latest general article

ABSTRACT

Dental caries is a worldwide oral disease that effects individuals of all ages. It has only worsened with the introduction of refined and processed food and their ease of availability. Fluoride has been in use since the past 100 years in the control and prevention of dental caries in the form of various agents and concentrations but it has still been unable to be the perfect anti caries agent for a number of different reasons. Silver has also been used in the same breath has a caries control agent and as an antibacterial agent since a long time. A combination of both these elements called Silver Diamine Fluoride (SDF) has been found to have significantly improved caries arrest and halt its effects on tooth structure. It is a non-invasive method of caries arrest and is also used to reduce hypersensitivity. Reported studies have found no incidence of severe pulpal damage on the application of SDF. It has one drawback which stems from the Silver component of this agent and that is the discoloration that will be seen after application on the carious tooth structure. But its ease of applications and cost effectiveness makes SDF an ideal agent to help control the problem of dental caries.

INTRODUCTION

Dental caries is defined as an irreversible microbial disease of the calcified tissue of teeth, characterized by demineralization of the inorganic portion, and destruction of organic substance of tooth, which often leads to cavitation.1 It has been a major hurdle in the overall health of the population.2 As the world progressed, the factors leading to dental caries have also increased substantially. Even with the major advances in oral health treatments this disease has been difficult to control due to the difficulties in providing the necessary standard treatment to the masses, hence promoting minimal invasive dentistry as a very viable approach under field conditions.3,4

Fluorides have been the cornerstone of dental caries control since the discovery of their effects on the prevention of dental caries in the early 1940s, they have been implemented in numerous ways to make use of its different actions in the control of caries such as inhibition of demineralization of tooth surface, remineralization of lost tooth surface and also making the tooth more resistant to acid attacks which would otherwise result in dental caries formation.5

Different types of fluoride applications have been implemented to assure sustained, low concentrations of fluoride available to the teeth to promote caries prevention. Fluoride has been used in topical forms like varnishes, gels, fluoridated toothpastes and also systemic forms like fluoridated water sources, fluoridated milk to maintain the constant concentration of fluoride to maintain healthy dentition. But this is not without certain limitations like the occurrence of dental fluorosis in populations living in regions with high content of fluoride in water sources, Ingesting too much fluoride can also lead to fluoride toxicity which has fatal consequences if not provided with emergency treatment.6

Silver has well documented uses in ancient history and has been used extensively in the field of medicine mainly for its antibacterial activity to control and reduce infections7; Silver has been used in dentistry since the early 1840s in the form of silver nitrate for caries prevention and arrest.8 It can also be used as a dentin desensitizer, root canal disinfectant and also as restorative materials with small parts of silver content. The main problem with the use of silver compounds is the greyish to black discoloration of teeth and slight chances of pulpal inflammation.

Silver Diamine Fluoride was discovered in 1969 as part of a PhD thesis of Mizuho Nishino at Osaka University in Japan when she tried to marry the well documented antibacterial properties of silver to the applications of a high dose of fluoride, this combination had the added benefit of occluding dentinal tubules. Consequently, “diammine silver fluoride” was approved by the Central Pharmaceutical Council of the Ministry of Health and Welfare of Japan as a cariostatic agent and was marketed under the trade name Saforide (Toyo Seiyaku Kasei Co. Ltd., Osaka, Japan). It is actually misspelled as Silver diamine fluoride when its terminology should be silver diammine fluoride because it contains two ammine groups (NH3) and not amine groups (NH2), but over time the use of the term silver diamine fluoride has become so common that it has become the accepted term.8 It was used extensively in Japan but was discontinued due to reduced exposure; it has undergone a sort of resurrection in China at the beginning of the 21st century due to its reported excellent caries arresting capabilities, studies conducted in school children.9,10 In vitro studies were conducted in Australia by Knight et al to show its effect as an antimicrobial and caries arresting agent.11-14 SDF was successfully used as a caries arresting agent by Braga et al in the U.S. and Yee et al in Nepal.15 In October 2016, the FDA granted SDF the designation of “breakthrough therapy” in light of its ability to arrest dental caries in children and adults.8

RATIONALE FOR USING SILVER DIAMINE FLUORIDE16

Due to the combined actions of Fluoride and Silver in SDF, it can be used in several different conditions:

  • Dental Caries arrest
  • Dental Caries prevention
  • Dentinal Sensitivity
  • Root Caries
  • Radiation induced Caries
  • Indirect Pulp Capping

INDICATIONS

  • SDF could be used by most patients who would benefit from conservative treatment of non-symptomatic active carious lesions.
  • Extreme risk patients like patients with salivary dysfunctions like secondary to cancer radiotherapy treatment, Sjogren’s syndrome and the elderly.
  • Patients who cannot undergo standard treatment for medical or psychological reasons, mainly the elderly, pre cooperative children or patients with cognitive or physical disabilities.
  • Conditions where patients require immediate and quick treatment like busy hospital settings or treatment camps where logistics could be an issue with providing standard treatment.
  • Carious lesions difficult to treat due to morphological reasons and also lesions which are inaccessible by normal dental instrumentation.

CONTRAINDICATIONS

  • Patients with high aesthetic needs
  • Mainly patients with Silver or Fluoride allergy
  • Patients who are at risk of Fluoride toxicity
  • Lesions with exposed pulp
  • Patients suffering from desquamative gingivitis or mucositis

LIMITATIONS

  • Due to the staining of teeth, SDF cannot be used in permanent anterior teeth due to aesthetic reasons. This is a major drawback in the use of SDF.
  • Patients with silver or fluoride allergies.
MECHANISM OF ACTION

SDF is a mixed heavy metal halide coordination complex. Silver diamine Fluoride has been extensively studied in the past decade for its many properties which have made it an agent with multiple uses in the field of dentistry. Its main components Fluoride and Silver are renowned for their remineralization and antibacterial capabilities with ammonium used to keep the agent at a stable concentration for a period of time.17

Three possible mechanism of actions of SDF were described by Shimizu and Kawagoe in 197618

OBSTRUCTION OF DENTIAL TUBULES

One of major actions of Silver Diamine Fluoride may be the obturation of dentinal tubules. Gottlieb19 had described that deep caries spread could be prevented by obturation of the organic invasion road. The main path of invasion for caries in dentin is the dentinal tubules. According to a study conducted by Shimizu20, dentin treated with SDF decreased in dye permeability and increased in electric resistance. He also confirmed that silver and its compounds were present in the dentinal tubules. Hence, the diffusion of acid and invasion of microorganisms through the dentinal tubules may be blocked. Even if microorganisms invade dentinal tubules, their growth will be inhibited by the oligodynamic action of silver.21 Because of the occlusion of the dentinal tubules, the surface area of dentin, which may be attacked by caries, will decrease, and peritubular zone, which is most easily demineralized part of dentin, may be covered with obturating silver particles. Those factors in association with the obturation of dentinal tubules must contribute to increase in resistance to recurrent caries.22

EFFECT OF SDF ON MINERAL CONTENT OF TEETH

Fluoride is a known promoter of remineralization. The reaction products formed by the action of SDF on mineral component of tooth have cariostatic properties. According to Selvig23, the peri and inter tubular dentin showed increased resistance to acid decalcification after fluoride treatment thereby the penetration of acid into deeper layers of dentin is retarded. SDF has proven to decrease lesion depth of a demineralized tooth surface after application. It has been shown that the fluoride ions from SDF applied on dentin reach depths of 50 – 100 microns under in vivo conditions and react with hydroxyapatite and releases calcium fluoride and silver phosphate24, the calcium fluoride acts as a reservoir of fluoride for the formation of fluorapatite which makes the tooth more resistant to decalcification during an acid attack or chelating agent. The Silver phosphate component forms an insoluble precipitate on the tooth surface.25 The chemical formula of the reaction is as follows.26,27

In vitro studies have confirmed the formation of CaF2 and Ag3PO4 which are the major products of the reaction between SDF and tooth tissue.

Silver Diamine Fluoride has been proven to show an increased level of microhardness on dentinal surface of carious lesions arrested by SDF when compared to carious lesion not treated with SDF.28

ANTIENZYMATIC EFFECTS OF SDF

The reaction products of SDF with the organic components of tooth have antienzymatic actions. The antibacterial properties of SDF are derived from its inhibition of enzyme activities. Sunada et al29 discovered that dentin treated with Ag(NH3)2OH by ionophoresis increased its resistance to trypsin. It was stated that it was due to the reaction of silver and the organic component of dentin. Resistance of dentin protein treated with SDF towards collagenase and trypsin was shown by Yanagida et al.30 The antiplaque mechanism of SDF was studied by Suzuki et al and it showed excellent antibacterial action against cariogenic strains of S mutans and inhibited the dextran induced and sucrose induced activities completely at 0.59 and 0.2 µmole/ml. Suzuki et al31 also showed that on SDF application, penetration of fluoride and silver into enamel diffusely to about 25 µ and 20 µ respectively. Hydroxyapatite treated with SDF showed inhibition to adsorption of salivary proteins, this is due to the action of both silver and fluoride present in SDF. When used as individual agents of fluoride and silver this effect was not as potent. Thus, SDF inhibits adsorption of salivary proteins better than any other fluoridated agent. In a study conducted by Mei et al30 it was mentioned that 38% SDF inhibits multi-species cariogenic biofilms formation on dentin carious lesions thus reducing the demineralization process.

EFFECT OF SDF ON ORGANIC CONTENT OF TEETH

The composition of Dentin differs from enamel with an increased level of organic content present, mainly collagen which is a living tissue capable of responding biologically to carious attack.32 A vast majority (90%) of the organic component of dentin contains Type 1 Collagen while the other 10% consists of non-collagenous protein32; recent studies have shown that these collagen fibers are degraded by the action of Matrix Metalloproteinases (MMPs) are present in normal tooth structure and help regulate tissue modelling, cell modulation and differential during development of tooth, it mainly controls tissue turnover. These are present in the dentin matrix and saliva secreted by the odontoblasts. But due to its pH sensitive nature during an acid attack involving dental caries they are activated by low pH to degrade the collagen fibrils present in the dentin matrix, they also have a minimal effect on the degradation of protein content33 Cathepsins are proteases found in all organisms and have been found to act in tandem with Matrix Metalloproteinases in the degradation of extracellular matrix components34,35; they are proteolytic enzymes present in dentine caries as well as human pulp.32 These are closely related with MMPs in collagen degradation. The silver component of SDF is considered to be the contributing component in inhibiting the activity of cysteine cathepsins hence reducing degradation of the collagen matrix.36 The high alkalinity of SDF is considered to be the inhibiting factor when Matrix Metalloproteinases (MMPs) are considered. Hence SDF inhibits the action of both Matrix Metalloproteinases (MMPs) and Cathepsin in dentinal caries.

ANTIBACTERIAL EFFECT OF SDF ON TEETH

The presence of Silver gives SDF an additional antibacterial effect, the metallic silver component is relatively inert whereas the Silver ions produce the expected antibacterial effects.7 Metallic silver can react with the moisture in the oral environment and release silver ions which further follow three main antibiotic effects:

  • Destruction of cell wall structure
  • Denaturation of cytoplasmic enzyme and
  • Inhibition of microbial DNA replication

It eliminates bacteria by acting on the deoxyribonucleic acid (DNA) and sulfhydryl groups of proteins which are essential for bacterial survival. It also acts by altering the hydrogen bonding, cell division and metabolic processes.37,38 Silver ions can electrostatically bind with negatively charged peptidoglycans in the bacterial cell wall leading to loss of variability and cellular distortion. Streptococcus mutans is considered as a major etiological factor which results in caries formation. Multiple studies have been conducted showing the reduction of Streptococcus mutans by inhibiting enzyme actions and dextran induced agglutination that would normally occur if not treated with SDF.39

“ZOMBIE EFFECT” OF SILVER”41

Another fascinating action of Silver content in Silver Diamine Fluoride is the action of silver where biocidally killed bacteria are capable of killing living bacteria again resulting in a reservoir effect that last for a long time while eliminating bacteria. This phenomenon has two main characteristics.

  • The killing mechanism does not deactivate the metallic species and can hence carry on their bacteriocidal activity.
  • An efficient sustained reservoir of metallic cations is formed for further action against other live bacteria.

The Zombie effect of SDF follows the Le Chattelier’s principle which states that if a system in chemical equilibrium is subjected to a disturbance it tends to change in a way that opposed this disturbance.

The presence of new, viable bacteria in the cavity where SDF then acts as new, unoccupied adsorption sites for silver, and the equilibrium of silver between the reservoir and the liquid is shifted, according to Le Chattelier principle from the dead bacteria to the new viable ones.

The Zombie process can be explained by the following equations41:

This action of Silver makes Silver diamine Fluoride creates a reservoir effect which helps in reduction of bacterial action in dentinal caries even after the initial application of Silver Diamine Fluoride.

CHANGES IN SALIVA

Application of SDF on multiple teeth helps in increasing Fluoride content in saliva and in turn helping in the remineralization process. Each 38% Silver Diamine Fluoride contains 24.4-28.8% silver and 5.0- 5.9% fluoride, containing 55,800 ppm fluoride ions; 249,000 ppm silver ions and a pH of 10.2. This helps inhibit the demineralization process and increase the remineralization process.40

DIFFERENT CLINICAL USES OF SILVER DIAMINE FLUORIDE

IN CARIES ARREST OF PRIMARY AND PERMANENT DENTITION

SDF can be used in the arrest of dental caries in both primary and permanent dentition. In children, it is highly advantageous because only minimal (caries excavation) or no cavity preparation is needed in treatment of dental caries, it is a minimum or non-invasive procedure and patient anxiety, or cooperation is not a problem. It can be a great asset in treatment of children with special needs and also patients with management problems.42 This will also help improve the patient attitude to future dental treatments and reduce anxiety helping avoid development of psychological fear of dentists.

Multiple studies have been conducted across different countries to cement the effectiveness of SDF in arresting dental caries; most of studies had preschool children as the study subjects.

In 2001, An 18 month study was conducted by Lo ECM in preschool children in China comparing annual application of 44,800 ppm fluoride containing SDF solution with 22,600 ppm fluoride containing Sodium fluoride varnish application every 3 months.43 In 2002, the same children were followed up for making the initial study a 30-month using the same methodology and concluded that SDF is more effective than Sodium fluoride varnish at arresting dental caries in primary anterior dentition in preschool children.26

In 2005, Llondra et al conducted a 36 month clinical trial in Cuba to prove that SDF is effective in caries reduction of primary teeth as well as permanent first molars in school children.44

In 2009, R Yee et al conducted a 2 year study in Kathmandu, Nepal to assess the effectiveness of 38% SDF, 12% SDF and also to know if using tannic acid from tea as a reducing agent to check for any additional benefits, the study concluded that 38% SDF is the most effective concentration of SDF and tannic acid has no added benefits to caries arrest.15

In 2012, a study was conducted by Zhi QH to compare the effectiveness of annual, semi-annual application of SDF and annual application of high fluoride releasing Glass Ionomer restorations in arresting caries. The study concluded that semi-annual application of SDF is the most effective method of using SDF to arrest dental caries.45

In 2016, an 18-month study was conducted by Fung MHT to assess effectiveness of different concentrations and periodicity of SDF treatments in arresting dental caries. Semi-annual application of 38% SDF was found to be the most effective method for the treatment of dental caries using Silver Diamine Fluoride.46 This study was further extended to 30 months and offered the same conclusion to provide further proof of its efficacy.47

TREATMENT OF EARLY CHILDHOOD CARIES

Early Childhood Caries is a major problem in the primary dentition of preschool children worldwide. And children of this age group are difficult to treat.48 Anterior teeth lost to ECC can result in psychological trauma to children as well as problems with phonation.49 Due to the acute nature of the condition and future eruption of permanent dentition, aesthetic concerns can be sacrificed as primary dentition play a very important role in the normal eruption of permanent dentition. SDF provides an alternative to traditional treatment if diagnosed early.

TO PREVENT PIT AND FISSURE CARIES

Due to morphological reasons, Pit and fissures are found to be more susceptible to formation of dental caries than smooth surface caries. The cleaning of pit and fissures by toothbrushing is difficult and also diagnosis of such carious lesions is difficult. Topical fluoride application is far more effective in prevention of smooth surface caries than pit and fissure caries. The drawback here would be the blackish staining caused due to application of SDF which could be mistaken as an incipient carious lesion which makes record keeping of the application essential.30

However, according to studies by Sato et al50, SDF can be effective in the prevention of pit and fissure caries in first molar teeth. According to Nishino and Massler40, caries score of SDF treated teeth were significantly lower than teeth treated with Stannous Fluoride or Silver Nitrate.

TO ARREST ROOT CARIES

An individual becomes very prone to root caries at the later stages of life due to the ensuing periodontal problems and general reduction in immunity and general change in lifestyle.51,52 Silver Diamine Fluoride along with Oral Hygiene Education (OHE) has proven to arrest existing and prevent future caries formation in elderly patients in various studies. Multiple studies show that using fluoride agents together with OHE was an effective way to reduce root caries incidence in older communities.53-55 A study conducted on institutionalized elderly subjects using 38% SDF solution showed its effectiveness in preventing new root caries rather than giving oral hygiene instructions alone.56 Another study showed effectiveness of SDF application in conjunction with OHE.57

IN CARIES PREVENTION

Fluoride agents have been used in the prevention of dental caries since ages, so this use of Silver Diamine Fluoride is expected. SDF application resulted in prevention of caries on tooth surface adjacent to surface where caries arrest is seen.10,58 It can be used to prevent pit and fissure caries that are inaccessible by traditional oral hygiene methods and difficult to discover due to morphological reasons which also makes these areas of the tooth more prone to caries formation.59 Multiple studies have shown that SDF is equal to or better than other forms of topical fluoride application as it provides the added advantage of caries arrest as well as providing protection against future caries incidence.59,60

AS A DESENSITIZING AGENT

Tooth sensitivity is a very commonly seen in geriatric patients and individuals with periodontal problems; tooth wear, aggressive oral hygiene methods and also diet can be contributing factors for the development of sensitivity. It can be elicited by various types of stimulus like cold water and also cold air which result in activation of intradental nerves due to hydrodynamic changes in the dentinal tubules.19 SDF is found to be an effective and safe desensitizing agent due to its ability to occlude these dentinal tubules in cases of erosion or abrasion where dentinal hypersensitivity is initiated by mechanical/thermal sensation.61-64

TO TREAT INFECTED ROOT CANALS

Ammoniated silver nitrate solution has been commonly used for treating infected root canals, Tanaka showed that an aqueous solution of AgF has powerful disinfectant and protein coagulating actions and also occludes dentinal tubules. The numbers of treatments required were considerably reduced after application of SDF according to Okamoto et al. Hiraishi et al stated 3.8% SDF could be a potential antimicrobial root canal irrigant or interappointment dressing, especially in areas where brownish/blackish discoloration of teeth would not be a major concern.65 Mathew et al proved that SDF can be used to effectively remove microbes present in the root canals and circumpulpal dentin when used as an endodontic irrigant.66

TO PREVENT SECONDARY CARIES

Majority of restoration placed are prone to failure due to factors such as marginal leakage, presence of infected dentin or underestimation of the size of the carious infection, 40% of all cases of restoration replacements have been attributed to development of secondary caries. The important cariogenic bacteria associated with dentinal caries formation are Streptococcus mutans and Lactobacillus acidophilus and SDF has been proven to effectively inhibiting their growth.67 A study by Quock et al showed that SDF was also found to not have any adverse effect to the bond strength of composite resin restorations to dentin or cause any pulpal damage.68,69 38% SDF can be used to condition the prepared cavity before placement of glass ionomer cement and composite resin restorations to reduce the incidence of secondary caries formation.70,71 The only drawback being that the margins of the restorations will be stained by application of SDF.

ADDITIONAL USES OF SILVER DIAMINE FLUORIDE

INDIRECT PULP CAPPING

In Deep dentinal caries where softened dentin cannot be removed completely due to risk of exposing the pulp, the remineralizing efficacy of SDF is comparable to Glass Ionomer Cement and Calcium hydroxide, coupled with its impressive antimicrobial properties has made SDF a potential indirect pulp capping agent.72,73

USES OF SDF AS AN ANTIMICROBIAL AGENT

The antimicrobial action of SDF coupled with the “Zombie effect” has resulted in it being used as an endodontic medicament as well as antimicrobial and antiplaque agent. Enterococcus faecalis is a dentinophilic anaerobic organism that is the commonly associated with failed Root Canal Treatments and endodontic infection and formation of bacterial biofilms is considered as the initial stage of caries formation.66,65 SDF has been shown to have the added effect of disturbing the formation of biofilms and eliminating the Enterococcus faecalis organism hence making it a viable endodontic medicament.

SILVER MODIFIED ATRAUMATIC RESTORATIVE TREATMENT (SMART)

Treatment of caries affected tooth with silver diamine fluoride followed by placement of Glass Ionomer Cement is a new avenue of treatment known as Silver Modified Atraumatic Restorative Treatment. It was based on the following studies:

Quock et al74 proposed a hypothesis regarding drill less filling involving the utilization of SDF (38%) to arrest dental caries, followed by restoration with a bonded filling material to achieve adequate seal at the lesion margins. Hence, more research is required to evaluate the hypothesis. Santos et al40 examined whether, for underprivileged school children with cavities, treatment with 30% SDF gives better results than intermediate restorative technique (IRT) (Glass ionomer cement [GIC]) for carries arrest. After 1 year, The SDF technique had showed better results than IRT for the arrest of cavities in deciduous teeth, indicating that its use for underprivileged communities may justify a paradigm shift in dentistry. The GIC restoration should be placed hours after application of SDF as the ammonia in SDF is very corrosive to glass in its wet stage75 SDF has been proven to have remineralizing efficacy comparable to GIC and calcium hydroxide when used as an indirect pulp capping agent.72

ACCEPTANCE OF SDF TREATMENT

SDF meets the 6 quality aims of the U.S. Institute of Medicines that is, it’s safe, effective, efficient, timely, patient centered and equitable.76 The only main concern with its use is the staining of teeth and the slight change of gingival irritation if proper precautions are not taken during application. In the study done by Jennifer Clemens, the parents of the patients did not mind the staining of teeth in the communities where the study was conducted.77 According to a study by Crystal Y, it was concluded that parents of children did not mind the staining caused by SDF treatment when recommended as an alternative to treatment under General Anesthesia.78

ADVANTAGES AND DISADVANTAGES OF SDF

THE ADVANTAGES OF SDF as pointed out by Bedi and Infirri in 199979:

  1. Control of pain and infection. SDF is effective in arresting caries progression that if left untreated will cause pain and infection
  2. Affordable cost. The cost of SDF treatment is low and should be affordable in most communities
  3. Simplicity of treatment. The procedures are simple and enable non dental professionals including primary health care workers to be trained in the application of SDF hence making it more available and affordable.
  4. Minimal armamentarium and support required. The treatment being simple does not require any expensive equipment or support infrastructure such as piped water and electricity like other conventional dental treatments.
  5. It is a non-invasive procedure, thus the risk of spreading any sort of infection in very low. Also improving patient compliance and attitude towards dental treatment.

DISADVANTAGES OF USING SDF30:

  1. Irreversible Brownish or Blackish discoloration of the carious tooth surface caused due to the formation of insoluble silver phosphate.
  2. Discoloration can be seen on other tooth surfaces also but are reversible and wash off.
  3. SDF stains clothes and skin of the body and can take a long time to be removed but does not cause any pain.
  4. Slight gingival and mucosal irritation can be caused if the instructions are not followed carefully. But will heal in 1-2 days.27

CONTRAINDICATIONS TO USE OF SDF16:

  1. Patients with history of Silver allergy
  2. Patients suffering from Ulcerative gingivitis, stomatitis
  3. The use of Potassium Iodide for decreased staining of the teeth treated with SDF is contraindicated in pregnant and Breast-feeding women.
APPROACHES TO THE EFFICIENT USE OF SILVER DIAMINE FLUORIDE

SDF has been used in various methods to ascertain the most effective concentration and intervals that will prove all the numerous benefits of SDF.

According to multiple studies, 38% SDF applied biannually produces the desired benefits of SDF.10,47,58,80

COMPARISON WITH OTHER FLUORIDE AGENTS

SDF has been compared to other fluoride-based agents to compare the caries arresting and preventive capabilities and SDF has been proven to be the better agent along with the added latent antimicrobial properties and also ease of application.9,26,28,43,59,66,80,81

DISCOLORATION OF TEETH

The main disadvantage of SDF application is the black staining caused by the silver compounds present in it. The silver component turns black when it reacts to light or other reducing agents. Another reason for the staining is the formation of a silver phosphate layer on the carious dentin, silver sulphide precipitates can also be seen contributing to the staining effects of SDF.82

Potassium Iodide (KI) and Glutathione (GSH) biomolecules have been used in various studies to avoid this staining but the effects were found to be temporary. The usage of SDF is thereby limited to areas of lower aesthetic value like posterior dentition which will not be present in the smile line.11,12,83,84

Figure 1: Primaty Incisors before SDF treatment.

Figure 2: Primaty Incisors before SDF treatment

UCSF PROTOCOL FOR APPLICATION OF SILVER DIAMINE FLUORIDE

The following steps can be followed for the application of Silver Diamine Fluoride16:

  1. Plastic-lined cover for counter, plastic-lined bib for patient. Standard Personal Protective Equipment (PPE) for provider and patient. 
  2. One drop of SDF into the deep end of a plastic dappen dish as it corrodes metal and glass.
  3. (Also obtain one drop of SSKI in a separate dappen dish if selected). Remove bulk saliva with saliva ejector. 
  4. Isolate tongue and cheek from affected teeth with 2-inch by 2-inch gauze or cotton rolls. 
  5. If near the gingiva, consider applying petroleum jelly with a cotton applicator for safety. 
  6. Dry affected tooth surfaces with triple syringe or if not feasible dry with cotton. 
  7. Bend microsponge, immerse into SDF, remove excess on side of dappen dish. 
  8. Apply directly onto the affected tooth surface(s) with microsponge. 
  9. Allow SDF to absorb for up to one minute if reasonable, then remove excess with gauze or cotton roll. 
  10. (If using SSKI, apply with a different microsponge. Repeat one to three times until no further white precipitates are observed. Wait five to 10 seconds between applications. Remove excess with cotton.)
  11. Rinse with water. 
  12. Place gloves, cotton and microbrushes into plastic waste bags.
DISCUSSION

Silver Diamine Fluoride has been around as an anticaries agent for a very long time now and it has been found to be highly efficient in its many uses. It helps control dental caries by resolving nearly every symptom of dental caries bar the discoloration which is its only drawback. It helps in reducing demineralization by blocking the spread of dental caries through the dentinal tubules, it enhances remineralisation by acting as a reservoir for Fluoride which is an accepted initiator of the remineralisation process. It reduces the presence of caries causing bacteria which indirectly reduces dental caries and its unique “Zombie Effect” helps in the continuity of this bacterial control. SDF has been shown to not have any toxic effects on patients with proper use and it can be easily applied by a range of personnel therefore providing treatment to a larger population that would otherwise be without any form of treatment. SDF requires more research to successfully prove its efficacy as a method to prevent dental caries and also its use prior to restoration of teeth. The applications of SDF in the field of public health dentistry are limitless and it can help alleviate the worldwide disease of dental caries, particularly Early Childhood Caries.

CONCLUSION

Silver Diamine Fluoride is a multipurpose agent that can be used in various ways to resolve the rampant problem of dental caries all over the world. Its caries arresting properties cost effectiveness and comparatively easy application make it the perfect caries resolving material in developing countries. It has had no reported adverse effects since it was first approved in Japan about 80 years ago. The application of SDF in treatment of dental caries on a large scale is a major possibility considering its unique properties. It will help in fulfilling the WHO global goals for oral health 2020.

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