Page 15 - GP Fall 2020

Silver Diamine Fluoride Use in a Private Practice Setting

By Teresa Skalyo, DDS, FAGD and Analia Veitz-Keenan, DDS

Background Techniques for local application of SDF This can be a difficult decision because if
Even before the Covid-19 pandemic, the There are two techniques for application. you do decide to go ahead and excavate
use of Silver Diamine Fluoride (SDF) was Both work best on areas where the SDF can the lesion, you may be placing a shallow
gaining in popularity. Now, with many of get to the soft tooth structure such as open restoration on a dentin surface where bond-
us looking for ways to perform less inva- lesions on facial or occlusal surfaces. It is ed composite fillings don’t hold as well. It
sive dentistry and limit aerosol production, difficult to get the SDF to absorb into inter- is also important to remember to tell the
it is a key technique to consider. proximal lesions because the liquid has lim- patient that the area will turn black. Good
ited access to the weakened tooth structure. tooth structure will not change color. One
It is well known that prevention of oral dis- exception to be aware of is if you are using
eases is very important. However, despite The first technique has the advantage of this on a young child that has permanent
global efforts to prevent decay, dental caries easier application and fewer steps, but has teeth erupting, even if applying the materi-
prevalence remains elevated in adults and the disadvantage of leaving the black tooth al to a pediatric molar, if there is a perma-
children. In certain situations, the usual re- structure visible. The second technique has nent tooth (#8 or #9) partially erupted, it
storative treatment is not possible. There are the advantage of improved esthetics, but can absorb a small amount and it may ap-
patients who would benefit from conserva- this improvement comes with more steps pear as slight bands on the teeth that don’t
tive treatment of non-symptomatic active le- and takes more time. polish off, but do fade over a few months.
sions. These patients include those with sal-
ivary dysfunction, those unable to tolerate The first technique involves cotton roll iso- Upon subsequent visits, when the treated
standard treatment for medical or physio- lation. The teeth are air-dried and SDF liq- areas are evaluated, they seem to have a
logical reasons, those with severe cognitive uid is applied to the area with a microbrush lower amount of plaque on them than prior
or physical disabilities and dental phobias, for up to one minute, if possible. The area to treatment. This may also help the area
frail elders, or children with severe early is gently air dried and isolated for up to remain harder and prevent further decay.
childhood caries. It is also recommended for three minutes. A fluoride varnish is placed Stopping the progression of the targeted
patients with numerous carious lesions that over the SDF and surrounding dentition lesion may take several applications of
may not all be treated in one visit or are in without rinsing off the SDF. Areas affected SDF, and reevaluation should be done 2-4
areas that are difficult to restore. will turn black and the patient needs to be weeks after the initial application. Reapply
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SDF has been extensively researched for aware of this in advance. the SDF as needed at this appointment, and
many decades worldwide, but it was cleared additional applications may be needed at
in the US by the Food and Drug Adminis- The second technique is called the SMART recare appointments as needed in the future
tration (FDA) in 2014, and since 2015 the technique – Silver Modified Atraumatic depending upon progression of the lesion.
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product has been available. SDF was first Restorative Treatment. It gives enhanced
investigated in Japan as a thesis in 1969. esthetics and, in most cases, covers the The American Dental Association pub-
The researcher sought to combine the pow- black color. After polishing away the dis- lished a guideline (reference) to dissemi-
erful antimicrobial properties of silver with coloration on the margins you can cover nate the application of SDF. You can watch
the benefits of a high dose of fluoride. 2 the remaining area of discoloration with a video on its application at : https://www.
opaque glass ionomer followed by a com- youtube.com/watch?v=a0HH7GifdM4
The American Dental Association includes posite material. (Elevate Oral Care tech-
the use of SDF in the 2018 Evidence-Based nique pamphlet) Cases - All cases used Advantage Arrest
Practice Guidelines on Non-restorative (Silver Diamine Fluoride 38%) from El-
Treatment of Carious Lesions. There is a Situations where you may consider using evate Oral Care and Clearshield (5% So-
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code available for reimbursement (CDT either technique include any tooth that you dium Fluoride Varnish) by Kolorz/DMG
Code 1354) that covers the application of are not able to restore in a more traditional America.
SDF as Interim Caries Arresting Medica- method. These techniques are also useful in
tion Application, “conservative treatment of situations where definitive treatment will be Case 1. 59-year-old male. On tooth #27
an active, non-symptomatic carious lesion delayed such as when the patient has a large there was a shallow area of questionable
by topical application of a caries arresting amount of decay and we need to buy some dentin on the mesial. Clinically the region
or inhibiting medicament and without me- time while we restore the teeth one by one was not soft, but did not feel hard. (Figure
chanical removal of sound tooth structure.” as the patient is financially able to pay for 1) Without intervention, this was an area
treatment, or to do minimally invasive work that we felt would
SDF properties - Rationale for the use on a young child. SDF can help to stabilize definitely become
of SDF the demineralization of the root surface of a lesion covering a
SDF is a colorless liquid that when applied a tooth with a poor long-term prognosis large region on the
directly to the carious dentin will turn this due to periodontal disease and on abutment mesial. By treating
dentin black and arrest the decay process. teeth for removable partial dentures. this shallow surface
The process of arresting the decay happens defect, we hope
with a combination of the free silver ion in- When a tooth surface is starting to feel to preserve more
activating the bacterial metabolism and the slightly tacky, but isn’t cavitated, we may tooth structure and
fluoride release causing remineralization. face a tough decision. Do we prescribe a enhance the prog-
SDF advantages include its easy applica- fluoride product to the patient to stabilize Figure 1. Tooth #27
tion. A disadvantage is that SDF will turn the situation and hope that they will use it? at initial presentation.
the carious part of the tooth a dark black Do we go ahead and excavate the region?
color.
www.nysagd.org l Fall 2020 l GP 15