CariesManagement Enhanced CPD DO C

Yasmi O Crystal

Silver Diamine Fluoride (SDF): Its

Role in Caries Management
Abstract: Silver diamine fluoride (SDF) combines the antibacterial properties of silver and the remineralizing actions of fluoride in an
alkaline solution that creates an unfavourable environment for collagen degradation. Clinical trials have proven the efficacy of SDF as a
caries-arresting agent in primary teeth and root caries in the elderly. It is minimally invasive, inexpensive, safe and easy to apply, but a
sign of arrest is the dark discoloration of the lesions where it is applied. SDF provides clinicians with a valuable additional tool in their
armamentarium for caries management that aims to stop the disease process at the tooth surface, when traditional restorative therapy is
not the best option, and when aesthetic results are not a concern.
CPD/Clinical Relevance: Silver diamine fluoride (SDF) provides clinicians with an additional valuable option for arresting dental caries as
part of a comprehensive caries management plan when traditional restorative therapy is not the best option.
Dent Update 2019; 46: 1016–1022

Despite advances in caries prevention
and the reduction in caries prevalence
as a result of the widespread use of
fluoride in toothpastes and other
delivery forms, dental caries continues
to be a significant health problem for
vulnerable populations worldwide.
Increased consumption of sugar and
processed carbohydrates are partly
to blame for the persistent caries
prevalence,1 and large numbers of
individuals of all ages go untreated as
they face barriers of cost and access
to dental services. In addition, young
children may also be unable to cope
with undergoing conventional dental
restorative treatment and are often
treated with more risky procedures
like sedation or general anaesthesia
Yasmi O Crystal, DMD, MSc, FAAPD,
Clinical Professor of Paediatric Dentistry
Department of Paediatric Dentistry, New
York University College of Dentistry, New
York, USA (email: yasmioc@aol.com).
1016 DentalUpdate
for the delivery of care. Special needs
populations and the elderly may have
additional co-morbidities that prevent
them from receiving conventional
dental treatment, which has a negative
impact on their quality of life.2 Such
circumstances highlight the need to find
alternatives for caries control that are
safe, effective, affordable and are easy to
implement.
Silver compounds have been
used as an alternative for restorative
treatment for the management of
caries for over 100 years.3 In the early
1970s, Drs Nishino and Yamaga in Japan
developed a formulation combining
silver with fluoride using ammonia to
stabilize the solution.4 This product
was 38% w/v of Ag(NH3)2F and it was
recommended for the prevention
and arrest of dental caries in children,
prevention of secondary caries, and
dentine desensitization. They stressed
the downside of black dentinal staining
and therefore recommended to confine
its use to posterior teeth. Since then,
other products have been developed in
Downloaded from magonlinelibrary.com by 144.082.238.225 on December 20, 2019.
different countries and are available with
concentrations of 12%, 30%, 38% and 40%
SDF.
In the last 20 years, the rise
in caries rates in young children have
brought back interest in SDF as a viable
alternative for caries control in groups
with limited access to conventional
dental care. Clinical trials encompassing
over 4000 school children have proven
SDF’s efficacy, ease and safety for caries
arrest on primary teeth.5 In 2014, the
US Food and Drug Administration (FDA)
approved SDF for use in the United States
as a device for dentine desensitization
in adults over 21 years of age and a
38% SDF product was introduced in the
market (Advantage Arrest, Elevate Oral
Care LLC, Florida, USA). Recognizing
the need for innovative approaches
to address oral health problems in
vulnerable populations, the World
Health Organization (WHO) published
a report on Public Health Interventions
against Early Childhood Caries in 2016
and concluded that silver diamine
fluoride can arrest dentine caries in
December 2019

SDF 38% at 30 months
Annually
All surfaces 70
Lower anteriors 93
Upper anteriors 77
Lower posteriors 53
Upper posteriors 42
Table 1. SDF 38% arrest rates by tooth type and application.11
Three groups (ages 3−4, n = 309 at 30 months)
Cavitated dentine caries
SDF 30% annually
SDF 30% 3x/weekly at baseline
5% FV 3x/weekly at baseline
On moderate caries lesions (ICDAS 3−4)*
SDF 30% annually
SDF 30% 3x/weekly at baseline
5% FV 3x/weekly at baseline
Table 2. SDF 30% vs 5% fluoride varnish (FV) arrest rates by application type and lesion depth.12 *ICDAS
3-4. International caries detection and assessment system. Stages 3-4 refers to lesions in enamel only
without distinct cavitation.
primary teeth and prevent recurrence
after treatment (based on very low
evidence). Subsequently, the American
Academy of Pediatric Dentistry
(AAPD) published guidelines for the
use of SDF in 2017, which support
the use of SDF 38% for the arrest of
cavitated caries lesions in primary
teeth as part of a comprehensive
caries management programme
(conditional recommendation
based on low quality evidence).6 It
is important to note that the use of
SDF as a caries arrest medicament is
strictly off-license (off-label) in the US,
December 2019
CariesManagement
38%, as marketed in the USA, is a clear-
blue tinted, light sensitive liquid with
% Arrest a slight ammonia odour that contains
24−27% silver, 7.5−11% ammonia, 5−6%
Semi-annually fluoride (approximately 44,800 parts per
million), <1% blue colouring and ≤62.5%
76
deionized water. It is sold in 8 ml vials with
92 approximately 250 drops of liquid, enough
to treat 125 sites, with a site defined as
86 up to 5 teeth. It is also marketed as a unit-
dose ampoule with 0.1 ml per ampoule.7
62 A recent study cites that a drop of SDF,
with an average of 32.5 microliters, would
57 contain approximately 1.64 to 1.76 mg
of fluoride, and 8.08 to 8.71 mg of silver.8
The use of SDF is contra-indicated in
individuals with a silver allergy, and in
teeth with suspected pulpal involvement.
The exact mechanisms of
action of SDF continue to be under study.
% Arrest So far, we know that in dentine, silver
acts as an antibacterial, interacting with
48% bacterial metabolism which can inhibit
bacterial growth. It also inhibits cathepsin
33% action, therefore interfering with dentine
collagen degradation. The principal silver
34% precipitate is silver chloride (not silver
phosphate), which could not contribute to
% Arrest significant hardening of dentine. Fluoride,
however, enhances remineralization of
45% enamel and dentine, and it also interferes
with matrix metalloproteinases activity,
44% inhibiting dentine collagen degradation.
In addition, the synergistic combination of
51% silver and fluoride in an alkaline solution
(pH 9−10) results in an environment that
is unfavourable for collagen enzyme
activation, therefore preventing further
collagen degradation.9
SDF is an effective dentine
desensitizer and, as its application does
not require caries removal, it does not
similar to the use of fluoride varnish require the use of local anaesthesia. It
(FV), which is also only licensed as is easy to apply, inexpensive, minimally
a device for dentine desensitization
invasive and safe. It presents as a valuable
but used widely as the standard of
tool for caries management in specific
care for caries prevention. Guidelines
situations, as supported by the following
from recognized organizations are
evidence.
important to legitimize and encourage
the use of products like SDF, when
used to benefit the patients in their Current evidence to support
individual circumstances, after a SDF’s potential for caries
careful consideration of risks and arrest and prevention
benefits, and when compared to other Systematic reviews of clinical studies of
more complicated procedures or no SDF uniformly support its efficacy for
treatment. caries arrest on cavitated caries lesions
Silver diamine fluoride in primary teeth over periods up to 36
DentalUpdate 1017
Downloaded from magonlinelibrary.com by 144.082.238.225 on December 20, 2019.
 CariesManagement
Clinical Trial
Tan et al18
(n = 203 at 36 months)
Zhang et al19
(n = 227 at 24 months)
Li et al20
(n = 257 at 30 months)
Table 3. Clinical trials for caries arrest and prevention of root caries elderly populations. Abbreviations:
OHI = Oral hygiene instructions; CHX = Chlorhexidine rinse; NaF = Fluoride varnish; OHE = Oral hygiene
education programme; KI = Potassium iodide application to decrease staining.
months, and for arrest of root caries in
elderly populations over periods up to 30
months. These systematic reviews combine
studies that have different outcome
measures, different times of follow-up,
different application protocols, different
SDF concentrations, and heterogeneous
quality of each of the studies combined.
Quality refers to adequate performance/
reporting of randomization process,
blinding, control groups, etc. When the
studies are too heterogeneous to combine,
the comparison has to be assessed as
low quality evidence, as is the case in the
strength of the recommendations of WHO
and AAPD. There are just not enough
similar, well conducted studies at the time
of writing, where the combination of data
would result in a strong recommendation
for either caries arrest or prevention.
Caries arrest in primary teeth in children
One well conducted systematic review
reports the overall percentage of active
caries that became arrested over a period
of 24 months to be 81% (CI 68−89%).10
These results are consistent with other
1018 DentalUpdate
Outcomes Reported/Groups
Prevention: new caries
OHI+Placebo (q 3 months) 2.5
OHI+CHX (q 3 months) 1.1
OHI+NaF (q 3 months) 0.9
OHI+SDF (yearly)
0.7
Prevention and caries arrest: New/arrested
surfaces
OHI+Placebo 1.33/0.04
OHI+SDF(yearly) 1.00/0.28
OHI+SDF(yearly)+OHE (q. 6 months)
0.70/0.33
Caries arrest: at 12/24/30 months
OHI+Placebo 32%/28%/45%
OHI+SDF 61%/83%/90%
OHI+SDF+KI 76%/85%/93%
Colour of arrested lesions: No difference
between groups after 30 months
studies which also report a wide range of
confidence intervals. The following results
from two recently published clinical trials
that have not been included in previous
systematic reviews are important to
illustrate the potential clinical implications
of the wide range of caries arrest.
Fung et al studied arrest of caries on 788
3−4 year-old children followed for 30
months in 4 groups comparing 12% to 38%
SDF applied annually and semi-annually:11
38% SDF was better than 12% SDF, and
semi-annual applications worked better
than annual applications. Of great interest
to clinicians is that they report their results
broken down into type of teeth (Table 1),
where one can see the much greater rates
of arrest in anterior teeth than in posterior
teeth. Additional important results are that
children with a higher visible plaque index
score (VPI) had a lower chance to have their
caries arrested with annual applications.
Duangthip et al studied caries
arrest on 309 3−4 year-old children followed
for 30 months in three groups: SDF 30%
applied annually, SDF 30% applied 3 times
weekly at baseline, and 5% fluoride varnish
Downloaded from magonlinelibrary.com by 144.082.238.225 on December 20, 2019.
(FV) applied 3 times weekly at baseline.12
Arrest rates seen in Table 2 report results
in cavitated dentine caries and on small
lesions (ICDAS 3−4). From these results
they conclude that annual applications of
30% SDF are better than 3 times weekly at
baseline for cavitated dentine caries lesions;
but for moderate lesions, SDF 30% performs
equally as well as 5% FV, and annual
application works equally as well as 3 times
weekly at baseline. They also report that
lesions with visible plaque, posterior teeth
and occlusal surfaces (as opposed to buccal
or lingual surfaces) required a longer time
to achieve caries arrest.
When looking at the overall
arrest rates in both studies, SDF 38%
arrested 70% of lesions when applied
annually, compared to SDF 30% which
arrested only 48%. These results suggest
that the difference between these two
SDF concentrations is important. Results
of these two studies also suggest that SDF
does not work all the time, and that plaque
control is a crucial part of achieving caries
arrest.
It is important to note that
5% FVs can achieve significant rates of
arrest, especially when lesions are made
cleansable,13 but SDF achieves effects of
desensitization and arrest faster, often with
only one application.12
In an early study included in
most of the systematic reviews, Chu et
al applied SDF with and without caries
removal and concluded that caries removal
is not necessary to achieve similar rates of
caries arrest in young children, which adds
to its ease of application.14
Caries arrest in permanent teeth in children
Only one study15 reports similar arrest rates
on young permanent first molars to those
reported on primary molars (70%), while
another study reported arrest results to
be equal to glass ionomer sealants and
toothbrushing after 30 months.16 With such
limited studies, no solid recommendations
can be reached for the use of SDF for caries
arrest in permanent teeth in children.
Caries prevention in primary teeth
Two studies have reported new lesion
formation as a measure of caries prevention
on primary teeth. One of them15 studied
cuspids and molars comparing 38% SDF
December 2019
 CariesManagement
treatment to water placebo on
first grade school children where
both groups were participating in a
bi-weekly fluoride rinse programme;
children were followed for 36 months.
The other study14 included maxillary
anterior teeth only and compared
SDF to FV; posterior teeth with caries
present/restored were not included in
the study; children were followed for
30 months. Both studies indicate that
SDF prevented new lesion formation
during the time followed, but it is
unclear whether this happened only
on teeth where SDF was applied,
or if it was also on adjacent teeth
included in the study. With such
limited data, it is not possible to make
strong recommendations for caries
prevention with SDF.
Caries prevention in permanent teeth in
children
Two studies have reported new lesion
formation as a measure of caries
prevention on permanent teeth
in children. The first study found a
significant reduction in new caries
when SDF was applied compared
to water control15 after 36 months.
The second study compared SDF to
glass ionomer cement sealants and
no treatment in schools with and
without toothbrushing programmes.17
After 18 months, there was little
difference between the three groups,
and the determining factor in
caries prevention was the fluoride
toothbrushing programme. With such
limited evidence, it is too early to
make recommendations for the use
of SDF to prevent caries in permanent
teeth in children.
Caries arrest and prevention of root
caries in the elderly
Several systematic reviews have
compiled results from the only
three clinical trials18-20 conducted to
study caries arrest and prevention
of root caries in the elderly. They all
concluded that SDF is effective in
arresting and preventing root caries
in the elderly, but its effectiveness
improves when combined with
structured oral health education.
1020 DentalUpdate
Results from individual trials can be
seen in Table 3.
Toxicity, contra-indications and staining
None of the clinical trials mentioned,
encompassing over 4000 children,
has reported any major side-effects
or signs of toxicity. Minor side-effects
include transient gingival irritation,
metallic taste and staining of surfaces Figure 1. SDF staining in anterior teeth.
that come in contact with the
product, including skin. Skin staining
is temporary.21 Necessary precautions
like applying vaseline on lips, cotton
roll isolation and avoiding gingival
areas during application are important
to avoid accidental staining on the
patient.
Protecting work areas
during use is important to avoid
permanent stains.
Pharmacokinetics studies
have only been done on adults and
conclude that using 1−2 drops, as
indicated on an occasional basis,
Figure 2. SDF staining in anterior and posterior
should pose no dangers of toxicity.
teeth.
Because studies have not been carried
out on children, it is important to
limit its use to the minimum amount
necessary when using on young
children, and to consider the risks and
benefits of this treatment carefully
versus other options with the parents.
As already mentioned,
this treatment is contra-indicated
on patients who report silver or
other heavy metal allergies, or those
who present with oral ulcerations,
stomatitis or ulcerative gingivitis. Its
use is also contra-indicated on teeth Figure 3. SDF staining in posterior teeth.
that are suspected to have pulpal
involvement, as they will continue to
develop pulpal symptoms, sometimes
acute, after the use of SDF. Careful to avoid more involved and risky procedures
diagnosis, and ideally radiographic like sedation or general anaesthesia.22 To
evaluation, is recommended before identify parents who will be dissatisfied
considering its use. with the results, it is important to have a
Dark, sometimes black, thorough informed consent form, ideally
staining (Figures 1, 2 and 3) on carious with photographs that show clearly the
enamel and dentine are an indication potential staining.
of arrest. This can be very visible on Some studies have suggested
anterior teeth, depending on the the use of potassium iodide (KI) applied
size and the location of the cavities. after the SDF to minimize the staining.
Studies indicate that, although the Results with this protocol are inconclusive,
staining may be undesirable to some as one of the clinical trials studying root
parents, they will accept this therapy caries in elderly populations found that,
December 2019
Downloaded from magonlinelibrary.com by 144.082.238.225 on December 20, 2019.

after 30 months, there was no difference
in the colour of arrested lesions in the
group that had KI compared to the
other groups who didn’t have it.
SDF does not seem to
reduce adhesion of resin or glass
ionomer restorative material.23 This is
important because its use to reduce
sensitivity and/or caries control can be
eventually followed by more aesthetic
restorations.
Important gaps in knowledge and future
research
It is important to mention that most
of the studies that investigate the
antibacterial effects of SDF have
been conducted in in vitro biofilm
models with single or selected
species combinations, whereas the
oral microbiota involves at least 500
species with complex interactions
between them. Much work is still
required in situ and in vivo to determine
whether the bacterial suppression is
single species specific or specific to a
consortium of species; whether this
happens only at the tissue level (where
SDF is directly applied) or at the tooth
level (surfaces adjacent to application
area); or whether there is a whole
biofilm shift of the oral microbiome
(as surface application may spread in
saliva). It will also be important to find
out if single or repeated applications
have any effect on the whole gastro-
intestinal microbiome. Answers to these
questions, supported by clinical studies
of new caries development, are required
to determine the actual role of SDF in
caries prevention.
It is also important to point
out that all the studies mentioned here
had a maximum follow-up of 30−36
months, and none had either FV or any
kind of restorative treatment following
the SDF application. We do not have any
evidence of whether the caries arrest
can be sustained for longer periods, or
the effect of combination with other
treatments. Future studies should clarify
the true potential of SDF and its role for
caries management.
Clinical implications
From presented evidence, we can
December 2019
conclude that regarding SDF:
 It has shown efficacy to arrest
cavitated caries lesions in primary teeth,
with rates varying from 40% to 90%
depending on tooth location, tooth
surface, application frequency and
presence of plaque;
 38% SDF gives better caries arrest
results than lower concentrations, and
twice a year applications are more
effective to sustain caries arrest than
annual applications;
 Caries removal is not necessary, but
clean, dry, plaque-free dentine surfaces
will maximize contact of the solution
with the carious tissue. As there is no
need to remove carious tissue, there is
no need for local anaesthetics;
 Because presence of plaque is crucial,
and SDF application is not guaranteed
to work in all cases, it is best used as part
of a comprehensive caries management
programme where one can monitor its
effectiveness;
 Its effectiveness in incipient lesions,
especially occlusal lesions, is uncertain;
so it is best to combine it with other
proven treatments like sealants and
fluoride therapy;
 It has proven to arrest and prevent
root caries in elderly populations
when combined with an oral health
education programme, ideally as part
of a comprehensive caries management
programme;
 It is contra-indicated in individuals
with silver allergies or gingival
ulcerations and in teeth that are
suspected to have pulpal involvement;
 Patient selection should include
those who are not good candidates for
traditional restorative treatment, but
who have an established dental home
to follow-up the use of SDF as part of
a comprehensive caries management
plan that ideally includes components of
chronic disease management models to
address the behavioural risk factors;
 SDF therapy can be followed up with
restorative treatment when patient’s
circumstances or needs change.
Application
Once proper diagnosis has been
completed to identify the right patient/
teeth/lesions who will benefit from
Downloaded from magonlinelibrary.com by 144.082.238.225 on December 20, 2019.
CariesManagement
SDF therapy, application is simple and
requires minimal armamentarium.
Patient’s lips should be protected
with Vaseline. Tooth/cavity areas are
cleaned of visible plaque, isolated with
cotton rolls and dried gently to avoid
sensitivity. A drop of SDF is placed
on a glass dappen-dish or dispenser
provided, and immediately applied
with a micro-brush onto the cavitated
lesions. It should be allowed to air-dry
for at least a minute, if possible.
Follow-up
It is evident that as dental caries is
a multifactorial disease with strong
behavioural risk factors (diet and
plaque control), not unlike other
chronic diseases like diabetes and
heart disease, its treatment can’t be
successful with a single agent, whether
fluoride, SDF or other antibacterials.
A comprehensive plan that includes
chronic disease management model
strategies and where the behavioural
issues are identified and addressed
(eg through Motivational Interviewing
or other behavioural management
techniques) is desirable if one aims to
achieve long-term optimal oral health. A
caries risk assessment form at baseline
and follow-ups will help in identifying
the individual’s specific risk factors to
address them appropriately.24
Lesions treated should be
followed-up 2−4 weeks after application
to check for signs of caries arrest (dark
and hard surface). Large cavities may
require re-application at this time. SDF
should be re-applied every 6 months
to sustain the arrest when teeth are
not restored after SDF therapy. Treated
lesions should be closely monitored
for continued arrest.25 Plaque removal
should be stressed to optimize the
chances of sustained caries arrest and,
as all candidates of this therapy would
fall within the ‘high risk for caries’
category, they should be re-evaluated
at 3-monthly intervals. As the SDF
therapy is intended only to arrest the
selected cavitated lesions, preventive FV
applications would still be indicated to
prevent new lesions and arrest incipient
ones in the rest of the dentition. This
could be done at the alternating 3
DentalUpdate 1021
 CariesManagement
month visits.
Silver diamine fluoride is
an additional form of non-surgical
management for dental caries that
achieves fast caries arrest with a
minimally invasive technique. It is
invaluable when traditional treatment
has to be delayed for medical,
behavioural or other reasons, and it may
help delay or defer the need for more
complicated and invasive procedures.
As with all other treatments, it has risks
and benefits that should be carefully
considered and discussed with parents
when choosing the right therapy for
individual cases.
Conflict of interest statement
Dr Yasmi O Crystal declares no financial
involvement with any of the companies
or products that are mentioned in this
publication. The off-label use of an FDA-
approved device is mentioned.
References
1. Sheiham A, Williams DM, Weyant
RJ et al. Billions with oral disease:
A global health crisis − a call to
action. J Am Dent Assoc 2015; 146:
861−864.
2. Gregory D, Hyde S. Root caries in
older adults. J Calif Dent Assoc 2015;
43: 439−445.
3. Howe PR. A method of sterilizing
and at the same time impregnating
with a metal affected dentinal
tissue. Dent Cosmos 1917; 59:
891−904.
4. Yamaga R, Nishino M, Yoshida S,
Yokomizo I. Diammine silverfluoride
and its clinical application. J Osaka
Univ Dent Sch 1972; 12(20): 1−10.
5. Crystal YO, Niederman R. Silver
diamine fluoride treatment
considerations in children’s caries
management. Pediatr Dent 2016;
38: 466−471.
6. 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. Pediatr
Dent 2017; 39: 135−145.
7. Elevate Oral Care. Advantage Arrest:
SDF 38%. Product Package Insert.
1022 DentalUpdate
Elevate Oral Care: download from
website as instructions; 2015.
http://www.elevateoralcare.com/
site/images/AA_PI_040715.pdf
8. Crystal YO, Rabieh S, Janal MN,
Rasamimari S, Bromage TG. Silver
and fluoride content and short-
term stability of 38% silver diamine
fluoride. J Am Dent Assoc 2019; 150:
140–146.
9. Mei ML, Lo ECM, Chu CH. Arresting
dentine caries with silver diamine
fluoride: What’s behind it? J Dent
Res 2018; 97: 751−758.
10. Gao SS, Zhao IS, Hiraishi N et al.
Clinical trials of silver diamine
fluoride in arresting caries among
children. JDR Clin Transl Res 2016; 1:
201−210.
11. Fung MHT, Duangthip D, Wong
MCM, Lo ECM, Chu CH. Randomized
clinical trial of 12% and 38% silver
diamine fluoride treatment. J Dent
Res 2018; 97: 171−178.
12. Duangthip D, Wong MCM, Chu CH,
Lo ECM. Caries arrest by topical
fluorides in preschool children:
30-month results.
J Dent 2018; 70: 74−79.
13. Santamaria RM, Innes NPT,
Machiulskiene V et al. Alternative
caries management options for
primary molars: 2.5-year outcomes
of a randomised Clinical trial. Caries
Res 2017; 51: 605−614.
14. Chu CH, Lo ECM, Lin HC.
Effectiveness of silver diamine
fluoride and sodium fluoride
varnish in arresting dentin caries in
Chinese pre-school children. J Dent
Res 2002; 81: 767−770.
15. 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: 721−724.
16. Braga MM, Mendes FM, De
Benedetto MS, Imparato JC. Effect
of silver diammine fluoride on
incipient caries lesions in erupting
permanent first molars: a pilot
study. J Dent Child (Chic) 2009; 76:
28−33.
17. Monse B, Heinrich-Weltzien R,
Mulder J, Holmgren C, Helderman
Downloaded from magonlinelibrary.com by 144.082.238.225 on December 20, 2019.
WHvP. Caries preventive efficacy of
silver diammine fluoride (SDF) and
ART sealants in a school-based daily
fluoride toothbrushing program in the
Philippines. BMC Oral Health 2012; 12.
18. Tan HP, Lo EC, Dyson JE, Luo Y, Corbet
EF. A randomized trial on root caries
prevention in elders. J Dent Res 2010;
89: 1086−1090.
19. 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: 284−290.
20. 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; 51: 15−20.
21. Duangthip D, Fung MHT, Wong MCM,
Chu CH, Lo ECM. Adverse effects of
silver diamine fluoride treatment
among preschool children. J Dent Res
2017: 22034517746678.
22. Crystal YO, Janal MN, Hamilton DS,
Niederman R. Parental perceptions and
acceptance of silver diamine fluoride
staining. J Am Dent Assoc 2017; 148:
510−518.e4.
23. 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: 148−153.
24. Featherstone JDB, Crystal YO,
Chaffee BW, Zhan L, Ramos-Gomez
FJ. An updated CAMBRA caries risk
assessment tool for ages 0 to 5 years.
CDA Journal 2019; (47)1: 37–47.
cdafoundation.org/CAMBRA
25. Chairside guide: silver diamine fluoride
in the management of dental caries
lesions. AAPD Reference Manual
2017−2018; 39: 492−493. http://
www.aapd.org/media/Policies
Guidelines/R_ChairsideGuide.pdf
December 2019
RESOURCES: SDF CHAIRSIDE GUIDE
Chairside Guide: Silver Diamine Fluoride in the
Management of Dental Caries Lesions*
Dental caries affects about one out of four children ages two through five years.1 Silver diamine fluoride (SDF), recently approved
for use in the United States, has been shown to be efficacious in arresting caries lesions.2,3 It is a valuable therapy which may be
included as part of a caries management plan for patients. Caries lesions treated with SDF usually turn black and hard. Stopping
the caries process in all targeted lesions may take several applications of SDF, and reapplication may be necessary to sustain arrest.
Active cavitated caries lesions before application of SDF
Case selection for application of silver diamine fluoride
Patients who may benefit from SDF include those:
• With high caries risk who have active cavitated caries
lesions in anterior or posterior teeth;
• Presenting with behavioral or medical management chal-
lenges and cavitated caries lesions;
• With multiple cavitated caries lesions that may not all
be treated in one visit;
• With dental caries lesions that are difficult to treat; and
• Without access to or with difficulty accessing dental care.
Criteria for tooth selection include:
• No clinical signs of pulpal inflammation or reports of
unsolicited/spontaneous pain.
• Cavitated caries lesions that are not encroaching on the
pulp. If possible, radiographs should be taken to assess
depth of caries lesions.
• Cavitated caries lesions on any surface as long as they are
accessible with a brush for applying SDF. (Orthodontic
separators may be used to help gain access to proximal
lesions.)
SDF can be used prior to restoration placement and as part
of caries control therapy.4 Informed consent, particularly high-
lighting expected staining of treated lesions, potential staining
of skin and clothes, and need for reapplication for disease
control, is recommended.
Clinical application of silver diamine fluoride
• Remove gross debris from cavitation to allow better SDF
contact with denatured dentin.
• Carious dentin excavation prior to SDF application is not
necessary. As excavation may reduce proportion of arrested
caries lesions that become black, it may be considered for
esthetic purposes.
596 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
SDF-treated lesions with temporary gingival staining
• A protective coating may be applied to the lips and skin
to prevent a temporary henna-appearing tattoo that can
occur if soft tissues come into contact with SDF.
• Isolate areas to be treated with cotton rolls or other isola-
tion methods. If applying cocoa butter or any other product
to protect surrounding gingival tissues, use care to not
inadvertently coat the surfaces of the caries lesions.
• Caution should be taken when applying SDF on primary
teeth adjacent to permanent anterior teeth that may have
non-cavitated (white spot) lesions to avoid inadvertent
staining.
• Careful application with a microbrush should be adequate
to prevent intraoral and extraoral soft tissue exposure. No
more than one drop of SDF should be used for the entire
appointment.
• Dry lesion with gentle flow of compressed air.
• Bend micro sponge brush. Dip brush into SDF and dab
on the side of the plastic dappen dish to remove excess
liquid before application. Apply SDF directly to only the
affected tooth surface. Remove excess SDF with gauze,
cotton roll, or cotton pellet to minimize systemic absorption.
• Application time should be at least one minute if possible.
(Application time likely will be shorter in very young and
difficult to manage patients. When using shorter applica-
tion periods, monitor carefully at post-operative and recall
visits to evaluate arrest and consider reapplication.)
• Apply gentle flow of compressed air until medicament is
dry. Try to keep isolated for as long as three minutes.
• The entire dentition may be treated after SDF treatment
with five percent sodium fluoride varnish to help prevent
caries on the teeth and sites not treated with SDF.
* Refer to AAPD Clinical Practice Guideline: 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. Pediatr Dent 2017;39
(5):E135-E145. ( Available at: http://www.aapd.org/policies/)

Follow-up
Estimations of SDF effectiveness in arresting dental caries
lesions range from 47 to 90 percent with one-time application
depending on size of the cavity and tooth location.4-7 Anterior
teeth have higher rates of arrest than posterior teeth.5 There-
fore, follow-up for evaluation of caries arrest is advisable.2-3
• Follow-up at two to four weeks after initial treatment to
check the arrest of the lesions treated.
• Reapplication of SDF may be indicated if the treated
lesions do not appear arrested (dark and hard). Addi-
tional SDF can be applied at recall appointments as
needed, based on the color and hardness of the lesion
or evidence of lesion progression.
• Caries lesions can be restored after treatment with SDF.
• When lesions are not restored after SDF therapy, bi-
annual reapplication shows increased caries arrest rate
versus a single application.
References
1. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental
caries and sealant prevalence in children and adolescents
in the United States, 2011–2012. NCHS data brief, no
191. Hyattsville, Md.: National Center for Health Stat-
istics. 2015. Available at: “https://www.cdc.gov/nchs/
products/databriefs/db191.htm”. Accessed September 6,
®
2017. (Archived in WebCite at: “http://www.webcita
tion.org/6tX0D6qO1”)
RESOURCES: SDF CHAIRSIDE GUIDE
2. Gao SS, Zhang S, Mei ML, Lo EC, Chu CH. Caries
remineralisation and arresting effect in children by pro-
fessionally applied fluoride treatment – A systematic
review. BMC Oral Health 2016;16:12.
3. Duangthip D, Jiang M, Chu CH, Lo EC. Restorative
approaches to treat dentin caries in preschool children:
Systematic review. Eur J Paediatr Dent 2016;17(2):
113-21.
4. Crystal YO, Niederman R. Silver diamine fluoride treat-
ment considerations in children’s caries management:
Brief communication and commentary. Pediatr Dent
2016;38(7):466-71.
5. Fung M, Duangthip D, Wong M, Lo E, Chu C. Arresting
dentine caries with different concentration and perio-
dicity of silver diamine fluoride. JDR Clin Transl Res
2016;1(2):143-52.
6. Llodra JC, Rodriguez A, Ferrer B, Menardia V, Ramos T,
Morato M. 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.
7. Zhi QH, Lo ECM, Lin HC. Randomized clinical trial
on effectiveness of silver diamine fluoride and glass
ionomer in arresting dentine caries in preschool children.
J Dent 2012;40(11):962-7.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 597