12
New Mexico Dental Journal, Summer 2015
continues
Silver Nitrate:
a tool that belongs in your toolbox
By Jeremiah Dye, DDS
“So, are you ready
to discuss moving
toward dentures?”
I’m sure every general dentist has had a
similar conversation to the one I had in
December 2013. The patient was a 62
year old male with arthritis, hepatitis C
and a history of drug and alcohol abuse.
He didn’t take any prescription medica-
tions. My initial FMX showed the patient
was missing all mandibular molars and
also teeth
#1
,
3
,
15
, and
16
. The patient
had generalized 2–3mm of horizontal
bone loss, and there was radiographic
evidence of caries on all remaining teeth
except
#25
,
26
, and
27
. When I asked
him to open his mouth to begin the
clinical exam the reason for his rampant
decay became clear. I was looking at a
case of severe xerostomia. My mirror
physically adhered to his tongue and
cheeks as I examined his mouth and I
had to wipe it frequently to complete my
exam. To me the restorative prognosis
in his mouth seemed hopeless. Dental
caries would destroy any restorative work
I might consider.
In these kinds of cases I like to ask a
question like the one above to gauge
where the pat ient i s emot iona l ly
regarding losing all of his or her teeth.
Sometimes the patients already know
what kind of condition they’re in and are
just ready to move on from a long losing
battle with caries or periodontal disease.
Those conversations go pretty smoothly.
However, sometimes you’re giving bad
news to people who really haven’t consid-
ered losing their teeth as an option. That
conversation can be a little more work.
For my rampant caries due to xerostomia
patient, dentures were not an option he
was willing to discuss. In fact, he would
not consent to any extractions—not
even teeth
#2
and
#14
which had no
opposers. I could have simply sent him
on his way with a warning like, “You’ll
be back when they start to hurt!” I could
have proposed a lot of restorative treat-
ment with a high likelihood of failure
or endodontic involvement. Instead, I
dug deeper into my figurative toolbox
and started to talk to him about silver
nitrate.
Stephen Duffin’s protocol
I first learned about silver nitrate as a
treatment to arrest dental caries in late
2012. Stephen Duffin, DDS, published
an article in the
Journal of the California
Dental Association
that November titled,
“Back to the Future: The Medical
Management of Caries Introduction.”
His article opened my eyes to a totally
different way of thinking about the
treatment of dental caries. When I
was in dental school I was taught that
carious lesions on smooth surfaces
can be arrested and remineralized, but
once cavitation has occurred the only
treatment is removal of the caries and
placement of a restoration. Dr. Duffin
described a totally different treatment
modality in which cavitated carious
lesions can be arrested using medication
without any surgical intervention at all
in many cases.
As I began to study his protocol I found
out that the use of silver nitrate to arrest
dental caries isn’t actually anything new.
In fact, W.D. Miller and G.V. Black wrote
about using silver nitrate to arrest dental
caries in 1890 and 1906 respectively. In
the 1920s Percy Howe became so affili-
ated with its use that the silver nitrate
began to be called Howe’s Solution. I
learned that carious lesions treated with
silver nitrate will turn black and harden
and cease to progress. I spent a lot of
time studying the safety of the silver
exposure and convinced myself that the
concentration and quantity Dr. Duffin
was using were well within established
safety guidelines. I learned about human-
ity’s long history of benefiting from the
antimicrobial effects of silver. Then I
ordered a bottle and started using it.
Over the last 2+ years of using silver
nitrate in my clinical practice, I’ve found
several situations where following Dr.
Duffin’s protocol to achieve complete
arrest has become my treatment of
choice. Those include caries in very
young and very old patients as well as the
mentally and physically disabled. All of
these groups have a hard time tolerating
routine restorative dentistry. In addi-
tion, I often recommend caries arrest
for inaccessible lesions like the buccal
surfaces of upper second molars or the
lingual surfaces of lower molars. I have
also found silver nitrate to be extremely
effective in arresting root caries.
FMX taken December 2013 showing rampant caries.
