May 24, 2016

Easing the Burden of Caring in Frail Patients

VHSO

Gretchen Gibson, DDS, MPH, Veterans Healthcare System of the Ozarks (VHSO)

Dentistry still does not have a silver bullet that will cure all cavities for our patients…but we have not given up. In the meantime, silver diamine fluoride (SDF) was approved for use to prevent cavities and began being marketed in the United States in 2015. For those of us treating frail older patients where more extensive dental care is difficult for many reasons, this material may prove to be a needed help.

SDF was FDA-approved to treat dentin or tooth sensitivity. However, much like fluoride varnish, which was also approved to treat tooth sensitivity, this material has a large body of evidence behind it regarding the arrest of existing cavities and the prevention of new cavities. SDF has been in use to treat cavities in other countries throughout the world for over 75 years.

The product currently available in the US is 38% Ag(NH3)2F. It is a colorless liquid with a pH of 10. When the material is placed on a cavity, a matrix of silver/protein forms and then fluoride and other minerals will form a matrix on top. All of this forms a hardened surface to the lesion and decreases the depth of the lesion, leading to remineralization of the lesion. Though this remineralization may not be to the depth of the lesion, it seals it and “arrests” the carious lesion, negating its continued growth. In addition, the silver has antibacterial properties. This product is currently marketed in the United States by one company, Elevate Oral Care, under the name Advantage ArrestTM.

This treatment has been championed for pediatric and frail patients, when dental care is not easily tolerated. To use this product to arrest cavities, it is placed directly on the dried and isolated dental cavity and allowed to soak for 1-3 minutes if possible. Excess material is wiped off. Research suggests that that to maintain the lesion arrest, the product needs to be reapplied every 6-12 months for at least three years.

This material is not without its detractions. The biggest is the fact that all carious tooth structure that it touches will turn very dark. If this is experienced in the anterior region of the mouth, then it can cause a very negative aesthetic outcome. Side effects are minimal, but include some gingival irritation at times, non-permanent darkening or tattooing of the soft tissue and staining of clothing and countertops. Protocols for use include minimizing gingival contact and draping of surfaces and clothing to avoid these issues. A true silver allergy would be a contraindication of this product. Safety literature reviews show that using one drop per treatment, even a lifetime exposure of 400 times would be within safety standards. It is suggested that one drop will treat up to six teeth and that is usually more than is needed in a visit to arrest specific lesions.

As a geriatric dentist, this is an exciting addition to my armamentarium. Dementia patients who cannot sit for long periods of time would benefit if I could maintain their natural teeth longer. High cavity risk patients, such as those with Sjogren’s syndrome or post head and neck radiation may be able to hold on to teeth much longer if we can arrest the caries, rather than trying to restore each new lesion and risk more cavities around the new fillings. This is certainly not the treatment for all patients, but it is exciting to know that we now have other options to help us maintain natural teeth much longer for our frail and high risk patients.

 

Reference:
*Horst JA, Ellenikiotis H, Milgrom PM. UCSF protocol for caries arrest using silver diamine fluoride: Rationale, indications and consent. J Calif Dent Assoc.2016;44(1):16
*This article is available for free download through PubMed.