Silver Fluoride as a Treatment for Dental Caries

Abstract

Medical management of caries is a distinct treatment philosophy that employs topical minimally invasive therapies that treat the disease and is not merely prevention. This strategy is justified as an alternative or supplement to traditional care by significant disease recurrence rates following comprehensive operative treatment under general anesthesia. Silver diamine fluoride (SDF) is one agent to enable effective noninvasive treatment. The announcement of breakthrough therapy designation by the Food and Drug Administration (FDA) suggests that SDF may become the first FDA-approved drug for treating caries. Since our systematic review performed in April 2015, 4 clinical trials have been completed, which inform an update to the application protocol and frequency regimen. Suggestions from these studies are to skip the rinsing step due to demonstration of safety in young children, start patients with high disease severity on an intensive regimen of multiple applications over the first few weeks, and continue with semiannual maintenance doses as previously suggested. Breakthroughs in elucidating the impact of SDF on the dental plaque microbiome inform potential opportunities for understanding caries arrest. SDF can be added to the set of evidence-based noninvasive methods to treat caries lesions in primary teeth, such as the Hall crown technique and sealing lesions with accessible margins.

Keywords: caries treatment; evidence-based dentistry; silver diamine fluoride; silver nitrate; tooth remineralization; topical anti-infective agents.

Figure 1.

Relapse of signs of dental caries following treatment under general anesthesia (GA). Incidence of new caries lesions following treatment under general anesthesia is plotted against time of evaluation. Linear regression follows y = 1.3x + 29.6, with a correlation coefficient R² = 0.4. Adapted from Twetman and Dhar (2015, Table 4). References: Almeida et al. 2000; Primosch et al. 2001; Chase et al. 2004; Foster et al. 2006; Zhan et al. 2006; Amin et al. 2010; Berkowitz et al. 2011; Hughes et al. 2012.

Figure 2.

Graphic summary of randomized controlled trials demonstrating caries arrest after topical treatment with silver diamine fluoride (SDF). Studies are arranged vertically by frequency of SDF application. Caries arrest is defined as the fraction of initially active carious lesions that became inactive and firm to a dental explorer. SDF (38% unless noted otherwise); GIC, glass ionomer cement; NaF, 5% sodium fluoride varnish; + OHI q6mon, SDF every year and oral hygiene instructions every 6 mo; q1year, every year; q3mon, every 3 mo; q6mon, every 6 mo. Updated from Horst et al. (2016).