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Alternative for fill and drill treatment of cavities

Eli Powell, who is 4 years old, brushes his teeth at home with the supervision of his mother, Heather Powell.

Heather Powell got a big surprise when she took her 4-year-old son for a routine dental checkup — young Eli had several cavities and needed eight crowns on his back teeth.

The Baltimore mom worried about her child undergoing such a complex medical treatment, which the doctor said would require general anesthesia.


"I could not wrap my head around the fact that my kid would have to go through a procedure of this magnitude," Powell said.

Desperate for an alternative, Powell began searching the Internet for other options. She discovered a handful of dentists around the country who use a mixture called silver diamine fluoride to freeze cavities, preventing the infection from spreading. The clear concoction is simply painted on — a process that takes mere seconds per tooth. The silver makes the tooth hard.


Powell was sold.

But use of silver diamine fluoride is not widespread and not usually offered as an option to patients. Some dentists have not even heard of the treatment. Powell had difficulty finding a doctor who used it, finally persuading her dentist to order it and try it on her son.

While dentists around the world have used silver diamine fluoride for decades, it wasn't approved for use in the United States by the Food and Drug Administration until the past year and then only for limited use as a device to treat teeth sensitivity in adults and not cavities. Dentists who use it to treat cavities do it off label — when a drug is used for purposes other than intended.

Some dentists and patients are turned off because the process turns the spot on the tooth where it's applied permanently black.

Yet for all the critics, there is a growing movement among some dentists in favor of its use. Clinical trials at least two universities — the University of Michigan and the University of Iowa — are underway, seeking to gather more evidence of its effectiveness that could eventually pave the way for an FDA application for treatment of cavities. Supporters of the treatment call it a less invasive option then the traditional "drill and fill" methods that may scare young children, and even adults. It also is a much cheaper option.

"I think it is an exciting new tool in our tool kit," said Amr Moursi, chairman of the department of pediatric dentistry at the New York University College of Dentistry. "It is certainly not a silver bullet for every cavity or every child who has tooth decay, but it has the potential to significantly change the way we approach tooth decay, especially in young children and underserved populations."

Not everyone is completely on board with the treatment. Dr. Norman Tinanoff, chief of the division of Pediatric Dentistry at the University of Maryland School of Dentistry, said better studies need to be done in the United States before it is widely used. And while silver diamine fluoride stops cavities from growing, it doesn't repair the existing damage.

"Cavities need to be fixed," Tinanoff said. "You can't walk around with a big hole in your mouth. The tooth will catch food."


Dentists use the treatment in various ways. Some use it as a stop measure until they can fix a tooth later or, if it is a baby tooth, until it falls out. Others use it as a permanent solution and reapply the silver diamine fluoride periodically.

A spokesman for the American Academy of Pediatric Dentistry said that dentists use similar products, such as silver nitrate, off label. The biggest obstacle to getting silver diamine fluoride on the market has been the expensive and expansive FDA process, said academy spokesman Kevin Donly, who is also a Texas dentist who uses the product.

"It comes down to federal rules to what it takes to get FDA acceptance," Donly said. "The laboratory research that is out there makes it look real promising."

The Children's Dental Health Project in Washington said that while they see high potential for the drug, it is not necessarily a panacea for treating tooth decay in children.

"This is a disease that's diet-dependent and must also be managed through interventions focused on behavior change in addition to clinical interventions," said Colin Reusch, a senior policy analyst with the group. "That being said, in particularly severe cases of decay, providers are looking to put the fire out, so to speak, and silver ion products like silver diamine fluoride seem to help stem the disease."

Reusch said that the American Dental Association has introduced a new treatment code that, among other things, includes the application of products like silver diamine fluoride with the aim of arresting dental caries. He said further study would help gather better data on effectiveness of the products.


"The science isn't yet settled in terms of the most effective methods of and settings for application, ideal frequency, long-term impact on disease trajectory, or perception by the populations that are most likely to receive these kinds of treatment," he said.

The American Dental Association said in a statement that it "does not advocate for off-label use of FDA-approved products yet recognizes that individual dentists who are familiar with their patients' health history, current state of oral health and who take into account the risks and benefits to the individual patient may choose to recommend FDA-approved products off label."

Powell wants more parents and dentists to know about the treatment. So far it has worked for her son. He will go back in a few months for a follow-up.

"We avoided tons of trauma, pain and discomfort," she said.