Jeffrey Smith

December 15 2018
Intern Mentor
Periods 5 and 6

Research Paper
In 2013 Oregon’s Board of Dentistry voted on a measure that would allow dental

hygienists and assistants to apply silver nitrate while under the supervision of a dentist. During

the public hearing, dentists and board members discussed the practice of applying silver diamine

fluoride to arrest decay. Steven Timm, president-elect of the Oregon Dental Association, cited

the lack of research and serious health implications of ingestion. Supporters, like Steven Duffin,

reviewed the ancient history of silver nitrate in dentistry and its reduced cost. Even with its

history and proven effectiveness, the board voted against the measure. Vice president of the

board, Brandon Schwindt, claimed that silver nitrate was an excuse for dentists that failed to treat

children. If silver nitrate is an excuse, where do dentists fail to treat the patient? Treatment is not

guaranteed to prevent decay because caries risk differs from patient to patient. Dental caries is a

disease that results in the demineralization of tooth tissue. Fermenting food creates a low pH

environment that allows cariogenic bacteria, like streptococcus mutans, to thrive. Decay begins

as small white lesions on the surface of teeth, the decay will continue to develop and

demineralize the enamel. Once the bacteria has cavitated through the enamel, the decay will

spread to the dentin. The dentin is softer and less dense than enamel, so decay expands at a faster

rate until it reaches the nerve. Is it fair to consider the development of decay a failure? Strict

preventative plans can include sealants, fluoride varnishes, and prescription toothpaste or

mouthwash to stop decay before it cavitates through the enamel. Aggressive forms of cariogenic

bacteria can still persist in a high pH environment and demineralize tooth tissue. Silver nitrate

should not be viewed as an excuse, it is a treatment that kills cariogenic bacteria and prevents the
progression of decay. The U.S. Food and Drug Administration approved the use of silver

diamine fluoride (SDF) to treat hypersensitivity in 2014. In 2017, the FDA approved silver

diamine fluoride in a 38% Advantage Arrest formulation. Research supports silver nitrate’s

effectiveness at killing cariogenic bacteria and remineralizing weak enamel. Silver diamine

fluoride is an important treatment option due to its reduced cost, versatility when treating

patients that suffer from compromising medical conditions, and its effectiveness at limiting the

development of caries.

The traditional treatment to prevent the development of decay is sealing the at risk tooth.

Sealants are physical barriers applied to anatomic surface pits and fissures on the occlusal

surface of teeth (“Dental Sealants”). The acrylic resin used can last up to ten years before being

worn or chipped away. Sealants typically cost 30 to 40 dollars per tooth (Mool 3). Sealants are a

cost effective way to prevent the development of decay on sealed teeth, but they can only be

applied before the decay cavitates through the enamel. Once the decay passes the enamel and

begins demineralizing the dentin, the tooth needs to be filled. Fillings with a resin composite can

cost 135 to 240 dollars, depending on the number of surfaces the composite is applied to

(“Dental Fillings”). SDF’s cost is one of the reasons that it has become such a popular treatment

for decay. The cost of silver diamine fluoride varies from office to office, but it costs around 25

dollars per tooth (Louis 9). The low cost of SDF makes it the ideal treatment for patients of a

lower socioeconomic status. Caries risk is the likelihood that a patient will develop dental caries.

Caries risk is one of the main factors that dentists take into account when creating a treatment

plan. If a patient’s parents have a low socioeconomic status, the patient is immediately classified

as high caries risk. The higher caries risk can be credited to “earlier acquisition of oral cariogenic

bacteria, greater intake of dietary carbohydrates, exposure to environmental toxins, such as led
and tobacco smoke, differences in enamel calcification, lack of fluoridated water, and

inaccessibility of dental health care” (Boyce 4). A study conducted in the San Francisco Bay

Area found that half of the surveyed children had already developed dental caries by the age of

five and children in families of socioeconomic status had higher counts of cariogenic bacteria

(Boyce 25). Dentists have the ability to close the healthcare gap and reduce the abnormally high

rate of dental caries development with the use of SDF.

Fillings require the use of nitrous oxide and local anesthetic to make the patient more

comfortable during treatment. Not all patients are candidates for composite fillings because of

the use of nitrous oxide. Contraindications for nitrous oxide include emotional disturbances,

chronic obstructive pulmonary disease, and recent illness (“Use of Nitrous Oxide”). Even with

the precautions that dentists take to make the patient comfortable, the treatment can cause

anxiety. Unlike traditional fillings, SDF has a wide range of candidates and the appointments are

ideal for patients with severe anxiety or behavioral complications. Appointments are shorter and

less taxing on the patient. SDF is applied the same way that a fluoride varnish is applied, so

local anesthetic and nitrous oxide are not required. The versatility of SDF opens treatment up to

groups that tend to have high caries risk, like elderly patients. Systemic diseases, medical

complexity, physical frailty, and physiological barriers in the elderly population has put stress on

the U.S. oral health care system (Horst 1). The increased number of surfaces prone to decay and

reduced number of cavitated teeth being extracted further complicates oral health for elderly

patients. The connection between general health and oral health can be seen clearly in elderly

patients. SDF is a non-invasive treatment that applies to an under treated population. Lack of

mobility prevents many elderly patients from receiving traditional oral health care, but SDF

application by a licensed dental professional is more versatile. Conditions like Parkinson’s and
Dementia can pose compliance issues, so a treatment like SDF reduces the reliance on patient

compliance. The versatility of SDF makes it a valuable tool for patients with compromising

conditions. The cost and versatility of SDF have helped popularize it as a treatment for decay,

but its effectiveness is its most important attribute.

Fluoride remineralizes enamel and protects the tooth from harmful bacteria. Fluoride has

been proven to minimize the effects of cariogenic bacteria. Incorporating additional fluoride into

a patient’s treatment through toothpaste and risnes is a critical component of preventive

treatment. Even with fluoride’s effectiveness at preventing decay, cariogenic bacteria can still

survive in the mouth. Silver has antibacterial properties that have been utilized in medicine for

hundreds of years. Unlike other antibiotics, silver does not create any resistant strains of bacteria.

SDF works by killing the cariogenic bacteria on the tooth’s surface, remineralizing the weakened

enamel, and raising the pH of the mouth. A problem with traditional preventative treatment is

that the cariogenic bacteria has the potential to survive. By raising the pH of the mouth and

killing the cariogenic bacteria, the chance that decay-causing bacteria will return is reduced. SDF

does not permanently stop the development of decay in a patient's mouth cause dental caries is a

transmissible disease and it may be reintroduced. Single application of SDF will not have

permanent results, but reapplication will continue the remineralization of the tooth tissue. At

reapplication appointments, the dentist may deem additional treatment necessary because the

decay was not arrested to the desired level. SDF has a high success rate, but it is not 100 percent

(“Silver Diamine Fluoride”). On average the success rate of SDF is 70% (Zhi 4). Even with the

reduced cost and high success rate, some parents are hesitant to opt for fillings over SDF because

of its’ side effects. The main side effect of SDF is black and brown staining on areas of decay,
and the staining indicates that the bacteria is being killed. The staining cannot be brushed or

lightened by a teeth whitening product.

Ever since its introduction to the U.S. as a treatment for dental caries, silver diamine

fluoride has opened doors to underserved communities. Patients of a lower socioeconomic status

now have an option to treat decay that is within their financial means. Caretakers in nursing

homes have to worry less about the compliance of residents with dementia or parkinson’s.

Patients with emotional or behavioral complications can be considered candidates for treatment.

With a price tag ranging from 135 to 240 dollars per surface filled, fillings can be an

overwhelming burden for many patients to handle. In addition to the financial pressure, the

treatment has the potential to cause fear or anxiety. Instead of having a tooth filled, patients have

the option of choosing SDF. SDF caters to a wider patient population because of its versatility

and cost. The staining that accompanies treatment may not be aesthetically pleasing, but it is a

proven treatment that arrests decay by killing cariogenic bacteria and remineralizing the tooth

tissue. Oregon dentist Brandon Schwindt claimed that silver nitrate does not kill bacteria or stop

cavities, but in the years since his testimony, SDF has become one of the most important

treatments for high risk communities.

Bibliography

Boyce, W. Thomas, et al. “Social Inequalities in Childhood Dental Caries: The Convergent
Roles
of Stress, Bacteria and Disadvantage.” Social Science & Medicine (1982), U.S. National
Library of Medicine, Nov. 2010, www.ncbi.nlm.nih.gov/pmc/articles/PMC2954891/.
“Dental Fillings | Evaluate the Procedure & Costs.” Your Dentistry Guide, 2013,
www.yourdentistryguide.com/fillings/.

Dental Sealants. American Dental Association, 19 Oct. 2016,

www.ada.org/en/member-center/oral-health-topics/dental-sealants.

Horst, Jeremy A. “Silver Diamine Fluoride Use in Older Adults.” Decisions in Dentistry, 1 Aug.
2016, decisionsindentistry.com/article/silver-diamine-fluoride-use-older-adults/.

Louis, Catherine Saint. “A Cavity-Fighting Liquid Lets Kids Avoid Dentists' Drills.” The New
York Times, The New York Times, 11 July 2016,
www.nytimes.com/2016/07/12/health/silver-diamine-fluoride-dentist-cavities.html.

Mool, Tricia. “Is the Cost of Dental Sealants Worth It?” Colgate® Oral Care, 2018,
www.colgate.com/en-us/oral-health/cosmetic-dentistry/bonding/is-the-cost-of-dental-seal
Ant-worth-it-0316.

Silver Diamine Fluoride. California Dental Association, 2017,

www.cda.org/Portals/0/pdfs/fact_sheets/silver_diamine_fluoride_english.pdf.

Use of Nitrous Oxide for Pediatric Dental Patients. American Academy of Pediatric Dentistry,
2013, www.aapd.org/media/Policies_Guidelines/BP_UseofNitrous.pdf.

Zhi, Quing Hui. Randomized Clinical Trial on Effectiveness of Silver Diamine Fluoride and
Glass Ionomer in Arresting Dentine Caries in Preschool Children. Journal of Dentistry,
Nov. 2012, www.sciencedirect.com/science/article/pii/S0300571212002060.