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