Not regularly using silver fluoride diamine? Here’s why you should be

Hygienists pride themselves on preventing disease and providing consistent oral care education. When you think about tooth decay prevention, I challenge you to think about what we can do differently and better in dentistry. The statistics on dental caries in pediatric patients are alarming. 50% of patients aged 6-8 are affected by caries in their primary teeth and 50% of children aged 12-19 are affected by caries in their permanent teeth.¹ Children aged 5-19 from low-income families are twice as likely to develop tooth decay in their young lives.²

Early childhood caries is still the number one childhood disease in the world. In 2022, the US Department of Health and Human Services reported that more than 51 million school hours are lost each year due to dental problems.¹ We have to do better. Of the adult patients we treat, a third report hypersensitivity and a quarter are likely to have untreated dental caries. Fifty percent of the elderly suffer from tooth decay.³

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Reasons to add SDF

The FDA approved silver diamine fluoride (SDF) for dental hypersensitivity in 2014. More than half of the offices for which I have consulted and worked have purchased SDF, but the percentage of patients who benefit from SDF is less than 1%. SDF is used first to stop caries, second to prevent caries and last to reduce dental hypersensitivity. It is a powerful tool to have in our everyday arsenal.

There are many reasons to add SDF to your daily routine:

• Silver destroys bacterial cells and stops cell synthesis.
• SDF has a fluoride concentration of 44,800 ppm. This is double what is in the polish.
• Fluoride creates fluorapatite, which is vital for remineralization.
• Fluoride is bacteriostatic.⁴

There are many benefits to using SDF to:

• Those at moderate to high risk of tooth decay
• Those with behavioral or medical problems
• Patients without access to appropriate dental care
• Young children awaiting hospital treatment
• Non-invasive treatment for teeth close to exfoliation
• Dental hypersensitivity
• Biofilm control
• Crack protection
• Treatment of root caries
• Patients with caries that cannot all be treated in one visit⁴

The latest research supports the use of SDF, which is 89% more effective at controlling/preventing tooth decay than other treatments or placebos.⁴ Annually, 38% of SDF applications to exposed root surfaces in older adults is a simple, inexpensive, and effective way to prevent caries initiation and progression.⁴ When we talk about minimally invasive procedures like SDF, the goal is to present the clinically acceptable options and provide education so that the parent or patient can make the best decision for them.

More reasons to support SDF usage

When SDF was applied only to carious lesions, impressive prevention was observed for other tooth surfaces. In both children and the elderly, an annual application of SDF prevented many more caries than four times a year application of fluoride varnish.⁴ SDF has been shown to prevent initial lesions from needing restorative treatment.⁵ This begs the question – why aren’t dental practices treating initial lesions with SDF?

Clinicians assume that parents will reject SDF for their children due to poor aesthetics. But if that means a child doesn’t have to be drugged or have their teeth drilled and filled, many parents I am doing select SDF. The survey shows that more than 90% of clinicians in a dental residency program believe that parental acceptance of SDF in a pediatric setting is a concern, when in fact they found that less than 7% of parents are concerned about staining.⁶

When submitting insurance, the CDT code to be used is D1354 and applies to treatment per tooth, not per application. The frequency of application depends on the risk factors and the size of the damage. If you are treating an incipient lesion, reapplying can be done in six months. If the damage is in the dentin, you can reapply in two to four weeks.

In offices that have SDF on hand but are not using it to their full potential, the opportunity for preventive care is inferior. Clinicians worry about stained teeth, benches and dental equipment and are nervous about implementing new protocols. Intact tooth structure does not stain.²

Research supports many patient situations where SDF is the best solution.

Examples of practical use of SDF

• A 90-year-old man presents with recurrent oral decay at number 19 around the existing porcelain-to-metal fused crown. He has a complex medical history and a high plaque index. Apply SDF to arrest the damage and maintain the life of the rim.
• Multiple mesoproximal lesions are present on bitewing examination of an uncooperative 4-year-old patient. Use SDF to stop decay until the patient can complete definitive restoration work.
• Occlusion at number 30 is present in a healthy 20-year-old patient. Rehabilitation programs have been closed for three months. Use SDF to stop decay to keep the restoration conservative.
• SDF has become a standard of care in minimally invasive procedures. Its use can control the biofilm, stop the progression and remineralize the damage first. You can then restore the teeth as time, resources and money allow.⁵ When we think about reinventing and improving our standard of care in caries prevention strategies, think about what we can do differently and what we can do better.

Editor’s note: This article appeared in its November-December 2023 print edition RDH magazine. Dental hygienists in North America are eligible for a free print subscription. Register here.

bibliographical references

1. Oral health surveillance report, 2019. Centers for Disease Control and Prevention. The page was last evaluated on December 9, 2021.
2. Dye BA, Xianfen L, Beltrán-Aguilar ED. Selected indicators of oral health in the United States 2005–2008. NCHS Data Summary. 2012? 96 (5): 1-8.
3. Chan AKY, Tamrakar M, Jiang CM, Lo ECM, Leung KCM, Chu CH. A systematic review of the dental caries status of the elderly. Int J Environ Res Public Health. 2021? 18(20):10662. doi:10.3390/ijerph182010662
4. Horst JA, Ellinikiotis H, Milgrom PL. UCSF protocol for caries arrest using silver diamine fluoride: rationale, indications, and consent. J Calif Dent Assoc. 2016? 44 (1): 16-28. PMID: 26897901
5. Braga MM, Mendes FM, De Benedetto MS, Imparato JC. Effect of silver diamine fluoride on incipient caries lesions in emerging permanent first molars: a pilot study. J Dent Child (Chic). 2009? 76 (1): 28-33. PMID: 19341576
6. 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

Brooke Ackerman, MSDH, is an expert in the dental field, an advocate for successful dental practices and high quality, comprehensive patient care. She is a clinical dental hygienist and holds a master’s degree in dental hygiene with a focus in management through the University of Minnesota Carlson School of Business. Brooke is also a practice management consultant at Advanced Practice Management. She can be reached at (952) 921-3360 or through advancedpracticemanagement.com.