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Policy on the Use of Silver Diamine Fluoride for Pediatric Dental Patients

Purpose

The American Academy of Pediatric Dentistry (AAPD) recognizes that dental caries continues to be a prevalent and severe disease in children. This policy addresses the use of silver diamine fluoride (SDF) as part of an ongoing caries management plan with the aim of optimizing individualized patient care consistent with the goals of a dental home. When SDF is indicated, it is essential that the infants, children, adolescents, or individuals with special health care needs receive a comprehensive dental examination, diagnosis, and plan of ongoing disease management prior to placement of the material. The dental profession has long viewed dental caries as an acute disease condition requiring surgical debridement, cavity preparation, and mechanical restoration of the tooth, but increasingly, especially for the infant and child population, practitioners are utilizing individually tailored strategies to prevent, arrest, or ameliorate the disease process based on caries risk assessment. One of these strategies employs application of SDF as an antimicrobial and remineralization agent to arrest caries lesions after diagnosis and at the direction of a responsible dentist of record.

Methods

This document was developed by the Council on Clinical Affairs and adopted in 2017. This policy is a review of current dental and medical literature and sources of recognized professional expertise and stature, including both the academic and practicing health communities, related to SDF and silver nitrate. In addition, literature searches of PubMed®/ MEDLINE and Google Scholar databases were conducted using the terms: diamine silver fluoride and caries, Howe’s solution, silver nitrate and caries, and silver diamine fluoride; fields: all; limits: within the last 15 years, humans, English, birth through age 99. One hundred eight articles matched these criteria. Papers for review were chosen from this list and from the references within selected articles. Expert and/ or consensus opinion by experienced researchers and clinicians also was considered

Background

Treatment of incipient caries usually involves early therapeutic intervention using topical fluoride, and non-surgical restorative techniques such as dental sealants and resin infiltration. The use and outcomes of these techniques have been welldocumented, and there are current policies and guidelines with recommendations for their use in the practice of dentistry.1-3  In contrast, treatment of caries lesions traditionally requires surgical intervention to remove diseased tooth structure followed by placement of a restorative material to restore form and function. Barriers to traditional restorative treatment (e.g., behavioral issues due to age and/or limited cooperation, access to care, financial constraints) call for other alternative caries management modalities.

Silver topical products, such as silver nitrate and SDF have been used in Japan for over 40 years to arrest caries and reduce tooth hypersensitivity in primary and permanent teeth. During the past decade, many other countries such as Australia and China have been using this compound with similar success.4,5  As marketed in the United States, SDF is a 38 percent silver diamine fluoride which is equivalent to five percent fluoride in a colorless liquid, with a pH of 10. The exact mechanism of SDF is not understood. It is theorized that fluoride ions act mainly on the tooth structure, while silver ions, like other heavy metals, are antimicrobial. It also is theorized that SDF reacts with hydroxyapatite in an alkaline environment to form calcium fluoride (CaF2) and silver phosphate as major reaction products. CaF2 provides sufficient fluoride to form fluorapatite which is less soluble than hydroxyapatite in an acidic environment.6,7  A side effect is the discoloration of demineralized or cavitated surfaces. Patients and parents should be advised regarding the black staining of the lesions associated with the application of SDF. Ideally, prior to use of SDF, parents should be shown before- and afterimages of teeth treated with SDF. Recently, the Food and Drug Administration approved SDF as a device for reducing tooth sensitivity, and off-label use for arresting caries is now permissible and appropriate for patients.8-12

Many clinical trials have evaluated the efficacy of SDF on caries arrest and/or prevention,6,10-33 although clinical trials have inherent bias because of the staining (i.e., since the difference between control and treated teeth is obvious to the researcher). However, studies consistently conclude that SDF is indeed more effective for arresting caries6,10-12,17-33  than fluoride varnish. SDF reportedly also has approximately 2-3 times more fluoride retained than delivered by sodium fluoride, stannous fluoride, or acidulated phosphate fluoride (APF) commonly found in foams, gels, and varnishes.28  Additionally,SDF has not been shown to reduce adhesion of resin or glass ionomer restorative materials.6,3-37  The use of SDF is safe when used in adults and children.38-41  Placement of SDF should follow AAPD’s Chairside Guide: Silver Diamine Fluoride in the Management of Dental Caries Lesions.41  Delegation of the application of SDF to auxiliary dental personal or other trained health professionals, as permitted by state law, must be by prescription or order of the dentist after a comprehensive oral examination.

The ultimate decision regarding disease management and application of SDF are to be made by the dentist and the patient/parent, acknowledging individuals’ differences in disease propensity, lifestyle, and environment.42  Dentists are “required to provide information about the dental health problems observed, the nature of any proposed treatment, the potential benefits and risks associated with the treatment, any alternatives to the treatment proposed, and potential risks and benefits of alternative treatment, including no treatment.”43  The SDF informed consent, particularly highlighting expected staining of treated lesions, potential staining of skin and clothes, and the need for reapplication for disease control, is recommended.41  Careful monitoring and behavioral intervention to reduce individual risk factors should be part of a comprehensive caries management program that aims not only to sustain arrest of existing caries lesions, but also to prevent new caries lesion development.42  Although no severe pulpal damage or reaction to SDF has been reported, SDF should not be placed on exposed pulps.42  Therefore, teeth with deep caries lesions should be closely monitored clinically and radiographically by a dentist.42

SDF, when used as a caries arresting agent, is a reimbursable fee through billing to a third-party payor, when submitted with the appropriate dental code recognized by the American Dental Association’s current dental terminology44.  Reimbursement for this procedure varies among states and carriers. Third-party payors’ coverage is not consistent on the use of the code per tooth or per visit.42  Because there is a recommended code for SDF application, billing the procedure using any other code would constitute fraud, as defined by the Federal Code of Regulations.45  The AAPD supports the education of dental students, residents, other oral health professionals and their staffs to ensure good understanding of the appropriate coding and billing practices to avoid fraud.46

Policy Statement

The AAPD:

  • Supports the use of SDF as part of an ongoing caries management plan with the aim of optimizing individualized patient care consistent with the goals of a dental home.
  • Supports third-party reimbursement for fees associated with SDF.
  • Supports delegation of application of SDF to auxiliary dental personnel or other trained health professionals according to a state’s dental practice act by prescription or order of a dentist after a comprehensive oral examination.
  • Supports a consultation with the patient/parent with an informed consent recognizing SDF is a valuable therapy which may be included as part of a caries management plan.
  • Supports the education of dental students, residents, other oral health professionals and their staffs to ensure a good understanding of appropriate coding and billing practices.
  • Encourages more practice-based research to be conducted on SDF to evaluate its efficacy.

References

  1. American Academy of Pediatric Dentistry. Fluoride therapy. Pediatr Dent 2018;40(6):250-3.
  2. American Academy of Pediatric Dentistry. Pediatric restorative dentistry. Pediatr Dent 2018;40(6):330-42.
  3. American Academy of Pediatric Dentistry. Policy on use of fluoride. Pediatr Dent 2018;40(6):49-50.
  4. Mei ML, Zhao IS, Ito L, et al. Prevention of secondary caries by silver diamine fluoride. Int Dent J 2016;66(2):71-7.
  5. Zhao IS, Gao SS, Hiraishi N, et al. Mechanisms of silver diamine fluoride on arresting caries: a literature review. Int Dent J 2018;68(2):67-76.
  6. Fung MHT, Wong MCM, Lo ECM, Chu CH. Arresting early childhood caries with silver diamine fluoride – A literature review. J Oral Hyg Health 2013;1:117. Available at: “https://www.omicsonline.org/open-access/arresting-early-childhood-caries-with-silver-diaminefluoridea-literature-review-2332-0702.
    1000117.php?aid=21896”. Accessed September 25, 2017. (Archived by WebCite® at: “http://www.webcitation.org/6tkIYecuP”)
  7. Yamaga R, Nishino M, Yoshida S, Yokomizo I. Diammine silver fluoride and its clinical application. J Osaka Univ Dent Sch 1972;12:1-20.
  8. Mei ML, Lo EC, Chu CH. Clinical use of silver diamine fluoride in dental treatment. Compend Contin Educ Dent 2016;37(2):93-8; quiz100.
  9. Sharma G, Puranik MP, K RS. Approaches to arresting dental caries: An update. J Clin Diagn Res 2015;9(5):ZE08-11.
  10. Gao SS, Zhang S, Mei ML, Lo EC, Chu CH. Caries remineralisation and arresting effect in children by professionally applied fluoride treatment – A systematic review. BMC Oral Health 2016;16:12.
  11. Duangthip D, Jiang M, Chu CH, Lo EC. Restorative approaches to treat dentin caries in preschool children: Systematic review. Eur J Paediatr Dent 2016;17(2):113-21.
  12. Duangthip D, Chu CH, Lo EC. A randomized clinical trial on arresting dentine caries in preschool children by topical fluorides–18 month results. J Dent 2016;44:57-63.
  13. Li R, Lo EC, Liu BY, et al. Randomized clinical trial on arresting dental root caries through silver diammine fluoride applications in community-dwelling elders. J Dent 2016;51:15-20.
  14. Deutsch A. An alternate technique of care using silver fluoride followed by stannous fluoride in the management of root caries in aged care. Spec Care Dentist 2016;36(2):85-92.
  15. Chu CH, Gao SS, Li SK, et al. The effectiveness of the biannual application of silver nitrate solution followed by sodium fluoride varnish in arresting early childhood caries in preschool children: Study protocol for a randomised controlled trial. Trials 2015;16:426.
  16. Zhang W, McGrath C, Lo EC, Li JY. Silver diamine fluoride and education to prevent and arrest root caries among community-dwelling elders. Caries Res 2013;47(4):284-90.
  17. Mattos-Silveira J, Floriano I, Ferreira FR, et al. Children’s discomfort may vary among different treatments for initial approximal caries lesions: Preliminary findings of a randomized controlled clinical trial. Int J Paediatr Dent 2015;25(4):300-4.
  18. Duangthip D, Jiang M, Chu CH, Lo EC. Non-surgical treatment of dentin caries in preschool children–systematic review. BMC Oral Health 2015;15:44.
  19. Mattos-Silveira J, Floriano I, Ferreira FR, et al. New proposal of silver diamine fluoride use in arresting approximal caries: Study protocol for a randomized controlled trial. Trials 2014;15:448.
  20. Shah S, Bhaskar V, Venkataraghavan K, et al. Efficacy of silver diamine fluoride as an antibacterial as well as antiplaque agent compared to fluoride varnish and acidulated phosphate fluoride gel: An in vivo study. Indian J Dent Res 2013;24(5):575-81.
  21. Gluzman R, Katz RV, Frey BJ, McGowan R. Prevention of root caries: A literature review of primary and secondary preventive agents. Spec Care Dentist 2013;33(3):133-40. 
  22. Zhi QH, Lo EC, Lin HC. Randomized clinical trial on effectiveness of silver diamine fluoride and glass ionomer in arresting dentine caries in preschool children. J Dent 2012;40(11):962-7.
  23. Monse B, Heinrich-Weltzien R, Mulder J, et al. Caries preventive efficacy of silver diammine fluoride (SDF) and ART sealants in a school-based daily fluoride toothbrushing program in the Philippines. BMC Oral Health 2012;12:52.
  24. Liu BY, Lo EC, Chu CH, Lin HC. Randomized trial on fluorides and sealants for fissure caries prevention. J Dent Res 2012;91(8):753-8.
  25. Castillo JL, Rivera S, Aparicio T, et al. The short-term effects of diammine silver fluoride on tooth sensitivity: A randomized controlled trial. J Dent Res 2011;90(2):203-8.
  26. Tan HP, Lo EC, Dyson JE, Luo Y, Corbet EF. A randomized trial on root caries prevention in elders. J Dent Res 2010;89(10):1086-90.
  27. Beltrán-Aguilar ED. Silver diamine fluoride (SDF) may be better than fluoride varnish and no treatment in arresting and preventing cavitated carious lesions. J Evid Based Dent Pract 2010;10(2):122-4.
  28. Chu CH, Lo EC, Lin HC. Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children. J Dent Res 2002;81(11):767-70.
  29. Llodra JC, Rodriguez A, Ferrer B, et al. Efficacy of silver diamine fluoride for caries reduction in primary teeth and first permanent molars of schoolchildren: 36-month clinical trial. J Dent Res 2005;84(8):721-4.
  30. Chu CH, Lo EC, Lin HC. Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children. J Dent Res 2002;81(11):767-70.
  31. Lo EC, Chu CH, Lin HC. A community-based caries control program for pre-school children using topical fluorides: 18-month results. J Dent Res 2001;80(12):2071-4. 
  32. Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: A caries “silver-fluoride bullet”. J Dent Res 2009;88(2):116-25.
  33. Lo EC, Chu CH, Lin HC. A community-based caries control program for pre-school children using topical fluorides: 18-month results. J Dent Res 2001;80(12):2071-4. 
  34. Dos Santos VE Jr., de Vasconcelos FM, Ribeiro AG, Rosenblatt A. Paradigm shift in the effective treatment of caries in schoolchildren at risk. Int Dent J 2012;62(1):47-51.
  35. Wu DI, Velamakanni S, Denisson J, et al. Effect of silver diamine fluoride (SDF) application on microtensile bonding strength of dentin in primary teeth. Pediatr Dent 2016;38(2):148-53. 
  36. Savas S, Kucukyilmaz E, Celik EU, Ates M. Effects of different antibacterial agents on enamel in a biofilm caries model. J Oral Sci 2015;57(4):367-72.
  37. Han L, Okiji T. Dentin tubule occluding ability of dentin desensitizers. Am J Dent 2015;28(2):90-4.
  38. Vasquez E, Zegarra G, Chirinos E, et al. Short term serum pharmacokinetics of diammine silver fluoride after oral application. BMC Oral Health 2012;12:60.
  39. Chu CH, Mei L, Seneviratne CJ, Lo EC. Effects of silver diamine fluoride on dentine carious lesions induced by Streptococcus mutans and Actinomyces naeslundii biofilms. Int J Paediatr Dent 2012;22(1):2-10. 
  40. de Almeida Lde F, Cavalcanti YW, Valenca AM. In vitro antibacterial activity of silver diamine fluoride in different concentrations. Acta Odontol Latinoam 2011;24(2):127-31.
  41. American Academy of Pediatric Dentistry. Chairside guide: Silver diamine fluoride in the management of dental caries lesions. Pediatr Dent 2018;40(6):492-3.
  42. Crystal YO, Marghalani AA, Ureles SD, et al. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Pediatr Dent 2017;39(5):E135-E145.
  43. American Dental Association Division of Legal Affairs. Dental Records. Chicago, Ill. American Dental Association; 2007:16.
  44. American Dental Association. Code on Dental Procedures and Nomenclature (CDT Code). Available at: “https://www.ada.org/en/publications/cdt”. Accessed May 2, 2018. (Archived by WebCite® at: “http://www.webcitation.org/722PF58LG”)
  45. U.S. National Archives and Records Administration. 2018. Code of Federal Regulations. Title 42-Public Health. Part 455-Program Integrity: Medicaid. Section 455.2-Definitions. Available at: “https://wwwecfr.gov/cgi-bin/text-idx?tpl=/ecfrbrowse/Title42/42cfr455_main_02.tpl”. Accessed May 2, 2018. (Archived by Web Cite® at: “http://www.webcitation.org/6z7WVaF9d”)
  46. American Academy of Pediatric Dentisty. Policy on third-party payor audits, abuse, and fraud. Pediatr Dent 2018;40(6):126-9.