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The SDF Decade by Michele Jerrell, Publisher

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The SDF Decade 

Ten years after the story that changed the conversation

by Michele Jerrell, Publisher

A well-respected pediatric dentist stood at the front of a packed conference hall and, with a dismissive laugh, waved off the entire idea of silver diamine fluoride. “People don’t want black teeth,” he said. Sitting in the audience was a clinician who had once admired him, and as the room chuckled along, her heart sank. It also hardened into something useful.

“That lit a fire in me to prove him wrong,” Dr. Jeanette MacLean recalls.

So she did the only thing she could think to do. She started publishing. MacLean posted SDF case studies and research articles to her website and social media, building a public record of what the treatment could actually do. That trail is how a journalist from The New York Times eventually found her, and in 2016, found the story that would follow her for the next decade.


The shockwaves
When the article ran, the response was immediate and divided. “I remember the shockwaves it sent through the dental community and the general public, which were an interesting mixture of excitement and skepticism,” she says. Her practice phone and her social media accounts filled with inquiries from dentists, hygienists, patients, and parents around the world. Did she have any sense, at the time, that SDF would become as influential as it has? “I had no idea, but I was hopeful,” she admits.


A deliberate choice
The patient at the center of the story was not chosen at random. MacLean selected Knox deliberately, with a point to make. One of the misconceptions she still hears from colleagues is that patients will reject SDF over its appearance, or that it’s “only for Medicaid patients.” Knox is the son of a medical anesthesiologist.

“That was my subliminal message to the world,” she explains, “that here is a child whose mother clearly has the knowledge and money to do what she feels is the best treatment for her child, and she chose SDF.”

The lesson she draws from it is one about humility at the chairside. “As clinicians, we should never make assumptions about what parents or patients want for their treatment,” she says. Informed consent, in her telling, means laying out the risks, benefits, and alternatives, including the option of no treatment at all, and then allow the family to choose. “Give them the options, review the pros and cons, then empower them to decide which treatment option best fits their individual needs and goals.”

Knox, for his part, still comes to see her. He now says he wants to be a dentist when he grows up, a detail MacLean reads as its own kind of evidence. A child who grew up with minimally invasive care, rather than fear, is a child who associates the dental office with something other than dread.


What the article set in motion
The piece changed the trajectory of her career, though not in the way people might assume. It informed patients that SDF existed, so they began asking for it by name, and it nudged clinicians who had never heard of it to learn more. That chain of events launched MacLean’s speaking career, even as she has continued to treat patients full-time in her private practice.

Her office, notably, does no marketing. Offering minimal interventions like SDF, she says, has done the work that advertising usually does: attracting new patients, retaining existing ones, lifting satisfaction among patients, parents, and staff alike, and generating word-of-mouth referrals.
The SDF Decade
Photo credit: Caitlin O’Hara with The New York Times


What she got right, and what blindsided her
Some of what came next, MacLean predicted. She knew that parents hoping to delay or avoid sedation for young children would want SDF, and she knew those same parents would go looking for it when no one offered it. “As a mom, I also knew these would be the parents to seek second opinions when SDF wasn’t mentioned or offered,” she says.

Other developments outran her expectations, mostly in a good way. She has been struck by how quickly most Medicaid plans and several private insurers began reimbursing the SDF code. Coverage still isn’t universal, she notes, but even when it isn’t covered, plenty of families are willing to pay out of pocket for a noninvasive option.

One controversy, though, she never saw coming, and it came from inside the profession. The Times article mentioned the fee paid for Knox’s treatment. MacLean had refused to discuss pricing with the journalist, explaining that it would amount to price-fixing or collusion. What she didn’t know was that the reporter had also asked Knox’s mother, who simply said what she had paid. “A lot of dentists got upset about this and directed their anger towards me,” she recalls.


The gateway
If anything, MacLean argues, SDF cracked open a much larger conversation about treating cavities without the drill. “You could argue that SDF became the ‘gateway drug’ to other minimal interventions,” she says, pointing to atraumatic restorative treatment, Icon resin infiltration, Curodont, Papacarie Duo, and the Hall Technique.

Adoption, however, has been uneven. Among pediatric dentists, she says, SDF use is now pervasive. The general dentist community is another matter, where she sees inherent bias and a lack of awareness still working as barriers.


The case she can’t forget
For all the talk of aesthetics and reimbursement codes, MacLean is clear about what is actually at stake. Over the past decade, she has watched SDF improve safety, lower costs, and widen access to care, but its most important role, in her view, has been helping young children and special needs patients delay or avoid deep sedation and general anesthesia.

She knows the cost of the alternative firsthand. MacLean served as an expert witness in a wrongful death lawsuit involving a 14-month-old who died from complications of general anesthesia, administered in a dental office to treat teeth that were asymptomatic. SDF, she believes, could have prevented that death. “I made a promise to her mother that I would do everything in my power to help spread the word about the safety and efficacy of SDF,” she says.
The SDF Decade

Not a magic wand
The advocacy comes with a caveat she is careful to repeat. Her biggest worry about SDF is unrealistic expectations, from clinicians and patients alike. “I love SDF, it’s amazing, but it’s not a magic wand,” she says. It demands careful case selection, proper application, ongoing monitoring, and reapplication, and cavitated lesions that can’t be cleaned still need a restoration. Caries, she stresses, is a chronic disease that has to be managed in partnership with patients over a lifetime, not cured in a single visit.


Where it goes next
The science, meanwhile, keeps catching up to what early adopters already believed. MacLean points to Advantage Arrest SDF from Elevate Oral Care, which she says is now eligible for FDA approval as a drug to treat caries, on the strength of multimillion-dollar, NIH-funded clinical trials conducted in the U.S. SDF was originally cleared in this country only as a device for dentinal hypersensitivity, the same clearance as fluoride varnish. She credits two of her dental heroes, Dr. Peter Milgrom and Dr. Mike Shirtcliff, with getting it into the hands of U.S. clinicians in the first place.

She’s also watching the products evolve. A new gel formulation from Elevate Oral Care has caught her attention because it clings better to tricky surfaces like exposed roots, letting her place it with precision instead of watching it run away from the treatment site.


I told you so
Asked what she would tell her 2016 self, the clinician bracing for that first New York Times article, MacLean doesn’t hesitate. “Be bold, be outspoken, and do not be afraid,” she says. “The good old boys can no longer control the narrative, and you will help shift the paradigm.”

A decade on, she seems to know it landed. Among the SDF cases pinned to her Instagram is a video of MacLean applying the treatment to her own teeth, set to Chappell Roan’s “Good Luck, Babe!” The caption, more or less, is the same thing she has been saying since a respected colleague laughed at her from a conference stage.

I told you so.
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