SILVER DIAMINE FLUORIDE
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 significantly alter caries arrest or prevention . 42 This was confirmed 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 fluoride to arrest interproximal carious lesions , to compare the relative efficacy of silver diamine fluoride to the combination of silver nitrate plus fluoride varnish and to compare the effects on populations with or without access to fluoridated water . Final reports from these studies will follow in the coming years .
Recommendations From the Literature on Clinical Efficacy These studies show that 38 percent silver diamine fluoride is effective and efficient 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 insufficient 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 first two years .
For any patient with active caries , we recommend considering replacement of fluoride varnish as the primary means to prevent new lesions , with application of silver diamine fluoride to the active lesions only . For patients without access to both sealants and monitoring , silver diamine fluoride 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 .
FIGURE 3 . Clinical protocol for the UCSF dental clinics .
Silver Diamine Fluoride ( SDF ) UCSF Protocol for Arresting Dental Carious Lesions or Treating Tooth Sensitivity
Material : “ Advantage Silver Arrest™ ( 38 % SDF , purified water ) from Elevate Oral Care . Shelf life : 3 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 . Difficult to treat dental carious lesions . 5 . Patients without access to dental care .
Maximum dose : 25 uL ( 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 2-3 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 . 1 drop of SDF into the deep end of a plastic dappen dish . ( also obtain 1 drop of SSKI in a separate dappen dish if selected )
4 . Remove bulk saliva with saliva ejector . 5 . Isolate tongue and cheek from affected teeth with “ 2x2 ” gauze or cotton rolls . 6 . If near the gingiva , consider applying petroleum jelly with a cotton applicator for safety . 7 . Dry affected 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 affected tooth surface ( s ) with microsponge .
10 . Allow SDF to absorb for up to 1 minute if reasonable , then remove excess with gauze or cotton roll . ( If using SSKI , apply with a different microsponge . Repeat 1-3 times until no further white precipitates are observed . Wait 5-10 seconds between applications . Remove excess with cotton .)
11 . Rinse with water . 12 . Place gloves , cotton , and microbrushes into plastic waste bags .
20 JANUARY / FEBRUARY 2017 | PENNSYLVANIA DENTAL JOURNAL