TUCSON — Five-year-old Ivanna Chavez has a cavity and she is terrified.
The small, bespectacled girl shrinks behind her mother as they walk into the El Rio Community Health Center exam room, where pediatric dental resident Dr. Aaron Duffy is waiting, holding what looks like a tiny, doll-sized paintbrush.
In less than the five minutes it takes for Duffy to tell Ivanna to “sit still like a statue” and to recount his favorite characters from the Disney movie “Moana,” he has painted a drop of a solution called silver diamine fluoride onto Ivanna’s cavity, which is on one of her bottom teeth. Then it’s time for Ivanna to get princess stickers and go home.
The children’s dental clinic at El Rio is using the brush-on liquid silver diamine fluoride — SDF — nearly every day now, and other local dental providers are beginning to use it, too.
Dentists say SDF has the potential to help not only children, but people with special needs, including medically fragile people who cannot tolerate anesthesia, and older adults with dementia who may be frightened by a drill.
The Tohono O’odham Nation’s reservation southwest of Tucson has four dental clinics that started using SDF for children in November. In April, the Southern Arizona Oral Health Coalition held a training for SDF that drew 74 providers from across the state.
Arizona’s Medicaid program began reimbursing dentists for SDF treatments last year, and as a result, more are beginning to use it, said Kevin Earle, executive director of the Arizona Dental Association.
“Basically it works like an antibiotic on tooth decay. I think it is becoming more common and it is saving a lot of money,” Earle said. “It will help to eliminate the prospects of kids having rampant decay in their mouths that would necessitate the use of sedation or anesthesia.”
In October 2017 the American Academy of Pediatric Dentistry issued the first evidence-based guideline on SDF, recommending its use on active cavities in pediatric and special needs patients, “likely leading to broader adoption of the treatment.”
At that time, academy president Dr. James Nickman said that aside from fluoridated water, silver diamine fluoride, “may be the single greatest innovation in pediatric dental care in the last century…Given its minimal cost and easy, painless application, it could help close the gap in healthcare disparities.”
The SDF liquid kills bacteria, makes the tooth harder, prevents further decay, and allows children like Ivanna to avoid needles, drills, sedation and extended time in the dental chair.
“There’s no way I’d put a drill in her mouth,” Duffy says of Ivanna.
The SDF does have a major aesthetic downside — it turns the treated cavity area black. Yet the treatment is nonetheless being touted by many as a game-changer in dentistry, as the health benefits of a cheap, easy-to-apply paint-on liquid far outweigh a toothache or progressing dental infection, many providers say.
Dental providers say the black color is an indicator that the silver is reacting with the bacteria and the liquid is working. The liquid does not stain any healthy areas treated with SDF.
When bacteria killed by silver ions are added to living bacteria, the silver is re-activated, so that effectively the dead bacteria kill the living bacteria. It’s what some dental providers have nicknamed a “zombie effect” — with the dead zombie bacteria acting as avengers of future decay.
An inexpensive follow-up treatment called glass ionomer can somewhat minimize the dark color with a tooth-colored covering, though it turns more gray than white at the edges and is far from perfect.
Still, SDF is part of what dental providers say is a shift in oral health care from “drill and fill” to medical management of dental disease.
“I know a number of people adamantly afraid of going to the dentist. This gives them hope for having a healthy mouth,” said Alicia Thompson, coordinator for the local oral health coalition and manager of El Rio’s dental department.
“It’s fast, it’s easy, it’s inexpensive and it works. If I’d had SDF on my cavities as a child, I possibly wouldn’t have needed crowns. SDF has the potential for really upending the paradigm of how we treat our patients.”
Scientific data shows SDF is both safe and effective. It is not perfect — it is not a cure for cavities. But it is easy, said Dr. Jeremy Horst, a pediatric dentist and biochemist at the University of California San Francisco who researches the effects of SDF on tooth decay.
“SDF stops most cavities, not all. It arrests 81 percent of caries (cavities) when used twice per year on kids, which is about the same success rate as traditional fillings. Successful treatment depends on other factors — diet, and saliva doing its magic.”
SDF is not appropriate for people who are allergic to silver, or on people with painful sores or raw areas on their gums.
The Tohono O’odham Nation’s dental program began using SDF in November after reviewing medical literature and hearing positive stories about the use of silver nitrate to treat cavities at an American Indian clinic in Warm Springs, Oregon.
Tooth decay is a persistent public health issue among American Indian children, which is one of the reasons SDF is so important, said Dr. Rodrigo Villar, public and preventive health officer pediatrician at the Sells Indian Hospital.
“We want to catch those children early and use this(SDF) as an alternative to the drill and fill that you wouldn’t be able to do otherwise until they are older,” he said.
As part of implementing SDF as a treatment, the tribe decided to try a dental-medical collaboration, and dental hygienist Sylvia Carbajal-Leon began working in the pediatric medical clinic in the tribal capital of Sells.
Carbajal-Leon teams with pediatricians to screen and treat children with SDF on the same day they see a pediatrician. The goal is to intercept the kids as early as possible.
At the clinic, families are given handouts with oral health tips such as “Never put your child to bed with milk or juice!” And Carbajal-Leon emphasizes to families that oral health is part of a child’s whole body health.
The American Academy of Pediatric Dentistry recommends every child over the age of 1 visit the dentist every six months for cleanings and checkups, and that they brush their teeth twice per day with fluoride toothpaste.
On one recent Friday, Carbajal-Leon saw 14 kids. Six of them had cavities on a total of 18 teeth and all received SDF.
SDF is particularly effective on very young children between the ages of 1 and 3, said Dr. Heshmat Mortazavi, chief dental officer for the tribe. For those kids, SDF can serve as a bridge until they are old enough to tolerate longer dental exams and sedation, if needed.
“The whole goal is to reduce the number of caries (cavities) and save teeth long-term,” Mortazavi said. “It may take a couple of generations. It is a public health issue, just like diabetes. It is preventable.”
The tribe is interested in extending the use of SDF to elderly members in nursing homes and to special needs patients, Mortazavi said.
Carbajal-Leon said not all families return for their follow-up SDF treatment. But it’s a work-in-progress and part of an effort to improve prevention and overall oral hygiene with parent education, she said.
“Oral health is finally starting to get the recognition it should have among the medical community,” said Karen Woods, dental director at St. Elizabeth’s Health Center in Tucson, which began using SDF late last year.
“Medical illnesses work hand in hand with what is going on with the mouth.”
To call SDF a new treatment is actually a misnomer, Woods noted. It’s an old treatment that is making a comeback.
Silver compounds have been used to treat cavities in Japan for decades. And silver nitrate was used to treat cavities in the U.S. as far back as the late 1800s by Dr. G.V. Black, who is often referred to as the father of modern dentistry, said Earle of the Arizona Dental Association.
The use of silver compounds began to go away in the 1950s with the advent of fluoride toothpaste, fluoridated water and improved anesthesia and dental fillings. But the benefits of silver compounds are earning renewed appreciation.
Elevate Oral Care, the Florida-based company that makes the popular SDF product Advantage Arrest, is honoring Dr. Black and the compound he touted with a “Back In Black” campaign to raise money for children’s dental charities.
Advantage Arrest, which both the Tohono O’odham and El Rio are using, was approved by the U.S. Food and Drug Administration in 2014 for reducing hypersensitivity in adult teeth, and that’s when off-label use of the product for treating cavities in children began to pick up.
Advantage Arrest consists of 62 percent water, 25 percent silver, 8 percent ammonia and 5 percent fluoride.
SDF gives dentists another option for dealing with cavities, particularly for patients who are fearful of the dentist or who otherwise cannot cooperate with traditional treatment, said Dr. Amanda Pinder, El Rio’s associate dental director.
For kids like Ivanna, it also removes the trauma that causes so many adults and children to spend the rest of their lives avoiding the dentist.
Thompson said when a child becomes fearful of going to the dentist, it hurts their likelihood of going as a young adult. The fact that SDF involves no pain or discomfort is a boost for overall oral health, she said.
SDF is also much less expensive than more traditional dental treatment. It requires less time in the dental chair, and one drop of SDF costs roughly 60 cents. No single tooth ever requires more than four drops.
Insurers are typically covering SDF treatments, and their reimbursements vary. Horst, who was an instructor at the local SDF training, found reimbursement examples in Arizona of $20 per tooth for two yearly treatments.
Horst has been using SDF since 2006. His first patient was an extremely fragile, chronically hospitalized child with a seizure disorder who had almost died from the anesthesia during a prior dental procedure. The SDF stopped 16 of the boy’s 17 cavities, Horst said.
Horst has known patients to travel hundreds of miles just because they want to avoid a drill.
Cavities in children are preventable, but they remain a problem. Six in 10 U.S. children experience a cavity by the age of 8, the American Academy of Pediatric Dentistry says. And untreated cavities in baby teeth can spread and cause decay in other teeth, including permanent teeth, the organization says.
Also, when baby teeth are lost early, it has the potential to cause space loss and long term orthodontic issues, Pinder said.
Pinder said some parents opt against SDF because of the black stain. Others just want the treatment for the back teeth. But many choose SDF for their children because it’s better than the alternatives.
El Rio pediatric dental resident Dr. Allie Inouye recently treated two of 3-year-old José Manuel Peraza’s bottom teeth with SDF as a way of “buying time.” José will need more dental work and general anesthesia in a few months, but in the meantime the SDF will stop his tooth decay from progressing.
Inouye used fluoride varnish on top of the SDF to keep it in place, and vaseline to prevent the liquid from staining José’s skin. The treatment took a few minutes.
The biggest risk with not treating cavities in children is that the dental infection could spread, compromising airways, causing facial swelling, painful abscesses or systemic sepsis. In extreme cases, the infection can go to the brain.
Duffy and other pediatric dental residents at El Rio are regularly called to see young patients with severe infections at the emergency room of Banner-University Medical Center Tucson. If a child ends up in the ER with a swollen face from an untreated cavity, the health system ends up using more resources, Duffy said.
“I think you can call it a game-changer,” El Rio’s Pinder said of SDF. “It opens up great opportunities in the medical management of the disease process. It has been a huge benefit to our patients.”