What is Silver Diamine Fluoride?
Silver Diamine Fluoride, commonly referred to as SDF, is a topical medicament that can be applied to teeth in order to treat dental cavities for patients of all ages. For the first time ever, SDF effectively allows dentists to treat cavities in a way that avoids any numbing or drilling. Until now, there has been no other intervention or treatment strategy that has been so effective in eliminating cavities other than traditional fillings, which involves numbing and drilling.
History of SDF
While used in Japan for over 80 years, the Food and Drug Administration (FDA) just recently cleared SDF for use in the United States in 2015. Its FDA approval is actually for treating sensitive teeth, but SDF’s recent gain in popularity stems from an alternative use to treat cavities.
Prior to the approval of SDF, some practitioners were applying silver nitrate to teeth, in an effort to treat cavities noninvasively. However, this treatment approach was seldom reported in the dental literature, and therefore never gained much popularity and was rarely taught in dental schools. Alternatively, many dentists relied on increased fluoride exposure (from fluoridated water to prescription pastes, rinses, and tablets) to help keep enamel hard and resist breakdown from cavity-causing bacteria, but this treatment alone was not effective in treating cavities that had already formed.
Currently, Elevate Oral Care LLC is the only company who sells SDF in the US, naming the product “Advantage Arrest.” Originally the composition of SDF was a colorless liquid, but now Elevate Oral Care sells SDF with a blue tint to allow better visual assistance and improved accuracy when applying to teeth.
How Silver Diamine Fluoride works
It’s simple. The silver acts as an antimicrobial, killing the bacteria that comprise a cavity, and the fluoride acts to re-mineralize or harden weakened tooth structure that was subject to breakdown by the cavity-causing bacteria. For you chemistry geeks, SDF is actually a 38% solution made of about 25% silver and about 5.5% fluoride.
When cavities start, the bacteria first weakens and then breaks through the tooth’s outer enamel structure, usually resulting in a small hole in the enamel that can then allow the bacteria to travel deeper into the tooth. When silver is applied to the teeth, the action of bacterial breakdown is slowed or stopped as the silver binds to the bacteria, hence inactivating (or killing) the bacteria. At the same time, the fluoride incorporates back into the enamel, re-mineralizing, or re-hardening the tooth structure, and making it resistant to future breakdown.
Studies have shown that application of SDF to at-risk patients just once per year prevents more cavities than applying fluoride alone four times per year. Wow! Now isn’t that impressive!?
Who SDF is for
Infants and toddlers: Sometimes small children get cavities. Most frequently, these first cavities will appear on the top front teeth (the incisors). These cavities on the front teeth may develop along the gum line, in between the teeth, or on the back side (near the roof of the mouth). Unfortunately, many 1-3 year-olds have a difficult time sitting still for traditional fillings, and the thought of having to get them numb and using a fast moving drill makes us cringe. Even if parents are willing to hold their child’s hands if the kids get a little wiggly, doing esthetic white fillings on a moving toddler is immensely difficult for everyone involved.
SDF is a great treatment alternative for infants and toddlers, as it buys time. SDF can be applied to early cavities in an effort to stop the progression of decay. Once the patient is a bit older (and more cooperative), traditional white fillings can be completed to cover up the old cavities.
Children with baby teeth: Cavities on baby teeth generally start faster and grow faster compared to cavities on permanent teeth because of a thinner enamel layer. Whether cavities have developed on the biting surface of the tooth, or in between teeth, SDF can help stop cavities from getting bigger. SDF is a great option for parents who want an alternative treatment approach besides traditional fillings.
Kids and teenagers with permanent teeth: When cavities start on the outer enamel surface, dentists often refer to these itty-bitty cavities as “incipient lesions,” or “watches.” Incipient lesions can often be monitored over time if they stay within the outer shell of enamel and don’t cause a hole (aka cavity) in the enamel. Historically, fluoride has been the primary agent in slowing down incipient cavities, but now with the arrival of SDF, incipient lesions on permanent teeth can be treated more strategically, with delaying (and sometimes even completely avoiding) having to drill teeth to place traditional fillings.
While SDF can be applied to any tooth in the mouth, studies have shown that SDF works best on smooth or flat surfaces of teeth. If SDF is applied to grooves of the teeth (think the biting surface), some of the cavity may stop growing, but probably not to the same extent if the same cavity were on a smooth surface of the tooth (think in between the teeth).
Limitations of Silver Diamine Fluoride
We think SDF is pretty amazing, but there are a few drawbacks to its use. While it only takes approximately 60 seconds to apply SDF, regular reapplication is essential. Therefore, families must return approximately every 3 months for reapplication to see the greatest benefit.
When the silver binds to the bacteria of the cavity, the silver turns a dark gray or black color, permanently staining the tooth or leaving a “scar.” Luckily, healthy enamel is not affected by the SDF and will remain white. Only the cavity portion of the tooth will change color. When SDF is applied to cavities in between the teeth, the black staining is virtually invisible. However, when applied to cavities on the top front teeth in small children, the staining can be an esthetic concern for some parents. In many instances though, white fillings can be placed over the top of the SDF-stained tooth structure once patients are cooperative enough to withstand longer appointment times.
While SDF permanently stains cavities, it can also stain clothes and other surfaces. If accidently exposed to the skin or lips, SDF can leave a temporary light gray stain, similar to a henna tattoo, which will eventually fade within 2-14 days.
SDF cannot be used in patients with a silver allergy and is not recommended for patients with open sores on the inside of their mouth (like canker sores).
How SDF is Applied
Because SDF can stain clothes and other surfaces, it’s important that the patient is properly draped with a bib or napkin. To avoid any accidental exposure of SDF to the lips or cheeks, your dentist will usually apply a thin layer of Vaseline, which will help prevent unwanted staining. When applying SDF to the teeth, it is important to remove most of the saliva from the mouth using a saliva ejector (the suction straw thing), or wiping away excess saliva with a gauze. The amount of absorption of SDF into the cavity is highest if the tooth is dried first with a steady air stream. Next, your dentist will use a small plastic brush with a cotton end (called a micro brush) to dab the SDF onto the tooth. SDF only needs to be applied to the cavity portion of the tooth.
Healthy enamel does not need to be painted using the micro brush. Your dentist will want to allow the SDF to be absorbed into the tooth for about one minute. To prevent saliva from getting onto the tooth while the SDF is soaking in, the tooth is often isolated by soft cotton rolls, which can absorb excess spit. Some dentists may apply a steady air stream to the teeth if comfortable for the patient during this one minute absorption period.
If applying SDF to cavities that are in between the teeth, your dentist will probably use some sort of thick floss. Once the floss is in between the teeth, the SDF is applied to the string of floss and will be absorbed onto the enamel.
While the taste of SDF can be bitter or sour, it is best to not rinse immediately with water, as this can dilute or wash away some of the SDF from the cavity surface. Many studies and clinical trials recommend no eating or drinking for 30-60 minutes following the application of SDF.
After SDF is applied to all the necessary teeth, your dentist may recommend applying a thin layer of clear fluoride varnish. This is the same varnish your child receives at his or her check up visits. This varnish helps lock in the SDF so it can be absorbed deeper into the cavity. Think of the varnish as a temporary “top coat,” similar to a top coat of clear nail polish, which helps protect the colored layer of polish that was applied below.
Support from the American Academy of Pediatric Dentistry (AAPD) and the American Dental Association (ADA)
In late 2017, the AAPD issued an evidence-based guideline, recommending the use of SDF by pediatric dentists to treat cavities and tooth decay in baby teeth. Countless research studies are now showing the true benefit of silver diamine fluoride as a way of treating cavities, rather than placing traditional fillings. Support from the AAPD helps legitimize this new treatment modality and will hopefully encourage more insurance companies to further back the use of SDF.
Cost And Insurance Coverage
Because SDF is still relatively new in the US, insurance companies are just catching on to its amazing benefits. With endorsements from the American Dental Association (ADA) and the American Academy of Pediatric Dentistry (AAPD), we hope to see an increase in coverage from major insurance companies soon.
However, if your insurance company does not yet cover the expense of SDF, the cost of SDF out of pocket is often less than what a co-pay would be for a filling on the same tooth. We also offer significant discounts when patients return for SDF re-application.
Alternatives to SDF
Brush, floss, and don’t eat too much sugar! Cavities are preventable, so these simple preventive procedures can stop decay from forming in the first place. These routine oral hygiene practices can also slow down the growth and progression of early cavities that are just beginning to form.
Once cavities become more sizable, fillings are often the next step. This is the most traditional treatment option, which includes numbing, drilling out the decayed portion of the tooth, and placing a definitive filling or restoration. Restorations can be either white composite, silver (amalgam), or stainless-steel crowns. While placing fillings requires more time and patient cooperation, they generally don’t require much follow-up, as fillings can be placed in just one appointment.
For patients with behavioral issues, SDF can easily be applied to active dental cavities to slow or potentially stop the progression of decay. In some cases, the application of SDF alone has been useful in treating cavities for patients who otherwise aren’t cooperative enough to sit through traditional filling appointments. If treatment is urgent, some patients may benefit from oral conscious sedation or general anesthesia. As there are often more risks associated with sedation procedures, our hope is to delay, if not fully avoid, sedation and general anesthesia.
We think SDF has been a major breakthrough in pediatric dentistry. Is has slowed down the progression of decay immensely and has enabled many patients to avoid numbing and drilling. If you’re interested in SDF for your child and want to find out more, call, text, or email us to schedule your next SDF appointment!