SILVER DIAMINE FLUORIDE
CLINICAL EVIDENCE
Silver Nitrate Plus Fluoride Varnish Before the FDA cleared silver diamine fluoride, some U. S. dentists sequentially applied silver nitrate then fluoride varnish to dentinal decay as the only available noninvasive option for caries treatment. Duffin rediscovered silver nitrate from the early literature, 24 which had been lost to modern cariology. Surprisingly, there is no mention of silver nitrate in either of the American Dental Association Council on Scientific Affairs reports on Nonfluoride Caries-Preventive Agents 25 or Managing Xerostomia and Salivary Gland Hypofunction, 26 and it is not part of standard dental school curricula. Case series of carious lesions arrested by silver nitrate date to the 1800s, for example in 1891 87 of 142 treated lesions were arrested. 27 Percy Howe, DDS, then director of the Forsyth Institute in Boston, added ammonia to silver nitrate, making it more stable and effective as an antimicrobial for application to any infected tooth structure from early cavitated lesions to infected root canals. 28 Duffin added the application of fluoride varnish following silver nitrate, simulating silver diamine fluoride. While his clinic doubled in patients, cases needing general anesthesia disappeared. His review of randomly selected charts showed only seven of 578 treated lesions progressed within two and a half years to the point that extractions were needed. 24 Thus, with the exception of Duffin’ s and one other report, attention to silver nitrate largely disappeared by the 1950s. The lore is that use and teaching of this intervention were lost with the introduction of effective local anesthetic to enable painless restorations and fluoride for caries prevention. Because n o high-quality clinical trials have been performed, we did not include the silver nitrate plus fluoride varnish regimen in our recommendation.
FIGURE 2.
Graphic summary of randomized controlled trials demonstrating caries prevention after topical treatment of carious lesions with 38 % silver diamine fluoride. Prevented caries is defined as the fraction of new carious lesions in treatment groups as compared to those in the placebo or no treatment control group. Chlorhex, 1 % chlorhexidine varnish.
Prevented caries
Prevented caries
50 %
0 %
Silver Diamine Fluoride We found nine published randomized clinical trials evaluating silver diamine fluoride for caries arrest and / or prevention of at least one year in duration. These studies each involved hundreds of children aged 3 to 9 or adults aged 60 to 89( FIGURES 1 and 2). Most participants had low(< 0.3 ppm) fluoride in the environmental water and reported using fluoride toothpaste( e. g., 73 percent). 29 Silver diamine fluoride was applied with cotton isolation. Lesions were detected with mirror and explorer only. All studies were registered and meet the Consolidated Standards of Reporting Trials requirements. Clinical cases and studies not meeting these criteria can be found elsewhere. 30
373 6 year olds | Control 2.5 new lesions( only applied to lesions)
Llodra et al., 2005
100 %
100 %
50 %
0 %
0.5 1 1.5 2 2.5 3 Time( years)
482 9.1 year olds | Control: 4.6 new lesions Liu et al., 2012
0.5 1 1.5 2 2.5 3 Time( years)
SDF q6mon
SDF q1year Sealant once NaF q6mon
Caries Arrest Caries arrest increased dramatically after reapplication from one year posttreatment 31-33 to one and a half years, 31, 34 and increasingly
29, 31, 35 to two to three years( FIGURE 1). Single application without repeat lost effect over time in the elderly. 32 Twice per year application resulted in more arrest than once per year. 31, 35 Twelve percent silver diamine fluoride was markedly less effective. 32
Darkening of the entire lesion indicated success at follow-up and is suggested to facilitate diagnosis of caries arrest status by nondentists. A longitudinal study reported that color activation of silver diamine fluoride with 10 % stannous fluoride resulted in less first molar caries. 36
18 JANUARY / FEBRUARY 2017 | PENNSYLVANIA DENTAL JOURNAL