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Silver Diamine Fluoride Silver Diamine Fluoride Who, What, Where, When and How? Dr. Brooke MO Fukuoka DMD March 10, 2017 SCDA Annual Meeting Charlotte, NC Disclosures and Affiliations Dr. Brooke MO Fukuoka Affiliations President of local component of ADA South Central Idaho Dental Society “Private Practice” owner Your Special Smiles PLLC HQFC Employee Dentist Family Health Services “Lecturer/Rotation supervisor” for special care College of Southern Idaho Member of the Special Care Dental Association Institute for Diversity in Leadership Class of 2016-2017 Disclosures and Affiliations Dr. Brooke MO Fukuoka Recent and upcoming presentations on this topic: Special Care Dentistry, Silver Diamine and Soft Liners South Central Idaho Dental Society (SCIDS) o Aug 2016- Sun Valley, ID Silver Diamine Fluoride- Team Presentation with Advantage SCIDS and IDHA combined meeting o January 2017- Twin Falls, ID Who, What, Where When and How of SDF AT Still University- o Feb 2017- Phoenix, AZ SCDA- Annual Session, o March 2017- Charlotte, NC Idaho State Dental Association Annual Session o June 2017- Sun Valley, ID Disclosures and Affiliations Stand on the Shoulders of Giants SDF “Training” Learned about it vaguely last June 2015 at the ISDA Annual Session from Advantage Dental Lecture from Advantage Dental at FHS January 2016 Asked about it at SCDA 2016- round table discussion Met a hygienist who used silver nitrate and fluoride Told it was an “old drug” by Japanese dentist Read many articles Briefly Discussed with Dr. Gordon Christensen Briefly Discussed with Dr. Brian Novy at ADA 2016 Traveled to UCSF to talk with Dr. Sean Mong, Dr. John Featherstone, and Dr. Jeremy Horst. –multiple emails with Jeremy Currently using in private practice and at the HQFC Met with Japanese hygienist who has applied it hundreds of times Discussed “Saforide” with Bee Brand representative via email Disclosures and Affiliations Dr. Brooke MO Fukuoka Financial interest Has no conflict of interest and no financial interest in SDF So Why do I do this? Your Special Smiles PLLC Mission Statement: “To increase the quality of life for adults with Neurodevelopmental/Intellectual Disabilities and Brain Injuries through caregiver education and increasing access to comprehensive dental care.” Silver Diamine Fluoride Who, What, Where, When and How? Dr. Brooke MO Fukuoka DMD March 10, 2017 SCDA Annual Meeting Charlotte, NC Who can apply SDF SDF ≠ Varnish It is currently treated as a varnish in multiple states It is NOT Varnish, through understanding of risks and benefits needs to be understood by the provider for proper consent from the patient. Leaves staining that can last FOREVER Who can apply SDF? In Idaho according to our board of dentistry “It is an authorized function under topical fluoride application.” Rules of the Idaho State Board of Dentistry Rule 30: Dental Hygienists- Practice o 01- General Supervision- (dentist needs to authorize) • L- All duties which may be performed by a dental assistant • Careful with expanded access- standing orders Rule 35: Dental Assistant Practice o 01-Direct Supervision- (dentist needs to be present) • X- application of topical fluoride agents Who can apply SDF?- Arizona According to the board of dentistry in AZ: “It is an authorized function under application of topical fluoride varnish.” That means that hygienist and dental assistants are authorized to place it Nothing in the dental practice act specific about SDF The board has not discussed it at this point Who can apply SDF? § 32-1289 Employment of dental hygienist by public agency, institution or school; definition B. A dental hygienist employed by or working under contract or as a volunteer for a public health agency or institution or a public or private school authority before an examination by a dentist may perform a screening or assessment and apply sealants and topical fluoride. ( I would say DON’T DO THIS WITH SDF- it is not the same as varnish) Who can apply SDF? 32-1291.01 Expanded function dental assistants; training and examination requirements; duties D. An expanded function dental assistant may apply sealants and fluoride varnish under the general supervision and direction of a licensed dentist.- after the dentist plans it without the dentist being there. –(THIS IS NOT VARNISH, make sure this is what is planned and not ordinary varnish. ) Who can apply SDF? R4-11-701. Procedures and Functions Performed by a Dental Assistant under Supervision A. A dental assistant may perform the following procedures and functions under the direct supervision of a licensed dentist: 9. Apply topical fluorides;- (so without expanded function can do this while the dentist is present. ) Who can apply SDF? Summary It is my understanding that: Hygienist- can apply it without prior doctor planning if they work I public health or a school setting An expanded function assistant can apply it under general supervision (without dentist present) An assistant can apply it with direct supervision Who can apply SDF? North Carolina Can only be applied by a licensed dentist According to Casie S. Goode- Assistant Director of Investigations and Terry W. Friddle- deputy operations officer NC State Board of Dental Examiners Who is applying SDF? Has been used for over 80 years in Japan and other countries. Australia, China, Brazil Seen as an “old drug” when asking Japanese dentists. “Fukka jianmin gin” Typically Placed By Hygienists in Japan Japanese Hygienist Ikumi Fukuoka- aka my sister-in-law Japanese product Japanese Articles 1967, 1969 Japanese article 1974, 1975 Saforide Instructions Who is applying it across the US? Leaders in SDF- “stand on the shoulders of giants” Dentists Dr. Jeremy Horst Dr. John Featherstone Dr. Sean Mong Dr. Brian Novy Dr. Mike Shirtcliff Dr. Peter Milgrom Who is applying it across the US? Leaders in SDF Organizations and groups Advantage Dental UCSF University of Washington Community Health Centers Pediatric Practices What is Silver Diamine Fluoride? History in the USA August 2014: Obtained FDA cleared for sensitivity: April 2015: Advantage Arrest became available in the US January 2016: UCSF published protocol for use in the Journal of the California Dental Association What is Silver Diamine Fluoride? History in the USA July 11, 2016: A lot of attention was drawn to it with article from New York Times What is Silver Diamine Fluoride? History in the USA July 12, 2016: ADA’s response to NY Times What is Silver Diamine Fluoride? Obtained FDA clearance for treatment of caries October 30, 2016 What is Silver Diamine Fluoride Insurance Codes D1354 interim caries arresting medicament application. D1208- topical application of fluoride D1206 – topical application of fluoride varnish D9910- topical application of desensitizing medicament The code 1354 us a per tooth code People’s charge ranges $15-50 What is SDF Biochemically ? Ag(NH3)2F Silver Diamine Fluoride Silver Nitrate Silver Phosphate Colorless or white powder, What is SDF? odorless, water soluble and extremely soluble in Similar to Silver NH3 Nitrate Gives up this outer electron to become Ag+ What is SDF? Acts Like Silver Nitrate and Fluoride What is SDF? From their elemental forms To their more stable forms Dissolved in What is SDF? What is SDF? (Compared with silver nitrate + Fluoride) What is SDF? How does it work? Interacts with Thiol groups Binds to proteins in bacterial cell walls Problems with respiration, distortion, cell death, makes cells more permeable by generating free radicles Binds to DNA in bacteria takes out of relaxed state “Denaturing” Effects hydrogen bonding Inactivates bacterial enzymes What is SDF? Silver Interacting with Thiol Groups pH of SDF = 10 What is SDF? Silver diamine has shown superior bactericidal effects in dentinal tubules Hamama HH, Yiu CK, Burrow MF. Effect of silver diamine fluoride and potassium iodide on residual bacteria in dentinal tubules. Australian Dental Journal. 2015; 60(1):80–87.10.1111/adj When should SDF be considered “SDF is an ideal treatment, when traditional treatment is not indicated”- MY OPINION- When esthetics is NOT an issue When is Silver Diamine Fluoride NOT indicated? When esthetics is an issue “Look at all my wrinkles” When should it be considered “SDF is an ideal treatment, when ideal treatment is not indicated”- MY OPINION- Medically compromised patients Unless you feel that they will not live long enough for it to benefit them When should it be considered “SDF is an ideal treatment, when ideal treatment is not indicated”- MY OPINION- Small children- keeping them out of the OR Also consider mesial caries on a molar with a primary about to exfoliate- buying Can buy time until they time for better are older and you can access! treat. When should it be considered “SDF is an ideal treatment, when ideal treatment is not indicated”- MY OPINION- Patients who are non-compliant with oral hygiene When should it be considered “SDF is an ideal treatment, when ideal treatment is not indicated”- MY OPINION- Patients who have extensive work needed When should it be considered “SDF is an ideal treatment, when ideal treatment is not indicated”- MY OPINION- In Difficult to reach furcations When should it be considered Difficult crown margins and non restorable endodontically treated teeth Prolonging the poor px tooth or bridge When should it be considered “SDF is an ideal treatment, when ideal treatment is not indicated”- MY OPINION- With ITR or Questionably Restorable Teeth
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