UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride : Rationale , Indications and Consent
Patients note a transient metallic or bitter taste . In our experience , with judicious use , the taste and texture response is more favorable than the response to fluoride varnish .
Even a small amount of silver diamine fluoride 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 fluoride .
Silver diamine fluoride 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 fluoride 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 fluoride 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 fluoride decreased dentin bonding strength of resin-based crown cement by approximately one-third . 58 Thus , rinsing will suffice for direct restorations , while excavation of the silver diamine fluoride-treated superficial dentin is appropriate for cementing crowns .
INDICATIONS Countless patients would benefit from conservative treatment of nonsymptomatic active carious lesions . We discuss the following indications .
First , extreme caries risk is defined 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 immunocompromised 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 other 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 financial 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 efficient instrument to be used at the diagnostic visit to provide a step towards controlling the disease .
Fourth , some lesions are just difficult 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 fluoride :
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 .
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 without dental insurance , and 4,230 shortage areas with 49 million people without access to a dental health professional . 60 Unlike fillings , failure of silver diamine fluoride treatment does not appear to create an environment that promotes caries , and thus need to be monitored . Thus , a final important indication is :
5 . Patients without access to dental care .
JANUARY / FEBRUARY 2017 | PENNSYLVANIA DENTAL JOURNAL 23