Content uploaded by Jeremy Horst
Author content
All content in this area was uploaded by Jeremy Horst on Mar 23, 2018
Content may be subject to copyright.
Journa
CALIFORNIA DENTAL ASSOCIATION
Periodontics and
Oral-Systemic Relationships
Atypical Presentation
of Zoster
Leadership Trajectories
of U.S. Dentists
January 2016
CDA JOURNAL, VOL 44, Nº1
JANUARY 2016 3
Jan. 2016
DEPARTMENTS
FEATURES
UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale,
Indications and Consent
This paper presents a systematic review, clinical indications, clinical protocol and consent
procedure to guide application for caries arrest treatment using silver diamine fluoride.
Jeremy A. Horst, DDS, PhD; Hellene Ellenikiotis, DDS; and Peter L. Milgrom, DDS
Periodontics and Oral-Systemic Relationships: Diabetes
It has been proposed that periodontal disease is a risk factor for systemic diseases. This
paper explores its relationship to diabetes.
Alison Glascoe, DDS, MS; Ronald Brown, DDS, MS; Grace Robinson, DDS; and Kassahun Hailu, DDS
Atypical Presentation of Zoster Mimicking Headache and Temporomandibular
Disorder: A Case Report
This article reports on a case of trigeminal herpes zoster, which presented as sudden onset
headache and acute temporomandibular pain in the prodromal phase.
Mohammad Reza Zarei, DDS, MSc, and Goli Chamani, DDS, MSc
A National Survey of Positional Leadership Trajectories of U.S. Dentists
This paper extends the nascent work in understanding leadership among dentists.
David Chambers, EdM, MBA, PhD
17
29
35
39
The Editor/My Microbiome and Me
Impressions
RM Matters/Top Seven Data Breach Considerations
Regulatory Compliance/HIPAA Security Rule
Technical Safeguards
Periscope
Tech Trends
Dr. Bob/Protest Now
5
7
49
55
59
64
65
7
CDA JOURNAL, VOL 44, Nº1
JANUARY 2016 17
silver diamine
Since its approval in Japan more
than 80 years ago,2 more than 2 million
containers have been sold. The silver acts
as an antimicrobial, the uoride promotes
remineralization and the ammonia
stabilizes high concentrations in solution.3
Because silver diamine uoride
is new to American dentistry and
dental education, there is a need for a
standardized guideline, protocol and
consent. The University of California,
San Francisco, School of Dentistry
paradigm shift committee assembled a
subcommittee with the following goals:
■ Use available evidence to develop
a list of clinical indications.
■ De ne a protocol that
maximized safety and ef cacy
and minimized inadvertent
staining of clinical facilities.
Until now, no option for the
treatment of dental caries in
the U.S. besides restorative
dentistry has shown
substantial ef cacy.1 Silver
diamine uoride is an inexpensive topical
medicament used extensively in other
countries to treat dental caries across
the age spectrum. No other intervention
approaches the ease of application and
ef cacy. Multiple randomized clinical
trials — with hundreds of patients each
— support its use for caries treatment,
thus substantiating an intervention
that addresses an unmet need in
American dentistry. In August 2014,
the Food and Drug Administration
(FDA) cleared the rst silver diamine
uoride product for market, and as of
April 2015, that product is available.
AUTHORS
Jeremy A. Horst, DDS,
PhD, is a fellow at the
University of California,
San Francisco, School
of Dentistry studying the
bacteria that cause cavities,
a pediatric dentist at
Alameda Pediatric Dentistry
and co-founder and CSO
at OraViz.
Confl ict of Interest
Disclosure: Dr. Horst is
co-founder and CSO at
OraViz.
UCSF Protocol for
Caries Arrest Using Silver
Diamine Fluoride: Rationale,
Indications and Consent
Jeremy A. Horst, DDS, PhD; Hellene Ellenikiotis, DDS; and Peter L. Milgrom, DDS
ABSTRACT The Food and Drug Administration recently cleared silver diamine
uoride for reducing tooth sensitivity. Clinical trials document arrest and prevention
of dental caries by silver diamine uoride. This off-label use is now permissible
and appropriate under U.S. law. A CDT code was approved for caries arresting
medicaments for 2016 to facilitate documentation and billing. We present a
systematic review, clinical indications, clinical protocol and consent procedure to
guide application for caries arrest treatment.
Hellene Ellenikiotis, DDS,
is a resident in the University
of California, San Francisco,
general practice residency
and a recent graduate of the
University of California, San
Francisco School of Dentistry.
Confl ict of Interest
Disclosure: None reported.
Peter L . Milgrom, DDS, is
a professor of dental public
health sciences and pediatric
dentistry and director of the
Northwest Center to Reduce
Oral Health Disparities at
the University of Washington
in Seattle.
Confl ict of Interest
Disclosure: Dr. Milgrom is
a principal in ADP Silver
Dental Arrest LLC, which
licenses permission to market
Advantage Arrest to Elevate
Oral Care LLC.
CDA JOURNAL, VOL 44, Nº1
18 JANUARY 2016
■ Build an informed consent
document at the eighth-
grade reading level.
We conducted a systematic review,
inquired of authors of published clinical
and in vitro studies about details and
considerations in their protocols and
consulted experts in cariology and
materials chemistry where evidence was
lacking. The work of this committee
resulted in the adoption of silver diamine
uoride use in the UCSF student clinics.
Methods
A literature review was designed by
a medical librarian to search PubMed
and the International Association of
Dental Research abstract archive with
the following search terms: “33040-28-7”
OR “1Z00ZK3E66” OR “silver diamine
uoride” OR “silver uoride” OR “silver
diamine uoride” OR “diammine silver
uoride” OR “ammonical silver uoride”
OR “ammoniacal silver uoride”.
Differences in nomenclature have
led to confusion around this material.
Another review was completed with
the terms “dental” OR “caries” AND
“silver nitrate” AND “clinical.”
Material
Silver diamine uoride (38% w/v
Ag(NH3)2F, 30% w/w) is a colorless
topical agent comprised of 24.4-28.8%
(w/v) silver and 5.0-5.9% uoride at pH
10,4 and marketed as Advantage Arrest
by Elevate Oral Care LLC (West Palm
Beach, Fla.). Other companies may market
silver diamine uoride in the future
following determination of substantial
equivalence and FDA clearance.
Mechanisms
Silver diamine uoride is used for
caries arrest and treatment of dentin
hypersensitivity. In the treatment
of exposed sensitive dentin surfaces,
silver diamine
topical application results in the
development of a squamous layer on the
exposed dentin, partially plugging the
dentinal tubules.5 High concentration
aqueous silver has been long known to
form this protective layer.6 Decreased
sensitivity in treated patients7,8 is
consistent with the hydrodynamic
theory of dentin hypersensitivity.9
Dental caries is a complex
progression involving dietary sugars,
bacterial metabolism, demineralization
and organic degradation. The
collagenous organic matrix is
exposed once a dentin surface is
demineralized and destroyed by native
and bacterial proteases to enable a
lesion to enlarge.10 Upon application
of silver diamine uoride to a decayed
surface, the squamous layer of silver
protein conjugates forms, increasing
resistance to acid dissolution and
enzymatic digestion.11 Hydroxyapatite
and uorapatite form on the exposed
organic matrix, along with the presence
of silver chloride and metallic silver.5
The treated lesion increases in mineral
density and hardness while the lesion
depth decreases.5 Meanwhile, silver
diamine uoride speci cally inhibits
the proteins that break down the
exposed dentin organic matrix: matrix
metalloproteinases,11 cathepsins12
and bacterial collagenases.5 Silver
ions act directly against bacteria
in lesions by breaking membranes,
denaturing proteins and inhibiting
DNA replication.13,14 Ionic silver
deactivates nearly any macromolecule.
Silver diamine uoride outperforms
other anticaries medicaments in killing
cariogenic bacteria in dentinal tubules.15
Silver and uoride ions penetrate
~25 microns into enamel16 and 50-
200 microns into dentin.17 Fluoride
promotes remineralization, and silver
is available for antimicrobial action
upon release by re-acidi cation.18
Silver diamine uoride arrested
lesions are 150 microns thick.19
Arti cial lesions treated with
silver diamine uoride are resistant
to bio lm formation and further
cavity formation, presumably due
to remnant ionic silver.20,21 More
silver and uoride is deposited in
demineralized than nondemineralized
dentin. Correspondingly, treated
demineralized dentin is more resistant
to caries bacteria than treated sound
dentin.22 When bacteria killed by
silver ions are added to living bacteria,
the silver is re-activated so that
effectively the dead bacteria kill the
living bacteria in a “zombie effect.”23
This reservoir effect helps explain
why silver deposited on bacteria and
dentin proteins within a cavity has
sustained antimicrobial effects.
Clinical Evidence
Silver Nitrate Plus Fluoride Varnish
Before the FDA cleared silver
diamine uoride, some U.S. dentists
sequentially applied silver nitrate then
uoride varnish to dentinal decay
as the only available noninvasive
option for caries treatment. Duf n
rediscovered silver nitrate from the
early literature,24 which had been lost
Silver diamine
fl u o r i d e o u t p e r f o r m s
other anticaries
medicaments in killing
cariogenic bacteria
in dentinal tubules.
CDA JOURNAL, VOL 44, Nº1
JANUARY 2016 19
to modern cariology. Surprisingly, there
is no mention of silver nitrate in either
of the American Dental Association
Council on Scienti c Affairs reports on
Non uoride Caries-Preventive Agents25
or Managing Xerostomia and Salivary
Gland Hypofunction,26 and it is not part
of standard dental school curricula.
Case series of carious lesions arrested
by silver nitrate date to the 1800s. For
example, in 1891, 87 of 142 treated
lesions were arrested.27 Percy Howe,
DDS, then director of the Forsyth
Institute in Boston, added ammonia
to silver nitrate, making it more stable
and effective as an antimicrobial for
application to any infected tooth
structure from early cavitated lesions
to infected root canals.28 Duf n added
the application of uoride varnish
following silver nitrate, simulating
silver diamine uoride. While his clinic
doubled in patients, cases needing
general anesthesia disappeared. His
review of randomly selected charts
showed only seven of 578 treated
lesions progressed within two and a half
years to the point that extractions were
needed.24 Thus, with the exception of
Duf n’s and one other report, attention
to silver nitrate largely disappeared
by the 1950s. The lore is that use
and teaching of this intervention
were lost with the introduction of
effective local anesthetic to enable
painless restorations and uoride
for caries prevention. Because no
high-quality clinical trials have been
performed, we did not include the
silver nitrate plus uoride varnish
regimen in our recommendation.
Silver Diamine Fluoride
We found nine published randomized
clinical trials evaluating silver diamine
uoride for caries arrest and/or prevention
of at least one year in duration. These
studies each involved hundreds of
children aged 3 to 9 or adults aged 60 to
89 (FIGURES 1 and 2). Most participants
had low (< 0.3 ppm) uoride in the
environmental water and reported using
uoride toothpaste (e.g., 73 percent).29
Silver diamine uoride was applied
with cotton isolation. Lesions were
detected with mirror and explorer
only. All studies were registered and
met the Consolidated Standards of
Reporting Trials requirements. Clinical
cases and studies not meeting these
criteria can be found elsewhere.30
Caries arrest increased dramatically
after reapplication from one year
posttreatment31-33 to one and a half
years,31,34 and increasingly to two to three
years (FIGURE 1).29,31,35 Single application
without repeat lost effect over time in
the elderly.32 Twice per year application
resulted in more arrest than once per
year.31,35 Twelve percent silver diamine
uoride was markedly less effective.32
Darkening of the entire lesion
indicated success at follow-up and is
suggested to facilitate diagnosis of caries
arrest status by nondentists. A longitudinal
study reported that color activation of
silver diamine uoride with 10% stannous
uoride resulted in less rst molar caries.36
Tea extract was used in one group to
activate color change for improved
follow-up diagnosis; no differences
in arrest were seen.32 Indeed, when
stannous uoride was used to activate
color change, a break in the black color
within a lesion at six months was highly
sensitive and speci c for active caries.37
Silver diamine uoride greatly
outperformed uoride varnish for
caries arrest29 and was equivalent or
better than glass ionomer cement
(GIC) (FIGURE 1).31,33 The addition
of semiannual intensive oral health
education with the application of silver
diamine uoride in the elderly increased
the arrest of root caries (FIGURE 1).38
Caries Prevention
When silver diamine uoride
was applied only to carious lesions,
impressive prevention was seen for
other tooth surfaces.29,35 Fluoride-
releasing GIC can have this effect
but it is limited to surfaces adjacent
to the treated surface and of short
duration. Direct application to healthy
surfaces in children also helps prevent
caries (FIGURE 2).29,35,39 Two studies
show great difference in the level
of prevention in the elderly;38,40 the
difference is hard to reconcile. As seen
for arrest, prevention is less after one
year without repeat application.41
Annual application of silver
diamine uoride prevented many more
carious lesions than four-times-per-
year uoride varnish in both children29
and the elderly.40 Prevention was
roughly equivalent to twice-per-year
varnish in one study (FIGURE 2).39
The addition of semiannual intensive
oral health education in a study of
the elderly increased prevention.38
Although many fell out, GIC or resin
sealants outperformed silver diamine
uoride in preventing caries in the
rst molars of children,39,41 though
the cost was ~20 times more.
When stannous fl uoride
was used to activate color
change, a break in the black
color within a lesion at six
months was highly sensitive
and specifi c for active caries.
CDA JOURNAL, VOL 44, Nº1
20 JANUARY 2016
Ongoing Trials
Unpublished reports of clinical
studies unanimously con rm better
caries arrest and/or prevention by
silver diamine uoride over control or
other materials. A one-year report of a
study of the elderly demonstrated that
the addition of a saturated solution of
potassium iodide (SSKI) to decrease
discoloration did not signi cantly alter
caries arrest or prevention.42 This was
con rmed in the two-year examinations
(personal communication, Edward Lo).
A one-year report of a study in children
showed that the application once per
week for three consecutive weeks, once
per year, was more effective than that
of single annual application.43 Other
studies have recently begun to evaluate
the ability of silver diamine uoride to
arrest interproximal carious lesions, to
compare the relative ef cacy of silver
diamine uoride to the combination of
silver nitrate plus uoride varnish and
to compare the effects on populations
with or without access to uoridated
water. Final reports from these studies
will follow in the coming years.
Recommendations From the Literature
on Clinical Ef cacy
These studies show that 38%
silver diamine uoride is effective and
ef cient in arresting and preventing
carious lesions. Application only
to lesions appears to be similarly
effective in preventing cavities in
other teeth and surfaces as applying
directly. Single application appears
insuf cient for sustained effects,
while annual re-application results in
remarkable success, and even greater
effects with semi-annual application.
From these data, we recommend
twice-per-year application, only to
carious lesions without excavation,
for at least the rst two years.
silver diamine
FIGURE 1. Graphic summary of randomized controlled trials demonstrating caries arrest after topical treatment
with 38% silver diamine fl uoride (SDF). Studies are arranged vertically by frequency of silver diamine fl uoride
application. Caries arrest is defi ned as the fraction of initially active carious lesions that became inactive and fi rm to
a dental explorer. SDF (38% unless noted otherwise); q6mon, every six months; q1year, every year; q3mon, every
three months; GIC, glass ionomer cement; NaF, 5% sodium fl uoride varnish; + OHI q6mon, SDF every year and
oral hygiene instructions every six months.
For any patient with active caries,
we recommend considering replacement
of uoride varnish as the primary means
to prevent new lesions, with application
of silver diamine uoride to the active
lesions only. For patients without access
to both sealants and monitoring, silver
diamine uoride is the agent of choice for
prevention of caries in permanent molars
— particularly as there is no margin to
leak and thereby facilitate deep caries
and it does not stain sound enamel.
■ SDF q6mon
■ control
■ SDF q6mon
■ SDF q1year
■ GIC q1year
■ SDF q1year
■ exc SDF q1year
■ exc NaF q3mon
■ NaF q3mon
■ control
■ SDF q1year
■ + OHI q6mon
■ control
■ SDF once
■ SDF, tannate
■ 12% SDF once
■ control
■ 30% SDF once
■ GIC once
Llodra et al., 2005
373 6-year-olds
3.2 lesions at start
Zhi et al., 2012
181 3- to 4-year-olds
3.4 surfaces at start
Chu et al., 2002
308 3- to 5-year-olds
6 lesions at start
Zhang et al., 2013
227 60- to 89-year-
olds
0.91 lesions at start
Yee et a l., 20 09
624 3- to 9- year olds
6.8 lesions at start
Santos et al., 2014
322 5- to 6-year-olds
3.8 lesions at start
3
0%
Time (in years)
Arrested caries
.5 21.512.5
50%
50%
50%
50%
50%
50%
100%
100%
100%
100%
100%
100%
CDA JOURNAL, VOL 44, Nº1
JANUARY 2016 21
Safety
Maximum Dose and Safety Margin
The margin of safety for dosing is of
paramount concern. In gaining clearance
from the FDA, female and male rat
and mouse studies were conducted to
determine the lethal dose (LD50) of silver
diamine uoride by oral and subcutaneous
administration. Average LD50 by oral
administration was 520 mg/kg and by
subcutaneous administration was 380
mg/kg. The subcutaneous route is taken
here as a worst-case scenario. One drop
(25 μL) is ample material to treat ve
teeth and contains 9.5 mg silver diamine
uoride. Assuming the smallest child with
caries would be in the range of 10 kg, the
dose would be 0.95 mg/kg child. Thus,
the relative safety margin of using an
entire drop on a 10 kg child is 380 mg/kg
LD50/0.95 mg/kg dose = four-hundredfold
safety margin. The actual dose is likely
to be much smaller, for example 2.37
mg total for three teeth was the largest
dose measured in six patients.46 The
most frequent application monitored in a
clinical trial was weekly for three weeks,
annually.43 Thus, we set our recommended
limit as one drop (25 μL) per 10 kg per
treatment visit, with weekly intervals at
most. This dose is commensurate with the
Environmental Protection Agency’s (EPA)
allowable short-term exposure of 1.142 mg
silver per liter of drinking water for one
to 10 days (Agency for Toxic Substances
and Disease Registry, ATSDR, 1990).
Cumulative exposure from lower-
level acute or chronic silver intake has
no real physiologic disease importance,
but the bluing of skin in argyria should
obviously be avoided. The EPA set the
lifetime exposure conservatively at 1
gm to safely avoid argyria. The highest
applied dose for three teeth measured
in the pharmacokinetic study, 2.37 mg,
would enable > 400 applications.46 Silver
FIGURE 2. Graphic summary of randomized controlled trials demonstrating caries prevention after topical
treatment of carious lesions with 38% silver diamine fl uoride. Prevented caries is defi ned as the fraction of new
carious lesions in treatment groups as compared to those in the placebo or no treatment control group. Chlorhex,
1% chlorhexidine varnish.
Longer studies are needed to
determine whether caries arrest and
prevention can be maintained with
decreased application after two to three
years, and whether more frequent use
would enhance ef cacy. Traditional or
nontraditional restorative approaches, such
as the atraumatic restorative technique
(ART)44 and Hall crowns,45 should be
performed as dictated by the response
of the patient, disease progression and
the nature of individual lesions.
■ SDF q6mon
■ SDF q1year
■ Sealant once
■ NaF q6mon
■ SDF q1year
■ exc SDF q1year
■ exc NaF q3mon
■ NaF q3mon
■ SDF q1year
■ NaF q3mon
■
Chlorhex q3mon
■ SDF q1year
■ + OHI q6mon
■ SDF once
■ GIC sealant
once
Llodra et al., 2005
373 6-year-olds
control: 2.5 new lesions
(only applied to lesions)
Liu et al., 2012
482 9.1-year-olds
control: 4.6 new lesions
Chu et al., 2002
308 3- to 5-year-olds
control: 1.6 new lesions
(only applied to lesions)
Tan et a l., 2010
203 79-year-olds
control: 2.5 new lesions
Zhang et al., 2013
227 60- to 89-year-olds
control: 1.3 new lesions
Monse et al., 2012
708 6- to 8-year-olds
control: 0.44 new lesions
0%
Time (in years)
Prevented caries
.5
50%
50%
50%
50%
50%
50%
100%
100%
100%
100%
100%
100%
321.512.5
CDA JOURNAL, VOL 44, Nº1
22 JANUARY 2016
nitrate (typically a 25% solution) has
been used for more than 100 years in
the U.S. without incident, including
acceptance by the ADA, and in other
countries for arresting dental caries.3
Adverse Effects
Not a single adverse event has been
reported to the Japanese authorities since
they approved silver diamine uoride
(Saforide, Toyo Seiyaku Kasei Co. Ltd.,
Osaka, Japan) more than 80 years ago.47
The manufacturer estimates that more
than 2 million multi-use containers have
been sold, including > 41,000 units in
each of the last three reporting years.
In the nine randomized clinical
trials in which silver diamine uoride
was applied to multiple teeth to arrest
or prevent dental caries, the only side
effect noted was for three of 1,493
children or elderly patients monitored for
one to three years who experienced “a
small, mildly painful white lesion in the
mucosa, which disappeared at 48 [hours]
without treatment.”29,31-33,35,38,40,41,48 The
occurrence of reversible localized changes
to the oral mucosa was predicted in the
rst reports of longitudinal studies.49 No
adverse pulpal response was observed.
Gingival responses have been minimal.
In a pharmacokinetic study of silver
diamine uoride application to three
teeth in each of six 48- to 82-year-olds,
no erythema, bleeding, white changes,
ulceration or pigmentation was found
after 24 hours. Serum uoride hardly
went up from baseline, while serum silver
increased about tenfold and stayed high
past the four hours of measurement.46 In
a two-site hypersensitivity trial of 126
patients in Peru, at baseline 9 percent of
patients presented redness scores of 2 (1
being normal, 2 being mild to moderate
redness and 3 being severe); and after
one day, 13 percent in silver diamine
uoride treated patients versus 4 percent
in controls. All redness was gone at seven
days. Meanwhile, gingival index improved
slightly in silver diamine uoride treated
patients.7 Nonetheless, gingival contact
should be minimized. In our experience,
it has been adequate to coat the nearby
gingiva with petroleum jelly, use the
smallest available microsponge and dab
the side of the dappen dish to remove
excess liquid before application.
Concerns for uoride safety are most
relevant to chronic exposure,50 whereas
this is an acute exposure. Chronically
high systemic uoride results in dental
uorosis. The ubiquitous use of uoride-
based gas in general anesthetics has shown
that the rst acute response is transient
renal holding, and is rare.51 Concerns
have been raised about poorly controlled
silver diamine uoride concentrations52
and uorosis appearing in treated rats.53
However, silver and uoride levels are
closely monitored for the U.S. product,
and the Health Department of Western
Australia conducted a study that found
no evidence of uorosis resulting from
long-term proper use of silver diamine
uoride.54 Therefore, we have concluded
that the development of uorosis after
application of the U.S.-approved product
is not a clinically signi cant risk.
Silver allergy is a contraindication.
Relative contraindications include any
signi cant desquamative gingivitis or
mucositis that disrupts the protective
barrier formed by strati ed squamous
epithelium. Increased absorption and
pain would be expected with contact.
Heightened caution and use of a
protective gingival coating may suf ce.
A saturated solution of potassium
iodide (SSKI) is contraindicated in
pregnant women and during the rst
six months of breastfeeding because
of the concern of overloading the
developing thyroid with iodide; thyroid
specialists suggested a pregnancy test
prior to use in women of childbearing
age uncertain of their status.
Nonmedical Side Effects
Silver diamine uoride darkens carious
lesions. At least for children, many
parents have seen the color changes as
a positive indication that the treatment
was effective.29 Application of an SSKI
immediately following silver diamine
uoride treatment is thought to decrease
staining (patent US6461161). This
is an off-label use; potassium iodide is
approved as an over-the-counter drug to
facilitate mucus release to breathe more
easily with chronic lung problems and
to protect the thyroid from radioactive
iodine in radiation emergencies. In
our clinical experience, SSKI helps
but does not dramatically effect stain;
arrested lesions normally darken. Most
stain remains at the dentin-enamel or
cementum-enamel junction. However,
SSKI maintains resistance to bio lm
formation or activity in laboratory
studies.20 Also, SSKI maintained caries
arrest ef cacy in the early results of an
ongoing clinical trial.42 Meanwhile, silver
diamine uoride-treated lesions can
also be covered with GIC or composite
(see below for discussion on bonding).
Patients note a transient metallic
or bitter taste. In our experience, with
judicious use, the taste and texture
silver diamine
At least for children,
many parents have seen
the color changes as a
positive indication that the
treatment was eff ective.
CDA JOURNAL, VOL 44, Nº1
JANUARY 2016 23
response is more favorable than the
response to uoride varnish.
Even a small amount of silver diamine
uoride can cause a “temporary tattoo” to
the skin (on the patient or provider), like
a silver nitrate stain or henna tattoo, and
does no harm. Stain on the skin resolves
with the natural exfoliation of skin in two
to 14 days. Universal precautions prevent
most exposures. Long-term mucosal
stain, local argyria akin to an amalgam
tattoo, has been observed when applying
silver nitrate to intraoral wounds; we
anticipate similar stains with submucosal
exposure to silver diamine uoride.
Silver diamine uoride stains clinic
surfaces and clothes. The stain does not
come out once it sets. Spills should be
cleaned up immediately with copious
water, ethanol or bleach. High pH solvents
such as ammonia may be more successful.
Secondary containers and plastic liners
for surfaces are adequate preventives.
Effects on Bonding
Using a contemporary bonding system,
silver diamine uoride had no effect on
composite bonding to noncarious dentin
using either self-etch or full-etch systems.55
In one study, simply rinsing after silver
diamine uoride application avoided a
50 percent decrease in bond strength for
GIC.56 In another study, increased dentin
bond strength to GIC was observed.57
Silver diamine uoride decreased dentin
bonding strength of resin-based crown
cement by approximately one-third.58
Thus, rinsing will suf ce for direct
restorations, while excavation of the silver
diamine uoride-treated super cial dentin
is appropriate for cementing crowns.
Indications
Countless patients would bene t
from conservative treatment of
nonsymptomatic active carious lesions.
We discuss the fo llowin g indi cation s.
First, extreme caries risk is de ned
as patients with salivary dysfunction,
usually secondary to cancer treatment,
Sjogren’s syndrome, polypharmacy, aging
or methamphetamine abuse. For these
patients, frequent prevention visits and
traditional restorations fail to stop disease
progression. Similar disease recurrence
occurs in severe early childhood caries.
Second, some patients cannot
tolerate standard treatment for medical
or psychological reasons. These include
the precooperative child, the frail elderly,
those with severe cognitive or physical
disabilities and those with dental phobias.
Various forms of immunocompromise
mean that these same patients have a
much higher risk of systemic infection
arising from untreated dental caries. Many
only receive restorative care with general
anesthesia or sedation and others are not
good candidates for general anesthesia due
to frailty or another medical complexity.
The Centers for Disease Control and
Prevention (CDC) estimates 1.4 million
people in the U.S. live in nursing
homes and 1.2 million live in hospice.59
These individuals tend to have medical,
behavioral, physical and nancial
limitations that beg a reasonable option.
Third, some patients have more
lesions than can be treated in one visit,
such that new lesions arise or existing
lesions become symptomatic while
awaiting completion of treatment. This
is particularly relevant to the dental
school setting where treatment is slow.
American dentistry has been desperately
lacking an ef cient instrument to be
used at the diagnostic visit to provide
a step toward controlling the disease.
Fourth, some lesions are just dif cult
to treat. Recurrent caries at a crown
margin, root caries in a furcation or
the occlusal of a partially erupted
wisdom tooth pose a challenge to
access, isolation and cleansability
necessary for restorative success.
Following the above considerations, we
developed four indications for treatment of
dental caries with silver diamine uoride:
1. Extreme caries risk (xerostomia or
severe early childhood caries).
2. Treatment challenged by behavioral
or medical management.
3. Patients with carious lesions that
may not all be treated in one visit.
4. Dif cult to treat dental carious
lesions.
Finally, these indications are for
our school clinics. They do not address
access to care. The U.S. Department of
Health and Human Services estimates
108 million Americans are without dental
insurance, and there are 4,230 shortage
areas with 49 million people without
access to a dental health professional.60
Unlike llings, failure of silver diamine
uoride treatment does not appear to
create an environment that promotes
caries, and thus needs to be monitored.
Thus, a nal important indication is:
5. Patients without access
to dental care.
Clinical Application
We considered practical strategies
to maximize safety and effectiveness
in the design of a clinical protocol for
the UCSF dental clinics (FIGURE 3).
The key factor is repeat application
Countless patients
would benefi t from
conservative treatment
of nonsymptomatic
active carious lesions.
CDA JOURNAL, VOL 44, Nº1
24 JANUARY 2016
over multiple years. We believe that
dryness of the lesion during application
is also important. Isolation with gauze
and/or cotton rolls is suf cient, while
air drying prior to application is thought
to improve effectiveness. Allowing one
to three minutes for the silver diamine
uoride to soak into and react with
a lesion is thought to effect success.
Allowing only a few seconds to soak
in due to the cooperation limits of
very young patients commonly results
in arrest. Application time in clinical
studies does not correlate to outcome.
However, our committee decided to be
cautious in our recommendations for
initial use. Longer absorption time also
decreases concerns about removing silver
diamine uoride with a posttreatment
rinse. Removing any excess material
with the same cotton used to isolate is
routine to minimize systemic absorption.
Many clinicians place silver diamine
uoride at the diagnostic visit, then at
one and/or three-month follow ups, then
at semiannual recall visits (six, 12, 18,
24 months). Whether application needs
silver diamine
Silver Diamine Fluoride (SDF)
UCSF Protocol for Arresting Dental Carious Lesions or Treating Tooth Sensitivity
Material: Advantage Silver Arrest (38% SDF, purifi ed water) from Elevate Oral Care.
Shelf life: three years unopened. Do not refrigerate. Avoid freezing or extreme heat.
Indications:
1. Extreme caries risk (xerostomia or severe early childhood caries).
2. Treatment challenged by behavioral or medical management.
3. Patients with carious lesions that may not all be treated in one visit.
4. Diffi cult to treat dental carious lesions.
5. Patients without access to dental care.
Maximum dose: 25 µL (1 drop) / 10kg per treatment visit.
SDF Contraindication: Silver allergy.
SDF Relative Contraindications: Ulcerative gingivitis, stomatitis.
SSKI Contraindications: Pregnancy, breastfeeding.
Considerations:
• Decayed dentin will darken as the caries lesions arrest. Most will be dark brown or black.
• SDF can stain the skin, which will clear in two to three weeks without treatment.
• SDF can permanently stain operatory surfaces and clothes.
• A control restoration (e.g., GI via ART or other material) may be considered after SDF treatment.
• Saturated solution of potassium iodide (SSKI, Lugol’s Solution, various sources) can be used after SDF to decrease color changes.
• Re-application is usually recommended, biannually until the cavity is restored or arrested or the tooth exfoliates.
Procedure:
1. Plastic-lined cover for counter, plastic-lined bib for patient.
2. Standard personal protective equipment (PPE) for provider and patient.
3. One drop of SDF into the deep end of a plastic dappen dish
(also obtain one drop of SSKI in a separate dappen dish if selected).
4. Remove bulk saliva with saliva ejector.
5. Isolate tongue and cheek from aff ected teeth with 2-inch by 2-inch gauze or cotton rolls.
6. If near the gingiva, consider applying petroleum jelly with a cotton applicator for safety.
7. Dry aff ected tooth surfaces with triple syringe or if not feasible dry with cotton.
8. Bend microsponge, immerse into SDF, remove excess on side of dappen dish.
9. Apply directly onto the aff ected tooth surface(s) with microsponge.
10. Allow SDF to absorb for up to one minute if reasonable, then remove excess with gauze or cotton roll.
(If using SSKI, apply with a diff erent microsponge. Repeat one to three times until no further white precipitates are observed.
Wait fi ve to 10 seconds between applications. Remove excess with cotton.)
11. Rinse with water.
12. Place gloves, cotton and microbrushes into plastic waste bags.
FIGURE 3. Clinical protocol for the UCSF dental clinics.
CDA JOURNAL, VOL 44, Nº1
JANUARY 2016 25
to continue after two or three years to
maintain caries arrest is not known.
Another approach is simply to substitute
silver diamine uoride for any application of
uoride varnish to a patient with untreated
carious lesions. Increased frequency
with higher disease burden follows the
caries management by risk assessment
(CAMBRA) principles.61 It is relevant to
take photographs to track lesions over time.
Efforts to improve the penetration
of silver diamine uoride into affected
dentin by chemical cavity preparation
have not been studied but are being
explored clinically. Pretreatment with
ethylenediaminetetraacetic acid (EDTA)
to remove super cial hydroxyapatite in
affected dentin may open the dentinal
tubules to further silver diamine
uoride penetration. Pretreatment
with hypochlorite (bleach) may help
breakdown bacteria and exposed dentin
proteins, but this may be redundant to
the action of the silver. Hypochlorite to
decrease discoloration after silver diamine
uoride treatment is not recommended, as
the color comes from silver that cannot be
broken down like organic chromophores
and might break down dentin proteins
stabilized against the effects of bacteria
and acid by interactions with silver.
Experience with the combination of
silver nitrate plus uoride varnish (see
above) has many practitioners asking
about a topical varnish after silver
diamine uoride placement to prevent
silver diamine uoride taste and keep the
silver diamine uoride in the lesion. We
see no evidence that varnish would help
achieve either goal. Varnish does not seal.
Rather, allowing more time for residence
and diffusion of silver diamine uoride to
react with and dry into the lesion is more
likely to improve effectiveness. Also, in
our experience, silver diamine uoride
results in less aversive taste and texture
responses than to uoride varnish.
Decreased darkening of lesions in
the esthetic zone improves acceptance.
SSKI is an option if the patient is not
pregnant, though signi cant darkening
should still be expected. SSKI and silver
diamine uoride are not to be combined
prior to application — SSKI can be
placed after drying the silver diamine
uoride-treated tooth. Silver diamine
uoride does not prevent restoration of a
lesion, thus it does not prevent esthetic
options. While silver diamine uoride
has been shown to be more effective than
ART or interim restorative treatment
(IRT),33 the two are compatible and can
be combined across one or more visits.
The California Business and Professions
Code permits dental hygienists and
assistants to apply silver diamine uoride for
the control of caries because they are topical
uorides (Section 1910.(b)). Physicians,
nurses and their assistants are permitted to
apply uorides in California and in many
other states and federal programs. The
recent decision of the Oregon Dental Board
to allow dental hygienists and assistants to
place silver diamine uoride under existing
rules for topical uoride medicaments
sets a precedent. Dental hygienists and
assistants in Oregon were barred from
providing silver nitrate in a previous
decision. All providers need to be trained.
Applications should be tracked if applied
to the same patient by multiple clinics.
Documentation and Billing
A new code, D1354, for “interim
caries arresting medication application”
was approved by the Code on Dental
Procedures and Nomenclature (CDT)
Code Maintenance Commission
for 2016. The code de nition is
“Conservative treatment of an active,
nonsymptomatic carious lesion by
topical application of a caries arresting
or inhibiting medicament and without
mechanical removal of sound tooth
structure.” The CDT Code is the
U.S. HIPAA standard code set and is
required for billing. The Commission
includes representatives from the
major insurers, Medicaid, ADA, AGD
and specialty organizations. Insurers
are in the process of evaluating
coverage for this treatment.
Legal Considerations
Silver diamine uoride is cleared
by the FDA for marketing as a Class
II medical device to treat tooth
sensitivity. We are discussing off-label
use as a drug to treat and prevent dental
caries. This is a parallel situation to
uoride varnish, which has the same
device clearance but is ubiquitously
used off label by dentists and physicians
as a drug to prevent caries. The same
public health dentists who achieved
the FDA device clearance are now
applying for a dental caries indication.
However, this is a more complicated
process, normally only carried out
by large pharmaceutical companies,
and is likely to take longer.
Consent
Because silver diamine uoride
is new in the U.S., it is important to
communicate effectively. In the UCSF
clinics, we are using a special consent
form (FIGURE 4) as a way to inform
patients, parents and caregivers, and
In our experience, silver
diamine fl uoride results
in less aversive taste
and texture responses
than to fl uoride varnish.
CDA JOURNAL, VOL 44, Nº1
26 JANUARY 2016
to standardize procedures because we
have so many inexperienced student
clinicians. All practices have established
procedures for consent and an extra form
may not be needed in the community.
The normal elements of informed consent
apply. We sought to ensure awareness
of the expected change in color of the
dentin as the decay arrests, likelihood of
reapplication and contraindications in the
presence of silver allergy and stomatitis.
Note the importance of distinguishing
between allergy to nickel and other trace
metals rather than silver allergy, which is
rare. We used readability measurements
to guide intelligibility and included a
progressively discoloring lesion to show
stain of a lesion but not healthy enamel.
UCSF Dental Center Informed Consent for Silver Diamine Fluoride
Facts for consideration:
• Silver diamine fl uoride (SDF) is an antibiotic liquid. We use SDF on cavities to help stop tooth decay. We also use it to treat tooth
sensitivity. SDF application every six to 12 months is necessary.
• The procedure: 1. Dry the aff ected area. 2. Place a small amount of SDF on the aff ected area. 3. Allow SDF to dry for one minute.
4. Rinse.
• Treatment with SDF does not eliminate the need for dental fi llings or crowns to repair function or esthetics.
Additional procedures will incur a separate fee.
• I should not be treated with SDF if: 1. I am allergic to silver. 2. There are painful sores or raw areas on my gums (i.e., ulcerative
gingivitis) or anywhere in my mouth (i.e., stomatitis).
Benefi ts of receiving SDF:
• SDF can help stop tooth decay.
• SDF can help relieve sensitivity.
Risks related to SDF include, but are not limited to:
• The aff ected area will stain black permanently. Healthy tooth structure will not stain. Stained tooth structure can be replaced
with a fi lling or a crown.
• Tooth-colored fi llings and crowns may discolor if SDF is applied to them. Color changes on the surface can normally be polishe d
off . The edge between a tooth and fi lling may keep the color.
• If accidentally applied to the skin or gums, a brown or white stain may appear that causes no harm, cannot be washed off and will
disappear in one to three weeks.
• You may notice a metallic taste. This will go away rapidly.
• If tooth decay is not arrested, the decay will progress. In that case the tooth will require further treatment, such as repeat SDF, a
fi lling or crown, root canal treatment or extraction.
• These side eff ects may not include all of the possible situations reported by the manufacturer. If you notice other eff ects, please
contact your dental provider.
• Every reasonable eff ort will be made to ensure the success of SDF treatment. There is a risk that the procedure will not stop the
decay and no guarantee of success is granted or implied.
Alternatives to SDF, not limited to the following:
• No treatment, which may lead to continued deterioration of tooth structures and cosmetic appearance. Symptoms may increase in severity.
• Depending on the location and extent of the tooth decay, other treatment may include placement of fl uoride varnish, a fi lling or
crown, extraction or referral for advanced treatment modalities.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT
AND ALL MY QUESTIONS WERE ANSWERED:
________________________________(signature of patient) ___________________(date)
________________________________(signature of witness) ___________________(date)
FIGURE 4. UCSF special consent form.
silver diamine
CDA JOURNAL, VOL 44, Nº1
JANUARY 2016 27
Conclusion
Silver diamine uoride is a safe,
effective treatment for dental caries
across the age spectrum. At UCSF, it
is indicated for patients with extreme
caries risk, those who cannot tolerate
conventional care, patients who must
be stabilized so they can be restored
over time, patients who are medically
compromised or too frail to be treated
conventionally and those in disparity
populations with little access to care.
Application twice per year outperforms
all minimally invasive options including
the atraumatic restorative technique
— with which it is compatible but 20
times less expensive. It approaches the
success of dental llings after two or more
years, and again, prevents future caries
— while llings do not. Silver diamine
uoride is more effective as a primary
preventive than any other available
material, with the exception of dental
sealants, which are > 10 times more
expensive and need to be monitored.
Saliva may play a role in caries arrest
by silver diamine uoride. Lower rates of
arrest are seen in geriatric patients.38 The
elderly tend to have less abundant and
less functional saliva, which generally
explains their higher caries rate. In
pediatric patients, higher rates of arrest
are noted for buccal or lingual smooth
surfaces and anterior teeth.31 These
surfaces bathe more directly in saliva
than others. It is surprising that silver
chloride is the main precipitant in treated
dentin, as chloride is not a common
component of dentin or silver diamine
uoride, so may come from the saliva.
Tr a di t i o n a l a p p r o a ch e s o f te n p r o vi d e
only temporary bene t, given the highest
rates of recurrent caries are in patients
with the worst disease burden. The advent
of a treatment for nonsymptomatic
caries not requiring general anesthesia
or sedation addresses long-standing
concerns about the expense, danger and
practical complexity of these services.
Experience suggests that dryness prior
to application enhances effectiveness.
Good patient management is still
profoundly relevant to the very young
and otherwise challenged patients,
though this one-minute intervention is
more tolerable than other options. Silver
diamine uoride can readily replace
uoride varnish for the prevention of
caries in patients who have active caries.
This as a powerful new tool in the ght
against dental caries, particularly suited for
those who suffer most from this disease.
Clinical evidence supports continued
application one to two times per year
until the tooth is restored or exfoliates,
and otherwise perhaps inde nitely.
Some treated lesions keep growing,
particularly those in the inner third
of the dentin. It is unclear what will
happen if treatment is stopped after two
to three years and research is needed. ■
ACKNOWLEDGMENT
The UCSF paradigm shift committee subcommittee on silver
caries arrest included Sean Mong, DDS, EdD; Spomenka
Djordjevic, DDS, MS; Paul Atkinson, DDS, PhD; George Taylor,
DMD, MPH, DrPh; Natalie Heaivilin, DDS; Ling Zhan, DDS,
PhD; John Featherstone, PhD; Hellene Ellenikiotis, DDS; and
Jeremy Horst, DDS, PhD. Thanks to Linda Milgrom for designing
the PubMed search. Thanks to Chad Zillich, DDS, for help
with the literature review. Thanks to study authors, particularly
Edward Lo, BDS, MDS, PhD; Chun Hung Chu, BDS, MDS, PhD;
and Geoff Knight, BDSc, MSc, MBA, for helpful discussions.
REFERENCES
1. Clarkson BH, Exterkate RAM. Noninvasive dentistry: A
dream or reality? Caries Res 2015;49 suppl 1(1):11-17.
doi:10.1159/000380887.
2. Yamaga R, Yokomizo I. Arrestment of caries of
deciduous teeth with diamine silver fl uoride. Dent Outlook
1969;33:1007-1013.
3. Rosenblatt A, Stamford TCM, Niederman R. Silver
diamine fl uoride: A caries “silver-fl uoride bullet.” J Dent Res
2009;88(2):116-125. doi:10.1177/0022034508329406.
4. Mei ML, Chu CH, Lo ECM, Samaranayake LP. Fluoride
and silver concentrations of silver diamine fl uoride solutions
for dental use. Int J Paediatr Dent 2013;23(4):279-285.
doi:10.1111/ipd.12005.
5. Mei ML, Ito L, Cao Y, Li QL, Lo ECM, Chu CH. Inhibitory
eff ect of silver diamine fl uoride on dentine demineralisation
and collagen degradation. J Dent 2013;41(9):809-817.
doi:10.1016/j.jdent.2013.06.009.
6. Hill TJ, Arnold FA. The eff ect of silver nitrate in the prevention
of dental caries. I. The eff ect of silver nitrate upon the
decalcifi cation of enamel. J Dent Res 1937;16:23-28.
7. Castillo JL, Rivera S, Aparicio T, et al. The short-term
eff ects of diamine silver fl uoride on tooth sensitivity: A
randomized controlled trial. J Dent Res 2011;90(2):203-208.
doi:10.1177/0022034510388516.
8. Craig GG, Knight GM, McIntyre JM. Clinical
evaluation of diamine silver fl uoride/potassium iodide
as a dentine desensitizing agent. A pilot study. Aust
Dent J 2012;57(3):308-311. doi:10.1111/j.1834-
7819.2012.01700.x.
9. Markowitz K, Pashley DH. Discovering new treatments
for sensitive teeth: The long path from biology to therapy. J
Oral Rehabil 2008;35(4):300-315. doi:10.1111/j.1365-
2842.2007.01798.x.
10. Featherstone JDB. The continuum of dental caries —
evidence for a dynamic disease process. J Dent Res 2004;83
Spec No C:C39-C42.
11. Mei ML, Li QL, Chu CH, Yiu CKY, Lo ECM. The inhibitory
eff ects of silver diamine fl uoride at diff erent concentrations on
matrix metalloproteinases. Dent Mater 2012;28(8):903-908.
doi:10.1016/j.dental.2012.04.011.
12. Mei ML, Ito L, Cao Y, Li QL, Chu CH, Lo ECM. The
inhibitory eff ects of silver diamine fl uorides on cysteine
cathepsins. J Dent 2014;42(3):329-335. doi:10.1016/j.
jdent.2013.11.018.
13. Klasen HJ. A Historical Review of the Use of Silver in the
Treatment of Burns. II. Renewed Interest for Silver. 2000:131-
138.
14. Youravong N, Carlen A, Teanpaisan R, Dahlén G.
Metal-ion susceptibility of oral bacterial species. Lett Appl
Microbiol 2011;53(3):324-328. doi:10.1111/j.1472-
765X.2011.03110.x.
15. Hamama HH, Yiu CK, Burrow MF. Eff ect of silver diamine
fl uoride and potassium iodide on residual bacteria in dentinal
tubules. Aust Dent J 2015;60(1):80-87. doi:10.1111/
adj.12276.
16. Suzuki T, Nishida M, Sobue S, Moriwaki Y. Eff ects of
diamine silver fl uoride on tooth enamel. J Osaka Univ Dent Sch
1974;14:61-72.
17. Chu CH, Lo ECM. Micro-hardness of dentin in primary teeth
after topical fl uoride applications. J Dent 2008;36(6):387-
391. doi:10.1016/j.jdent.2008.02.013.
18. Englander HR, James VE, Massler M. Histologic eff ects
of silver nitrate of human dentin and pulp. J Am Dent Assoc
1958;57(5):621-630.
19. Mei ML, Ito L, Cao Y, Lo ECM, Li QL, Chu CH. An ex
vivo study of arrested primary teeth caries with silver diamine
fl uoride therapy. J Dent 2014;42(4):395-402. doi:10.1016/j.
jdent.2013.12.007.
20. Knight GM, McIntyre JM, Craig GG, Mulyani, Zilm PS,
Gully NJ. Inability to form a biofi lm of Streptococcus mutans
on silver fl uoride- and potassium iodide-treated demineralized
dentin. Quintessence Int 2009;40(2):155-161.
21. Knight GM, McIntyre JM, Craig GG, Mulyani, Zilm PS,
Gully NJ. An in vitro model to measure the eff ect of a silver
fl uoride and potassium iodide treatment on the permeability of
demineralized dentine to Streptococcus mutans. Aust Dent J
2005;50(4):242-245.
22. Knight GM, McIntyre JM, Craig GG, Mulyani, Zilm PS,
Gully NJ. Diff erences between normal and demineralized
CDA JOURNAL, VOL 44, Nº1
28 JANUARY 2016
dentine pretreated with silver fl uoride and potassium iodide
after an in vitro challenge by Streptococcus mutans. Aust Dent
J 2007;52(1):16-21.
23. Wakshlak RB-K, Pedahzur R, Avnir D. Antibacterial
activity of silver-killed bacteria: the “zombies” eff ect. Sci Rep
2015;5:9555. doi:10.1038/srep09555.
24. Duffi n S. Back to the future: The medical management of
caries introduction. J Calif Dent Assoc 2012;40(11):852-858.
25. Rethman MP, Beltrán-Aguilar ED, Billings RJ, et al.
Nonfl uoride caries-preventive agents: Executive summary of
evidence-based clinical recommendations. J Am Dent Assoc
2011;142(9):1065-1071.
26. Plemons JM, Al-Hashimi I, Marek CL. Managing
xerostomia and salivary gland hypofunction. J Am Dent Assoc
2014;145(8):867-873. doi:10.14219/jada.2014.44.
27. Stebbins EA. What value has argenti nitras as a therapeutic
agent in dentistry? Int Dent J 1891;12:661-670.
28. Howe PR. A method of sterilizing and at the same time
impregnating with a metal aff ected dentinal tissue. Dent
Cosmos 1917;59:891-904.
29. Chu CH, Lo ECM, Lin HC. Eff ectiveness of silver diamine
fl uoride and sodium fl uoride varnish in arresting dentin caries in
Chinese preschool children. J Dent Res 2002;81(11):767-770.
30. Shah S, Bhaskar V, Venkataraghavan K, Choudhary
P, Ganesh M, Trivedi K. Effi cacy of silver diamine fl uoride
as an antibacterial as well as antiplaque agent compared
to fl uoride varnish and acidulated phosphate fl uoride gel:
An in vivo study. Indian J Dent Res 2013;24(5):575-581.
doi:10.4103/0970-9290.123374.
31. Zhi QH, Lo ECM, Lin HC. Randomized clinical trial on
eff ectiveness of silver diamine fl uoride and glass ionomer
in arresting dentine caries in preschool children. J Dent
2012;40(11):962-967. doi:10.1016/j.jdent.2012.08.002.
32. Yee R, Holmgren C, Mulder J, Lama D, Walker D, van
Palenstein Helderman W. Effi cacy of silver diamine fl uoride for
arresting caries treatment. J Dent Res 2009;88(7):644-647.
doi:10.1177/0022034509338671.
33. Santos Dos VE, de Vasconcelos FMN, Ribeiro AG,
Rosenblatt A. Paradigm shift in the eff ective treatment of
caries in schoolchildren at risk. Int Dent J 2012;62(1):47-51.
doi:10.1111/j.1875-595X.2011.00088.x.
34. Lo EC, Chu CH, Lin HC. A community-based caries
control program for preschool children using topical fl uorides:
18-month results. J Dent Res 2001;80(12):2071-2074.
35. Llodra JC, Rodriguez A, Ferrer B, Menardia V, Ramos
T, Morato M. Effi cacy of silver diamine fl uoride for caries
reduction in primary teeth and fi rst permanent molars
of schoolchildren: 36-month clinical trial. J Dent Res
2005;84(8):721-724.
36. Green E. A clinical evaluation of two methods of caries
prevention in newly erupted fi rst permanent molars. Aust Dent J
1989;34(5):407-409.
37. Craig GG, Powell KR, Price CA. Clinical evaluation of
a modifi ed silver fl uoride application technique designed to
facilitate lesion assessment in outreach programs. BMC Oral
Health 2013;13(1):73. doi:10.1186/1472-6831-13-73.
38. Zhang W, McGrath C, Lo ECM, Li JY. Silver diamine
fl uoride and education to prevent and arrest root caries among
community-dwelling elders. Caries Res 2013;47(4):284-290.
doi:10.1159/000346620.
39. Liu BY, Lo ECM, Chu CH, Lin HC. Randomized trial on
fl uorides and sealants for fi ssure caries prevention J Dent Res
2012;91(8):753-758. doi:10.1177/0022034512452278.
40. Tan HP, Lo ECM, Dyson JE, Luo Y, Corbet EF.
A randomized trial on root caries prevention in
elders. J Dent Res 2010;89(10):1086-1090.
doi:10.1177/0022034510375825.
41. Monse B, Heinrich-Weltzien R, Mulder J, Holmgren C, van
Palenstein Helderman WH. Caries preventive effi cacy of silver
diamine fl uoride (SDF) and ART sealants in a school-based
daily fl uoride toothbrushing program in the Philippines. BMC
Oral Health 2012;12(1):52. doi:10.1186/1472-6831-12-52.
42. Li R, Lo ECM, Chu CH, Liu BY. Preventing and arresting root
caries through silver diamine fl uoride applications. In: 2014.
iadr.confex.com/iadr/14iags/webprogram/Paper189080.
html.
43. Duangthip D, Lo ECM, Chu CH. Arrest of dentin caries in
preschool children by topical fl uorides. In: 2014. iadr.confex.
com/iadr/14iags/webprogram/Paper189031.html.
44. Frencken JE, Pilot T, Songpaisan Y, Phantumvanit P.
Atraumatic Restorative Treatment (ART): Rationale, Technique
and Development. J Public Health Dent 1996;56(3):135-140.
doi:10.1111/j.1752-7325.1996.tb02423.x.
45. Innes NP, Evans DJ, Stirrups DR. The Hall Technique:
A randomized controlled clinical trial of a novel method of
managing carious primary molars in general dental practice:
Acceptability of the technique and outcomes at 23 months.
BMC Oral Health 2007;7(1):18. doi:10.1186/1472-6831-
7-18.
46. Vasquez E, Zegarra G, Chirinos E, et al. Short-term
serum pharmacokinetics of diamine silver fl uoride after
oral application. BMC Oral Health 2012;12(1):60.
doi:10.1186/1472-6831-12-60.
47. Chu CH, Lo ECM. Promoting caries arrest in children
with silver diamine fl uoride: A review. Oral Health Prev Dent
2008;6(4):315-321.
48. Liu Y, Zhai W, Du F. [Clinical observation of treatment
of tooth hypersensitiveness with silver ammonia fl uoride and
potassium nitrate solution]. Zhonghua Kou Qiang Yi Xue Za
Zhi. 1995;30(6):352-354.
49. Yamaga R, Nishino M, Yoshida S, Yokomizo I. Diamine
silver fl uoride and its clinical application. J Osaka Univ Dent
Sch 1972;(12):1-20.
50. Milgrom P, Taves DM, Kim AS, Watson GE, Horst JA.
Pharmacokinetics of fl uoride in toddlers after application
of 5% sodium fl uoride dental varnish. Pediatrics
2014;134(3):e870-e874. doi:10.1542/peds.2013-3501.
51. Goldberg ME, Cantillo J, Larijani GE, Torjman M, Vekeman
D, Schieren H. Sevofl urane versus isofl urane for maintenance of
anesthesia: Are serum inorganic fl uoride ion concentrations of
concern? Anesth Analg 1996;82(6):1268-1272.
52. Gotjamanos T, Afonso F. Unacceptably high levels of
fl uoride in commercial preparations of silver fl uoride. Aust Dent
J 1997;42(1):52-53.
53. Gotjamanos T, Ma P. Potential of 4 percent silver fl uoride
to induce fl uorosis in rats: Clinical implications. Aust Dent J
2000;45(3):187-192.
54. Neesham DC. Fluoride concentration in AgF and dental
fl uorosis. Aust Dent J 1997;42(4):268-269.
55. Quock RL, Barros JA, Yang SW, Patel SA. Eff ect of Silver
Diamine Fluoride on Microtensile Bond Strength to Dentin.
Oper Dent 2012;37(6):610-616. doi:10.2341/11-344-L.
56. Knight GM, McIntyre JM, Mulyani. The eff ect of silver
fl uoride and potassium iodide on the bond strength of
auto cure glass ionomer cement to dentine. Aust Dent J
2006;51(1):42-45.
57. Yamaga M, Koide T, Hieda T. Adhesiveness of glass
ionomer cement containing tannin-fl uoride preparation (HY
agent) to dentin — an evaluation of adding various ratios of HY
agent and combination with application diamine silver fl uoride.
Dent Mater J 1993;12(1):36-44.
58. Soeno K, Taira Y, Matsumura H, Atsuta M. Eff ect of
desensitizers on bond strength of adhesive luting agents to
dentin. J Oral Rehabil 2001;28(12):1122-1128.
59. Centers for Disease Control and Prevention. Long-Term
Care Services in the United States: 2013 Overview, table
4. www.cdc.gov/nchs/data/nsltcp/long_term_care_
services_2013.pdf.
60. U.S. Department of Health and Human Services.
Integration of Oral Health and Primary Care Practice. www.
hrsa.gov/publichealth/clinical/oralhealth. Accessed June 5,
2015.
61. Featherstone JDB, Adair SM, Anderson MH, et al. Caries
management by risk assessment: Consensus statement, April
2002. J Calif Dent Assoc 2003 Mar;31(3):257-69.
THE CORRESPONDING AUTHOR, Jeremy A. Horst, DDS, PhD, can
be reached at jeremy.horst@ucsf.edu.
silver diamine