Andrew Osafo talks about the benefits that silver diamine fluoride can bring to minimally invasive dentistry, treating hypersensitivity and its potential for caries control.
In which clinical situations would you recommend the use of silver diamine fluoride (SDF)?
Andrew Osafo (AO): SDF has been used in dentistry for decades around the world, both as a desensitising agent and as a caries inhibitor. There’s an abundance of evidence to prove the efficacy of SDF with numerous in vitro and in vivo studies showing its effectiveness in managing caries (Trieu, 2019).
SDF is currently only licenced to treat dentine hypersensitivity in the UK. However it is increasingly used off-label to treat and prevent dental caries. This is a parallel situation to fluoride varnish that has the same clearance for marketing as a class II medical device to treat tooth sensitivity but is ubiquitously used off-label to prevent caries.
This means that although SDF is not licenced for caries arrest, it can be used by licenced professionals when judged by the prescriber to be in the best interests of the patient, based on available evidence.
It’s important when treating patients in this way to have their full consent. You must tell them that this product is only licensed as a desensitiser. However, there are known benefits that it is not licensed for. The British Society of Paediatric Dentistry provides independent resources for the use of SDF, including:
- Standard operating procedure for SDF
- Patient information leaflet on silver diamine fluoride
- Consent form for using SDF.
I always ask for specific patient consent for using SDF and use two consent forms. One copy for the patient and one copy for the notes. This is to ensure they are fully informed before any treatment can commence.
Riva Star (SDI) is currently the only licenced desensitising agent in the UK. What is so unique about this product?
AO: Scientific studies have shown the effectiveness of SDF in the stabilisation and disinfection of carious dentine and hypersensitivity. However, it is also responsible for black staining of carious lesions caused by free/unreacted silver forming silver sulphides. This is something that patients need to be fully aware of.
What makes Riva Star special is its patented, two-step procedure that minimises the risk of staining. Applying an immediate application of potassium iodide (KI) over the silver fluoride forms a silver precipitate. This then turns clear, effectively reducing the chance of discolouration.
You have a particular interest in minimally invasive dentistry (MID). How does Riva Star fit into that from a clinical perspective?
AO: MID is seeking to conserve as much of the tooth as possible. Traditionally when treating decay, clinicians use a surgical approach, completely removing the decayed or infected area and filling it. However, with Riva Star you can remove the softened decay and apply agent on the remaining surface to kill bacteria.
You can allow for remineralisation without staining. This allows you to be more conservative and deliver more aesthetic results. In many cases, you can avoid having to use local anaesthetic.
Are there any contraindications for the use of SDF?
AO: Before treating any patient with SDF you need to look at the clinical signs and symptoms:
- Patients with known allergies to silver, fluoride or ammonia
- Clinical signs or symptoms of irreversible pulpitis or dental abscess/fistula
- Radiographic signs of pulpal involvement or peri-radicular pathology
- Infection or pain from pulp or food packing
- If there are any painful sores or raw areas on the gums (ie, ulcerative gingivitis) or anywhere in the mouth (ie, stomatitis)
- SDF/KI is contraindicated in pregnant women and during the first six months of breastfeeding due to concern of overloading the developing thyroid with iodide.
In the current climate, does SDF offer benefits to patients who are unable to undergo treatment due to COVID-19 restrictions?
AO: Since practices were forced to close during the first COVID-19 lockdown, it has led to huge waiting lists of patients still waiting to be seen. If you don’t address patient issues, they will get worse. I fear the consequences if they continue not to get the treatment they need. This is combined with new targets for NHS practices increasing from 20% to 45% with the additional problem of finding ways to treat patients effectively without the use of aerosol-generating procedures (AGPs).
Every practice has had to adapt to the current situation as best it can. Most practices only have limited space, so finding ways of avoiding AGPs and subsequent fallow time while treating as many patients as possible is problematic.
SDF is a non-invasive, non-aerosol-generating procedure. It reduces risk to patients and staff, and with the right training is easy to use. It’s ideal for cost-effective emergency care to stabilise problem areas and hypersensitivity until you can recall the patient at a later date for follow-up treatment.
Dentistry: How do you find SDI’s customer service and support?
AO: I have been very impressed. I work in general practice and hospital services. The evidence SDI have for the efficacy of Riva Star makes me think it can be a game-changer for our service. MID is a very necessary part of dentistry.
With the growing emphasis on prevention and more conservative treatment in such difficult times I believe a product such as Riva Star is essential for the long-term health of our patients.
References
Trieu A, Mohamed A, Lynch E (2019) Silver diamine fluoride versus sodium fluoride for arresting dentine caries in children: a systematic review and meta-analysis. Nature Scientific Reports 9: 1-9
This article first appeared in Dentistry magazine. You can read the latest issue here.
