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