This document provides an overview of silver diamine fluoride (SDF) as a tool for managing dental caries. It discusses the history of using silver compounds to prevent infections, outlines the components and mechanism of action of SDF, and describes its clinical applications in arresting caries in both children and adults. Some key points include that SDF is a 38% solution containing silver and fluoride ions that reacts with tooth minerals to form protective layers, it has been shown to arrest up to 80% of caries lesions with annual applications, and it provides a low-cost, minimally invasive option for managing caries in situations where advanced restorative treatment is not possible or acceptable. The document concludes that SDF has unique

1. GOOD MORNING

2. SilverDiamineFlouride–ANew
Tool

3. Caries Challenge
• Dental caries is a bacterial driven chronic, site specific ,
multifactorial dynamic process that results from the imbalance
in the physiologic equilibrium between the tooth mineral and
biofilm.
• The treatment of dental caries can be challenging requiring
advanced skill of the clinician and high cost of instrumentation
and requiring more cooperation especially when it is present in
a young child with limited coping ability.
• Arresting caries has been proposed to manage untreated dental
caries in such disadvantaged situations.

4. History of Silver
• 1000 BC Silver bowls for potable water
• 1890 Silver sutures+silver nitrate: prevent
infections (Halsted)
• 1920 Silver nitrate: caries prevention (Howe)
• 1960 Silver diamine fluoride: caries
prevention in Japan

5. What is SDF?
• Silver flouride was used in japan for over 900 years for
cosmetic blackening of teeth
• Recently 80 years ago NH3+ was added to AgF to
produce SDF
• A fluoridated agent silver diamine fluoride’s (SDF)
hypothesized ability to halt the caries process and
simultaneously prevent the formation of new caries was
tested in japan in 1960.

6. What is SDF?
• In 1970 it was accepted by Central Council of the
Ministry of Health and Welfare in Japan for dental
treatment.
• In October 2016, the FDA awarded SDF the designation
of “breakthrough therapy” based on its arrest of dental
decay in children and adults, a first for an oral health
therapy.

7. What is SDF?
• 38% SDF contains 44,800 ppm F & 253,870 ppm Ag
• Silver diamine fluoride, a chemical that is claimed to be
more stable than silver flouride and that can be kept in a
constant concentration but it is not as alkaline.(pH 8-9)
• Mechanism of action of silver
• 25% silver - antimicrobial
• 8% ammonia - solvent
• 5% fluoride – remineralization

8. Mechanism of Action
• Shimizu and Kawagoe (1976) described three possible
mechanisms of action of SDF on caries.
1. Obturation of dentinal tubules:
• Decreased in dye permeability
• Increased in electric resistance
• Limiting the acid invasion of microorganisms
• Preserves collagen from degradation.
2. Cariostatic action : F- increased resistance of the peri-
and inter-tubular dentin. Shimooka et al (1972) reported
penetration to a depth of 50–100 μ.

9. Control Silver Diamine Flouride
*Featherstone & Horst. Decisions in Dentistry, Sept/Oct 2015.

10. Mechanism of Action
(Ag(NH3 ) 2 F) reacts with the tooth mineral
hydroxyapatite (HA)(Ca10(PO4)6 (OH)2 )
Calcium fluoride (CaF2) + Silver phosphate (Ag3PO4)
(Reservoir of F) (Precipitate – darkens to light)
Hardens the tooth
3.Antienzymatic actions: of the reaction products between
Ag(NH3 ) 2 F and organic components.
Dextran-induced agglutination of cariogenic strains of
Streptococcus mutans

11. Effects of silver diamine fluoride on Streptococcus
mutans biofilm
*Chu et al. IntJ PaediatrDent2011;22:2-10

13. Clinical Application of SDF
1. To deal with the high caries prevalence and
management problem of young children with a minimal
invasion approach.
First proposal to use this approach was
made by Yamaga et al.in Japan as a useful
approach to deal with young patient.
McDonald and Sheiham (1994) in
London, Braga et al. (2009) in Brazil found
that SDF is significantly effective in
arresting the cavitated as well as incipient
carious lesions & as an alternative when
restorative treatment for primary teeth is not
an option

14. Clinical Application of SDF
2. The ability of SDF to arrest caries in anterior primary
teeth of young children
3. To prevent pit and fissure caries
Nishino and Massler (1977)in their study mentioned that
caries score of Ag(NH3 ) 2 F treated teeth was
significantly lower than the fissures treated with SnF2
8% or Ag(NO)3

15. Clinical Application of SDF
4. To prevent Secondary Caries
5. To Arrest Root Caries
Zang et al. (2013) reported annual application of SDF
is quite effective in arresting the caries on root
surfaces.

16. Clinical Application of SDF
6. To Desensitize sensitive teeth
It was suggested that 4 times repeated application was
the most appropriate and no further desensitizing effect
could be obtained
7. To treat Infected Root Canals
Mathew et al. (2012) found that SDF as an endodontic
irrigant can effectively remove the microbes present in
the canal and circum-pulpal dentin

17. Advantages of SDF
1. Control of pain and infection
2. The cost of SDF treatment is low and should be
affordable in most communities.
3. The treatment does not require expensive equipment or
support infrastructure such as piped water and
electricity.
4. Non-invasive procedure the treatment is non-invasive
and thus the risk of spreading infection is very low

18. Drawbacks of SDF
1. The inherent drawback of using SDF to arrest caries is
that the lesions will be stained black.
2. Silver phosphate is yellow when it is first formed, but
readily turns black under sunlight or the influence of
reducing agents.
To overcome this limitation Knight et al. proposed to
used Potassium iodide after application of SDF to the
tooth structure remaining free silver ions in solution will
react with Potassium Iodide to precipitate creamy white
silver iodide crystals.

19. Safety of SDF
1. The Dental Services of the Health Department of
Western Australia, had carried out an investigation and
had found no evidence to support the view that use of
Ag(NH3) 2 F would cause fluorosis.
2. Recently, a short-term study done by Vasquez et al.
found that serum concentrations of fluoride and silver
after topical application of SDF should pose no toxicity
risk.

20. Applications on the horizon- SDF
As an indirect pulp capping agent
 Studies reported that SDF has remineralizing, re-
hardening and antimicrobial efficacy and hence can act
as effective Indirect Pulp Capping materials.
As an agent for atraumatic restorative technique
 SMART a new technique which stands for -Silver
Modified Atraumatic Restorative Treatment – in which
SDF is applied followed by GIC restoration of the
lesion.

21. Applications on the horizon- SDF
Restorations and silver diamine fluoride
 Recently, Quock et al. found that SDF does not adversely
affect the bond strength of resin composite to non-carious
dentin, contrary to this another in vitro study from Japan
found that SDF enhances the bond strength of GIC to
bovine dentin. Further research is required to come to
conclusion.

22. SDF Availability
• Elevate Oral Care, West Palm Beach, FL
8 ml bottle
Provides ~250 drops

23. Indications
• For children suffering with Xerostomia and Severe ECC.
and difficult to reach areas.
• Clinically acceptable treatment alternative for individuals
with challenging behavior or whose safe dental treatment
is precluded by other medical management complexities.
• To treat dentin hypersensitivity and is a conservative
alternative to restorative treatment.

24. Contraindications
• Teeth that require pulpal therapy (i.e., irreversible pulpitis
or necrosis).
• Individuals at risk for developing a silver allergy from
medical (e.g., burn treatment with silver sulphadiazine) or
industrial (e.g., metallurgical processing) exposure.
• SDF can irritate already sensitive open mouth sores (e.g.,
herpetic gingiva stomatitis, ulcerative gingivitis).

25. Clinical Technique – SDF
• Dispense SDF into dappen-dish.
• One drop treats five surfaces.
• Isolation with gauze and/or cotton rolls is sufficient,
while air-drying prior to application is thought to improve
effectiveness.
• Immerse a stiff micro-brush into the SDF in the dappen-
dish and saturate the lesion with SDF using a scrubbing
motion.
• Allowing 1-3 minutes for the silver diamine fluoride to
soak into and react with a lesion is thought to effect
success.

26. Clinical Technique - SDF
• SDF can be applied to proximal caries lesion using a
spongy floss. A small section next to the contact is then
saturated with SDF and pulled under the contact area.
• Protect the site by brushing fluoride varnish or petroleum
jelly over SDF-treated surfaces
• The use of varnish will not “seal in” the SDF; in this
protocol, varnish is used to create a short-term barrier
between the treated surface and saliva.

27. Clinical Technique - SDF
Evidence of Caries Arrest
• 5 clinical trials of 38% SDF for dentin caries arrest in
children
3 used annual application: arrested caries range: 65.2%
–79.2%
1 applied every 6 mo : 84.8% arrested
1 used single application : 31.2% arrested

28. Conclusion
• The supporting science and clinical use of SDF suggest
that it has unique disinfection and remineralisation
properties that can halt the caries process rapidly.
• It makes a very strong case for its utilization in every
appropriate situation and should be a part of every
clinician’s caries management tool kit.

29. References
• Mei ML, Nudelman F, Marzec B, et al. Formation of
Fluorohydroxyapatite With Silver Diamine Fluoride. J Dent Res 2017
Sep;96(10):1122-1128.
• Shah S , Bhaskar V , Venkatraghavan K , Choudhary P , Ganesh M.,
Trivedi K, Silver Diamine Fluoride: A Review and Current Applications.
Journal of Advanced Oral Research 2014:5(1).
• Dos Santos VE, De Vasconcelos FMN, Ribeiro AG, Rosenblatt A.
Paradigm shift in the eff ective treatment of caries in schoolchildren at
risk. Int Dent J 2012;62(1):47–51.
• Shah N, Gupta A, Sinha N, Logani A. Remineralizing effi cacy of silver
diamine fluoride and glass ionomer type VII for their proposed use as
indirect pulp capping materials — Part II (a clinical study). J Conserv
Dent 2011;14(3):233.
• Rosenblatt A, Stamford TCM, Niederman R. Silver Diamine Fluoride: A
Caries “Silver Fluoride Bullet”. J Dent Res 2009;88:116-125.
• Yamaga R, Nishino M, Yoshida S, Yokomizo I. Diammine silver fluoride
and its clinical application. J Osaka Univ Dent Sch 1972;12:1–20.

30. THANK YOU