Silver Diamine Fluoride

Silver diamine fluoride is a colorless or blue-tinted liquid with a pH between 10 and 13, which is comprised of approximately 24.4% to 28.8% (weight/volume) silver, 5.0% to 5.9% fluoride and 8.0% ammonia.^8-12 The U.S. Food and Drug Administration (FDA) has classified SDF as a Class II medical device, and it is cleared for use in the treatment of tooth sensitivity, which is the same type of clearance as fluoride varnish, and must be professionally applied.

Although some additional products are commercially available in other countries, as of September 2023, Advantage Arrest™ (Elevate Oral Care, L.L.C.) and Riva Star™ (SDI, Inc.) are the only commercially available SDF products for dental use in the U.S.¹³ In 2016, Advantage Arrest™ was designated by the FDA as a breakthrough therapy for the arrest of caries in children and adults; this designation indicates that a therapy has the potential to address a currently unmet medical need.¹⁴ Although use of SDF has been reported in caries control and management, it is not specifically FDA-labeled for use for this indication (i.e., “off-label use”). When applied to a carious lesion, SDF has also been shown to decrease caries risk of adjacent tooth surfaces.¹⁵ SDF has also shown efficacy in management of root caries in the elderly.^16-20 It has additional applicability as an interim approach for managing caries in individuals currently unable to tolerate more involved dental treatment, including special needs populations.^21-23 

SDF offers the possibility of arresting or slowing progression of caries lesions in primary and permanent teeth without removal of sound tooth tissue.^{24, 25} In addition, SDF appears to promote remineralization of demineralized dentin.^{24, 26} The effectiveness of treating carious lesions with SDF is demonstrated by the increase in mineral density of the previously carious tissue.²⁷ The main benefits of SDF are: control of pain and infection, ease of application, low cost, minimal application time and training required, and as a noninvasive method of caries arrest.²⁸ Single application of SDF has been reported to be insufficient for sustained benefit and requires reapplication.²⁹ Its potential downsides include a reportedly unpleasant metallic taste, potential to irritate gingival and mucosal surfaces, and the characteristic black staining of the tooth surfaces to which it is applied.³⁰ Occasional diarrhea and stomach ache were also reported in a clinical trial of pediatric patients, but the events were mild in severity and resolved within two days of reporting.³¹