E – SDF (Silver Diamine Flouride 1.25ml)

Carious dentin excavation prior to SDF application is not necessary. Caries dentin excavation may reduce the 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 practices, settings, and patients:

• Remove gross debris from cavitation to allow better SDF contact with denatured dentin
• Minimize contact with the gingiva and mucous membranes to avoid potential pigmentation or irritation; consider applying cocoa butter or using cotton rolls to protect surrounding gingival tissues, with care to not inadvertently coat the surfaces 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 pellet to minimize systemic absorption
• Continue to isolate the site for up to three minutes when possible

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

Application time

An application time of one minute, drying with a gentle flow of compressed air is recommended. Clinical studies that report application times range from 10 seconds to three minutes. A current review states that application time in clinical studies does not correlate to outcome. 24 More studies are needed to confirm an ideal protocol

POST-OPERATIVE INSTRUCTIONS:

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

Application frequency:

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

The effectiveness of caries lesion arrest, however, decreases over time. After a single application 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. An annual application of SDF is more effective in arresting caries lesions than the application of five percent sodium fluoride varnish four times per year.

Increasing the frequency of application can increase caries’ arrest rate. Biannual application of SDF increased the rate of caries lesion arrest compared to annual application Studies that had three times per year applications showed higher arrest rates. Frequency of application after baseline has been suggested at three-month follow-up, and then semiannual recall visits over two years

One option is to place SDF on active lesions in conjunction with fluoride varnish (FV) on the rest of the dentition, or alternate SDF on caries lesions and FV on the rest of the dentition at three-month intervals to achieve arrest and prevention in high-risk individuals. Another study recommends a one-month post-operative evaluation of treated lesions with optional reapplication as required to achieve arrest of all targeted lesions. Individuals with high plaque index and lesions with plaque present display lower rates of arrest. Addressing other risk factors like the presence of plaque may increase the rate of successful treatment outcomes.

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