Arthur a Dugoni School of Dentistry Patient Review
Clinical Instructions for Using Silverish Diamine Fluoride (SDF) in Dental Caries Management
Douglas A. Immature, DDS, EdD, MBA, MS; Ryan L. Quock, DDS; Jeremy Horst, DDS, PhD; Roopwant Kaur, BDS, MS; Jeanette Yard. MacLean, DDS; John C. Frachella, DMD; Steve Duffin, DDS; Adriana Semprum-Clavier, DDS, MS; and Andrea G. Ferreira Zandona, DDS, MSD, PhD
Abstract
Background: Manufacturer instructions for 38% silverish diamine fluoride (SDF) are express to current FDA clearance for tooth desensitization. At that place is a need for instructions to provide best-practise recommendations for off-label use of SDF for caries prevention and arrest. Methods: The authors considered existing clinical approaches to the apply of 38% SDF at pH 10 for the prevention and arrest of active dental caries, in calorie-free of the best current evidence. Application of SDF, with or without subsequent direct restoration, is included. The content was reviewed past stakeholders including but non limited to those listed on the consensus statement (Appendix A, below). Results: 38% SDF for the prevention and abort of active caries lesions, also as compatibility with common direct restorative materials, such as glass-ionomer cement and resin blended, has a foundation in the scientific literature. A applied decision-flow diagram and accompanying all-time practices for handling of caries lesions, based on clinical access and intention to restore, were developed based on bachelor evidence and expert clinical observation when no evidence was bachelor. Conclusions: Based on the best bachelor show, a logical arroyo can be adopted regarding the practical apply of 38% SDF for caries prevention and arrest. Applied implications: SDF used as per these instructions for prevention on loftier-risk tooth surfaces and arrest of active caries lesions has a identify in the practitioner's dental caries direction armamentarium. When SDF is practical to active lesions, it tin can be used with or without subsequent restoration, depending on clinical context, expert judgment, and patient input.
Authors' note: Appendix A Consensus Statement, which appears at the end of this article, sets the phase for this review of silver diamine fluoride, and readers may benefit from reading it first. Additionally, the applied decision menses diagram (Figure ane) will be useful to readers, both in helping to organize consumption of this commodity'southward content as well as applying its content to clinical scenarios.
In the "Show-based Clinical Practice Guideline on Nonrestorative Treatments for Carious Lesions" from the American Dental Association (2018), silverish diamine fluoride (SDF) is recommended to arrest cavitated coronal carious lesions on primary or permanent teeth.1,2 Once arrested, demineralization and lesion progression is halted. Systematic reviews and meta-analyses of controlled clinical trials conclude that SDF should be used as a preventive amanuensis on loftier-risk surfaces.3-7 Mechanistic studies suggest that SDF should be applied under restorative materials as a liner to harden infected or affected decayed dentin8-13 and provide long-term antibacterial effects.xiv-xvi
Because current US Food and Drug Administration (FDA) clearance for SDF is for treatment of tooth sensitivity (and not dental caries prevention or lesion abort), in that location are no manufacturers' instructions for use of SDF to prevent or arrest dental caries lesions. Similar to fluoride varnish, this off-label employ is permissible and advisable nether U.s. constabulary. This instructional article provides recommendations for the arrest and prevention of dental caries lesions using 38% SDF solution at pH 10 (Appendix B, SDF at a Glance) based on current available evidence. It should exist noted that these instructions and protocols are not applicative nor intended for other products that comprise a higher ammonia component and college pH, which require a gingival barrier or dental dam to prevent soft-tissue burns,17 or the addition of potassium iodide. For reader convenience, a period diagram of the clinical utilise of SDF on an active lesion has been adult and is provided (Figure 1). Subsequent sections of these instructions are section-titled to sync with the diagram. The flow diagram is cogitating of the international consensus statements on carious tissue removal and when to arbitrate in the caries process,xviii,19 and is in accordance with the original meanings of the terms "cavity" and "carious" as indicating that a full enamel cavitation is necessary for bacteria to infect the dentin and therefore possibly indicate invasive treatment.
Instructions for Application of SDF
Always obtain informed consent and discuss how the utilise of SDF and subsequent applications must be used in conjunction with existing caries management and prevention strategies. The following step-by-step protocol is based on both published research and clinical experience. When combined with other minimally invasive caries management techniques equally presented in this article information technology is expected that incorporation of SDF into restorative procedures will yield significant advantages for long-term disease direction. Presently, there is no strong scientific evidence supporting the effectiveness of any ane protocol over another. Commonly used alternatives are noted. Particularly, drying with cotton fiber gauze instead of compressed air avoids product of microbial aerosols during SDF application.
one. Use of personal protective equipment (PPE) for patient (safety glasses, plastic lined bib, other peel and apparel protection as indicated) and operator (condom glasses, mask, gloves, gown, etc) is strongly recommended. Protective coverings to protect clinical environmental surfaces are also advised.
2. Dispense SDF into a plastic dappen dish for immediate use; epitomize bottle immediately. Ane drop treats up to five surfaces, depending on the size of the lesion or surface.
Note: When using unit of measurement-dose capsules (~0.13 ml ≃ four drops) the following instructions utilise: (A) Place a unit dose upright on a plastic-lined tray or countertop. (B) Tap the unit on the counter/tray to ensure the liquid is at the bottom of the container. (C) Hold a 2x2 gauze over the ampoule and advisedly snap off the cap while holding the base of operations. (D) Dispose of the gauze and cap inside of your gloves in a proper receptacle. (E) Re-glove and utilize equally described in the subsequent sections.
3. Utilize optional extraoral protection for the lips and surrounding area using petroleum jelly or lip lotion. Scented lip lotion or a dab of toothpaste on the natural language may be used to mask any smell or gustatory modality perceived by some patients. Protecting the intraoral soft tissues is non needed, and the material could inadvertently go on the lesion or surface and inhibit SDF uptake.
four. Isolate tooth surfaces to be treated and protect other areas at run a risk for unwanted staining by using gauze, cotton rolls, absorbent triangles, a saliva ejector, and/or suction bite-block device. A clinical dental assistant may be helpful, peculiarly when applying SDF in young patients or difficult situations.
5. No caries removal is necessary prior to applying SDF.
6. Dry the area to be treated besides as the surrounding high-hazard surfaces with compressed air to control excess moisture. Dry with high-speed vacuum and/or cotton wool/gauze if compressed air is not available or if drying is not well tolerated past the patient, or if aerosol is a concern. Use of gauze avoids microbial droplets production from the flow compressed air on saliva, simply may decrease absorption.
7. Saturate the lesion or high-risk surface with SDF using a microbrush and allow absorption of SDF by capillary action for at to the lowest degree 1 minute. Practise not rinse, lite-cure, or accident compressed air while the SDF is beingness absorbed. Some clinicians prefer to lightly scrub the SDF into the lesion or surface while applying, to release the liquid'south surface tension. Avoid contact of SDF with unintended structures. After waiting at least 1 infinitesimal for the SDF to absorb, lightly blot whatever backlog SDF with cotton.
eight. Apply a varnish such every bit fluoride varnish on elevation of the SDF (optional) to keep the SDF in contact with the caries lesion or high-adventure surface for as long as possible, prevent saliva from diluting the SDF, reduce adventure of unwanted stain on other tooth surfaces, and to mask the taste from the SDF.20,21 Notation:If a restoration is going to be placed on the same day as SDF awarding, exercise NOT complete this stride.
9. Cleanup by carefully bringing all materials to a waste product receptacle while avoiding contact or dripping, for example, by inverting into a glove.
Approximal Techniques
SDF can exist practical to an approximal caries lesion and other difficult-to-admission high-adventure surfaces by ii methods. Both rely on capillary activity:
Method ane: Simply desiccate/dry out the contact point with compressed air or cotton fiber and and then saturate the contact expanse with SDF using a microbrush on the occlusal, facial, and lingual embrasures.
Method ii: Use woven unwaxed floss (Effigy two and Effigy iii).22 Place the dry "fuzzy" part of the floss into the dry out, isolated contact and utilize SDF to the floss with a microbrush on the lingual, buccal, and over the occlusal attribute. Do not move the floss. Remove the floss subsequently at to the lowest degree 1 minute. It is of import to protect the soft tissues (e.k., with a gloved finger) from whatsoever SDF migrating along the floss.
SDF Remember and Re-application Recommendations (When No Restoration is Placed)
If no restoration is planned, repeated applications of SDF are recommended, at least annually.6,23-26 Greater effectiveness is achieved with biannual than annual application25,26 and increased frequency of applications early in treatment.27
Restoring SDF-Treated Lesions
The rationale for restoring SDF-treated lesions may include but is not limited to eliminating food traps and improving cleansability,restoring form and function, and enhancing esthetics. Restorative options are guided by evidence, clinical judgment, and patient decisions. A recent big trial in young children that compared SDF to a placebo placed at a separate visit prior to restoration showed the combination of SDF and restoration with selective caries removal using atraumatic restorative treatment (ART) to be clinically compatible.28 A successful restoration has a sealed margin that prevents nutrients from reaching leaner in deeper areas, halting the demineralization process. Indeed, if clean margins can exist achieved and a sealed restoration placed, SDF may not always be needed.
Conservative cavity preparation with selective caries removal29,30 focuses on clean healthy external cavity preparation walls (from enamel margins through the dentino-enamel junction [DEJ]).18,29-31 Calorie-free-curing in the presence of free silver tin can darken the restoration and/or margins. If clean margins can be achieved after SDF placement it will limit SDF to the internal portion of the training and minimize staining at the junction of the tooth and restoration. When bonding SDF-treated dentin with resin adhesives, rinse at least 1 minute afterwards SDF application to optimize bond strength.32 The final sections offering some boosted best practice treatment suggestions and examples.
Glass-Ionomer/Resin-Modified Glass-Ionomer Cement Best Practices
Silver-modified atraumatic restorative handling (SMART) is divers here as a modified application of the atraumatic restorative treatment (ART) philosophy, that allows the flexibility to use SDF with or without cleaning the margins-using rotary or other minimally invasive methods-before placing a restoration. SMART is often indicated for its combination of characteristics, including selective caries removal sealing off nutrient sources from remaining leaner,29,xxx antimicrobial action,fourteen-16 desensitization,33 remineralization,10 and restoration of active cavitated carious lesions.34
Drinking glass-ionomer cement (GIC) is the preferred material for SMART restorations because information technology is the only restorative material that is water-based and has a significant anticaries effect,35-37 with less recurrent disuse at the margins38,39 and adjacent surfaces.40-42 The long-term release of fluoride ions supports remineralization,43,44 and as these ions are released from the GIC they are also able to be "recharged" by ions from other sources such as fluoride toothpaste.45 GIC restorations take been shown to exist antibacterial and to decrease acidogenicity of the biofilm, most likely from the fluoride release.46
Option A. Multiple-Appointment SMART: Abort First With SDF, Then Restore Later
Apply SDF in one case or more depending on the activeness and size of the lesion(s), wait ii to 4 weeks, then restore or seal with material of choice. During the intervening period, the lesion will harden, creating a foundation twice every bit hard equally healthy dentin.xiii Likewise, the gratis silver will dissipate, avoiding stain to the restoration or sealant fabric. Dramatically less or even no caries removal is necessary depending on the hardening or arrest of the lesion.47 Stain in areas that would show through can be selectively excavated (external walls) or blocked with opaquer (internal walls) prior to restoration.
Pick B. Same-Solar day SMART: SDF During a Restorative or Sealant Process Using GIC or Resin-Modified Glass Ionomer
Same-twenty-four hour period SMART restorations and sealants may turn gray when placed at the same appointment (as noted for calorie-free-cured materials) (Figure 4 and Figure 5). This can be minimized or eliminated by first placing SDF, and then completely cleaning the perimeter of the preparation equally in selective caries removal18,29-31 and rinsing, followed by restoration with conventional GIC, or resin-modified drinking glass ionomer (RMGI) every bit described in the 11-stride procedure below. Annotation that CDT lawmaking D1354 contains no linguistic communication that precludes delivery of a restorative (or any other) process on the same date of service, but does forestall mechanical removal of sound molar structure.
The suggested instructions for same-day SMART restorations/sealants are as follows:
one. Remove biofilm and pellicle with pumice or defocused air abrasion, or with cotton products if using microbial aerosol precautions, in the surrounding area of the lesion to be treated (GIC has no chemical bail to biofilm or pellicle).35,48-50
two. Employ SDFas per the step-by-footstep instructions detailed previously. (Annotation: Some clinicians prefer to wait and apply the SDF later on dentin conditioning at step seven.)
3. Clean the perimeter of the lesion xxx using your preferred technique (rotary handpiece, air abrasion, or hand instruments such as mitt drills or spoon excavators).
iv. Condition the lesion and surrounding areas with 20% polyacrylic acid for 10 seconds (removing the smear layer and activating the surface for ionic exchange). It is of import to condition not just the lesion just the surrounding areas as well.
v. Rinse with h2o for 10 seconds and blot dry (leaving a moist "sleeky" surface).
6. Place a matrix and wedge, if needed.
7. If any contagion occurs, rinse briefly over again with water and blot dry with cotton fiber (leave a moist "sleeky" surface). (Notation: Some clinicians prefer to apply the SDF at this footstep after dentin conditioning rather than in pace 2.)
eight. Mix the GIC or RMGI for ten seconds and utilize immediately to the cavitation to prevent voids.
9. Work quickly to place, shape, and remove excess because whatsoever increase in temperature volition greatly decrease manufacturer's stated working time. Avert over-manipulating the GICone time initial gel crosslinking has begun (when the setting GIC begins to lose its gloss).48
10. Protect from water loss or h2o gain. Exercise not let the GIC to dry out or get diluted with water/saliva.48,51,52 Methods for preventing backlog h2o loss or water gain from or to the GIC include turning suction isolation systems downward or off during set, and/or coating the surface of the GIC with a microbrush dipped in unfilled resin, using a damp (not drenched) cotton-tip applicator, or gloved finger remoisten with h2o/saliva.48,51,52
xi. Do not disturb the restorative material while it is setting (approximately 2.v to 3.5 minutes for GIC or until RMGI is lite-cured).48 In one case set, if placing anatomy, or finishing and polishing, utilise water to prevent desiccation.48
Instruct the patient not to chew on SMART restorations for at least 1 to 2 hours (for large restorations, 48 hours is fifty-fifty safer), or recommend a soft diet for 2 days.
Resin Composite Best Practices
Dentin caries arrested by SDF can be treated similarly to caries arrested by other processes. Principles of crenel preparation, based on material selection, should exist followed. Equally such, because a primary aim of a successful restoration is a well-sealed margin, conservative cavity grooming should focus on external walls (accent on enamel margins and the DEJ); infected, demineralized, or SDF-stained tooth structure should be removed from these areas. Stained but arrested axial and pulpal walls can be left free of mechanical preparation. It should be noted that SDF-treated dentin is compatible with resin-bonding adhesives (Figure 6 and Figure 7).32,53-55
Option A. Multiple-Appointment SDF-Resin: Arrest First With SDF, And then Restore Later
Look 2 to iv weeks afterward the concluding SDF awarding prior to restoring with a resin composite. To avoid "show through" of night centric/pulpal dentin on the primary expanse of esthetic concern, use an opaque restorative material, like traditional GIC for the entire definitive restoration or every bit a base for a sandwich technique. Alternatively, an opaque RMGI liner can be placed over the dark centric/pulpal area prior to customary restoration with a more than translucent material, like resin composite.
Pick B. Same-24-hour interval SDF-Resin: SDF During a Restorative Procedure Using Resin Composite
Restore with resin composite at the aforementioned appointment equally SDF application. In this case, SDF should be rinsed prior to bonding.56 From an esthetic perspective, same-day resin blended restoration is at risk for silver staining nigh the margins. To avoid this, a brusk ~ane second "tac"-style curing low-cal flare-up after SDF application and rinsing will photo-reveal remainder silvery with the subset of curing units that cover the argent absorption spectrum. Many focused operating lights will precipitate the silverish in 1 or 2 minutes. Once visible, selectively and minimally prepare dark silverish-stained areas at the enamel margins and DEJ, leaving silvery-stained dentin internally on the axial/pulpal walls. Repeat until there is no more residual silver at enamel margins and DEJ. Then, opaque and restore every bit to a higher place.
If a resin blended is chosen for the restorative cloth, the strongly preferred approach is to arrest with SDF starting time and then restore at a later date. GIC is preferable for same-mean solar day application of SDF and restoration for reasons mentioned in the previous "Drinking glass-Ionomer/Resin-Modified Glass-Ionomer Cement All-time Practices" section.
Conclusion
Using these instructions, SDF tin be incorporated into all caries management protocols by utilizing a logical flow diagram. Active caries lesions can exist managed with or without subsequent restoration, depending on clinical context. GIC is a preferred restorative material, especially for same-day restorations, due to its fluoride release and recharge potential. Resin blended is a restorative selection and is nearly appropriate after prior arrest with SDF and full general caries control.
About the Authors
Douglas A. Young, DDS, EdD, MBA, MS
Professor Emeritus, Department of Diagnostic Sciences, University of the Pacific, Arthur A. Dugoni Schoolhouse of Dentistry, San Francisco, California
Ryan Fifty. Quock, DDS
Distinguished Teaching Professor, Department of Restorative Dentistry and Prosthodontics; Academy of Texas Schoolhouse of Dentistry at Houston, Houston, Texas
Jeremy Horst, DDS, PhD
Director of Clinical Innovation, CareQuest Innovation Partners, Boston, Massachusetts
Roopwant Kaur, BDS, MS
Clinical Assistant Professor, Division of Operative Dentistry, Department of General Dentistry, East Carolina Academy School of Dental Medicine, Greenville, N Carolina
Jeanette K. MacLean, DDS
Private Practice, Glendale, Arizona; Diplomate, American Board of Pediatric Dentistry; Fellow, American Academy of Pediatric Dentistry
John C. Frachella, DMD
Pediatric Dental Consultant, Bend, Oregon
Steve Duffin, DDS
Dental Director, NODK, LLC and Oral Health Outreach, LLC, Wilsonville, Oregon; Private Do, Keizer, Oregon
Adriana Semprum-Clavier, DDS, MS
Clinical Associate Professor, Department of Restorative Dentistry, University of Illinois at Chicago Higher of Dentistry, Chicago, Illinois
Andrea G. Ferreira Zandona, DDS, MSD, PhD
Professor and Chair, Department of Comprehensive Care, Tufts University School of Dental Medicine, Boston, Massachusetts
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APPENDIX A. CONSENSUS Statement
Clinical Instructions for the Utilize of Silverish Diamine Fluoride (SDF) for Dental Caries Management
Silver diamine fluoride (SDF) has U.s.a. Nutrient and Drug Administration (FDA) clearance for tooth desensitization. Although leading organizations have recommended the use of SDF "off-characterization" for dental caries prevention and arrest, and its use in these situations is legally permitted, manufacturers are not permitted to issue instructions for these off-label uses. To accost the demand of clinicians and administrators for a standard protocol, a working group has compiled practical instructions for the use of SDF for caries abort and prevention. This guidance is intended to employ to all patients, including children, adults, older adults, and patients with special healthcare needs.
Further it is recognized that:
SDF has a prominent function in the 2018 American Dental Association Show-based Clinical Practise Guideline on Nonrestorative Treatments for Carious Lesions.one,2 SDF has been cleared by the FDA to utilize for tooth desensitization since 2014. In 2016, SDF was granted Quantum Therapy designation for caries arrest in young children by the FDA. The FDA stage III pivotal trial, which could establish SDF as the first drug to care for caries, is underway. As of 2020, reimbursement for the caries-arresting medicament awarding, reported with Code on Dental Procedures and Nomenclature (CDT) code D1354, was provided past most US state Medicaid programs, equally well as a number of commercial dental benefit plans. CDT code D1355, which documents commitment of a caries preventive medicament, became effective as of January i, 2021. SDF is a medicament that could exist used when delivering either of these "per-tooth" procedures.
SDF is supported by the American Academy of Pediatric Dentistry (AAPD) in the 2018 "Policy on the Apply of Silver Diamine Fluoride for Pediatric Dental Patients" and past the World Wellness Organization (WHO) in the 2017 "WHO Global Consultation on Public Health Intervention Against Early on Childhood Caries."57 In 2019, the FDI World Dental Federation (FDI) revised the 2002 Policy Statement on "Minimal Intervention in the Management of Dental Caries" to clarify that "an operative ("surgical") approach should only be used when specifically indicated, eg, when cavitation is such that the lesion cannot be arrested, or when there are esthetic or functional requirements."58 The FDI Policy Argument includes the following principles: modification of the oral flora to favor health; patient education and informed participation; remineralization of noncavitated and cavitated lesions of enamel and dentin/cementum; minimal operative intervention of cavitated lesions; repair of lacking restorations every bit a possible alternative to replacement.
The SDF clinical instructions presented in this article represent a foundation using the all-time bachelor scientific show, combined with practiced clinical experience and observation. These initial clinical instructions take been reviewed and their value affirmed by the following organizations, understanding that they will need updating as the body of cognition continues to expand.
The organizations are:
Academy of General Dentistry
American Academy of Developmental Medicine and Dentistry
American Dental Hygienists' Association
Association of State and Dental Territorial Dental Directors
California Dental Association Foundation
Caries Direction by Hazard Assessment (CAMBRA) Coalition
Consortium of Operative Dentistry Educators
Maine Academy of General Dentistry
Northern California Academy of Full general Dentistry
Project Accessible Oral Health
San Francisco Dental Gild
Southern Alameda County Dental Society
Special Intendance Dentistry Association
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APPENDIX B. SDF AT A GLANCE
Material: 38% SDF (in purified water, pH 10)
Storage: Avoid freezing or extreme heat
Maximum Dose: 260 μL (eight drops) per treatment visit59 (see #7 in the Safety section of Appendix C)
Indications:
• Tooth hypersensitivity
• High or extreme caries risk (xerostomia or severe early childhood caries)
• Patients undergoing radiations therapy for head and neck cancers
• Active caries lesions
• Treatment challenged past behavioral or medical factors
• Hard-to-treat dental carious lesions
• Patients without access to regular dental care
• When a less invasive treatment pick is preferred
• In combination with selective caries removal29,30 as a liner to harden infected or affected dentin8-thirteen and provide antimicrobial furnishings8,14-16
• Preventive amanuensis at high-risk surfaces4-6
SDF Actions:
• Desensitization33
• Prevention of new caries lesionsthree-five,7
• Caries indicator23
• Caries abort1,ii,60
• Hardening carious dentineight-13
o Forms argent-protein conjugates in carious surfaces11
o Inhibits the proteins that break down the exposed dentin organic matrix: matrix metalloproteinases,eleven cathepsins,9 and bacterial collagenases10
o Promotes remineralization10 and decreases lesion thickness10
o Fluoroapatite increases resistance to acrid dissolution and enzymatic digestionxi
• Silvery ions have antimicrobial action by breaking membranes, denaturing proteins, and inhibiting DNA replicationeight,14-16
• Silver and fluoride ions penetrate ~25 microns into enamelfourteen and up to 2.one mm into dentin61
• Silver microstructures fill exposed dentinal tubules and microcavitations produced by the caries procedure61
SDF Contraindicationsvi:
• Pulp exposure
• Irreversible pulpitis
• Allergy or intolerance to silver, fluoride, or ammonia
• Direct exposure to open mucogingival lesions
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APPENDIX C: OTHER SDF CONSIDERATIONS
Advantages
• A quick, simple, painless, and affordable means of managing many caries lesions at 1 appointment
• Procedure may not produce aerosol
• Procedure can exist completed in virtually whatever setting without the demand for expensive dental equipment, local anesthetic, sedation or even electricity
• Tin be combined with other prevention, therapeutic, and restoration options to evangelize risk-based, patient-centered comprehensive care
• Approximately 81% of caries lesions are arrested with semi-annual application60
• Will not stain healthy tooth structure
Disadvantages
• Does not restore grade, role, or esthetics
• Some caries lesions fail to arrest with SDF handling alone
• Permanently stains agile caries lesions blackness
• Stains demineralized and hypomineralized, non-cavitated surfaces
• Stains clinic surfaces, clothing, and skin if non handled properly
Precautions Related to Unintended Staining
• Inform patients and utilise circumspection as early on demineralization (white spots) may be subclinical
• Protect patient and dispensary surfaces (see instructions for application)
• Apply to site-specific lesions versus full-mouth application (such as with fluoride varnish)
• Do non use the same brush that has come in contact with SDF to apply varnish to other teeth
• Avoid exposing SDF to stiff light (curing, headlight, operatory) that has merely been applied to avert the silver ions from precipitating out of solution
Disadvantages
• Does not restore form, function, or esthetics
• Some caries lesions neglect to arrest with SDF treatment lone
• Permanently stains active caries lesions black
• Stains demineralized and hypomineralized, non-cavitated surfaces
• Stains clinic surfaces, clothing, and skin if not handled properly
Precautions Related to Unintended Staining
• Inform patients and use circumspection as early demineralization (white spots) may exist subclinical
• Protect patient and dispensary surfaces (see instructions for application)
• Use to site-specific lesions versus total-mouth application (such as with fluoride varnish)
• Do not use the aforementioned brush that has come in contact with SDF to apply varnish to other teeth
• Avoid exposing SDF to strong light (curing, headlight, operatory) that has but been practical to avert the silver ions from precipitating out of solution
Stain Removal
Difficult with varying degrees of success. The following suggestions are made:
Lips and skin:
• Stain will become away on its own within a few days or up to a few weeks.62
• Hydrogen peroxide, makeup remover, or exfoliation with a slurry of common salt may aid remove or lessen the stain.
Surfaces
• Sodium hypochlorite
• Some household cleaning products
Fabrics
• Potassium iodide
• Sodium percarbonate
Restorations
• Same-twenty-four hour period argent-modified atraumatic restorative handling (SMART) restoratives with resin volition immediately turn night.
• Same-day SMART restoratives with no resin may plow gray over time.
• Consider conventional atraumatic restorative treatment (Art) without SDF in the esthetic zone if staining is a business.
• Delay placement of a restoration for 2 weeks after SDF application and the restorative materials will non plough greyness. Stained tooth structures may show through depending on opacity and material thickness.
• Clean/sound cavosurface margins using selective caries removal and/or opaquers tin can help mask SDF stain.
Documentation
• Obtain informed consent from the patient or legal guardian, reviewing the risks, benefits, and alternatives to SDF.
• CDT Lawmaking "D1354 interim caries arresting medicament application - per tooth"
• CDT Code "D1208 topical awarding of fluoride - excluding varnish
• CDT Code "D1355 caries preventive medicament awarding - per molar," effective January one, 2021
Safety
• 38% SDF consists of 25% silverish, viii% ammonia, and 5% fluoride, with a pH of 10 (Reward Arrest, Elevate Oral Care).
• 0.05 ml drop of a 38% SDF contains 19 mg SDF, 4.74 mg argent, 2.24 mg fluoride.
• 0.1 ml unit dose ampule of a 38% SDF contains 38 mg SDF, 9.48 mg silver, 4.48 mg fluoride.
• In a curt-term serum pharmacokinetic written report, fluoride exposure was beneath the United states Ecology Protection Agency (EPA) oral reference dose. Silver exposure exceeded the EPA oral reference dose for cumulative daily exposure over a lifetime, but for occasional utilise (typically biannual application) was well below the concentrations associated with toxicity.63
• In another serum pharmacokinetic study,64 SDF was well tolerated and no agin events were reported.
• No studies have yet evaluated the safe of SDF during pregnancy in women or animals, thus the authors cannot make a recommendation on use of SDF in pregnant women and advise consideration of silver nitrate and fluoride varnish instead. There are long histories of safely using silvery nitrate to cauterize HPV warts on the cervix of pregnant women24 and fluoride varnish to prevent caries lesions in pregnant women.25 The combination of 25% silverish nitrate and fluoride varnish26 has been shown to have equivalent effectiveness to SDF.27
• The SDF dose of 260 μL (eight drops) per treatment visit listed in this document is a pregnant change to the previous recommendation of one driblet per 10 kg of body weight. The dose limit of 260 µL SDF per patient was developed to assure safety based on the weight of a small 12-month old child by the FDA drug panel for the phase Three, multicenter, randomized, placebo-controlled superiority trial run by University of Michigan, New York University, and University of Iowa.59
• When covering SDF with fluoride varnish there is an additive fluoride dose. The maximum dose of 260 µL SDF (8 drops) contains 11.6 mg fluoride, essentially the same as the 11.3 mg dose in a standard 0.5 mL parcel of fluoride varnish. For adults or children over twenty kg (44 lbs.), combining the total doses is condom. The individual product dose limits are based on condom for a x kg (15-calendar month onetime) child. The authors have not encountered a situation that would require even half the dose of either SDF or fluoride varnish at this young age. All the same, combined dose limits can be adjusted according to weight using a total dose of ane.13 mg/kg fluoride when a child is less than xx kg (44 lbs.), eg, four drops of SDF and the smallest (0.25 mL) packets for fluoride varnish.
References
1. Urquhart O, Tampi MP, Pilcher Fifty, et al. Nonrestorative treatments for caries: systematic review and network meta-analysis. J Paring Res. 2019;98(1):14-26.
two. Slayton RL, Urquhart O, Araujo MWB, et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: a report from the American Dental Association. J Am Dent Assoc. 2018;149(10):837-849.e19.
3. Zhang J, Sardana D, Li KY, et al. Topical fluoride to preclude root caries: systematic review with network meta-analysis. J Dent Res. 2020;99(5):506-513.
4. Oliveira BH, Rajendra A, Veitz-Keenan A, Niederman R. The effect of silver diamine fluoride in preventing caries in the primary dentition: a systematic review and meta-analysis. Caries Res. 2019;53(1):24-32.
5. Oliveira BH, Cunha-Cruz J, Rajendra A, Niederman R. Controlling caries in exposed root surfaces with silver diamine fluoride: a systematic review with meta-assay. J Am Dent Assoc. 2018;149(viii):671-679.e1.
six. Horst JA, Ellenikiotis H, Milgrom PL. UCSF protocol for caries abort using silvery diamine fluoride: rationale, indications and consent. J Calif Paring Assoc. 2016;44(one):xvi-28.
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Source: https://www.aegisdentalnetwork.com/cced/2021/06/clinical-instructions-for-using-silver-diamine-fluoride-sdf-in-dental-caries-management
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