A change in practice: Reducing the burden of dental caries with silver diamine fluoride

Oral Science/Elevate Oral Care. This chairside treatment had recently been approved by Health Canada to arrest active dental caries in both primary and permanent teeth. Three years earlier, the US Food and Drug Administration (FDA) had given SDF clearance for desensitization, but using it for arresting dental caries was considered off label.¹ In 2016, the FDA recognized SDF with “breakthrough therapy” designation to treat dental caries.¹ As I continued to research this newly approved treatment, its place in dentistry became clear, as did the need for dental professionals to reassess their current path of preventive dentistry.

A change in direction

A large part of my role in public health was spent screening patients for preventive needs as well as nonurgent and urgent findings. With the ongoing identification of cavitated lesions resulting in referral and delay in treatment, I knew SDF was an innovative solution that could help address unmet needs and have a positive impact on treatment outcomes. My desire to get involved with the promotion and integration of SDF into practice sent me in a direction I never expected. I found myself resigning from my almost seven-year career in public health and accepting a position with Oral Science as an oral health sales consultant and educator. I was excited to be joining a company with a mission directly related to my core values, i.e., improving clinical outcomes. I welcomed the opportunity to bring awareness to such a game-changing product. 

In my 17 years in dentistry, I had never felt so strongly about the need for such a major change in the direction of prevention as I did when I heard about SDF. In my opinion, dentistry was awaiting a treatment option for dental caries that could be used as an interim solution for challenging situations in which traditional treatment might be delayed or avoided. It is evident that minimally invasive dentistry is here to stay. It is an area of dentistry that is showing exceptional growth in funding for research and innovation. 

How does SDF stop the caries process? 

A clear and deep understanding of how SDF works will allow for easy, yet detailed, conversations with our patients and/or their decision makers. There are three active ingredients in SDF, each with a unique purpose. Thirty-eight percent silver diamine fluoride consists of 25% silver, 5.5% fluoride, and 8% ammonia.² Bendit and Young discuss how silver acts as an antimicrobial with substantivity and fluoride as a remineralizer.¹ Ammonia acts as a solvent for the solution in either bottle or ampule form. During

application, the decayed tooth structure will start to form a silver protein conjugate layer, causing silver minerals to form and increasing tooth hardness and resistance to acid (figures 1 and 2).¹

Supporting dental professionals through change 

Over the last few years I have been privileged to support hundreds of dental professionals in the integration of SDF. An essential part of my current role is following up with providers of oral health care. I listen to their perspectives on SDF use (specifically Advantage Arrest) and the impact it has made on their practices. A recurring theme during discussions with dental professionals is the acknowledgment that SDF has changed their assessment and treatment planning stages. This is because they now have an option to present to patients and families who may have a financial hardship, anxiety and/or compliance issues, access-to-care limitations, or areas that are difficult to treat where traditional restorations would not be ideal.

Applications of SDF for the elderly

Dentists and hygienists have shared numerous stories during my follow-up discussions on the use of SDF, and not just in the private practice setting, but also in long-term care facilities and volunteer/mission work. The stories that I find most powerful are when providers share their insights into how SDF is changing oral health outcomes for the elderly who live in long-term care residences. The aging population has increased oral health needs and treatment can be a struggle. Dental professionals need something easy and effective to use. SDF is a welcomed solution for the required care. In 2018, Oliveira et al. discussed findings that concluded annual applications of 38% SDF in older adults decreased the incidence of new caries lesions in exposed roots by at least 50%.³

Another amazing capability related to this alkaline topical solution that is specific to an older demographic is the desensitization effect it has on exposed root surfaces. In some situations, SDF works so well as a desensitizer that it reduces or eliminates the need for local anesthetic.¹ Application of SDF to exposed root surfaces of older adults will help prevent sensitivity as well as initiation and progression of dental caries.

What is our responsibility?

When presenting treatment options, remember that we are not making decisions for our patients; we are making decisions with our patients or their decision makers. Oral health-care providers should discuss all possible treatment options without making assumptions. This is directly related to the importance of receiving informed consent. When patients or their decision makers are made aware of all of the possible treatment options, they can give informed consent to move ahead with treatment that meets their needs and preferences. 

The more dental professionals understand how SDF can be used in multiple situations, the more doors will open to early intervention, which will also lead to an overall caries risk reduction. Horst and Heima stated that “results suggest that one application of SDF per year is at least as effective as two to four applications of fluoride varnish per year, and may be more so.”⁴ We need to always have our patients’ best interests at heart, and being proactive in stopping dental caries at the earliest possible stage should be one of the fundamental areas we focus on with each patient interaction.

Conclusion 

Once the SDF treatment option is explored by dental professionals, they quickly see how its uses are much broader than initially thought. It is a tool that is extremely cost-effective and can be used in multiple settings to treat patients of all ages. The practice of dentistry has shifted toward minimally invasive techniques. Many dentists and hygienists—as well as patients—welcome a pharmacological approach to dental caries rather than drilling and removal of tooth structure in appropriate cases. SDF is a treatment regimen that can be used with young or noncompliant children; the elderly population; and patients with access-to-care issues, limited or no dexterity, or financial barriers.  

Author’s note: For more information on Advantage Arrest silver diamine fluoride, dental professionals in Canada may contact Oral Science at oralscience.ca. Dental professionals in the US may contact Elevate Oral Care at elevateoralcare.com.

References

1. Bendit J, Young DA. Silver diamine fluoride: The newest tool in your caries management toolkit. Dental Academy of Continuing Education. July 2017.

2. Safety data sheet. Advantage arrest SDF 38%. ElevateOralCare. Accessed June 11, 2020. http://www.elevateoralcare.com/site/images/AASDS082415.pdf

3. Oliveira BH, Cunha-Cruz J, Rajendra A, Niederman R. Controlling caries in exposed root surfaces with silver diamine fluoride: a systematic review with meta-analysis. J Am Dent Assoc. 2018;149(8):671-679.

4. Horst JA, Heima M. Prevention of dental caries by silver diamine fluoride. Compend Contin Educ Dent. 2019;40(3):158-163. 

Lisa Hardill, BHADM, RDH, has 17 years’ experience in the dental industry. She has worked in private practice, independent practice, and public health. Hardill is currently working as a dental hygiene preventive care partner with Oral Science, a company specializing in prevention and improving clinical outcomes through a focus on caries management, periodontal disease, xerostomia, and tooth sensitivity.Her areas of passion also include access to care and infection control. Hardill can be found on Instagram @strictlydentalpro or at strictlydentalpro.com.