Advocacy for Silver Diamine Fluoride; A Paradigm Shift in Treating Caries
Silver diamine fluoride is a trending topic in dentistry today, and Dr. Jeanette MacLean, a pediatric dentist from Arizona, is making it her mission to help spread the word to
patients and other dentists. Frustrated by the continued epidemic of caries (the number one most common chronic disease of childhood), and concerned with the costs and risks associated with the increasing use of sedation and general anesthesia in pediatric dentistry, she questioned what she could do differently and better. This desire to better serve her patients led her to silver diamine fluoride (SDF), a topical anti-microbial capable of arresting 80-90% of carious lesions with little more than a microbrush. SDF is unique in that it targets the biofilms contributing to cavities, unlike the traditional surgical approach of dentistry (fillings and crowns), which, although sometimes necessary, merely treat the symptoms of the disease.
A solution since the 1800s?
After first hearing about SDF in an online dental magazine in 2014, Dr. MacLean was shocked to discover that using silver to treat caries was not a new concept in dentistry. In fact, the Father of Modern Dentistry, GV Black, wrote about using silver nitrate to treat caries in children in the late 1800s and early 1900s. Silver nitrate was so popular in the 1920s that it became known as “Howe’s Solution” (after Percy Howe, ADA President 1928-1929). Silver nitrate (SN) was effective for arresting caries, however it was flawed in that it weakened tooth structure by leaching calcium and phosphate. In the 1950s, using silver to treat caries seemingly vanished from U.S. dentistry. The demise of silver treatment coincides with the rise in popularity of fluoride (added to toothpastes and drinking water) along with improved dental anesthesia.
Meanwhile in Japan…
Professor Emeritus Mizuho Nishino developed silver diamine fluoride as her PhD thesis from 1965-1969 in Japan. It was approved in 1970 and sold as Saforide, which is still used today. SDF is an improvement on SN with the synergy of silver’s antimicrobial properties and fluoride’s remineralizing effect, according to Dr. MacLean. While caries arrest is considered an “off label” use for SDF in the U.S. (much like the U.S. off-label use of fluoride varnish), it has been used in other countries such as Japan, China, and Australia to arrest caries for decades, according to US National Library of Medicine National Institutes of Health,
What does the FDA have to say?
There are 12 randomized control trials with more than 4,000 participants which demonstrate its efficacy. Many dentists “in the know” would actually smuggle in Saforide or Riva Star (SDF in Australia) into the United States. In 2014 the FDA cleared SDF for the treatment of dentinal hypersensitivity in the U.S., according to US National Library of Medicine National Institutes of Health. In 2015 Advantage Arrest Silver Diamine Fluoride 38% became the first and only commercially available SDF in the US, distributed by Elevate Oral Care. In October of 2016, the FDA granted Advantage Arrest Silver Diamine Fluoride 38% the Breakthrough Therapy Designation for caries arrest, making it the first and only oral medicine to ever receive this prestigious recognition.
Why an early adopter?
As an early adopter of Advantage Arrest SDF, Dr. MacLean saw firsthand with her patients just how effective this new (old) option for treating caries was. Quick, painless, and effective treatments like SDF and SMART (Silver Modified Atraumatic Restorative Treatment) have allowed Dr. MacLean to dramatically reduce the number of minimal oral conscious sedation cases she does in her pediatric practice, and completely eliminate the use of in-office deep IV sedation. SDF truly satisfies the triple aim of healthcare by improving patient’s health, improving the patient’s experience, and reducing cost.
The increased use of SDF will greatly benefit an over-burdened public health system, says Dr. MacLean. Further, she notes that SDF has the potential to increase access to care since multiple quadrants can be treated in one appointment, often the same day as the exam. Using SDF as a first line of defense in the treatment of caries represents a paradigm shift from a primarily surgical approach (“drill and fill”) to a minimally invasive approach (arrest and remineralize), otherwise known as the medical management of caries (MMC), she said.
Thrilled with the many benefits SDF afforded her, Dr. MacLean set out to help raise awareness amongst other dentists and patients. On July 11, 2016, she was featured in the New York Times article entitled A Cavity-Fighting Liquid Lets Kids Avoid Dentists’ Drills, which triggered a huge surge in interest in SDF. Her office was flooded with calls and emails from dental professionals and patients from around the world. Dr. MacLean has even had parents drive or fly their children from out of state to see her for SDF and SMART treatment in an effort to avoid or delay traditional restorative treatment under general anesthesia for their young children.
Her efforts have not been without criticism. In fact, the response by many dentists to the Times article inspired Dr. MacLean to write The Top 5 Misconceptions About Silver Diamine Fluoride, which was published in the August 2017 issue of Dentaltown magazine. Most negative connotations for SDF stem from a general lack of knowledge on the topic since SDF was not part of the vast majority of practicing dentist’s education.
The demand for information has been overwhelming, according to Dr. MacLean, inspiring her to provide independent consulting, continuing education courses and lectures, YouTube instructional videos, articles, blogs, website content, as well as sharing her clinical cases and photos in online dental forums on this popular topic. She hopes that her efforts will help inform more patients that this option exists and to increase adoption amongst other dental professionals.
Read more about silver diamine fluoride
- Affiliated Children’s Dental Specialists www.kidsteethandbraces.com
- Dr. Jeanette MacLean Top 5 Misconceptions About Silver Diamine Fluoride http://www.dentaltown.com/magazine/articles/6538/continuing-education-top-5-misconceptions-about-silver-diamine-fluoride
- Catherine Saint Louis A Cavity Fighting Liquid Lets Kids Avoid Dentists’ Drills https://www.nytimes.com/2016/07/12/health/silver-diamine-fluoride-dentist-cavities.html
- Dr. Jeremy Horst, UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications, and Consent
- Dr. Steven Duffin, www.mmclibrary.com
Credit where credit is due
Dr. MacLean would like to acknowledge her friends and mentors, Dr. Harris Contos, Dr. Steven Duffin, Dr. John Frachella, Dr. Jason Hirsch, Dr. Jeremy Horst, Dr. Martin MacIntyre, and Dr. Douglas Young, for their invaluable support and collaborative discussion on the clinical uses and scientific evidence for SDF.
Get to know Dr. Jeanette MacLean
Dr. Jeanette MacLean is a Diplomate of the American Board of Pediatric Dentistry, Fellow of the American Academy of Pediatric Dentistry, private practice owner, and mother of two. Dr. MacLean has become a nationally recognized advocate and expert on silver diamine fluoride therapy, appearing in newspapers, magazines, television, and continuing education lectures on this hot topic. Most notably, she was featured in the New York Times article A Cavity-Fighting Liquid Lets Kids Avoid Dentists’ Drills, which brought national attention to the option of treating cavities non-invasively with silver diamine fluoride. Visit Kidsteethandbraces.com for more information.