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Unique ability of silver diamine fluoride arrests dentinal caries

July 14, 2011
From their table clinic presentation, Micaela D’Egidio, Courtney Mason, and Morgan Kozek from the Ostrow School of Dentistry in the USC Dental Hygiene Program, explain that the antimicrobial ability of the silver and the reminerializing capability of fluoride of silver diamine fluoride--also known as the Silver Bullet--help arm hygienists against dentinal caries.
By Micaela D’Egidio, Courtney Mason, and Morgan Kozek, The Ostrow School of Dentistry of USC Dental Hygiene Program
Dental caries are one of the most common oral diseases for a clinician to treat in children. Unfortunately, many children have a high prevalence of untreated dental caries. As we progress in knowledge and research, an emphasis has been placed on whether or not it is possible to find an alternative for the interim treatment of caries. Fortunately, research shows that silver diamine fluoride, which we will refer to as SDF, may be a solution because it is able to arrest caries in the dentin. No other product on the market has been able to arrest dentin caries until now. Current treatments on the market, such as sodium fluoride and calcium phosphate pastes are only effective in decreasing the spread of caries that are enamel deep and reducing sensitivity.
SDF is unique because it is able to act in two ways. The silver component kills bacteria and prevents the formation of new biofilm at the application site. The silver and the fluoride then work together to form fluorapetite, strengthening the tooth’s outer surface. Given the germicidal nature, silver compounds have been used in dentistry since the early 1900s, falling only out of favor due to the tendency to cause dark stain. Research conducted in 2002 showed that parents were more likely to be dissatisfied with their children’s caries than the dark stain produced by SDF. A study in Santiago de Cuba found SDF to be 80% effective at arresting deciduous dentinal caries and 60% effective in the permanent dentition. In addition, a study done in China examined 375 children with dentin caries on their maxillary anterior teeth. The children were assigned to five groups, consisting of the following: In the first group of children, caries were removed prior to application 38% SDF once per year. In the second group, 38% SDF was applied once per year without lesion excavation. The third and fourth group were given 5% NaF every three months with and without the excavation of caries prior to treatment. The final group was a control, in which no fluoride treatment was given. Results showed that patients receiving no fluoride treatment developed more carious lesions than those who had received either NaF or SDF. When it came to arresting caries, children who received the 38% SDF once a year had more arrested caries and fewer new caries than children who received the 5% NaF every 3 months. Finally, the study found the removal of caries prior to SDF application had no significant benefit when compared to SDF placed directly on the lesion. Researchers found that caries had been stained black due to SDF application. Although this initial side effect can be undesirable, it can easily be reduced with potassium iodide application. Furthermore, a third study in Peru found that in addition to arresting caries, the short-term effects of SDF reduced tooth sensitivity, a common side effect of deep dentinal caries. Application of SDF is simple and noninvasive, leading to good cooperation among children. Initially, the teeth are brushed without paste and rinsed. The carious teeth are isolated, kept dry, and all excess debris is removed. One drop of SDF is placed on the lesion for two minutes. Finally, excess SDF is removed and patients are advised to not eat or drink for one hour. The application of SDF is low cost; practitioners who are currently using SDF in the U.S. state the cost is around twenty dollars. Because the treatment is non-invasive, the risk for spreading infection is low. With the number of children not receiving definitive treatment for their dentinal carries, SDF has the potential to play a part in the interim treatment. While SDF will be a great asset to clinics across the U.S., it is not FDA approved although it is in review. In 2010, SDF was recognized as a viable compound at the ADA symposium regarding early childhood caries.

As dental hygienists, our primary concern is the health of our patients. With the antimicrobial ability of the silver and the reminerializing capability of fluoride, SDF, also known as the “Silver Bullet,” will help arm hygienists against dentinal caries.

1. Chu, C H, E C.M Lo, and H C Lin. “Effectiveness of Silver Diamine Fluoride and Sodium Fluoride Varnish in Arresting Dentin Caries in Chinese Pre-schools Children.” Journal of Dental Research 81.11 (2002): 767-770.
2. Domino, Donna. “Researchers tout ‘silver bullet’ for caries.” Dr. Bicuspid. 3M ESPE, 1 Apr. 2010. Web. 10 Mar. 2011.
3. Roseblatt, A, T.C. M Stamford, and R Niederman. “Silver Diamine Fluoride: A Caries ‘Silver-Fluoride Bullet.’” Journal of Dental Research 88.2 (2009): 116-125.
4. Rosenblatt, A, TCM Stamford, and R Niederman. “Silver Diamine Fluoride (SDF) may be Better than Fluoride Varnish and no Treatment in Arresting and Preventing Cavitated Carious Lesions.” Journal of Dentistry for Children 76.1 (2009): 122-124.
5. Yee, R, et al. “Efficacy of Silver Diamine Fluoride for Arresting Caries Treatment.” Journal of Dental Research 88.7 (2009): 644-647.