Silver Diamine Fluoride
An option for more effective dental care
Jason Hirsch, DMD, MPH
As people live longer and the population of the United States continues to increase, practitioners need to rethink prevention in oral healthcare. For decades, some leaders in the profession have been talking about the medical management of caries.1 It is time for more practitioners to embrace that concept, because managing caries as a disease whose effects can frequently be reversed or arrested with the use of proper medications in the office and at home is more effective dental care.
In keeping with this principle, silver diamine fluoride (SDF) merits discussion as a tool to not just prevent, but to arrest decay. SDF is a combination of silver and fluoride that was cleared for use by the FDA as a desensitizer for adults over 21 years old, but is being used off-label for adults and children to prevent and treat caries. Currently the only brand of SDF cleared by the FDA is Advantage Arrest from Elevate Oral Care (elevateoralcare.com), but SDF does have a long history of worldwide use (over 50 years in Japan and other countries) and it was recently approved by Health Canada to prevent and treat caries. In late 2016, SDF also received FDA Breakthrough Therapy Designation, which represents the FDA’s effort to expedite the development and review of drugs that are intended to treat a serious condition; it is issued when preliminary clinical evidence indicates that the drug may demonstrate substantial improvement over available therapies on a clinically significant endpoint(s).
Prevention in Practice
SDF can be used either as a standalone therapy or part of restorative therapy. In this author’s experience, it is generally a much less invasive and more effective way to treat patients. As it has been gaining attention, practitioners should prepare to understand its uses.
SDF is extremely effective in reducing or eliminating sensitivity. However, the fact that it stops the growth of bacteria, remineralizes teeth, and hardens treated lesions has generated the most excitement among US dentists in the past few years.
In addition to arresting caries, SDF also acts as a disclosing agent. Normally, after only one application, SDF will turn a carious lesion dark. It does not stain sound enamel or dentin, but it will stain any irregularities such as pits and fissures. The darkening may be visible almost immediately or it may take up to 24 hours to develop, depending on how much the treated area is exposed to light, which acts as a catalyst for the chemical reaction. If the lesion stays dark in color and asymptomatic, an increase in hardness of the treated area will be noted.
Would this dark stain be acceptable to patients and parents? A recent study of parents’ reactions to the option of using SDF was published in the Journal of the American Dental Association. The study found that in the case of posterior teeth about 53.6% of parents preferred the idea of a stain on their children’s posterior teeth versus the option of a surgical procedure. Even in anterior teeth, 26.9% said yes to SDF. In extreme cases where general anesthesia is needed, acceptance rates increased to 60.3% on anterior teeth and 68.5% on posterior teeth.2
The author has also reviewed several other studies presented at recent conferences that had similar findings. These have only served to reinforce his opinion that when patients are presented with the options and issues associated with each approach, practitioners may be surprised by the response. Although dentists might assume patients would prefer restorative work, many will select the non-invasive option, especially for interproximal or posterior locations where esthetics are not an issue.
While the treated, darkened lesions can be left dark if the patient accepts that outcome, another option is to cover the treated area with a restorative material. Glass ionomer can be placed over the stained, arrested lesion using the Silver Modified Atraumatic Restorative Technique (SMART).3 The clinician can also remove some of the arrested lesion for a less invasive but more esthetic traditional restoration, assured that the SDF disclosed and arrested bacteria prior to the restoration.
After using SDF on more than 600 hundred children, the author believes this therapy to be a game changer. Successfully implementing a new protocol never rests solely with the doctor, however. Dental hygienists are central to the change in mindset that needs to take place, as they are on the frontline when it comes to fighting primary and recurrent tooth decay. Their buy-in is essential when shifting a practice’s understanding of prevention, which is the first step towards more effective dental care for the sake of patients and the profession.
1. Edelstein BL. The medical management of dental caries. J Am Dent Assoc. 1994;125(1):31S-39S.
2. Crystal YO, Janal MN, Hamilton DS, Niederman R. Parental perceptions and acceptance of silver diamine fluoride staining. J Am Dent Assoc. 2017;148(7):510-518.
3. Fa BA, Jew JA, Wong A, Young D. Silver modified atraumatic restorative technique (SMART): an alternative caries prevention tool. Stoma.EDU Journal. 2016;3(2). Available at: http://dental.pacific.edu/faculty-and-research/research-in-the-spotlight/silver-modified-atraumatic-restorative-technique-(smart)-an-alternative-caries-prevention-tool. Accessed July 29, 2017.
About the Author
Jason Hirsch, DMD, MPH
Private Practice Limited to Pediatrics
Royal Palm Beach, Florida