SILVER DIAMINE FLUORIDE
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 over multiple years . We believe that dryness of the lesion during application is also important . Isolation with gauze and / or cotton rolls is sufficient , while air drying prior to application is thought to improve effectiveness . Allowing one to three minutes for the silver diamine fluoride 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 fluoride 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 fluoride 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 to continue after two or three years to maintain caries arrest is not known . Another approach is simply to substitute silver diamine fluoride for any application of fluoride 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 fluoride into affected dentin by chemical cavity preparation have not been studied but are being explored clinically . Pretreatment with ethylenediaminetetraacetic acid ( EDTA ) to remove superficial hydroxyapatite in affected dentin may open the dentinal tubules to further silver diamine fluoride 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 fluoride 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 fluoride varnish ( see above ) has many practitioners asking about a topical varnish after silver diamine fluoride placement to prevent silver diamine fluoride taste and keep the silver diamine fluoride 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 fluoride to react with and dry into the lesion is more likely to improve effectiveness . Also , in our experience silver diamine fluoride results in less aversive taste and texture responses than to fluoride varnish .
Decreased darkening of lesions in the esthetic zone improves acceptance . SSKI is an option if the patient is not pregnant , though significant darkening should still be expected . SSKI and silver diamine fluoride are not to be combined prior to application — SSKI can be placed after drying the silver diamine fluoride-treated tooth . Silver diamine fluoride does not prevent restoration of a lesion , thus it does not prevent esthetic options . While silver diamine fluoride 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 fluoride for the control of caries because they are topical fluorides ( Section 1910 .( b )). Physicians , nurses and their assistants are permitted to apply fluorides 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 fluoride under existing rules for topical fluoride 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 definition 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 .
In our experience , silver diamine fluoride results in less aversive taste and texture responses than to fluoride varnish .
24 JANUARY / FEBRUARY 2017 | PENNSYLVANIA DENTAL JOURNAL