19 Questions (and Answers) about Brush-On Dental Therapies 

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December 13, 2022

Brush-on therapies have become a popular form of minimally invasive care in recent years. As an alternative to surgically managing caries, silver diamine fluoride (SDF), povidone iodine (PI), and non-staining peptide-guided enamel regeneration P11-4 offer patients and providers options that are often preferable to the “drill-and-fill” approach.

Change, in this case, is happening quickly.

“The adoption of SDF has been the most rapid adoption of any kind of new strategy in dentistry in its history,” said Peter Milgrom, DDS, emeritus professor of oral health sciences at University of Washington, during the latest CareQuest Institute webinar on patient-centered brush-on therapies for caries management. “As more students who graduate dental school use it, and as more managed care dental programs adopt care guidelines, you’ll see greater adoption of SDF as a whole.”  

More than 600 oral health stakeholders joined Milgrom, Jeremy Horst Keeper, DDS, PhD, and Laura Skaret, BS, RDH — both from CareQuest Innovation Partners, a for-profit subsidiary of CareQuest Institute — to explore these minimally invasive therapies and how to offer them based on patient needs. The expert panel also discussed how to empower oral health teams to use the therapies to provide patient-centered care and how to navigate future advancements.

Not surprisingly, there were dozens of questions from learners — dentists, dental hygienists, educators, and others interested in the topic — throughout the webinar. As a helpful recap for anyone who attended the webinar and an introduction to the topic for anyone who missed it, here are the top 19 questions the experts answered:

1. Is silver diamine fluoride good to be used on adults? 

The American Dental Association and World Health Organization say YES! 

2. Is SDF useful for seniors, as well?

Absolutely. The Journal of the American Dental Association (JADA) and Caries Research have published systematic reviews showing consistent strong effects on arresting root caries. 

3. What is the recommended reapplication frequency when using SDF for prevention? 

The best evidence thus far is once per year, but always consider patient factors. 

4. What is the success rate of using SDF on permanent teeth? 

Meta analysis shows ~81% caries arrest in patients with open active advanced caries lesions.    

5. Is six months payment the frequency limit or efficacy limit? 

Some dental benefits plans have this limit. Usually not. There are clinical trials of [using SDF] 1x or 2x per year, but commonly this is exceeded based on patient-specific factors. See the case study by Doug Young et al in JADA. 


6. Some products with SDF mention that it’s only FDA cleared for ages 18 and above. Can it still be used for pediatric patients? 

Yes, just like a fluoride varnish. 

7. What are the criteria of the lesions indicated to use SDF? 

Any active caries lesion without frank pulp exposure or irreversible pulpitis.    

8. Which codes should we use for SDF applications? 

D1354 for treatment and D1355 for prevention.    

9. How soon after application do you evaluate SDF efficiency, and how do you know it’s working? 

It depends on the disease activity and caries risk. It’ll usually be three or six months.

10. Do you recommend the use of a rubber dam when applying SDF? 

No. You should use cotton isolation only. 

11. For patients with limited access to dental care or with dental homes, there are concerns when it comes to pulpal exposure. What might happen if the tooth abscesses after SDF treatment? 

SDF does not cause abscesses. That’s been studied very thoroughly. If you have a D4 lesion where you’re using it as an indirect pulp cap, then it’s very effective at arresting caries and does not cause pain or infection. If you put it on an exposed pulp, it’ll probably sting. But the question is what were you going to do if you didn't use that? You could make a mistake and put it on a tooth where it’s a little uncomfortable, but that tooth’s either going to have a pulp treatment or it’s going to be extracted. So, if you made a mistake, and caused someone a little bit of discomfort, you’re not really changing the outcome at all.     

12. Do you have any feedback on how to help get colleagues on the dental side to start using SDF? 

I think that consumers are the ones who are the most effective at changing what dentists do. As SDF becomes a drug, and there’s more direct advertising to patients, when it gets more coverage, more and more dentists will adopt it.

13. What about getting medical colleagues to use SDF?

About 20% of pediatricians already apply a fluoride varnish, and that 20% is concentrated among providers who see largely Medicaid patients where it’s very hard to be referred to a dentist. All of these people are likely to start using SDF and they will continue to try to make referrals. The good thing about that is this is going to stop this problem while they’re in line to get care from a dentist. It’s not intended as a substitute. It’s intended as a complement to keep kids out of pain and out of the emergency room.

I [Keeper] personally believe that the medical teams will pick up SDF, whereas they’ve been slow to pick up fluoride varnish, because of its effectiveness. Prevention is boring, unfortunately. It’s a lot of what medical teams do, but you don’t see the effect of prevention. When it works, there’s no change. And fluoride varnish prevents, when done at a sufficient frequency, about 40% of cavities. When you place silver diamine fluoride, and keep placing it year over year, you’re stopping 80% of cavities. And you see it. Teeth harden, gums get healthy. So, the visible health feedback that medical teams will get, we believe, will spread like wildfire.

14. How about hygienists being able to apply SDF and being able to apply iodine? 

To our knowledge, there are no rules against hygienists placing SDF. If used for prevention, it usually follows fluoride varnish rules. If used for treatment, it may require a dentist diagnosis of caries first. ADHA and the Oral Health Workforce research group have wonderful state-by-state descriptions of detail [of permitted functions and levels of supervision].

Povidone iodine is an over-the-counter medicine, so I don’t believe that there’s anything limiting to dental hygienists from placing povidone iodine. It’s a very common practice to put povidone iodine on the trough of an ultrasonic scaler. That’s commonly done, and there’s no regulation against that to my knowledge.

15. Does iodine stain teeth? How does it taste? 

Iodine does not stain teeth, but it can stain clothes, so care should be taken near clothing. The volume is so very low that you really don’t taste much at all. If you use 400x the volume so you can swish, it'd be different (but don’t do that!).    

16. Is it better to apply 10% PI with a microbrush or other mini brush?  

The amount of iodine that you can absorb in one Q-tip is about the perfect dose of iodine to keep from applying too much, but you may use a microbrush as well.    

17. Are PI consumer rinses effective against caries as well? 

Great question; no, unfortunately not.    

18. Does P11-4 work on the root surface? 

Unfortunately not.   

19. What do you recommend in terms of brush-on therapies for elderly patients who cannot care for their hygiene well and have root caries? 

SDF. SDF has shown that if you paint it on the facial surface of the teeth that have bone loss and where the individuals have gingivitis, and place it once a week for three weeks, then that will basically completely clear the gingivitis and either arrest or prevent root caries.

Editor’s note: You can watch the full recording of the webinar — and access the accompanying slides — in the CareQuest Institute webinar library.

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