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Silver DiamineFluorideRebeccaL.Slayton,DDS,PhD

February2018

Objectives• LearnthehistoryofsilvercompoundsinDentistry• WhatisSilverDiamine Fluoride(SDF)?• WhatdoesSDFdo?• Whataretheindications/contraindicationsforusingSDF?

• HowdoIuseSDFwithpatients?• Isthereevidencetosupportitsuse?• HowdoIbillforSDF?

• Usedhistoricallytotreatcolds,infections,tetanusandrheumatism

• Priortoinventionofantibiotics,usedtotreatGonorrhea• Silversulphadiazine usedastopicalagenttotreatburns

• Peng JJetal.JDent.2012Jul;40(7):531-41• PaulDirkes,DDS(PoarchBandoftheCreekIndians)

Silver compounds History of Silver Compounds• Dr G.V.Blackusedmultipleapplicationsofsilvernitratesolutiontoslowtheprogressionofcaries.

• 1920’sammoniiacal silvernitrateusedbyDrHoweforcaries,thechemicalprecursorofSDF.

Silver Nitrate• PriortoFDAapprovalofsilverdiamine fluorideintheUS,silvernitratewascombinedwithsodiumfluoridevarnishtoreducetheneedforhospitaldentistryinEECpatients

Silver Nitrate• J Calif Dent Assoc.2012;40(11):852-8.• Dr Duffin reportsonuseofsilvernitrate+fluoridevarnish:• 25%silvernitratewith5%NaF varnish• 5000childrenoverafiveyearperiod• 7of578teethtreatedhadtobeextracted• 98%oflesionsremaininactiveafter4years• Samemagnitudeexpectedinrootcaries• Pulpitisisnotanissue

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What is Silver DiamineFluoride?

• 24.4-28.8%(w/v)silverand5.0-5.9%fluoride(~44800ppm)

• Ammoniaandsilverfluoridecombinetoformadiamine silverioncomplex[Ag(NH3)2+]o Ammoniahelpsstabilizethesolutionataconstantconcentrationforlongertime

• pH10

• Silverandfluorideionspenetrate~25micronsintoenamel,and50-200micronsintodentin.

• Silverisantimicrobialandinhibitsenzymesthatbreakdowndentinorganicmatrix

• Fluorideaidsinremineralization oflesion

• Horstetal,JCalif DentAssoc.2016January;44(1):16–28

How it works• Formssilver-proteinconjugatesindecayedsurfaces• Increasesresistancetoaciddissolutionandenzymaticdigestion.

• Hydroxyapatiteandfluoroapatite formontheexposedorganicmatrix,alongwiththepresenceofsilverchlorideandmetallicsilver.

• Increasesinmineraldensityandhardnesswhilethelesiondepthdecreases.

• Inhibitstheproteinsthatbreakdowntheexposeddentinorganicmatrix:matrixmetalloproteinases;cathepsins;andbacterialcollagenases.

How it Works• Silverionsactdirectlyagainstbacteriainlesionsbybreakingmembranes,denaturingproteins,andinhibitingDNAreplication.

• Ionicsilverdeactivatesnearlyanymacromolecule.• Silverdiamine fluorideoutperformsotheranti-cariesmedicamentsinkillingcariogenicbacteriaindentinaltubules.

• Silverandfluorideionspenetrate~25micronsintoenamel,and50-200micronsintodentin.

• Fluoridepromotesremineralization,andsilverisavailableforantimicrobialactionuponreleasebyre-acidification.

SilverDiamine Fluoride• Effectivenessestablishedbasedona30-monthprospectivecontrolledclinicaltrial(Chuetal.,2002)o 376pre-schoolChinesechildrenwithcariesintheirmaxillaryprimaryanteriorteeth.

o Subjectsweresequentiallyassignedto:

• excavation+38%silverdiamine fluoride(SDF)appliedevery12months;

• SDFappliedevery12months(noexcavation)• excavation+5%NaF varnishappliedevery3months;• 5%NaF varnishappliedevery3months(noexcavation)• watercontrol

SilverDiamine Fluoride• AnnualapplicationofSDFwasmoreeffectiveinarrestingdentincariesthanapplicationoffluoridevarnishevery3months.

• TheremovalofcariestissuedidnotimprovetheeffectivenessofSDForfluoridevarnishtoarrestdentincaries.

• Forfluoridevarnishonly,cariesexcavationimprovedesthetics

Chuetal.,2002.JDentRes81:767-770

Silver Diamine Fluoride• Silverdiamine fluoridewasfoundtobeeffectiveinarrestingdentincariesinpermanentfirstmolarsinschool-agedchildren.

• Mechanismisthoughttobeanti-microbialactivityagainstS.mutans

• SDFrecentlyapprovedbyFDAfordentinsensitivity• AdvantageArrestgivendesignationas“breakthroughtherapy”

• J.C.Llodra,A.Rodriguez,B.Ferrer,V.Menardia,T.Ramos,andM.Morato.J.Dent.Res.,August 1, 2005;84(8):721- 724.

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Indications for Use• Highcariesrisk• Behavioralormedicalmanagementissues• Dentinalhypersensitivity• Cariesstabilization• Xerostomia fromcancertreatmentormedications• Difficulttotreatcarieslesions– crownmargin,furcation• Patientswithdentalphobia• Patientswithlimitedaccesstorestorativeservices• Physicalorcognitivedisabilities• Veryyoung/veryold

Contraindications• Silverallergy• Ulcerativegingivitis/stomatitis• Abscessedtoothneedingextraction• Irreversiblepulpitis

Side Effects• Metallictaste• Decayedteethturnblack• Transientgingivalirritation• Stainsclothes,skin,floor– mustusemeticuloustechnique

Advantages of silver solutions

• Controlspainbyarrestingcaries• Affordableforanycommunity• Procedureisfast• Minimalsupportinstafforequipmentneeded.• Non-invasiveandsafe

Informed Consent• Mayuseaseparateformorincorporateintoclinicconsentdocument

• PhotosshowinghowteethwilllookafterapplyingSDFmaybehelpful

• Parent,grandparent,otherfamilymembersmayhavestrongopinions

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Parental Perception• Crystaletal,JADA2017• Stainingonposteriorteethwasmoreacceptablethanonanteriorteeth

• MostparentspreferredstainingratherthantreatmentwithGAorsedation

Clinical Issues• Invitrostudiesshownoeffectonbondingtonon-cariousdentin(Quock etal,2012)

• BondingofacrowntoSDFtreateddentinmaybecompromised,sorecommendexcavationoftreateddentinpriortocementation(Soeno etal,2001)

• SDFeffectiveforsecondarycariespreventionwhenplacedunderamalgam(ShimizuandKawagoe,1976)

• 40%AgF placedondeepcariesinprimaryteethplannedforextraction;91%showedfavorablepulpresponse(Gotjamanos,1996)

Advantage Arrest Silver Diamine Fluoride 38%

Advantage Arrest• FDAclearedasadentinalhypersensitivitytreatment(similartofluoridevarnishes)

• 50+yearsofuseinJapan,China,India,NewZealand,AustraliaandmanyothersasCariesArrestingAgent

Breakthrough Therapy• Recently,FDAgaveAdvantageArrestthedesignationof‘breakthroughtherapy’

• ThebreakthroughtherapydesignationrepresentstheFDA’sefforttoexpeditethedevelopmentandreviewofdrugsthatareintendedtotreataseriouscondition;itisgrantedwhenpreliminaryclinicalevidenceindicatesthedrugmaydemonstratesubstantialimprovementoveravailabletherapies.

• FromDecisionsinDentistry.December2016.2(12):10.

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Toxicity• Onedropisapproximately25 μL andshouldbesufficienttotreat1-5teethandcontainsabout11.88mgofSDF. LDoforaladministrationisapproximately520mg/kgbodyweight;whileLDsubcutaneousadministrationis380mg/kgbodyweight. Achildof10kgwouldreceive1.185mg/kg.

• Ifyouusethe380mg/kgnumberbeingoverlycautious,thatisa400foldsafetymargin. TheEPAhasalsosetshortterm silver exposurelevelsindrinkingwaterat1.142mgperLfor1-10days.

• Typicalapplicationisonceperyear

Toxicity• Applicationsgreaterthanone

weekapartfallinlinewiththese

recommendations. TheEPA

longtermexposurelimitshave

beensetat1gramtosafely

avoidargyria.

• AccordingtoVasquezet.al,the

highestapplieddoseof2.37mg

wouldenable400+applications

overalifetime.

• Vasquezetal,BMCOralHealth.

2012Dec31;12:60.

Protocol• Covercountersandpatientwithplasticlinedbib/towel• UsestandardPPEforprovider,assistantandpatient• Place1dropofSDFintodisposableplasticdish• Forsingleuseampule,have2x2gauzeavailabletopreventsplashingwhenopening

• Usesalivaejectortoremovebulkofsaliva• Isolatetongueandcheekfromaffectedareawithgauzeorcottonrolls

• Iflesionisneargingiva,considerapplyingvaseline totissueinadvance

Protocol• Dryaffectedtoothsurface(s)withair/watersyringeorcottonpellet

• Dipapplicatorintodishandremoveexcessonsideofdish• ApplySDFtoaffectedtoothsurface• AllowSDFtoabsorbintotoothsurfacefor1minuteifpossible

• Removeexcesswithgauzeorcotton• Rinsewithwater• Discardallitemsinplasticbag

• LightcuringSDFisnot recommended• Itdoesspeedthedryingprocesssodarkstainisvisibleimmediately

• Lightcuringtakesfreesilverionsandcausesthemtooxidizerapidly.

• Onceoxidized,theyarenolongerabletobindwiththecollagenorphosphatesinthetooth,effectivelyweakeningtheSDF.

To Light Cure or Not? Advantage Arrest• Ifstainisanissue,canbecoveredwithGlassIonomer.• PotassiumIodidehasalsobeenusedtoreducethestaining

o ResearchisinconclusiveaboutKIreducingstain,orreducingefficacy

• Excesscanberinsedawayafterapplication• Canbereappliedatintervalsof>oneweek;oneapplicationperyearisnormallysufficient

• Clearliquid,LightSensitive• 10mlbottlefilledto8ml/alsoavailableasunitdose• 3yearshelflife

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• Beforeitdries,useanammoniabasedcleanersuchasWindex,orLysolwipes.

• FordriedandsetSDFstains,o Mr.CleanMagicErasero Bleacho BarKeepersFriendandComet

• Forskin,waterandsaltslurryaswellashydrogenperoxidehavebeeneffectivetosomeextent.

Oops, I spilled – Now what? Before and After SDF

Case #1• 16montholdchildpresentstoyourclinicwithECC• Childishealthybutparentsdon’thaveinsurancetopayforGAanddon’twantchildtobeasleepfortreatment

• Options:o Applyfluoridevarnishandputon3monthrecallo Attempttoplaceglassionomer restorationso PlaceSDF

Case #2• An8yearoldgirlwithalymphaticmalformationinvolvinghertongue,face,mediastinumandmandible

• Untilrecently,shewas100%G-tubefedbutnoweatsavarietyoffoodbymouth

• Anytraumatohertonguecausesexcessivebleeding• Shehasextensivecarieswithsomeprimaryteethandpermanentteethneedingtobeextracted

• Definitivetreatmentundergeneralanesthesiaisrecommendedwithpossibleadmissionforobservation

• ThecurrentbacklogfortheORfordentistryis1year

Case #2• Treatmentoptions:• SeeforfrequentrecallappointmentsandapplyFvarnish• Attempttoplaceglassionomer restorations• ApplySDFandexpediteORcase

• Inaddition:• Managediettodecreasesweetenedbeveragesandfoods• Regular2timesdailybrushingwithFtoothpaste

Case #3• 45yearoldmalewithahistoryofbisphosphonatetreatmentandnon-restorablemolar.Extractionnotrecommendedduetoriskforosteonecrosis.

• Optionstoconsider:o SDFapplicationo Decoronation andreplacementrootresorptiono RCTanddecoronationo Otherideas?

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Case #4• Frail,elderlypatientwithrootcarieswhoisunabletotraveltoclinicforroutinecare.

• Possibleoptions:o Glassionomer – ARTo SDFapplicationo Fvarnish

SDF + Glass ionomer =SMART

• Silvermodifiedatraumaticrestorativetreatment(SMART)• IfGIisplacedthesamedayasSDF,willhavestainingoftherestoration

• Someinsurancewon’tpayforSDFandGIdoneonthesameday

• SomeprovidersrecommendplacingGIoneortwoweekslater– maystillhaveadarkmarginduetoSDF

SMART• AfterplacingSDFfollowingpreviousprotocol• Cleanmarginsofthecavitated lesionwithslow-speedroundburorspoonexcavator

• Applyconditioner(20%polyacrylic acid)for10secondsandthenrinsefor10seconds

• Blotdrybutdon’tdessicate• MixGICandapplytolesion• Shapeandremoveexcess• Don’tlightcure• After2.5minutes,placeanatomy,adjustocclusionwithwaterspray

SDF use on proximal lesions• Noclinicalstudiestodate• SomeprovidersrecommendapplyingSDFusingsuperfloss• OtherproviderssuggestseparatingteethwithorthodonticelasticsandthenapplyingSDFdirectly

• Morestudiesneeded

Photo courtesy of Dr. JasonHirsch

SDF and GI• Bendit andYoung.SilverDiamineFluoride:Thenewesttoolinyourcariesmanagementtoolkit.CEcourseavailableat:o https://www.dentalacademyofce.com/

• CEcoursebyDr.JeanetteMacLeanandDentaltowno http://www.dentaltown.com/onlinece/details/803/silver-is-the-new-black-

improving-your-practice-with-silver-diamine-fluoride

Stains skin, clothes, floors, counters.

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Advantage Arrest• Perapplicationcost• $149=8mLbottle=250drops=$0.60/Drop• $11.25for100Applicators– $0.11perapp.

• Onedropapplication=$0.71perapplication• Twodropapplication=$1.42perapplication

• Unitdose=$4perapplication• EqualorlessthanFluorideVarnish

www.elevateoralcare.com/dentist/AdvantageArrest

Billing• In2016,newcodeestablished:D1354– interimcariesarrestingmedicamentapplication

• SomeMedicaidprogramsreimbursebutnotall• WashingtonHCAwillreimbursestartinginJanuary2018

Washington HCA• Theagencycoverssilverdiamine fluorideperapplicationasfollows:o Whenusedforstoppingtheprogressionofcariesonly;o Twotimesperclientpertoothinatwelve-monthperiod;ando Cannotbeperformedandbilledwithinterimtherapeuticrestorationonthesame

tooth.

• Providermusthavesignedinformedconsentthatincludes:o Benefitsandrisksofsilverdiamine fluorideapplication;o Alternativestosilverdiamine fluorideapplication;ando Colorphotographexamplethatdemonstratesthepost-procedureblackeningofa

toothwithsilverdiamine fluorideapplication.

• Reimbursement=$3.00/tooth• D1354codenowrequiresatoothnumber

Questions?• Ifunsureofbillingprotocol,contactHCA

o Dental-relatedservicesprogrambillingguide

• https://www.hca.wa.gov/assets/billers-and-providers/Dental-related-serv-bi-20181801.pdf

• MayalsocontactDr.JonGibbons(ADAtrusteeanda

pediatricdentist)o jkagib@Comcast.net

o Dr.RebeccaSlayton– rslayton@uw.edu