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General Questions

With CaviGuard, the medicines 38% silver diamine fluoride (SDF) and 5% sodium fluoride varnish (FV) are used to stop the infection and allow the cavity to remineralize naturally. The dark spot left behind is silver embedded within the cavity which acts as a protective barrier to reinfection and even protects nearby teeth by preventing new cavity formation. This treatment is painless, fast, and up to 96% effective at stopping cavity growth. If a filling is needed after treatment, it can be done without shots or drills using glass ionomer cement (GIC), which can also cover up the dark spot.

 

The use of silver as an antimicrobial has been around for thousands of years, such as placing a silver spoon in milk to keep it from spoiling. Over 100 years ago, silver nitrate (SN) was used for the identification and treatment of caries. In Japan during 1969, silver was combined with fluoride to form silver diamine fluoride (SDF) which is currently used around the globe. This material combines the antimicrobial features of silver with the tooth strengthening features of fluoride.

 

Yes, CaviGuard is registered as a Covid-19 product. This is because with this treatment system, the clinician can treat tooth decay without causing aerosols, which are often created when using traditional dental drills. Oral aerosols are a common pathway for transmission of the Covid-19 virus.

 

All silver diamine fluoride (SDF) products, CaviGuard included, are known to stain almost anything they come in contact with. It is recommended that barrier materials are setup prior to treatment to prevent staining. If SDF comes in contact with skin or gingiva, a temporary stain will form but it will disappear within a few days since both regularly exfoliate, similar to a henna tattoo. If SDF comes in contact with floors or counter tops, mild bleach can be used. Stains on clothing unfortunately are more than likely permanent.

 

When SDF is applied to healthy enamel, there is no staining. However, staining does occur when SDF is applied to demineralized tooth structure or cementum.

 

It is estimated that about 134 treatments can be provided from one tube set, assuming patients have four cavities on average.

 

Not necessarily, but this depends on each country’s regulatory requirements. For example, in the United States, most states allow both medical and dental professionals to apply SDF. Examples of these types of professionals include nurses, dental hygienists, medical or dental assistants, physicians, surgeons, etc… We do not recommend that the public uses CaviGuard to treat themselves or others since some training is necessary to provide safe and effective treatments.

 

No, and that is a major advantage over traditional treatments. The CaviGuard treatment system was designed for large scale public health settings both inside and outside of the dental office. Treatment cost is kept down significantly since the device and materials are reusable, reagents are applied in a controlled metered dose fashion, and an entire mouth can be treated very quickly in the same appointment.

 

Yes, this system does not require traditional dental settings or even electricity. A clinician can take the CaviGuard treatment system in a backpack to a remote location and treat up to one hundred people by themselves in a day.

 

Clinical

Many studies have shown carries arrest effectiveness of 80-96% and the variation in these results are likely due to application protocols. Using the CaviGuard treatment system and protocol, effectiveness of up to 96% can be achieved.

 

The lesion does not grow during future examinations, it turns black, and it is hard to gentle surface probing (DO NOT PROBE USING ANY SHARP INSTRUMENT).

 

Studies have shown that 2-3 applications of 38% silver diamine fluoride (SDF) provide a higher level of success for arresting cavity growth and preventing future cavity formation. Sometimes, limited access to the patients may reduce the number of applications that can be done. Even when applied appropriately, one treatment with SDF provides better outcomes than the alternative.

 

Any cavity that has not reached the pulp of the tooth is a candidate. It is recommended that at least 1mm of dentin is present between the pulp and the base of the cavity to prevent the occurrence of pulpitis after treatment. Treatment of white spot lesions is not recommended since they still have the ability to become remineralized and reversed naturally. In addition, the application of 38% SDF will turn a white spot lesion grey, which is why it is sometimes used as a cavity detector.

 

Yes, sometimes it is necessary to fill a cavity after treatment with CaviGuard, because of aesthetic or functionality concerns. The first approach involves waiting 3-7 days after final treatment with CaviGuard, to confirm cavity arrest, followed by placement of a glass ionomer cement (GIC) in a separate appointment. The second approach involves placement of GIC directly after the final treatment with CaviGuard on the same appointment. Keep in mind that if you follow the second approach, DO NOT PLACE FLUORIDE VARNISH (FV) AFTER PLACING SILVER DIAMINE FLUORIDE(SDF)! Placement of FV will prevent the GIC from properly binding to the tooth. Please note that if you follow the second approach where you apply SDF and GIC in the same appointment, the filling material resin or GIC will also turn dark, especially if a curing light is used.

When treating primary teeth, it is often not necessary to fill the cavity after treatment since it will eventually exfoliate and be replaced with a permanent tooth.

 

Three different filling materials can be used; amalgam, resin and glass ionomer cement (GIC). Amalgam does not get stained by silver diamine fluoride (SDF) but it does contain mercury. Resin requires acid etching, a curing light, and it does not create a chemical bond to the tooth which can lead to microleakage around the margin. In addition, the acid etching step removes silver from the SDF treated lesion, limiting its cavity arrest and prevention effects. GIC on the other hand self-cures, creates a chemical bond with tooth structure, and doesn’t require acid etching prior to filling placement.
Many clinicians opt to use both GIC and resin. First, GIC is placed as the bulk-fill base material. Second, resin is then placed on top as a veneer to provide better aesthetic results. This method can be done atraumatically.

 

Placement of SDF on a pre-existing resin or GIC filling may result in staining of the filling, especially around the margins.

 

Yes, if there is suspicion of decay in the deep occlusal groves. SDF will enter those hidden spaces and kill bacteria prior to placement of the sealant material (GIC is preferred). We don’t recommend the use of resin-based sealants because the acid etching step will remove silver from the treated surface and they could have microleakages around the margin of the sealant.

 

Yes, any site of demineralization will become stained. White spot lesions may become a light grey whereas fully developed caries will turn black. This color change occurs because the silver ion present in 38% silver diamine fluoride (SDF) binds to demineralized tooth structure and then becomes silver oxide which is dark in color. This dark stain, and presence of a hard surface, indicate that the decay process has been arrested. This stain is also a reservoir of silver ions that provides protective effects throughout the mouth, especially neighboring teeth, and prevents reactivation of the treated lesion. If this dark spot is in an area of aesthetic concern, it can be easily covered up with glass ionomer cement without the need for drills or injections. For best aesthetic results, it is suggested that the margins of the cavity be cleaned before filling with glass ionomer cement.

 

When 38% SDF comes in contact with skin, it leaves a temporary dark stain which is gone within a few days since skin regularly exfoliates. To help prevent this staining from occurring on the patients’ lips and face, we recommend that a thin layer of petroleum jelly or chapstick be applied to the area prior to treatment.

 

The CaviGuard treatment system was designed to have disposable applicator tips and plastic barrier sleeves to help keep treatment aseptic between patients. After treating a patient, please remove and dispose of both applicator tips and plastic barrier sleeves. When preparing for the next patient, use new applicator tips and plastic barrier sleeves. Although it is not required, the tubes and devices can be wiped down using a disinfectant wipe.

 

The two medicines that are used, 38% silver diamine fluoride (SDF) and 5% sodium fluoride varnish (FV), are both extremely safe and used widely around the world. The only contraindications are a silver or fluoride allergy, which is extremely rare, or pulpal involvement. If the pulp is exposed or less than 1mm of dentin is left between the pulp and the base of the cavity, CaviGuard treatment should not be used. Treatment when less than 1mm of dentine is left can lead to pulpitis. In addition, the CaviGuard dispensing devices provide a metered dose for each reagent and each one should only be dispensed when the applicator tip is in contact with the treatment site. It is important to note that patients should wear eye protection during treatment.

 

Yes, the patient and the dentist should always be wearing eye protection during treatment with CaviGuard. The eyes do not have skin to provide protection like the rest of the body, so the SDF can damage the eyes if not protected.

 

While both materials contain fluoride, the amount of material placed topically is very small and should not lead to fluorosis of other toxic events.

 

It is recommended that the gingiva be protected by using cotton rolls or gauze pads. We don’t recommend covering the gingiva with petroleum jelly because it can accidentally be placed on the cavity before treatment, which can prevent the SDF and 5% sodium fluoride varnish (FV) from interacting with the cavity. Even if the SDF does stain the gingiva, it will be temporary since the gingiva regularly exfoliates like skin. In addition, the CaviGuard treatment system uses an SDF with a balanced pH of 7-9, which is quite safe. Some SDF products, on the other hand, have a very high pH (up to 13) which can cause a chemical burn, and those products recommend the use of rubber dams to protect the gingiva.

 

It is more challenging to treat interproximal caries due to their location and limited access. However, many clinicians have successfully treated these types of caries using non-waxed floss. Essentially, the floss is placed between the teeth, one click of 38% silver diamine fluoride (SDF) from dispenser one is applied to the floss, and then the floss is moved back and forth several times and allowed to sit for one minute. Then, after retracting the cheek, the floss is carefully pulled out from the buccal side, to avoid accidental staining of the skin from residual 38% SDF on the floss. The treatment site is then covered with two clicks of 5% sodium fluoride varnish (FV) from dispenser two to prevent saliva contamination. There are clinical training videos on the CaviGuard website that provide further information on this technique and how to implement it with your patients.

 

Saliva contamination can dramatically reduce the effectiveness of 38% silver diamine fluoride (SDF) when not properly controlled. If an active cavity is not thoroughly dried prior to treatment, the saliva present within the cavity will physically prevent SDF from deeply penetrating the lesion. Fluoride varnish (FV) is placed on top of the SDF because it creates a hydrophobic barrier that prevents saliva from washing away the SDF after treatment. Finally, saliva is highly proteinaceous, meaning that the proteins in saliva will bind silver ions present in SDF, preventing them from killing the bacteria that created the cavity in the first place.

 

If FV is placed first, it will prevent the SDF from interacting with the cavity, resulting in the treatment being ineffective.

 

Yes, SDF can be placed on primary and permanent teeth for the arrest of tooth decay and treatment of dentinal hypersensitivity.

 

It is recommended that you do not eat or drink for 3 hours after treatment and don’t brush your teeth until the following day. This gives the fluoride varnish enough time to protect the SDF from saliva contamination for maximal treatment effect.

 

Although no official clinical trials have been conducted, some clinical observations have demonstrated continued cavity arrest of four years or more.

 

Several studies and clinical trials on SDF have shown a preventive effect on the formation of new carious lesions after active cavities have been treated with SDF.

 

Device Functionality

The most common reason why material won’t come out, even after depressing the dispensing button, is when the slider on the underside of the device wasn’t slid all the way forward until it hit resistance and then locked into place using the lock button on the side. Another reason could be that the end and tip caps were not placed back onto the fluoride varnish tube when not in use and the varnish dried up, making it difficult for the internal piston to move forward or the opening at the tip of the tube is blocked.

 

This could mean that the lock on the side of the device isn’t in the proper position, in which case you should unlock and then lock the device again after pushing the slider forward until it meets resistance. It is also possible that the end and/or tip caps were not placed back onto the fluoride varnish tube for a prolonged period of time and the varnish dried up. When the varnish dries up, it becomes very sticky, making it very difficult for the piston within the tube to push forward when pressing the dispensing button.

 

It is recommended that you first ensure the dispenser is unlocked. Push the slider back and forth multiple times, then push it forward until it hits resistance again, and finally retry to lock the dispenser. This often fixes the problem.

 

Not necessarily, as long as the tip cap is placed back on the tube when not in use to prevent the material from drying out. However, if the time between patients is significant or you are done treating with CaviGuard for the day, we recommend that the tube be removed. Once removed, the end and tip caps would need to be placed back on the tubes and they it should be stored in a cool dark place like a drawer.

 

We do not recommend that the tubes are left within the dispensers for a prolonged period of time. Even if the tip cap is placed back on the tube while it is within the dispenser, fluoride varnish can still dry around the piston within the tube making it difficult to dispense when ready to use later.

 

Make sure that both tubes have their end and tip caps firmly in place. For the device, make sure the slider on the underside is pushed all the way to the end (not towards the front) and then lock it in place using the lock button on the side.

 

The plastic used for the tubes and the housing of the dispensing devices are highly resistant to staining from 38% SDF. However, if it is left on the tube or device for an extended period of time, the staining can become permanent, albeit very light. Use of a bleach solution may help remove any residual staining.

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