Treating Decay Medically: No Drilling, No Anesthesia; Restoring with Silver Diamine Fluoride and GI

You're listening to the Phil Klein Dental Podcast. So I'm pretty sure that most of you listening to this podcast today have heard of silver diamine fluoride. But did you know that combining silver diamine fluoride with the application of glass anomer can be a long-term solution to restoring a badly decayed tooth? And did you know that this can be accomplished with no anesthesia and no rotary instrumentation? No doubt this sounds far -fetched, but the reality is Dr. John Frachella has been doing this successfully for 50 years. He's a strong advocate for treating dental decay medically before we even pick up a handpiece, or we may not even have to pick up a handpiece. And using his method of combining SDF with glass ionomer, you can conserve tooth structure while restoring a tooth to its full strength and glory. Throughout this episode, you'll find our guest, Dr. John Frachella , informative and entertaining, and we'll no doubt get a whole new look at the use of silver diamine fluoride in dentistry. Dr. Frachella is a pediatric dentist with 50 years experience in the delivery of dental services in the public and private setting. He currently lectures at NYU Dental School for the largest dental residency program in the United States. So we're very happy to have Dr. Frachella on our program. Dr. Frachella, thanks for joining us. Thank you. Glad to meet you and glad to be here. Thanks for inviting me. Yes. So you certainly have had a lot of years in dental practice and you have a lot of experience with using silver diamine fluoride and other materials like glass ionomer for the management of caries. And we're going to be talking to you about that today. But before we get started... And before we get into the details of silver diamine fluoride as a material and its applications, tell us why you think it's important to look at caries as a bacterial disease and treat it as such. Well, first, I'd like to address what you just said, which is a material. You said SDF is a material. And that's really correct, but it's also, it's a medicine. And if we look at it as a medicine, it helps to answer your question. We're using it as a medicine because it carries, foundationally, is a... a bacterial disease. It's also a behavioral disease and it's multifactorial because it's a biofilm disease. But the underlying cause is certain bacteria, not all bacteria. And we don't certainly want to kill all bacteria in the mouth or even in a lesion in a tooth. But what we want is selective um uh killing of bacteria which is what the medicine and that's what makes it a medicine silver diamine fluoride does now you also mentioned glass ionomer we use it in combination with glass ionomer both being medicines but the glass ionomer also being a restorative treatment but they're symbiotic so they can be used together yeah and i want to hear about how you do use these synergistically and we'll talk about that further into the podcast so We've been hearing a lot about this medicine, silver diamine fluoride, which certainly falls under the category of minimally invasive medical management of caries. And although many dentists understand the benefit of SDF, quite a few of us believe that the use of SDF should primarily be designated for pediatric patients or for homebound or non-ambulatory patients, patients who just can't get to the office. And for all the other patients, we should be doing the traditional drill and fill dentistry. So what do you say to that? It's a total myth. It's a misconception. It's wrong. And we need to look at it in an entirely different way. You know, please don't shoot the messenger. Point being that we have a bacterial disease. And let me ask you this. What disease with a bacterial foundation in the human body Do you treat surgically first in any patient, regardless of age? You don't. What you do is you apply some antibacterials in whatever way, shape, and form. Surgery would be your last resort. You may go in surgically, but not until if it's a bacterial disease. You use antibacterials, either orally or IV or whatever. actually gets into the very lesion itself and arrests it. It stops it. It doesn't know age. It doesn't have, you know, it doesn't have a specificity for children or ambulatory adults or anyone. What it does is it puts out the fire. So if you look at the bacterial disease in someone's mouth who has decay, no matter what their age, no matter what their socioeconomic status, etc. If they have a cavity, they probably have more than one because that's the way carries works. And it's the most common infection in the mouth. It's the most common infection of humans, oral infection in humans in the world. So, you know, it applies to everybody. And what SDF does is it puts out the fire so that. If indicated, we can go in afterwards. After we've controlled the bacteria, we can go in and do restorations. I've talked to a lot of dentists about SDF. A lot of them use it. They don't use it on every patient, but they really enjoy it as a interim procedure. So in other words, like you said. Very rarely does a patient come in and you only find decay on one tooth. When they have not been to the dentist for many years and they have poor oral hygiene, you're going to find decay on more than one tooth. So to get everything under control or at least arrest everything in their current stage, do you recommend using STF as an interim material and then move through the rest of the mouth once everything is treatment planned, everything's accepted? and the patient is ready to move forward with treatment, at least you have that SDF working everywhere while you're going through that whole process before you actually do definitive dentistry. Well, first and foremost, there's no such thing as definitive dentistry. No restoration is definitive. All restorations are interim, and some are more temporary than others. To answer your question, we have to address what patient population are we treating and who is the patient in front of us. For instance, in the populations that need SDF the most, many of those individuals, those patients, are never going to be seen again. by a given dentist. For instance, in an FQHC or in a public health setting, I may come in as a hired hand, as a hired gun, if you will, dentist to work for the day. And I've got a patient or two or 10 or 20 in the waiting room in front of me who I know I will never see again. And they have mouthfuls of decay. So I'm going to apply SDF on that day. And then on the same day, I'm going to put glass ionomer on top of it. Now, the point being that when we use SDF, it does something very important. First and foremost, it desensitizes the tooth so that I don't need anesthesia. I don't have to wrestle with a patient to get a needle in their mouth to make their tooth numb. Because as soon as I touch that to the tooth, it instantly, it's not numb. but it is instantly desensitized. So now I can do what the American Dental Association has recommended in 2023 and 2024, which is minimal excavation or no excavation. Instead of complete excavation of the decay, we only remove some of the decay. That leaves a layer over the nerves on the inside, which is insulatory. And then we've disinfected it. The decay is no longer active. And then we can put the glass ionomer on top of it, which is also desensitizing. and disinfecting, and as permanent as anything we've ever done in dentistry. For instance, silver fillings, which we don't use anymore because they have mercury in them, or plastic fillings like composite resin. And the glass ionomer... top of the silver diamine fluoride has been proven in many studies to last as long or longer than resin composite because a resin composite is not a medicine or a combination of medicines. Now, I might add, I've just talked to you about combinations of medicines. So we have medicine, two medicines working synergistically together, the SDF and the glass ionomer. So combination therapy. So just to clarify, you're going to put the SDF on first before you do any excavation. Is that correct? That's the first thing you're going to do. To desensitize so that you can do some excavation of infected versus affected karyostan. Okay, so you put the SDF on to get the desensitization, which works. You go in there and then you excavate. Not all of it. You leave some decay over the pulp chamber so you're not... a root canal for sure you want to avoid that do you put sdf on again absolutely okay so that's the part that's the part you didn't make clear so then you reapply the sdf once the excavation whatever level you want to take it to is complete and then after that's done you put the glass ionomer on Yeah, let's look at the decay as a sponge, okay? So we have a lesion, a caries lesion, which we call tooth decay. Okay, think of it as a sponge. In each individual patient, that sponge is going to be variable in its porosity. The point is we want that SDF. to penetrate through the sponge to the floor of the lesion. Now, that might take a little longer in some patients than it does in others. It may require removing infected dentinal material, infected by bacteria, off of the top of it so that we can get to the leathery dentin, which is affected dentin, underneath, and then... through the sponge. So we want the sponge to be dry of saliva. So we dry, dry, apply, buy is what we say. Dry, apply, buy. So we want it dry. Then we want to re-saturate the sponge with SDF. It used to have saliva in it. We take the saliva and the polysaccharides and everything out of there and we re-saturate the sponge with the SDF. Then we leave it moist. And because glass ionomer likes moisture, not too wet, not too dry, and we put the glass ionomer on top. So just curious, Dr. Frachella, if you had the opportunity to see the patient a second time and you knew you would, would you just place the SDF on first, have them come back, place another layer of SDF, and then do the glass ionomer restoration and call it a day? Well, first of all, I gave you a scenario of if I wasn't going to see the patient again. Let's say the patient was you and I knew that if you were coming back, you're a good patient. You're going to say, well, I'm going to come back, doctor. I wouldn't do it in one appointment. What I would do is I would remove infected dentin and then I would dry apply and then I would say bye. And then I would say, Dr. Phil, I want to see you in a week or I want to see you in two weeks or I want to see you in a month. And I would dry apply again until I could see the. lesion is black and hard. And then at that point, I would resaturate the lesion again, even though it was black and hard. And I would use that as my moisture because the SDF is... 38% silver ions, but that means that it's 62% water and that's plenty enough moisture for the glass ionomer. And then I would put a glass ionomer on top of it and I would not have to touch it with SDF again, but I might have to reapply the glass ionomer every once in a while because it sacrifices itself into your mouth by releasing fluoride and therefore some material. And so the outer layer of that glass ionomer is a bit sacrificial depending upon how acidic your mouth is. I might want to apply a little glass ionomer on top of it, but no more SDF at that time. They're working together. The glass ionomer is typically more opaque than traditional composite resin. So I assume that helps mask the darkness from the silver that's impregnated into the tubules and into the porosities in the enamel. Is that correct? That is correct. And it does mask it. And if you don't remove any of the stain, because SDF doesn't stain the tooth, but it does stain the lesion. And if staining is an issue, like in the front, we may not even want to use SDF because we may never be able to get rid of the staining. Or maybe we'll use SDF and we can scrape the outer layer of the staining off and then put glass ionomer on top. Or if it's in the front, we might want to use just glass ionomer. dark, it's certainly with the opaque, because of the opaquing that you mentioned, the opaque material of the glass ionomer, this SDF under the glass ionomer, which by the way, we call that a smart filling, silver modified atraumatic restorative treatment. That smart filling is going to end up being grayish. It is going to be much less. dark than an amalgam much less dark than a stainless steel crown but it's not going to be sparkling white but do we need it sparkling white in the back of your mouth when when social distancing is six feet and you're smiling at someone and i mean unless you have a huge mouth and you gape it open, no one's going to see that you have a kind of gray filling instead of a white one. It very much blends in with the teeth. And by the way, I might add, as the glass ionomer matures in its mature state stage, which is the third setting stage of glass ionomer, it becomes more and more white, or if you will, chameleon-like, more tooth-like. Indeed, it might take six or eight months or maybe even a year, but it gets actually lighter. and lighter and lighter, even with the SDF under it. Yeah, I mean, when you compare it to Amalgam, it certainly makes a lot of sense. Social distancing, that's over for us in Texas. Where do you live that they still have that? No, I'm saying social distance. I mean, how do I ever get... Close enough to you and smile that you can see whether I have an old amalgam on number 30? I don't think so. I mean, I'm looking at you right now, man. I can't tell if you have any fillings in the back of your mouth that are dark colored. You know, this is what I'm calling social distance. Comfortable conversation distance. Okay, so let's talk about the other scenario where a dentist is working in a practice where there's not 20 people in the waiting room. They have a regular flow of... compliant patients that come back for their re-care appointments. These patients have DO on number 30, maybe an MOD on number 12, and it's not severe decay, but it's into the dent in a little bit. What do you say to the dentist that says, I'm just going to remove the decay, put in a nice base liner for protection? and I'm going to put in a composite resin or glass ionomer, and I'm not going to mess around with SDF. What do you say to that doctor? Well, if you're going to play some kind of bass and then put your composite resin on top... I'm saying that you're putting in a karyogenic filling. It's going to cause cavities. Look at the data. Look at the statistics that we have today. Look at the randomized RCTs that we have, clinical trials, and you will see that what ends up happening is the micromechanical... that a composite filling creates with that base that you were talking about is actually debonds and bacteria underneath get underneath and you have recurrent decay. You don't get that with the SDF and the glass ionomer. And if you have five people in your waiting room, you know, considering your scenario that you just drew, you know, how would you like to have 25 people in your waiting room because Number one, you're not going to have to give anesthesia, so you're not going to have to wait for it. And number two, it's so much easier to place this. SDF and glass ionomer, it's a higher standard of care because you have less recurrent decay. It lasts longer than the composite does. And why wouldn't you want to treat 25 patients instead of those five that you're doing traditionally when you can get paid exactly the same? Because when you put the glass ionomer in that MOD, you can charge for an MOD composite because we've convinced the American Dental Association in the their codebook to include glass ionomer as a composite. Why? Because it is a composition of materials by definition. So glass ionomer can be charged out as a composite. Ka-ching. I see your point with the revenue, but I certainly think the main benefit here is the conservation of tooth structure. I think that's what SDF is doing very effectively here. We're conserving tooth structure, which is such an important part of the whole pathway, the journey for a human being to maintain their teeth. throughout their lifetime without having a fracture, without having an extraction, without having an implant. So the idea is to actually remove as little tooth structure as possible, and using SDF is certainly a way to do that. Do you agree? Yes, and spoken as a healer versus a Wheeler dealer, because I was just giving you the ka-ching. That's the Wheeler dealer. So a lot of dentists that are listening are Wheeler dealers. Okay, so we took care of them, ka-ching. Now we're going to take care of the healers like you. And as a healer, what do you want in your mouth? Dr. Phil, I'm asking you, what do you want in your mind? Do you want me to remove material anywhere? I mean, as a physician, do you want your physician to remove a maximum? Do you want minimal invasion? Do you want less removed? Do you want to keep this indigenous material that can be repurposed? So here's the point. You have this material that we, you and I, when we went to dental school, we were taught that we need to remove all of that down to white. That's wrong. And the reason for that is that leathery material can be. There is no stage at which it can't be remineralized. How do we remineralize it? With SDF and glass ion, and we're working together. And why does that work? Because those two medicines put the materials back the... back into the tooth that were lost in the decay process in the first place. It's exactly the same minerals. So the minerals that are in SDF and the minerals that are in glass ionomer are exactly the same minerals that were in a virgin tooth. Now, when you put those two together and then you leave them through the maturation phase three, four or five years later, we've proven that they fuse together through a zone of chemical fusion. the glass ionomer and the dentin and the enamel, and they all become one. Not micromechanically locked, but chemically fused. And that tooth, that smarted tooth, is actually stronger than a virgin tooth before it became decayed. Yeah, well, that's impressive. I didn't know that the tooth would be stronger after treating it with STF and glaucionomer. But that's, again, it does matter how much tooth structure is destroyed by the carious lesion in the first place. If it's bombed out, even if you use STF and glaucionomer, you're telling me that it's going to be stronger than it was before it had any decay? Well, yes. I would like to refer you to a colleague's video that is on YouTube, and I can send that to you, Dr. Phil. And what it is is he has taken a totally bombed-out tooth. And he has soaked it in a saliva-like substance and kept it in an incubator. So then he does a crown prep. This is Dr. Doug Young, professor emeritus at University of the Pacific. And he does a complete glass ionomer crown, according to manufacturer recommendations, our recommendations, what he calls his Ten Commandments. He makes a glass ionomer crown, and then he lets it mature. Again, in an incubator in saliva for X number of months. And then he takes a hammer to it and he starts hammering on it. And the first thing that happens in the video is that the root starts breaking. And then eventually he hammers so hard and it's scary to watch because you think he's going to hit his fingers. But then he goes bang and the thing cleaves. completely along the long axis of the tooth. You try that with a composite, mister, and it ain't going to work. You'd have to compare that to a virgin tooth, too. Well, try it with a virgin tooth. You'll crack the enamel off of it and everything. The glass anomer is so strong. after maturation now no wait this is important because if you try that before maturation if you try it in one week post-op or in two weeks or even three or maybe even up to eight weeks it isn't going to work so we have to look at it you know, realistically, nine or 10 or 12 months down the line. That's where we get that strength. So there is that time period during which it isn't even as strong as a composite, let alone a virgin tooth. But eventually, it becomes one mass. You know, I say, say ohm grasshoppers, you know, this is one, it is one. And it's fused chemically. So that's important to make sure that that waiting time goes. to completion because otherwise the tooth is more vulnerable than it was as a virgin tooth. So let's talk about fluoride varnish for a second. That's the last step that you employ into your procedure when you use SDF and glass on them. Or tell us about how you use fluoride varnish on top of it all. And what is your goal there? Sure. So let's talk about first about putting SDF in the tooth without glass on them. This is Dr. Phil in the chair. He's going to be coming back. We're not going to do it all in one appointment. We're going to wait until it's black and hard. We're going to put the SDF in there and wait for it to be black and hard. Now, when we're done with dry, apply, buy, just before buy, we're going to apply fluoride varnish. Why do we apply the fluoride varnish? Not for more fluoride. That's for sure. I mean, the SDF already has, you know, 48,000 parts per mil. You don't need more. So you're putting the fluoride varnish over the top of it for two reasons. It masks the metallic taste, number one. Number two, and probably much more importantly, what it does is it forms a seal over that SDF so it doesn't become immediately diluted by your saliva. So the patient's saliva starts diluting the SDF and now suddenly you're diluting those silver and fluoride ions in the SDF, making it much less effective because the ionic concentration, the concentration of fluoride ions, concentration of the silver ions is what the medicine is all about. So we don't want it diluted immediately by saliva and the fluoride varnish. protects that immediate dilution as well as masking the taste. Now, on the glass ionomer, if we do SDF and glass ionomer all at once, and we put the fluoride varnish on top of the glass ionomer, what that does is it allows the fluoride, the glass ionomer, to begin its first and its initial set. phase, which is its cross-linking phase, without being influenced by too much moisture. Saliva is glass ionomer's best friend. Why? Because it has all of the same minerals in it that the glass ionomer has and all of the same minerals in it that the tooth has. But we also don't want to be... washed by too much H2O. And so the fluoride varnish helps that for those first few minutes or hour or so after you put the glass ionomer on top of the SDF. So I hope that helps. No, that makes, yeah, no, that totally makes sense. And that certainly, which, what is your favorite SDF at this point? What do you like to use in your practice? Well, let's be clear about this. They are all the same. 38% silver diamine fluoride is 38% silver diamine fluoride. The original one was Elevate, and their product is Advantage Rest. Centrix came in behind Elevate, but it's still 38% SDF. I have both. I've used both in my own mouth. They both have a metallic taste. They both arrest decay. I've arrested decay in my own mouth. And they both work equally because they are... the same chemical formula. The Advantage Rest is interesting in that it's only available from Elevate directly. You can't go through a dental supply house like Shine or Patterson. Centrix, on the other hand, is available from Shine and Patterson in the supply houses, which is really good for some dentists, especially those working in FQHCs, where the FQHC administrators say, oh no, you have to buy everything. through Shine because we have an account with Shine and we get a discount. You can't go direct to elevate because you're spending too much money. We'll then get to Centrix. As we wrap up this podcast, Dr. Frachella, and you've really provided us with some incredible insight on SDF, I do want to ask you this last question, and that is, does the hesitancy about SDF or the reluctance to use SDF, does that come mainly from the patient or do you think it comes mostly from the dental professional? 99.9% from you as dental professionals. The patients love it until the doctor says, like I've been told as a dental patient, that stuff doesn't work. Well, you're probably either not using it properly or you just rather not change your ways because this is the future. Well, there's no question. We're all healthcare providers, whether you're a physician or a dentist or whatever you do. It's good to be open-minded and explore different methods of treating patients. And there's certainly a lot to be said for silver diamine fluoride. There's no question in combination with glass ionomer, it does amazing things. The results are out there. The literature supports it. And I think more dentists should take a look at this more seriously. And it does align with a lot of what we do in medicine, which is to... the infection under control before you do surgery. And doing a dental filling is surgical. You're cutting live tooth structure. That's surgery. So maybe we should open our eyes to the fact that we can actually treat this medically first, see where it goes. Maybe we don't need to do the dental surgery necessarily and combine it with, as Dr. Frachella talked about today, Glass ionomer and making this super strong tooth. gets stronger over time as more minerals get into it. And it fuses into this incredible monolithic type structure that supports the tooth. There's certainly a lot to look at. And we thank Centrix for their support for this informative podcast. Centrix has their own SDF, which take a look at. You can get that through your dental dealer. Thank you very much, Dr. Frachella. Thank you.