13/10/23, 17:36 Silver Diamine Fluoride | American Dental Association

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Silver Diamine Fluoride

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Key Points
There has been strong research interest in the use of silver
diamine fluoride (SDF) to arrest caries lesions, which is an off-
label use. SDF currently has FDA clearance for treating tooth
sensitivity.

The potential benefits of SDF treatment for caries arrest include

its low cost and ease of application.

One common adverse effect of SDF treatment is permanent

black staining of the arrested caries lesions.

Biannual applications of SDF are recommended for sustained

benefit.
13/10/23, 17:36 Silver Diamine Fluoride | American Dental Association

preventable disease, researchers are continuing to

investigate the effectiveness of fluoride-containing
materials in arresting carious lesions and preventing
future development of caries lesions, including an
increasing focus on silver diamine fluoride (SDF).

Silver diamine fluoride is a colorless or blue-tinted

liquid with a pH between 10 and 13, which is comprised
of approximately 24.4% to 28.8% (weight/volume) silver,
5.0% to 5.9% fluoride and 8.0% ammonia.8-12 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 September 2023,
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.13 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.14 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.15 SDF has also shown efficacy in
management of root caries in the elderly.16-20 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.21-23

SDF offers the possibility of arresting or slowing

progression of caries lesions in primary and permanent
teeth without removal of sound tooth tissue.24, 25 In
addition, SDF appears to promote remineralization of
demineralized dentin.24, 26 The effectiveness of treating
carious lesions with SDF is demonstrated by the
13/10/23, 17:36 Silver Diamine Fluoride | American Dental Association

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 desirable or available.

SDF may 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 conventional
restorative treatment. SDF treatment has also been
shown to be as effective in stopping caries progression
as atraumatic restorative treatment (ART), while being
up to twenty times less costly.29

SDF Composition and Mechanisms of Action

SDF is an alkaline solution with 38% weight/volume

Ag(NH3)2F. The silver functions as an antimicrobial,
while fluoride is present in sufficient concentration to
promote remineralization;32-34 the ammonia (NH3)
present stabilizes the solution.29 When in contact with
the tooth, the diamine-silver ion complexes react with
hydroxyapatite forming silver phosphate (Ag3PO4) and
silver oxide (Ag2O).28 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.29 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.33

The formation of silver compounds results in striking

tooth structure color change,32 which is the main
13/10/23, 17:36 Silver Diamine Fluoride | American Dental Association

conjugates forms.29 This squamous layer formed on

the exposed dentin surface partially closes the exposed
dentin tubules.29

Use of SDF for Caries Arrest

The caries process commonly occurs through exposure

to dietary sugars and complex bacterial interactions in
the oral cavity, including biofilm formation, bacterial
metabolism, frequent acid production, tooth mineral
demineralization, and organic matrix degradation.38-42
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.42 Therefore, it is important to
enhance the protective and minimize the pathologic
factors associated with tooth decay. Current strategies
for caries management focus on the individual’s risk
assessment and establishment of preventive and/or
restorative treatments.43

Caries progression occurs by simultaneous

demineralization of enamel and dentin and
degradation of the organic matrix.41 Once the caries
lesion is developed, treatment options include
restorative and non-restorative measures.43
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.42

In 2018, the ADA Center for Evidence-Based Dentistry

conducted a systematic review and network meta-
analysis44 informing a clinical practice guideline42 on
nonrestorative treatments for carious lesions. The
13/10/23, 17:36 Silver Diamine Fluoride | American Dental Association

A 2017 guideline45 from the American Academy of

Pediatric Dentistry (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 dentin treated with SDF.

According to an umbrella review, application of 38%

SDF prevented root caries in adults with success rates
72% higher than a placebo treatment.46 The same
review reported a prevented fraction for successful root
caries arrest, between 100% and 725% higher as
compared to a placebo treatment.46 Another study
indicated that application of 38% SDF in combination
with oral health education was the most effective
method for preventing root caries in adults.47

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.27 Mature and sound enamel is not stained,
unless there is any superficial defect, such as
hypomineralization or carious/demineralized or
immature enamel, where the porosities allow silver
ions to penetrate.48

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.49
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.49 SDF treatment does not seem
to impair GIC bonding.50, 51

A 2019 systematic review found that once-yearly SDF

application was more effective in preventing caries
than more frequent application (i.e., 2 to 4 times yearly)
48
13/10/23, 17:36 Silver Diamine Fluoride | American Dental Association

ADA Policy on the Use of SDF to Arrest Carious Lesions

ADA Statement on the Use of Silver Diamine Fluoride

(SDF) to Arrest Carious Lesions (Trans.2020:304)

38% Silver Diamine Fluoride (SDF) is a topical

antimicrobial and remineralizing agent which was
cleared by the FDA as a Class II medical device to treat
tooth sensitivity. In certain circumstances, SDF may be
used as a non-restorative treatment to arrest carious
lesions on primary and permanent teeth. The use of
SDF to arrest carious lesions requires diagnosis and
monitoring by a dentist.

When using SDF for caries management, the following

protocols should be followed:

1. Development of a patient-specific treatment

plan by the dentist.

2. Patients or their lawful guardians should be

informed of all available treatment options,
possible side effects, and the need for follow-up
monitoring when giving informed consent.

3. The application of SDF may be delegated to

qualified allied dental personnel with the
appropriate training and supervision in
accordance with state laws and in conjunction
with the above protocols.

and be it further

Resolved, that the ADA supports SDF as a covered

benefit by third-party payers, and be it further

Resolved, if the tooth treated with SDF requires further

treatment, that this restorative treatment or extraction
of the tooth also remain a covered benefit.
13/10/23, 17:36 Silver Diamine Fluoride | American Dental Association

sealants, tooth retention, and edentulism, United

States: 1999–2004 to 2011–2016. 2019.

5. Iheozor‐Ejiofor Z, Worthington HV, Walsh T, et al.

Water fluoridation for the prevention of dental
caries. Cochrane Database of Systematic
Reviews, 2015(6).

6. O'Mullane D, Baez R, Jones S, et al. Fluoride and

oral health. Community Dental Health
2016;33(2):69-99.

7. Kassebaum NJ, Bernabé E, Dahiya M, et al.

Global burden of untreated caries:a systematic
review and metaregression. J Dent Res
2015;94(5):650-58.

8. Elevate Oral Care. Safety Data Sheet--Advantage

Arrest Silver Diamine Fluoride 38%. 2023.
"https://www.elevateoralcare.com/site/images/A
ASDS082415.pdf".

9. Seifo N, Robertson M, MacLean J, et al. The use of

silver diamine fluoride (SDF) in dental practice.
British Dental Journal 2020;228(2):75-81.

10. 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.

11. 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(2):140-46.

12. Yan IG, Zheng FM, Yin IX, et al. Stability of silver
and fluoride contents in silver diamine fluoride
solutions. International Dental Journal 2023.

13. Burgette JM, Weintraub JA, Birken SA, Lewis TA,

White BA. Development of a silver diamine
fluoride protocol in safety net dental settings.
Journal of Dentistry for Children 2019;86(1):32-39.

14. Horst JA. Silver fluoride as a treatment for dental

13/10/23, 17:36 Silver Diamine Fluoride | American Dental Association

Effectiveness and application in older adults.

Gerodontology 2017;34(4):411-19.

19. Chan AKY, Tamrakar M, Jiang CM, et al. Clinical

evidence for professionally applied fluoride
therapy to prevent and arrest dental caries in
older adults: a systematic review. Journal of
Dentistry 2022;125:104273.

20. Grandjean ML, Maccarone NR, McKenna G,

Müller F, Srinivasan M. Silver diamine fluoride
(SDF) in the management of root caries in elders:
a systematic review and meta-analysis. Swiss
Dent J 2021;131(5):417-24.

21. 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.

22. 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.

23. American Academy of Pediatric Dentistry. Policy

on the use of silver diamine fluoride for pediatric
dental patients. American Academy of Pediatric
Dentistry, 2023.
"https://www.aapd.org/globalassets/media/polici
es_guidelines/p_silverdiamine.pdf". Accessed
September 12, 2023.

24. Zhao IS, Gao SS, Hiraishi N, et al. Mechanisms of

silver diamine fluoride on arresting caries: a
literature review. International Dental Journal
2018;68(2):67-76.

25. Young DA, Quock RL, Horst J, et al. Clinical

instructions for using silver diamine fluoride
(SDF) in dental caries management. Compend
Contin Educ Dent 2021;42(6):e5-e9.

26. Cifuentes-Jiménez CC, Bolaños-Carmona MV,

13/10/23, 17:36 Silver Diamine Fluoride | American Dental Association

30. 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.

31. Milgrom P, Horst JA, Ludwig S, et al. Topical silver

diamine fluoride for dental caries arrest in
preschool children: A randomized controlled trial
and microbiological analysis of caries associated
microbes and resistance gene expression. J Dent
2018;68:72-78.

32. Crystal YO, Niederman R. Evidence-Based

Dentistry Update on Silver Diamine Fluoride.
Dent Clin North Am 2019;63(1):45-68.

33. 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.

34. Sorkhdini P, Gregory RL, Crystal YO, Tang Q,

Lippert F. Effectiveness of in vitro primary
coronal caries prevention with silver diamine
fluoride-chemical vs biofilm models Journal of
Dentistry 2020;99:103418.

35. 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.
"https://www.aapd.org/media/policies_guideline
s/g_sdf.pdf". Accessed September 15, 2023.

36. Castillo J, Rivera S, Aparicio T, et al. The short-

term effects of diammine silver fluoride on tooth
sensitivity: a randomized controlled trial. J Dent
Res 2011;90(2):203-08.

37. de Almeida Piovesan É T, Alves JB, Ribeiro C, et

al. Is silver diamine fluoride effective in reducing
dentin hypersensitivity? A systematic review. J
Dent Res Dent Clin Dent Prospects 2023;17(2):63-
70.

38. Selwitz RH, Ismail AI, Pitts NB. Dental caries. The
13/10/23, 17:36 Silver Diamine Fluoride | American Dental Association

management. Dent Clin North Am 2019;63(1):119-

28.

44. Urquhart O, Tampi MP, Pilcher L, et al.

Nonrestorative treatments for caries: systematic
review and network meta-analysis. J Dent Res
2018:22034518800014.

45. Crystal YO, Marghalani AA, Ureles SD, Wright JT,

Sulyanto R, Divaris K, Fontana M, Graham L. Use
of silver diamine fluoride for dental caries
management in children and adolescents,
including those with special health care needs.
Pediatric Dentistry. 2017 Sep 15;39(5):135E-45E.

46. 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.

47. 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.

48. Horst JA, Heima M. Prevention of Dental Caries

by Silver Diamine Fluoride. Compend Contin
Educ Dent 2019;40(3):158-63; quiz 64.

49. 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.

50. 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.

51. 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
13/10/23, 17:36 Silver Diamine Fluoride | American Dental Association

Professional Product Review, Vol 12, Iss 2: Fluoride

Analysis of Fluoride Varnish and SDF (ADA log-in
required)

Professional Product Review, Vol 10, Iss 3: Fluoride

Analysis of Fluoride Varnish (ADA log-in required)

Clinical practice guideline on nonrestorative

treatments for carious lesions

ADA Oral Health Topic on Fluoride topical and

systemic supplements

Patient Resources

Video: Fluoride: The Superhero of Cavity Fighting

Other Resources

American Academy of Pediatric Dentistry

Chairside Guide: Silver Diamine Fluoride in the

Management of Dental Caries Lesions (PDF)

Policy on the Use of Silver Diamine Fluoride for

Pediatric Dental Patients (PDF)

American Dental Hygienists’ Association

State-Specific Information on Silver Diamine

Fluoride (PDF)

Association of State and Territorial Dental Directors

Silver Diamine Fluoride (SDF) Fact Sheet (PDF)

U.S. Department of Health and Human Services (Head

Start—Early Childhood Learning & Knowledge Center)

Understanding Use of Silver Diamine Fluoride

13/10/23, 17:36 Silver Diamine Fluoride | American Dental Association

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Content on this Oral Health Topic page is for informational purposes only. Content is neither intended to nor does it establish a stan
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