Silver diamminefluoride (SDF) is an antimicrobial liquid that can be used to treat cavities(Latin America, Canada)to help stop tooth decay. SDF can also be used to treat tooth sensitivity. Reapplication of SDF to control caries is recommendedevery six (6) to twelve 12 months butmay be applied as necessary at a frequency determined by the dentist(min 1 week between applications). Treatmentwith SDF maynot eliminate the need for dental fillings or crowns to repair function or aesthetics. Additional procedures might incur a separate fee.

RIVA STAR is the first Australian manufactured SDF + KI solution that acts as a tooth desensitising agent). It immediately alleviates tooth sensitivity and it is a minimal invasive dentistry technique (it may avoid the need for general anaesthesia). In the US, Riva Star has been registered through FDA as Desensitiser for 21 years of age and over. Riva Star is perfect for elderly dentistry as well as all of those who have severe carious lesions and still are very afraid of any treatment in the dental chair. It is a new generation of treatment, it is quick and effective, making the whole experience non-traumatic and a relief for those experiencing toothache caused by caries.

SDF can help relieve sensitivity on cervical tooth.

Yes. You can find consent forms in English, Spanish, Mandarin, Cantonese and Arabic for download at the following link:
https://sites.google.com/site/jeremyahorst/sdfconsents
Please download, edit, and use as it benefits your patients.

Yes, please download it here:
www.rivastar.com/us_downloads_consentform

Yes. The American Dental Association has released Evidence-based clinical practice guidelines on nonrestorative treatments for carious lesions. These guidelines include SDF recommendations for various clinical cases.
https://ebd.ada.org/en/evidence/guidelines/nonrestorative-treatments-for-caries-lesions
The American Academy of Paediatric Dentistry has also released, “Use of Silver diamine fluoride for Dental Caries Management in Children and Adolescents Including those with Special Health Care Needs.” http://www.aapd.org/media/policies_guidelines/g_sdf.pdf

From a safety and handling perspective, price should not be the number one consideration. We would like to highlight the following points for the clinician to consider:

1. SDI’s patent protected Riva Star capsule was specially designed to address the patient’s safety, ease of use and time saving for the clinician. A pre-dosed encapsulated system has several benefits to offer:

• No over dosing – no wastage
• No over dosing - safer
• No cross-infection control procedure required
• No procedural cleaning required
• No stained dishes to clean
• No messy hands, benches, sink etc.
• No spillages – no mess and no stains

2. Cleaning stained operatory, clothes, hands etc. is time consuming and reduces efficiency.

3. A bulk system may be more economical to purchase but its content (qty) could potentially be lethal to a small child. (A lethal dose for an 80Kg adult is ~7mL.)

Each country and state’s dental practice act is different. Since Riva Star Step 1 is a fluoride-containing product indicated for the control of dentinal hypersensitivity, it should fit into the same rules as fluoride varnish. Please confirm that within your own state’s dental practice acts.

Yes, it can. Riva Star will not discolour sound enamel or dentin. SDF can discolour demineralized tooth structure brown/black. Some of this discoloration may shadow a restoration and can create less than optimal aesthetic restorations.

It has been suggested that by applying a saturated solution of potassium iodide (KI) (Step 2 of Riva Star – green capsule) immediately after the application of silver fluoride, staining of the dentin carious lesion can be minimized while the caries arrest effect of silver fluoride is not affected. Iodide ions from the KI solution will react with the excess silver ions from the silver fluoride solution to form a precipitate of silver iodide.

No. When applied to a carious lesion or at-risk site, Riva Star has demonstrated the ability in studies summarized in this packet to act as a reservoir for silver and fluoride. The silver is bactericidal against cariogenic biofilm not only at the site, but has a halo effect as saliva flows throughout the oral cavity. The same is true for the fluoride, helping to promote remineralization and prevent demineralization on all dentition.

SDF should not be placed on exposed pulps. Studies have shown that silver diamine fluoride conveys more effective protection against decay in other teeth than fluoride varnish with reduced overall fluoride exposure.

>Do not use silver diammine fluoride on patients:

• With an allergy to silver, fluoride or ammonia
• With ulcerative gingivitis or stomatitis
• Patients having had full mouth gingivectomies
• Patients with abnormal skin sensitisation in daily circumstances
• Without an informed consent
• With a low caries risk, CDT code D 0601
• Near any open wound including exposed pulp (direct pulp caps)

Do use silver diamine fluoride for patients:

• With any non-symptomatic active caries
• With deep caries as an indirect pulp cap
• With any incipient watch spot
• With newly erupted molars

With any at-risk sites such as: unsealed deep pits and fissures, enamel   defects, exposed root surfaces, furcations, food traps and old restoration margins.

Do not use silver diamine fluoride on patients:

• With an allergy to silver, fluoride or ammonia
• With ulcerative gingivitis or stomatitis
• Patients having had full mouth gingivectomies
• Patients with abnormal skin sensitisation in daily circumstances
• Without an informed consent
• With a low caries risk, CDT code D 0601
• Near any open wound including exposed pulp (direct pulp caps)

Desensitising indication is for use on sound tooth structure. Riva Star may cause some discoloration if used on carious lesions.
The FDA clearance only covers the use of this product as a desensitizing agent.

Estimations of SDF effectiveness in arresting dental caries lesions range from 47 to 90% * with one-time application depending on size of the cavity and tooth location. Reapplication of SDF controls caries and treat dentinal hypersensitivity and is recommended every six (6) to twelve (12) months. Anterior teeth have higher rates of arrest than posterior teeth. Therefore, follow-up for evaluation of caries arrest is advisable.
*http://www.aapd.org/media/Policies_Guidelines/R_ChairsideGuide.pdf

To date, there isn’t any report of adverse effects, outside of patients with an allergy to silver, fluoride or ammonia, where silver diammine fluoride has been used in any country.

Ask doctor in which clinical situation did he use it for? If he answers “for desensitising” then ask if there were caries/plaque on the treated site. Non-carious teeth will not stain. If he says “yes”, let him know that if used on carious lesions then the site will darken. If there was a layer of plaque, removing the plaque should remove the stain. If there is still staining after removing the plaque, then there are early stages of carious lesions. This is good because it highlighted a not detectible problem for the doctor.

Darkening of decayed and demineralized sites occurs as the lesion arrests. Non-lesioned tooth structure does not stain with the application of silver diammine fluoride. Similar to the treatment of eroded and hypersensitive dentin, the treated area can be restored using glass ionomer or with a sandwich restoration of both glass ionomer and composite.

Riva Star should not be diluted in an attempt to reduce discoloration. Studies have shown that diluted solutions may not be effective for caries arrest.

Ionic silver adsorbs onto almost any protein surface and is especially tenaciously bound to denatured proteins. This accounts for the specificity to carious collagen over normal collagen, but both will stain. The differentiator between these stains is that with SDF use intrinsic pigmentation of a carious lesion occurs and surface protein staining occurs primarily on healthy tissue. These oxides are bound to the tissue and don’t wash or polish away. Therefore, the blackened lesion retains its dark colour, and is most likely the reason the antimicrobial effect is long-lasting applying a saturated solution of potassium iodide (KI) immediately after the application of silver fluoride, staining of the dentin caries lesion can be minimized while the caries arrest effect of silver fluoride is not affected. iodide ions from the KI solution will react with the excess silver ions from the silver fluoride solution to form a precipitate of silver iodide. It would be a win-win situation if KI can prevent the staining associated with SDF without reducing its effectiveness in arresting caries.

For the site-specific control of hypersensitivity, the technique to apply Riva Star is similar to that of fluoride varnish. SDF is not for generalized or full mouth applications. Read the package insert for full application and precaution instructions.

Practitioners have shared success treating interproximal lesions using tufted or sponged floss soaked with silver diammine fluoride, then pulled into the contact point and left for 60 seconds. Additionally, some dry interproximal sites will wick SDF into the contact point from the micro brush applicators without the need for this floss technique.

It is not recommended to light cure after an application of Riva Star. Light curing causes the silver to oxidize before allowing it to fully penetrate the tooth and it might cause staining.

However, if you are placing a restoration on top of the Riva Star treated surface at the same appointment, wait at least 60 seconds to allow Step 1 to penetrate the lesion. Followed immediately by Step 2 of Riva Star capsule solution that contains Potassium Iodide (KI). Applying a saturated solution of potassium iodide (KI) immediately after the application of silver fluoride, staining of the dentin caries lesion can be minimized while the caries arrest effect of silver fluoride is not affected. Iodide ions from the KI solution will react with the excess silver ions from the silver fluoride solution to form a precipitate of silver iodide. It is a win-win situation if KI can prevent the staining associated with SDF without reducing its effectiveness in arresting caries.

Please refer to the procedure recommendation below for more information:
PROCEDURES

Silver and fluoride penetrate about 25 microns into healthy enamel and 200- 300 microns into healthy dentin without discoloration. The fluoride creates calcium fluoride and fluorapatite while silver binds with phosphates and protein structures in the tooth.

More info on page 318:
https://www.researchgate.net/publication/23958259_
Promoting_caries_arrest_in_children_with_silver_diammine_fluoride

There are no postoperative limitations. Patients may eat or drink immediately. Patients may brush their teeth with fluoridated toothpaste on their regular schedule.

Yes, through August of 2017 there have been two published studies/surveys and one poster presented on this topic, with all three showing similar results.

Parental Perceptions and Acceptance of Silver Diammine Fluoride Staining, YO Crystal, MN Janal, DS Hamilton and R Niederman, J Am Dent Assoc., Jul 2017.

The aim of the study was to assess parental perception of SDF staining and to determine whether parents’ level of acceptability of SDF would change with the location in the mouth, the child’s behaviour and demographic factors. A diverse group of 120 parents (98 mothers and 22 fathers) were surveyed. 67.5% of those surveyed judged SDF staining to be aesthetically tolerable on posterior teeth, with only 27.9% making this same assessment if the stain was located in the anterior region. In the absence of behavioural barriers to conventional restorative treatments 53.6% of parents were likely to choose SDF on posterior teeth, while only 26.9% would choose SDF for anterior areas. The level of acceptance increased as children’s behavioural barriers increased. At the extreme, when provided the option of general anaesthesia, acceptance of SDF application increased to 68.5% in the posterior and to 60.3% on anterior teeth. Socioeconomic status did impact acceptance of treatment.

Four major findings were presented:

• Acceptance of SDF staining was greater in posterior than the anterior teeth;
• Acceptance levels increased as the child required more advanced methods of behaviour guidance;
• The effects of location and cooperation changed with socioeconomic status;
• Only approximately one-third of parents found SDF to be unacceptable under any circumstances.

Discussion emphasized the need for parental/patient informed consent forms for the application of SDF.

Effect and Acceptance of Silver Diammine Fluoride Treatment on Dental Caries in Primary Teeth, J Clemens, J Gold, J Chaffin, J Pub Hlth Dent, July 2017.

This study enrolled 32 pre-cooperative children aged 2-5 years with 118 active caries lesions in primary teeth. Teeth were treated with SDF and children were recalled at two weeks (assess colour, hardness, pain and a parent survey were conducted on ease, taste, discoloration and painlessness) and at 3 months (assess colour, hardness and pain). Survey results showed:

• 0% strongly agreed or agreed with the statement “SDF application is an easy process.”

The use of potassium iodide (KI) can be used when silver diammine fluoride (SDF) is used on a prepared tooth cavity during a restorative procedure in an attempt to limit silver oxides from shadowing through restorative materials. When restoring with composites it is recommended to first line cavity with Conventional GIC or use RMGIC bonding agent such as Riva Bond LC (Prior to placement, ensure that the cavity is washed out with copious amounts of water or follow the etching protocols. See the procedures recommendations below: Situations with and without Clinical Site Restoration

KI binds the silver portion of SDF forming a white precipitate of silver iodide. Repetitive, applications of KI are used to scrub, wash, rinse and repeat on cavity floors and walls to remove the free silver.

Studies have shown that there is a protective effect to the site of the application of silver diammine fluoride and a halo effect for the entire mouth.

Yes, if Riva Star is used during a diagnostic appointment to arrest active disease, during the restorative visit the treated site can be evaluated for caries arrest providing you and the patient several options.

You could choose to 1) reapply Riva Star, 2) simply leave the site as is, 3) cover the site without anaesthetics or excavation or finally 4) excavate the site and place a restoration.

Contact to skin may cause irritation or burn and may cause temporary skin discoloration. With discoloration, the effect is not immediate, rather it will be noticed within hours. The speed of discoloration is accelerated with light contact. Flush with running water (an eschar may form on soft tissue, this should disappear within 24-48 hours).

Patients should be protected with bibs and safety glasses as in any clinical procedure. If you believe you have touched the applicator to the skin of a patient, it is good to advise them of possible temporary discoloration, and to wash or wipe the surface with water.

Take care to protect soft tissue with petroleum jelly or cocoa butter when an application is adjacent to gingival tissue (root caries, treatment of restoration margins). Light blanching is also possible from prolonged direct contact, but has been reported to be minor and resolves within 1-2 days.

There are no studies comparing the difference between caries arresting capabilities of SDF v’s SDF + KI. Both SDF and KI independently are known for their antimicrobial properties. SDF acts immediately on the treatment site therefore KI does not dilute the antimicrobial effect of the SDF. Furthermore, KI also has anti-microbial properties.

“Isolate area to be treated with cotton rolls or rubber dam or protect the gingival tissue around the affected tooth with petroleum jelly”.

SDI Gingival Barrier resin is not provided in kits for the US. However, it is available for sale separately.

Yes. Desensitizing agents have been shown to be protective of the pulp when placed on crown preparations to reduce dentin permeability. Riva Star, a tooth desensitizer, has been shown to be safe to the pulp when placed on exposed dentin. In addition, studies have shown desensitization and efficacy in treating softened dentin before placing direct restorations. Usually the tooth is first treated with silver diammine fluoride. This provides the benefit of sealing tubules plus the antimicrobial benefits of both silver and fluoride. Followed by Step 2 of Riva Star capsule solution that contains Potassium Iodide (KI). applying a saturated solution of potassium iodide (KI) immediately after the application of silver diammine fluoride, staining of the dentin caries lesion can be minimized while the caries arrest effect of silver fluoride is not affected. Iodide ions from the KI solution will react with the excess silver ions from the silver fluoride solution to form a precipitate of silver iodide. It is a win-win situation if KI can prevent the staining associated with SDF without reducing its effectiveness in arresting caries.

SDI conducted a clinical trial on tooth desensitization (Clinical evaluation of diammine silver fluoride/potassium iodide as a dentine desensitising agent. A pilot study” ADJ 2012;57: 308-311).

Follow up results at 2 years indicated desensitising still effective.

The research supporting reapplication of SDF is specific to cases where the lesion is left open without placement of a restoration. Reapplication has shown to be more effective in high risk groups.

Riva Star is ideal for use on patients where more complex treatment may be difficult. An example of this is in paediatric use where caries progression can be stopped with the use of Riva Star. Since primary teeth will eventually be exfoliated, placing a restorative is not always required.

Riva Star can be used to immediately prevent further progression of caries, with the idea of restoring later (I.e.: cost restraints).

Riva Star can be safely shipped to customers in un-air-conditioned transport for short periods of time such as up to 1 week at 30ºC then to be refrigerated. Exposure to temperatures over 30ºC (86º Fahrenheit) for prolonged periods of time will affect the shelf life of the product. We advise not to ship this product when forecast temperature is 35 degrees Celsius or above (95º Fahrenheit or above) for more than one day.

Riva Star capsules should be stored at refrigerated conditions, 2-8°C (35-45°F). Allow material to come to room temperature before use to avoid applying cold material on teeth. For transport purposes, Riva Star can be stored at room temperature up to 1 week.

Do not apply Riva Star on pregnant or lactating women. Neither do not repeat treatment on pregnant or lactating women.

Yes, it does.

Clothing: Soak in any fabric stain remover overnight and wash per normal.

Hard surfaces: Immediately apply household bleach (sodium hypochlorite) then wipe off with water. For stubborn stains, saturate a paper napkin with household bleach and place over affected area. Leave overnight and mop up with water.

The use of Riva Star results in a reduced likelihood of black staining compared to that associated with the use of traditional SDF treatments. It is vital that the IFU is followed correctly to ensure application techniques are performed correctly to reduce the likelihood of black staining. For lesions that are covered / restored with a conventional Glass ionomer cement after treating with Riva Star, no staining should be visible if the IFU is followed correctly. Naturally arrested caries typically presents with a brown colour, this is also true for those arrested with Riva Star.

According to the research from the School of Dental Medicine of Tufts University in Observational Staining Properties of Silver Fluoride on Dental Materials (2009), intrinsic staining by silver fluoride on dental materials (GIC, RMGIC, TMC and Com) appeared to be reduced by addition of KI Step 2 of Riva Star capsules solution). This would prove useful to dentists hoping to use the benefits of silver diammine fluoride on surfaces adjacent to these materials, but who are worried about aesthetics. Although the orthodontic adhesive and composite samples did not show any discoloration, clinically the use of KI could provide protection against staining of the patient’s mucosa by the silver fluoride.

Arrested lesions look like a lesion (scar) on radiographs. You will observe only slight increases in radio-opacity as the mineralization of the previously softened dentin increases. Ultimately the best test of arrest is still the colour change and tactile hardness of the dentin surface.

It is advised that you educate your referring dentist about your use of Riva Star since the appearance of a treated lesion might be new and confusing for many practitioners.

We don’t know any research from any current detection devices on the impact of SDF treated sites on device detection abilities/anomalies. If you have one of these devices, we encourage you to ask them what you can expect from the use of SDF in your practice.

Our Experience in this field leads us to the following thoughts;

CariVu® is a trans-illumination device. It shines light through the tooth and looks for shadows (which can be active/inactive decay, cracks or anything that blocks light). We would anticipate the CariVu would see SDF treated sites similar to images of decay.

DiagnoDent® detects porphyrins (by products from bacteria) trapped in the tooth. DiagnoDent does not see the tooth itself. We would anticipate DiagnoDent to show lower readings as SDF lowers bacteria levels within lesions.

Spectra® is a blue light, yellow filter caries detector. This uses the tooth’s auto-fluorescence to detect decay and anomalies in the tooth. Spectra is also capable of seeing porphyrins. We would anticipate where good images can be acquired, especially near marginal edges, you would notice a lower reading of red fluorescence from the device, indicating a lowering of bacterial activity.

Yes. Since Riva Star contains fluoride and studies/articles in this packet demonstrate the ability of SDF to prevent caries, D1208 is an appropriate code when the product is used as a topical application of fluoride in primary prevention. Clinical notes should reflect the reason for the application. It is also helpful to identify caries risk to justify the reimbursement with a recognized caries risk assessment tool.

Codes D0602 – caries risk assessment and documentation, with a finding of moderate risk and D0603 - caries risk assessment and documentation, with a finding of high risk are especially important to justify patient use.

D1999 – unspecified preventive procedure by report (and including a report) can also be used to record your patient encounter.

Yes. Many carriers have already included reimbursement for D1354 within many of their plans. It is common for insurance providers to not reimburse for new codes as they develop usual and customary payment data. However, it is important the new D1354 code is used so providers can see the volume and associated fees to determine future coverage.

Yes. The American Academy of Paediatric Dentistry indicated in a 2016 publication (“Are Your Kids Covered?” that 19 States were covering D1354. Based on direct feedback from various State agencies we believe an additional 8-10 State have begun coverage for D1354 through 2018.

SDF is cleared for dentinal hypersensitivity treatment. That code is:

D9910 – application of desensitizing medicament

Includes in-office treatment for root sensitivity. Typically reported on a “per visit” basis for application of topical fluoride. This code is not used for bases, liners or adhesives under restorations.

On January 1, 2016 a new CDT code became effective for the use of SDF or 25% silver nitrate and has had one revision effective January 1, 2018. The code that will be effective on January 1, 2018 has the addition of “……per tooth” and reads as follows:

D1354 – interim caries arresting medicament application per tooth

Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without removal of sound tooth structure.

The ADA has provided a guide to report D1354, linked here:

https://bit.ly/2zdechr