Silver diamine fluoride
No caries removal and apply silver diamine fluoride
Suitable for:
- a primary tooth with cleansable cavitated lesions*
Aim: To arrest cavitated lesions in primary teeth
Application of silver diamine fluoride (SDF) can be used as part of non-restorative cavity control. SDF is a minimally invasive intervention composed of silver and fluoride, stabilised in ammonia. The silver and fluoride act synergistically for caries arrest; silver is bactericidal and disrupts the cariogenic biofilm while fluoride promotes remineralisation of the tooth surface.
There is very low to low certainty evidence of the effectiveness of SDF in arresting caries in primary teeth compared to no treatment. However, it is uncertain whether SDF is more effective than comparative treatments, notably fluoride varnish.87 There is insufficient evidence to support the use of SDF for caries prevention.87
SDF is licensed in the UK for the management of dentine hypersensitivity. Using SDF for the arrest of dental caries “off-label” requires explanation of what off-label use means to the child or young person and their parent/carer, and the practitioner should be able to justify and feel competent in its use.88
SDF permanently discolours carious tooth tissue, turning it dark brown/black. It also may temporarily cause brown staining of the soft tissues for 1-3 weeks. Rarely, it can cause a chemical burn to the gingiva.89 SDF will also stain clothing or work surfaces if protection is not used during application.87 Some SDF products additionally include potassium iodide, which can be applied following SDF application with the aim of reducing staining. However, it has been reported that staining persists despite use of potassium iodide and that it may reduce the efficacy of SDF.89
To ensure valid consent, clinicians should explain all treatment options and their potential adverse effects (such as brown/black discolouration of carious lesions in teeth treated with SDF) to the child or young person and their parent/carer.90 This may also include a discussion of whether to use potassium iodide with the aim of reducing staining.
Contraindications to SDF use89 include:
- signs/symptoms of irreversible pulpitis, or dental abscess or sinus
- radiographic periradicular radiolucency or signs of pulpal involvement
- infection/pain from pulpal origin or food packing
- allergy to any ingredient inclusive of silver and other heavy metals
- active ulceration, mucositis or stomatitis
- pregnant or breastfeeding
- patients undergoing thyroid gland therapy or on thyroid medication (if potassium iodide used)
* Note that if SDF is being used to treat a child with advanced, cavitated lesions, it is acceptable to also apply SDF to initial lesions in that child, with the consent of the child and parent/carer.
Before treatment
Ensure that the child is able to cooperate with SDF application.
Ensure that the child and parent/carer are aware of and accept the tooth surface discolouration associated with SDF application and that valid consent is obtained.
To avoid accidental staining of hands or surfaces ensure that personal protective equipment (PPE) is worn by the dental team members and the patient and protect surfaces.
Take pre-operative photographs and radiographs, where indicated, to allow monitoring of caries progression.
Handle SDF containers with care and change gloves as required to minimise accidental spillage and staining.
Clinical procedure
Ensure the teeth are clean and free of debris.
Protect the soft tissues and gingiva, including the lips if possible, for example by applying petroleum jelly, and isolate the treatment area with cotton wool roll or dental dam.
- Some SDF products include a specific gingival barrier.
- If SDF is being applied to multiple teeth, it might be helpful to adopt a systematic quadrant-based approach, or to begin with the tooth with the largest cavity.
Dry the carious lesion/tooth tissue gently with 3-in-1 airflow or cotton wool roll/ball or gauze.
Carefully apply the SDF solution to the treatment site using a single use applicator.
- If using a capsule-based product, note that each capsule is for use on one patient only, with a maximum of one SDF capsule to be used per visit.
Wait the manufacturer recommended time period (e.g. a minimum of 1 minute) to allow adsorption of SDF; keep isolation in place for up to 3 minutes if possible.
Blot the teeth dry using a cotton wool roll, gauze or similar.
If it has been agreed that potassium iodide will be used, apply the potassium iodide solution to treatment site using a single use applicator. Continue application until the creamy white solution present on the lesion turns clear. Blot the teeth dry using a cotton wool roll, gauze or similar.
Note: Fluoride varnish can also be applied after SDF application. The recommended volume of varnish for the child’s age should not be exceeded to avoid fluoride overdose (i.e. 0.25ml Duraphat® varnish for age 2-5 years and 0.4ml for age 5 and above).
Follow up
Review the patient 2-4 weeks after first SDF application to assess caries arrest and to carry out reapplication if indicated.
- A hard, darkened lesion indicates that caries is arrested.
- SDF can be re-applied 6-monthly for ongoing caries arrest. Alternatively, the teeth can subsequently be restored.
Carry out clinical and radiographic follow up as indicated by the patient’s caries risk (see Assessing carious lesions).
Resources to support clinicians in using SDF, including more specific detail on the application of SDF, as well as videos and patient information, are available from the British Society of Paediatric Dentistry.