Author: Melody Mosenfelder

GIVE KIDS A SMILE
Silver Diamine Fluoride Consent Form (SDF)

Silver Diamine Fluoride (SDF) is an antibiotic liquid. We use SDF on cavities to help stop tooth decay from growing. We also use it to treat tooth sensitivity. Treatment with SDF does not eliminate the need for dental fillings or crowns to repair function or esthetics. While SDF can treat the bacteria that causes tooth decay, it will not restore the tooth structure that has been affected by the disease process. You may still require restoration of the teeth such as fillings, crowns or possible nerve treatment. Repeat applications of SDF have been shown to provide the best results; one application can stop decay by up to 70%.
Benefits of receiving SDF: SDF can help stop tooth decay, SDF can help relieve sensitivity, SDF can postpone the need for traditional dental treatment, SDF can delay or eliminate the need for sedation/general anesthesia to complete dental treatment in young children and adults
Alternatives to SDF Include but are not limited to: No treatment, Placement of fluoride varnish, Restorative dental treatment such as fillings, crowns, nerve therapy
Most Common Risks related to SDF Treatment: The affected area will stain black permanently. Healthy tooth structure will not stain. Stained tooth structure can be replaced with a filling or a crown. Tooth-colored fillings and crowns may also discolor if SDF is applied to them. Normally this color change is temporary and can be polished off. If accidentally applied to the skin or gums, a brown stain may appear that causes no harm and will disappear in 1-3 weeks . You may notice a metallic taste, this will go away rapidly. If tooth decay is not arrested, the decay will progress. In that case the tooth will require further treatment, such repeat SDF application, a filling or crown, root canal treatment, or extraction. These side effects may not include all of the possible situations reported by the manufacturer. If you notice other effects, please contact your dental provider.
Most Common Side Effects: With the application of Silver Diamine Fluoride (SDF) on top of a cavity will turn the cavity portion of the tooth dark. If SDF comes in contact with skin and/or gums, temporary discoloration will occur that may take up to 1-3 weeks to go away. If SDF is placed on a tooth that has a tooth colored restoration, discoloration may occur. The front teeth will be avoided if possible.
Authorization for Dental Treatment: I authorize The Give Kids a Smile Program with Bethany For Children & Families and their associates to provide and/or administer the dental service Silver Diamine Fluoride to my student, if their associates determine in their professional judgement, necessary or appropriate in my student’s care. I understand that repeat applications of SDF have been shown to provide the best results. I am informed and fully understand that there are inherent risks involved in the administration of any drug, medicament, antibiotic, or local anesthetic. I am informed and fully understand that there are inherent risks involved in any dental treatment. I understand that my student should not be treated with SDF if they are allergic to silver, or if they have painful sores or raw areas on my gums (i.e., ulcerative gingivitis) or anywhere in their mouth (i.e., stomatitis). I realize that it is mandatory that we follow any instructions given by the dentist and dental office staff. Alternative treatment options, including no treatment, have been provided. No guarantees have been made as to the results of treatment. I understand the most common risks/side effects associated with SDF that are stated above.

Photos Courtesy of Elevate Oral Care

I CERTIFY THAT I HAVE READ AND UNDERSTAND THIS PAGE and authorize Bethany for Children & Families to treat my student with Silver Diamine Fluoride if needed. Please sign on permission form or give verbal consent to GKAS.