Preparing the Child for Silver Diamine Fluoride (SDF) Application

Some children will have special considerations for assessment and treatment. For example, a child may need help with calming techniques or to be positioned in a specific way. Parents and caregivers can be engaged for best results. Consider using visual supports. Optimal positioning will vary by patient age, development, and ability. Position your patient to optimize patient comfort and ability to see the lesion(s).  

For children with needs that require a measured approach to assessment and treatment, progressive oral desensitization may be necessary and can be applied both in the office and at home. 

• At home: Families may need to start by using the toothbrush to touch their child’s lips or just inside the mouth. They may also want to teach their child to “open wide” so that this direction is understood. Parents and caregivers can model how to brush their  own teeth (or using a prop or stuffed animal) may also be helpful.
• In the office: It is important to end each visit on a positive note so that you and your patient can build upon your success. Let families know that together you will revisit the mutually agreed upon treatment decision and monitor its effectiveness. 

If your practice does not currently gather information on personal preferences, it may be helpful to create a brief family survey and/or consider using visual supports/schedules. Questions might include: 

• Does your child prefer to wait in the car until the exam room is ready or wait in the lobby?
• Does your child have any specific oral sensitivities (gagging, gum sensitivities, etc.)?
• Are there certain tastes or smells that bother your child?
• Are there any sounds that your child is very sensitive to? Does your child prefer quiet?
• Is your child more comfortable in a dimly lit room?
• Is your child sensitive to motion and movement (i.e., moving to a reclining position)?
• Are there any useful phrases or words that work best for your child? 

Calming Techniques and Distractions

Ask caregivers to provide approaches or techniques that they have found effective for their child. Examples include holding the parent’s or caregiver's hand or a favorite toy, poppers, a fluffy pillow or blanket, ability to listen to music or watch a video. 

Positioning 

It is important to work with the caregiver and patient on the best ways to calm and/or position each child. Ideally you will be able to position your patient to optimize 1) patient comfort and 2) your ability to see the lesion(s) being treated. Positioning will vary by patient age, development, ability, and individual needs. 

• Method 1: Sitting on the parent’s lap may be appropriate if the patient is able to cooperate with minimal movement. Otherwise supine positioning will likely be needed.
• Method 2: Knee-to-Knee positioning 
  1. Parent or caregiver sits knee to knee with the health professional applying silver diamine fluoride, and, if indicated, fluoride varnish.
  2. Parent or caregiver lays the child down, head in the health professional's lap.
  3. Parent or caregiver gently holds the child's hands, holding the child's legs and feet in place with the forearms. Clinician provides eye protection for the child prior to shining exam light.

• Method 3: Supine positioning on exam table. To better see and access upper tooth lesions, position patients with pillow behind head with neck extended at the edge of the examination table.
• Method 4: Supine positioning with assistance. Have the patient lie on the exam table with head in the parent’s lap. Have the parent support their child’s head and shoulders with their arm. If the child is unable to tolerate lying in a prone position, a second caregiver or assistant can gently hold his or her hands and feet, as needed.
• Method 5: If the child uses a wheelchair, sit or stand behind it, remembering to lock the wheels. If you are seated, tilt the wheelchair back into your lap. Use your arm to brace the child’s head against the wheelchair or against your body. Consider using a pillow so the child is comfortable. 
• Method 6: Have the child sit on the floor while you sit immediately behind them on a chair. Have them lean their head against your knees. Note that if the child is unable to tolerate sitting in this position, you can gently place your legs over his or her arms to keep them still.