Silver diamine flouride

 Recently I have used silver flouride a couple of times in a clinical setting. The product we have access to is Riva star which comes in a two bottle system or a single use 2 capsule system. The supposed benefits of this compound is that it forms a precipitate that has a desensitising effect on the dentine, a remineralising effect on the tooth structure and an antibacterial effect which is supposed to arrest the caries process.

It comes in a two bottle system with silver flouride in the grey bottle and potassium iodide in the green bottle. This differs from other systems which is purely application of silver flouride solution. The main downside with silver flouride is the staining of soft and hard tissues that comes with it's application. The Riva star product claims to eliminate this with the application of potassium iodide which precipitates out the excess silver ions into potassium iodide. My concern is that this may reduce the effectiveness of the product in terms of remineralisation and potentially the precipitate may effect immediate bond strength to the tooth. I will have to see the level of staining associated with these patients but hopefully this is another useful tool to add to my armamentarium. 

The criteria for use of this product for me is a patient with:

-    Low aesthetic desires, typically elderly, with low compliance or ability to comply with lifestyle and hygiene instructions

-    Has caries which is of significant size and actively progressing typically root surface caries bt can be anywhere

-    Has a carious lesion that may potentially be a pulpal exposure if completely excavated

 The cases where I used it included: 

- Root caries on a long span bridge in a non aesthetic area. Here, there was caries that covered a wide area but was quite shallow so if it was able to be arrested, I may elect to leave it alone or if we were to intervene, the restoration of the lesion would potentially be more simple.

-Deep caries in a very elderly, post stroke patient with poor ability to perform oral hygiene. This was done in combination with atraumatic restorative technique and just prior to GIC restorations.

When using this product, the tooth surface is ideally clean so cavity prep and/or pumicing of the tooth surface is important. Isolate the area well as there is risk of dark staining despite the company's claims. Soft tissue staining will resolve within a few days, I am unsure how long hard tissue staining is expected to last. To minimise staining, place a small amount of bottle 1 solution to the area of interest then immediately apply bottle 2 solution in excess. A white precipitate will form but keep applying bottle 2 in excess until the white precipitate stops forming. 

I will see how these cases pan out but if effective, this material will be useful in a number of vulnerable populations.