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