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Case Conference Medically Compromised Patients Oncology Oral Radiology Supporting Your Practice

Can Silver Diamine Fluoride Arrest Post-Radiation Caries? Case Report

Dr. Jessica Metcalfe prepared an Oasis presentation about the possibility of using silver diamine fluoride to arrest post-radiation caries. Silver diamine fluoride is fairly new in Canada; and to date its efficacy has only been proven with children and older adults. Through these cases, Dr. Metcalfe is exploring the possibility of helping patients who undergo radiation and experience dry mouth and subsequent caries.

Dr. Metcalfe is staff dentist in the Department of Dental Oncology and Maxillofacial Prosthetics at Princess Margaret Hospital Cancer Centre.

I hope you find the information valuable and we always welcome your feedback, suggestions and questions at oasisdiscussions@cda-adc.ca

Until next time!

Chiraz Guessaier
CDA Oasis Manager


  • Head and neck cancer patients that receive radiation develop xerostomia (dry mouth). This is due to exposure of radiation to the salivary glands. Consistent xerostomia leads to demineralization and dental caries.
  • If post radiation dental caries is unchecked and teeth need to be extracted in the radiated field, there is a higher incidence of osteoradionecrosis – a highly morbid condition that is expensive to manage.
  • As of February 2017, Health Canada has approved silver diamine fluoride (SDF) which has been shown to work in pediatric patients and in the geriatric population. We know that SDF is anti-cavity and can arrest caries after application. If this holds true then stopping progression of caries in a patient with dry mouth seems plausible. The author presents a case of a patient at Princess Margaret Cancer Centre Dental Clinic using the conventional management of amalgam restorations as well as SDF.
  • It is understandable that esthetics can be an issue. Although, when both dentist and patient are well-informed about the use of SDF, then it does not become disconcerting. Patients who neglect to comply with daily fluoride application may eventually require extractions potentially  leading to osteoradionecrosis (ORN). In this case SDF prevented the progression of caries at an early stage – preventing a potential cascade of radiation caries, multiple extraction, and elevated risk of osteoradionecrosis. Esthetics can be dealt with after oral hygiene and fluoride compliance is re-established at which point esthetic restorations can be planned.

Full Case Presentation (12.39″)





  1. Dr. Hardy Limeback March 16, 2018

    Very nice presentation. SDF results in very low ingestion of fluoride. On the other hand fluoride custom trays with high conc. NaF gels can result in significant fluoride ingestion that can be toxic. See https://www.ncbi.nlm.nih.gov/pubmed/15693498
    Chronic daily ingestion of large amounts of fluoride can also promote bone cancers, something you don’t want to induce in head and neck cancer patients.
    See our NRC Report. https://www.nap.edu/catalog/11571/fluoride-in-drinking-water-a-scientific-review-of-epas-standards
    Any comments?

    1. Dr. Pasquale Duronio April 4, 2018

      Wow an antifluoridationist admitting that a substance’s toxicity is relayed to dosage. How refreshing.

      1. Dr. Hardy Limeback April 4, 2018

        Yes fluoride’s toxicity is related to ingested dosage (always said it was). One drop of SDF swallowed approx = the amt. of fluoride swallowed from 1 L of fluoridated water. BUT if SDF contacts soft tissues there may be a concern since SDF is almost 45000 ppm. So in a very small area of soft tissue tht comes in contact with the SDF, the SDF could be extremely toxic to the cells. Fluoride in known to disrupt DNA so converting even one mucosal cell to a cancerous cell is not good. This has not been studied.

  2. Dr. Caroline Fulop March 27, 2018

    Excellent presentation Dr. Metcalfe! We just received SDF at The Ottawa Hospital Dental Clinic and are looking forward to offering this as a treatment option for our regional head and neck cancer patients as well as our medically complex patient population. Looking forward to future updates!

  3. Reza Nouri April 5, 2018

    nice presentation, Dr. Metcalfe. A regimen for reapplication of SDF needs to be developed as well, since its effect is transitory. looking forward to more updates, and especially well-designed studies.

  4. Dr. Nabil Ouatik April 5, 2018

    Very good presentation. I would like to invite all dentists interested in learning more and exchanging about silver diamine fluoride to attend our International Symposium on Silver diamine fluoride which will be held at McGill University in Montréal in one month: http://www.cvent.com/events/silver-diamine-fluoride-symposium/event-summary-0b7ce09895bc4037892d2d95dc6849af.aspx

  5. Stephanie Fung April 7, 2018

    An unrelated question to SDF, but with post radiation patients. What about periodontally involved teeth that are mobile and have minimal bone support? What is the treatment protocol if extraction might not be preferred?

    1. Jessica Metcalfe April 11, 2018

      I need a bit more information on why the teeth might not be extracted?

      1. Stephanie Fung April 12, 2018

        Wouldn’t extraction pose a risk of Osteoradionecrosis?

  6. Dr. Richard Wilczek April 9, 2018

    Does applying SDF as a base before placing an amalgam restoration reduce the chances of recurrent caries ?

    1. Jessica Metcalfe April 11, 2018

      Unfortunately, there isn’t research out there yet in this regard. If you are asking if I use it under restorations, the answer is yes. I know some other dentists across north america who are using it for caries control under restorations. Like anything, only time will tell.

  7. Dr. Trey Petty April 12, 2018

    Great presentation, Dr. Metcalfe.
    Although I am no longer head of the clinic, at the Foothills Hospital / Tom Baker Cancer Centre in Calgary, we had followed some patients for over 20 years post head&neck radiation therapy, and we pretty much have universally found that despite excellent compliance with fluoride trays, things just really start falling apart after a few decades. This is particularly with patients in the 6500-7000cGy levels.
    As protocols for treatment are improving, and as patients are surviving longer and longer, it is making me re-think some of the “optimizing” assessments we were doing, wondering if more aggressive tooth removal is more realistic.
    Are you seeing this in your multi-decade survivors?

  8. Vasant Ramlaggan February 26, 2019

    Thank you very much for the great presentation! Excellent demonstration of prevention and intervention.


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