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Who, What, Where, When and How? Dr. Brooke MO Fukuoka DMD March 10, 2017 SCDA Annual Meeting Charlotte, NC Silver Diamine Fluoride
Who, What, Where, When and How? Dr. Brooke MO Fukuoka DMD
March 10, 2017
SCDA Annual Meeting
Charlotte, NC
Silver Diamine Fluoride
Disclosures and Affiliations
Dr. Brooke MO Fukuoka
Affiliations
President of local component of ADA
South Central Idaho Dental Society
“Private Practice” owner
Your Special Smiles PLLC
HQFC Employee Dentist
Family Health Services
“Lecturer/Rotation supervisor” for special care
College of Southern Idaho
Member of the Special Care Dental Association
Institute for Diversity in Leadership Class of 2016-2017
Disclosures and Affiliations Dr. Brooke MO Fukuoka Recent and upcoming presentations on this topic: Special Care Dentistry, Silver Diamine and Soft Liners
South Central Idaho Dental Society (SCIDS) o Aug 2016- Sun Valley, ID
Silver Diamine Fluoride- Team Presentation with Advantage SCIDS and IDHA combined meeting
o January 2017- Twin Falls, ID
Who, What, Where When and How of SDF AT Still University-
o Feb 2017- Phoenix, AZ
SCDA- Annual Session, o March 2017- Charlotte, NC
Idaho State Dental Association Annual Session
o June 2017- Sun Valley, ID
Disclosures and Affiliations Stand on the Shoulders of Giants
SDF “Training” Learned about it vaguely last June 2015 at the ISDA Annual Session
from Advantage Dental
Lecture from Advantage Dental at FHS January 2016
Asked about it at SCDA 2016- round table discussion
Met a hygienist who used silver nitrate and fluoride
Told it was an “old drug” by Japanese dentist
Read many articles
Briefly Discussed with Dr. Gordon Christensen
Briefly Discussed with Dr. Brian Novy at ADA 2016
Traveled to UCSF to talk with Dr. Sean Mong, Dr. John Featherstone, and Dr. Jeremy Horst. –multiple emails with Jeremy
Currently using in private practice and at the HQFC
Met with Japanese hygienist who has applied it hundreds of times
Discussed “Saforide” with Bee Brand representative via email
Disclosures and Affiliations
Dr. Brooke MO Fukuoka
Financial interest
Has no conflict of interest and no financial interest in SDF
So Why do I do this?
Your Special Smiles PLLC Mission Statement:
“To increase the quality of life for adults with Neurodevelopmental/Intellectual Disabilities and Brain Injuries through caregiver education and increasing access to comprehensive dental care.”
Who, What, Where, When and How? Dr. Brooke MO Fukuoka DMD
March 10, 2017
SCDA Annual Meeting
Charlotte, NC
Silver Diamine Fluoride
Who can apply SDF
SDF ≠ Varnish
It is currently treated as a varnish in multiple states
It is NOT Varnish, through understanding of risks
and benefits needs to be understood by the
provider for proper consent from the patient.
Leaves staining that can last FOREVER
Who can apply SDF?
In Idaho according to our board of dentistry
“It is an authorized function under topical fluoride
application.”
Rules of the Idaho State Board of Dentistry
Rule 30: Dental Hygienists- Practice
o 01- General Supervision- (dentist needs to authorize)
• L- All duties which may be performed by a dental assistant
• Careful with expanded access- standing orders
Rule 35: Dental Assistant Practice
o 01-Direct Supervision- (dentist needs to be present)
• X- application of topical fluoride agents
Who can apply SDF?- Arizona
According to the board of dentistry in AZ:
“It is an authorized function under application of
topical fluoride varnish.”
That means that hygienist and dental assistants are
authorized to place it
Nothing in the dental practice act specific about
SDF
The board has not discussed it at this point
Who can apply SDF? § 32-1289 Employment of dental hygienist by
public agency, institution or school; definition B. A dental hygienist employed by or working
under contract or as a volunteer for a public health
agency or institution or a public or private school
authority before an examination by a dentist may
perform a screening or assessment and apply
sealants and topical fluoride. ( I would say DON’T
DO THIS WITH SDF- it is not the same as varnish)
Who can apply SDF? 32-1291.01 Expanded function dental
assistants; training and examination
requirements; duties D. An expanded function dental assistant may
apply sealants and fluoride varnish under the
general supervision and direction of a licensed
dentist.- after the dentist plans it without the dentist
being there. –(THIS IS NOT VARNISH, make sure
this is what is planned and not ordinary varnish. )
Who can apply SDF? R4-11-701. Procedures and Functions
Performed by a Dental Assistant under
Supervision
A. A dental assistant may perform the following
procedures and functions under the direct
supervision of a licensed dentist: 9. Apply topical fluorides;- (so without expanded
function can do this while the dentist is present. )
Who can apply SDF? Summary
It is my understanding that:
Hygienist- can apply it without prior doctor planning
if they work I public health or a school setting
An expanded function assistant can apply it
under general supervision (without dentist present)
An assistant can apply it with direct supervision
Who can apply SDF?
North Carolina
Can only be applied by a licensed dentist
According to Casie S. Goode- Assistant Director of
Investigations and Terry W. Friddle- deputy operations
officer NC State Board of Dental Examiners
Who is applying SDF?
Has been used for over 80 years in Japan and
other countries. Australia, China, Brazil
Seen as an “old drug” when asking Japanese
dentists.
“Fukka jianmin gin”
Typically Placed By
Hygienists in Japan
Japanese Hygienist
Ikumi Fukuoka- aka
my sister-in-law
Japanese product
Japanese Articles 1967, 1969
Japanese article 1974, 1975
Saforide Instructions
Who is applying it across the US? Leaders in SDF- “stand on the shoulders of giants”
Dentists
Dr. Jeremy Horst
Dr. John Featherstone
Dr. Sean Mong
Dr. Brian Novy
Dr. Mike Shirtcliff
Dr. Peter Milgrom
Who is applying it across the US?
Leaders in SDF
Organizations and groups
Advantage Dental
UCSF
University of Washington
Community Health Centers
Pediatric Practices
What is Silver Diamine Fluoride?
History in the USA
August 2014:
Obtained FDA cleared for sensitivity:
April 2015:
Advantage Arrest became available in the US
January 2016:
UCSF published protocol for use in the Journal of
the California Dental Association
What is Silver Diamine Fluoride?
History in the USA
July 11, 2016: A lot of attention was drawn to it
with article from New York Times
What is Silver Diamine Fluoride?
History in the USA
July 12, 2016: ADA’s response to NY Times
What is Silver Diamine Fluoride?
Obtained FDA clearance for treatment of caries
October 30, 2016
What is Silver Diamine Fluoride
Insurance Codes
D1354 interim caries arresting medicament
application.
D1208- topical application of fluoride
D1206 – topical application of fluoride varnish
D9910- topical application of desensitizing
medicament
The code 1354 us a
per tooth code
People’s charge
ranges $15-50
What is SDF Biochemically ? Ag(NH3)2F
Silver Nitrate
Silver Phosphate
Silver Diamine
Fluoride
What is SDF?
Gives up this
outer electron to
become Ag+
Colorless or white powder,
odorless, water soluble
and extremely soluble in
NH3 Similar to Silver
Nitrate
Acts Like Silver Nitrate and
Fluoride
What is SDF?
What is SDF?
From their
elemental forms
To their more
stable forms
Dissolved in
What is SDF?
What is SDF? (Compared with silver nitrate + Fluoride)
What is SDF?
How does it work?
Interacts with Thiol groups
Binds to proteins in bacterial cell walls
Problems with respiration, distortion, cell death, makes
cells more permeable by generating free radicles
Binds to DNA in bacteria
takes out of relaxed state “Denaturing”
Effects hydrogen bonding
Inactivates bacterial enzymes
What is SDF? Silver Interacting with Thiol Groups
pH of SDF = 10
What is SDF? Silver diamine has shown superior bactericidal effects in dentinal tubules
Hamama HH, Yiu CK, Burrow MF. Effect of silver
diamine fluoride and potassium iodide on residual
bacteria in dentinal tubules. Australian Dental Journal.
2015; 60(1):80–87.10.1111/adj
When should SDF be considered “SDF is an ideal treatment, when traditional treatment is not indicated”-
MY OPINION-
When esthetics is NOT an issue
When is Silver Diamine Fluoride
NOT indicated?
When esthetics is an issue
“Look at all my wrinkles”
When should it be considered “SDF is an ideal treatment, when ideal treatment is not indicated”- MY
OPINION-
Medically compromised patients
Unless you
feel that
they will not
live long
enough for
it to benefit
them
When should it be considered “SDF is an ideal treatment, when ideal treatment is not indicated”- MY
OPINION-
Small children- keeping them out of the OR
Can buy time until they
are older and you can
treat.
Also consider
mesial caries on a
molar with a
primary about to
exfoliate- buying
time for better
access!
When should it be considered “SDF is an ideal treatment, when ideal treatment is not indicated”- MY
OPINION-
Patients who are non-compliant with oral
hygiene
When should it be considered “SDF is an ideal treatment, when ideal treatment is not indicated”- MY
OPINION-
Patients who have extensive work needed
When should it be considered “SDF is an ideal treatment, when ideal treatment is not indicated”- MY
OPINION-
In Difficult to reach furcations
When should it be considered
Difficult crown margins and non restorable
endodontically treated teeth
Prolonging the poor px tooth or bridge
When should it be considered “SDF is an ideal treatment, when ideal treatment is not indicated”- MY
OPINION-
With ITR or Questionably Restorable Teeth
When should it be considered? Does Silver Diamine Fluoride Effect Bonding?
Not a lot of studies, but the ones that are out
there show no difference in bond strength with
composite and glass ionomer
Total etch is more effective than self etch- so if
you try it make sure you etch and rinse.
Riva silver has both components of SDF in it
Glass ionomer restoration with silver particles in it
When is Silver Diamine Fluoride NOT
indicated?
Silver allergy
Open soft tissue lesions
Pregnant patients- I couldn’t find studies to show
safety so I don’t use on pregnant people
Where can we get it?
http://www.elevateoralcare.com/dentist/Advantag
eArrest
Where can we store it?
Store at room temperature
If it gets cold it balls up and is hard to get on the
brush
Store upright
Put the lid on tight
How do you use Silver Diamine
Fluoride?
UCSF Protocol
Has been published
Involves rinsing and
isolation
How do you use Silver Diamine
Fluoride? My procedure Wear eyewear, gloves and protect your clothes Don’t Spill it- put in dappen dish, use provided microbrush
Don’t spill on table Don’t rinse in a white sink- use 2x2 to wipe it then dispose of it
in your gloves
Dry tooth if possible Apply silver diamine Suck up any excess if suction available Place varnish over top Repeat q3m (if possible evaluate the next week, if not
arrested then do it again and repeat, then q3m)
Vasoline on lips and gingiva can help protect from staining- but don’t
get it on the lesion.. Or it can protect from working
Superfloss and
interproximal
How to use SDF: My Method
11
60-1:45
2:00
How do you use Silver Diamine
Fluoride?
Caries removal?
Caries removal does not make a difference in
effectiveness but does make a difference in staining
If patients can tolerate removal I like to remove
caries with a spoon
How do you Use Silver Diamine
Fluoride ?
Recommended dose
1 drop for every 10kg (22lbs) per visit with weekly
intervals at most
Problems with SDF?
Negatives?
Poor esthetics
Not magic ferry dust- doesn’t always work
Problems with SDF?
Negatives?
Nephro/hepato toxic in large quantities
Intestinal irritation
Does cross blood testes barrier and effects sperm
Interferes with mitochondria by altering membrane
permeability to sodium and potassium
Signs of adverse rxn
Greying of sclera and skin
Problems with SDF?
Though it does arrest decay, it does NOT fill
cavitations,
Problems with SDF
Stains EVERYTHING-
Magic Eraser or Soft Scrub on table- sometimes still
doesn’t come out
Cells exfoliate, tables do not
Turtle shells and fingernails are slower …. Epithelial
turnover….
CONSENT is way important
When you don’t have color photos for consent did
you really get informed consent?
Consent form From
Dr. Jeremy Horst
Silver Diamine Fluoride
Anyone working on something with the color?
Potassium iodide
Reacts with free silver particles and forms a white
precipitate
Must be rinsed prior to bonding- has shown to decrease
bond strength
Not sure if safe with pregnant ladies
Precipitates chalky white
Not in the USA
Questions? Do you see any radiographic change with this? I have not but very good question. I have not
looked.
Other questions I think I went back and added to applicable slides. I also corrected the verbage FDA approved to FDA cleared- I learned from a member that the FDA does not approve products, they clear product
Please let me know if I didn’t answer your question.
Sources for information and articles Mahendra Rai. “Silver nanoparticles as new generation of antimicrobials”. Biotechnology Advances. (2009)
RL Quock. “Effect of Silver Diamine Fluoride on microtensile bond strength to dentin.” Operative Dentistry. (2012)
GM Knight. “The effect of silver fluoride and potassium iodine on the bond strength of autocure glass ionomer cement.” Australian Dental Journa. (2006)
Prabhu Sukumaran. “Silver nanoparticles: mechanism of antimicrobial action, synthysis, medical applications and toxicity effects.” International Nan Lett. (2012)
Juan Francisco Hernandez-Sierra. “The antimicrobial sensitivity of strep mutans to nanoparticles of silver, zinc oxide and gold.” Nanomedicine:Nanotechnology, biology and medicine. (2008)
S.Y. Liau. “Interaction of silver nitrate with radially identifiable groups: relationship to antibacterial action of silver ions” (1997)
CH Chu. “ Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children.” Journal of Dental Research (2002)
A. Rosenblatt. “Silver diamine fluoride : A Caries Silver –Fluoride Bullet”. Journal of Dental Research. (2009)
Mei May Lei. “Caries arresting effect of silver diamine fluoride on dentin carious lesion with S. Mutans and L. Acidophilus- duel speciies cariogenic biofilm.” Oral Medicine and Pathology (2013)
Bruxton D Spacciapoli. “Antimicrobial activity of silver nitrate against periodontal pathoens.” Journal of Periodontal Research. (2001)
Lei-Mei “Fluoride and silver concentrations of silver diamine fluoride solutions for dental use.” International Journal of Paediatic Denitstry. (2012)
R.Yee. “Efficacy of silver diamine fluoride for arresting caries treatment.” Journal of Dental Research. (2009)
W. Zhang, C. McGrath. W . Zhang “Silver Diamine Fluoride and Education to Prevent and Arrest Root Caries among Community-Dwelling Elders “. Caries Research (2013)
Jeremy A. Horst, DDS, PhD; Hellene Ellenikiotis, DDS; and Peter L. Milgrom, DD. “UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications and Consent” CDA Journal. (2016)
Discussions with: Dr. Jeremy Horst UCSF, Dr. John Featherstone UCSF, Dr. Gordon Christiansen, Dr. Sam Zwetchkenbaum (geriatric dentist Rutgers)
Electrospun poly(lactic acid) fibers containing novel chlorhexidine particles with sustained antibacterial activity
Dong Luo,*, Biomater. Sci., 2017,5, 111-119. Received 14 Sep 2016, Accepted 11 Nov 2016 First published online 25 Nov 2016
Cheng, Linda. “Limited evidence suggesting silver diamine fluoride may arrest dental caries in children.” Critical summaries, Feb 2017 JADA
