A new seven-state study finds that in treating young children for tooth decay, substituting silver diamine fluoride (SDF) for traditional restorative care could significantly cut Medicaid spending over three years, ranging from $2.1 million in Vermont to $48.5 million in North Carolina.
SDF, a liquid solution brushed on tooth decay, contains silver, which stops the growth of bacteria. Fluoride strengthens the surface of the damaged tooth. SDF can arrest the growth of decay without drilling or sedation. It can also prevent new cavities from forming. Although relatively new to the United States, this treatment has been used in other countries for decades.
Despite being largely preventable, tooth decay remains one of the most common chronic diseases of childhood. Federal data show that 9 percent of children ages 2-5 have untreated decay, and 21 percent have experienced decay at some point. Rates are considerably higher for low-income children. But the traditional procedures used to treat cavities can cause significant stress for young children and their parents. Children who are anxious, fidget, or disabled might have difficulty sitting for care and may need deep sedation or general anesthesia. But research finds that sedating children comes with serious health risks, and the U.S. Food and Drug Administration (FDA) has issued warnings about the use of sedation for this population. In addition to mitigating the risks of sedation, SDF offers an effective alternative to the use of a hand drill, which would help make dental visits less traumatic for children.
The study examined Medicaid claims data for 1- to 5-year-olds in seven states (Alabama, Connecticut, Massachusetts, North Carolina, New Hampshire, South Carolina, and Vermont) from 2010 through 2012 who had traditional restorative procedures, such as fillings or crowns. The authors compared per-visit Medicaid spending for a restorative visit, including any associated sedation and anesthesia costs, to the alternative SDF treatment. Researchers calculated that if 50 percent of cavities were treated with SDF instead of the traditional approach, SDF could reduce the average per-restorative visit costs by $119 to $338, depending on the state. (The size of the Medicaid population and varying reimbursement rates account for the difference in costs.) The costs associated with sedatives and anesthesia help explain why restorative visits can be so expensive. Per-visit costs across the states ranged from about $100 to $600 for those involving nitrous oxide and from about $1,000 to $5,000 when general anesthesia was used.
According to one of the study’s authors, Dr. Scott Tomar, “For a young child with decay, the primary goal is to preserve the tooth until it falls out naturally or until we can manage the cavity without having to put the child under general anesthesia or use some form of sedation. That alone will not only reduce costs but reduce risks to the child.”
Evidence that SDF is a viable noninvasive alternative to traditional restorative treatments continues to grow, and leading experts on oral health support its use. Yet, the American Academy of Pediatric Dentistry (AAPD) reports that as of April 2017, less than 40 percent of state Medicaid programs reimburse for SDF. The AAPD recommends SDF for primary teeth in children and adolescents. The American Dental Association endorses the use of SDF to arrest decay in primary teeth and, in some circumstances, permanent teeth. It also recommends applying SDF to decayed teeth twice yearly to maximize effectiveness. The main drawback of SDF is that it leaves a permanent black stain on the area of the tooth where it is applied. For this reason, some question its use for permanent teeth or teeth in the front of the mouth.
The FDA approved SDF as a treatment for dental hypersensitivity for adults in 2014 and, two years later, granted SDF its “breakthrough therapy” designation, signaling that it will expedite the clinical review process of SDF as a treatment to prevent and arrest decay.
Untreated decay in children can lead to pain, infection, missed school days, missed work days for parents, and other serious consequences. But SDF can significantly improve the oral health of children while also helping states benefit from lower Medicaid expenditures.
Jane Koppelman is a senior manager and Allison Corr is an officer with The Pew Charitable Trusts’ dental campaign.