In September 2017, the American Academy of Pediatric Dentistry (AAPD) published an evidence-based guideline on silver diamine fluoride (SDF). (1) Originally approved in 2014 by the Food and Drug Administration for tooth desensitization, SDF has been used recently in an off-label application to arrest tooth decay. The AAPD’s Evidence-Based Dentistry Committee reviewed all appropriate published literature that met evidence-based dentistry (EBD) guidelines and issued a conditional recommendation for its use. As more EBD quality studies are published, it is expected that this recommendation will strengthen and that SDF may possibly become a standard of care in caries management.
What does all of this mean for us in daily practice? The take-home messages are that SDF works and that the benefits of its use outweigh the potential risks.
Unfortunately, dental caries remains one of the most common chronic diseases of childhood. Twenty-five percent of children have a cavity by age three and six out of 10 children have decay by their eighth birthday. In addition to lost school hours for children and lost work hours for their caregivers, dental caries can exact a large toll physically on those with special health-care needs. Caries can also be a difficult disease to manage in elderly individuals facing end-of-life issues.
SDF has the potential to be a breakthrough product in the caries management world. It is a painless, fast, relatively inexpensive option to break the decay process as part of a comprehensive treatment plan. SDF is easy to apply in a minimally cooperative individual. When SDF is applied to a carious lesion, the product turns the decalcified and carious portions of the lesion black. SDF is successful in 76% of the lesions to which it is applied, but it does require reevaluation and reapplication at set intervals on teeth that are not restored. SDF is contraindicated for use on teeth that are abscessed, contain pulp exposures, or have an otherwise poor prognosis.
The major downside of SDF is the nonesthetic permanent black discoloration of the arrested lesion. This can be overcome with eventual restoration of the tooth. The staining can occur if accidentally applied to other tissues (e.g., gingiva, oral mucosa), but it is temporary in nature and usually resolves several days after exposure. Permanent staining can occur on clothing and countertops.
While not appropriate for all carious lesions, SDF offers great promise. Here are three scenarios to consider:
- Imagine a mother who presents with a 14-month-old female child with a chief complaint of staining on her front teeth. The mother reports that recently the teeth appear to be chipping. Examination reveals carious lesions on the lingual surfaces of the child’s maxillary incisors with early decalcification extending on the mesial and distal surfaces. The child is eating normally, and her mother indicates that she does not appear to be in pain or have difficulty eating. The child is mildly cooperative, and her mother would like to treat her in as atraumatic a manner as possible.
- An autistic seven-year-old male presents to your office for a recall appointment. He is marginally cooperative and allows you to perform a limited visual examination of his oral cavity. Visually you can see what appears to be incipient decay on the occlusal surfaces of his molars. You are unable to obtain radiographs. His guardians indicate that he does not appear to be in pain and that he is scheduled for an ENT procedure in several months. His guardians would like you to treat his decay in conjunction with the ENT procedure, but they are concerned about the cavities growing, as they are only able to provide limited oral health care at home.
- You receive a call from a local nursing home regarding one of its residents. An 84-year-old male with Alzheimer’s disease possibly has some cavities. You perform a limited examination and notice root caries. The patient is cooperative, but he is too frail at the current time to undergo dental treatment in a traditional setting. His family has been told that he has a limited time to live, and they would like for him to be comfortable from possible dental pain.
While possibly extreme and more deserving of a discussion beyond the scope of this article, these cases highlight the possible potential of SDF. In the first scenario, SDF may be used to arrest the decay and potentially allow the child to mature so that she is able to receive care in a clinic setting. If esthetics are an issue, glass ionomer or other esthetic materials may be used to cover the arrested lesions. In the second case, time is needed to prevent the progression of the lesion until the teeth can have an appropriate restoration placed in conjunction with the scheduled ENT procedure in a hospital setting. The last example is more difficult; SDF may be part of a palliative care plan.
Silver diamine fluoride offers great promise not only for pediatric dentistry, but dentistry as a whole. Caries management is a large component of dental practice and is at times frustrating due to reliance on patient compliance. SDF is an additional tool that allows dentists to halt the decay process at an early stage and provide patients with options for future treatment and treatment settings. For more information or access to other AAPD oral health policies and recommendations, please visit aapd.org.
1. 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):135-145.
James D. Nickman, DDS, MS, a graduate of the University of Minnesota, is the president of the American Academy of Pediatric Dentistry and the second vice president of the Minnesota Dental Association. He is a fellow of the American College of Dentists, International College of Dentists, and the Pierre Fauchard Academy. He teaches part-time at the University of Minnesota and is in private practice in the Twin Cities.