Silver Diamine Fluoride

Key Points 

  • There is growing appreciation of silver diamine fluoride (SDF) to arrest caries lesions, which is an off-label use; SDF currently has FDA clearance as a desensitizing agent.
  • The potential benefits for use of SDF treatment for caries arrest include its low cost and ease of application.
  • The potential harms for use of SDF treatment for caries arrest include permanent black stain on the arrested caries lesions.
  • Semi-annual application of SDF is recommended for sustained benefit.
Introduction

Dental caries is one of the most prevalent chronic diseases in the population.1 However, a significant decrease in prevalence and severity of caries have been reported, which is believed to be in part due to water fluoridation and fluoride-containing oral products. Means to arrest and prevent the development of caries lesions have been studied, with focus on fluoride-containing materials.

Silver diamine fluoride (SDF) is a colorless liquid that at pH 10 is 24.4% to 28.8% (weight/volume) silver and 5.0% to 5.9% fluoride.2 The U.S. Food and Drug Administration (FDA) has classified SDF as a Class II medical device and it is cleared for use in the treatment of tooth sensitivity, which is the same type of clearance as fluoride varnish, and must be professionally applied. Although some additional products are commercially available in other countries, as of March 2021, Advantage Arrest™ (Elevate Oral Care, L.L.C.) and Riva Star™ (SDI, Inc.) are the only commercially available SDF products for dental use in the U.S.3 In 2016, Advantage Arrest™ was designated by the FDA as a breakthrough therapy for the arrest of caries in children and adults; this designation indicates that a therapy has the potential to address a currently unmet medical need.4 Although use of SDF has been reported in caries control and management, it is not specifically FDA-labeled for use for this indication (i.e., “off-label use”). When applied to a carious lesion, SDF has also been shown to decrease caries risk of adjacent tooth surfaces.5 SDF has also shown efficacy in management of root caries in the elderly.6-8 It has additional applicability as an interim approach for managing caries in individuals currently unable to tolerate more involved dental treatment, including special needs populations.9-11

SDF offers the possibility of stopping the progression or arresting caries lesions without removal of sound tooth tissue. In addition, SDF appears to remineralize dentin.12 The effectiveness of the treating carious lesions with SDF is demonstrated by the increase in mineral density of the previously carious tissue.13 The main benefits of SDF are: control of pain and infection, ease of application, low cost, minimal application time and training required, and as a noninvasive method of caries arrest.14 Single application of SDF has been reported to be insufficient for sustained benefit and requires reapplication.15 Its potential downsides include a reportedly unpleasant metallic taste, potential to irritate gingival and mucosal surfaces, and the characteristic black staining of the tooth surfaces to which it is applied.3 SDF may be a preferred option to arrest caries in deciduous teeth, older individuals, when physical limitations do not allow more extensive treatment or when access to conventional restorative techniques, such as resin composite or amalgam restorations, are not available. Because conventional caries treatment in young children and/or individuals with special care needs may require advanced sedation techniques, SDF may be a viable treatment option when sedation is either not be desirable or available.

SDF may also have utility in the situation of multiple caries lesions that cannot be treated by conventional means in one single visit. It allows for stabilization of the disease prior to proceeding with the conventional restorative treatment. SDF treatment has been shown to be as effective in stopping caries progression as atraumatic restorative treatment (ART), while being up to twenty times less costly.15

SDF Composition and Mechanisms of Action

SDF is a basic solution (pH of 10-12) with a 38% w/v Ag(NH3)2F. The silver functions as an antimicrobial, while fluoride is present in sufficient concentration to promote remineralization;16, 17 the ammonia (NH3) present stabilizes the solution.15 When in contact with the tooth, the diamine-silver ion complexes react with hydroxyapatite forming silver phosphate (Ag3PO4) and silver oxide (Ag2O).14 While SDF inhibits the collagenolytic enzymes that break down exposed dentin organic matrix, ionic silver acts as an antibacterial by disrupting membranes, denaturing proteins, and inhibiting DNA replication.15 Antibacterial mechanisms of SDF can also be attributed to the formation of organometallic complexes inside the bacterial cell. Organometallic complexes can (a) deactivate enzymes by blocking the electron transport system in bacteria, resulting in bacterial cell death; (b) induce rupture of the bacterial cell and (c) interact with the DNA of bacterial cells resulting in mutation and death.17

The formation of silver compounds results in striking tooth structure color change.16 This is the main adverse effect following SDF treatment. With respect to patient concerns about fluoride, there is less fluoride content in the amount of SDF used to treat a tooth with caries than in fluoride varnish. The American Academy of Pediatric Dentistry (AAPD) reports no known systemic or serious adverse effects reported for SDF when used according to manufacturer directions.11

SDF for Treatment of Dentin Sensitivity

SDF has been cleared by the FDA as a dentin desensitizing agent.15 When applied to areas with sensitive dentin surfaces, a layer of silver and dentin organic matrix protein conjugates forms.15 This squamous layer formed on the exposed dentin surface partially closes the exposed dentin tubules.15

Use of SDF for Caries Arrest

The progression of caries involves ingestion of dietary sugars, bacterial metabolism, tooth mineral demineralization, and tooth organic matrix degradation. The cariogenic process is initiated by an imbalance in the demineralization and remineralization equilibrium, induced by the presence of acid-producing and acid-tolerant bacteria, shifting to a lower pH, resulting in loss of tooth minerals.18 Therefore, it is important to enhance the protective and minimize the pathologic factors associated with tooth decay. Current strategies for caries treatment focus on the individual’s risk assessment and establishment of preventive and/or restorative treatments.19

Caries progression occurs by simultaneous demineralization of enamel and dentin and degradation of the organic matrix. Once the caries lesion is developed, treatment options include restorative and non-restorative measures.19 Nonrestorative approaches may be invasive, such as preventive resin restorations; or noninvasive, such as SDF, fluoride therapy, or sealants.

Although most studies reported caries arrest in deciduous teeth, the proposed mechanisms by which SDF may help arrest caries would likely apply for permanent teeth.18

In 2018, the ADA Center for Evidence-Based Dentistry conducted a systematic review and network meta-analysis20 informing a clinical practice guideline18 on nonrestorative treatments for carious lesions. The expert panel formulated 11 clinical recommendations, each specific to lesion type (i.e., cavitated, noncavitated), tooth surface (i.e., coronal, root surface [in adults]) and dentition (i.e., primary or permanent). The panel provided recommendations for the use of the most effective treatment options, which included 38% SDF, along with other topical fluoride products. The expert panel recommended that clinicians prioritize the use of 38% SDF solution biannually to arrest advanced cavitated carious lesions on coronal surfaces of primary teeth.18 The expert panel extrapolated these results to suggest that clinicians could also use biannual application of 38% SDF solution to arrest advanced cavitated lesions on coronal surfaces of permanent teeth. Biannual application of 38% solution SDF for advanced cavitated lesions may be relevant if access to care is limited, for uncooperative patients, or for patients when general anesthetic is not considered safe.18

A 2017 guideline11 from the AAPD made a conditional recommendation (based on low-quality evidence) for the use of SDF in the management of caries in children and adolescents, including those with special health care needs. Panel members were confident that given its low cost and the disease burden of caries, the benefits of SDF application in the target populations outweighed the undesirable dark discoloration of carious SDF-treated dentin.

According to an umbrella review, application of 38% SDF prevented root caries in adults with success rates 72% higher than a placebo treatment.21 The same review reported a prevented fraction for successful root caries arrest, between 100% and 725% higher as compared to a placebo treatment.21 Moreover, application of 38% SDF in combination with oral health education was found to be the most effective method for preventing root caries in adults.22

The disadvantages of SDF include potential pulpal and oral soft tissue irritation and dental staining. Attention is needed during the application to avoid contact of the solution with the gingiva, since it may cause irritation.13 Mature and sound enamel is not stained, unless there is any superficial defect, such as hypomineralization, carious/demineralized, or immature enamel, where the porosities allow silver ions to penetrate.23

Further restoration of the arrested caries lesion may be needed to recover form and function of a cavitated tooth, which will also diminish tooth discoloration.12 There is limited evidence on the adhesive performance of traditional restorative options, such as resin composite and glass ionomer cement (GIC), following caries arrest with SDF.12 SDF treatment does not seem to impair GIC bonding.24, 25

A 2019 systematic review by Horst et al. found that once-yearly SDF application was more effective in preventing caries than more frequent application (i.e., 2 to 4 times yearly) of fluoride varnish.23 Whereas when compared to occlusal sealants, SDF was only more effective in preventing caries if continuously applied.23

Summary

Evidence shows that SDF at 38% can be a noninvasive treatment option to arrest dentinal caries.3, 18 Among the reasons for such success, are the synergistic effect of silver and fluoride ions, inhibiting bacterial/biofilm growth and supporting remineralization, respectively. Anti-enzymatic activity of silver and fluoride ions can also inhibit activity of collagenolytic enzymes that break down exposed dentin matrix. Permanent staining is observed in dentin and enamel caries-arrested lesions, limiting its use in esthetic areas.

References
  1. National Institute for Dental and Craniofacial Research. Dental Caries (tooth decay). 2018. https://www.nidcr.nih.gov/research/data-statistics/dental-caries. Accessed January 8, 2021.
  2. Mei ML, Chu CH, Lo EC, Samaranayake LP. Fluoride and silver concentrations of silver diammine fluoride solutions for dental use. Int J Paediatr Dent 2013;23(4):279-85.
  3. Mei ML, Lo EC, Chu CH. Clinical Use of Silver Diamine Fluoride in Dental Treatment. Compend Contin Educ Dent 2016;37(2):93-8; quiz100.
  4. Horst JA. Silver Fluoride as a Treatment for Dental Caries. Adv Dent Res 2018;29(1):135-40.
  5. 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.
  6. Li R, Lo EC, Liu BY, Wong MC, Chu CH. Randomized clinical trial on arresting dental root caries through silver diammine fluoride applications in community-dwelling elders. J Dent 2016.
  7. Zhang W, McGrath C, Lo EC, Li JY. Silver diamine fluoride and education to prevent and arrest root caries among community-dwelling elders. Caries Res 2013;47(4):284-90.
  8. Hendre AD, Taylor GW, Chavez EM, Hyde S. A systematic review of silver diamine fluoride: Effectiveness and application in older adults. Gerodontology 2017;34(4):411-19.
  9. Giusti L, Steinborn C, Steinborn M. Use of silver diamine fluoride for the maintenance of dental prostheses in a high caries-risk patient: A medical management approach. J Prosthet Dent 2018;119(5):713-16.
  10. Gao SS, Zhao IS, Hiraishi N, et al. Clinical Trials of Silver Diamine Fluoride in Arresting Caries among Children: A Systematic Review. JDR Clin Trans Res 2016;1(3):201-10.
  11. Crystal YO, Marghalani AA, Ureles SD, et al. Use of Silver Diamine Fluoride for Dental Caries Management in Children and Adolescents, Including Those with Special Health Care Needs. American Academy of Pediatric Dentistry 2017. http://www.aapd.org/media/Policies_Guidelines/G_SDF.pdf. Accessed October 5, 2020.
  12. Jiang M, Wong MCM, Chu CH, Dai L, Lo ECM. Effects of restoring SDF-treated and untreated dentine caries lesions on parental satisfaction and oral health related quality of life of preschool children. J Dent 2019;88:103171.
  13. Roberts A, Bradley J, Merkley S, et al. Does potassium iodide application following silver diamine fluoride reduce staining of tooth? A systematic review. Aust Dent J 2020;65(2):109-17.
  14. Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: a caries "silver-fluoride bullet". J Dent Res 2009;88(2):116-25.
  15. Horst JA, Ellenikiotis H, Milgrom PL. UCSF protocol for caries arrest using silver diamine fluoride: rationale, indications and consent. J Calif Dent Assoc 2016;44(1):16-28.
  16. Crystal YO, Niederman R. Evidence-Based Dentistry Update on Silver Diamine Fluoride. Dent Clin North Am 2019;63(1):45-68.
  17. Mei ML, Lo ECM, Chu CH. Arresting Dentine Caries with Silver Diamine Fluoride: What's Behind It? J Dent Res 2018;97(7):751-58.
  18. Slayton RL, Urquhart O, Araujo MWB, et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association. J Am Dent Assoc 2018;149(10):837-49.e19.
  19. Fontana M, Gonzalez-Cabezas C. Evidence-Based Dentistry Caries Risk Assessment and Disease Management. Dent Clin North Am 2019;63(1):119-28.
  20. Urquhart O, Tampi MP, Pilcher L, et al. Nonrestorative Treatments for Caries: Systematic Review and Network Meta-analysis. J Dent Res 2018:22034518800014.
  21. Seifo N, Cassie H, Radford JR, Innes NPT. Silver diamine fluoride for managing carious lesions: an umbrella review. BMC Oral Health 2019;19(1):145.
  22. Zhang J, Sardana D, Li KY, Leung KCM, Lo ECM. Topical Fluoride to Prevent Root Caries: Systematic Review with Network Meta-analysis. J Dent Res 2020;99(5):506-13.
  23. Horst JA, Heima M. Prevention of Dental Caries by Silver Diamine Fluoride. Compend Contin Educ Dent 2019;40(3):158-63; quiz 64.
  24. Wu DI, Velamakanni S, Denisson J, et al. Effect of Silver Diamine Fluoride (SDF) Application on Microtensile Bonding Strength of Dentin in Primary Teeth. Pediatr Dent 2016;38(2):148-53.
  25. Jiang M, Mei ML, Wong MCM, Chu CH, Lo ECM. Effect of silver diamine fluoride solution application on the bond strength of dentine to adhesives and to glass ionomer cements: a systematic review. BMC Oral Health 2020;20(1):40.
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Last Updated: July 19, 2021

Prepared by:

Department of Scientific Information, Evidence Synthesis & Translation Research, ADA Science & Research Institute, LLC.


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