silver diamine fluoride - dentaquest partnership › system › files... · •a copy of the slides...

SILVERDIAMINEFLUORIDESeptember 19, 2019

2

Learning Objectives

By the end of this webinar, participants will be able to:

1. Understand the science of SDF

2. Recognize appropriate application of SDF

3. Identify important considerations when implementing SDF in practice

4. Understand scope of practice issues for hygienists in a public health setting

when new tools are introduced

5. Acknowledge how SDF can impact community-based care delivery

3

Housekeeping

• All lines will remain muted to avoid background noise.

• A copy of the slides and a link to the recording will be shared after the webinar

concludes.

• In order to receive CE credit you must fill out the webinar evaluation, which

will be shared at the end of the presentation. The evaluation must be

completed by EOD Wednesday, September 25 to receive CE credit. CE

certificates will be distributed by October 1.

The DentaQuest Partnership is an ADA CERP Recognized Provider. This presentation

has been planned and implemented in accordance with the standards of the ADA CERP.

*Full disclosures available upon request

4

Q&A Logistics

After the presentations we hope to have some

time for Q&A

Two ways to engage:

• Use the raise hand feature and we will

unmute you

• Type your question in the chat box

5

Presenters:

Jeremy Horst DDS, PhD Margaret Langelier, MSHSA

Jeremy HorstDDS,PhD

UCSF

Silver Diamine Fluoride

is a Treatment for Dental Caries

SDF - what is it?

Colorless liquid

25% silver: antimicrobial

8% ammonia: solvent

5% fluoride: remineralization

SDF - what does it do?

- Arrests dental caries

- Prevents dental caries• directly & indirectly

- Decreases dentin hypersensitivity

- Turns de-/hypo-mineralized areas BLACK.

October 2018, the ADA

“Clinicians are encouraged to prioritize use of [nonrestorative treatments] based on effectiveness, safety, and feasibility." - JDR

"38% silver diamine fluoride solution applied biannually [is] effective for arresting advanced cavitated carious lesions on any coronal surface (moderate to high certainty).” - JADA

Hamama, Aust Dent J 2015

SDF chases bugs down into tubules

metagenomic NextGen Sequencing

Milgrom + Horst et al. J Dent, 2018

No dangerous effects on microbiome.

●

●

●

●

●●

●

● ●●

●●

●●

● ●●●

●●● ●● ● ●●●●● ●●

●●●● ●●●● ●● ●●● ●● ●●●●● ● ●● ● ● ●● ●● ●●

●●

● ●●

●●

●●●

●

●

●

●● ●

●●●●

●

●

●

●●

●●● ● ●●●●

●

●●

●●

● ●●

●

●●

●● ●

●

●● ●● ● ●● ●● ●● ● ●●● ● ●● ●●●●●● ●● ●●● ●●●●● ●●●●●●● ●●● ●●●●● ●● ●● ●●●● ●●●● ●●● ● ●●● ●●● ●●●●●● ●● ●●●●●●●● ● ●●● ●●●● ●●● ● ●● ●●● ●●● ●●● ●●●● ●●● ●●● ●●●● ● ●●●● ● ●●● ●●●● ●●● ● ●●● ●●● ●● ●●●●●●●●●●●●●●●●●●●

● ●●●●●●● ●●●●●● ●● ●●●●●●●●●●●●●●

●●●●●●● ●●●● ●●●●●●●●●●●●●●

−15 −10 −5 0 5 10 15

02

46

log2FoldChange

−lo

g1

0(p

va

lue)

●

●

●

●

●

●

●

●●

●

●

●●

●●

●

●●

●●●

●

●●

●●

●●● ●●

●●● ●●●●

●

●

●Lactobacillus reuteri

Acidithiobacillus caldus

Sulfuriferula sp. AH1

●

●

●

FDR<0.01

|LogFC|>2

both

microbes post- vs pre-arrest

No significant decreases

stat

sig

(lo

g 10) Lactobacillus

reuteri

antimicrobial resistance genes

●

●

●

●

●●

●

● ●●

●●

●●

● ●●●

●●● ●● ● ●●●●● ●●

●●●● ●●●● ●● ●●● ●● ●●●●● ● ●● ● ● ●● ●● ●●

●●

● ●●

●●

●●●

●

●

●

●● ●

●●●●

●

●

●

●●

●●● ● ●●●●

●

●●

●●

● ●●

●

●●

●● ●

●

●● ●● ● ●● ●● ●● ● ●●● ● ●● ●●●●● ● ●● ●●● ●●●●● ●●●●●●● ●●● ●●●●● ●● ●● ●●●● ●●●● ●●● ● ●●● ●●● ●●●●●● ●● ●●●●●●●● ● ●●● ●●●● ●●● ● ●● ●●● ●●● ●●● ●●●● ●●● ●●● ●●●● ● ●●●● ● ●●● ●●●● ●●● ● ●●● ●●● ●● ●●●●●●●●●●●●●●●●●●●

● ●●●●●●● ●●●●●● ●● ●●●●●●●●●●●●●●

●●●●●●● ●●●● ●●●●●●●●●●●●●●

−15 −10 −5 0 5 10 15

02

46

log2FoldChange

−lo

g10(p

valu

e)

●

●

●

●

●

●

●

●●

●

●

●●

●●

●

●●

●●●

●

●●

●●

●●● ●●

●●● ●●●●

●

●

●Lactobacillus reuteri

Acidithiobacillus caldus

Sulfuriferula sp. AH1

●

●

●

FDR<0.01

|LogFC|>2

both

No changes

SDF microstructures

SDF casts silver rebar millimeters into dentin, reinforcing the lesion and sustaining kill.

Seto, Horst, Frachella, Duffin, MacLean

Accessiblecaries lesion.

1. Isolate with cotton.2. Air dry. 3. Apply with microbrush.4. Protect reaction for ~1 minute.

Arrested cavities after 1 year

How do you use it?

Suggested frequency protocol

• For mild caries:

q6mo

• For moderate caries:

q6mo + 2-6 week loading dose

• For severe caries:

q6mo + two 2-6 week loading doses + 3mo

, 2018

309

Car

ies

Arr

est

in k

ids

Horst, Adv Dent Res 2018

, 2018

309

Car

ies

Arr

est

in k

ids

no caries removal before SDF!!!


, 2018

309

Car

ies

Arr

est

in k

ids 2x > 1x / year

keep applying!!!


, 2018

309

Car

ies

Arr

est

in k

ids


9%

9%

loading doses help, keep applying.

, 2018

309

Car

ies

Arr

est

in k

ids

similar effect vs ART


arrested

What to watch for:

active growing

@ 6 months.

45% 35% 20%

Car

ies

Arr

est

in k

ids

Car

ies

Arr

est

in k

ids

6mo 18mo

least

most

Likelihood of SDF caries arrest = cleansibility

Craig & Powell, Dental Outlook. 2013

most

least

medium

medium

Car

ies

Pre

ven

tio

nin

kid

s

pre

ve

nte

d f

raction

of

carie

s le

sio

ns

0%

0.5 1 1.5 2 2.5 3

time (years)

50%

100%

50%

100%

50%

100%

50%

100%

50%

100%

50%

100%

50%

100%

50%

100%

SDF q1year

Resin Sealant

NaF q6mos

Liu et al., 2012

482 9.1 year olds

control: 4.6 new lesions

SDF q1year

exc SDF q1year

exc NaF q3mos

NaF q3mos

Chu et al., 2002

308 3-5 year olds


SDF once

GIC Sealant

Monse et al., 2012

708 6-8 year olds


40% AgF once

849 5-8 year olds


background: 10% SnF2

Green, 1989

50%

100%

SDF q1year

SDF q6mos

Nguyen et al., 2017

295 2-3 year olds


SDF 3x/1week

25 6-8 year olds


Sato & Saito, 1970

SDF q6mos

Llodra et al., 2005

373 6 year olds


50%

100%

SDF q3mosTsutsumi et al., 1981

58 5-7 year olds

mean (61%)

weighted average

SDF q3mos

Yoshida et al., 1976

26 1-2 year olds


Horst & Heima, Compendium 2019

0%

50%

100%

0.5 1 1.5 2 2.5 3

SDFq1year

+OHIq6mon

control

Zhang et al., 2013 227 60-89 year olds

0.91 lesions at start

0%

50%

100%

SDFq1year

SDF,KIq1year

control

Li et al., 2016 67 72 year olds

1.9 lesions at start

0%

50%

100%

SDFq1yearNaFq3monChlorhexq3mon

0%

50%

100%

0.5 1 1.5 2 2.5 3

SDFq1year

+OHIq6mon

Tan et al., 2010 203 79 year olds


Zhang et al., 2013 227 60-89 year olds


Arr

est

Older adults

Pre

ven

tio

n

time (years)

Patient Name:

Date of Birth:

Medical Record Number: SanFranciscoDepartmentofPublicHealthDentalServices

INFORMEDCONSENTFORSILVERDIAMINEFLUORIDE

Factsforconsideration:

· Silverdiaminefluoride(SDF)isaliquidthathelpsstoptoothdecay.SDFisappliedevery3,6or12months.

· AsmallamountofSDFisappliedtothedecayedtootharea.

· AfterSDFapplicationnoeatingordrinkingfor60minutesandnotoothbrushinguntilthefollowingmorning.

· Thedecayedareawillstainblackpermanently.Healthytoothstructurewillnotstain.

· IshouldnotbetreatedwithSDFif:1)Iamallergictosilver.2)Therearepainfulsoresorrawareasonmygumsoranywhereinmymouth.

BenefitsofreceivingSDF:

· Helpsstoptoothdecay.· Fast.

· Donotneedtonumbteeth.· Doesnothurt.

RisksofreceivingSDF:

· Theaffectedareawillstainblackpermanently.ThismeansSDFisworking.· Tooth-coloredfillingsandcrownsmaydiscolorifSDFisappliedtothem.· After SDF treatment, a filling or crown might still be needed.

· Ifaccidentallyappliedtotheskinorgums,abrownorwhitestainmayappearthatcausesnoharm,cannotbewashedoffandwilldisappearinonetothreeweeks.

· Permanent dark spots if spilled on clothing.· Allergic reaction.

· Riskthattheprocedurewillnotstopthedecay.· Not every cavity can be treated with SDF

AlternativestoSDF,notlimitedtothefollowing:

· Notreatment,whichmayleadtocontinuedbreakdownofthetooth.Symptomsmaygetworse.· Placementoffillingsorcrowns,extractionsorreferraltoaspecialist.

I have read this form. I understand the treatment and have had the chance to ask questions. I have seen the photo

of how teeth may look after SDF discolors the cavities. I understand that I may refuse treatment with SDF. I

understand that I can decide to have no treatment or I can have fillings, crowns, or extractions done at this or

another dental office.

I consent and authorize SFDPH Dental Services to use Silver Diamine Fluoride to help stop tooth decay.

Signatureofpatient/parent/guardian______________________________________________________Date____________Signatureofwitness____________________________________________________________________________Date____________

Consent = Conversation

This is a consent document.

Risks?Benefits?Alternatives?

Simple language.

Show pictures!

sites.google.com/site/jeremyahorst/SDFconsents

SDF take-homes

1. Arrests 81% of lesions when used 1+/year.

2. Prevents 62% of new lesions.

3. Dry before use.

4. Safe.

5. Stains the crap out of everything.

THANK YOU

You can get these slides and more at:

http:// bit.ly / JeremyDQPH

My email:

jahorst @ gmail.com

pH 13!!!!

compiled by Dr. Jeanette MacLean

compiled by Dr. Jeanette MacLean

Dr. Jason Hirsch

Esthetics? SSC or SDF

Dr. John Frachella

Esthetics? Handled.

Dr. John Frachella

=32.5 µL

50,000 ppm F

2.3 L0.7 ppm FHow much Fluoride?

6 1=

Implications of Scope of Practice Regulations on

Administration of Silver Diamine Fluoride

Presented by: Margaret Langelier

The Oral Health Workforce Research Center

Center for Health Workforce Studies

University at Albany, School of Public Health

September 19, 2019

Why Are We Having This Discussion?

• Fluoride is widely recognized as an effective primary prevention tool

o In water supplies, in toothpaste, children and others receive fluoride supplementation in many forms

o Some concern about fluorosis but guidelines are well established and mainly accepted

o Many states allow not only dental professionals but school nurses, medical assistants and physicians, etc. to apply

• So what is the issue with Silver Diamine Fluoride (SDF)?

o It would appear that the use of SDF would readily fall within regulatory permissions to apply fluoride

o The general rule is that clinicians who are permitted to place fluoride varnish would likely be allowed to place SDF but in some states it could

be that only dentists are permitted to “perform caries arrest by medicament (Avear Fa et al, 2016)

• On second thought - Is SDF different and if so, what are the conditions under which it can be placed?

o Fluoride is considered a primary measure to prevent caries

o SDF might be considered a primary or a secondary or a tertiary preventative measure – it is used to prevent caries, to control existing caries,

and to also reduce symptoms of the disease

oralhealthworkforce.org 36

What Do We Know From the Literature?

• SDF is considered one of many tools in a caries management protocol that also include educational and

motivational interviewing interventions with patients

• Dental hygienists (DHs) are well positioned by training and education to provide preventive and educational

services, including application of SDF

• SDF is useful in the young, especially the uncooperative or those without easy access to a dental home,

among special needs population with limited tolerance for traditional therapies, and for the elderly

• These populations are often found in the dental safety net

• Many states permit expanded scope of practice for DHs in public health settings

• However, do states permit DHs to supply this service?


A Primer on Scope of Practice For Health Professions

• Term inclusive of the who, what, where, and when of practice

• Scope of practice (SOP) is described in statute and regulation by each state

o Legislature determines basic qualifications and parameters/ boundaries

o Governing board interprets legislative intent, describes the details of practice allowances, and manages

compliance and discipline

• Areas where barriers may arise in SOP that limit the ability of DHs to apply SDF

o Tasks allowed

o Classification of SDF

o Levels of required supervision

o Requirements for dental visit prior to any DH intervention

o Assessing or diagnosing

o Prescriptive/ dispensing authority


Scope of Practice for DHs Varies Widely by State


The Content and Composition of Statutes

and Regulations is State Specific

• Explicit or implicit permission to provide SDF may be found in various parts of statute

or regulation

o Definitions of the practice of dental hygiene

o Explicit provisions (e.g. list of allowable tasks)

o Implicit provisions (e.g. not included on list of prohibited tasks)

• Provisions in law or rules may be specific/ descriptive (FL)

• General permission by inference (AK, AZ)

• Board advisory opinions – over recent three or four years

o In many states, the board has rendered specific opinions relative to SDF (MT, GA, NH, NJ, etc.)


Level of Required Supervision is Critical to Enabling

Provision of SDF in Public Health Settings


• Application of SDF in traditional practice settings is mostly not problematic

o Task delegated by the supervising dentist

• Patients may not always present in private dental office

o WIC programs, schools, nursing homes, mobile and portable programs, migrant health centers, group

homes

• Many possible barriers In public health settings where patients may be ideal candidates for SDF therapy

o Dentist is not always present when DHs are with patients

o Application requires prior diagnosis and treatment planning

o Patient may not have access to a dentist to order or prescribe SDF

• Some states allow unsupervised or independent practice, collaborative practice protocols or public health

supervision in public health settings or to treat underserved populations (NY, ME, MT, SD)

Level of Supervision Required by States

for Fluoride Application by DHs

• The American Dental Hygienists’ Association provides an overview of DH practice acts by state on its Website. Fluoride application is permitted in every state but level of required supervision of the DH varies widely

o 2 states - direct supervision under all circumstances

o 26 states - under general supervision (dentist must authorize) but these states also have

some provision for direct access to this service from a DH without prior dental

authorization

o 2 states - direct access to fluoride application from a DH under all circumstances

o 14 states - under general supervision/prior authorization of a dentist

o 6 states - direct supervision but also allow general supervision under certain

circumstances

o 1 state - general supervision but allows direct access if a collaborative protocol is in place


How is Silver Diamine Fluoride Classified

• Is SDF a fluoride, a topical solution, a preventative chemical agent, a desensitizing agent, a medicament for

control or prevention of caries?

o FDA approved use in 2014 as a medical device to be used as a desensitizing agent

o In 2017, FDA gave the product breakthrough therapy status which allowed clinical trials and off label use as a “caries

arresting” treatment

o D1354 “interim caries arresting medication application” (CDT 2016)

• Is SDF the same as fluoride varnish?

o Regulations may limit the fluoride concentration that is permissible for dispensing by a DH

o SDF is 5% fluoride (2X concentration of varnish), 25% silver, 8% ammonia, remainder is water

• Colorado allows fluoride varnish with 5% concentration

• Is SDF a dental sealant ?

o Sealants are usually placed on non-cavitated teeth

o SDF is generally used on teeth with incipient or carious lesions


Is SDF Provisional or Permanent, Preventative or

Therapeutic?

• Is SDF an atraumatic restoration?

o Atraumatic restorations are considered provisional (reversible) therapies

o SDF application may cause permanent, irreversible changes to the tooth

o Guidelines - SDF should be considered an “interim” solution until patient can access dental consultation and intervention

o SDF is a useful tool for palliative interventions in the elderly where the cosmetic effects are of less importance than in

young children and may be the only treatment planned

• Is SDF preventative or therapeutic?

o Stannous/sodium fluoride varnish is widely viewed as preventive therapy

o SDF is generally applied to teeth with active caries to control and prevent progression

o SDF is both preventive and therapeutic with collateral impact on adjacent teeth

o SDF may also have some restorative properties

o Some boards mandate that SDF can only be used preventatively


States Classify SDF in Various Ways

• Arizona - “preventive and therapeutic agents” under general supervision

• Alabama - “topical fluoride” under direct supervision

• Florida - application of topical fluorides approved by the ADA or FDA including SDF

under general supervision or without supervision

• Hawaii - apply preventive chemical agents approved by the board. Board minutes

(January 23, 2017) indicate that SDF is a “preventive chemical agent”

• Georgia - use SDF for “preventative purposes only but not for treatment” (Georgia

Board of Dentistry minutes, May 4, 2018)

• Indiana - use antiseptic sprays, washes or medicaments for “control or prevention” of

dental caries


What Provisions in SOP Enable Access to SDF?

Public Health Dental Hygiene Practice/ Collaborative Practice/ Unsupervised

• Massachusetts allows DHS to apply anti-cariogenic agents including fluoride varnish and desensitizing agents under

general supervision. Public health DHs can apply these agents under the written collaborative agreement (234CMR:

5.11: Delegable Procedures)

• Florida permits DHs who have received formative or continuing education in SDF to apply SDF and fluoride varnishes

without supervision (645B-16.007 (4))

• Vermont Board issued an opinion (Meeting minutes November 2018) that Public Health DHs could apply SDF if several

conditions were met

o DH was appropriately trained

o Caries were suspected and patient presented with immediate need for care

o Patient did not have an accessible dental home

o Patient or parent executed a board approved informed consent

o Limited to two applications to the same tooth – patient must be referred to see dentist


How does a DH determine the need for SDF?

• Very few states allow DH diagnosis, most allow DH assessment and several also allow DH

treatment plans

• Fluoride is considered a preventive measure; preventive measures are generally within scope of

allowable services when public health dental hygiene is being practiced

• Some benign neglect relative to this issue

o Likely viewed as within DHs ability to “assess” the need for SDF

o SDF has primary preventive effects even though therapeutic/restorative effects are

coincident

• American Academy of Pediatric Dentistry suggested guidelines -a DH can place SDF, a dentist

should first diagnose incipient or mild caries, build a treatment plan that includes SDF, and

actively monitor the patient post application.

• Oklahoma - apply SDF but only after a dentist has diagnosed the patient and prescribed SDF

• Utah - apply SDF in accordance with a dentist’s diagnosis and treatment plan


What Other SOP Issues Affect Provision of SDF by

DHs?

• Regulations addressing dispensing or prescriptive authority vary by state

o Colorado law allowed unsupervised DHs to prescribe, administer, and dispense fluoride, fluoride varnish,

and antimicrobial solutions (CO Section 12-35-124 (1) but SDF was not on the prescriptive formulary

▪ Board issued a rule that SDF could only be applied under direct, indirect, or telehealth supervision

o Montana prescriptive/ dispensing authority specific to stannous or sodium fluoride (unless otherwise

stated) Rules (24.138.419(3) – amended in 2019 to include SDF 5%

• Payment restrictions

o Does the state Medicaid program cover the service? If so, under what conditions?

o Do managed care organizations in the state recognize DHs as providers?

o What about patients who lack dental insurance (e.g. the elderly)? Is there an adult dental benefit in

Medicaid?

• Prior education and training required in some states – formative program or CE?


What is the Impact of this Variability on Patient Care?

• States continue to issue opinions to clarify permissions to apply SDF

• Patients with limited ability to complete a dental visit may not benefit from the positive effects

of SDF when a prior dental visit is required

• Patients with compromised access to services may not be able to complete multiple visits to

obtain dental permission for SDF

• Especially for difficult to treat patients, more extensive or expensive dental interventions may

not be the most appropriate treatment choice

• While there is a CDT code to bill for SDF applications, state Medicaid programs may not be

paying for the services and some may only pay when it is part of a dentists’ services


Thank You

Acknowledgments:

• The American Dental Hygienists’ Association for their help with identifying state level provisions related to dental hygiene scope of practice and provision of Silver Diamine Fluoride

Questions?

Visit Us:

http://www.chwsny.org/

www.oralhealthworkforce.org


http://www.chwsny.org/

http://www.oralhealthworkforce.org/

ReferencesAlaska Board of Dental Examiners, Minutes of Meeting, December 8, 2017

https://www.commerce.alaska.gov/web/Portals/5/pub/DEN_Minutes_2017.12.pdf

American Dental Hygienists Association. Dental Hygiene Practice Act Overview: Permitted Functions and

Supervision Levels by State. https://www.adha.org/resources-

docs/7511_Permitted_Services_Supervision_Levels_by_State.pdf

American Dental Hygienists Association. State Information on Silver Diamine Fluoride. Personal Communication/

Unpublished Document

American Academy of Pediatric Dentists. AAPD Fact Sheet on Silver Diamine Fluoride in Arresting Dental Caries

and its Use in Medicaid Populations.

http://www.elevateoralcare.com/site/images/AAPDSDFmedicaid.pdf?promocode=&promocodeaction=overwrite

Arizona State Board of Dental Examiners. Open Session Minutes June 7, 2019.

https://dentalboard.az.gov/sites/default/files/Open_Session_MInutes_6-7-2019.pdf

Arizona State Board of Dental Examiners. Board Rules. https://dentalboard.az.gov/statutes-rules/rules


https://www.commerce.alaska.gov/web/Portals/5/pub/DEN_Minutes_2017.12.pdf

https://www.adha.org/resources-docs/7511_Permitted_Services_Supervision_Levels_by_State.pdf

http://www.elevateoralcare.com/site/images/AAPDSDFmedicaid.pdf?promocode=&promocodeaction=overwrite

https://dentalboard.az.gov/sites/default/files/Open_Session_MInutes_6-7-2019.pdf

https://dentalboard.az.gov/statutes-rules/rules

References

Avear Fa B, Horst JA, Hirsch JP, Duffin S, Wong A, Young DA. Arresting Caries. Dimensions of Dental Hygiene.

July 2016. https://dimensionsofdentalhygiene.com/article/arresting-caries/

Board of Dental Examiners of Alabama Administrative Code. Chapter 270-x-3 Dental Hygienists.

http://www.alabamaadministrativecode.state.al.us/docs/den/270-X-3.pdf

Board of Dental Examiners, State of Hawaii. Minutes of Meeting. Monday January 23, 2017.


Colorado Dental Association. Silver Diamine Fluoride Application by Dental Hygienists.

https://cdaonline.org/wp-content/uploads/2017/09/GRTab5c-SDF.pdf

Commonwealth of Massachusetts. Board of Registration in Dentistry. Meeting Minutes. December 7, 2016.

https://www.mass.gov/lists/previous-meetings-of-the-board-of-registration-in-dentistry#2016-

Florida Administrative Code. https://floridasdentistry.gov/Forms/laws-and-rules-dentistry.pdf

Georgia Board of Dentistry. Meeting Minutes. May 4, 2018. https://gbd.georgia.gov/2018-meeting-minutes


https://dimensionsofdentalhygiene.com/article/arresting-caries/



https://cdaonline.org/wp-content/uploads/2017/09/GRTab5c-SDF.pdf

https://www.mass.gov/lists/previous-meetings-of-the-board-of-registration-in-dentistry#2016-

https://floridasdentistry.gov/Forms/laws-and-rules-dentistry.pdf

https://gbd.georgia.gov/2018-meeting-minutes

ReferencesIndiana General Assembly. Indiana Code. Article 13. Dental Hygienists.

http://iga.in.gov/legislative/laws/2019/ic/titles/025#25-13

Montana Secretary of State. The Board of Dentistry.

http://www.mtrules.org/gateway/ChapterHome.asp?Chapter=24%2E138 and

http://boards.bsd.dli.mt.gov/Portals/133/Documents/den/24-138-76pro-arm.pdf?ver=2019

South Dakota Dental Association. Dentistry in South Dakota. Silver Diamine Is Seeing Use in South Dakota.

Summer 2018. https://www.sddental.org/docs/librariesprovider46/default-document-library/2018-s

Vermont Board of Dental Examiners. November 14, 2018 meeting minutes.

https://www.sec.state.vt.us/media/914464/dental-minutes-2018-1114.pdf

Kelly M. Are RDHs allowed to apply Silver Diamine Fluoride (SDF) in your state? Access. November 2017.

Oral Health Workforce Research Center. Variation in Dental Hygiene Scope of Practice by State.

http://www.oralhealthworkforce.org/resources/variation-in-dental-hygiene-scope-of-practice-by-state/


http://iga.in.gov/legislative/laws/2019/ic/titles/025#25-13

http://www.mtrules.org/gateway/ChapterHome.asp?Chapter=24.138

http://boards.bsd.dli.mt.gov/Portals/133/Documents/den/24-138-76pro-arm.pdf?ver=2019

https://www.sddental.org/docs/librariesprovider46/default-document-library/2018-s

https://www.sec.state.vt.us/media/914464/dental-minutes-2018-1114.pdf

http://www.oralhealthworkforce.org/resources/variation-in-dental-hygiene-scope-of-practice-by-state/

QUESTIONS?

55

Webinar Evaluation

https://www.surveymonkey.com/r/DQPSept19Webinar

*Must complete by EOD Wednesday, September 25 in order to receive CE

credit

https://www.surveymonkey.com/r/DQPSept19Webinar

56

Next Webinar

ICD-10: Diagnostic Coding in Dental

Thursday, October 31 1-2 p.m. ET

Click here to register

https://dentaquest.webex.com/dentaquest/k2/j.php?MTID=tc55db06be15458f9a5474b412aa0c55b