12. SDF

38% SDF- A colorless liquid ingredients

-25% silver: antimicrobial agent -8% ammonia: solvent- stabilizes the solution -5% fluoride: remineralization -remaining ingredient is water

How does it work?

-38% SDF contains 44,800 ppm fluoride and 253,870 ppm silver -Fluoride reacts with hydroxyapatite producing calcium fluoride (CaF2) and silver phosphate (Ag 3PO4) -Calcium fluoride acts as a reservoir of fluoride which neutralizes imbalance in demineralization/mineralization -Silver phosphate is a crystal of low solubility in the oral environment. Yellowish in color; is darkened by sunlight or reducing agents -SDF inhibits dentin demineralization, preserves collagen by inhibiting collagen breakdown, and increases dentin hardness. >The silver-protein conjugates on decayed dentin, increasing resistance to acid  dissolution and enzymatic digestion. >Hydroxyapatite and fluorapatite form on exposed organic matrix and inhibit  the proteins that break down exposed dentin organic matrix

SDF compared to other fluorides

-Acidulated phosphate fluoride - 12,000 ppm -Sodium fluoride - 9,040 ppm -Stannous fluoride - 19,360 ppm -Dentifrices - 1,000 ppm -Pediatric toothpaste - 250-550 ppm *38% SDF contains 44,800 ppm fluoride* (strongest fluoride!!)

what does SDF do?

-Remineralizes hydroxyapatite to fluorapatite -Increases lesion hardness -Prevents demineralization -Occludes dentinal tubules (which also helps to reduce sensitivity) -Penetrates far into dentin : 200 - 300 microns

History when did it become available in the US?

-Silver Diamine Fluoride (SDF) has been approved and used in Japan for over 80 years; over 2 million containers sold. 1 -August 2014: FDA cleared SDF for market as a varnish to treat hypersensitivity, using SDF to prevent or arrest caries is considered off-label. 2 -April 2015: SDF is commercially available in the U.S. -January 2016: CDT code is approved for caries arresting medicaments for documentation and billing. 2 -January 2016: Oregon becomes first state to reimburse Medicaid providers for treating caries with SDF

Antimicrobial use of silver

-Silver denatures proteins -Breaks cell walls and membranes -Inhibits DNA replication -Zombie effect: Bacteria killed by silver continues to kill living bacteria!***

what have we learned from clinical trials?

12 randomized control trials with 1,816 patients treated with SDF -6 trials targeted caries arrest. ~90% arrest with 2x/year application. 40-80% arrest with 1x/year application. -6 trials targeted caries prevention (3 of the trials overlapped). 70-80% reduction in children by application of SDF only to lesions. As compared to 25-70% prevention with other treatment modalities, thus outperforming all other forms of prevention at this time.

possible side effects

A cavity in the presence of SDF will turn that part of the tooth dark. This is an indication that the decay in the tooth is arresting. SDF placed on demineralized enamel (white lesions) may cause discoloration SDF placed on a tooth that has a tooth colored restoration may discolor around the margins of the restoration staining

xerostomia caused by...

Aging Medications Diabetes, Alzheimer's, HIV/AIDS, Sjogren's,stroke & autoimmune disorders Radiation treatment Methamphetamine use Tobacco & alcohol use

D9910

Application of a desensitizing medicaments, per visit

SDF effects on biofilm

Confocal laser scanning microscopy images of biofilms in control and silver diamine fluoride (SDF) group (x600). (a) Streptococcus mutans biofilm. (b) Streptococcu mutans biofilm with SDF (c) Actinomyces naeslundii biofilm (d) Actinomyces naeslundii with SDF Red= dead bacteria Green = live bacteria

caries arrest code

D1354

results of xerostomia

Dry mouth caused by a lack of saliva Dryness or a feeling of stickiness in the mouth Saliva that seems thick & stringy Difficult chewing, speaking & swallowing Dry or sore throat and hoarseness Dry or grooved tongue A changed sense of taste and/or bad breath *should be considering using SDF with these patients

indications

Extreme caries risk (xerostomia or severe early childhood caries) Treatment challenged by behavioral or medical management (young children requiring sedation , patients with dementia) Patients with carious lesions that may not all be treated in one visit. Difficult to treat dental carious lesions (distal of 3rd molars) Patients without access or limited access to regular dental care. Patients treatment planned for restorative at Pacific University, but must wait to be scheduled for restorative clinic. Patients with sensitivity due to recession.

SDF uses in the US

FDA clearance for hypersensitivity Off label use for caries treatment D1354 caries arrest CDT code became active January 2016

informed consent needed provides..

Facts PARQ -Procedure -Alternatives -Risks & Benefits (with photo) -Questions Statement: Tx with SDF does NOT eliminate the need for dental fillings to repair function and aesthetics of the treated teeth. Additional procedures will incur a separate fee. Signatures & date

Fluoride

Fluoride prevents and inhibits caries progression by: -Enhancement of remineralization (deposition of fluorapatite) -Inhibition of demineralization -Inhibition of bacterial activity

fluoride reacts with ____ producing _____ and ______.

Fluoride reacts with hydroxyapatite producing calcium fluoride (CaF2) and silver phosphate (Ag 3PO4)

application protocol

Generously apply petroleum jelly to the patient's lips extending past the vermillion border to protect staining on the skin. Also place on any composite margins, crown margins, and white lesions (areas of previously arrested decay or demineralization to prevent staining) Remove bulk saliva with saliva ejector Clean the tooth of food debri Isolate tongue and cheek from affected teeth with "2x2" gauze or cotton rolls and/or Dri-angle and place bite block (if needed) If near the gingiva, consider applying petroleum jelly with a cotton tip applicator Dry the tooth thoroughly. Bend microbrush, immerse into SDF, remove excess on side of dappen dish. Apply directly onto the the affected tooth surface(s) with microbrush. If lesion is interproximal, place Super-Floss interproximally and then apply SDF to the floss (via the microbrush) and pull through to the interproximal area.  ***Allow SDF to absorb for up to 1 minute, then remove excess with gauze or cotton roll*** Rinse with water. Hold dappen dish, microbrush, floss, cotton, etc. in one hand and remove glove onto supplies. Switch hands and repeat into the other glove. Place gloves and other barriers into plastic waste bags immediately to avoid staining.

SDF Contraindications - Questions to Ask Prior to Application

How long does the pain last? -Do not apply to pain that lasts more than 5 minutes Type and severity of pain? -Do not apply to teeth that have severe throbbing or steady pain indicating pulpal involvement What causes the pain? -Sensitivity to heat is indicative of irreversible pulpitis and should not receive SDF; sensitivity to cold and sweets are appropriate for application Do you take any medication for the pain? -If medications are needed to address tooth pain, SDF should not be applied. Is there a bump on the gum? -Do not apply to a tooth that has a fistula. *Be suspicious of pain!* sensitivity to cold and sweets is okay to apply, NOT sensitivity to heat ***

________ and _________ forms on exposed organic matrix and inhibits the proteins that break down exposed dentin organic matrix.

Hydroxyapatite and fluorapatite

D1354

Interim caries arresting medicament application

SDF manufactured by.... price?

Manufactured by Elevate TM Oral Care,Advantage Arrest silver diamine fluoride 38% ~ $100/bottle = ~ 250 drops ~ 40 cents/drop 1 drop treats ~ 5 teeth

does SDF restore form and function?

NO****

how safe is SDF?

No adverse reports in >60 years of use in Japan 1 drop per 10 kg of weight → 400-fold safety margin Minimal gingival responses: 0.2% of patients (~1500) from a collection of9 randomized clinical trials reported a "small, mildly painful white lesion in the mucosa, which resolved at 48 hours without treatment." 1 No significant risk of developing fluorosis when using U.S. approved product due to silver and fluoride levels being closely monitored.

follow-up

Reschedule patient at one week intervals for 2 additional applications; then for semi annual (6 month) recall application until the tooth is restored or exfoliated. Be sure to inform the patient NOT to eat or drink for one hour and do not brush teeth for 24 hours after treatment. **Treatment with SDF does NOT eliminate the need for dental fillings in the future to repair function and/or aesthetics**

SDF inhibits ____, preserves ____ by _____, and increases ______.

SDF inhibits dentin demineralization, preserves collagen by inhibiting collagen breakdown, and increases dentin hardness.

what is the biggest side effects of SDF?

STAINING Permanent staining (dark brown or black) -Clinic surfaces -Clothing -Carious tooth structures -Margins of composite restorations and crowns Temporary staining of the skin (similar to a henna tattoo) -Skin of the hands, face or gingiva -Rinse with water, not harmful, will go away naturally within days

how is there an increased resistance to acid dissolution and enzymatic action?

The silver-protein conjugates on decayed dentin

application protocol preparation

Use plastic to cover the counter, plastic-lined bib for the patient. Standard personal protective equipment (PPE) for provider SDF has a pH of 10 - use eye protection for the patient and provider Prepare the tray set-up -Plastic dappen dish -Mirror, explorer -Cotton rolls -2 X 2 gauze -Microbrush -Saliva ejector -Air water syringe tip Place one drop of SDF into the deep end of a plastic dappen dish.

Calcium fluoride

a reservoir of fluoride which neutralizes imbalance in demineralization/mineralization

Best practices to minimize adverse effects

coat nearby gingiva with petroleum jelly, use the smallest available microsponge, dab the side of the dappen dish to remove excess SDF.

SDF Contraindications

fistula, adversity to aesthetic appearance Allergy to silver or other heavy-metal ions Patient experiencing consistent, throbbing type pain or pain to HEAT (sensitivity to cold and sweets is fine) Pulp exposure uncontrolled bleeding

SDF relative contraindications

oral ulcerations, stomatitis, ulcerative gingivitis (may use petroleum jelly to protect the area)