14
New Mexico Dental Journal, Summer 2015
Silver Nitrate:
a tool that belongs in your toolbox,
continued
In my practice
In addition, I now routinely use silver
nitrate as an adjunct to my restorative
treatment plans. Patients with numerous
carious lesions at new patient exam
typically receive an initial silver nitrate
treatment during the exam. I have found
that this makes my operative work much
easier going forward. Gingival health
next to class V lesions greatly improves
so that I’m not constantly fighting
gingival bleeding. I also find I much
prefer removing the flaky, discolored
caries that transitions suddenly to sound
dentin in silver nitrated treated teeth
rather than dealing with light colored
mush that may extend far too close to
the pulp with a much less distinct tran-
sition from carious to healthy dentin. I
used to prioritize the largest lesion in
a patient’s mouth to be treated first.
Now I may apply several rounds of silver
nitrate while dealing with the patient’s
more routine cavities. By the time I work
on the largest lesion the pulp has had a
chance to recede from the caries so that
the tooth has a much better endodontic
prognosis.
So in the case of my denture patient
who wasn’t willing to become a denture
patient, we discussed the potential to
arrest the progression of his cavities
using silver nitrate. This was acceptable
to him as an option to potentially delay
any further degradation of his teeth
and allow him to retain them as long as
possible. During his exam visit I spent
five minutes to apply 25% aqueous silver
nitrate with a microbrush to each of his
cavities and immediately cover each site
with 5% fluoride varnish. He returned
three more times over the next six weeks
for repeat applications. At the end of
that time his cavities were not fully hard-
ened, but they were significantly darker
and had much less plaque over them.
His gingival health also greatly improved
next to the carious root surfaces, and in
many cases the previously subgingival
lesions were now fully supragingival due
to reduction in gingival inflammation.
My plan at that point was to start to
restore some of his anterior teeth with
glass ionomer to improve the esthetics
of his smile while continuing to apply
silver nitrate to the remaining lesions at
each visit. Unfortunately, he didn’t keep
the restorative appointment and I didn’t
see him again for almost a year. Finally,
in December of 2014 he returned again
for a new periodic exam. When asked
whether he had made any of the diet or
oral hygiene changes we had discussed a
year before he admitted that he hadn’t.
His mouth was still as dry as ever.
However, of the nineteen previously
documented carious teeth, only eight
had any evidence of current activity or
progression.
#14
was now clearly non-
restorable by any definition and
#12
had developed an apical radiolucency.
The remaining sites had black, hard
surfaces with minimal plaque. The thing
that really shocked me, though, was
the number of sites with radiographic
evidence of remineralization. I re-applied
silver nitrate and fluoride varnish to all
the lesions and convinced my patient to
schedule for extraction of
#12
and
#14
.
He didn’t keep his extraction appoint-
ment and I haven’t seen him since, but I
have the peace of mind that I did make a
positive impact on his oral health despite
the many challenges in this case.
My sincere hope is that my experience
will encourage other dentists to add non-
surgical caries arrest with silver nitrate
to their armamentarium. Think of it as
a fire extinguisher for dental caries. If
you’ll take the time to put out the fire
you’ll find that it’s much easier to start
rebuilding the house. The full text of Dr.
Duffin’s groundbreaking article is freely
available on the California Dental Asso-
ciation
Journal’s
website. Please study it
for yourself. I believe you’ll come to the
same conclusions I have.
FMX taken February 2015. Lesion progression only on #14.
Multiple sites of radiographic remineralization.
Premolar bitewings before and after.
