Silver Diamine Fluoride for Caries Management

Key Facts

• Silver diamine fluoride (SDF) is an FDA-approved topical medication used to treat tooth sensitivity with off-label use to treat dental caries
• It is a colorless liquid containing silver particles, water, fluoride, and ammonia
• SDF has been used for several decades in other countries and gained attention in the United States as an effective treatment for caries in recent years
• This non-invasive treatment can be particularly beneficial for children, elderly patients, and individuals with special needs
• One of the side effects of SDF is that it can stain carious lesions black

Off-label use warning as of 2023

Silver Diamine Fluoride (SDF) currently has FDA clearance as a desensitizing agent (medication to treat tooth sensitivity). There is a growing appreciation of SDF to arrest caries lesions, which is an off-label use.

What is Silver Diamine Fluoride?

Silver diamine fluoride is a unique dental treatment that combines the antimicrobial properties of silver with the remineralizing attributes of fluoride. It is primarily used to halt the progression of existing dental caries and prevent the development of new caries. Silver acts as an antimicrobial agent, killing bacteria, while fluoride helps to rebuild the minerals in the tooth enamel, strengthening the tooth.
SDF is especially significant as it provides a non-invasive alternative to traditional cavity drilling and filling procedures, making it particularly beneficial for pediatric patients or individuals who have anxiety or difficulties undergoing traditional dental procedures.

The Procedure: Application of Silver Diamine Fluoride to Arrest Caries Lesions

The application of silver diamine fluoride is relatively simple and painless, which makes it appealing, especially for young children or patients with dental anxiety.
The procedure involves the following steps:

• Cleaning the Teeth: The dentist starts by removing any debris or plaque from the tooth surfaces that need treatment.
• Isolating and Drying the Tooth: The tooth is then isolated and dried. This is crucial as SDF needs to be applied to a dry tooth to be effective.
• Application of SDF: The dentist applies SDF to the affected areas with a microbrush. The liquid is left in place for a couple of minutes to allow it to penetrate and treat the carious lesions.
• Rinsing: After the SDF has been given time to work, the mouth is rinsed thoroughly.
• Follow-up: The dentist will give instructions on not to eat or drink for a certain period (usually an hour) to allow the SDF to be effective. A follow-up appointment may be scheduled to evaluate the treatment’s effectiveness and determine if additional applications are needed.

SDF Composition and Mechanisms of Action

Silver Diamine Fluoride (SDF) is composed of silver, ammonia, fluoride, and water.
Each component in SDF plays a significant role in its efficacy for caries arrest and prevention:

• Silver: Acts as an antimicrobial agent. It kills bacteria by interfering with their cell membranes and enzymes, which helps to prevent the growth and reproduction of bacteria that cause cavities.
• Ammonia: It helps in stabilizing the solution, which is crucial for the dissolution of silver fluoride, and ensures that the compound remains effective and does not decompose.
• Fluoride: Plays a role in tooth remineralization. It helps to form fluorapatite, a compound that is more resistant to acids, by reacting with the calcium and phosphate in teeth. This helps to strengthen tooth enamel and prevent the formation of cavities.
• Water: Serves as a solvent in the solution.

The combination of these ingredients makes SDF highly effective. When applied to a tooth, the silver component targets and eliminates bacteria, while the fluoride works to strengthen the tooth and prevent further decay.

Benefits of Silver Diamine Fluoride Use

• Non-Invasive and Painless: As SDF is a topical agent, it can be applied directly to the tooth without the need for drilling or injections, making it non-invasive and painless.
• Efficient Caries Control: It’s highly effective in halting the progression of existing cavities and preventing new ones.
• Cost-Effective: It’s more affordable compared to traditional restorative treatments like fillings or crowns.
• Reduction in Tooth Sensitivity: SDF can help reduce tooth sensitivity.
• Ease of Application: It can be applied quickly, which is particularly beneficial for children, elderly patients, or those with special needs.
• Antimicrobial Properties: The silver in SDF has antimicrobial properties which help in reducing oral bacteria.

Potential Harms Related to Silver Diamine Fluoride Use

• Staining: One of the most notable side effects of SDF is that it blackens the decayed area of the tooth. This may not be aesthetically pleasing, especially if the tooth is in a visible area when smiling or talking.
• Gum Irritation: If SDF comes into contact with the gums, it may cause temporary irritation or a white discoloration.
• Taste: Some patients may dislike the metallic taste of SDF.
• Repeated Applications Needed: For sustained benefits, SDF usually requires repeated applications.
• Allergic Reactions: Though rare, there could be allergic reactions to the silver component in some patients.

SDF for Treatment of Dentin Sensitivity

Dentin hypersensitivity, commonly referred to as tooth sensitivity, is a widespread dental problem characterized by sharp pain in response to stimuli such as cold, heat, or pressure. Silver Diamine Fluoride (SDF) has been increasingly used as a treatment for dentin hypersensitivity due to its dual action in both reducing sensitivity and providing anti-microbial effects.
When SDF is applied to the affected areas, the fluoride ions penetrate the dentinal tubules (tiny channels in the dentin) and promote the formation of a mineral called fluorapatite. This mineral helps to occlude the dentinal tubules, which in turn reduces the sensitivity of the teeth to various stimuli. The silver ions present in SDF act as potent antimicrobials, which help in reducing the bacterial count, further contributing to decreased sensitivity.

Considerations and Limitations

While SDF is highly effective in arresting caries, it is not a definitive restoration method. In some cases, restorative dental procedures may still be necessary to fully repair function and aesthetics. Additionally, one of the known side effects is that it blackens the decayed area, which can be a cosmetic concern for some patients. It’s essential for the dentist to discuss this with the patient or the parents (in case of children) and weigh the benefits and drawbacks before proceeding.
SDF does not remove the decay; it only halts its progression. Therefore, dental practitioners should use SDF as part of a comprehensive caries management plan.

Bottom Line

Silver Diamine Fluoride is a versatile and potent dental treatment with applications ranging from the management of dentin hypersensitivity to the arrest of caries lesions. Its ease of application, coupled with its efficacy and cost-effectiveness, make it an attractive option for patients and practitioners alike. SDF can be especially beneficial in pediatric patients, elderly, and special needs patients where compliance and cooperation for traditional restorative procedures might be challenging. It’s a minimally invasive and cost-effective approach compared to traditional restoration methods. However, it’s essential to consider the aesthetic implications such as the blackening of decayed tooth structure. It’s always advisable for patients to have a thorough discussion with their dentist about the pros and cons and to understand if SDF is the best option for their specific dental needs.

This article is complete and was published on August 15, 2023, and last updated on September 6, 2023.