How to get your boss to adopt silver diamine fluoride (SDF), and other new ideas

What do roadblocks, mountains, and massive walls have to do with the dental hygiene profession? At first thought we might think about the physical aspect of all three, but as we look more deeply, we start to see them as obstacles that prevent us from providing the best care possible for our patients.

Often, scope of practice is the biggest barrier we deal with, depending on where we live and practice. At other times, it is the dentist-employer who creates these obstacles. I am sure many of you have experienced such barriers when approaching your dentist about implementing something new. We may have attended an amazing continuing education course that renewed our passion for hygiene, only to be deflated by a “no” from our employer.

Perhaps the dentist you work with is not ready to implement new protocols or methods. Could it be that the dentist is not familiar with the product or technique and so has decided it is too this or too that to employ? Maybe the dentist is not receptive because they feel threatened by the input. The past 18 months and all of the COVID-19 protocols may have put a damper on excitement about new things.

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In a perfect world, we would be valued for our opinions and creativity in ways to help improve the office environment and provide the best care for patients. While many dentists have now added silver diamine fluoride (SDF) to their arsenal, I still hear from colleagues who are experiencing pushback. It’s frustrating.

Esthetics

One of the biggest excuses dental professionals find to not use SDF is esthetic concerns. They assume patients will be opposed to the black color on their teeth and say, therefore, “We are not going to use it at our office.” But how do you know what patients really think unless you examine your own biases and ask your patients?

A 2017 survey of 120 parents asked if the brown or black staining on their child’s teeth from SDF would be acceptable. 67.5% of parents were comfortable with SDF staining on the posterior teeth, but there was a much lower acceptance of staining on anterior teeth at 29.7%.¹ Parents of children with behavioral issues were much more likely to choose SDF than those without.¹ But if parents had only two options—SDF or general anesthesia (GA)—the acceptance rates for posterior application increased by 1% and doubled to 60.3% for anterior teeth.¹

In another study, researchers surveyed caregivers (the majority were parents) regarding satisfaction with SDF while waiting to have GA.² Caregivers were overwhelmingly satisfied regardless of SDF’s dark color. In the past while waiting for GA, the quality of life for young patients decreased, but caregivers surveyed in the study found that kids had a better quality of life when SDF was used.² Researchers found that 87.5% of caregivers were not bothered by the black stains, and 91.7% of the kids were not concerned.²

As practitioners, we need to offer all possible treatment options and let our patients make an informed decision on how to proceed. Even though SDF is becoming a mainstay in some dental practices, there is still the assumption that patients will not want it.

I recently met a mother who has been bringing her three-year-old biannually to see us for SDF application on his anterior teeth. She has been taking her son to see a pediatric dentist, but they do not do SDF at that practice because they assume parents will be opposed to it. This mom’s only other option was GA, which she wanted to avoid if possible. The mother had heard about SDF and asked where she could get it done and was subsequently referred to us.

The child’s caries lesions are arrested and for now there is no concern by parent or child about SDF staining. Later, when esthetics might be of concern, glass ionomer cement restorations can be used to cover the black scars. I saw the application of SDF on this little one, and he was so comfortable in the chair, opened wide, and was cooperative. Having growing patients who love to come to the dental office is just as important as treating their dental disease. The mother is happy and grateful. Assuming patients will reject SDF can prevent them from getting necessary treatment. It is important to share the pros and cons of using SDF and offer informed consent.

Not my patient population

Many hygienists are frustrated that their dentist will not purchase and use SDF in the practice because they do not have pediatric patients. Maybe this is because early studies about SDF were done mostly on primary teeth. However, this is shortsighted as SDF can be used in many preventive circumstances as well as for arresting caries throughout many populations, not just children.

Further, SDF can be used on any adult, not just for patients in long-term care facilities. SDF is great for root caries since roots are more susceptible to decay and filling them can be frustrating for dentists due to their location. More than likely, the fillings are lost once filled.³

SDF is not just for people who cannot afford traditional dental care; it can be used when there are wait times for definitive dental treatment, for special needs patients, and for those who cannot tolerate traditional treatments. It can be used for cancer patients as well. Read my article on silver diamine for cancer patients for more about this. SDF is great for dry mouth resulting from polypharmacy, Sjögren’s syndrome, diabetes, and any issues caused by hyposalivation.

What we learn in school does not always span time. We need to stay up-to-date with new technologies and evidence-based research. Dentists would still be drilling with old belt-driven, slow-speed handpieces if they hadn’t adapted to novel paradigms. If you remember these, you know you wouldn’t want to go back.

There are so many uses for SDF for patient populations: leaking fillings, crown margins, and those “watch spots” for high-risk caries.

The costs

Some dentists are concerned about losing money if they incorporate SDF. But SDF is cheap, easy, and quick to apply. The materials needed to treat five lesions cost about the same as one fluoride varnish application.

In most states, hygienists can apply SDF, and in some states, dental assistants can too. Allowing hygienists and assistants to work at the scope of their practice not only benefits them, but it increases production and frees up the dentist to perform more lucrative procedures. With the new preventive code, there are even more ways to incorporate SDF into treatment, increasing revenue and improving patient health outcomes.

But what are the actual costs of using SDF, or better yet, what are the costs of not offering it? Some might argue that if SDF is used, the dentist will lose money from not doing fillings. SDF can be used solely or as a stopgap until future definitive work is completed, so there’s no loss to the dentist. SDF might be all some patients need, but they may also require a SMART filling (silver modified atraumatic restorative treatment) with a glass ionomer cement filling after the SDF is placed.

SDF can be a practice-builder as it reduces pain from hypersensitivity, is painless for the patient, and is quick and easy to apply. Fearful patients will be more likely to come back for subsequent appointments and refer their friends and family. Patients will save money, and who doesn’t love that?

What about GA and sedation for dental work for kids? One study found costs for GA to range from $7,300 to more than $13,331 for one case.⁴ Can you imagine if 50% or more of these cases could be eliminated by using SDF? It has been done.

What about the nonmonetary costs to children who undergo sedation or GA? These modalities have their place, but if their incidences can be decreased, so can possible poor health outcomes for children, such as behavioral and physical health, learning disabilities, mental health, and even death.

Two retrospective studies in 2009 compared children who had nondental surgeries to same-aged children who did not have surgeries. In the first study, Sandra Juul, MD, PhD, stated that “Children who underwent surgery were twice as likely as controls to receive diagnoses of developmental or behavioral disorder.”⁵ The second study found that when more than two types of general anesthetics were used, the risk of having learning disabilities increased.⁵

In one retrospective study, researchers compared medical and school records of 1,000 kids who had GA before age three to those who had no GA exposure during the period 1996–2000.⁵ Researchers found that kids who had more than one GA experience ended up having more issues with learning, cognition, and success in school as well as an increase in attention deficit hyperactivity disorder.⁶

Ethics

Dental hygienists have shared with me that the reason their employer is not using SDF is because they feel it is unethical. I’m not sure why they feel this way; maybe they think it isn’t practicing dentistry as the gold standard—e.g., using anesthetic and treating decay with a filling or crown (i.e., what they learned in dental school). Actually, not giving patients all options is more unethical.

According to Lee et al., traditional dental treatment for early childhood caries frequently necessitates the use of sedation or GA, which increases costs and leads to potential poor outcomes.⁷ In another study, researchers looked at kids who had GA for dental treatment, and found that 54.2% had recurrent caries at their six-month recall.⁸ Even when kids have GA and dental treatment, we have not addressed the disease, which is why recurrent caries occurs so often.

Because of the downsides of GA, in 2016, the American Academy of Pediatric Dentistry (AAPD) created a policy statement regarding the need for prevention and arrest of disease.⁷ In the statement, the AAPD encourages the use of minimally invasive dentistry that emphasizes nonsurgical treatments when at all possible, thus reducing the need for sedation and GA.⁷

Time for change

So, how do you use this information to get your dentist on board with using SDF? When you first discuss your ideas with the dentist, highlight how adding this new treatment will benefit the dentist, practice, and patients.

Anytime you want your employer to adopt something new, have the team member who is most comfortable communicating with him or her be the spokesperson; this should be someone the dentist trusts. You may decide to talk with other team members first to get their support and then take your idea to the dentist.

For some, the team meeting will be the ideal place to broach the subject. You might explain that SDF can be placed during the hygiene visit or an assistant can apply it in another treatment room, increasing revenue. Unless there is a shortage of team members, this will free up the dentist to do other high-end treatments. Be sure to explain how using SDF is a practice-builder if your dentist worries about revenue.

Try to anticipate any objections from your employer and make sure you are ready to take on the task. Empathize with the dentist when needed and let them know you will take responsibility for making the change happen. This could involve ordering the supplies and starting with one easy application—a sensitive root surface, for example.

Change can be frightening. Maybe your dentist tried using SDF once and thought it didn’t work so they gave up on it. Remember, with SDF, there is not 100% caries arrest; it can take time to see the benefits. Be prepared to share high-quality evidence-based information via systematic reviews, studies, and webinars. Find other dentists who have realized the benefits of SDF and connect them with your dentist. If one dentist is using it, others are more likely to adopt it into their practices.

The great scholar and communication theorist/sociologist Everett Rogers said regarding change: “Every change requires effort, and the decision to make that effort is a social process.”⁹ He also said that mass media can spread ideas, but adoption occurs because “...people follow the lead of other people they know and trust when they decide whether to take it up.”⁹

I hope you can find a way to step into your awesomeness and approach your dentist when you feel strongly about adopting new technologies and treatments. Remember, a “no” is not really a no; it just means you may need to find a different approach at a different time. The time is right for dental hygienists to demonstrate to the world that they are educated health-care providers who know how to decipher evidence-based information and make informed decisions that will benefit our profession and patients.

Editor's note: This article originally appeared in the January 2022 print edition of RDH.

References

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.e4. doi:10.1016/j.adaj.2017.03.013
Cernigliaro D, Kumar A, Northridge ME, et al. Caregiver satisfaction with interim silver diamine fluoride applications for their children with caries prior to operating room treatment or sedation. J Public Health Dent. 2019;79(4):286-291. doi:10.1111/jphd.12338
Rigert J, ed. 2020. Root caries: a guide for patients. University of Michigan. Updated October 25, 2020. http://www.med.umich.edu/1libr/Dentistry/RootCaries-Patient%20Guide.pdf
Warren JJ, Thrap S, Starr D. Dental caries treatment completed under general anesthesia among American Indian children in a northern plains tribal community. J Public Health Dent. 2020;80(3):254-256. doi:10.1111/jphd.12369
Juul S. A new look at general anesthesia and the developing brain. NEJM Journal Watch. May 4, 2011. https://www.jwatch.org/pa201105040000001/2011/05/04/new-look-general-anesthesia-and-developing-brain
Hu D, Flick RP, Zaccariello MJ, et al. Association between exposure of young children to procedures requiring general anesthesia and learning and behavioral outcomes in a population-based birth cohort. Anesthesiol. 2017;127(2):227-240. doi:10.1097/ALN.0000000000001735
Lee H, Milgrom P, Huebner CE, et al. Ethics rounds: death after pediatric dental anesthesia: an avoidable tragedy? Pediatr. 2017;140(6):e20172370. doi:10.1542/peds.2017-2370
Lin YT, Kalhan AC, Lin YTJ, et al. Risk assessment models to predict caries recurrence after oral rehabilitation under general anaesthesia: a pilot study. Int Dent J. 2018;68(6):378-385. doi:10.1111/idj.12396
Gawande A. Slow ideas. Some innovations spread fast. How do you speed the ones that don’t? The New Yorker. July 22, 2013. https://www.newyorker.com/magazine/2013/07/29/slow-ideas