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UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications and Consent

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The Food and Drug Administration recently cleared silver diamine fluoride for reducing tooth sensitivity. Clinical trials document arrest and prevention of dental caries by silver diamine fluoride. 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.
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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
JANUARY20163
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
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The Editor/My Microbiome and Me
Impressions
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Regulatory Compliance/HIPAA Security Rule
Technical Safeguards
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CDA JOURNAL, VOL 44, Nº1
JANUARY201617
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
18JANUARY2016
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
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
JANUARY201619
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 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
20JANUARY2016
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
JANUARY201621
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
22JANUARY2016
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 e ective.
CDA JOURNAL, VOL 44, Nº1
JANUARY201623
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
24JANUARY2016
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. Di 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 a 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 a 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 a 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 di 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
JANUARY201625
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
26JANUARY2016
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 a ected area. 2. Place a small amount of SDF on the a 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 a 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
o . 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 o 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
lling or crown, root canal treatment or extraction.
These side e ects may not include all of the possible situations reported by the manufacturer. If you notice other e ects, please
contact your dental provider.
Every reasonable e 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
JANUARY201627
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 Geo Knight, BDSc, MSc, MBA, for helpful discussions.
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THE CORRESPONDING AUTHOR, Jeremy A. Horst, DDS, PhD, can
be reached at jeremy.horst@ucsf.edu.
silver diamine
... Among the numerous therapies indicated for preventing and treating dental caries, silver diamine fluoride (SDF), also known as a cariostatic agent, is used in several countries [7]. It is a low-cost topical product that stops caries lesions and reduces dental hypersensitivity [6]. ...
... Despite the esthetic disadvantage of tooth surface darkening, it has several advantages, such as being safe, effective, inexpensive, and easy and fast to apply [8,9]. Most patients can use SDF, especially those at high risk for caries activity, non-cooperative with treatment, or without oral health care access [7]. ...
... The constant emergence of several new therapies for preventing and treating caries lesions has caused a considerable reduction in SDF use [12] over the years. Recent studies, such as systematic literature reviews and in vivo clinical trials, demonstrate the scientific evidence of SDF efficacy [7,9,[13][14][15][16][17]. ...
Article
Full-text available
Objective: To evaluate the use of silver diamine fluoride (SDF) among undergraduate dental students and graduate students/specialists in pediatric dentistry in Brazil. Material and Methods: The data were collected with online questionnaires sent to the participants (n=404) by e-mail and were analyzed by logistic regression models (α=0.05). Results: A total of 26.2% were unfamiliar with SDF. The product effectiveness (84.8%) was the main reason reported by respondents who used SDF in pediatric dental care. Professionals who had graduated for 1-15 years (OR=4.83), those with more than 15 years since graduation (OR=21.58), postgraduate students, graduates and professors (OR=10.01), or professionals who work in a dental office (OR=7.73) were more likely to have used the SDF. Most participants (67.8%) reported that they would use SDF even considering the unfavorable aesthetic result, especially those who would consider its use in a pandemic situation (OR=26.90), who know the SDF (OR=3.39), professionals who had graduated for 1-15 years (OR=2.40) or those with more than 15 years of graduation (OR=2.93). Conclusion: Most participants who know and use SDF are professionals who have graduated for longer and have more contact with the academic environment. Its use has become more considered by participants within a pandemic context.
... 12 Further research is therefore necessary to establish a standardized protocol for applying SDF, including determining the optimal technique for achieving the best outcomes. 13 For instance, the AAPD recommends minimum application time of 1 minute for SDF with a requirement to isolate the operative field for as long as 3 minutes, 14 with a caveat that the application time may be shortened for very young children and for patients with challenging conditions. ...
... 28 These amounts are well below the probable toxic doses of fluoride (5 mg/kg) 29 and the lethal dose of silver (380-520 mg/kg). 13 Throughout the entire study period, no systematic adverse effects were reported or observed. Therefore, the results of this study support the safety of using 1 drop (25 mL) of 38% SDF regardless of the use of light curing in children. ...
Article
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Objective: This study aimed to compare the effectiveness of semi-annual application of 38% silver diamine fluoride (SDF) with and without light curing in arresting dentine caries in primary teeth. Methods: Children aged 5-7 years with at least 1 active dentine carious lesion were randomly allocated into: Group 1 (38% SDF with light curing: applied SDF for 10 seconds and exposed to LED light for 20 seconds) and Group 2 (38% SDF without light curing: applied SDF for 10 seconds and isolated for 20 seconds). Both interventions were repeated every 6 months. At the baseline, demographic data, oral health-related behaviors and clinical parameters of the children were collected. The activity of carious lesion was assessed using the visual-tactile method and adverse effects, if any, were recorded at both 6-month and 12-month follow-up periods by the same examiner. Intention-to-treat analysis was employed to analyze the data. Results: At baseline, 40 children (218 lesions) and 37 children (261 lesions) were recruited into Group 1 and Group 2. There were no significant differences between the 2 groups in terms of demographic data, oral health-related behaviors, and clinical parameters of the children at baseline (P >.05). After 12 months, 66 out of 77 children (85.74%) remained in the study. There was no significant difference in caries arrest rate between Group 1 (74.8%) and Group 2 (69.0%) with P = .161. Conclusion: The semi-annual application of 38% SDF with or without light curing is equally effective in arresting dentine carious lesions in primary teeth. The addition of light curing to SDF-treated teeth has no significant effect in arresting dental caries in primary teeth.
... Silver Diamine Fluoride (SDF) appears to be a potential medical approach because it acts on the microbiome as well as the hard tissues; SDF promotes remineralisation of enamel and dentin, reduces the number of bacteria in the biofilm, and hinders the degradation of collagen, thereby halting the caries progression [5,6]. In 2014, the Food and Drug Administration classified SDF as a Class II medical device and approved its use for the treatment of tooth sensitivity; three years later, the American Academy of Paediatric Dentistry (AAPD) endorsed its use to stop cavitated lesions in primary teeth [7,8]. The World Health Organization has included SDF together with fluoride toothpaste and glass ionomer cement in its list of essential medicines. ...
... Similar results have been reported in a survey in Saudi Arabia, while worse results have been reported in the USA [19,24]. This finding is not surprising, as SDF was licensed in 2014, and less than a quarter of the respondents have been practising for less than five years, so it can be assumed that they were trained in dental school after 2015 [8]. ...
Article
Full-text available
Objective To investigate the education, knowledge and behaviour of Italian dentists regarding Silver Diamine Fluoride (SDF). Methods A cross-sectional study was conducted from January to December 2022, through an online survey linked to an online continuing medical education (CME) course sent to Italian dentists. A priori power analysis estimated the necessary sample to be 1480 dentists with an anticipated frequency of 50% and a power of 99.99%. The questionnaire included 46 questions on participants ‘ demographic characteristics, training received, clinical knowledge of SDF, and attitudes and behaviours regarding its use. Descriptive statistics, bivariate, and mutlivariable regression analyses were performed to determine the association between the variables. Results The response rate was 6.1% with 3876 respondents, evenly distributed geographically. Less than 10% of respondents had received training at undergraduate, postgraduate or masters level. A minority of dentists were familiar with the use of SDF for the treatment of dentine hypersensitivity (19.0%) and for the treatment of caries in children (22.2%) and adults (15.7%). The percentage of dentists who reported SDF use at least once was 20.6%. On mutlivariable analysis (χ²(11) = 995.9 p-value < 0.01), dentists who used SDF were positively associated with those who cared for patients with special needs, those who received good undergraduate or postgraduate training, and those who knew how to use SDF (p < 0.01). A second mutlivariable analysis (χ²(11) = 47.9 p-value < 0.01) revealed that younger respondents were associated with good training and knowledge of the use of SDF received during undergraduate studies, while older respondents were associated with good training received on managing hypersensitivity and caries in adults (p < 0.01). Conclusions Overall, Italian dentists ‘ education, knowledge, and use of SDF were relatively poor. The majority of the sample ‘s responses were not consistent with scientific evidence. The use of SDF among Italian dentists is still far from being a reality. In Italy, it is necessary to increase training on SDF, primarily through the university, to hopefully increase its use, especially in non-invasive caries treatment.
... SDF was defined by the Food and Drug Administration in the United States in 2014 for managing dentine hypersensitivity [7]. Since then, there has been growing interest in its "offlabel" use for managing carious lesions, especially in children [8]. ...
... SDF was first introduced in Japan for use in dentistry, and as such, has the highest usage rate in the country, even higher than the country's own university students [13]. A possible justification for the low rate of use in our environment could be the mainly aesthetic disadvantages that exist with its use [7] and the lack of academic training. ...
Article
Full-text available
Background/Objectives: The use of silver diamine fluoride (SDF) has increased in recent years for the management of caries lesions in children and adults. The aim of this study is to determine the level of knowledge and the attitude of Spanish dentists (GDPs) and final-year dental students (DSs) regarding the use of SDF. Methods: A cross-sectional survey (questionnaire) was carried out aimed at final-year dental students (DSs) (n = 43) and registered dentists (GDPs) (n = 1050) in the autonomous community of the region of Murcia (Spain). Results: the response rates were GDPs 7.7% (n = 81) and DSs 84.5% (n = 38). Only 20.98% of GDP respondents reported having been trained on SDF versus 100% of DSs. Significant differences were observed between the groups (p < 0.05). While 94.7% of the students were aware of the indications for the use of SDF, only 56.8% of the general dentists reported it. Similarly, for hypersensitivity treatment, 71.1% of the students were informed versus 40.7% of the general dentists, and indications for paediatric patients, 100% for the DS group and 59.3% in GDPs. In adult patients, indications vary from GDPs’ (50%) to DSs’ (25.9%) responses. About 94.7% of DSs know the advantages of use and only 50.6% of GDPs. Both groups showed reluctance to use SDF in esthetic zones, with greater acceptance in non-esthetic areas (p < 0.05). In practice, fewer GDPs (27.16%) and DSs (23.68%) had applied SDF, reflecting a gap between knowledge and implementation. Conclusions: Dental students had a significantly higher level of knowledge, a situation that evidences the high level of education and training in the curricular guides of the universities.
... SDF is a straightforward topical substance that has proven effective in stopping dental decay by creating a protective barrier that blocks the channels in exposed dentin [9]. The silver ingredient in SDF hinders the development of biofilms by oral microorganisms, therefore preventing the progression of decay [10]. SDF has been endorsed by the American Dental Association and the American Academy of Pediatric Dentistry as a safe, feasible, cost-effective, and minimally intrusive treatment for active dental caries [11]. ...
Article
Full-text available
Objectives The present study aimed to assess parental acceptance of silver diamine fluoride (SDF) treatment for dental caries in children in Najaf city, Iraq. Methods A cross-sectional design was used, involving 670 parents of children aged 6–7 years from primary schools in Najaf city, Iraq, during the academic year 2023–2024. The participants were selected via a multistage random sampling method. A structured questionnaire was administered to gather the participants’ views on tooth staining caused by SDF application to cavitated teeth. Statistical procedures included descriptive analysis, chi-square tests, and ordinal logistic regression. Results In total, 670 parents were recruited for this study. The mean age of the participants was 34.47 ± 8.2 Approximately half of the respondents were male and aged 31–50 years, and approximately three-fourths of the parents reported having a low education level and were in the low-income category. Parental acceptance of SDF treatment was greater for posterior teeth, with 51.2% agreeing, and 24.2% strongly agree. For anterior teeth, acceptance was lower, with only 23.3% agreeing and 10.7% strongly agreeing. Parental age ( p = 0.008), education level ( p < 0.001), and income ( p = 0.003) were significantly associated with acceptance of SDF treatment for posterior teeth. However, for anterior teeth, parental education ( p < 0.001) and income ( p = 0.029) were significantly associated with acceptance of SDF treatment. Conclusion Parents showed high acceptance of SDF treatment, particularly for posterior teeth, although concerns about aesthetics affected their views of anterior teeth. Improving parents’ awareness and addressing their apprehensions could increase the adoption of this evidence-based caries management approach for children.
... In this study, children who received GIC applications showed significantly more definitely positive behaviour than the AgF/KI group (p < 0.05). This difference in behaviour scores might be due to the issue of taste acceptability is especially significant, considering that children usually have a low preference for bitter-tasting medications, and silver fluoride is known for its bitter metallic taste [36,37]. However, the result of another study reported high levels of acceptance for sealants in children aged between 3 and 16 years of age with improved overall patient acceptance of the dental visit and increased treatment experience [38]. ...
Article
Full-text available
Aim: To compare caregiver satisfaction and children’s acceptance of silver fluoride/potassium iodide (AgF+KI) treatment (Riva Star Aqua®, SDI Limited, Victoria, Australia) and glass-ionomer cement (GIC) application (Ionostar Plus + Easy Glaze, VOCO, Germany) in reducing hypersensitivity in permanent molars affected by molar incisor hypomineralisation (MIH) with the MIH treatment need index (MIH-TNI) 3 and 4 immediately after its application and after 12 weeks. Materials and Methods: This prospective, comparative, clinical study recruited schoolchildren with at least one hypersensitive MIH molar with a Schiff cold air sensitivity score (SCASS) of 2 and 3. Caregivers in both groups (AgF+KI and GIC + glaze) answered a questionnaire (5-Point Likert Scale) regarding the perception of the treatment immediately (15 min post application) and in the 12 weeks follow-up. Children’s behaviour during both applications was assessed using FBRS (Frankl Behaviour Rating Scale). Results: A total number of 47 children (n = 22 for AgF/KI and n = 25 for GIC) with a mean age of 8.6 ± 1.42 were recruited. A high proportion of the children in both arms (n = 40 out of 44; 90.1%) reported a reduction in hypersensitivity in the last 12 weeks. On average, children (n = 39; FBRS ≥ 3) in both groups showed positive behaviour, with a significantly more definitely positive behaviour in the GIC group (p < 0.05, independent student t-test). Caregiver satisfaction with both study procedures was high after immediate assessment (n = 19 out of 22, 86.4% for AgF/KI and n = 19 out of 25, 76.0% for GIC application) and in 12 weeks of follow-up (n = 17 out of 20, 85.0% for AgF/KI and n = 22 out of 24, 91.6% for GIC application). However, the taste AgF/KI is more frequently considered not acceptable for the child (n = 10; 45%) than smell (n = 2; 9%). Interestingly, there was a statistically significant difference in caregivers’ preference toward alternative desensitisation treatment (tooth restoration coverage, desensitisation paste, stainless steel crown and fluoride varnish) in both treatment groups (p < 0.05, Mann–Whitney U test). Conclusions: Both GIC and AgF/KI applications can be considered acceptable approaches to reduce hypersensitivity in permanent molars affected by MIH both immediately and in long-term follow-up for schoolchildren based on caregivers’ assessments.
Article
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Comprehensive caries therapy has relied on eliminating contaminated tooth structure and replacing it with restorative materials in pediatric dentistry. SDF with GIC can be administered together to stop the caries in cavitated lesions. Therefore, it is of interest to assess the shear bond strength of glass ionomer cement (type IX) to demineralized dentin in primary teeth treated with SDF and KI. The occlusal edges of sixty non-carious primary molar teeth were sliced until the yellow dentin was discernible. Each sample was embedded in an acrylic block with its occlusal surface facing upward after being submerged in a demineralizing solution for 7 days. Three groups were created from the samples: Group 1: The untreated group (control group) to which GIC type IX was placed directly; Group 2: Samples received immediate application of GIC type IX after getting treated with silver diamine fluoride (Experimental group) and Group 3: Silver diamine fluoride followed by potassium iodide followed by GIC type IX application (Experimental group). A Universal Testing Machine was subsequently utilized to perform a shear bond test on the specimens. Data shows that previously treated cement with SDF+KI increases the shear bond test without negatively impacted the bond strength GIC to dentin.
Article
Background and Objectives Silver diamine fluoride (SDF) is a clear solution composed of ammonia, silver, and fluoride ions, used as an alternative treatment for early childhood caries. The study sought to assess the educational experiences, knowledge, attitudes, and professional behavior of postgraduate pediatric dentists regarding SDF, as well as to explore the connections among these factors. Methods Postgraduate pediatric dental students ( n = 200) participated in the survey. The SDF evaluation covered education, clinical knowledge, attitudes, and professional behavior, as well as parental acceptance. Results Despite the limited scope of undergraduate education regarding SDF, the majority of the respondents knew about its uses and limitations. In spite of their high knowledge and positive attitude, the clinical use of SDF was found lacking. There was a positive correlation between the constructs, and the associations were statistically significant ( P = 0.00). Interpretation and Conclusion Even with the knowledge and positive attitude, clinical use seemed lacking. This can be overcome by increasing SDF education and encouraging postgraduates to incorporate the use of SDF into their routine practice. Moreover, clinicians must stress the advantages of SDF to parents and encourage them to look beyond the esthetic limitations.
Article
Introduction Early childhood caries (ECC), dental cavities in children younger than 6 years, is common, consequential, and inequitably concentrated among socially disadvantaged children. The World Health Organization and authoritative clinical and public health agencies promote 4 chronic disease management (CDM) approaches that are low-cost and can be delivered in home and community sites: pharmacologic, behavioral, monitoring, and minimally invasive dentistry (MID). The extent of adoption of these approaches among US pediatric dentists is unknown. Methods From November 2021 through July 2023, trained research staff members administered and videorecorded via Zoom a semistructured survey on ECC management to 1,639 clinically active pediatric dentists in the US, including 170 thought leaders (organizational and academic leaders). Data collected included treatment approaches, time allocated to counseling, and personal, practice, and patient population characteristics. Results The survey response rate was 27.7%. Among CDM approaches, 88.7% cited pharmacologic approaches, 43.4% behavioral, 41.1% monitoring, and 39.3% MID approaches. MID was significantly associated with thought leaders and with more recent graduates engaged as associates in larger practices or in safety-net settings serving high volumes of low-income children and children with a history of caries. We noted fewer significant associations between other CDM approaches and the characteristics of dentists, practices, and populations served. CDM was not associated with the race or ethnicity of dentists or patients, the numbers of ancillary personnel in practice, or dental management organizations. One-third (32.4%) of respondents reported scheduling 5 or fewer minutes for counseling on caries. Conclusion Except for pharmacologic treatments and despite professional guidelines, CDM approaches are underused. We posit that CDM approaches hold strong promise to enhance oral health equity as value-based care arrangements expand in dentistry.
Article
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Untreated dental caries in Chinese pre-school children is common. This prospective controlled clinical trial investigated the effectiveness of topical fluoride applications in arresting dentin caries. Three hundred seventy-five children, aged 3-5 years, with carious upper anterior teeth were divided into five groups. Children in the first and second groups received annual applications of silver diamine fluoride solution (44,800 ppm F). Sodium fluoride varnish (22,600 ppm F) was applied every three months to the lesions of children in the third and fourth groups. For children in the first and third groups, soft carious tissues were removed prior to fluoride application. The fifth group was the control. Three hundred eight children were followed for 30 months. The respective mean numbers of arrested carious tooth surfaces in the five groups were 2.5, 2.8, 1.5, 1.5, and 1.3 (p < 0.001). Silver diamine fluoride was found to be effective in arresting dentin caries in primary anterior teeth in pre-school children.
Article
Background. In this article, the authors present evidence-based clinical recommendations regarding the use of nonfluoride caries-preventive agents. The recommendations were developed by an expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs. The panel addressed several questions regarding the efficacy of nonfluoride agents in reducing the incidence of caries and arresting or reversing the progression of caries. Types of Studies Reviewed. A panel of experts convened by the ADA Council on Scientific Affairs, in collaboration with ADA Division of Science staff, conducted a MEDLINE search to identify all randomized and nonrandomized clinical studies regarding the use of nonfluoride caries-preventive agents. Results. The panel reviewed evidence from 50 randomized controlled trials and 15 nonrandomized studies to assess the efficacy of various nonfluoride caries-preventive agents. Clinical Implications. The panel concluded that certain nonfluoride agents may provide some benefit as adjunctive therapies in children and adults at higher risk of developing caries. These recommendations are presented as a resource for dentists to consider in the clinical decision-making process. As part of the evidence-based approach to care, these clinical recommendations should be integrated with the practitioner's professional judgment and the patient's needs and preferences. (The full report can be accessed at "http://ebd.ada.org/ClinicalRecommendations.aspx".)
Article
Instead of expected fluoride ion concentrations of around 60 000 ppm, commercial preparations of 40 per cent aqueous silver fluoride were found to contain 120 000-127 000 ppm. Information received from the Western Australian Chemistry Centre which provided independent confirmation of the higher than expected [F -] indicates that the currently available commercial preparations contain silver difluoride rather than silver fluoride. In view of the potential of fluoride-containing products such as dentifrices (1000-1500 ppm F) and topical fluoride gels and solutions (6000-12 000 ppm F) to cause adverse effects if excessive quantities are ingested, any product that contains 120 000 ppm [F -] should be regarded as carrying a high risk of toxicity when used on young children.
Article
We report a previously unrecognized mechanism for the prolonged action of biocidal agents, which we denote as the zombies effect: biocidally-killed bacteria are capable of killing living bacteria. The concept is demonstrated by first killing Pseudomonas aeruginosa PAO1 with silver nitrate and then challenging, with the dead bacteria, a viable culture of the same bacterium: Efficient antibacterial activity of the killed bacteria is observed. A mechanism is suggested in terms of the action of the dead bacteria as a reservoir of silver, which, due to Le-Chatelier's principle, is re-targeted to the living bacteria. Langmuirian behavior, as well as deviations from it, support the proposed mechanism.
Article
Various caries prevention and repair strategies are reviewed in this article ranging from the use of fluoride to nanohydroxyapatite particles. Several of the strategies which combine fluoride and calcium and phosphate treatments have both in vitro and in vivo data showing them to be efficacious if the surface integrity of the lesion is not breached. Once this has occurred, the rationale for cutting off the nutrient supplies to the pathogenic bacteria without the removal of the infected dentine, a noninvasive restorative technique, is discussed using existing clinical studies as examples. Finally two novel noninvasive restorative techniques using fluorohydroxyapatite crystals are described. The need for clinical data in support of emerging caries-preventive and restorative strategies is emphasized.