E – SDF (Silver Diamine Flouride 1.25ml)

Carious dentin excavation prior to SDF application is not necessary. Caries dentin excavation may reduce proportion of arrested caries lesions that become black, and may be considered for esthetic purposes.

Functional indicator of effectiveness (i.e., caries arrest) is when staining on dentinal carious surfaces is visible

The following steps may vary depending on differing prac-tices, settings, and patients:

• Remove gross debris from cavitation to allow better SDFcontact with denatured dentin
• Minimize contact with gingiva and mucous membranes toavoid potential pigmentation or irritation; consider apply-ing cocoa butter or use cotton rolls to protect surroundinggingival tissues, with care to not inadvertently coat thesurfaces of the carious lesion.
• Dry with a gentle flow of compressed air (or use cotton >rolls/gauze to dry) affected tooth surfaces
• Bend micro sponge brush, dip and dab on the side of the dappen dish to remove excess liquid before application;24 apply SDF directly to only the affected tooth surface
• Dry with a gentle flow of compressed air for at least one minute
• Remove excess SDF with gauze, cotton roll, or cotton pelletto minimize systemic absorption
• Continue to isolate sitefor up to three minutes when possible

Practical recommendation:No need for surgical intervention(e.g., dentin excavation). SDF application is minimally invasiveand easy for the patient and the practitioner. It may be desirablefor the caries lesion to be free of gross debris for SDF to havemaximum contact with the affected dentin surface

Application time

An application time of one minute, drying with a gentle flowof compressed air, is recommended. Clinical studies that reportapplication times range from 10 seconds to three minutes. Acurrent review states that application time in clinical studiesdoes not correlate to outcome.24More studies are needed toconfirm an ideal protocol

POST OPERATIVE INSTRUCTIONS:

No postoperative limitations are listed by the manufacturer.Eating and drinking immediately following application isacceptable. Patients may brush with fluoridated toothpaste asper regular routine following SDF application.Several SDF clinical trials recommended no eating or drink-ing for 30 minutes one hour.13,31,32As patients are used tothese recommendations for in-office topical fluoride applications,the recommendation may not be unreasonable to patients, andit may allow for better arrest results. More clinical studies areneeded to establish best practices

Application frequency:

The effectiveness of one-time SDF application in arresting dentalcaries lesions ranges from 47 percent to 90 percent, dependingon the lesion size and the location of the tooth and the lesion.One study showed that anterior teeth had higher rates ofcaries lesion arrest than posterior teeth

The effectiveness ofcaries lesion arrest, however, decreases over time. After a singleapplication of 38 percent SDF, 50 percent of the arrested sur-faces at six months had reverted to active lesions at 24 months.

Reapplication may be necessary to sustain arrest.Annualapplication of SDF is more effective in arresting caries lesionsthan application of five percent sodium fluoride varnish fourtimes per year.

Increasing frequency of application can increasecaries arrest rate. Biannual application of SDF increased the rateof caries lesion arrest compared to annual applicationStudiesthat had three times per year applications showed higher arrestrates.Frequency of application after baseline has beensuggested at three month follow up, and then semiannual recallvisits over two years

One option is to place SDF on activelesions in conjunction with fluoride varnish (FV) on the rest ofthe dentition, or alternate SDF on caries lesions and FV on therest of the dentition at three months interval to achieve arrestand prevention in high risk individuals.Another study recom-mends one month post operative evaluation of treated lesionswith optional reapplication as required to achieve arrest of alltargeted lesions.Individuals with high plaque index and lesionswith plaque present display lower rates of arrest. Addressingother risk factors like presence of plaque may increase the rate ofsuccessful treatment outcomes.

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