PaediatricDentistry Enhanced CPD DO C

Jilen Patel

Robert P Anthonappa and Nigel M King

Silver Diamine Fluoride: a

Critical Review and Treatment
Recommendations
Abstract: Over the last decade there has been a renewed interest in the use of Silver Diamine Fluoride (SDF) as an adjunctive modality
in the management of caries among high-risk populations. This review presents the current evidence behind the use of SDF and
recommendations for its use in caries management dental practice.
CPD/Clinical Relevance: Silver diamine fluoride is an effective, evidence-based modality that can contribute towards arresting carious
lesions among high-risk children and disadvantaged populations.
Dent Update 2019; 46: 626–632

Dental caries remains a global public health
issue affecting over 621 million children
worldwide.1 For high-risk groups who
continue to experience high burdens of
dental caries, the traditional restorative
approach to caries management is neither
readily available, accessible nor affordable,
and has shown limited success in controlling
the carious process on a population level.2
Non-restorative techniques aimed at
managing the caries biofilm and supporting
remineralization are therefore becoming
more common.3,4
Jilen Patel, BDSc(Hons), DClinDent(Paed
Dent), MRACDS, FADI, FICD, Paediatric
Dentist, Robert P Anthonappa,
BDS, MDS(Paed Dent), AdvDipDS,
PhD, MPaedDent RCSEd, FDS RCSEd,
MRACDS(Paed), Discipline Lead and
Program Convenor, Paediatric Dentistry
(email: robert.anthonappa@uwa.edu.
au) Nigel M King BDS(Hons), MSc(Hons),
FDS RCSEd, FDS RCS(Eng), LDSRCS, PhD,
Professor of Paediatric Dentistry, UWA
Dental School, The University of Western
Australia, Australia.
626 DentalUpdate July/August 2019
Over the last decade there has of fluoride varnishes, increased access to
been a renewed interest in the use of silver surgical care and improved restorative
diamine fluoride (SDF) as an adjunctive techniques. Duffin proposed the use of
modality in the management of dental caries 25% silver nitrate (AgNO3) solution followed
among high-risk groups. SDF is deemed to be by 5% sodium fluoride (NaF) varnish to
a safe, effective, efficient and equitable cariesarrest carious lesions in dentine.9 Although
control agent that can be used to help meet this protocol has shown some promise in
the WHO Millennium oral health goals and the laboratory setting, further research is
fulfil the USA Institute of Medicine’s criteria required to establish the clinical efficacy
for 21st Century medical care.5,6 and safety of this mixture.
This review discusses the current During the 1960s and 1970s,
evidence and guidelines on the use of SDF in SDF was further developed and studied in
caries management. Japan.10 SDF use was supported by Japan’s
Ministry of Health and Welfare and has
been in use for the last 40 years. Advances
History in the formulation and preparation of silver
As long ago as 1891, a mixture of fluoride solutions internationally have led
nitric acid and amalgam scraps was used to to a number of commercially available
inhibit caries progression.7 This silver nitrate forms of SDF (Table 1). Currently in the
solution was popularized by Howe who used UK, Riva StarTM (SDI, Bayswater, Victoria) is
it to arrest caries among disadvantaged the only available preparation and uses a
children in Boston, USA, leading to the formulation of 38% SDF with potassium
solution being termed ‘Howe’s solution’.8 iodide (KI) as a separately applied reagent.
Silver nitrate was advocated by leaders in the The application of KI following SDF has
dental profession such as WD Miller, GV Black been advocated to reduce the degree of
and Percy Howe; hence the solution was black staining, which is the main clinical
widely used in the USA up until the 1960s. disadvantage of using SDF alone.11 Notably,
The use of silver nitrate declined in popularity preparations such as Riva StarTM are
after this time, probably due to the advent registered only as desensitizing agents;

Product Name SDF Concentration Country
Cariostatic 10% Brazil
Cariestop 12% Brazil
Cariestop 38% Brazil
Bioride 30% Brazil
Saforide 38% Japan
Advantage Arrest 38% USA
Fluoroplat V 38% Argentina
Riva StarTM 38% United Kingdom
Table 1. Commercially available preparations of silver diamine fluoride (SDF).
a thus, the use of such preparations for caries
prevention or caries arrest is considered to be restorative caries treatment, SDF offers
off-label.
Terminology
There are a number of terms
used in the literature to describe SDF and
the variations (Table 2). The term SDF is
b successful caries stabilization.
often colloquially used interchangeably with
silver fluoride (AgF), however, these are two
distinctly different compounds. The bound
ammonia in SDF confers different chemical
properties on the compound, making it
significantly more stable than AgF, which
enhances the shelf-life characteristic by
maintaining a constant concentration for a
Figure 1. (a) Carious lesions on anterior teeth at
longer period.12
baseline prior to application of 38% SDF. (b) Six
months post-application of SDF.
How does it work?
The exact mechanism of action
a of SDF, whether it is chemical, physical,
mechanical or antibacterial, remains
unclear. However, it has been proposed
that SDF interacts with the structure of
both enamel and dentine, as well as having
an antibacterial action on the organisms
in oral biofilms. Studies have shown that
SDF has the ability to preserve collagen
b from degradation in demineralized dentine
while inhibiting collagenases such as
matrix metalloproteinases and cysteine
cathepsins.13,14 SDF produces a highly
remineralized zone that is rich in calcium
and phosphate in cavitated dentinal lesions
of primary teeth that in turn protects
collagen from being exposed to the oral
Figure 2. (a) Carious lesions on posterior teeth at environment.6,15 Furthermore, SDF inhibits
baseline prior to application of 38% SDF. (b) Six
multi-species cariogenic biofilm formation on application?
months post-application of SDF.
dentine carious lesions.16,17 In addition, SDF
July/August 2019 DentalUpdate 627
PaediatricDentistry
reacts with calcium and phosphate ions
to produce fluorhydroxyapatite, thereby
inhibiting demineralization.18
Justification for SDF use
The challenge to provide oral
healthcare for vulnerable populations
with limited access to care led to the
development of non-restorative caries
treatments and the ‘atraumatic restorative
technique’ (ART).4,19 The use of SDF can be
considered a non-restorative approach
to caries management and may be used
in cases where conventional treatment
is impossible, such as for children who
are pre-cooperative or are medically
compromised. With respect to non-
more time for improving and stabilizing
caries-affected dentition. In the interim,
heightened preventive regimes focused
on dietary and oral hygiene practices can
be implemented. Definitive restorative
treatment can then be planned following
How effective is SDF in
arresting caries?
A meta-analysis of eight
randomized control trials (RCTs) using 38%
SDF found that the caries arresting rate of
SDF treatment was 86% (95% confidence
interval (CI), 47% to 98%; P = 0.06) at 6
months, 81% (95% CI, 59% to 93%; P =
0.01) at 12 months, 78% (95% CI, 70% to
85%; P < 0.001) at 18 months, 65% (95% CI,
35% to 86%; P = 0.32) at 24 months, and
71% (95% CI, 56% to 83%; P = 0.01) at or
beyond 30 months. The overall proportion
of arrested dental caries after SDF treatment
was 81% (95% CI, 68% to 89%; P < 0.001).20
Recently, a meta-analysis by Chibinski and
co-workers reported that the available
evidence was of a high quality and
concluded that SDF was 89% more effective
in controlling or arresting caries than other
treatments or placebos.21 In vitro studies
have suggested that treatment with SDF
can increase resistance of cavity margins
around GIC restorations to secondary caries
development.22,23
Does caries need to be
removed prior to SDF
In a RCT involving 375 children
 PaediatricDentistry

Ammoniated silver fluoride application time may be shorter in very

young and difficult to manage patients. In
Ammoniacal silver fluoride these cases, the patient should be regularly
Diamine silver fluoride reviewed and consideration made for
re-application. Re-application of SDF may
Silver diamine fluoride (most commonly used spelling in the literature) be indicated if the treated carious lesions
Silver diammine fluoride (most chemically correct description referring to the complex do not appear arrested (dark and hard) 2 to
between ammonia molecules and a metal ion) 4 weeks post-application.
 After application, blot the carious lesion
Diammine silver fluoride with gauze, cotton roll, or cotton pellet to
Table 2. Different terminologies used to describe silver diamine fluoride. minimize systemic absorption.
 After treating specific carious lesions with
the SDF, the entire dentition can be coated
with a follow-up period of 24 months, Chu treatment and require surgical treatment. with a thin layer of 5% NaF varnish for
and colleagues24 compared 38% SDF to 5% Similarly, teeth with deep dentine lesions primary prevention, if appropriate.
NaF and further divided the groups into encroaching on the pulp are not suitable for
‘with’ or ‘without’ caries excavation (n = SDF treatment due to the ammonia content How often should SDF be
70 approximately per group). The findings and high pH, which may trigger pulpal applied?
demonstrated that removal of carious tissue inflammation. Other contra-indications to
The commonly adopted
prior to the application of the fluoride agents use include patients with a silver allergy and
frequency of SDF application is either
did not enhance the ability to arrest dentine parents or patients who object to potential
6-monthly or 12-monthly. However, the
caries.24 This is in contrast to the belief that staining.
optimal protocol for SDF application still
‘one has to strive for as near as complete
requires further research before a definitive
caries removal as possible’ prior to fluoride How is SDF applied? protocol is established. Nevertheless, Zhi
treatment because the bacterial load in the
Prior to SDF application it and co-workers suggest that 6-monthly
carious lesion is reduced.25
is imperative that (i) both the patient applications increase the caries arrest
and practitioner have standard personal rate compared to 12-monthly application
What concentration of SDF is protective equipment, and (ii) appropriate protocol.30 This recommendation is
most effective? diagnosis of the carious lesion and the pulp supported by the findings of the RCT
The different commercially status has been made to ensure that the conducted by Fung and co-workers who
available preparations of SDF are presented lesion is suitable for treatment using SDF. The found that carious lesions treated with
in Table 1, with the most commonly available recommended procedure for SDF application SDF on a biannual basis had a higher
concentration being a 38% solution. In a is as follows:28 chance of becoming arrested compared
RCT involving 976 Nepalese schoolchildren  Gross debris from the cavity can be to those receiving annual applications of
followed-up at 6 months, Yee and co-workers removed to allow better contact of SDF with SDF (odds ratio, 1.33; 95% CI, 1.04−1.71;
found that a one off application of 12% SDF denatured dentine. However, carious dentine P = 0.025).27 However, fundamental
solution was ineffective for arresting carious excavation prior to SDF application is not preventive protocols, such as twice-daily
lesions in primary teeth, while the use of 38% necessary. toothbrushing using fluoridated toothpaste
SDF was found to be effective.26 This finding  Isolate the carious lesion from the adjacent along with a balanced diet, should always
was supported by a recent RCT with a 30 soft tissues using cotton wool rolls, use a maintain priority. As such, SDF should never
month follow-up in which the 38% SDF was saliva ejector to remove excess saliva from be used or thought of as an alternative to
clearly more effective than 12% SDF.27 the site of application. Note: petroleum jelly proper oral health care.
can be used as a gingival barrier, if required.
What are the criteria for SDF  Dispense no more than a drop of SDF into How does SDF compare with
use? a dappen dish. One drop (25 μL) is ample to traditional NaF varnish?
SDF is indicated as an adjunctive treat 5 teeth, and contains 9.5 mg SDF. The NaF has long been considered
modality for treating caries among high- University of California, San Francisco (UCSF) the best preventive therapeutic agent to
risk patients who are unable to access protocol recommends a limit of 1 drop (25 arrest carious lesions in enamel. However,
dental treatment or tolerate conventional μL) per 10 kg per treatment visit, with weekly the results of some clinical trials suggest
dental care. This includes young or ‘pre- intervals at most.29 that 38% SDF was found to be more
cooperative’ children, medically or physically  Dip the microbrush into SDF and dab on effective in arresting caries in primary
compromised patients and those that may be the side of the dappen dish to remove excess teeth among children when compared
unable to access routine comprehensive care solution. with 5% NaF varnish.24,31 The results of a
due to barriers such as geographic isolation.  Apply SDF directly to the affected tooth recent RCT involving 309 children with a
Teeth with evidence of pulpitis surface only. Application time should be 30 month follow-up period found that the
or pulp necrosis are not appropriate for SDF at least one minute, if possible. However, annual applications of SDF solution were
628 DentalUpdate July/August 2019

more effective in arresting dentine caries in
primary teeth than three consecutive weekly
applications of NaF varnish.32
Can SDF be used prior to placing which contributes to the discoloration of the
a restoration?
SDF can be used in a two-
stage approach to (i) stabilize and arrest
caries initially, and (ii) place a conventional
restoration at a later time. To date, the
majority of studies indicate that SDF
application does not adversely affect dentinal
bond strength to resin composite or glass
ionomer cement (GIC). 33-35
Furthermore,
in vitro studies suggest that conditioning
with SDF prior to placement of GIC or
resin composite restorations may increase
resistance to secondary caries, 36,37
while SDF
has also been shown to have good capability
to induce tertiary dentine deposition.
SDF can also be used in
conjunction with ART, a concept that has
been referred to as the Silver Modified
Atraumatic Restorative Technique (SMART).
This technique involves application of SDF
followed by placement of a GIC restoration.
However, further studies are required to
demonstrate the success of this technique.
When investigating the caries
arrest potential of SDF with GIC, Dos Santos
and co-workers compared the application
40
of 30% SDF with an interim restorative
treatment (IRT) using GIC (Fuji IX) in primary The NOAEL reported for fluorosis is 0.05 mgF/
teeth over 12 months. The results indicated
that, after 12 months, the caries arresting rate adopted frequency of SDF application
of SDF application alone was 67% compared is annually or biannually, and the SDF
with 39% for GIC. The authors suggested
that this could be a paradigm shift in the
treatment of carious lesions in high-risk
children.40
Is SDF safe to use?
To date, several RCTs have been
conducted on the use of SDF and these have
found no serious adverse events following
the application.41 Nevertheless, the main
concerns around SDF use are:
(i) The development of black staining post-
application;
(ii) Transient gingival irritation; and
(iii) High fluoride concentrations and
potential toxicity.
Black staining following SDF
application to the tooth occurs as a soluble
silver phosphate layer is formed after the
application of SDF on carious dentine. This
July/August 2019 DentalUpdate 631
layer appears yellow initially, then turns
dark brown or black under the influence of
a reducing agent or under sunlight. Silver
sulphide precipitates can also be formed
tooth.31
Llodra and co-workers42 reported
three cases (n = 675) where contact of
SDF with the oral mucosa caused small
white lesions that were mildly painful
but disappeared within 48 hours without
any treatment.42 Recently, a systematic
review concluded that the reports on oral
pain, gingival swelling and bleaching are
uncommon and probably not related to the
application of SDF.41 However, the mechanism
of this phenomenon is unclear.
Concerns around the potential
toxicity of SDF have been raised, given
38 the high concentration of fluoride in
SDF, reported to be around 44,800ppm.43
However, only a minute volume of SDF is
actually applied to a carious lesion and it has
39 been suggested that the average amount of
fluoride following SDF application per patient
ranges from approximately 0.17 mg to
0.36 mg, which is well below the No
Observed Adverse Effect Limit (NOAEL).44
The NOAEL is defined as the
highest dose of a chemical in a single study,
found by experiment or observation, which
causes no detectable adverse health effect.45
kg/body weight.45 As the most commonly
application is restricted to carious lesions, the
total amount is far below the NOAEL dose.
Conclusions
The use of SDF in paediatric
dentistry may be a paradigm shift towards a
more medical model of caries management,
leading to an effective, affordable and
sustainable solution for high-risk children
around the world.
SDF has been used for over 40
years in dentistry; however, its use in the
western world has increased and gained
significant interest in the last decade. SDF is
inexpensive, painless, and it is easy to apply.
It has been shown to be more effective for
arresting caries in the primary dentition
than 5% NaF varnish or GIC restorations
placed using the ART technique. The silver
component acts as an antimicrobial agent,
PaediatricDentistry
the fluoride promotes remineralization, and
the ammonia stabilizes high concentrations
in solution. The available literature supports
the biannual use of 38% SDF and the
available studies suggest a caries arrest
rate of 80% after 24 months. Although SDF
has the potential to arrest caries among
high-risk groups, it should never be used or
thought of as an alternative to proper oral
healthcare and therefore implementation of
fundamental preventive protocols, such as
twice-daily toothbrushing using fluoridated
toothpaste, a balanced diet and access to
comprehensive care, should always remain
a priority.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
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