My PEAK Presentation: Minimally Invasive Treatment

Janine Burkhardt, DMD, MPH, FAGD

In April of 2018, my PEAK presentation focused on minimally invasive treatment with silver diamine fluoride (SDF). During the COVID-19 pandemic where minimizing aerosols has been recommended, it seems to be a fitting time to revisit the presentation. Silver diamine fluoride (SDF) has long been a staple in my health center, even in a world where we performed aerosol-generating treatment without question.

In my presentation, I shared the case of a 9-year-old boy who started to develop interproximal incipient carious lesions. As interproximal lesions develop, we are faced with a decision.

As professionals, we can use our clinical judgment to determine when a handpiece is needed, but watching alone should never be an option. We know that by watching, we are just waiting for the lesion to grow. While taking out a handpiece and placing a restoration may certainly be acceptable to restore the tooth for someone with high caries risk, there will be little long term success without a change in hygiene and dietary habits. Over the span of this 9-year-old’s lifetime, the restoration will inevitably need to be replaced, and likely with a larger restoration each time. This “molar life cycle” image comes to mind. Whenever a tooth is prepared for a restorative treatment, the structural integrity of the remaining tooth is weakened.

In this case, I applied SDF interproximally and combined the treatment with oral hygiene instructions and nutritional counseling. The plan was to arrest the carious lesions, and by stopping them in their tracks, prevent the progression of the lesions into ones that would need a surgical intervention. While SDF is most easily applied to occlusal surfaces of teeth, it also has a role in management of interproximal caries.

To apply the SDF, I first protect the surrounding gingiva with Vaseline. Cotton rolls can also help to isolate the teeth. Once the tooth is isolated, superfloss should be used between the teeth with the interproximal lesions and pulled upwards into a U shape. With a microbrush, the SDF can be applied to the superfloss just above the contacts of the teeth and allowed to soak in for about a minute. By rinsing after with an air/water syringe, you can eliminate some of the metallic taste. The application of a fruity fluoride varnish immediately after can also help to mask some of the flavor. This is an easy in-office intervention that can help to prolong or eliminate the need for a restoration.