Stand Out in Your Community by Using Silver Diamine Fluoride

By Dr. Chris Griffin

It’s really hard for a general dentist to stand out these days. It seems that so many of us are doing implants, sedation, and orthodontics, but there is a way to position yourself that’s currently being overlooked.

Have you ever considered becoming a hero for the underserved? If not, you’re not alone. It took an eventful mission trip to Mexico for me to discover this myself. When I realized just how much the children of Guaymas needed simple solutions that could literally save them hours of pain and suffering, my next thought was, “I wonder how many kids in my hometown need the same thing?”

As it turns out, the answer was that a lot of them needed help. I’m sure you’ve noticed that there is a prevalence of caries in certain large populations. Studies show that about a third of kindergartners have tooth decay. While the causative factors can be debated, what is undeniable is that our efforts at prevention have so far fallen short of the goal.

One of the main reasons is that caries is not a single pathogen disease that can easily be cured by vaccines or antibiotics. It’s a biofilm disease.

Dr. Bruce Paster of the Forsyth Institute stated that there are 600 species of bacteria found in the mouth and less than half have been cultured. As such, caries presents problems that have made its eradication difficult to say the least.

Would you be surprised to find out that over 100 years ago two of the legends of dentistry had the epidemic of caries in their sights and made tremendous inroads to find that elusive cure? Drs. GV Black and Percy Howe were both proponents of the use of silver to treat caries by way of silver nitrate solution. They would paint the silver nitrate on cavities, usually primary teeth in young people, to arrest the decay. Dr. Black even published his protocol for this in his textbook that every dentist in America received as part of their education for decades.

Their success is well documented. What is not well documented is why the pursuit of silver as an agent in the fight against decay fell out of favor by the 1960s. Some say it was water fluoridation. Others point to the introduction of local anesthetic and the high speed handpiece. No one knows for sure, but for over 50 years very few dentists used silver in any form to fight against caries in America.

While we went to sleep in our pursuits, the Japanese picked up the ball and ran with it. Dr. Mizuho Nishino wrote “Studies on the Topical Application of Ammoniacal Silver Fluoride for the Arrest of Dental Caries” in 1969 and the product, Saforide Silver Diamine Fluoride, was introduced into their market. Amazingly, in over 40 years of use there, there have been virtually zero reported adverse outcomes.

All the time the Japanese people were benefitting from the availability SDF, the incidence of caries in the U.S. has steadily grown. Unfortunately, with that increase, we also see a higher incidence of children visiting operating rooms for conscious and general sedation to have needed dental work completed. Luckily for all of us, Dr. Steve Duffin was one dentist who just wouldn’t accept that this was normal. Undertaking what I would consider a Herculean research task, he unearthed the buried literature on silver use here in the states and began using it in his own Medicaid-heavy practice in Oregon.

His results were startling. He saw his own incidence of needed hospital cases drop from a high in 2008 of 25 cases, to zero only five years later. He credits the use of silver for that dramatic reduction. Not only did his hospital cases drop dramatically, he was able to help more children than ever receive minimally invasive treatment using his Medical Management of Caries model.

You may be wondering why silver is so effective. The antimicrobial effects of silver have been known for literally thousands of years. The Romans even used silver basins to clean water before using it. Now we know many of the cellular processes that make this possible. It is believed that silver enters into bacterial cells via transportation through the cell membrane using proteins that were meant to transport copper into the cell. Once inside, the silver ions act, as Dr. Jeremy Horst puts it, as a silver wrecking ball. It inactivates the bacteria by a multitude of disruptions that also can create apoptosis. Another reason it is so effective is that it penetrates the teeth. SDF will penetrate about 25 microns into enamel and a whopping 200–300 microns into dentin. This is thought to protect the teeth from future invasion as inactivated bacteria with silver ions inside demonstrate a unique mechanism that was coined the Zombie Effect by Emily Conover in 2015. These seemingly dead bacteria will reanimate and pass silver ions back to the invading active bacteria and those bacteria are inactivated at the same or even higher rates than were the original bacteria.

You might be wondering why you haven’t heard of this amazing wonder drug if all this is true. In 2015 only 25% of pediatric dental residencies were using SDF. That number is growing, but there is a generation of dentists out there who had little or no exposure to this in school. Until recently there was also no standard protocol for dentists to fall back on if they wanted to start using it. Lucky for us the American Academy of Pediatric Dentistry came out with the first ever evidence-based guidelines to treat cavities using Silver Diamine Fluoride in 2017.

So, how can you start using Silver Diamine Fluoride in your practice? The good news is that it is one of the simplest procedures I have ever implemented. First, I highly recommend doing a web search for the AAPD guidelines and printing off a copy. Read that thoroughly and follow their recommendations.

The procedure itself is strikingly simple. However, there are a few things to consider.

This treatment will turn caries black. There’s no getting around that. The silver precipitates and the color will not be what we currently consider esthetic. Considering the importance that Americans place on white teeth, this will bother some people. Informed consent that shows how the appearance of the teeth will change is of paramount importance. Even though a parent may understand that this simple procedure can prevent their child having to undergo anesthesia, there are those who will choose that over poor esthetics.

There are also detractors in our own profession that will point to the lack of income generated by offering this new procedure. While anyone would admit that you won’t get rich billing the code D1354, which is usually less than 20 dollars per tooth, let me offer a few benefits that are commonly overlooked.

This gives you an opportunity to stand out in your area as a kind of community hero for children who can’t help themselves. This lends itself to many outstanding opportunities for good public relations.

Also, most of your patients who need this will be children. Those kids aren’t driving themselves to your office. With a little encouragement, you should be able to convert both the children and the parents into your preventative programs in hygiene.

And a last big benefit you rarely treat just one tooth. Usually there are several teeth that can be treated in one appointment. Plus, after the decay is arrested, Silver Modified Atraumatic Restorative Treatment (SMART) can be accomplished by placing glass ionomer resins over the arrested decay. These are resins that you would normally never get the opportunity to treat.

This procedure and the dental codes for this are very new, so I encourage you to reach out to your state board, insurance companies, and government agencies for guidance as you get started.

The bottom line is this: Silver Diamine Fluoride is a powerful new weapon in the age-old fight against dental disease and every one of us should be informed enough to offer it when the time is right.

Dr. Chris Griffin is a solo, private practicing general dentist in Ripley, Mississippi. You can reach him with any questions at