Medical Management of Caries: Demystifying the Use of SDF and Glass Ionomer

Well, the incredible thing is that SDF obstructs dentinal tubules. which decreases sensitivity almost on contact, which is why studies show that it can be used within half a millimeter of the pulp without inducing inflammation or pulpal necrosis. See, this is a big myth. You know, most dentists think, oh, my gosh, if I put it anywhere near the pulp, it's going to cause pain and sensitivity and then eventual pulp death, which it doesn't. In fact, just the opposite. Welcome to the Phil Kliein Dental Podcast. Today we'll be talking to a dentist who is a firm believer of medical management of caries. He believes we as dental professionals should first treat dental decay medically with silver diamine fluoride. And then we always have the option of surgical intervention, which in our profession means picking up the dental handpiece. He has been using silver diamine fluoride for over 40 years. during which time he has seen SDF arrest the carious process in literally tens of thousands of teeth. And not only that, in addition to killing the microbes that cause tooth decay, he has seen those same teeth remineralize, where they are completely restored to their natural state, free of decay. And then there's the zombie effect, where the silver ions continue to protect the tooth long after the SDF is applied. And needless to say, all this is accomplished without local anesthesia or the use of a dental drill. No needles, no drilling. In this episode, you will hear firsthand what SDF can do and why every dentist should consider using it on posterior teeth that are infected with dental caries. Our guest is Dr. John Frachella, a pediatric dentist with 50 years experience in the delivery of dental services in public and private settings. He's worked in private practices across the country and for a decade was on staff at Oregon Health Sciences University Dental School. He currently lectures at NYU Dental School for the largest dental residency program in the United States. We'll be getting to Dr. Frachella in a second, but first, are you looking for an air-driven handpiece that rivals the power and torque of electric? Well, I have good news. It's finally here. It's called the TMAC-Z and it's from NSK, a company we all know and trust as a world leader in dental handpieces. In addition to being lightweight and ergonomic, this revolutionary air-driven handpiece delivers unprecedented 44 watts of power, allowing it to cut through tough zirconia smoothly and quickly. In fact, the TMac-Z reduces overall cutting time by 30%. That means less chair time, reducing the burden on you and your patient. Take a test drive of the TMac-Z air-driven handpiece from NSK. For a free 10-day trial, go to nskdental.com and find your local rep to inquire. Experience the power and excitement of the TMAX Z series. Dr. Frachella, it's a pleasure to have you on our show. Thanks, Phil. Really an honor to be here. Yeah, we've been listening to your stuff. You've been doing some stuff with Viva Learning over this past year, and we've all noticed it, that it really covers information that a lot of... KOLs and educators are not talking about, at least to the degree that you are with your clinical experience. So to begin this episode, Dr. Frachella, tell us what the term medical management of caries means in contrast to what most dentists are currently doing in the treatment of dental decay. Well, most dentists, what they do involves the surgical amputation of tooth structure. But that's stuff that we now know can be disinfected, remineralized, and essentially repurposed. Using drills to remove remineralizable tooth structure doesn't treat the disease because biofilm diseases can't be treated with surgical instrumentation. So the medical management of caries is different. It treats the affected symptoms of the disease called cavities by healing and sealing after partial decay excavation, while it also is deactivating caries-causing microbes. So the healing in the sealing is done with topical liquids and solid medicines that are also restorative and that contain minerals, mineral ions specifically, that arrest, detect, prevent, remineralize, and desensitize lesions without using needles and drills. Let me ask you one question before we go on, and I think you covered that well. In the medical field, traditionally, before a physician sends a patient out to have surgery, they diagnose what the condition is. If it's a disease or infection of whatever kind, if they could treat it with antibiotics, they do that. If they could treat it with something else, they do that. And that's called treating it medically. Why is dentistry so different that the first thing we do is go into the surgery as soon as we know that there's dental decay there, which essentially is a disease, which we know is an infection. And removing not only infected dentin, but often affected dentin, as well as healthy tooth structure, which normally comes with it. Explain that concept to us. So the logic, you know, behind treating decay medically mostly centers around using the mineral ions of silver, fluoride, calcium, phosphate, potassium, and strontium. Now, these specific mineral ions are in liquid form in SDF and in solid form in glass ionomer. to varying degrees. The mineral ions are what make silver fluoride and glass medicine in the first place. Those minerals are parts of atoms, of mineral atoms, that put the same minerals back into decayed teeth that were removed by the decay process itself. But those same mineral ions also simultaneously arrest the microbes that cause caries, and they keep those microbes deactivated over time. In that way, the mineral ions prevent recurrent decay, which is the very thing that conventional dentistry does not accomplish. You covered that very well, Dr. Frichello. But I haven't even asked you about silver diamond fluoride, and you brought it up, which is good. But again, it's the concept of doing surgery in dentistry before we even treat the problem medically. Tell us the mindset of dentistry versus medicine, why we go in surgically and drill away tooth structure, which is a surgery, before we treat it medically, which you just described. All other bacterial infections of the human body are treated with topical or systemic antibacterial medicines as a first measure before surgery. Shouldn't dentistry do the same since caries is a bacterial infection? You know, when we have a bacterial infected cut, physicians don't surgically remove our skin and replace it with plastic. If our skin has a surface infection that's maybe irreversible, then maybe. But first, doctors usually use systemic topical... antibiotics. Another example is that we no longer remove duodenal ulcers, but instead control these bacterially caused ulcers with antibacterial medicine. And Cary's lesions are just bacterially caused tooth ulcers. They too should be treated with antimicrobial medicine, not surgery. And that's called the medical management of caries. So with your combined career of teaching, as well as clinical dentistry for many decades, tell me why this isn't being taught in the dental schools. Why aren't dental students taught this concept so that when they get out, their approach to dental caries is first medical and then surgical? Because we've lost our way, Dr. Phil. We have bought into using inert non-bioactive materials. And we have ignored the fact the microbes laugh at us when we try to drill at them. It's not so when we apply antibiotic high concentration silver and fluoride ionic liquids and provide, say, providone iodine and other antimicrobial solids like glass. We lost our way by getting into inert, non-bioactive materials that were pretty. And now we actually have new glasses that are just as pretty or prettier in some cases than those plastics. We lost our way. We need to find our way back. All right. So tell us on a microscopic level. What's actually happening with silver diamine fluoride? Okay. So microscopically, silver ions are so small and penetrating that they actually pass through decay-causing microbial cell walls. So these microbes that cause decay, their cell walls are penetrated by these extremely small and powerful ions. Those ions are in the trillions and just one drop of silver fluoride. They perforate the bacterial cell walls on contact and then bind to essential cellular apparatuses in a way that stop bacteria from performing even the most basic functions by causing mitochondria dysfunction, ribosome assembly, protein damage, and eventually... Now, when the silver actually begins its process of killing those microbes, it does something else too. It begins building structural support inside the lesions themselves by creating these silver nanowires that we can see on scanning electron microscopes that penetrate about a millimeter into sound dentin, underneath lesions. Now, these nanowires are like structural support rods. They're kind of like rebar in concrete. They provide scaffolding that supports the glass ionomer that we apply later, which is more than just, as you just said, more than just a restorative material. It's medicine also. The SDF also contains 44,800 parts per million of fluoride. Now, by comparison, fluoridated water contains 0.7 parts per million. Another difference between silver fluoride and fluoridated water is that with the silver fluoride, the ions don't enter the bloodstream. Instead, they're locked in very high concentration only inside caries lesions inside teeth. Now, that many fluoride ions sealed inside teeth slow down bacteria, additional to silver ion bacteria slow down. The high concentration of fluoride ions also changes hydroxyapatite into fluoride appetite, making affected dentin more crystalline and acid resistance so that each ion, silver and fluoride, is highly reactive against bacteria. and highly reactive with minerals inside teeth in a way that gives structure to decay to actually repurpose it. And to top things off, the silver ions stay inside the dead bacteria in deactivated lesions, poised to attack new bacteria in the future. which in 2014, the Journal of Nature called the zombie effect of silver. Let me ask you one question as you're covering this. So based on what you're saying, how necessary is it to use a rotary instrument? Why can't you just apply this medicine directly onto the decay as a first step and see how that all goes? Why even pick up a drill? Correct. That is exactly what we suggest. Do not pick up the drill. What we need to do first before we apply the SDF is we want to make sure that we clean as much of the biofilm off. So we want to clean the top of the lesion. And if there's unremineralizable stuff, what you and I know as infected dentin, let's remove that too. Now that stuff's kind of mush, if you will. And what we want to do with that mush is get it out of there because it can't be remineralized. So think of it. as cottage cheese or, you know, or something like that. You know, it's just this goopy stuff. And we can get that out with, we don't need a drill to get that. In fact, drills don't get that out. What we need there is either a cotton palette or a micro brush to scrub that out by using a 360 degree kind of motion between our fingers and between our thumb and our forefinger as we twist it, but not with a drill. Absolutely. We'll be getting right back to our guest in a second. But first, silver diamine fluoride, SDF, is a game changer in carries management. offering clinicians more time to plan appropriate care while effectively desensitizing teeth and arresting caries. Centrix, a trusted leader in dental materials, offers SilverSense SDF, a cost-effective, fast, and easy-to-use solution. Its bactericidal silver particles stop caries' progression in its tracks and instantly eliminate hypersensitivity, providing a more comfortable experience for your patients. Unlike other SDF products, SilverSense SDF won't stain healthy tooth structure. Only the treated lesion darkens, which can later be restored to full form, function, and aesthetics. So it's time to elevate your caries treatment with SilverSense SDF from Centrix. To learn more, visit centrixdental.com. So Dr. Frachella, you addressed the antibacterial effect of the silver ions and what it actually does to the cell wall. and the actual activities, the mechanisms of how a cell operates, it destroys those mechanisms, the silver does, when it comes to the bacteria. What does it do for dentin sensitivity? What does it do for discomfort that patients typically experience when a dentist goes down deep into that cavity to get that decay out? and they're not using silver diamine fluoride. They're just going in there, excavating with a drill. Hopefully, they're cooling with water. But as you get deeper, obviously, you're getting in an area where the patient is more prone to postoperative sensitivity, which could be severe if it's really close to the pulp. But using silver diamine fluoride changes that whole equation. Tell us about that. Well, the incredible thing is that SDF obstructs dentinal tubules, which decreases sensitivity almost on contact, which is why studies show that it can be used within... half a millimeter of the pulp without inducing inflammation or pulpal necrosis. See, this is a big myth. You know, most dentists think, oh, my gosh, if I put it anywhere near the pulp, it's going to, you know, it's going to cause pain and sensitivity and then eventual pulp death, which it doesn't. In fact, just the opposite. So it plugs the tubules, forming a protective layer. Now, parents who watch me apply SDF to their kids' teeth often ask me to apply it to their sensitive teeth, like where they have excessive toothbrush abrasion, like at the gum line. And I apply it for them, and they marvel. at the immediate relief. So the point is that if we do need to remove, let's say we have a sensitive tooth on a child or an adult, and we need to remove that infected, unremineralizable material, but we're afraid to do it because the patient is sensitive, well, apply SDF first and foremost to get the desensitivity before you do any mechanical removal of anything. And then whatever you do, don't ever remove beyond that leathery dentin that we learned in dental school. We learned that term in dental school, leathery dentin. And dentists love to pick at that stuff. And it comes off like layers of an onion. And then all of a sudden you're looking at a bleeding pulp. Don't touch that stuff. Once you're down to the leathery dentin, that's remineralizable tooth material, indigenous to the patient, leave it alone. Okay, so that makes sense. Now let's say we're excavating and we get rid of the mush, but it's so far down towards the pulp that we get a very tiny exposure, although there's still leathery dentin around it and coronal to it. But we do get in one spot a very pinpoint exposure of the pulp. Can we still use silver diamine fluoride there? First of all, in my clinical experience, that doesn't happen until we use instruments. Doesn't happen with a micro brush. I've never gone in with a micro brush or a cotton pellet on a college player and scrubbed that stuff out and gotten that kind of exposure. I don't remember ever seeing that unless I went in mechanically with something harder than that. So let's say that we're somewhere in between. Let's say that we've removed it with cotton and let's say we've removed it with a micro brush and suddenly it looks like we might have a pulp exposure or we might not. What I do in situations like that is I apply the silver diamine fluoride anyway because it can do no harm. even if we've come to the party too late. It does no further harm. It doesn't make it worse. It doesn't make it blow up and get a whole lot worse. It was going to blow up anyway. Okay, so you still go ahead, put the SDF directly over the pinpoint exposure and move forward with applying it all over that leathery dentin, that affected dentin, and then hope for the best, obviously. No, and then put glass ionomer on and then do more than hope for the best. Well, no, no, hope for the best. I know there's another step to this, but we haven't gotten to that. So what I would do, because this is very specific, let's stay on this point. So let's say I might suspect that I had a pulp exposure. I'm going to take a chance here because I can. always extract the tooth later. So I explained to the parent, I explained to the child, I explained to my adult patient, look, I'm going to take a chance here because I would like that chance given to me if I were in the same situation, because we can always extract later. So what I'm going to do is I'm going to put glass ionomer on top of this, which will also be antimicrobial and start the remineralization process. But I am going to give you a prescription for an antibiotic in case this blows up and you're not able to reach me. If this begins to throb and you start getting swelling and you have this unbelievable... Take it and then call the office. Call me later when you know I'm in and let's get you back in. We got to the party too late. We did not cause this by the medicines that we put in. We just got to the party too late. You did as a patient. I did as your provider. One point I do want to add, Dr. Frachella, as an endodontist, of course, if you see that there's an exposure pinpoint and there's. vital tissue in there, you're getting a little bit of red blood, then you're looking at a vital case and antibiotics probably won't help or in most cases will not help. I think it'd be wise to make sure they have an analgesic script and that's what I would have them take if they start to develop pain. Now, on the other hand, if the tooth, of course, is necrotic and they get a blow up, then, of course, antibiotics is indicated. But if that tooth is vital, antibiotics is not going to do anything. What the patient needs is analgesic. Not a bad idea for them to have both scripts and to be instructed to use the analgesic first if there's no swelling, if it's just sensitive to hot and cold. And then, of course, if it does swell, they can start the antibiotic therapy. Just thought I would throw that in from the endodontic perspective. So you put the SDF on restoratively and then the glasonomer in the same visit? Or is there ever an indication to put the silver diamine fluoride on? and then have the patient come back for the glass ionomer. Okay. All of the studies that we've done on this show that it's better to do it the way you just mentioned the second way, which is to apply SDF repeatedly until the lesion becomes black and hard, and then to put glass ionomer over it. reality of the situation is that in the clinics that I work in, the patients are itinerant because those clinics where I'm called in are treating Medicaid patients and they often don't return or they just don't show up for their next appointment. Not only that, but I'm as itinerant as they are. I'm apt not to be there. If they do come back, I'm apt not to be there the next time and somebody's picking up a drill. So because of their itinerancy and my itinerancy, I developed within the patient populations that I treat what we call one visit smart, silver modified atraumatic restorative treatment, where I apply the SDF and put the glass ionomer on top in one visit. But if I know, if I'm in a private practice and it's It's a different patient population, and this is a regular patient. They live right down the street, and they can come right over after the caries lesions have become black and hard. I prefer doing it that way because our studies show that we have more effectiveness that way. Okay, so how do you address, let's talk about the patient that lives next door to you. How do you address the pushback from patients when they are told that the side effect of SDF? on dental decay is a black stain. And I know it depends where, which tooth you're working on, but generally what's your communication with that patient? How do you present it to them? And then how do you handle that black stain? First of all, I have yet to meet a patient who wants needles and drills, but when they don't want stain either, I tell them that one, we can begin to arrest all of their lesions in one appointment. And two, we will need to reapply the SDF till all lesions are black and hard. And three, when money, time, and behavior line up, we can remove surface stains and make their teeth white with glass ionomer, again, without needles or drills. Now, actually, we have five studies showing that less than 7% of patients are concerned with the stain and that 70 to 76% prefer SDF to dental general anesthesia. Okay. Now in the smile line, I personally prefer using glass ionomer only over partially removed decay. Most of the time I only use SDF on posterior teeth. All right. I think that's important for our audience to understand. Okay. So if you have a tooth in the smile line, and I assume that's around what, six teeth? Yeah, around six teeth. Yeah. So you will not use SDF at all. Is that what you're saying? I do not use SDF in the smile line. Instead, I use glass ionomer. But I use SDF on the posterior teeth. And there's an effect in the whole mouth when we use SDF. What is that effect? No, that effect that we put it on a lesion in one tooth. Remember, we've got silver ions that are spinning around onto other teeth. And there is an effect on other teeth. We have this 2014 study by Segeti in Italy that shows that glass ionomer, for instance, on occlusal surfaces. prevents carries interproximately. Well, the same is true with SDF because these are ions, very small parts of atoms, and they're around everywhere. So there's an overall effect. even if we're only putting the SDF on the posterior. And then we have to protect those anterior teeth by, you know, if we don't want, if the patient definitely doesn't want staining and we don't want staining on the front, then what we do is when we put the SDF on the back teeth, we actually apply. Either we use Vaseline, you know, just petroleum jelly. You can use fluoride varnish also to protect the front teeth from getting stained if they're decayed. And sometimes you don't know if they're decayed, you know, they're questionable. So for that small percentage of patients, Dr. Frachella, that want that black stain removed as soon as possible, what do you do for them clinically to get rid of it? We remove the stains with dull spoons or with hand instruments like hand burrs. Without needles and drills, because remember, the SDF has desensitized the tooth. Now, the stain scrapes off very easily without a need for the local anesthesia, again, because it profoundly desensitizes. The SDF has done that for us. And then it's important to know that when we scrape it, it doesn't reduce the zombie effect of the underlying silver because the silver ions penetrate deeper than the stain does. Then after the stain removal, we add glass ionomer, which becomes more aesthetic and enamel-like as it matures. So honoring the maturation phase of glass ionomer gives us even better aesthetics than composite resins. But providers and patients need to be patient by waiting for those glass ionomer changes on and in teeth over time. What kind of timeframe are we talking about where the glass on them are placed on top of the SDF becomes so strong, it becomes like a monolithic restoration? What are we talking about as far as maturation time? At least eight weeks. And, you know, that maturation begins within the first 48 hours. But for it... For the glass ionomer to become chameleon-like and become more like enamel, we're noticing that the Van Dwyane studies out of Australia say somewhere in the vicinity of eight weeks for glass ionomer to become as enamel-like as it possibly can. And then it becomes more enamel-like than any composite resin I've ever seen. But we need to wait for that. There's a maturity process. And we need to make sure we remove all the stain underneath because the more it becomes enamel-like, of course, the more translucent it becomes. And if we're leaving any black stain underneath, well, it's going to start to shine through. So if we're concerned with aesthetics and it's in the front, then we want to remove the black stain as much as possible. So let me ask you one last question for this episode, Dr. Frachella, and it's been very good. There are companies that have claims. that they don't have black stains with their SDF. What's that all about? Okay, that that isn't quite so I understand, you know, you're close. But what they're claiming is that they have another product that they sell with their SDF. And that product is potassium iodide. So they put the SDF on the teeth, okay, and then immediately put the potassium and it and, you know, when you use SDF, and you put it on on Frank Decay, whether you know it's Frank Decay or not, it will turn black. okay uh it diagnoses the caries lesion for you if it's a questionable lesion it turns black and now it's not questionable anymore okay now what this other company does is they sell potassium iodide that you put on top of that and it removes the stain but it also we've found through our studies and many others have done independent studies on this it deactivates the silver diamine fluoride And the stain comes back anyway. We did this in vitro in extracted teeth. And yeah, the stain went away. And then a couple of weeks later, it came back. And we also studied the microbes and the microbes came back also. So it deactivates the medicinal. and bacterial killing properties of the SDF. So we strongly recommend against using it. And the potassium iodide also burns tissue because it's very, very basic. And if you get it on the gum tissue, like of a child, it burns and it causes a dark spot of burn and it hurts. So we strongly advise against that. Okay. So, and I said I was going to end the podcast episode, but I have one more quick one for you. You're focused on pediatric dentistry. Is SDF also really applicable for an adult patient population? Okay. I used to be a pediatric dentist. But I've changed to becoming what I was originally, which is a general dentist. And the reason for that is I can, because SDF and glass ionomer allow me to treat that adult population that I always disliked treating. And now really enjoy treating. And I think you're going to find that among many pediatric dentists who are switching over to general dentistry because they want to be able to serve the indigent adult population also. And because now they're able because of the medical management of caries. Dr. Frachella, great conversation. Thank you very much. And we look forward to having you on future podcasts. Thank you. Thank you so much.