Silver Diamine Fluoride (SDF): A Proven Caries Management Strategy

By Back Mike Wong January 3, 2019

Dental caries reportedly affects 97% of the people on the planet during their lifetimes. 1Berg J. The marketplace for new caries management products: dental caries detection and caries management by risk assessment. BMC Oral Health. 2006;6(Suppl1):S6 But thanks to one of the earth’s most precious metals, dental practitioners have a powerful ally in the fight against tooth decay.

Silver is a natural antimicrobial agent. Silver diamine fluoride (SDF), a formulation of 25% silver, 8% ammonia (a stabilizer), and 5% fluoride (which promotes remineralization), has been used for years across the globe to treat and prevent dental caries. But it was only recently approved for use in the United States. 2 Horst JA. Silver diamine fluoride use in older adults. Decisions in Dentistry. 2016;2(08):30–33. 3Mei ML, Chu CH, Lo EC, Samaranayake LP. Fluoride and silver concentrations of silver diamine fluoride solutions for dental use. Int J Paediatr Dent. 2013;23:279–285. 4Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: a caries “silver-fluoride bullet.” J Dent Res. 2009;88:116–125.

The Silver Solution

In 2014, the US Food and Drug Administration (FDA) approved SDF as a Class II medical device for use as a varnish to curb dentinal hypersensitivity.5US Food and Drug Administration. 510(k) Premarket Notification. Available at  Accessed November 5, 2018.However, most of the buzz around SDF has to do with its caries-fighting ability. And apparently, that’s no secret as many dental practitioners used SDF off-label, as a caries intervention agent. 6Horst JA. Silver diamine fluoride use in older adults. Decisions in Dentistry. 2016;2(08):30–33.

In 2016, the FDA granted clearance for use of a commercially available 38% formulation under the “Breakthrough Therapy Designation,” to arrest caries in children and adults. 7Horst JA. Silver diamine fluoride use in older adults. Decisions in Dentistry. 2016;2(08):30–33. 8American Dental Association. Silver Diamine Fluoride in Caries Management. Available at Accessed November 5, 2018.

SDF Benefits

SDF is the silver bullet that can help salvage teeth from the ravages of caries regardless of age. The American Academy of Pediatric Dentistry supports the use of 38% SDF on primary teeth9American Academy of Pediatric Dentistry. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Available at:  Accessed November 5, 2018. as it comes in particularly handy in the treatment of very young children.

Study after study has proven the efficacy of SDF in preventing and arresting caries in children simply and affordably.10Ruff RR, Niederman R. Silver diamine fluoride versus therapeutic sealants for the arrest and prevention of dental caries in low-income minority children: study protocol for a cluster randomized controlled trial. Trials. 2018;19:523  But as effective as it is in children, it’s also demonstrating efficacy in adults. Research shows that yearly applications of 38% SDF to exposed root surfaces in older adults offers an easy, affordable way to prevent caries and stop its progression.11Oliveira BH, Cunha-Cruz J, Rajendra A, Niederman R. Controlling caries in exposed root surfaces with silver diamine fluoride: A systematic review with meta-analysis.J Am Dent Assoc. 2018;149:671–679.

Keeping Stains At Bay

The downside to SDF application lies in esthetics. When painted onto carious lesions, it turns them a telltale black. And the stain is permanent. In deciduous teeth, this may not be a huge concern. Much depends on where the stain is located. Of course, stains can be masked at a later date by restorative work. And there is some evidence that use of potassium iodide in conjunction with SDF,12Vinh N, Cody N, Joel F, Carolyn P. Potassium iodide: the solution to Silver Diamine Fluoride discoloration? Adv Dent Oral Health. 2017; 5: 001–006. or the use of nanosilver fluoride in lieu of SDF may limit staining.13Santos VE Jr, Vasconcelos Filho A, Targino AG, Flores MA, Galembeck A, Caldas AF Jr, Rosenblatt A. A new “silver-bullet” to treat caries in children—nano silver fluoride: a randomized clinical trial. J Dent. 2014;42:945–951.

But the jury is still out on these alternatives, and patients must be advised of this shortcoming in advance.

Because SDF may also temporarily stain soft tissues, some form of protection is recommended. One method is to paint them with petroleum jelly before application. Another way of protecting adjacent tissues and structure is through isolation devices. The Isolite system, for example, will help clinicians maintain a dry surface, which is required for SDF application, while shielding other areas from exposure. The illumination offered by the device also helps clinicians keep the SDF application on target. And, thanks to the protective mouthpiece, soft tissues, which could be temporarily stained, are kept out of harm’s way, while the inherent metallic taste of SDF is also minimized.

Research is ongoing, but many clinicians are finding SDF to be a reliable partner in caries prevention and intervention. It’s effective, noninvasive and affordable — and that’s a good thing, no matter the patient’s age.