About 27% of older adults have untreated tooth decay. Dental hygienist Jennifer Geiselhofer treats seniors with silver diamine fluoride, an alternative to combating cavities, in order to obtain a filling. (Courtesy of Jennifer Geiselhofer / TNS)
Image credit: TNS
Image credit: TNS
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Geiselhofer was unable to enter nursing homes during the COVID-19 pandemic, but does use the liquid on older adults she visits in private homes. She also uses it to treat the cavities of patients in homeless shelters, prisons, and Head Start programs – she now wears larger protective gear, including gloves, a surgical mask, an N95 mask, and a face shield.
The topical drug is a particularly good option for seniors, according to experts in the dental industry, as dental care has remained a huge void in health insurance coverage despite poor dental hygiene related to heart disease and other health problems such as diabetes and pneumonia. Medicare does not cover most dental care, and fixed income patients often cannot afford treatment. But because of the effectiveness and low cost of silver diamine fluoride, more government Medicaid programs are now covering it – and older adults who pay out of pocket can afford it right away.
Silver diamine fluoride has been used in other countries for decades, and studies have shown it to be safe. Its biggest disadvantage is that it permanently blackens the decayed area – a turnoff, especially for people with tooth decay on a front tooth.
Dentists say that the black spots can be covered with tooth-colored material for an additional charge. For older adults, Geiselhofer said, a dark spot is a small price to pay for a treatment that quickly stops cavities without the need for a drill, needle prick, or visit to the dentist.
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Silver diamine fluoride was approved by the Food and Drug Administration in 2014 for reducing tooth sensitivity. However, its off-label use for treating cavities was quickly adopted. It made headlines as a trauma-free treatment for tooth decay in children under 5.
Pediatric dentists have viewed it as a solution for children who cannot sit still for treatment and whose parents want to avoid general anesthesia. In 2018, then-President of the American Academy of Pediatric Dentistry, James Nickman, said the topical cavity warmer, along with fluoridated water, “could be the greatest innovation in pediatric dental health of the last century.”
But today, with more older Americans retaining their natural teeth than in decades past, the treatment is a blessing for another generation as well. Due to insurance gaps and the prohibitive cost of most dental procedures, many seniors miss out on the preventive care measures to prevent tooth decay and put them at risk for dental disease, which can cause serious health problems. About 27% of Americans age 65 and older have untreated cavities, according to the Centers for Disease Control and Prevention.
Studies show that residents of long-term care facilities are at particularly high risk. Medications dry the mouth and encourage decay. You can also have cognitive problems that make it difficult to practice good oral care. And many are either too frail for traditional dental work or too weak to be transported.
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Take, for example, 87-year-old Ron Hanscom. Geiselhofer’s patient has been in a Denver nursing home since his stroke six years ago and needs a mechanical elevator to get in and out of his wheelchair.
During a visit to Hanscom’s nursing home earlier this year, Geiselhofer discovered a cavity under one of his crowns before the pandemic. After checking in with his dentist, she painted the silver treatment with a small brush.
“It’s good she had the silver because I couldn’t get into a dentist’s office – no way,” said Hanscom. “She did it right in my room.”
Silver diamine fluoride (SDF) is a topical medication that is painted on teeth to stop tooth decay. Originally touted as a solution for children, SDF could become a game changer for treating cavities in older adults. (Courtesy of Jennifer Geiselhofer / TNS)
Image credit: TNS
Image credit: TNS
Across the country, dental assistants mostly care for patients like Hanscom who otherwise might never see a dentist. You will also see patients in homeless shelters, schools, prisons, and low-cost medical clinics. Since the pandemic broke out, Geiselhofer has received a spate of home care requests from seniors who are too nervous to go to a dental office, but they turned them down because they are too busy looking after underserved populations.
In many states, hygienists can work directly with public health patients without the supervision of a dentist, and Colorado is one of the few countries where they can have a completely independent practice.
Because silver treatment is relatively new in this country and can stain, the Colorado state legislature passed a law in 2018 that states that hygienists must enter into an agreement with a supervising dentist to apply it. The law also requires that they receive specific fluid handling training from at least 700 hygienists across the state.
Other states, including Maryland and Virginia, don’t have specific requirements for using cavity treatment, but do require some dental supervision, said Matt Crespin, president of the American Dental Hygienists’ Association. In these places, hygienists apply it by the same rules that apply to the use of other fluoride products.
Studies show that silver diamine fluoride stops decay in 60% to 70% of cases with one application. A second application six months later increases the long-term effectiveness of the treatment to over 90%.
The treatment not only kills cavity-causing bacteria, but also hardens the tooth structure, desensitizes the tooth and even prevents new cavities from forming. Applying the liquid to the exposed root surfaces of older adults once a year is “a simple, inexpensive, and effective way” to avoid voids, according to a 2018 study.
One of the key benefits of using it in the elderly is that the fluid can reach tooth decay that forms with existing dental work such as crowns and bridges, said dental hygienist Michelle Vacha, founder of Community Dental Health, the Colorado Springs and Colorado clinics Springs operates Pueblo, Colorado.
Previously, a dentist had to remove the crown, drill out the cavity, and make a new crown – a traumatic, time-consuming procedure that typically cost $ 1,000 or more, Vacha said. Many patients could not afford the costs and instead had the tooth extracted.
The coating liquid is significantly cheaper than conventional treatment. Estimates vary, but a private dentist can charge $ 10 to $ 75 for an application compared to $ 150 to $ 200 for a filling. Hygienists often have lower fees. At Vacha’s community clinics, the cost is $ 10 per tooth.
About half of the state’s Medicaid programs now reimburse treatment, said Steve Pardue, a research fellow at Elevate Oral Care, which sells Advantage Arrest, the main brand of topical drugs used nationally. Reimbursement rates range from $ 5 to $ 75 per application.
According to Pardue, more private insurers – around 20% to 30% of them – have also started to cover these.
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