The minimally invasive approach
How SDF and biomimetic agents can treat carious lesions now—without drilling
Fred W. Michmershuizen
The use of minimally invasive treatments for caries and pre-carious lesions is improving the way dental professionals care for many types of patients. Traditionally, the standard of care has been immediate drilling of caries or, commonly, a "watch and wait" approach for trouble spots that might later turn into caries. But today, thanks to the availability of silver diamine fluoride (SDF), as well as products containing biomimetic agents, dental professionals can take proactive action now, without the need for a drill.1,2 This often means less discomfort and fear for patients, especially those who are young or vulnerable.3
Dental hygienists are among the greatest advocates for the minimally invasive approach when it comes to treating caries and incipient decay. Take Erin Haley-Hitz, RDH, BSDH, MS, FADHA, MAADH, for example. Haley-Hitz, a hygienist with 30 years of experience working in clinical practice who is also president of the American Dental Hygienists' Association (ADHA®), uses SDF every day.
"The research states that SDF is great for children, patients with special needs, and individuals in the older population, but I have found that it can be utilized on any patient of any age and in any socioeconomic situation," Haley-Hitz says. "It's not only for caries. It's also for prevention in places that could become caries, as well as for treatment of dental sensitivity."
The American Dental Association (ADA) states that while SDF has been cleared by the FDA to treat tooth sensitivity, it has also been identified as a low-cost, easy-to-apply treatment for arresting caries lesions.4 SDF has various drawbacks, including permanent dark staining where the decay was present, as well as the need to re-apply the treatment every six months.4 SDF can also cause burning and temporary staining of soft tissue, as well as clothing or anything else it touches, and it also has an ammonia-like odor and taste.3
For dental hygienists interested in learning more about SDF, the ADHA provides various resources, including a fact sheet5 developed in conjunction with the Association of State & Territorial Dental Directors (ASTDD) and state-by-state scope of practice guidelines6 developed in partnership with Elevate Oral Care, manufacturer of Advantage Arrest®, a product containing SDF that is available in both liquid and gel formulations. (SDF is also available from Centrix, under the brand name SilverSense SDF™, and from SDI, in its Riva Star line.)
Based on her own clinical experience, Haley-Hitz says SDF is especially useful for areas that look like they're going to be at risk for developing decay. For example, she tells of a case involving a 12-year-old patient with an erupting second permanent molar. The patient had a flap of tissue over the tooth and was having difficulty brushing. A sealant was not an option because she couldn't isolate the tooth and get it dry. When she placed SDF it arrested a spot of decay, causing a stain that looked like a piece of pepper stuck in the tooth. Months later, after the tooth fully erupted, the doctor was able to treat it with a small occlusal filling. "If we would have waited, that decay would have progressed probably a lot farther into the tooth," Haley-Hitz says. "The SDF treatment kept that tooth in his mouth and kept the treatment minimal. If the decay had entered the pulp, it could have done so much more damage."
For other young patients who require extensive restorative work, Haley-Hitz says, SDF can be a godsend because it can stop progression of decay, allowing time for a staged treatment plan to be implemented. Haley-Hitz cautions that SDF should not be used on any tooth that has progressed to the point of pulp involvement. "If there's any concern from the hygienist's perspective that a tooth is much more progressed, it's probably not the right place to put SDF because that tooth needs immediate attention," she says. She also advises against using SDF on front teeth, because of the staining. But even with the staining, there are occasions where using SDF on front teeth is warranted, such as with elderly patients in nursing homes who might be more concerned with tooth function than appearance.
Yet another success story: Haley-Hitz applies SDF treatment every year to one of her patients who wears a lower removable partial. "He has four teeth on his mandible, and we place SDF around those four teeth every year because he doesn't want to lose those teeth to decay," she says. "He pays out of pocket for that, but for him it's worth it because he can keep that partial."
Haley-Hitz, who hails from Nebraska, attributes her confidence in using SDF to time she spent working in a public health setting in Montana, alongside Crystal Spring, RDH, BSDH, LAP, FADHA. Spring is executive director of Smiles Across Montana, a non-profit mobile preventive and restorative dental program that brings access to exceptional dental care to underserved populations throughout the Treasure State.
"We use SDF all day, every day," Spring says. "We use it mainly on posterior teeth, in areas that would normally be a watch, to areas that are cavitated. We use SDF with glass ionomer cement (GIC) and have seen amazing results on teeth that would normally have had to be extracted, or the patient put under sedation, which I think we should avoid at all costs to protect developing brains and bodies."
Products such as Curodont™ Repair Fluoride Plus, a unique biomimetic product manufactured by the Swiss company vVARDIS, are also used frequently by Smiles Across Montana, Spring says. (Other products that can be used to treat incipient lesions include Icon Smooth Surface, available from DMG, and others.)
Adriana Forino, RDH, who has used Curodont Repair Fluoride Plus in clinical practice, says the product is recommended for all patients, but especially suited for pediatric patients, orthodontic patients who might develop white spot lesions around brackets, and special needs patients; however, this truly is an ideal product for all patients. Today, Forino works as an oral science liaison for vVARDIS (the company name is pronounced "va-vardis"). She says she was inspired to become a hygienist because of a traumatic dental visit she experienced as a child. What she likes the most about Curodont, she says, is its ability to take the fear away from dental treatment.
After being applied to a tooth, Forino explains, Curodont's proprietary formulation diffuses throughout the lesion to provide the remineralizing agent, fluoride, together with calcium and phosphate from the saliva to where it's needed most. Over time, the watch area is remineralized, enabling preservation of the natural tooth. There is no staining, no taste or odor, and the product typically only requires a one-time application; however, there are no contraindications to re-apply, she says. "I want hygienists to know that this is truly revolutionary technology, and if they want to be pioneers in preventive dentistry it's time to hop on board," Forino says.
"We use a lot of Curodont Repair Fluoride Plus in our program, which is also great for watch areas," Spring says. "It was a game changer for us and has allowed us to help patients we couldn't in the past. In addition, we are so excited that CariFree just gave our program over $20,000 of its Gel 1100 toothpaste that has nano-hydroxyapatite in it. We can't wait to see what this is going to do for our patients. The science is amazing." (Other products that foster remineralization include the MI Paste® line of pastes and toothpastes, available from GC America.)
Spring says that in her scope of practice, SDF and products with biomimetic agents can be used on anyone, including babies, adults, medically compromised patients, patients who are frightened, or those who are unable to understand or communicate and who would normally be put under sedation for treatment of any kind. The primary advantage of minimally invasive care, Spring says, is that tooth structure is not being removed. "If healing and remineralization can occur, I believe it is better to try this first," Spring says. "Why watch something until it is time to fill if you could do something to arrest or reverse the problem now?"
As is true in many other facets of medical and oral care, early intervention for caries and pre-carious lesions can make a big difference for patients. "Minimally invasive techniques are not used by everyone, and I guess that is how it has to be right now, but I think everyone should be given the choice," Spring says. "Our patients deserve to hear their options, not just the options we want them to hear." She points out that minimally invasive treatments can be administered by the dental team and not just the DDS in many states. "It can really increase production," Spring says.
"In my opinion any minimally invasive treatments, and there are quite a few on the market with others on the horizon, are especially useful because they allow us to intercede early," Haley-Hitz says. "And that aligns with what I like most about being a dental hygienist: the ability to prevent disease and get patients on a path to good oral health."
SDF Resources
For those who wish to learn more about SDF, the American Dental Hygienists' Association (ADHA) provides the following resources:
Silver Diamine Fluoride Fact Sheet
https://www.adha.org/wp-content/uploads/2024/01/SDF-Fact-Sheet_ASTDD_Updated-Oct_2023.pdf
Silver Diamine Fluoride - Scope of Practice by State
https://www.adha.org/wp-content/uploads/2022/11/Silver_Diamine_Fluoride_State_by_State_Information.pdf
SDF - Dry, Apply and Say Goodbye (podcast)
https://adhapodcast.libsyn.com/sdf-dry-apply-and-say-goodbye-ep-114
References
1. Seibert M, Burgess JO. Managing Caries With Silver Diamine Fluoride. Inside Dentistry. 2023;19(9):22-26.
2. Quock RL. Silver Diamine Fluoride: A Missing Link for Predictable Restorations. Compendium. 2024; 45(2). https://www.aegisdentalnetwork.com/cced/2024/02/silver-diamine-fluoride-a-missing-link-for-predictable-restorations. Accessed August 21, 2024.
3. Crystal YO, Niederman R. Evidence-Based Dentistry Update on Silver Diamine Fluoride. Dent Clin North Am. 2019 Jan;63(1):45-68.
4. Silver Diamine Fluoride. American Dental Association website. https://www.ada.org/resources/ada-library/oral-health-topics/silver-diamine-fluoride. Updated: September 19, 2023. Accessed August 21, 2024.
5. Silver Diamine Fluoride (SDF) Fact Sheet. American Dental Hygienists' Association website. https://www.adha.org/wp-content/uploads/2024/01/SDF-Fact-Sheet_ASTDD_Updated-Oct_2023.pdf. Updated October 2023. Accessed August 21, 2024.
6. State Specific Information on Silver Diamine Fluoride. American Dental Hygienists' Association website. https://www.adha.org/wp-content/uploads/2024/07/SDF-State-by-State-7-2024.pdf. Updated July 2024. Accessed August 21, 2024.
