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AbstractSilver diamine fluoride (SDF) has been used worldwide since 1970 to arrest decay. In the United States, the product received FDA clearance in 2014 as a desensitizing agent (similar to fluoride varnish) and in October 2016 it was recognized by the Food and Drug Administration with breakthrough therapy designation for caries treatment. This course will look at the latest tool in the caries management toolkit to help the reader incorporate this new technology into clinical practice. Keeping in mind that SDF is relatively new to the US, and research/protocols are still evolving, clinical findings and guidelines for SDF currently being used for patients of all ages will be discussed.

Educational ObjectivesAt the conclusion of this educational activity participants will be able to:1. Understand the mechanism of

action of Silver Diamine Fluoride2. Discuss indications/

contraindications for use3. Identify challenges associated

with Silver Diamine Fluoride4. List steps for Non-Restorative and

SMART placement

Authors’ ProfilesJudy Bendit, RDH, BS, has more than 45 years of experience in dentistry. She is a speaker, author, clinician, faculty member at the Temple University School of Dentistry, an alumni board member of the University of Pennsylvania Dental School, and an advisory board member for Palm Beach State College’s dental hygiene program. She is also a longstanding member of the American Dental Hygienists’ Association and a distinguished academy member of the Pennsylvania Dental Hygienists’ Association, and she is a volunteer clinician both at home and abroad.

Douglas A. Young DDS, EdD, MBA, MS, is a professor at the University of the Pacific where he is an active and ardent educator in the field of minimally invasive dentistry and cariology. He was one of the founders of the CAMBRA (caries management by risk assessment) Coalition, ADEA Cariology Section, and the American Academy of Cariology (AAC). Dr. Young served on the ADA Council of Scientific Affairs (2012-2016) and is currently a cariology consultant for the ADA. Dr. Young has presented at congresses and universities around the world. He has been published in numerous peer-reviewed dental journals and textbooks focusing on minimally invasive dentistry, glass ionomer, and cariology.

Authors’ DisclosureJudy Bendit and Douglas A. Young have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Publication date: Jul. 2017 Expiration date: Jun. 2020

This educational activity was made possible through an unrestricted educational grant by Elevate Oral Care, LLC. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content.Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%.CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at hhodges@pennwell.comEducational Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.Image Authenticity Statement: The images in this educational activity have not been altered.Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $59.00 for 3 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

PennWell designates this activity for 3 continuing educational credits.

Dental Board of California: Provider 4527, course registration number CA# 03-4527-15217“This course meets the Dental Board of California’s requirements for 3 units of continuing education.”

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# 320452.

INSTANT EXAM CODE 15217

Silver diamine fluoride: The newest tool in your caries management toolkitA Peer-Reviewed Publication Written by Judy Bendit, RDH, BS, and Douglas A. Young, DDS, EdD, MBA, MS

2 www.DentalAcademyOfCE.com

Educational ObjectivesAt the conclusion of this educational activity participants will be able to:1. Understand the mechanism of action of Silver Diamine

Fluoride2. Discuss indications/contraindications for use3. Identify challenges associated with Silver Diamine

Fluoride4. List steps for Non-Restorative and SMART

placement

AbstractSilver diamine fluoride (SDF) has been used worldwide since 1970 to arrest decay. In the United States, the product re-ceived FDA clearance in 2014 as a desensitizing agent (simi-lar to fluoride varnish) and in October 2016 it was recognized by the Food and Drug Administration with breakthrough therapy designation for caries treatment. This course will look at the latest tool in the caries management toolkit to help the reader incorporate this new technology into clinical prac-tice. Keeping in mind that SDF is relatively new to the US, and research/protocols are still evolving, clinical findings and guidelines for SDF currently being used for patients of all ages will be discussed.

BackgroundDental caries is a complex, multifactorial disease which remains a significant problem across all age groups.1 Caries management by risk assessment (CAMBRA) is an evidence-based strategy to prevent and treat the underlying disease causing caries lesions. CAMBRA uses caries risk assessment (CRA) to identify pathologic risk factors that are unique to the patient in order to develop treatment options to reduce the progression of caries disease. These options include chemical therapeutics coupled with behavioral modification targeted at altering biofilm behavior, halting further demin-eralization, and supporting remineralization.2 Recently, SDF has demonstrated great promise in the United States when used as a chemotherapeutic option for caries management3 and when used alone or in combination with glass ionomer cement restorations.4

The ADA Caries Classification System (ADA CCS) was published to provide US oral health-care professionals the terminology needed to discern when caries lesions should be treated chemically and when surgical restoration would be in-dicated.5 The ADA CCS addresses all stages of caries lesions (non-cavitated and cavitated) based on the site, extent, and when possible, activity.5

What is SDF?Silver diamine fluoride is chemically 38% weight/volume Ag(NH3)2F. The silver acts as an antimicrobial with substan-tivity, preventing reinvasion of cariogenic bacteria after ap-

plication.6 The fluoride provides remineralization,7 and the silver diamine is a metal complex that dramatically stabilizes the high concentrations of silver and fluoride in solution.7 SDF has the highest fluoride concentration (44,800 ppm fluoride ion) of any available material and is about twice that of fluoride varnish. (Table 1) Upon application of SDF to a demineralized or infected surface, a silver-protein conjugate layer forms, increasing resistance to acid dissolution and en-zymatic digestion.8,9 Treated lesions remineralize, increasing mineral density and hardness while decreasing the deminer-alization layer.10 A 2016 systematic review with meta-analysis by Gao and colleagues demonstrated the efficacy of SDF at arresting dentinal caries.11

Why use SDF?The possibility of avoiding more invasive treatments involv-ing dental injections, dental drills, and even general anes-thesia are just a few of the significant advantages of using SDF to chemically arrest an active caries lesion. SDF has been shown to be especially advantageous in populations such as young children; the elderly; those with multiple car-ies; those with caries lesions with problematic access where treatment by conventional means is not possible; special needs patients; and phobic patients. SDF can transform a child’s first dental experience from traumatic to pleasant, instilling trust and making subsequent interactions with dental professionals more successful. Most significantly, SDF may save lives. Many patients are being scheduled for IV sedation or general anesthesia simply because they are not manageable in the normal clinical setting. Sedation and general anesthesia techniques are not without risk and deaths have been reported. Even when there is a medical reason for general anesthesia in a hospital setting, there is often one- to two-year waiting periods for nonurgent care for some populations. SDF is invaluable in these situations by arresting disease progression without sedation or general anesthesia. If necessary, for medical reasons, more compre-hensive treatment in a hospital setting can be scheduled once the lesions are arrested.

Usually, to effectively arrest and remineralize caries le-sions, a comprehensive dental examination, caries risk assess-ment, access to dental equipment, products, and interventions to modify the oral chemistry and behavior of the patient are required. A trained clinician and a high level of patient motiva-tion and cooperation to implement these curative strategies are needed. When patient cooperation is less than ideal, SDF can now offer an alternative.

SDF is minimally invasive and preserves tooth structure.7 Therefore, once the caries lesion is arrested and disease pro-cess has been halted,7 one could argue that an arrested caries lesion (non-cavitated or cavitated) may not require a dental restoration to maintain health unless the patient wants to improve form, function, or esthetics.

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Table 1 Comparison of common fluoride productsFluoride concentration Parts per million (ppm)Silver diamine fluoride 44,800 ppm5% fluoride varnish 22,600 ppmAPF (in office) 12,300 ppmNaF2 (Rx) 9,000 ppmRinse (Rx) 3,300 ppmSnF2 w/ACP 970 ppmCPP ACP with fluoride 900 ppmOTC .05% NaF2 rinse 200 ppm

Safety and toxicityThe safety profile of SDF is remarkable. The maximum dose was determined to be one drop (25 uL) of SDF per 10kg (~ 22 lbs.) per treatment visit, based on LD50 rat studies required for FDA clearance using a 400-fold safety margin.3 LD stands for “Lethal Dose.” LD50 is the amount of a material, given all at once, which causes the death of 50% (one half) of a group of test animals. The LD50 is one way to measure the acute toxicity of a material.12

Topical application of SDF to teeth with caries lesions is very safe. One drop of SDF is roughly equivalent to drinking a liter of fluoridated water or using fluoridated toothpaste. Also, a good proportion of the material on the brush remains on the brush and is never bioavailable, further reducing the dose and potential for toxicity.

Classification, coding, and cost In 2014, SDF was cleared by the US Food and Drug Admin-istration for marketing as a Class II medical device to treat tooth sensitivity. Like fluoride varnish, SDF is used off label to treat caries lesions.

SDF became commercially available in the US in 2015 and is marketed as Advantage Arrest by Elevate Oral Care LLC (West Palm Beach, Fla.). In January of 2016, the Cur-rent Dental Terminology (CDT) billing code 1354 became active. It is interesting to note that this process took only one year as compared to fluoride varnish that took 16 years. CDT 1354 can be used for “Conservative treatment of an active, asymptomatic caries lesion by topical application of a caries-arresting or inhibiting medicament without mechani-cal removal of sound tooth structure.” With the introduction of CDT 1354, some third-party payers have started to reim-burse for the application of SDF, but reimbursement has yet to become widespread. SDF is cost effective at $.60 per drop (one drop treats approximately five surfaces). In fact, some state Medicaid programs are currently reimbursing for CDT 1354.

In October 2016, SDF attracted further attention by be-ing awarded breakthrough therapy designation by the FDA because it demonstrated “substantial improvement over existing therapies.”

Table2: CDT codes used for fluoride

D1354 - Interim caries arresting medicament application

D1208 - Topical application of fluoride

D9910 - Application of a desensitizing medicament, per visit

D1999 - Unspecified preventive procedure by reportNote: In March 2017, the ADA Code Revision Committee approved the change from “per application” to “per tooth” beginning January 1, 2018.

Who can place SDF?A licensed dentist in any state can apply SDF. We advise all other clinicians to examine their states’ dental board practice acts to determine if they can place SDF. For hygienists, this web site may be helpful: http://www.adha.org. Many state regulatory agencies consider SDF under existing guidance for the use of topical fluorides.

Indications1. SDF is used for the treatment of high or extreme caries risk

patients, especially those with xerostomia or severe early childhood caries (SECC).6-9, 11 (see Figure 1)

Figure 1: Pre-and post-operative SDF on a xerostomic patient (no restoration).

(Photos courtesy of Dr. Angela Lee)

Arresting a lesion before conservative caries removal and final restoration, if needed, will preserve tooth structure and reduce mechanical pulp exposures. It is also indicated for patients with multiple caries lesions that may not all be treated in one visit, or will likely get worse before treatment can be completed (e.g., long waiting time for hospital dentistry under general anesthesia).

2. SDF is warranted when traditional treatment is chal-lenged by behavioral or medical management.

3. SDF may access areas impossible to reach with traditional approaches, including partially erupted third molars, furcations, and under and around existing restorations. (see Figure 2)

Figure 2: SDF Application in difficult to reach locations.

(Photo courtesy Monica Savalli RDH, DDS)

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4. SDF can be used for patients with limited access to dental care or limited financial resources for traditional care, e.g., patients in developing countries, nursing homes, rural areas, etc.

5. SDF is an excellent desensitizer and often reduces or eliminates the need for local anesthesia.

6. Regardless of financial status, SDF should be considered as an option when the patient requests more conservative care.

Contraindications and precautionsSDF is contraindicated if there is a history of silver allergy and should be used with caution with ulcerations or stomatitis. While SDF is safe, clinicians should exercise caution with a tooth that is symptomatic, partially necrotic, or otherwise pulpally involved. With careful application, SDF should not go beyond treated caries sites, but patients and providers should be aware that SDF may cause stinging if it contacts soft tissue, ulcerations, or lacerations. SDF will soon be available in a blue tint, making it much easier to visualize upon placement.

Patients who are concerned about fluoride must be made aware that SDF contains fluoride. The patient can be educated that there is ten times less fluoride in one drop of SDF than 0.5 ml unit-doses of fluoride varnish because so little is actually used. Patients are reminded that SDF is not ingested but merely placed topically on the caries lesion.

Clinical observation It should be noted that multiple applications (minimum of two applications annually) of SDF are required for predictable caries arrest.13,14 In 2016, a suggested SDF protocol was published by Horst.3 There are some updates on this protocol based on stud-ies and clinical observation since those protocols were originally proposed. Many clinicians are reporting they no longer see the need for rinsing off the SDF after placement, given its margin of safety and lack of clinical complaints from patients. It is also reported that it is no longer mandatory to protect the gingiva with petroleum jelly since adverse reactions are few and very minor regarding SDF contacting the gingiva. In contrast, there is a greater risk that the petroleum jelly can get on the caries lesion and affect SDF uptake and glass ionomer cement (GIC) bonding. Originally, clinicians were concerned that SDF would affect bond strength or restoration retention. This has not been reported with conventional GIC restorations, nor does it seem to compromise the integrity of crown adhesion. At least one study reported that SDF will not weaken bond strength of composite.15 Light curing SDF is not necessary or recommended and will cause darkening of resin-based restorations.

Side effects and precautions Placement of SDF should be restricted to the caries lesion be-ing treated. Predictable side effects include darkening of the treated lesion (it will not usually stain healthy tooth structure)

and a short-lived, bitter metallic taste. A dab of toothpaste on the tongue may help with the taste. If SDF contacts soft tissue, a temporary stinging and/or staining may occur (usually brown in color on the skin and white or gray in appearance on the oral tissues). Any staining or soft tissue irritation will be temporary, typically disappearing in several days. Caution should also be taken with clinical surfaces and uniforms as staining can oc-cur and will not come off. There are several existing informed consent forms available on the internet. A consent form should be read and signed by the patient prior to placing SDF.

Step-by-step SDF placement (no restoration) The following example is based on clinical experience and it is important for the reader to understand that at this time, there is no scientific evidence to support one method of placing SDF over another. The research base for SDF use is evolving rapidly. What we know today may be disproved or modified tomorrow. The information presented is accurate to the best of our knowledge as of June 2017.1. Wear standard personal protective equipment (PPE),

and make sure the patient is wearing safety glasses and a plastic-lined bib.

2. Dispense SDF into a plastic dappen dish. One drop treats five surfaces.

3. If you wish, you may apply extraoral protection for the lips and surrounding area using petroleum jelly or lip balm. Some patients, with a keen sense of smell, find a scented lip balm will mask the odor of SDF as it is placed in the mouth. It is critical to make sure that no petroleum jelly or lip balm gets on the caries lesion or it will inhibit uptake of the SDF and affect bonding of any dental restor-ative materials placed that day.

4. Use of a saliva ejector and/or suction bite-block device can be helpful.

5. If a suction bite-block device is not used, try to isolate the tongue and cheek from the affected teeth using gauze, cotton rolls, or absorbent triangles.

6. Petroleum jelly is not normally needed to protect the in-traoral soft tissues given the safety of SDF and the risk of detrimental effects of getting it on the lesion. Some feel it is helpful when there are already irritations on surrounding soft tissues such as ulcerations or mucositis. See critical note in No. 3.

7. Desiccate the carious surface with air or a cotton swab if air is not available.

8. Immerse a stiff microbrush into the SDF in the dappen dish and saturate the lesion with SDF using a scrubbing motion. This is best done with a dental assistant to avoid SDF contact with other unintended structures.

9. While scrubbing, allow the SDF to absorb for at least one minute, if possible. For uncooperative patients, one minute may not be achievable; for cooperative patients, longer exposure time may be advantageous.

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10. SDF can be applied to interproximal caries lesions with the use of spongy floss. The spongy floss is inserted so the “fuzzy” part of the floss is adjacent to the contact. A small section next to the contact is then saturated with SDF and pulled under the contact area. Let sit for at least one minute when possible. (see Figure 3)

Figure 3: Placing SDF on an approximal caries lesion using Super flossTM.

(Photo courtesy of Dr. Jason Hirsch)

11. When done applying the SDF, many feel it is helpful to cover the area immediately with fluoride varnish or petroleum jelly to keep the SDF in contact with the caries lesion as long as possible and to mask any taste from the SDF. If a restoration is going to be placed on the same day as SDF application, do NOT do this step.

12. Cleanup: Invert all used cotton, microbrush, and dappen dish into a glove so SDF can’t drip on any surface or skin. Dispose of materials in a trash can.

Silver-modified atraumatic restorative treat-ment (SMART) As stated previously, at least two applications of SDF will dramatically improve the arrest rate.13,14 However, there are instances when it is not practical to leave a gross cavitation open while implementing SDF arrest procedures. In addi-tion, it may not be possible for the patient to return for dental care for multiple SDF treatments and subsequent restoration. In either case, for purposes of this manuscript, we will define SMART as “Silver Modified Atraumatic Restorative Treat-ment,” because SDF is applied and immediately restored with sealed margins and conventional GIC (self-curing) at the same appointment. A conventional GIC restoration may be the ideal restorative material for SMART because it is hydrophilic and must be placed directly on a moist surface. It does not require light curing, which will turn the restoration dark. SMART attempts to combine three proven clinical pro-cedures with high levels of evidence, without violating any of the individual principles of each: 1) caries arrest with SDF11; 2) partial or incomplete caries removal16; and 3) placement

of a conventional GIC restoration.17,18 In the case of a deep cavitated lesion on a vital and asymptomatic tooth, systematic reviews demonstrate that partial/incomplete caries removal by cleaning the perimeter of the lesion (where mechanical pulp exposure is unlikely) while not excavating the deeper areas of the lesion, and cutting off the nutrient source for any remaining bacteria by placement of a sealed restoration, has better outcomes than total caries removal.16,19 Partial caries removal now has international consensus as a best practice.20 SDF is bactericidal to remaining bacteria in the dentin, and arrests caries and remineralizes the surface. Conventional GIC will chemically bond to the moist surface, and enhance remineralization and acid resistance at the tooth-restorative interphase.4,18,21 Because the perimeter of the lesion was me-chanically cleaned, it ensures a chemically sealed restoration that will arrest and remineralize the caries lesion, preserving tooth structure and enhancing pulp vitality. Please note that mechanically cleaning the perimeter of the lesion may not be possible in all instances (uncooperative patients) and some flexibility of the SMART procedure is expected.

Step-by-step SMART1. Remove biofilm and pellicle with pumice or defocused air

abrasion in the surrounding area of the lesion to be treated. (GIC has no chemical bond to biofilm or pellicle.)

2. Apply SDF as per steps 1-9 in the above Step-by-step SDF placement (no restoration).

3. Clean the perimeter using your preferred technique (slow-speed round bur, hard-tissue laser, air abrasion, or a spoon excavator).

4. Condition the lesion and surrounding area with 20% polyacrylic acid by scrubbing for 10 seconds (removing the smear layer and activating the surface for ionic exchange).

5. Rinse with water for 10 seconds. 6. Place a matrix if needed.7. If any contamination occurs, rinse briefly again with water

and blot dry with cotton (leaving a moist “glossy” surface).8. Mix the GIC for 10 seconds and apply immediately, avoid-

ing voids.9. Shape and remove excess but do not manipulate the GIC

after about 30 seconds from start of mix.10. When crosslinking is initiated, the wet glossy surface of the

GIC will start to look “frosty.” This means it is losing water and should be surface sealed with the recommended resin based surface sealant. (do not light cure as it will turn dark from the free SDF.) An alternative to surface sealant is to use petroleum jelly or wet the surface with water.

11. Do not disturb for 2.5 minutes from start of mix. Once set, place anatomy, adjust occlusion, polish with rubber abrasives and discs, ALL with profuse water spray.

(see Figure 4)Note: Ask the patient not to chew on the restoration for a

few days, if possible.

6 www.DentalAcademyOfCE.com

Figure 4: Immediate post-op. SDF application 1 minute and GIC restoration.

(Photo courtesy of Dr. Kenneth Han)

Perception of dental professionalsA very common barrier for the use of SDF on children or adults is the perception of dental professionals that parents and patients would never accept SDF treatment because of the discoloration. Yet, when properly educated and informed about the pros and cons of the SDF procedure, many patients choose to have SDF despite the tooth darkening. Is it possible that health-care providers are bothered by the idea of teeth darkening more than patients? A recently published study by Crystal and colleagues looked into parental perceptions of the dark staining of SDF.22 They found that the dark staining on posterior teeth was more acceptable than staining on anterior teeth, with 67.5% judging the staining as esthetically tolerable in the poste-rior compared to 29.7% in the anterior (P<.001). However, as the number of children’s behavioral issues increased, so did the parents’ level of acceptance of the staining. Although staining on anterior teeth was undesirable, most of the parents preferred this option to advanced behavioral techniques such as sedation or general anesthesia. Yet, almost one-third of the parents still found the SDF staining unacceptable under any situation.22

With regard to esthetics on deciduous teeth, the SDF option could be in many cases presented as an alternative to a stainless steel crown. (see Figure 5)

Figure 5: Image of SDF vs. Stainless Steel crown

(Photo courtesy of Dr. Jason Hirsch)

However, if a stainless-steel crown is indicated, SDF could also be used as a pretreatment before the crown is cemented. SDF treatment could be a substantial benefit for patients if it helps retain the deciduous tooth until natural exfoliation or if SDF prevents a tooth from being extracted in an aging or medically challenged adult. An attempt to mask the dark-ened area with conventional GIC can also be considered for improved esthetics. (see Figure 6)

Figure 6: Intra- and post-operative SMART #7,8, & 10, showing clean perimeters and final GIC restorations. Note: tooth #10 had incomplete stain removal on internal margin.

(Photo courtesy of Dr. Douglas A. Young)

Conclusion The supporting science and clinical use of SDF presents a very strong case for the utilization of SDF in appropriate patients and should be in every clinician’s caries management toolkit. The placement of SDF does not preclude additional options that include subsequent placement of restorations for purposes of restoring form, function, or esthetics. Remem-ber that SDF has unique disinfection and remineralization properties that can halt the caries process rapidly and perhaps reduce the need for traditional, more invasive operative pro-cedures. By combining the compatibilities of SDF and con-ventional GIC, we can offer new ways to medically manage our patients as well as energize and motivate health providers to transform disease to health.

References:1. Beltran-Aguilar E, Barker L, Canto M, et al. Centers

for Disease Control MMWR Surveillance Summaries August 26, 2005 / 54(03);1-44. Surveillance for Dental

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Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis. United States. 1988-1994 and 1999-2002. [cited 2009 February 14] http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm.

2. Hurlbutt M, Young DA. A best practices approach to caries management. J Evid Based Dent Pract. 2014;14 Suppl:77-86.

3. Horst JA, Ellenikiotis H, Milgrom PL. UCSF protocol for caries arrest using silver diamine fluoride: rationale, indications and consent. J Calif Dent Assoc 2016;44(1):16-28.

4. Ngo HC, Mount G, McIntyre J, Tuisuva J, Von Doussa RJ. Chemical exchange between glass-ionomer restorations and residual carious dentine in permanent molars: an in vivo study. J Dent 2006;34(8):608-13.

5. Young DA, Novy BB, Zeller GG, et al. The American Dental Association Caries Classification System for Clinical Practice: A report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2015;146(2):79-86.

6. Knight GM, McIntyre JM, Craig GG, et al. Inability to form a biofilm of Streptococcus mutans on silver fluoride- and potassium iodide-treated demineralized dentin. Quintessence Int 2009;40(2):155-61.

7. Zhao IS, Gao SS, Hiraishi N, et al. Mechanisms of silver diamine fluoride on arresting caries: a literature review. Int Dent J 2017.

8. Mei ML, Li QL, Chu CH, Yiu CK, Lo EC. The inhibitory effects of silver diamine fluoride at different concentrations on matrix metalloproteinases. Dent Mater 2012;28(8):903-8.

9. Mei ML, Nudelman F, Marzec B, et al. Formation of fluorohydroxyapatite with silver diamine fluoride. J Dent Res 2017:22034517709738.

10. Mei ML, Ito L, Cao Y, et al. Inhibitory effect of silver diamine fluoride on dentine demineralisation and collagen degradation. J Dent 2013;41(9):809-17.

11. 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.

12. https://www.ccohs.ca/oshanswers/chemicals/ld50.html13. Yee R, Holmgren C, Mulder J, et al. Efficacy of silver

diamine fluoride for arresting caries treatment. J Dent Res 2009;88(7):644-7.

14. 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.

15. 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.

16. Thompson V, Craig RG, Curro FA, Green WS, Ship JA. Treatment of deep carious lesions by complete excavation or partial removal: a critical review. J Am Dent Assoc 2008;139(6):705-12.

17. Mickenautsch S, Yengopal V. Caries-preventive effect of high-viscosity glass ionomer and resin-based fissure sealants on permanent teeth: a systematic review of clinical trials. PLoS One 2016;11(1):e0146512.

18. Peumans M, Kanumilli P, De Munck J, et al. Clinical effectiveness of contemporary adhesives: a systematic review of current clinical trials. Dent Mater 2005;21(9):864-81.

19. Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database Syst Rev 2006;3:CD003808.

20. Schwendicke F, Frencken JE, Bjorndal L, et al. Managing carious lesions: consensus recommendations on carious tissue removal. Adv Dent Res 2016;28(2):58-67.

21. Ngo H, Ruben J, Arends J, et al. Electron probe microanalysis and transverse microradiography studies of artificial lesions in enamel and dentin: a comparative study. Adv Dent Res 1997;11(4):426-32.

22. Crystal YO, Janal MN, Hamilton DS, Niederman R. Parental perceptions and acceptance of silver diamine fluoride staining. J Am Dent Assoc 2017.

Authors’ ProfilesJudy Bendit, RDH, BS, has more than 45 years of experience in dentistry. She is a speaker, author, clinician, faculty member at the Temple University School of Dentistry, an alumni board member of the University of Pennsylvania Dental School, and an advisory board member for Palm Beach State College’s dental hygiene pro-gram. She is also a longstanding member of the American Dental Hygienists’ Association and a distinguished academy member of the Pennsylvania Dental Hygienists’ Association, and she is a volunteer clinician both at home and abroad.

Douglas A. Young DDS, EdD, MBA, MS, is a professor at the University of the Pacific where he is an active and ardent educa-tor in the field of minimally invasive dentistry and cariology. He was one of the founders of the CAMBRA (caries management by risk assessment) Coalition, ADEA Cariology Section, and the American Academy of Cariology (AAC). Dr. Young served on the ADA Council of Scientific Affairs (2012-2016) and is currently a cariology consultant for the ADA. Dr. Young has presented at con-gresses and universities around the world. He has been published in numerous peer-reviewed dental journals and textbooks focusing on minimally invasive dentistry, glass ionomer, and cariology.

Authors’ DisclosureJudy Bendit and Douglas A. Young have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

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1. SDF stands for?a. Sodium Dioxide Fluorideb. Stannous Diamine Fluoridec. Silver Diamine Fluorided. Silver Dioxide Fluoride

2. FDA clearance (which of the following are correct?)a. Cleared in 1970b. Cleared for caries managementc. Same breakthrough designation as fluoride

varnishd. Cleared for treating sensitivity

3. Which of the statements are correct regarding caries disease?a. It is a multifactorial disease.b. Risk assessment is an integral partc. Goal is halting demineralization, supporting

remineralization. d. All of the above

4. All of the following are required to place SDF EXCEPT:a. proper isolation (i.e. cotton rolls)b. microbrush and product (SDF)c. Dental chair, compressed air, cuspidor, and

suctiond. a caries lesion

5. SDF may decrease the need for which of the following: a. Injectionsb. Drillsc. General Anesthesiad. All the above

6. What is the mechanism of action for SDF?a. Silver acts as an antimicrobialb. Fluoride promotes remineralizationc. A silver-protein conjugate layer forms,

increasing resistance to acid dissolution and enzyme digestion.

d. All of the above

7. Which of the following statements are true about SDFa. It is minimally invasiveb. It preserves tooth structurec. It halts the disease processd. All of the above

8. SDF is which of the following:a. 36% weight/volume Ag(NH3)2Fb. 28% weight/volume Ag(NH3)2Fc. 38% weight/volume Ag(NH3)2Fd. 12% weight/volume Ag(NH3)2F

9. Which of the following FDA statement is correct?a. The FDA classifies SDF as a Class I

medical deviceb. The FDA classifies SDF as a Class II

cosmetic devicec. The FDA classifies SDF as a Class II

medical Deviced. The FDA classifies SDF as a Class III

medical Device

10. The CDT 1354 code covers which of the following:a. Inactive lesion, asymptomaticb. Active lesion, symptomaticc. Inactive lesion, symptomaticd. Active lesion, asymptomatic

11. The definition of the CDT 1354 code is:a. Interim caries arresting medicament applicationb. Topical application of Fluoridec. Application of a desensitizing medicament, per

visitd. Unspecified preventive procedure by report

12. Which of the following is NOT an indication for SDF?a. Patients with low risk of caries with no caries

lesionsb. Patients with high risk of cariesc. Patients with extreme risk of cariesd. Patients with xerostomia or severe early

childhood caries (SECC)

13. Other indications for SDF include?a. Patients with active caries lesions with

behavioral issuesb. Patients with active caries lesions with medical

management issuesc. Patients with active caries lesions with limited

access to cared. All of the above

14. The contraindications for SDF include:a. Peanut allergyb. Silver allergyc. Sodium Lauryl Sulfate (SLS) allergyd. None of the above

15. All of the following support use of SDF in the nursing home environment EXCEPT:a. Easy to placeb. Must have suction to place SDFc. Takes just a few minutes d. Cost effective

16. Clinicians should exercise caution with placing SDF in what instance/s?a. If the tooth is symptomaticb. Partially necroticc. Pulpally involvedd. All of the above

17. Which of the following statements are correct?a. SDF will not stain countertops and upholstery? b. SDF will stain the entire tooth, even if there is

no decay?c. SDF will only stain where there is decay or

demineralization?d. SDF will wash out of uniforms if it gets on them?

18. Ideally, the minimum recommended time for the solution of SDF to contact the lesion is:a. 10 secondsb. 30 secondsc. 1 minuted. 2 minutes

19. The steps for placing SDF include all of the following except:a. Making sure the patient is sitting up for the

procedureb. Wearing personal protective equipment (PPE)c. Placing safety glasses and plastic lined bib on

patientd. Have an assistant help if possible

20. The following statements about petroleum jelly and lip balm are true EXCEPT:a. Helps prevent staining of extra-oral structuresb. Potentially masks the smell of the solution if

placed on lipsc. It is OK to get into the caries lesion as it will not effect the bonding of any restorative

material d. Helpful when there are irritations on

surrounding soft tissues such as ulcerations or mucositis

21. Which of the following statements best describes the clean-up of SDF:a. Just throw everything in the biohazard red trash

canb. Only invert the gauze in the glovec. Put any excess aside so you can use it on the next

patientd. Invert all cotton, microbrushes and dappen dish

into glove and dispose in trash can.

Questions

Online CompletionUse this page to review the questions and answers. Return to www.DentalAcademyOfCE.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

INSTANT EXAM CODE 15217

www.DentalAcademyOfCE.com 9

Questions

22. Instructions following placement of SDF should include:a. Brush teeth immediately after treatmentb. No eating or drinking for 30 minutesc. Must use a RX toothpaste after SDF treatmentd. No alcohol for 1 week after treatment

23. What does SMART stand for?a. silver modified atraumatic restorative treatmentb. Stannous mediator for atraumatic restorative

treatmentc. Sodium modified atraumatic restorative

treatmentd. Strontium material atraumatic restorative

treatment

24. Based on this article what is the ideal restorative material for SMART? a. Resin modified glass ionomer (RMGI)b. Conventional GICc. Composite d. IRM

25. SMART attempts to combine three proven clinical procedures, which one of the following is NOT one of them? a. Caries arrest with SDFb. Complete caries removalc. Partial or incomplete caries removald. Placement of a conventional GIC restoration

26. In cleaning the perimeter of the lesion for SMART which of the following techniques was not mentioned in the article?a. Slow speed round burb. Ultrasonic insertc. Hard tissue laserd. Air abrasion

27. Which statement represents reasonable post-op instructions for SMART?a. Ask the patient not to chew on the GIC

restoration immediately after placement and ideally for a few days if possible.

b. Ask the patient to not chew on the restoration for 2 years

c. No eating drinking or rinsing for 24 hoursd. Do not brush the restoration with a toothbrush

for the first few days

28. All of the following are positive perceptions reported by patients after the SDF procedure EXCEPT:a. Easy to placeb. Did not object to taste or discolorationc. Very costlyd. Painless

29. Informed consent is indicated:a. When you have multiple teeth to treatb. On every patientc. Only if the patient complains about the dark

stainingd. Only when treating the anterior teeth that are

visible to the patient

30. Which statement is correcta. With the Breakthrough Therapy Designation

forthcoming from the FDA, widespread adaptation is forthcoming.

b. With the Breakthrough Therapy Designation forthcoming from the EPA, widespread adaptation is imminent.

c. With the Breakthrough Therapy Designation forthcoming from the FDA, widespread adaptation is unlikely.

d. With the Breakthrough Therapy Designation forthcoming from the ADA, widespread adaptation is imminent.

Notes

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

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AGD Code 011

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SIL1707DIG

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INSTANT EXAM CODE 15217