Breaking the Stigma: Why Every Dentist Should Be Using Silver Diamine Fluoride

Since I've been able to deploy this in the different phases of my practice with kids, with adults, with my geriatric patients, I have seen the benefits and how it helps me be able to transition or get them out of that disease control part or at least get it under control a lot faster than just trying to pick off one filling at a time, which is the way that I was taught in school. Welcome to the Phil Kline Dental Podcast. What if one of the most powerful tools in your restorative arsenal was something many dentists still overlook? On today's episode, we're talking about silver diamine fluoride, or SDF, a simple, affordable solution that's transforming how we manage decay, boost patient acceptance, and even improve practice profitability. Our guest, Dr. Timothy Bizga, is a seasoned general dentist, educator, and international speaker who calls SDF one of the most important tools in his toolkit. He shares how he uses it daily in his practice, why he applies a fluoride varnish directly over each SDF application, and even lets us in on his favorite SDF product and what makes it stand out. We'll also dive into how Dr. Bizga talks with colleagues who are hesitant to use SDF on adults, and how he reconciles using it in a cosmetic-focused practice, and what communication strategies help patients say yes to SDF treatment. Plus, he breaks down the financial side, showing how SDF actually supports a healthy, profitable, restorative model. It's a lively, practical, and eye-opening discussion that might just change how you think about this tiny bottle, with a big impact. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Bizga, it's a pleasure to have you on the show. It's a pleasure to be here with you. Yeah, and thanks for all your contributions over the years to Viva Learning. You've done a lot of webinars for us. Those of you who are interested in some of Dr. Bizga’s content, just go to vivalearning.com, type in B-I-Z-G-A in the search field, and you'll see all this stuff. Really, really good stuff. And again, we really appreciate your contributions. So we're going to be talking about silver diamine fluoride today. And it seems like there's a momentum with this material in the dental space. There was a time where... Some people used it and a lot of dentists had kind of closed-minded responses to suggestions to use silver diamine fluoride, but I think it's changing for the better now. As a general dentist yourself, Dr. Bizga, how do you talk to colleagues who might be hesitant about using silver diamine fluoride, especially on their adult patients? And the second part of that is what benefits do you highlight when you explain how it fits into the restorative process? Okay, great. So I would say that when I'm talking to colleagues, I describe silver diamine fluoride treatments as a tool that you have in your toolbox. And whenever I'm out on the road and I'm teaching, my primary focus is equipping my colleagues with tools that help them do the job that they do every day easier, better, with more efficiency, predictability. And when this hit the scene, In 2017, I think is when it came into my hands. I started putting it into practice. It seemed like a really natural fit. I have a practice that is multi-generational. I see children. I see adults. I see geriatric patients. My initial foray into kind of utilizing it in my practice was with children. And I found it to be a really easy way to be able, if you have a child, they can't sit still very long. Even the good kids, God love them, they're only good for 20 minutes in the chair. So it was a really great way to be able to provide a lot of value, do it in a simple, easy-to-do manner for kids. And then I thought, all right, I'm going to introduce it. into my adult patients. I have this geriatric population. Root caries is exploding. I think there's been a lot of changes over the years with the diet. And you're seeing more and more of these cases where, and we know that the critical pH on roots is 6.5. So they break down just a lot faster than enamel does. And I started to point, I tell colleagues, I'm like, look, it It is the easiest thing to begin deploying in your practice, and it's a tool in your toolbox that really helps you be able to fight dental disease with, I think, a lot more efficacy. Because I got frustrated through, I've been practicing chairside for almost 20 years, and there's cases that just come in where you never seem to be able to get ahead of the disease. And since I've been able to deploy this in... the different phases of my practice with kids, with adults, with my geriatric patients, I have seen the benefits and how it helps me be able to transition or get them out of that disease control part, or at least get it under control a lot faster than just trying to pick off one filling at a time, which is the way that I was taught in school. Now, let me ask you this. There are some dentists that are on the other side of the spectrum, and I'm curious to hear your response to this. And they say, You know, in medicine, we treat disease medically first. And then when things don't go the way we want them to go medically, which is through drugs, drug therapy, we do surgery. But in dentistry, we pick up a drill. We see decay, we pick up a drill. So those dentists say, let's treat carries medically first on almost every patient. And, you know, in dental school, we're taught to take that hand instrument and scrape until we can peel all that dentin out. But these dentists say, no, we don't do that. We leave affected dentin in. We try to remove all the infected dentin and use silver diamine fluoride as a medicine on top of that affected dentin. And then at that point, we can proceed with our restorative treatment. So you said something that was interesting. medicine. It's medicine. And I agree with that. I think silver diamine fluoride is medicine. And one of the things that I love about dentistry is that you can philosophically approach it from many different platforms. And this is an example of what I'm talking about. Yes. The way I was trained in school, you see a hole, you fill a hole, right? That's kind of the mentality that you're sort of taught. But I would argue that we're even seeing changes in the schools. I happen to adjunct at my alma mater, University of Michigan, a couple times a month, and silver diamine fluorides in our student clinics. And so graduating seniors, at least from the University of Michigan, I know. With certainty, they've been trained on how to utilize this. And we teach it as, you know, it's a way to be able to arrest disease, right? In the process, somebody comes in, they've got a lot going on. You can begin to treat that. And it is a infection, right? It's a bacterial infection. And I feel philosophically, some of my own feelings coming through here, like, why not? Why wouldn't you? If somebody comes in, they have, let's say, 20 teeth that have disease on them. Rather than go and try to treat, you know, two or three teeth at a time, because even if you're doing quadrant dentistry, it takes time to eradicate that amount of disease and the bacterial load that's in that mouth. Whereas we can come through and with silver diamine flora, we can paint it across all the surfaces. It'll get uptake and absorbed. It'll arrest the disease. You've got the bacterial load. way, way down. And now you can sort of, you can take an exhale and you can kind of go and systematically now go through each tooth, remove disease and choose the restorative material that you see fit for the case and the patient that you're treating. For the most part, in dental school, we were taught to scrape everything down until it was squeaky clean. But obviously, the research is showing that we can actually leave that affected dentin alone and remineralize it with the aid of silver diamine fluoride. And then we get all this antimicrobial activity. Are you leaving that leathery dentin there as a substrate for silver diamine fluoride? Or are you kind of getting down to the squeaky clean dentin? So I have to tell you, I take different approaches and individualize the care based on what I see in front of me. So let's start like, for instance, with like a child. Somebody comes in, they have, let's say each quadrant has several smooth surface lesions on it. And they're young, they're squirmy in the chair. i'm not going to do anything i'm not going to pick up a drill i'm not going to try to traumatize or introduce anything foreign i'm just going to kind of with the kid and the parent Of course, I'm going to talk like painting some medicine on your teeth, right? And we're going to go through and we're going to arrest all those lesions. And then what I'm going to do is I'm going to take a more slow approach to winning the child over, doing it so that I don't traumatize them and change out maybe periodically, depending on the size. Because some of them, they're really small and they're incipient. And I'm just kind of knocking it out. I might do two or three treatments spread out about. seven to 10 days apart with SDF, and then I feel like they're good and hardened and everything's arrested, their baby teeth, I may leave those until they shed, or I may come over and do some restorative material of choice. Let's say it's an adult and they come in like the one we described. It's just a hot mess going on in there. There's lots to do. Same approach. I'm going to go ahead. I'm going to just paint it on judiciously on all the areas. Make sure that it's absorbed. I really get a good uptake. And then I'm going to come back and systematically, you know, come through and treat. If it's somebody who, let's say it's an elderly patient and they're in visiting from the nursing home for a wellness check. And I spot that they have, you know, root carries a little bit going on underneath an old crown. And it's something that I can arrest the lesion right then and there. and maybe I have access where I can seal up that little bit of hole with glass ionomer. I love to combo that one-two punch of STF with a... a type 2 glass ionomer, nothing that's light cured because, of course, if you introduce heat from a curing light to freshly applied STF, the silver will precipitate too early at the surface and you really won't get deep penetration and get that full rest of caries down in the tubules like you're looking for. So I usually go with things that are... auto-set, which I know is a little disconcerting for my colleagues who like to move at the speed of light when you're in restorative procedures. But you do have to get something. They have nice, fast sets that will usually be set up in three to four minutes in the mouth. So you do a lot of aesthetic dentistry in your practice, yet you also use silver diamine fluoride very regularly on your patients, which some might see as a contradiction. And obviously, we know that silver diamine fluoride stains infected dentin. How do you reconcile the two? In other words, in what ways can silver diamine fluoride actually complement an aesthetic-focused practice? So I think the main concern people have with STF is that if you have an active karyogenic lesion going on, you apply this liquid to it, it will turn that surface black. And if that happens to be anywhere in the social six zone where you're smiling and flashing, that may not be something that any of us would want to go wearing around having, you know, dark spots on your teeth, drawing attention. I have found. That in the posterior, I have nobody even asked questions about it. It's very rare. You describe, hey, this has silver in it. And as it's going about its business, I usually say cauterizing and disinfecting the lesion. That's the two terms that I kind of use. The silver. will come to the surface and it turns the tooth dark or black in color. And that's something that we will later then go back and we can remove. And if it happens to be something that's in the front or I'm concerned the patient's going to notice when they look in the mirror, I just assure them, hey, we're going to get this changed out, you know, in short order. It's not going to be a long time. So it's all about sort of how you language it and explain. No one to date tell me no. Yeah, in the social zone, the aesthetic zone, if you do decide to use SDF, you can put glass on them or over it temporarily, right, just to block it out? Certainly. Certainly you can. Certainly. I just wouldn't do anything with resins and light carrying again so that you don't prematurely precipitate silver. to the surface so it doesn't impregnate and get deep into the tooth. We want it to sit. We want it to dwell. We want it to do its thing. And we don't want to rush it with the heat that's generated from curing light. So that's why I go with a nice, regular, auto-set glass ionomer. Some restorative dentists, Dr. Bizga, worry that using silver diamond fluoride means losing out on restorative procedures and income. Now, I know you don't agree with that. So from your perspective, How does SDF actually fit into a financially healthy practice model where the dentist depends on doing restorative dentistry to drive revenue to the practice? Yeah, so that argument to me is so foreign because I guess it's about how you lay it out to the patient. I suppose if you were to put into buckets or categorically, we have materials and things that we use on what I'd call an interim basis and then materials that we would call more definitive or long-term, right? And I think that this is a lovely bridge between the two. SDF sort of is a bridge between things that are interim. versus things that we're moving towards long term. So hear me out. If I apply this onto a tooth that has large carious lesion on it, my attempt is just to get the disease under control till we can later go back. That's usually part of the discussion. It's never, hey, I'm applying this one time to your tooth and you never have to return and you never have to worry about it. Usually I present and I say things like, This isn't bothering you yet. And that's a very powerful word yet, because it implies to the patient that, you know, there is something wrong. And in a matter of time, you're going to have a problem with it, even though sometimes we as dentists make the mistake of sort of correlating. If it's not hurting you, it's not a problem. And that's a bad sort of slippery slope to go down. So I like to frame it. I'm like, well, this isn't. This isn't bothering you yet. Well, we probably want to intervene. And I've got this wonderful medicine that I can apply to the tooth that will take. care of what's going on there so it doesn't bother you in the meantime until we can get a proper filling in there. And that's kind of how I frame it. So it's always setting it up for what's next because SDF on its own is really just a bridge between what I'd call interim versus more definitive care. So if you were giving a lecture, Dr. Bizga, on this interim treatment regimen. And you just finished showing your slides of how you can, you know, you do major caries control and disease control using silver diamine fluoride. And someone raises their hand and says, you know, I'm a traditional dentist. I'm doing what I learned in dental school. I look for decay. I excavate it. I get down to sound tooth structure. If it's deep, I put a liner in and then I go right in with my direct restorative or I do a... indirect onlay or crown, whatever is necessary, and I go right to the restorative treatment. What would be your response to that? Is there anything wrong with that? There is nothing wrong with that. There's nothing wrong. If somebody says, hey, listen, in my practice, my flow, the time that I have, block schedule, et cetera, to be able to see a patient and be able to knock. quadrants all out within a matter of a week or two god bless you you know but the way that typically works in my office i may be scheduled out six weeks seven weeks out for for seeing me And so I may not be able to see everybody. And so philosophically, to be able to know that I've treated or I've taken care of a patient, at least in part, until I can get to the final, that's what I love about it. I'm not making anything worse. I certainly would argue I'm making a situation better if I've done a medicinal treatment with SDF. But if somebody said to me and said, listen, I have the time. I love doing quadradentistry. And I'm just going to knock them out. out quadrant at a time and I'm going to skip all the interim steps, that's fine if they see that. But most of the time, I don't feel as though in my 20-year career, I found most people want to sit that long, want to come in for that, don't have that kind of free time to get in. Maybe they don't even have the cash to be able to do all that work at once. So here's another perspective I want to throw at you, Dr. Bizga. Somebody raised their hand and says, listen, as dentists, we are responsible to do whatever we can to preserve and conserve tooth structure. And by using silver diamine fluoride first on decay, that's much more selective and conservative than picking up a drill or using even a hand instrument and scraping out some of that leathery dentin that can be restored in some way by the silver diamine fluoride into a material that the literature shows can be as hard or even harder than natural dentin. So from the standpoint of conservation and reducing the chance of future endodontic complications or fractures or generalized loss of the tooth, it seems to me that somebody that raised their hand and made that point to you has a really good point saying, you know, we need to do whatever we can to conserve tooth structure and using silver diamond fluoride is a darn good way to do that. What would be your answer to that? Yes. So I think if now you're tying in it, I love it. You're getting into the weeds here, Phil. So like when you start thinking about and you look into the research, let's tie endo into this, right? If you look at all the endo literature, the premium from what our friends in the endodontic community have given us is that preservation of Denton. is the hallmark of the tooth making it through its life cycle or extending the life cycle of the tooth. The more tooth you can preserve when you're doing a root canal, the better chance that tooth has to making it to its 85th birthday. Similarly, and what you're saying is if, hey, if we are re-impregnating, you know, otherwise affected denin, with silver, which if you look at some of the rabbit studies and the rat tooth studies that they've done with silver diamine fluoride and extracted teeth and whatnot that were carious, you can see the silver actually impregnating into the tubules and reinforcing affected dentin. So yes, if you're... thinking of it from a tooth preservation and life cycle. If somebody comes in, you remove some of the soft leathery stuff, you hit it with silver diamine fluoride, maybe two to three treatments, you re-impregnate that affected dentin with silver. It's now bacteria-free. It's now hardened tooth structure again. And now you can build up off of that. Didn't you do something that in the long term is going to benefit the patient? Yes. And I always like to frame it in the terms of, I help the tooth make it or get closer to its 85th birthday. And then after that, I tell patients after 85, all bets are off. But my noble goal, try to get it to its 85th birthday. Yeah, no, I think that's a way to go. And I think if you approach the patient with that option and say, here's another way we can do this, I think a lot of patients will say, I'll go with the SDF. Now, let me ask you this. because we're about three quarters way through or more of the episode. We talked offline, you like SilverSense SDF. Tell us about that material, why you like it, and how you typically apply it. Well, it's great in that it's widely available through distribution. It's got a great dropper bottle. And if you work enough, and I have... since 2017 with various forms of silver diamine fluoride. Other manufacturers make it. They have various dispensing units and unit dose, et cetera. If you're not careful in your application or what you put, dispensing wells, et cetera, silver diamine fluoride having a bunch of silver in it, it can stain your countertops. It can give a temporary amalgam tattoo if you have a little bit on your glove and you were to graze the patient's cheek. Um, Ask me how I know. And so you learn little things like be careful about it. You want to have very precise dropping onto micro applicators. You want to have good cotton roll isolation. You want to contain and have the liquid just kind of touching the areas that you want it. You want to dry it off thoroughly. And then I like to even post application with using fluoride varnish because of more for sealing. in and keeping the silver flavoring from, it's a little taste averse for the patients because that silver is so potent. They get that metallic taste. So I like that it has a very, very precise dropper out of the dispensing bottle. So literally my assistant will just... put a drop of it onto a micro brush tip, and I will take that right to the patient's mouth. And that way you're not wasting. You don't put a bunch into a dappin dish with this dispenser. It's very precise. And then it air dries for about 60 seconds, right? You don't rinse. You don't rinse it off. That's right. No rinsing. Right. None at all. But you do take the excess off with a cotton pellet or something. And then you go in on top of that with Floridose. Yes. And that's more so for the taste, which I found interesting because we talked offline about this. But it also has other benefits as well, obviously, the fluoride that's in that fluoride. Certainly. You've got the, I think, fluoride varnish at a 5% sodium fluoride, 22,600 parts per million of fluoride, and one drop of... Silver diamine fluoride has something like 44,800. So on the magnitude, it's double almost the varnish. So if you think about it, if you apply it, another benefit if you're putting the varnish over the top, you're just introducing more fluoride into that ecosystem, which is going to kill that bacteria. Right. Now, interproximately, to get that SilverSense SDF in there, interproximately, does that just kind of wick in there by itself? You just kind of place it with a bender brush and it kind of wraps around and kind of looks for the infected dentin? That's one way to do it, but that one's a little bit, you're sort of at the whims of the curvatures and the angles of the tooth. My preferred way is one of my favorite treatments on college students. I do this a lot. They get incipient lesions. They leave mom and dad's care. They don't brush their teeth like they should. They end up getting... beginning incipient lesions. They come back for a wellness check. We take bite wings. Boom. There it is. I will get super floss. And I love that little foam padded section of super floss. Many orthodontists carry it. I think it's an oral B product. It's got a very stiff tip. You can floss it underneath the contact area, get that foam part below the area where the lesion is. And then I will wick SilverSense right onto that foam part. bring it into the contact area, and floss it up and down on that tooth surface. And that's how I get perfect penetration on incipient proximal lesions. Well, that's a great clinical tip for our listeners. That is fantastic. That helps our show, Dr. Bizga. Yeah, I mean, that's why people listen. So I'm curious to know, as we wrap up this episode, you started using silver diamine fluoride in 2017. So it's 20... 25 now, we're almost at the end of the year. And, you know, so you've only been using it eight years. How long have you been practicing dentistry? 20. 20. So what made you integrate STF into your workflow so routinely now that before 2017 you weren't? Well, all right. So... Two things. One, it wasn't available in the U.S. until 2017-ish. I think Oregon Health System might have brought it in in 2016, early 2017, then it got FDA cleared. So it really wasn't widely commercially available. 70-plus years of research out of Asia. This is not a new product to the world. This is just newer to the United States. And thanks to the Oregon Health System for their partnership for bringing this over into our country and getting FDA. cleared. The real reason that I got, I'm going to give a shout out to my man, Dr. Lou Graham, a good colleague and buddy of mine. He said to me, Tim, you should check this product out. It has a lot of promise. It's kind of cool. He was reading about it. He was checking it out. And that's how you learn friends. You know, if you have a good idea, you don't keep it to yourself. You share it with somebody. And so if it weren't for Lou Graham telling me you should check this out and see about bringing it into your practice, I probably wouldn't have looked at it. And I went ahead and brought it in, started playing around with it, saw some really great results. I mean, there's a lot more that it does than we even got to cover in our brief 30 minutes together. Right. Yeah. I mean, there's a zombie effect also that I've been reading about where actually over, you're laughing, but you're familiar with the zombie effect of STF. I got it. I got it. Yep. Yeah. And for our audience, look that up. That's the... residual effects of SDF years later where it continues to be what antimicrobial I would assume that's what the zombie effect is it continues to It's the silver. Yeah. There's a lot about that silver that we're learning. The fluoride, you know, it'll dissipate. It might recharge, but that silver is really something special. And as your listeners may know, medicals really embraced a lot of silver thread and things that they're putting into wound care because of how wonderful it is. Without antimicrobial, powerful antimicrobial agent for sure. Is there any reason in your mind, you're a key opinion leader, you do a lot of lecturing, you take a ton of continued education, you're a top-notch clinician and you're well-respected worldwide. Is there any reason in your opinion for a dentist not to have silver diamine fluoride in their armamentarium? None whatsoever. It's one of the best tools that I've added into my toolbox and I've kept it in there for the past eight years. Comes out almost... Every day, there's someone somewhere in my practice that I'm putting a drop here or there. I find it to be very useful. And I think those who embrace or at least have it as an option on the table, they'll find some wonderfully terrific uses for it as well. Very well said, Dr. Bizga. Appreciate your input. Lots of good clinical tips today. Really good clinical tips. Thanks for sharing them with us. And we look forward to having you on future programs. Have a great evening. Bill, thanks for having me.