Last year, this Dentistry for Children Blog, reported briefly on the use of 37% Silver Diamine Fluoride for fighting cavities. We wrote on the topic simply as a part of our coverage of news about dental research.  A prominent New York newspaper also wrote about fighting cavities with the 37 % silver diamine fluoride solution.  The newspaper referred to SDF enthusiastically, as a way of helping children “avoid the dentist’s drill.” 

As we have said before, we scour the Internet and the professional dentistry Journals to bring you the truth, “the whole tooth, and nothing but the tooth,” as we see it.  The AAPD has published a new Guideline for this therapy, and so we have an update on the story.

Fighting Cavities with What?

In case you are not aware of the SDF treatment, it is the delicate painting of teeth with 37% solution of silver diamine fluoride in an effort

Fighting cavities with silver diamine fluoride is painless and inexpensive.

Children who do not tolerate fillings could benefit from Silver Diamine Fluoride.

to stop cavities. Tiny cavities in primary teeth are painted over with the solution. It has only one rather large drawback. It turns treated teeth black.  In simple terms the recent big research studies compared treating primary teeth infected with caries with a 37 % silver diamine fluoride solution as opposed to the familiar drill-and-fill method.

We place the highest value on children’s safety, health and comfort. In 2016, the New York Times reported an article on “Liquid Lets Kids Avoid Dentists’ Drills.” To us the article seemed like premature celebration of a yet-to-be-proven technique. However, last years testing changed that.

Tooth Truth:  The Backstory on Fighting Cavities with Silver Diamine Fluoride

Tooth Truth 1. In Japan Silver Diamine Fluoride  has been used for years. However in the U.S., the FDA only approved it a year ago, but for adults.

Tooth Truth 2. The FDA previously approved SDF for primary use as a tooth desensitizer for adults. However, many dentists employed it “off label.” That means they were using it outside of the prescribed and recommended zone, as a treatment for cavity prevention. (Black stain and all.)

Tooth Truth 3.  The procedure does not require drilling. It is painless and thus a patient can avoid injections. (But we must consider the appearance of the black teeth.)

Tooth Truth 4.  In the USA, the FDA has authorized only one branded version. It is named “Advantage Arrest.” Although it is cheaper than a filling, the SDF therapy will have to be repeated.

New Review for Caries Management with Silver Diamine Fluoride

Now, with a year more research, we find the American Academy of Pediatric Dentistry has taken a cautious and conservative stance on the Silver Diamine Fluoride issue.  At last, they have now established the first ever official guide regarding SDF, for all children’s dentists.

So, the October release of the new policy was big news. On “October 13, 2017 . the American Academy of Pediatric Dentistry (AAPD) issued an evidence-based guideline that recommends use of 38% silver diamine fluoride (SDF) to treat active dental caries in primary teeth in pediatric and special-needs patients.”

Fighting Cavities With SDF:  Let’s Ponder the Meaning of Conditional

Fighting cavities requires every technique we know.

Willing little girl hopes for painless filling.

“The AAPD policy is based on a large 2016 systematic review and meta-analysis” of the results from Silver Diamine Fluoride treatments, by Gao and his team.

The research scientists studied the basic question, “Does the application of SDF arrest cavitated caries lesions as effectively as other treatment modalities in primary teeth?”

In other words, does the painting of teeth with 37% fluoride equal a filling in stopping power for tooth decay? Note the careful wording as the cavity fighting guideline continues, “After taking into consideration the low cost of the treatment and the disease burden of caries, panel members were confident that the benefits of SDF application in the target populations outweigh its possible undesirable effects.”

However, the group also added some caveats:  They stated the recommendation was conditional, and still based on too much low-quality evidence.  

In an email interview with, AAPD President James Nickman, DDS, said that SDF could provide additional treatment options. “While not appropriate for all cavities, SDF may provide a treatment option for children who may not otherwise receive care, for example, a young child who is unable to tolerate traditional restorations in an office-based setting,” he stated.

Sometimes a parent must decide that dental treatment is worth sedation or general anesthesia in very young children or in children with special needs. The use of Silver Diamine Fluoride gives parents an option in such a situation.  The black stain of this formula for fighting cavities, which can also leave its mark on skin, clothing, and counter-tops remains an issue. But we must keep it in perspective.

Drill-and-Fill:  The Tried-and-True Standard for Fighting Cavities

Here at Dentistry for Children in Orlando, we do not want this new conditional acceptance of a treatment to signal parents that dentists are abandoning tried and true techniques. The drill-and-fill method is still the standard method of treatment for cavities. We are in no way condoning an effort to just “paint away the cavities.”
Moreover, the new AAPD guide stipulates “Prevention of new caries lesion development and outcomes in permanent teeth, such as root caries lesion arrest, were not the focus of this guideline; however, because they are of interest and relevant to caries management within the scope of pediatric dentistry, they are mentioned and will be included in future iterations of the guideline as the supporting evidence base increases.”

Fighting Cavities Now and in the Future

This means there will be more guidelines released later, but as yet, according to existing research, your 13 year old son or daughter will probably need a filling or restoration to repair that cavity below the root-line in his or her caries-infected molar.
Likewise the panel of experts who supervised the creation of the guideline, recommended that researchers continue “to conduct well-designed randomized clinical trials comparing the outcomes of SDF to other treatments for the arrest of carious lesions in primary and permanent teeth.”

The translation here is that the committee desired more studies on which to base their recommendation. And they definitely want more studies completed before removing the word “conditional.”

Keep in mind that the conditional nature of this cavity fighting recommendation takes into consideration economic matters and specific groups.

1.     The recommending group considered the cost of untreated decay and the health burden it imposes. Given those matters, the panel gave the recommendation only as part of a comprehensive caries management program.

They added, “After taking in consideration the low cost of the treatment and the disease burden of caries, panel members were confident that the benefits of SDF application in the target populations outweigh its possible undesirable effects.”

2.     They conditionally recommended it because, “Untreated decay in young children remains a challenge, from clinical and public health

Fighting cavities can be frightful if pain is involved.

Facing drilling and filling can be frightening for a child, especially for a child with special needs. 

standpoints, in the U.S. and worldwide.

3.     Likewise, the committee stated, “Untreated caries “confers significant health and quality of life impacts to children and their families, and it is marked by pronounced disparities.”

Dr. Nickman, President of the AAPD  summarized the complex language of the guideline by stating, “Aside from fluoridated water, silver diamine fluoride may be the single greatest innovation in pediatric dental health in the last century,” And he added, “Given its minimal cost and easy, painless application, it could help close the gap in healthcare disparities.”

4.     In regard to fighting cavities in children with special needs, as noted above, the committee stated, “Surgical-restorative work in young children and those with special management considerations (e.g., individuals with special health care needs) often requires advanced pharmacologic behavior guidance modalities (e.g., sedation, general anesthesia).”  Just as we suggested, they stated, “Sedation and anesthesia can pose serious problems,” And the panel added, “These pathways of care have additional health risks and limitations (e.g., possible effects on brain development in young children, mortality risks), and often are not accessible, at all or in a timely manner.”

Fighting Cavities with Every Tool We Have

In conclusion, Dr. Yasmi Crystal noted that the goal of the workgroup who reviewed current research was to assist dentists in the understanding of Silver Diamine Fluoride treatments.  She added, “We want all dentists to learn about this new alternative therapy to treat those children who, for whatever reason, cannot be readily treated with traditional restorative methods.”And she added, “We want them to know the strengths and limitations of this therapy, so they can effectively evaluate who is a good candidate.”