing 3 alternate school-based approaches (comprehensive, sealant only, and no program) on only first molars and all posterior teeth. Probabilistic, 1-, and 2-way sensitivity analyses are included for robustness. Cost-effectiveness is assessed with a threshold of $54,639 per averted disability-adjusted life year (DALY). RESULTS/UNASSIGNED:We first compared the 3 programs under the assumption of treating only first molars. This assessment indicated that CariedAway was less cost-effective than school-based sealant programs (SSPs): the resulting incremental cost-effectiveness ratio (ICER) for CariedAway versus SSPs was $283,455 per averted DALY. However, when the model was extended to include CariedAway's treatment of all posterior teeth, CariedAway was not only cost-effective but also cost-saving relative to SSPs (ICER, -$943,460.88 per averted DALY; net cost, -$261.45) and no SCPP (ICER, -$400,645.52 per averted DALY; net cost, -$239.77). CONCLUSIONS/UNASSIGNED:This study finds that economic evaluations assessing only cost and health impacts on permanent first molars may underestimate the cost-effectiveness of comprehensive SCPPs 1) preventing and arresting decay and 2) treating all teeth. Hence, there is an urgent need for economic evaluations of SCPPs to assess cost and health impacts across teeth beyond only permanent first molars. KNOWLEDGE TRANSFER STATEMENT/UNASSIGNED:The results of this study can be used by policy makers to understand how to evaluate economic evaluations of school-based caries prevention programs and what factors to consider when deciding on what types of programs to implement.

This article reviews current evidence on the effectiveness of silver diamine fluoride (SDF) as a caries arresting and preventive agent. It provides clinical recommendations around SDF's appropriate use as part of a comprehensive caries management program. Systematic reviews confirm that SDF is effective for caries arrest on cavitated lesions in primary teeth and root caries in the elderly. It may also prevent new lesions. Application is easy, noninvasive, affordable, and safe. Although it stains the lesions dark as it arrests them, it provides clinicians with an additional tool for caries management when esthetics are not a primary concern.

OBJECTIVES/OBJECTIVE:To investigate whether silver diamine fluoride (SDF) is effective in preventing new caries lesions in primary teeth when compared to placebo or active treatments. METHODS:Systematic review (CRD42016036963) of controlled clinical trials. Searches were performed in 9 electronic databases, 5 registers of ongoing trials, and reference lists of identified review articles. Two researchers carried out data extraction and quality appraisal independently. The primary outcome was the difference in caries increment (decayed, missing, and filled surfaces or teeth - dmfs or dmft) between SDF and control groups. These differences were pooled as weighted mean differences (WMD) and prevented fractions (PF). RESULTS:Searches yielded 2,366 unique records; 6 reports of 4 trials that randomized 1,118 and analyzed 915 participants were included. Two trials compared SDF to no treatment, 1 compared SDF to placebo and sodium fluoride varnish (FV), and 1 compared SDF to high-viscosity glass ionomer cement (GIC). All studies had at least 1 domain with unclear or high risk of bias. After 24 months of follow-up, in comparison to placebo, no treatment, and FV, SDF applications significantly reduced the development of new dentin caries lesions (placebo or no treatment: WMD = -1.15, PF = 77.5%; FV: WMD = -0.43, PF = 54.0%). GIC was more effective than SDF after 12 months of follow-up but the difference between them was not statistically significant (WMD, dmft: 0.34, PF: -6.09%). CONCLUSION/CONCLUSIONS:When applied to caries lesions in primary teeth, SDF compared to no treatment, placebo or FV appears to effectively prevent dental caries in the entire dentition. However, trials specifically designed to assess this outcome are needed.

BACKGROUND:Dental caries is the most prominent childhood disease in the world. In the United States, more than 50% of children have experienced caries. Untreated caries can have negative impacts on quality of life, academic performance, and school attendance. To reduce oral health disparities, multiple organizations recommend school-based caries prevention. METHODS/DESIGN/METHODS:A longitudinal, cluster randomized, non-inferiority trial will be conducted in low-income children from primarily Hispanic/Latino backgrounds currently enrolled in public elementary schools in New York City, New York, United States, from 2018 to 2023. The primary objective is to compare the non-inferiority of silver diamine fluoride and fluoride varnish versus glass ionomer therapeutic sealants and fluoride varnish in the arrest and prevention of dental caries. Secondary objectives are to evaluate differences in effectiveness when care is provided by nurses versus dental hygienists and assess the impact of prevention on oral health-related quality of life and educational outcomes. Caries arrest will be evaluated after 2 years, and caries prevention and secondary outcomes will be assessed at the completion of the study. Data analysis will follow intent-to-treat, and statistical analyses will be conducted using a two-sided significance level of 0.05. DISCUSSION/CONCLUSIONS:The comparative effectiveness of alternative caries prevention delivery models is considered to be one of the highest research priorities in the United States. Many treatments are currently available to prevent and arrest dental caries. The simplicity and affordability of silver diamine fluoride may be a viable alternative for the prevention of dental caries in high-risk children. TRIAL REGISTRATION/BACKGROUND:U.S. National Library of Medicine, www.clinicaltrials.gov , ID: NCT03442309 . Registered on 22 February 2018.

BACKGROUND:In this systematic review, the authors aim to assess the effect of silver diamine fluoride (SDF) in preventing and arresting caries in exposed root surfaces of adults. TYPES OF STUDIES REVIEWED/METHODS:Two reviewers independently searched for controlled clinical trials with at least 12 months of follow-up, without language or date of publication restraints, in 8 electronic databases, 5 registries of ongoing trials, and reference lists of narrative reviews. RESULTS:The authors found 2,356 unique records and included 3 trials in which the investigators randomly assigned 895 older adults. Investigators in all studies compared SDF with placebo; investigators in 1 also compared 38% SDF with chlorhexidine and sodium fluoride varnishes. The primary effect measures were the weighted mean differences (WMDs) in decayed or filled root surfaces (DFRS) and the mean differences in arrested carious lesions between SDF and control groups. The studies had low risk of bias in most domains. SDF applications had a significantly better preventive effect in comparison with placebo (WMD DFRS: 24 months, -0.56; 95% confidence interval, -0.77 to -0.36; 30 months or more, -0.80; 95% confidence interval, -1.19 to -0.42), and they were as effective as either chlorhexidine or sodium fluoride varnish in preventing new root carious lesions. SDF also provided a significantly higher caries arrest effect than did placebo (pooled results not calculated). Complaints about black staining of the carious lesions by SDF were rare among older adults. CONCLUSIONS AND PRACTICAL IMPLICATIONS/UNASSIGNED:Yearly 38% SDF applications to exposed root surfaces of older adults are a simple, inexpensive, and effective way of preventing caries initiation and progression.

INTRODUCTION/BACKGROUND:Dental caries is the most prevalent childhood disease in the world and can lead to infection, pain and reduced quality of life. Multiple prevention agents are available to arrest and prevent dental caries; however, little is known of the comparative effectiveness of combined treatments when applied in pragmatic settings. The aim of the presented study is to compare the benefit of silver diamine fluoride and fluoride varnish versus fluoride varnish and glass ionomer therapeutic sealants in the arrest and prevention of dental caries. METHODS AND ANALYSIS/UNASSIGNED:A longitudinal, pragmatic, cluster randomised, single-blind, non-inferiority trial will be conducted in low-income rural children enrolled in public elementary schools in New Hampshire, USA, from 2018 to 2023. The primary objective is to compare the non-inferiority of alternative agents in the arrest and prevention of dental caries. The secondary objective is to compare cost-effectiveness of both interventions. Caries arrest will be evaluated after 2 years, and caries prevention will be assessed at the completion of the study. Data analysis will follow intent to treat, and statistical analyses will be conducted using a significance level of 0.05. ETHICS AND DISSEMINATION/UNASSIGNED:The standard of care for dental caries is office-based surgery, which presents multiple barriers to care including cost, fear and geographic isolation. The common intervention used in school-based caries prevention is dental sealants. The simplicity and affordability of silver diamine fluoride may be a viable alternative for the prevention of dental caries in high-risk children. Results can be used to inform policy for best practices in school-based oral healthcare. TRIAL REGISTRATION/BACKGROUND:NCT03448107. Pre-results.

The school and community context can contribute to inequity in child oral health. Whether the school and community affect the effectiveness of school-based caries prevention is unknown. The association between the school and community environment and dental caries, as well as their moderating effects with school-based caries prevention, was assessed using multilevel mixed-effects regression. Data were derived from a 6-y prospective cohort study of children participating in a school-based caries prevention program. For the school and community, living in a dental-shortage area and the proportion of children receiving free or reduced lunch were significantly related to an increased risk of dental caries at baseline. Caries prevention was associated with a significant per-visit decrease in the risk of untreated caries, but the rate of total caries experience increased over time. Caries prevention was more effective in children who had prior dental care at baseline and in schools with a higher proportion of low socioeconomic status students. There was significant variation across schools in the baseline prevalence of dental caries and the effect of prevention over time, although effects were modest. The school and community environment have a direct impact on oral health and moderate the association between school-based caries prevention and dental caries.Knowledge Transfer Statement:School-based caries prevention can be an effective means to reduce oral health inequity by embedding dental care within schools. However, the socioeconomic makeup of schools and characteristics of the surrounding community can affect the impact of school-based care.

BACKGROUND:Dental caries is the world's most prevalent childhood disease. School-based caries prevention can reduce the risk of childhood caries by increasing access to care. However, the optimal mix of treatment services, intensity, and frequency of care is unknown. METHODS:Data were derived from two prospective cohorts of US children participating in two caries prevention programs with different treatment intensities. One program provided primary and secondary prevention (glass ionomer sealants and interim therapeutic restorations) and one primary prevention only (glass ionomer sealants), both given twice yearly in six-month intervals. Primary study outcomes included untreated decay and the total observed caries experience. Analysis used generalized additive models to estimate nonlinear effects and trends over time. Results were compared to those estimated using generalized estimating equations and mixed-effects multilevel Poisson regression. RESULTS:Primary and secondary prevention combined did not significantly reduce total caries experience compared to primary prevention alone, but did reduce the risk of untreated decay on permanent dentition. Additionally, the rate of new caries experience was slower in the primary and secondary prevention group. Nonlinear trends for dental caries across both programs were statistically significant from zero (p < .001). CONCLUSION/CONCLUSIONS:Caries prevention consisting of primary and secondary prevention agents may be more effective than primary prevention alone in reducing the risk of tooth decay over time. Results suggest that the impact of caries prevention may not be constant over the medium- and long-term, suggesting reduced effectiveness with continued treatments.

INTRODUCTION: Tooth preservation in adults and children is one of the Healthy People 2020 goals for oral health. Although the overall prevalence of tooth loss has been declining in the United States, substantial racial/ethnic differences in preventable tooth loss persist as a public health problem. We examined the strength of the association of health risk factors and tooth loss in Hawai'i. METHODS: We used data from the Hawai'i Behavioral Risk Factor Surveillance System survey collected from 2011 through 2014. Participant responses were included if they self-identified as Native Hawaiian, white, Japanese, or Filipino. Differences in excess tooth loss (6 or more teeth) and known risk factors (demographics, diabetes, and dental visits) were analyzed by using univariate analyses and adjusted stepwise, logistic regression models. RESULTS: We identified oral health inequity among the 4 ethnic groups studied; among the groups, Native Hawaiians had the largest proportion of excess tooth loss. The univariate analyses found differences in the strength of these associations among the 4 racial/ethnic groups. The stepwise analyses found that the associations of excess tooth loss and race/ethnicity were not significant after adjusting for demographics, diabetes status, and dental visits. CONCLUSION: Findings suggest a need for programs and policies that improve access to oral health care in Hawai'i for those with low levels of income and education and those with diabetes.