___________________________________ DCA06DT Dental Treatment of Pediatric and Adolescent Patients
SILVER DIAMINE FLUORIDE A relatively new product to the United States, 38% silver diamine fluoride (SDF) was approved by the FDA for use in the management of hypersensitivity, and one SDF product, Advantage Silver Arrest (Elevate Oral Care), was the first to be cleared as caries arrest treatment (off-label use) [69; 78]. SDF has been used around the world as an alternative to restorative dentistry (particularly in Japan) for more than eight decades in people of all ages. Because SDF is a newer product in the United States, a committee of researchers and clinicians at UCSF has developed a protocol for using topical 38% SDF for caries treatment at dental clinics. The authors of the protocol describe the mechanism of action of SDF [78]: Upon application of silver diamine fluoride to a decayed surface, the squamous layer of silver-protein conjugates forms, increasing resistance to acid dis- solution and enzymatic digestion. Hydroxyapatite and fluoroapatite form on the exposed organic matrix, along with the presence of silver chloride and metallic silver. The treated lesion increases in mineral density and hardness while the lesion depth decreases. Meanwhile, silver diamine fluoride specifically inhibits the proteins that break down the exposed dentin organic matrix: matrix metallo- proteinases; cathepsins; and bacterial collagenases. Silver ions act directly against bacteria in lesions by breaking membranes, denaturing proteins, and inhibiting DNA replication. Ionic silver deactivates nearly any macromolecule. SDF may be used for caries preventative therapy in patients with salivary dysfunction secondary to aging, cancer treatment, methamphetamine abuse, polypharmacy, or Sjögren syndrome [78; 83]. SDF therapy is recommended for patients who have complications that preclude invasive restorative treatments. For children, indications for preventative therapy and treatment include extreme caries risk (e.g., xerostomia, severe early child- hood caries), treatment challenged by behavioral or medical management, and difficult-to-treat dental carious lesions based on access, isolation, and cleansability (e.g., recurrent caries at a crown margin, root caries in a furcation). An advantage of SDF is that it can be quickly applied at a diag- nostic visit; however, repeat applications are often performed at one- and three-month follow-up visits, and then at six-month semi-annual visits for two to three years [78]. Despite this, a single annual application of SDF is more effective for caries prevention than applying fluoride varnish two to four times per year or, if applied every year, than occlusal sealants [83]. For treatment of a carious lesion, the area is first thoroughly isolated using cotton or gauze; forced air may be used to ensure complete dryness, which improves efficacy. An applicator is used to place a small amount of SDF onto the lesion, where it is left for one to three minutes to soak into and react with the softened enamel and/or dentin; this timeframe is not critical but is a recommended caution for the first application.
Uncooperative children have been successfully treated within only a few seconds SDF reaction time. One disadvantage to SDF therapy is that the product perma- nently stains the lesion, but no other area, a dark grey color over time as the decay arrests; the color is similar to that of dental amalgam. Patients and/or parents should be informed of this effect [78]. Another disadvantage is that the treatment does not restore function of the tooth; fillings are recommended over SDF therapy if functional restoration is required. A consent form explaining these effects and limitations should be provided and signed by parents. The UCSF protocol and a sample consent form were published in the Journal of the California Dental Association and are available online at https:// www.dhcs.ca.gov/provgovpart/Documents/DTI/Domain 2/Domain-2-Informed-Consent-for-Silver-Diamine-Fluoride- Template.pdf [78]. CROWNS Restorative materials such as amalgam and composite resin are not the materials of choice when an extensive amount of deciduous coronal tooth structure has been destroyed by caries. In adults, such teeth are restored with full crowns of cast gold, porcelain-fused-to-metal, or a variety of all-ceramic options. However, when deciduous teeth that will not be shed for several years have extensive coronal caries and occlusal function must be restored, pre-formed stainless steel crowns are the restoration of choice. These stainless steel crowns can also be used to restore grossly carious permanent molars and bicuspids in children and adolescents in whom the roots of the teeth are not completely formed and in which adult occlusion has not yet been completed. In patients for whom amalgam or composite restorations have fractured or who have developed recurrent caries, these crowns may be used. The silver color of stainless steel crowns makes them unaesthetic, and the extended time for the preparation of the tooth, the trial fitting and contouring of the crown, and cementation can be beyond a pediatric patient’s ability to cooperate. Anterior deciduous teeth with extensive coronal caries can be restored with anterior strip crowns. This technique features the use of a pre-formed cellulose acetate strip crown into which the appropriate shade of composite resin material is inserted and then placed onto the tooth [16]. The composite material is light cured, and then the cellulose acetate strip crown is removed. Because this is a bonding procedure, isolation from blood and saliva is mandatory. The restoration of deciduous anterior or posterior teeth with stainless steel crowns or anterior strip crowns is an exacting procedure and should be attempted only by clinicians who have been appropriately trained.
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