UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride : Rationale , Indications and Consent
” 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 fluoride 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 fluoride 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 fluoride 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 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 .
CONCLUSION Silver diamine fluoride 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 fillings after two or more years , and again , prevents future caries — while fillings do not . Silver diamine fluoride is more effective as a primary preventative 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 fluoride . 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 fluoride , so may come from the saliva .
Traditional approaches often provide only temporary benefit , 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 fluoride can readily replace fluoride varnish for the prevention of caries in patients who have active caries . This as a powerful new tool in the fight 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 indefinitely . 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 .
JANUARY / FEBRUARY 2017 | PENNSYLVANIA DENTAL JOURNAL 25