Knowledge, Attitudes, and Behaviors of United States Dental Hygienists Use of

Silver Diamine Fluoride for Caries Management

ABSTRACT

Background: Silver diamine fluoride (SDF) is approved by the Food and Drug
Administration for the reduction of dentinal hypersensitivity, and has been shown to
prevent and arrest caries. While dental hygienists (DHs) are licensed to use SDF in
patient care, their knowledge, attitudes, and behaviors regarding use of SDF are
unknown.

Purpose: To assess DHs knowledge, attitudes, and behaviors regarding the use of SDF
during patient care for caries management in the United States (US).

Methods: The study used a cross-sectional and quantitative, email distributed survey of
a random sample of 10,000 licensed US dental hygienists in the American Dental
Hygienists Association member database. The 57-item questionnaire assessed DHs
knowledge, attitudes, and behaviors about the use of SDF in patient care. Responses
were analyzed using frequencies (percentages), chi-square tests, and analysis of
variance to describe and determine significant differences between groups of responses
using Qualtrics and SAS software.

Results: 1219 completed the survey for a 12% response rate. Knowledge: Over half of
the respondents (55%) were familiar with SDF use in patient care and 91-98% were
knowledgeable regarding SDFs mechanism of action and use for caries arrest. Attitudes:
77% agreed that application of SDF lies within the scope of DH practice, and 83% agreed
that the advantages of SDF outweigh the disadvantages. Behaviors: Majority (86%)
reported the likelihood of recommending SDF for caries arrest, but 75-88% have not
used SDF primarily because they do not have SDF available in their employment setting.

Conclusion: The knowledge among dental hygienists regarding use of SDF in patient
care was inconsistent. Although many think highly of the variety of benefits that SDF can
provide, the use of SDF is still lacking.

Keywords: silver diamine fluoride, dental caries, fluoride, dental hygienist

This study supports the NDHRA priority area, Clinic Level: Basic science (new therapies
and prevention modalities).

1
INTRODUCTION

Dental caries is one of most prevalent and chronic oral diseases spreading across

our globe.1 According to the Centers for Disease Control and Prevention (CDC), the

prevalence of untreated caries for children ages 5 through 19 is 17.5% and 27.4% for

adults between the ages of 20 and 44.2 CDC also reported that one in five adults aged 65

and older have untreated caries.3 Traditionally, management of a carious lesion has

primarily focused on operative treatment which can be expensive, time-consuming, and

access to care has been difficult for certain populations.4 Fortunately, dental caries are

highly preventable with use of fluoride treatments, which help decrease acid solubility,

aid in the remineralization of tooth structure, and inhibit bacterial enzyme activity. 1,4,6

Many fluoride products are effective at the superficial layer of the tooth, but few have

shown efficacy once the caries advance into the dentin layer.7 A potential solution exists

in the use of silver diamine fluoride (SDF), an inexpensive topical medicament that has

the ability to arrest the caries process and simultaneously prevent the formation of new

caries.5-6 SDFs simplicity of use, accessibility, and ability to be effective without

removing tooth structure can make it a preferable noninvasive alternative to certain

restorative procedures in dental care.5-9

SDF has been widely used to treat caries in Japan and other countries for over 80

years.4-6 In August 2014, the Food and Drug Administration (FDA) approved the first 38%

SDF product for reducing tooth sensitivity in the United States (US).5 Its off label use is

being promoted for caries arrest and prevention.5 Many clinical studies have shown the

effectiveness of SDF in arresting dental caries in children,4,9,11,14 and its management of

2
root caries in the geriatric population.12-13,16 Systematic reviews of clinical trials on

children and elderly adults reveal SDF is highly effective in arresting dentin caries when

applied every 6 months for a period of 2 to 3 years.9 While these clinical trials have

shown a successful arrest rate with bi-annual applications, some trials suggested that

annual applications proved to be just as effective.13,16 One major drawback to use of SDF

is the appearance of black stains on the treated carious lesion which may cause esthetic

concerns.9

With the recent growing promotion of SDF among the dental professional

community in the US, it is uncertain how dental hygienists will adopt its use in their

patient care. Their knowledge, attitudes, and behaviors surrounding its use are also

unknown. However, dental care professionals, i.e., dental hygienists (DH), are equipped

with the knowledge and skills to perform and teach best practices to achieve optimal

oral health and to stop the progression of dental caries.9 Since SDF is cleared as a topical

agent, DH may apply it in accordance with their current licensed duties once a dentist

provides a diagnosis of caries or, in the treatment plan, indicates its use as a preventive

measure.9-10

After conducting an exhaustive search using the following search engines and

key search terms: PubMed for silver diamine fluoride AND dental hygienist or

dental hygienists [Mesh] AND (Quaternary Ammonium Compounds[Mesh] OR silver

diamine fluoride [Supplementary Concept]), Embase for dental assistant/exp OR

dental assistant AND (silver diamine fluoride/exp OR silver diamine fluoride), and

3
Cochrane for silver diamine fluoride, no references were found regarding studies of

dental hygienists knowledge, attitudes, and behaviors of the use of SDF in patient care.

The purpose of this study is to assess US dental hygienists knowledge, attitudes,

and behaviors of the use of SDF for caries management using an online survey.

Therefore, the research questions asked for more specific information regarding: (1)

DHs knowledge about SDF in patient care in terms of familiarity, knowledge sources,

and indication for use, (2) DHs attitudes about the use of SDF in patient care in terms of

scope of practice, types of patients, advantages and disadvantages, and (3) DHs

behaviors toward the use of SDF in their practice in terms of recommendations and

frequency of use.

4
METHODS

This cross-sectional, quantitative study was approved by the Institutional Review

Board (#16-20960) of the University of California, San Francisco (UCSF).

The target study population consisted of licensed DHs working as clinicians in the

US. A sample of 10,000 participants was randomly selected from a population of 35,000

DHs in the American Dental Hygienists Association (ADHA) email database. Assuming a

10% response rate, a sample size of 1,000 respondents was estimated to be adequate

for determining statistical significance, based on the conservative expectation that 50%

of the DHs will not have familiarity with the use of SDF in patient care.17 Participants

who reported they had never heard of SDF were excluded. The ADHA approved and

supported this study.

The survey was pretested with a convenience sample of 9 dental hygienists in

the Master of Science in Dental Hygiene program and 1 dentist currently studying SDF at

UCSF for acceptability and feasibility. Following this feedback, the survey was modified

to improve comprehension of questions.

An invitation to participate in the survey was then distributed electronically by

ADHA to potential respondents using email addresses acquired from the ADHA member

database. The invitation described the purpose of the study and provided information

for giving informed consent as well as links to the survey instrument. The email also

provided contact information in the event a participant needed questions answered.

Access to the survey was accomplished by selecting the Yes box, indicating participant

5
consent. Follow-up email messages were sent at 3, 25, and 31 days to encourage non-

responders to participate.18

With regard to the surveys content, assessment of the knowledge, attitudes,

and behaviors of DHs concerning use of SDF for caries management was accomplished

by creation of a 57-item survey which addressed the following areas: the knowledge of

DHs concerning various uses of SDF in patient care (12 items), the attitudes of DHs

regarding uses of SDF for patient care (16 items), what recommendations concerning

SDF are DHs giving patients and, if DHs are using SDF, what purposes are being satisfied

with its use (9 items), and lastly, the demographic and practice-related characteristics of

the respondents (20 questions). The survey was distributed using Qualtrics, a web-based

research tool supported by UCSF.

Methods of measurement were primarily multiple choice and included 1

qualifying item (2 questions); 5-point fixed Likert scale items (24 questions);

dichotomous items, with 4 true and false and 7 yes and no items (11 questions);

and demographic items (21 questions). The scales of measurement included nominal,

ordinal, interval, and ratio data.

Knowledge of SDF in patient care was addressed by questions asking about the

participants familiarity with using SDF in patient care, what sources the participant had

used to gain knowledge of SDF, and whether the participant knew SDFs mechanism of

action and its indications for use in patient care.

Concerning the participants attitudes about the use of SDF, the survey asked the

participants whether they believed that SDF is within their scope of practice, that SDF

6
can enhance the oral health of various types of patients, that SDF provides advantages

for patients when they accept SDF as a treatment, that disadvantages would prevent

patients from accepting SDF for treatment, and whether the advantages of SDF

outweigh the disadvantages.

Recommendations, experiences, and actual use of SDF in the participants clinical

practice was ascertained by questions asking the participants likelihood of

recommending SDF treatments for patients, participants use of SDF for its 3 indications

in the last year, and if participants have SDF in their employment setting.

The demographic characteristics included participants year of birth, year

graduated from a dental hygiene program, number of years licensed as a dental

hygienist, highest dental hygiene degree earned, respondents employment setting,

state(s) in which he/she was licensed to practice in the past 6 months, approximate age

group of the patients he or she treated during the last 6 months, average hours of

clinical practice per week during the last 6 months, and the types of DH license held by

participant.

QualtricsTM and the SAS Software were used to tabulate the responses and

calculate the response frequency for each survey item. Chi-square analysis was

performed on the frequency of responses to behavioral variables to assess relationships

with selected characteristics of dental hygienists. Relationships were considered

statistically significant when P-values was less than or equal to 0.05. Lastly, Analysis of

variance (ANOVA) was conducted to compare the selected demographic and practice-

7
related characteristics of dental hygienists and their responses for the knowledge

variable.

8
RESULTS

The results are derived from a random sample of 10,000 dental hygienists

working in the US and with email addresses in ADHAs member database. The online

survey was completed by 1,219 dental hygienists, resulting in a 12% response rate.

Demographic and Practice-Related Characteristics (Table I)

The age range for almost half (49%) of the respondents was 50-64. Fifty-three

percent also graduated from their respective dental hygiene program in 1994 or earlier

and more than half (58%) have been licensed for over 20 years. The highest dental

hygiene degree reported was 38-39% for an Associate or Bachelor degree and 22% for a

Masters degree. In addition to having an RDH license, 4% were also licensed for

alternative practice (RDHAP) and 3% for extended functions (RDHEF). The majority of

respondents (59%) were employed in private practice, and the remaining respondents

(5-32%) were employed in education, public health, government, or worked

independently. The region where the respondent was licensed to practice was

distributed similarly, (20-29%) among four regions in the US: Northeast, Midwest, South,

and West. The majority of respondents (76-91%) treated a wide age range of patients

aged from infancy to 65 years and older (Results not shown). The average hours of

patient care practiced by the respondents during the last 6 months were also

distributed similarly (31-39%) among three categories: 1-16 hours, 17-32 hours, and

more than 33 hours (Results not shown).

Knowledge, Attitudes, and Behaviors

9
 Approximately half (55%) of the respondents were familiar with the use of SDF in

patient care while 29% have heard of SDF, but were uncertain of its use in patient care

(Table II). The respondents who reported, never heard of SDF (16%) were excluded

from the rest of the questionnaire. There were no significant relationships found when

comparing the respondents familiarity with SDF by regions of the US (Results not

shown). Among the other responses concerning knowledge of SDF, the majority (91-

98%) answered correctly when asked about the mechanism of action and its use for

caries arrest. The remaining respondents (33-43%) did not have knowledge concerning

its indication for dentinal hypersensitivity or prevention of caries (Table III). We found a

significant relationship (p <0.01) between when the graduation year and knowledge of

SDF (Table IV). No significant relationships were found when comparing any other

demographic or practice-related characteristics (Results not shown). Respondents were

given 9 sources of dental information and developments to choose from and asked

which had provided them with their knowledge concerning SDF (Table V): the 3 most

frequently reported were journals or magazines (50%), continuing education courses

(43%), and colleagues (30%).

Respondents rated their level of agreement concerning selected attitudinal

statements on the use of SDF using a Likert scale. Three-fourths (77%) strongly agreed

or agreed that the application of SDF was within their scope of practice (Table VI). There

were no significant relationships found when comparing any other demographic and

practice-related characteristics (Results not shown). A large proportion (75-95%)

strongly agreed or agreed that SDF treatment could enhance the oral health of the

10
following patient types: geriatric patients, patients living in undeserved areas, patients

with disabilities that reduce their capacity for oral self-care, pediatric patients with

challenges, patients with low income, patients with advanced carious lesions that

cannot be treated in one appointment, and patients with high dental anxiety (Table VII).

Interestingly, respondents who reported working in public health or governmental

settings (85-98%) had a greater percentage of agreement that SDF could enhance the

oral health of various types of patients than any other employment settings (74-97%)

(Results not shown). Among the perceived advantages of SDF, 86-95% of respondents

strongly agreed or agreed that SDF is less expensive than restorative treatment, more

time efficient, and can be an alternative to arrest caries without using a dental drill

(Table VIII). Ninety-five percent of respondents reported the most frequent advantage

of SDF was not requiring the use of local anesthesia. When reporting on the greatest

perceived disadvantages of SDF, respondents (67-88%) strongly agreed or agreed upon

SDFs property of staining a carious lesion black, patients lack of knowledge of SDF, and

the multiple visits recommended for re-applications (Table IX). Although respondents

reported a high level of agreement with the disadvantages of SDF, 83% strongly agreed

or agreed that the advantages outweigh the disadvantages (Table X).

Respondents rated their experiences regarding selected behavioral items on the

use of SDF using a Likert scale and a multiple-choice question. Among the 3 indications

for treatment with SDF, 86% of respondents were extremely likely or likely to

recommend SDF for arresting caries (Table XI). In comparing respondents likelihood of

recommending SDF with various employment settings, (64-67%) were extremely likely

11
to recommend for arresting caries in the independent, public health or government, and

other employment groups (Table XII). Less than half (45-46%) of respondents were

extremely likely or likely to recommend SDF for dentinal hypersensitivity or to prevent

caries. When associating other demographic and practice-related characteristics by

respondents likelihood to recommend SDF treatments, no significant relationships were

found (Results not shown). The majority of respondents (75-88%) have not reported use

of SDF for any of the indicated treatments of caries arrest, caries prevention, and

treatment of dentinal hypersensitivity in the past year (Table XIII). Overall, 72% of

respondents do not have SDF at their current employment setting (Table XIV). A

significant relationship exists when examining the presence of SDF in the employment

setting and various regions of US (Table XV).

12
DISCUSSION

This study indicated that approximately half of the respondents were unfamiliar

with SDF and its use in patient care. This is not surprising since SDF was recognized as a

new chemotherapeutic option for caries management in recent years, but was not

commercially available in the US until 20155. Before SDFs approval in the US, it was

used extensively in other countries such as Japan, Australia, and Argentina for caries

prevention, and the value of silver ions in the treatment of dental caries has been

known for more than a century4-6, 20.

Although most respondents were knowledgeable when asked questions

regarding SDFs indication for caries arrest, two-fifths did not have such knowledge

concerning its indication for caries prevention. One may speculate that respondents are

already familiar with other preventive interventions, e.g., daily 225-800 ppm fluoride

rinse, chlorhexidine, and fluoride varnish that are commonly used in the US for

preventing caries. Consider also that half of the respondents are employed in private

practice, where SDF is not available to them, according to their responses. This is

unfortunate, since studies show that SDF has always been more effective in preventing

caries compared to other preventive interventions for populations that are at greater

caries risk19.

Dentist and dental hygienists may not always agree on who is ultimately

responsible for the application of SDF. Although the majority of respondents agreed that

the application of SDF is within their DH scope of practice, one fourth did not.

Respondents who may be uncertain about their DH duties may need to examine their

13
states dental board regulations to determine which dental providers can lawfully place

SDF.20. In addition, the term to arrest caries may raise concerns since dental hygienists

may see their primary role as preventive rather than treatment-based. The diagnosis of

a caries is also not in DH scope of practice and therefore, a dentist must evaluate if SDF

can be used before a DH can apply SDF9-10.

By examining respondents attitudes regarding the advantages of SDF, we found

the majority of respondents agreed that patients (or parents/guardians of patients)

would consider accepting SDF treatment for a number of reasons. First, SDF does not

require the use of local anesthesia and can be an alternative to arrest caries without

using a dental drill to place a restoration. Individuals with dental phobia will typically

avoid dental treatments based upon a fear of dental injections and dental drills. 21 Since

SDF is applied like a varnish when indicated, however, there is no need for local

anesthesia or use of a drill. Secondly, SDF is less expensive than a restorative treatment.

Although preventive measures such as SDF incur some cost, the cost may be

significantly less when compared to conventional restorative treatments and/or may

reduce the future need for more aggressive and more costly restorative measures.

According to a study conducted by Delta Dental Insurance, patients who develop

cavities in their molars between ages 7 and 12 will require more than $1,000 in services

by age 40 to maintain each restoration22. When compared to the cost of a restorative

treatment, a bottle (8 mL) of SDF will only cost the provider $149.00. One bottle has

approximately 250 drops, which is sufficient to treat 125 sites with a site defined as up

to 5 teeth.23 And, in January 2016, the current dental terminology (CDT) billing code

14
1354 for interim caries arresting medicament application became active and Medicaid

began the reimbursement20.

In contrast, the majority of respondents also agreed that the greatest perceived

disadvantage that would prevent patients from accepting SDF treatment for dental

caries was SDFs property of black staining on a carious lesion. However, the advantages

of SDF may outweigh the disadvantages. In a 2017 survey, parents of children at New

York University Pediatric Dentistry Clinic and several private clinics in New Jersey

reported that SDF staining on posterior teeth was more acceptable than on the anterior

teeth. Moreover, although staining on anterior teeth was undesirable, a majority of

parents preferred this option over the use of advanced behavioral techniques such as

sedation or general anesthesia.24

Interestingly, many respondents who have a greater likelihood of recommending

SDF do not practice with it. This is not surprising since half of the respondents are

employed in private practice and their employer might not be familiar with SDF or

accept the efficacy of SDF treatment. In this study, more than 70% of respondents

reported not having SDF available where they practice dental hygiene.

The strengths of this study included a pretested survey by 9 dental hygienists

and 1 dentist studying SDF at UCSF to access questionnaire acceptability and feasibility.

To the best of our knowledge, this may be the first study to assess DHs knowledge,

attitudes, and behaviors of the use of SDF in caries management nationally.

This study may be limited and may not be generalized to all US dental hygienists

based on the 12% response rate. Given that only 12% of the total population responded

15
to the survey, it is possible that response bias has skewed the results unfavorably

against the use of SDF. Of the 88% of non-respondents, there could be a stronger

population of DH who believe in the positive effects of SDF. The exclusion of participants

who Never heard of SDF may be another limitation to our study. These participants

could possibly have provided us with valuable data and insight to our study. Lastly, some

terms may have been ambiguous and affected the results. For example, separating the

public health or government for independent consideration may have enhanced

clarity. Respondents who work in a public health setting may not be employed in

governmental work.

16
CONCLUSION

Results of this study suggest that the knowledge surrounding the use of SDF in

patient treatment and care was inconsistent among a large sector of practicing dental

hygienists. Dental hygienists need to have comprehensive knowledge to provide optimal

oral preventive care to the community. This knowledge can be obtained by reading

journal articles related to the topic or by attending continuing education courses. Most

respondents did agree to the substantial benefits SDF can offer to variety of patients

with different types of challenges; however, the reason for SDFs lack of use in practice

is still unclear. Further studies may need to address potential barriers that may prevent

DH from implementing SDF, but to also consider the employers interest of offering SDF

in their practice.

17
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9. Bowen, D. Effectiveness of Professionally-Applied Silver Diamine Fluoride in

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dental root caries through silver diammine fluoride applications in community-

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14. Llodra JC, Rodriguez A, Ferrer B, et al. Efficacy of silver diamine fluoride for caries

reduction in primary teeth and first permanent molars of schoolchildren: 36-

month clinical trial. J Dent Res 2005;84(8):721-4.

15. Gao SS, Zhang S, Mei ML, Lo EC, and Chu CH. Caries remineralisation and

arresting effect in children by professionally applied fluoride treatment a

systematic review. BMC Oral Health. 2016 Feb 1;16(1):12.

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16. Tan HP, Lo EC, Dyson JE, Luo Y, Corbet EF. A randomized trial on root caries

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21
DATA TABLES

Table I. Respondents Demographic and Practice-related Characteristics

Demographic Characteristic n (%)

Age (N=939)
23-29 58 (6)
30-39 162 (17)
40-49 183 (20)
50-64 462 (49)
65 and older 74 (8)

Practice-related Characteristics
Year graduated from dental hygiene program (N=941)
1994 or earlier 495 (53)
1995 - 2005 202 (22)
2006 - 2011 119 (13)
2012 or later 125 (13)

Years as a licensed hygienist (N=922)

1-5 years 127 (14)
6-10 years 100 (11)
11-20 years 166 (18)
21+ years 529 (58)

Highest dental hygiene degree (N=945)

Certificate 17 (2)
Associate 357 (38)
Bachelor 364 (39)
Masters 207 (22)

State licensed to practice (sort in regions) (N=943)

Northeast 183 (20)
Midwest 253 (28)
South 198 (22)
West 262 (29)

Employment/work setting* (N=947)

Private practice 561 (59)
Education 301 (32)
Public health or government 188 (20)

22
Independent 42 (5)
Other^ 100 (11)
Percentages may not add up to 100 due to rounding
*Participant may select more than one
^Other includes: retired, corporate, volunteer, sales, assisted living facility, research
Note: Northeast Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island,
Vermont, Delaware, New Jersey, New York, Pennsylvania; Midwest - Illinois, Indiana,
Michigan, Ohio, Wisconsin, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota,
South Dakota; South - Florida, Georgia, Maryland, North Carolina, South Carolina, West
Virginia, Alabama, Kentucky, Mississippi, Tennessee, Arkansas, Louisiana, Oklahoma,
Texas; West - Arizona, Colorado, Idaho, Nevada, New Mexico, Utah, Wyoming, Alaska,
California, Hawaii, Oregon, Washington

23
Knowledge Results.
Table II: Respondents familiarity of silver diamine fluoride

Familiarity (N = 1219) Respondents n (%)

Never heard of SDF# 198 (16)

Heard of SDF but unsure of its uses in patient care 354 (29)

Aware of SDF and its use in patient care 667 (55)

Percentages may not add up to 100 due to rounding
SDF silver diamine fluoride
#Excluded from the rest of the questionnaire

Table III: Responses to true statements regarding knowledge of silver diamine fluoride

True/False Items Respondents n (%)

SDF is used for arresting caries (N=978) 953 (98)

A mechanism of action of SDF inhibits cariogenic biofilm 845 (91)

formation on dentin carious lesions (N=933)

SDF is used for dentinal hypersensitivity (N=948) 638 (67)

SDF is used for preventing caries (N=960) 542 (57)

Percentages may not add up to 100 due to rounding
SDF silver diamine fluoride

24
Table IV: Differences in the mean sample score of correct knowledge statements by the
year graduated from the dental hygiene program

Respondents knowledge
scores regarding SDF
Year graduated from Mean Std Dev
DH program

1994 or earlier (n=491) 3.10 0.90

1995-2005 (n=202) 2.93 0.89

2006-2011 (n=119) 3.00 0.94

2012 or later (n=124) 2.84 0.91

P-value 0.0099
Percentages may not add up to 100 due to rounding
SDF silver diamine fluoride
BOLD significant differences between groups (p< 0.05)

25
Table V: Respondents sources of knowledge about silver diamine fluoride

Sources* of SDF (N=1019) Respondents n (%)

Journal or magazine 512 (50)

Continuing education course 433 (43)

Colleague 307 (30)

Dentist/Employer 222 (22)

Professional organization 222 (22)

Social media 134 (13)

While in dental hygiene school 71 (7)

Sales representative 71 (7)

Other^ 100 (10)

Percentages may not add up to 100 due to rounding
SDF silver diamine fluoride
*Participants may select more than one
^Other includes: Public health listserve, online research, poster presentation

26
Attitude Results.
Table VI: Respondents level of agreement towards their scope of practice

Respondents level of agreement n (%)

Attitudinal item (N=971) Strongly Agree Neither Disagree Strongly
Agree Agree nor Disagree
Disagree

The application of SDF in

patient care is within my 468 (48) 277 (29) 184 (20) 33 (3) 9 (1)
scope of practice
Percentages may not add up to 100 due to rounding
SDF silver diamine fluoride

Table VII: Respondents level of agreement towards silver diamine fluoride treatment

Respondents level of agreement n (%)

SDF treatment can enhance Strongly Agree Neither Disagree Strongly
the oral health of the Agree Agree nor Disagree
following types of patients: Disagree
Geriatric patients (N=961) 683 (71) 224 (23) 45 (5) 5 (1) 4 (<1)
Patients who live in
677 (70) 223 (23) 54 (6) 3 (<1) 5 (1)
underserved areas (N=962)

Patients with disabilities that

reduce their capacity for oral 678 (70) 237 (25) 42 (4) 5 (1) 4 (<1)
self-care (N=966)

Challenging pediatric patients 669 (70) 213 (22) 60 (6) 13 (1) 7 (1)
(N=962)

Patients with low income 657 (68) 227 (24) 63 (7) 8 (1) 7 (1)
(N=962)

Patients who have more

advanced carious lesions that 554 (58) 219 (23) 124 (13) 48 (5) 17 (2)
cannot all be treated in one
appointment (N=962)

Patients with high dental 512 (53) 213 (22) 193 (20) 30 (3) 13 (1)
anxiety (N=961)
Percentages may not add up to 100 due to rounding
SDF silver diamine fluoride

27
Table VIII: Respondents level of agreement to whether they agree to the advantages of
silver diamine fluoride

Advantages Respondents level of agreement n (%)

Strongly Agree Neither Disagree Strongly
Patients (or agree Agree nor Disagree
parents/guardians of Disagree
patients) would consider
each of the following as an
advantage to accepting SDF
as a treatment:

SDF does not require the

use of local anesthesia 602 (64) 293 (31) 39 (4) 0 (0) 4 (<1)
(N=938)

SDF can be an alternative to

arrest caries without using a 511 (55) 303 (32) 93 (10) 20 (2) 9 (10)
dental drill to place a
restoration (N= 936)

SDF is less expensive than a

restorative treatment 516 (55) 293 (31) 113 (12) 8 (1) 5 (1)
(N=935)

SDF is applied like a varnish

477 (51) 326 (35) 95 (10) 23 (3) 12 (1)
and is therefore time efficient
(N=933)
Percentages may not add up to 100 due to rounding
SDF silver diamine fluoride

28
Table IX: Respondents level of agreement to whether they agree to the disadvantages
of silver diamine fluoride

Disadvantages Respondents level of agreement n (%)

Strongly Agree Neither Disagree Strongly
Each of following is/are a agree Agree nor Disagree
disadvantage and would prevent Disagree
your patient (or
parents/guardians of patients)
from accepting SDF for
treatment:

Leaves a black permanent stain at

the carious lesion that may cause 516 (55) 320 (34) 86 (9) 20 (2) 4 (<1)
esthetic concerns (N=946)

Patients lack of knowledge about 333 (35) 403 (43) 126 (13) 75 (8) 9 (1)
SDF (N=946)

He/she (or their child) may have

to return multiple times for re- 191 (20) 408 (43) 253 (27) 88 (9) 2 (<1)
application of SDF (N=942)
Percentages may not add up to 100 due to rounding
SDF silver diamine fluoride

Table X: Respondents level of agreement that the advantages of silver diamine fluoride
outweigh the disadvantages.

Respondents level of agreement n (%)

Attitudinal item Strongly Agree Neither Disagree Strongly
agree Agree nor Disagree
Disagree

The advantages of
SDF outweigh the 443 (47) 342 (36) 143 (15) 17 (2) 4 (<1)
disadvantages (N=949)
Percentages may not add up to 100 due to rounding
SDF silver diamine fluoride

29
Behavior Results.
Table XI: Respondents degree of likelihood of recommending silver diamine fluoride to
patients for the following treatments.

Respondents likelihood of recommending SDF n (%)

Behavioral items Extremely Likely Neither Unlikely Extremely
likely Likely nor unlikely
Unlikely
Arresting caries (N=925) 451 (49) 346 (37) 80 (9) 34 (4) 14 (2)
Preventing caries from
161 (18) 245 (28) 206 (23) 201 (23) 70 (8)
occurring (N=883)

Dental hypersensitivity 129 (14) 278 (31) 227 (25) 191 (21) 69 (8)
(N= 894)
Percentages may not add up to 100 due to rounding
SDF silver diamine fluoride

30
Table XII: Respondents likelihood of recommending silver diamine fluoride by
employment setting

Recommending SDF for dentinal hypersensitivity n (%)

Employment/ work setting Extremely Likely Neither Unlikely Extremely
likely likely nor unlikely
unlikely
Private Practice (n=525) 68 (13) 154 (29) 135 (26) 129 (25) 39 (7)
Independent (n=42) 10 (24) 15 (36) 9 (21) 7 (17) 1 (2)
Public Health or
Government (n=184) 32 (17) 57 (31) 42 (23) 37 (20) 16 (9)
Education (n=281) 42 (15) 87 (31) 72 (26) 59 (21) 21 (8)
Other^ (n=96) 17 (18) 33 (34) 17 (18) 19 (20) 10 (10)

Recommending SDF for preventing caries n (%)

Private Practice (n=523) 78 (15) 147 (28) 128 (25) 128 (25) 42 (8)
Independent (n=41) 16 (39) 5 (12) 10 (24) 10 (24) 0 (0)
Public Health or
Government (n=179) 43 (24) 43 (24) 41 (23) 33 (19) 19 (11)
Education (n=280) 61 (22) 79 (28) 58 (21) 63 (23) 19 (7)
Other^ (n=93) 20 (22) 25 (27) 21 (23) 19 (20) 8 (9)

Recommending SDF for arresting caries n (%)

Private Practice (n=546) 227 (42) 229 (42) 54 (10) 25 (5) 11 (2)
Independent (n=42) 28 (67) 12 (29) 2 (5) 0 (0) 0 (0)
Public Health or
Government (n=187) 119 (64) 52 (28) 10 (5) 4 (2) 2 (1)
Education (n=293) 139 (47) 123 (42) 21 (7) 8 (3) 2 (1)
Other^ (n=94) 61 (65) 26 (28) 4 (4) 2 (2) 1 (1)
Percentages may not add up to 100 due to rounding
SDF silver diamine fluoride
^Other includes: retired, corporate, volunteer, sales, assisted living facility, research

31
Table XIII: Respondents reported behavior towards the use of silver diamine fluoride in
the past year

Respondents reported usage of SDF in patient care n (%)

Behavioral items Always Most of About half Sometimes Never
the time the time
Arresting caries (N=777) 58 (8) 41 (5) 19 (3) 79 (10) 580 (75)
Preventing caries (N=764) 10 (1) 26 (3) 14 (2) 45 (6) 669 (88)
Dentinal hypersensitivity
3 (<1) 14 (2) 13 (2) 64 (8) 675 (88)
(N=769)
Percentages may not add up to 100 due to rounding
SDF silver diamine fluoride

Table XIV: Respondents response to having silver diamine fluoride present at their
employment setting

SDF is present at my employment setting (N= 944) Respondents n (%)

Yes 226 (24)
No 678 (72)
Not sure 40 (4)
Percentages may not add up to 100 due to rounding
SDF silver diamine fluoride

32
Table XV: Respondents response to having silver diamine fluoride present at their
office/work setting by state regions

SDF present in office/work setting n (%)

Regions by State Yes No Dont Know
West (n=259) 77 (30) 174 (67) 8 (3)
Midwest (n=250) 63 (25) 172 (69) 15 (6)
Northeast (n=183) 42 (23) 132 (72) 9 (5)
South (n=197) 31 (16) 160 (81) 6 (3)
P-value x2 0.0118
SDF silver diamine fluoride
BOLD significant differences between groups (p<0.05)
Note: Northeast Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island,
Vermont, Delaware, New Jersey, New York, Pennsylvania; Midwest - Illinois, Indiana,
Michigan, Ohio, Wisconsin, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota,
South Dakota; South - Florida, Georgia, Maryland, North Carolina, South Carolina, West
Virginia, Alabama, Kentucky, Mississippi, Tennessee, Arkansas, Louisiana, Oklahoma,
Texas; West - Arizona, Colorado, Idaho, Nevada, New Mexico, Utah, Wyoming, Alaska,
California, Hawaii, Oregon, Washington

33