AAPD Guidelines for SDF Use!
The first professional organization recommendations for Silver Diamine Fluoride use were just issued. They come from the American Academy of Pediatric Dentists and recommend Silver Diamine Fluoride be considered as a treatment option. Some notable comments include, "Surgical-restorative work in young children and those with special management considerations (e.g., individuals with special health care needs) often requires advanced pharmacologic behavior guidance modalities (e.g., sedation, general anesthesia). These pathways of care have additional health risks and limitations (e.g., possible effects on brain development in young children, mortality risks), and often are not accessible, at all or in a timely manner. The U.S. Food and Drug Administration has issued a warning, [that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than three may affect the development of children’s brains.]” Also, "With caries lesion arrest rates upwards of 70 percent (i.e., higher than other comparable interventions), SDF presents as an advantageous modality. Besides its efficacy, SDF is favored by its less invasive (clinically and in terms of behavior guidance requirements) nature and its inexpensiveness. And finally, "The undesirable effects of SDF (mainly esthetic concerns due to dark discoloration of carious SDF-treated dentin) are outweighed by its desirable properties in most cases, while no toxicity or adverse events associated with its use have been reported." Read the full AAPD Guidelines here, and see their patient chair-side guide here!
The work to fully understand Silver Diamine Fluoride continues. We can’t say it better than the two press releases from New York University and The University of Michigan. Take a read!
Congratulations to NYU for receiving this PCORI grant!
The University of Michigan study below will be the pivotal Phase III trial for the Caries Arrest Claim for Advantage Arrest.
Light-Cure – it doesn’t “cure” in the way dental materials do, but it does react.
The application of SDF is a learning curve as we discover new attributes to the chemistry and new uses in conjunction with restorative work. We know that SDF is light sensitive liquid, and that exposure to light causes silver to oxidize rapidly. Originally clinicians thought light-curing SDF after application and a 60 second soak period on the tooth would simply show where the SDF is placed. Now we’re learning that doing this may limit the free silver ions available in the tooth, and cause them to oxidize which renders them useless or less effective. With this information, we don’t recommend light-curing SDF treated surfaces. The only time we’d consider this is if it’s used under a restoration where aesthetics are a concern. Light-curing after a minimum 60-second soak will allow you to see the discoloration and clean up any margins that may not be aesthetically pleasing. Otherwise, don’t light-cure it.
The randomized controlled trials demonstrating the efficacy of SDF for caries arrest do not use a curing light as part of their protocol. There is lack of formal research on the impact of light on the efficacy SDF, therefore, we recommend against it.
Varnish over SDF
If you’re applying a liquid that you want to interact with the tooth, wouldn’t you want it to remain there on the surface and active for as long as possible? We do. This is why we recommend you apply SDF, allow it to soak for about 60 seconds, and then paint over that surface with fluoride varnish. This process uses the resin of the varnish to create a barrier holding saliva out and SDF in. Don’t worry, there’s not too much fluoride as we’ll explain below. If you can’t get a 60-second soak on the tooth (i.e., pediatric patient), applying a fluoride varnish over the top can help prevent SDF from being washed away by saliva.
SDF and Fluoride Exposure
One drop of SDF is approximately 25 μL and should be sufficient to treat 1-5 teeth. This drop contains about 11.88 mg of SDF. The Lethal Dose (LD) of oral administration of SDF is approximately 520 mg/kg body weight; while LD subcutaneous administration is 380 mg/kg body weight so there is a large margin of safety. Additionally, a child of 10 kg would receive 1.185 mg/kg of fluoride which is 1/10th the amount of fluoride in a fluoride varnish application. If you use our FluoriMax 2.5% NaF Varnish, there's even less total fluoride.
If we use the 380mg/kg number, that is a 400 fold safety margin. The EPA has also set short term silver exposure levels in drinking water at 1.142 mg per L for 1-10 days. Applications of SDF greater than one week apart fall in line with these recommendations. The EPA long term exposure limits have been set at 1 gram to safely avoid argyria.
According to Vasquez et. al. in the study below, the highest applied dose of 2.37 mg would enable 400+ applications over a lifetime.
In short, it's best to be overly cautious. One Drop of SDF contains roughly the same amount of fluoride as a properly fluoridated liter of water. If you're using a sodium fluoride varnish after SDF application, use a 2.5% NaF Varnish rather than a 5% NaF Varnish.
Cleaning SDF Stains
If you catch SDF on a surface before it dries, use an ammonia-based cleaner such as Windex, or Lysol wipes.
So far for dried and set SDF stains, Mr. Clean Magic Eraser, and bleach have been the go-to options, while Bar Keepers Friend and Comet are good options as well. For skin, water and salt slurry, as well as hydrogen peroxide, have been effective to some extent.
But stay tuned; we’re working on something to help remove the stain even better! We’ve developed a chemistry that removes stains from counters and most other surfaces. As soon as it is ready for market you'll be the first to know.
SDF on PBS NewsHour
PBS NewsHour in January 2018 contained a 9-minute segment on SDF and its use in dentistry. The segment touched on research, history, use and current standards in dentistry. This may create an influx of patient questions in your office.
View the segment by clicking the image below and prepare yourself for any questions.
The CDA Journal will release back to back Silver Diamine Fluoride issues
The California Dental Association Journal that published the UCSF protocols for Silver Diamine Fluoride in 2016 has started the year off with another SDF issue (not just an article), and the promise of a second issue next month.
The CDA Journal the second of two Silver Diamine Fluoride issues
The California Dental Association Journal that published the UCSF protocols for Silver Diamine Fluoride in 2016 has released the second of two issues packed with SDF information.
Tim Wright DDS MS Silver Diamine Fluoride (SDF) article.
Dr. Timothy Wright wrote an article about the clinical use of Silver Diamine Fluoride. It provides great insight on SDF and various uses for the product.
A Second NIH Grant for New York University
Primary prevention, preventing caries from ever happening, should be the goal of every dental practice. Evidence for silver diamine fluoride demonstrates that SDF has preventive power when applied and dried on otherwise sound enamel or dentin. The NIH also thinks it is worth investigating, having just announced a second study on the use of SDF in primary prevention.
Drs. Niederman and Ruff, recipients of the $13.4MM PCORI study to evaluate SDF+FV (simple technique) against Sealant+FV (Complex technique) in NYC schools, are reproducing this same study in rural New Hampshire with funding just announced ($3.6MM) from the National Institute of Minority Disparities.
The announcement stated:
In the NIH-funded study, the New Hampshire schools will be selected at random to receive either the “simple” treatment of silver diamine fluoride and fluoride varnish, or the “complex” treatment of sealants and fluoride varnish. The simpler method takes six minutes to deliver, compared to the more complex method that takes 20 minutes. All children will receive the same preventive dental care twice each year.
The researchers will assess oral health to compare the outcomes of both treatments. The researchers expect that both treatments will be similarly effective in reducing untreated cavities. However, for the same time and cost, nearly four times more children can be treated with the simpler prevention. Therefore, if the simpler, less expensive strategy is found to be as effective as the more complex, more expensive method, the findings could support clinical and policy changes.
SCCDS Releases a great SDF Summary in The Cutting Edge
Dr. Eleni Ellenikiotis has written a great summary of the current information on Silver Diamine Fluoride and published it in the Santa Clara County Dental Society publication.
Be sure to visit the Santa Clara County Society page here as well.
SDF Research Continues to Expand - and you can help
Interested in a non-staining SDF, and/or restorative materials that contain and release SDF? Dr. Jeremy Horst and his research partner Dr. Jong Seto are continuing to work on Silver Diamine Fluoride and its expanded uses. However, much of their work requires funding to continue.
Please visit their gofundme site and if possible donate to help support their work and expand the knowledge base on this evolving chemistry.
SDF Symposium With Clinical Experts
If you're interested in learning more about SDF from the clinical experts, there's a symposium at McGill University in Montreal on May 5, 2018 that you should attend. Some of the greatest SDF minds will be present including Dr. Graham Craig, Dr. Jeanette Maclean, Dr. Ali Attaie, Dr. Nabil Ouatik and Dr. Hemaseh Nasseh.