SDF

Mechanism of Action of Silver Diamine Fluoride

  • SDF reacts with hydroxyapatite to form fluorapatite

  • By-product is silver phosphate, which reacts with thiol groups to form to form silver groups (gives black lesion)

  • Silver amino nucleic acids are unable to carry out metabolic and reproduction functions of bacteria, which kills them

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Indications of SDF

  • Cavitated lesions in children and adults, including root caries

  • Extreme/high caries risk patients

  • Carious lesions that may not all be treated in one visit

  • Difficult to treat carious lesions (accessible to micro brush)

  • Treatment of tooth sensitivity

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Clinical Technique for SDF

  • Wear PPE and have patient wear goggles and bib

  • Place 1-2 drops of SDF into a dappen dish

  • Place Vaseline or lip balm

  • Use saliva ejector when possible

  • Isolate with cotton rolls, Dri-angles, gauze

  • Dry teeth with air or cotton swab

  • Use microbrush to apply SDF on affected tooth surfaces for at least 1 min

  • Remove excess with cotton; do not rinse or cover with fluoride varnish

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Partial Caries Removal:

  • Know what the evidence shows (JADA article by Thompson, et al.)

    • Strong evidence of leaving infected dentin, the removal of which would put pulp at risk for exposure
    • When cariogenic bacteria is isolated from their source of nutrition by a restoration sufficient integrity, they either die or remain dormant and thus pose no risk to health of dentition

  • What were the inclusion criteria for the study by Maltz, et al. Why were they used?

    • Inclusion Criteria
    • Adults
    • Permanent molars
    • Caries lesion ≥ ½ of dentin on radiograph
    • Normal (+) response to cold test
    • No spontaneous pain
    • No percussion sensitivity
    • No periapical radiolucency
    • Rationale: aggressive excavation and physical trauma to pulp was damaging

  • How does Diagnodent work? 

    • Measure loss of enamel fluorescence caused by demineralization
    • Based on increase in fluorescence of carious tissues due to presence of bacterial metabolites

  • What are its limitations?

    • For early enamel and non-cavitated occlusal dentin caries
    • Adjunct use only; use combination of caries risk assessment, visual examination, and radiographs for caries detection

  • What are the takeaways from Bader and Shugars’ 2006 systematic review?

    • High mean sensitivity for dental caries, but wide range (19-100%)
    • Higher sensitivity, lower specificity than visual (more false positives)

Sensitivity: True positive rate

  • Probability that diagnosis method (test) indicates “carious lesion” when lesion is truly present

  • True Positive/(True Positive + False Negative)

  • Highly sensitive test means increased correct caries lesion detection (true positive)

  • Decreased missed caries lesions (false negative); thought it wasn’t caries lesion but it was

  • Low sensitivity → higher risk of undertreatment

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Specificity: True negative rate

  • Probability that diagnosis method (test) indicates “no carious lesion” when lesion is truly not present

  • True Negative/(False Positive + True Negative)

  • Highly specific test means increased correct identification of healthy teeth/sites (true negative)

  • Decreased misidentifying of health teeth (false positive); thought it was caries lesion but it wasn’t

  • Low specificity → higher risk of overtreatment

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Traditional Caries Detection: 

  • know meaning of cavitated, non-cavitated, active, and arrested lesion; clinical technique for visual/tactile clinical examination of teeth; differential diagnosis of enamel white spot lesions, what the ICDAS II system is designed to assess

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Cavitated lesion

  • Structural damage, surface integrity breached

  • Needs restorative management

  • Remember: restoration does not manage disease; only restores form and function and facilitates proper oral hygiene

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Non-cavitated lesion

  • Demineralized, but surface integrity remains intact

  • Non-restorative management: plaque control, diet modifications, fluoride, amphorous calcium-phosphate, sealants, monitoring

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Active lesion

  • Ongoing mineral loss

  • If non-cavitated, appears white (or yellowish), opaque, chalky, and rough surface texture. No restorative management needed

  • If cavitated, it appears soft, leathery, and dull (not shiny)

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Arrested lesion

  • No active mineral loss

  • A “scar” and no professional intervention needed

  • If non-cavitated, appearance vary in color (whitish to black), shiny, and smooth texture

  • If cavitated, appears hard and shiny

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Visual Examination of Caries

  • Dry with air/water syringe to increase refractive index between sound and carious enamel and to visualize surface texture

  • Look for white spots and lines and shadows beneath enamel

  • Use mirror to retract cheeks, lips, and tongue and to reflect light onto teeth

  • Use operator light

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Tactile Examination of Caries

  • Use a sharp explorer

  • Remove plaque to visualize enamel

  • Assess teeth surface roughness with tip of explorer using gentle pressure

  • Never force explorer tip into smooth surfaces or pits/fissures as it may damage intact surface or may transfer bacteria to other sites

  • “Explore stick” is not a valid detect method (17-40% correct)

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Differential Diagnosis of Enamel White Spot Lesions

  • Non-cavitated caries lesion

    • Arch, banana, or kidney shaped
    • Reflective of plaque accumulation along present (or former) gingival margin

  • Mild fluorosis

    • Symmetric distribution
    • Fine horizontal striae (reflective of perichymatal enamel pattern)

  • Developmental, non-fluoride origin

    • Round or oval shaped
    • Clearly defined from adjacent enamel
    • Appear on single tooth

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International Caries and Detection System II (ICDAS II)

  • A visual classification system that correlates with known histology 
  • A clinical scoring system for use in dental education, clinical practice, research, and epidemiology
  • Designed to lead to better quality information to inform decisions about appropriate diagnosis, prognosis, and clinical management at both the individual and public health levels
  • Provides a framework to support and enable personalized total caries management for improved long term health outcomes