Silver Diamine Fluoride in Adult Dentistry by Dr. Joy Void-Holmes

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Prevention of endodontic treatment in adults: A clinical perspective

by Dr. Joy Void-Holmes

Silver diamine fluoride (SDF) represents a significant advancement in modern dentistry, offering practitioners a powerful tool to preserve tooth vitality and prevent the need for root canal treatment in adult patients with deep caries.^1,2 Although SDF received clearance from the Food and Drug Administration (FDA) in 2014 for the treatment of dentinal hypersensitivity, its international use spans more than five decades, with emerging evidence demonstrating exceptional capacity to arrest deep carious lesions and maintain pulp vitality in adults.^1,2 The COVID-19 pandemic served as a catalyst for widespread adoption, highlighting SDF’s efficacy as a minimally invasive treatment modality that preserves tooth structure.¹ A retrospective case series of 277 adult teeth demonstrated that 95% did not require endodontic intervention during 16 months to six years of follow-up.³ Recent cohort data confirm these findings: A two-year study in older adults showed that repeated SDF applications extended tooth survival nine-fold longer than single treatments.⁴

From historical development to pioneering research in Japan
Silver’s antimicrobial properties have been recognized for centuries. Ancient Roman civilizations placed silver foil in wounds, and early American settlers dropped silver coins into water barrels to prevent microbial contamination. In dentistry, silver-based therapies emerged in the 1840s, when U.S. dentists employed silver nitrate (AgNO3) as a caustic agent to cauterize carious lesions.⁵

The foundation for modern SDF was established when Dr. Mizuho Nishino conducted groundbreaking research at Osaka University investigating silver diamine fluoride as part of her doctoral thesis.⁶ Nishino and Professor Yamaga Reiichin formulated a stable, bioavailable agent that combines silver’s antimicrobial properties with fluoride’s remineralizing effects while sealing dentinal tubules.^2,6 Their research, published in 1969 in the Journal of Osaka University Dental Society, established the SDF paradigm: synergistic antimicrobial action coupled with remineralization potential, a mechanism particularly valuable in preserving compromised pulps in deep carious lesions.⁶

Evolution and global recognition
SDF gradually gained international recognition through key regulatory and professional milestones. The FDA cleared Advantage Arrest SDF in 2014 for dentinal hypersensitivity^1,7 and granted Breakthrough Therapy Designation in 2016 for caries arrest.⁷ Health Canada approved SDF in 2017 for anti-caries management,² while the American Dental Association endorsed annual 38% SDF application for adults in 2020, recognizing superior efficacy compared to topical fluoride alternatives.⁴ SDF received further global validation when the World Health Organization included it in the 2021 Model List of Essential Medicines.⁸ One of the latest SDF products to enter the market, Centrix’s SilverSense SDF, demonstrates how this therapeutic category continues to evolve, offering practitioners modern formulations designed specifically for managing complex adult caries with minimally invasive, cost-effective approaches.

Chemical composition and formulation
The most commonly available SDF formulation in the U.S. is a 38% aqueous solution comprising 25% silver ions, 5.5% fluoride ions, and 8% ammonia as a stabilizer.^9,10 The ammonia maintains the diamine-silver complex in solution. This formulation results in an alkaline solution with a pH between 8 and 10, which promotes fluorapatite formation and enhances therapeutic efficacy.^11–13

The formulation delivers approximately 253,870 ppm total silver concentration that exerts therapeutic effects while remaining below established toxicity thresholds.^9,14 SDF penetrates 25 micrometers into enamel and 200–300 micrometers into dentin, with silver ions penetrating even deeper. This allows SDF to reach carious bacteria while maintaining safety margins when protective dentin remains between the lesion and pulp tissue.⁹

Mechanism of action: Three synergistic processes
Silver diamine fluoride’s clinical efficacy derives from three synergistic mechanisms of action, first systematized by Shimizu and Kawagoe in their 1976 investigation^2,15,16 and subsequently expanded through recent mechanistic research.9,10,17 These mechanisms work together to arrest deep lesions while preserving pulp vitality.

Mechanism 1: Obturation (sealing) of dentinal tubules
When SDF contacts demineralized dentin, silver compounds form and deposit within the dentinal tubules, sealing them closed.^9,10 These deposits create a protective barrier that blocks cariogenic bacteria pathways and increases resistance to acid attacks.^10,17 In deep caries, this bacteriologic seal prevents further bacterial invasion of the pulp chamber while allowing the pulp to mount a defensive response, significantly reducing vulnerability to recurrent caries and pulpal involvement.²

Mechanism 2: Remineralization and strengthening
Fluoride from SDF diffuses into dentin, reacting with hydroxyapatite to form calcium fluoride that converts to fluorapatite, which is more resistant to acid attacks.^9,10,17–19 The calcium fluoride serves as a fluoride reservoir, releasing ions to promote additional fluorapatite formation when oral pH exceeds 5.5.^2,9 Laboratory studies show SDF significantly hardens dentin surfaces, preserves collagen from enzymatic degradation, and reduces calcium dissolution, maintaining structural integrity critical for preserving the vitality of the pulp.^2,17,20,21

Mechanism 3: Antimicrobial action
Silver ions display potent bactericidal activity through multiple pathways: disrupting bacterial cell integrity, targeting DNA, and inhibiting specific bacterial enzymes, notably S. mutans glucosyltransferase.^{2,9,10,17,22,23} Recent evidence demonstrates a “zombie effect” wherein silver-killed bacteria retain antimicrobial effects against living bacteria, extending SDF’s biofilm suppression activity beyond immediate application.^9,24

Deep caries management in adults: Prevention of endodontic treatment
Clinical significance of deep caries in adults
Deep caries extending into the pulpal third of dentin represents one of the most challenging clinical scenarios in adult dentistry. Historically, clinicians faced a difficult choice: complete caries excavation with risk of pulp exposure and consequent endodontic treatment, or leave carious dentin beneath restorations with risk of continued progression and eventual pulpal necrosis. SDF offers a third option: arrest of deep lesions while preserving pulp vitality and avoiding the need for irreversible endodontic therapy.

Evidence for pulp preservation in adult deep caries
In a recent publication, 19 studies were identified demonstrating that SDF achieves high caries arrest rates in deep lesions, with outcomes comparable to conventional indirect pulp capping materials and radiographic evidence of tertiary dentin formation, indicating successful pulpal defenses and healing responses.³ A 12-month randomized controlled trial comparing SDF to mineral trioxide aggregate (MTA), the gold standard for indirect pulp capping, found SDF equally effective in maintaining pulp vitality in permanent molars with deep caries.25 This finding is particularly significant, as it establishes SDF as a viable alternative to more expensive materials, offering antimicrobial action and ease of application.

The most compelling evidence comes from a retrospective case series of 277 adult teeth (patients aged 26–90 years, with an average age of 64 years) treated with SDF for deep caries. This study reported that 95% of teeth did not require endodontic intervention over follow-up periods ranging from 16 months to six years, demonstrating SDF’s substantial pulp preservation capability.³ This finding carries profound clinical implications, showing that SDF can forestall or eliminate the need for irreversible endodontic treatment in the vast majority of adult cases with deep carious involvement.

A recent two-year cohort study in older adults demonstrated that repeated SDF applications significantly extended tooth survival and reduced the need for restoration or extraction, with patients receiving multiple applications experiencing 9.6 times longer survival compared to single treatments.⁴ SDF was more effective than sodium fluoride or chlorhexidine varnish in arresting root caries and preventing new lesions. A 2024 systematic review analyzing randomized controlled trials in adults found SDF caries arrest rates ranging from 25% to 99%, with SDF outperforming alternative materials on both tooth and surface levels—particularly relevant for the growing population of adults and seniors with root or deep lesions.²⁶

Histological evidence of pulpal response
Research has documented the histological response of pulps beneath SDF-treated deep lesions. Histological examination reveals the consistent formation of tertiary dentin across studies demonstrating the material’s capacity to stimulate protective processes within the pulp without triggering adverse inflammatory responses when a protective dentinal barrier remains intact.³

Critical safety consideration
Research has unequivocally demonstrated that direct contact of SDF with exposed pulp tissue results in severe inflammatory responses, including suppurative inflammation, hemorrhage, and eventual pulpal necrosis, even at dilute concentrations.³ As a result, SDF application is strictly contraindicated in cases of pulp exposure or suspected pulpal involvement. Clinical assessment must confirm that protective dentin remains between the lesion and pulp chamber before SDF application.

Safety profile in adult populations
Staining considerations
The most widely recognized limitation of SDF remains the black staining of carious tooth structure. This occurs through precipitation of metallic silver and silver chloride on demineralized, infected dentin.^2,3,9 Importantly, healthy enamel and sound dentin do not stain black; only porous, demineralized, infected tissue darkens following SDF application. For deep lesions that will receive restorations, staining is not a clinical concern, as the affected tissue will be covered.

Systemic safety in adults
The safety profile of SDF when applied topically to tooth surfaces is excellent. Clinical trials involving more than 3,800 participants across 80 years of cumulative use have reported no serious adverse events.^2,9 If SDF contacts soft tissue, temporary gingival whiteness or mild redness may occur, but it resolves without intervention.^2,9

Dosage calculations demonstrate substantial safety margins: one 25 μL drop contains approximately 9.5 mg SDF and can treat up to five teeth.² The EPA’s lifetime exposure limit for silver is 1 gram total, meaning 1,266 SDF treatments would be required to theoretically reach lifetime exposure limits.²

Fluoride safety in adults
While the fluoride concentration in SDF (44,800 ppm) appears high numerically, the actual volume applied is minimal compared to other topical fluorides. One 25 μL drop of SDF contains approximately 2.24 mg fluoride, whereas a typical 5% sodium fluoride varnish unit dose contains 5.65–11.3 mg fluoride.²⁷

Clinical contraindications in adults
SDF use is absolutely contraindicated in several clinical situations:

Pulp exposure or suspected pulpal involvement
Signs or symptoms of irreversible pulpitis
Dental abscess or fistula
Radiographic evidence of periradicular pathology
Known allergies to silver, fluoride, or ammonia
Ulcerated or severely inflamed soft tissues in the treatment area

Relative contraindications that require clinical judgment include:

Patients undergoing thyroid therapy or taking thyroid medications
Pregnancy or lactation (insufficient long-term safety data; avoidance recommended per manufacturer guidelines)
Advanced renal disease (altered fluoride metabolism)

Clinical significance for adult caries management and endodontic prevention
The emergence of SDF and its recognition as an essential treatment option in adult caries management has transformed clinical practice by providing a cost-effective, minimally invasive option averaging $1 per application versus $1,000 or more for restorations and $800–$1,500 for root canal therapy.^2,9

For older or medically complex adults, repeated SDF use prolongs tooth survival, reduces dental interventions, and is especially valuable for those with limited mobility or living in long-term care facilities.⁴ Its proven effectiveness across diverse adult populations and care settings establishes SDF as a foundation of modern caries management, helping to reduce disparities and support retention of natural teeth.^2,4,26

Conclusion
Silver diamine fluoride has evolved into a globally-recognized, evidence-based therapy offering adult patients with deep caries a compelling alternative to endodontic treatment. The robust scientific foundation, grounded in more than 80 years of research and recent clinical evidence demonstrating 95% pulp preservation and nine-fold improvement in tooth survival with repeated applications, represents a paradigm shift toward tissue preservation and minimally invasive intervention.^2,4 Continued product innovation, including Centrix’s SilverSense SDF, reflects market commitment to clinical flexibility and broader patient access.

For clinicians focused on patient-centered, minimally invasive care, SDF is critical for preserving natural tooth structure and pulp vitality in adult patients with deep caries. By preventing most endodontic procedures, SDF helps patients maintain their natural teeth and avoid the substantial costs and burdens of root canal therapy, delivering special value in underserved and medically complex populations.

References
1.Gao SS, Zhao IS, Hiraishi N, et al. Global Oral Health Policies and Guidelines Using Silver Diamine Fluoride for Caries Control. Front Oral Health. 2021 Jul 30;2:685557.
2.Crystal YO, Niederman R. Evidence-based dentistry update on silver diamine fluoride. Dent Clin North Am. 2019 Jan;63(1):45-68.
3. Sheridan A, Mei ML, Cooper PR, Milne T, Friedlander LT. Silver diamine fluoride treatment for the management of deep caries: A scoping review. J Dent. 2025;161:105946.
4. Kettelkamp K, Desai J, Lewis S, Comnick C, Marchini L. Outcomes of Silver Diamine Fluoride (SDF) Treatment Among Older Adults: A Retrospective Analysis. Spec Care Dentist. 2025;45(2):e70013. doi:10.1111/scd.70013.
5. Sarvas E. The history and use of silver diamine fluoride in dentistry: A review. J Calif Dent Assoc. 2018;46(1):19-22.
6. Chai HH, Kiuchi S, Osaka K, Aida J, Chu CH, Gao SS. Knowledge, Practices and Attitudes towards Silver Diamine Fluoride Therapy among Dentists in Japan: A Mixed Methods Study. Int J Environ Res Public Health. 2022 Jul 17;19(14):8705.
7. U.S. Food and Drug Administration. Breakthrough Therapy Designation for Silver Diamine Fluoride for caries arrest. 2016.
8. World Health Organization. World Health Organization model list of essential medicines. 21st ed. 2021.
9. Jamal D, AlMushayt A, Abujamel T, et al. Silver diamine fluoride: The science behind the action – a narrative review. BMC Oral Health. 2025 Jul 17;25:1195.
10. Lou YL, Botelho MG, Darvell BW. Reaction of silver diamine fluoride with hydroxyapatite and protein. J Dent. 2011 Sep;39(9):612-618.
11. Mei ML, Lo EC, Chu CH. Clinical use of silver diamine fluoride in dental treatment. Compend Contin Educ Dent. 2016 Feb;37(2):93-100.
12. Peng JJY, Botelho MG, Matinlinna JP. Silver compounds used in dentistry for caries management: A review. J Dent. 2012 Jul;40(7):531-541.
13. Shah S, Bhaskar V, Venkatraman H, et al. Silver diamine fluoride: A review and current applications. J Adv Oral Res. 2014;5(1):25-35.
14. Contreras V, Toro MJ, Elías-Boneta AR, et al. Effectiveness of silver diamine fluoride in caries prevention and arrest: A systematic literature review. Gen Dent. 2017 May-Jun;65(3):22-29.
15. Shimizu A, Kawagoe M. A clinical study of diamine silver fluoride on recurrent caries. J Osaka Univ Dent Sch. 1976;16:103-109.
16. Nishino M. Silver diamine fluoride - development and applications in Japan [dissertation]. Osaka University; 1969.
17. Kaur M, Singh H, Dhillon JS, et al. Characterization of chemical reactions of silver diammine fluoride and hydroxyapatite under remineralization conditions. Front Oral Health. 2024;5:1332298.
18. Mei ML, Li QL, Chu CH, et al. Formation of fluorohydroxyapatite with silver diamine fluoride. J Dent Res. 2012;91(8):788-793.
19. Chu CH, Mei ML, Lo EC. Effects of silver diamine fluoride on dentine carious lesions induced by streptococcus mutans and actinomyces naeslundii biofilms. Int J Paediatr Dent. 2012 Jan;22(1):2-10.
20. Prakash M, Chowdhary N, Kiran K, et al. In-vitro assessment of silver diamine fluoride effect on natural carious dentin microhardness. Front Dent Med. 2021;2:710506.
21. Sunny S, Vohra P, Kharab S, et al. Comparative evaluation of effect of silver diamine fluoride and glass ionomer cement on microhardness of artificial caries lesion in primary teeth: An in vitro study. Int J Clin Pediatr Dent. 2023 Nov-Dec;16(6):858-863.
22. Mei ML, Ito L, Cao Y, et al. Antibacterial effects of silver diamine fluoride on multi-species cariogenic biofilm on caries. Ann Clin Microbiol Antimicrob. 2013 Feb 14;12:4.
23. Duangthip D, Chu CH, Lo EC. A randomized clinical trial on arresting dentine caries in preschool children by topical fluorides – 18 month results. J Dent. 2016 Feb;44:57-63.
24. Trieu A, Mohamed A, Lynch E. Silver diamine fluoride versus sodium fluoride for arresting dentine caries in children: A systematic review and meta-analysis. Sci Rep. 2019 Feb 5;9:2115.
25. Zaghloul MA, Abou El Fadl RK, El-Harouni NS. Clinical and radiographic evaluation of silver diamine fluoride versus mineral trioxide aggregate as indirect pulp capping agents in deeply carious first permanent molars: a randomized clinical trial. BDJ Open. 2025 Jan 8;11:5. PMC11718176.
26. Alqaderi H, Splieth C, Jablonski-Momeni A. The role of silver diamine fluoride as dental caries preventive and management agent: a systematic review. Front Oral Health. 2024 Nov 25;1:1492762.
27. Crystal YO, Janal MN, Hamilton DS, Niederman R. Silver and fluoride content and short-term stability of 38% silver diamine fluoride. J Am Dent Assoc. 2019 Feb;150(2):140-146.
28. Elevate Oral Care. Advantage Arrest Silver Diamine Fluoride: Clinical evidence and product information. 2020.

Author Bio

Joy Void-Holmes, DHS, BSDH, RDH, founder of Dr. Joy, RDH, and co-founder of JELL-ED, is celebrated for nearly 30 years of expertise in oral healthcare. She empowers dental professionals through her innovative courses and signature hands-on workshops. She champions self-care and creating boundaries while raising awareness of implicit bias and DEI issues. Through her P3 Framework, Void-Holmes guides dental practices to sustainable growth by merging clinical skills and business strategy. Void-Holmes holds a dental hygiene certificate from Howard University, a bachelor’s degree from the University of Maryland School of Dentistry, and advanced degrees from Nova Southeastern University.

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