Silver diamine fluoride (SDF) is a clear, odourless liquid indicated for desensitisation of non-carious tooth lesions and molar incisor hypomineralisation. It is also useful for arresting carious lesions in adults and children who are high caries-risk and/or have difficult-to-control, progressing carious lesions, those who are unable to tolerate invasive treatment, elderly populations, and those who are medically compromised or have additional care and support needs. SDF may be used to manage lesions that are too extensive to restore but not associated with pain and/or infection. This can be important particularly where extractions might be contra-indicated for medical or behavioural reasons. This paper summarises the global evidence for the effectiveness and safety of SDF, describes what it is, its mechanisms of action and presents recommendations on how to use it. There are details on indications/contra-indications and risks/benefits to be considered in the use of SDF also discussion of how to approach SDF's side effect of black staining of carious tooth tissue. We give an example of an information sheet (Appendix S1, see online supplementary information) that may be used when discussing SDF with patients, particularly for primary teeth in children, but adaptable for the permanent dentition and for adults.
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Black G V. Operative dentistry, bacteriology and pathology of dental caries: A series of lectures in Northwestern University Dental School, session of 1900-1901. Chicago: Blakely Printing Co, 1903.
Kassebaum N J, Smith A G C, Bernabe E et al. Global, regional, and national prevalence, incidence, and disability-adjusted life years for oral conditions for 195 countries, 1990-2015: A systematic analysis for the global burden of diseases, injuries, and risk factors. J Dent Res 2017; 96: 380-387.
Innes N P T, Chu C H, Fontana M et al. A century of change towards prevention and minimal intervention in cariology. J Dent Res 2019; 98: 611-617.
Kearns C E, Glantz S A, Schmidt L A. Sugar industry influence on the scientific agenda of the National Institute of Dental Research's 1971 National Caries Program: a historical analysis of internal documents. PLoS Med 2015; 12: e1001798.
Seifo N, Cassie H, Radford J R, Innes N P T. Silver diamine fluoride for managing carious lesions: An umbrella review. BMC Oral Health 2019; 19: 145.
Horst J A, Ellenikiotis H, Milgrom P M, Committee USCA. UCSF protocol for caries arrest using silver diamine fluoride: Rationale, indications, and consent. J Calif Dent Assoc 2016; 44: 16.
Chu C H, Lo E C, Lin H C. 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.
Contreras V, Toro M J, Elias-Boneta A R, Encarnacion-Burgos A. Effectiveness of silver diamine fluoride in caries prevention and arrest: A systematic literature review. Gen Dent 2017; 65: 22-29.
Li R, Lo E C, Liu B Y, Wong M C, 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.
Castillo J L, 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: 203-208.
Knight G M, McIntyre J M, Mulyani. The effect of silver fluoride and potassium iodide on the bond strength of auto cure glass ionomer cement to dentine. Aust Dent J 2006; 51: 42-45.
Knight G M, McLntyre J M, Craig G G, Mulyani. Ion uptake into demineralized dentine from glass ionomer cement following pretreatment with silver fluoride and potassium iodide. Aust Dent J 2006; 51: 237-241.
Zhao I, Mei M, Burrow M, Lo E, Chu C-H. Effect of silver diamine fluoride and potassium iodide treatment on secondary caries prevention and tooth discolouration in cervical glass ionomer cement restoration. Int J Mol Sci2017; 18: 340.
Innes N P T, Frencken J E, Bjørndal L et al. Managing carious lesions: Consensus recommendations on terminology. Adv Dent Res 2016; 28: 49-57.
Schwendicke F, Frencken J E, Bjørndal L et al. Managing carious lesions: Consensus recommendations on carious tissue removal. Adv Dent Res 2016; 28: 58-67.
Li T, Zhai X, Song F, Zhu H. Selective versus non-selective removal for dental caries: A systematic review and meta-analysis. Acta Odontol Scand 2018; 76: 135-140.
Ricketts D, Lamont T, Innes N P T, Kidd E, Clarkson J E. Operative caries management in adults and children. Cochrane Database Syst Rev 2013; CD003808.
Schwendicke F, Dörfer C E, Paris S. Incomplete caries removal: A systematic review and meta-analysis. J Dent Res 2013; 92: 306-314.
Youravong N, Carlen A, Teanpaisan R, Dahlen G. Metal-ion susceptibility of oral bacterial species. Lett Appl Microbiol 2011; 53: 324-328.
Chu C H, Mei L, Seneviratne C J, Lo EC. Effects of silver diamine fluoride on dentine carious lesions induced by streptococcus mutans and actinomyces naeslundii biofilms. Int J Paediatr Dent 2012; 22: 2-10.
Knight G M, McIntyre J M, Craig G G, Mulyani, Zilm P S, Gully N J. An in vitro model to measure the effect of a silver fluoride and potassium iodide treatment on the permeability of demineralized dentine to streptococcus mutans. Aust Dent J 2005; 50: 242-245.
Zhao I S, Gao S S, Hiraishi N et al. Mechanisms of silver diamine fluoride on arresting caries: A literature review. Int Dent J 2018; 68: 67-76.
Chaussain-Miller C, Fioretti F, Goldberg M, Menashi S. The role of matrix metalloproteinases (mmps) in human caries. J Dent Res 2006; 85: 22-32.
Mei M L, Li Q L, Chu C H, Yiu C K, Lo EC. The inhibitory effects of silver diamine fluoride at different concentrations on matrix metalloproteinases. Dent Mater 2012; 28: 903-908.
Wakshlak R B-K, Pedahzur R, Avnir D. Antibacterial activity of silver-killed bacteria: The" zombies" effect. Sci Rep 2015; 5: 9555.
Frencken J E. The state-of-the-art of art restorations. Dent Update 2014; 41: 218-220; 222-214.
Alvear Fa B, Jew J A, Wong A, Young D. Silver modified atraumatic restorative technique (SMART): An alternative caries prevention tool. Stoma Edu J 2016; 3: 18-24.
SMART Oral Health: The medical management of caries. Duffin S, Juhl J, Schwab S, Duffin M (eds). 2019. Available online at https://www.smartoralhealth.com/ (accessed 7 January 2020).
Quock R L, Barros J A, Yang S W, Patel S A. Effect of silver diamine fluoride on microtensile bond strength to dentin. Oper Dent 2012; 37: 610-616.
Yamaga M, Koide T, Hieda T. Adhesiveness of glass ionomer cement containing tannin-fluoride preparation (hy agent) to dentin. Dent Mater J 1993; 12: 36-44.
Greenhill J D, Pashley DH. The effects of desensitizing agents on the hydraulic conductance of human dentin in vitro. J Dent Res 1981; 60: 686-698.
Craig G G, Knight G M, McIntyre J M. Clinical evaluation of diamine silver fluoride/potassium iodide as a dentine desensitizing agent. A pilot study. Aust Dent J 2012; 57: 308-311.
Thrash W J, Jones D L, Dodds W J. Effect of a fluoride solution on dentinal hypersensitivity. Am J Dent 1992; 5: 299-302.
2020 ICD-10-CM Diagnosis Code K02.3. Available online at https://www.icd10data.com/ICD10CM/Codes/K00-K95/K00-K14/K02-/K02.3 (accessed 7 January 2020).
UK Government. Off-label or unlicensed use of medicines: prescribers' responsibilities. 2014. Online information available at https://www.gov.uk/drug-safety-update/off-label-or-unlicensed-use-of-medicines-prescribers-responsibilities (accessed August 2019).
Crystal Y O, Janal M N, Hamilton D S, Niederman R. Parental perceptions and acceptance of silver diamine fluoride staining. J Am Dent Assoc 2017; 148: 510-518. e514.
Vasquez E, Zegarra G, Chirinos E et al. Short-term serum pharmacokinetics of diammine silver fluoride after oral application. BMC Oral Health 2012; 12: 60.
Pitts N B, Ekstrand K R, ICDAS Foundation. International Caries Detection and Assessment System (ICDAS) and its International Caries Classification and Management System (ICCMS)-methods for staging of the caries process and enabling dentists to manage caries. Community Dent Oral Epidemiol 2013; 41: e41-52.
Ekstrand K R, Gimenez T, Ferreira F R, Mendes F M, Braga M M. The International Caries Detection and Assessment System-ICDAS: A Systematic Review. Caries Res 2018; 52: 406-419.
The authors would like to acknowledge the role of Dundee Dental Hospital, Child Dental and Oral Health staff in supporting the introduction of SDF into the department and therefore making the production of this paper possible. We would like to thank Dr Travis Nelson for allowing us to reproduce the clinical photographs.
The University of Dundee supported the production of this manuscript and no other external funding was received.
The Child Dental and Oral Health department were gifted eight boxes of Riva Star from SDI to use at Dundee Dental Hospital and School in 2018. The company have had no say in its use in the department, and have not had any role in conceiving, designing, writing, commenting on or reviewing this paper.
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Seifo, N., Robertson, M., MacLean, J. et al. The use of silver diamine fluoride (SDF) in dental practice. Br Dent J 228, 75–81 (2020). https://doi.org/10.1038/s41415-020-1203-9
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