Medical management of caries: silver diamine fluoride

Clinical Dentistry Reviewed (2021) 5:5 https://doi.org/10.1007/s41894-021-00093-3 TECHNIQUES Medical management of caries: silver diamine fluoride Beril Mendi1 · Ece Eden1 Received: 31 August 2020 / Accepted: 9 January 2021 / Published online: 15 February 2021 © The Author(s), under exclusive licence to Springer Nature Switzerland AG part of Springer Nature 2021 Abstract Silver compounds like silver nitrate have been used as caries inhibitor and dentin sensitivity reliever for more than a century. In the early 1970s, silver and fluoride were combined to produce a Silver Diamine Fluoride (SDF) solution which became commercially available in Japan. In 2014, the FDA approved SDF for dentine hypersensitivity. SDF is used for arresting cavitated dentinal caries with no pulpal symptoms both in deciduous and permanent teeth. However, due to unaesthetic outcomes resulting in blackening of treated areas, SDF is not a popular choice for the treatment of permanent anterior teeth. Treating dentine hypersensitivity and arresting root caries in the elderly patients may be a viable option. Caries excavation prior to applying SDF is optional and it has been shown to reduce black staining which follows each application. SDF is available as a solution easily applied with a microbrush directly onto the carious surface. Once applied to a carious area, SDF causes darkening indicating material effectiveness in doing so. The biannual application of SDF has been shown to increase the rates of tooth remineralization. Keywords Caries management · Silver diamine fluoride · Dental caries · Caries arrest · Remineralization Quick reference/description Dental caries is an outcome of an ecologic shift in the dental biofilm from a fair community to an acidogenic, aciduric, and cariogenic microbiological community with the help of fermentable nutritional carbohydrates. SDF is a colorless liquid material which can be used in cavitated dentin caries to arrest the progress of caries in dentine tissue. Its usage is more common in deciduous dentition, but can also be used in permanent teeth. SDF contains silver particles and 38% (44,800 ppm) fluoride ion that at pH 10 is 25% silver, 8% ammonia, 5% fluoride, and 62% water. * Beril Mendi [email protected] 1 Department of Pediatric Dentistry, School of Dentistry, Ege University, Izmir, Turkey 13 Vol.:(0123456789) 5 Page 2 of 5 Clinical Dentistry Reviewed (2021) 5:5 • The silver acts as an antimicrobial • The fluoride promotes remineralization • The ammonia stabilizes high concentrations in solution. Indications • • • • • • Patients with a high caries risk presenting with dentin carious lesions Patients with special needs Patients with access to care issues No evidence of pulpal inflammation and pain Carious lesions limited to dentin as evident by radiographs Accessible lesions. Contraindications • • • • • Silver allergy Symptomatic and pulpally involved teeth Oral stomatitis Ulcerative gingivitis Esthetic concerns. Materials and instruments • • • • • • • Standard equipment for clinical dental examination (probe, mirror, and tweezers) Petroleum jelly Rubber dam and/or cotton rolls Silver diamine fluoride solution Excavator (optional) Micro sponge brush Plastic dappen dish Procedure Detailed consent, emphasizing staining of treated lesions, possible staining of skin and clothes, and the need for reapplication to disease control, is advised to be obtained. Relatively to tooth enamel dentine contains a greater amount of protein substrate, phosphates, and carbonates for the reaction of material. As such SDF is more effective in arresting dentine caries than enamel caries. Caries lesions treated with SDF generally become black and solid (Figs. 1, 2). Biannual application is recommended, although certain lesions may require repeated applications to arrest carious activity. 13 Clinical Dentistry Reviewed (2021) 5:5 Page 3 of 5 5 Fig. 1 Clinical view of 4 year old female patient with cavitated dentin caries lesions in her primary central and lateral incisor teeth Fig. 2 Clinical view after silver diamine fluoride application with visible dark staining in carious dentin Although dentine excavation is usually not required prior to SDF application, it may be performed as it has been shown to reduce the likelihood to staining in treated areas. The stepwise clinical protocol is as follows: • A petroleum jelly as a protective covering should be applied on the lips and peri- oral skin to avoid staining. • Isolate the teeth to be treated using a rubber dam. • To improve the SDF contact with denatured dentin, remove food debris from the cavity. • Dry lesion gently with flow of compressed air. (Cotton rolls may be used for dry- ing the cavity to avoid aerosolization.) • For the entire appointment, no more than one drop of SDF should be used. • Coat a microbrush with SDF, remove excess liquid and then apply SDF directly onto areas to be treated and left for 1 min. • Gently dry tooth/teeth treated with air or cotton pellets keeping the rubber dam for approximately 3 min. • Apply 5% sodium fluoride varnish to treated areas. • Prior to SDF application carious dentin excavation is not essential. However, it may be done for better esthetic results. Excavation of caries prior to application 13 5 Page 4 of 5 Clinical Dentistry Reviewed (2021) 5:5 of SDF may decrease the amount of dentin that turns black after application of SDF. • To avoid inadvertent staining caution should be taken when applying SDF on primary teeth next to permanent anterior teeth which have non-cavitated (white spot) lesions that might stain. • Follow-up – Treated areas should be followed up at 2–4 week intervals following SDF application and monitored for carious activity and retreated as necessary. – Teeth treated with SDF but not consequently restored should be retreated with SDF as this has shown to reduce carious activity. Pitfalls and complications • The hallmark of SDF is an apparent dark staining which is also a sign of car- • • • • ies arrest on treated dentin carious lesions. This dark staining is persistent if it is not restored. No severe pulpal damage or reaction to SDF has been reported. However, SDF should not be placed on exposed pulps. It has a significant metallic/bitter taste. SDF causes temporary staining in skin which resolves in 2–14 days. Mucosal irritation/lesions due to contact with SDF resolve within 48 h. Further reading 1. Crystal YO, Marghalani AA, Ureles SD et al (2017) Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Pediatr Dent 39(5):E135–E145 2. Bjørndal L, Ricucci D (2014) Pulp inflammation: from the reversible pulpitis to pulp necrosis during caries progression. In: Goldberg M (ed) The Dental Pulp. Springer, Berlin. https://doi. org/10.1007/978-3-642-55160-4_9 3. Crystal YO, Niederman R (2019) Evidence-based dentistry update on silver diamine fluoride. Dent Clin North Am. 63(1):45–68. https://doi.org/10.1016/j.cden.2018.08.011 4. Fejerskov O, Larsen MJ (2015) Dental caries: the disease and its clinical management. WileyBlackwell, Oxford 5. Horst JA, Ellenikiotis H, Milgrom PL (2016) UCSF protocol for caries arrest using silver diamine fluoride: rationale, indications and consent. J Calif Dent Assoc. 44(1):16–28 6. Li R, Lo ECM, Liu BY, Wong MCM, Chu CH (2016) Randomized clinical trial on arresting dental root caries through silver diamine fluoride applications in community-dwelling elders. J Dent 51:15–20. https://doi.org/10.1016/j.jdent.2016.05.005 13 Clinical Dentistry Reviewed (2021) 5:5 Page 5 of 5 5 Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 13