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Cited by 25Dental Health and Care UtilizationDental materials and restorationsEndodontics and Root Canal Treatments

Topical silver diamine fluoride (SDF) for preventing and managing dental caries in children and adults

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Worthington, Helen V, Lewis, Sharon R, Glenny, Anne-Marie, Huang, Shulamite S, Innes, Nicola PT, O'Malley, Lucy, Riley, Philip, Walsh, Tanya +3 more·2024·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd012718.pub2PMC PMC11542151
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Abstract

BACKGROUND: Dental caries is the world's most prevalent disease. Untreated caries can cause pain and negatively impact psychosocial health, functioning, and nutrition. It is important to identify cost-effective, easy-to-use agents, which can prevent or arrest caries. This review evaluates silver diamine fluoride (SDF). OBJECTIVES: To assess the effects of silver diamine fluoride for preventing and managing caries in primary and permanent teeth (coronal and root caries) compared to any other intervention including placebo or no treatment. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, Cochrane Oral Health's Trial Register and two clinical trials registers in June 2023. SELECTION CRITERIA: We included randomised controlled trials (RCTs), with parallel-group or split-mouth design, in children and adults (with or without carious lesions) that compared SDF with placebo or no treatment; different frequencies, concentrations or duration of SDF; or any other intervention. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane, and GRADE to assess the certainty of the evidence. We collected data for primary caries prevention (change in caries increment), arrest of carious lesions, secondary prevention of caries (lesions do not progress from initial classification), adverse effects, dental pain or sensitivity, and aesthetics at the end of study follow-up. MAIN RESULTS: We included 29 RCTs (13,036 participants; 12,020 children, 1016 older adults). We summarise outcome data for the five most clinically relevant comparisons. All studies included high risks of bias, and some findings were imprecise (e.g. because of small sample sizes). SDF versus placebo or no treatment (14 studies; 2695 children, 905 older adults) Compared to placebo or no treatment, SDF may help prevent new caries in the primary dentition (1 study, 373 participants), or on the coronal surfaces of permanent dentition (1 study, 373 participants) but the evidence is very uncertain. SDF likely prevents new root caries (mean difference (MD) -0.79 surfaces, 95% confidence interval (CI) -1.40 to -0.17; 3 studies, 439 participants; moderate-certainty evidence). SDF may help arrest caries in the primary dentition (MD 0.86 surfaces, 95% CI 0.39 to 1.33; 2 studies, 841 participants; low-certainty evidence) and the permanent dentition (coronal: 1 study, 373 participants; root: 1 study, 158 participants) but the evidence is very uncertain. The evidence is very uncertain for secondary prevention of caries (primary dentition: 1 study, 128 participants; permanent dentition (coronal): 1 study, 663 participants), for adverse effects (5 studies, 1299 participants), and aesthetics (1 study, 43 participants). Different approaches to SDF application (5 studies, 1808 children) Studies compared different frequencies or intervals of application, different concentrations of SDF, and different durations of treatment. Some studies included multiple comparisons of different approaches. Because of the different approaches, we could not combine findings from these studies. Due to very low-certainty evidence, we were unsure whether any approach to SDF application was better than another for caries arrest (4 studies, including 8 comparisons of different approaches, 1360 participants); secondary prevention of caries (1 study, 203 participants), or led to differences in adverse effects (3 studies, 1121 children) or aesthetics (1 study, 119 children). SDF versus fluoride varnish (8 studies, 2868 children, 223 older adults) Compared to flouride varnish, SDF may result in little or no difference to the prevention of new caries in the primary dentition (MD 0.00, 95% CI -0.26 to 0.26; 1 study, 434 participants; low-certainty evidence). The evidence is very uncertain for this outcome measure in the permanent dentition (coronal: 1 study, 237 participants; root: 1 study, 100 participants; very low-certainty evidence). Due to very low-certainty evidence, we were unsure whether or not there were any differences between flouride varnish (applied weekly for three applications) and SDF for caries arrest and secondary prevention of caries in the primary dentition (1 study, 309 participants). Similarly, we were unsure of adverse effects (3 studies, 980 children), dental pain or sensitivity (1 study, 62 children), or aesthetics (1 study, 263 children). SDF versus sealants and resin infiltration (2 studies, 343 children) Very low-certainty evidence in this comparison meant we were unsure if either treatment was better than the other for primary prevention of caries in permanent dentition (coronal: 1 study, 242 participants), or adverse effects (2 studies, 336 participants). SDF versus atraumatic restorative treatment (ART) with glass ionomer cement (GIC) or GI material (4 studies, 610 children) Very low-certainty evidence in this comparison meant we were unsure if either treatment was better than the other at arresting caries in the primary dentition (1 stud

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Crossref · 10.1002/14651858.cd012718.pub2

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  • Silver diamine fluoride (SDF) is effective for arresting cavitated lesions in many settings and can support access when definitive care is delayed.

    “Clinical guidelines and high-level syntheses recognize SDF as effective for arresting lesions in many contexts, while also emphasizing trade-offs (notably black staining), heterogeneity in evidence, and the need for follow-up and care pathways rather than single-visit “cures” [9,10,11,12,13].”

    From Equity or Two-Tier Care? Guardrails for Silver Diamine Fluoride and Delegated Early Childhood Caries Pathways (2026) · cites this paper as [9]

    The Abstract’s Main Results say SDF may help arrest caries in primary teeth, but the evidence is low-certainty; evidence for arrest in permanent teeth is very uncertain. The Authors’ Conclusions likewise describe a possible benefit, not established effectiveness across many settings. The passages do not support the claim that SDF helps maintain access when definitive care is delayed. (LLM, conf=0.87)

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  • Clinical guidelines and high-level syntheses recognize SDF as effective for arresting lesions in many contexts, while emphasizing trade-offs (notably black staining), heterogeneity in evidence, and the need for follow-up and care pathways rather than single-visit cures.

    “Clinical guidelines and high-level syntheses recognize SDF as effective for arresting lesions in many contexts, while also emphasizing trade-offs (notably black staining), heterogeneity in evidence, and the need for follow-up and care pathways rather than single-visit “cures” [9,10,11,12,13].”

    From Equity or Two-Tier Care? Guardrails for Silver Diamine Fluoride and Delegated Early Childhood Caries Pathways (2026) · cites this paper as [9]

    Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

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  • The evidence base suggests that frequency/regimen matters, although effects vary by population, setting, lesion type, and co-interventions, and the certainty of evidence differs across outcomes.

    “The evidence base also suggests that frequency/regimen matters, although effects vary by population, setting, lesion type, and co-interventions, and the certainty of evidence differs across outcomes [9,10,14].”

    From Equity or Two-Tier Care? Guardrails for Silver Diamine Fluoride and Delegated Early Childhood Caries Pathways (2026) · cites this paper as [9]

    The indexed Main Results passage (labelled Abstract; no page given) compares application frequencies and reports different certainty levels across outcomes. But it says the evidence was too uncertain to determine whether one application approach was better than another, so it does not establish that frequency or regimen affects outcomes. The retrieved passages also do not establish variation by setting or co-interventions. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • High-level syntheses continue to emphasize heterogeneity across outcomes and regimens, supporting the position that frequency results should not automatically translate into universal protocols without pathway guardrails.

    “High-level syntheses continue to emphasize heterogeneity across outcomes and regimens, supporting the position that frequency results should not automatically translate into universal protocols without pathway guardrails [9,10].”

    From Equity or Two-Tier Care? Guardrails for Silver Diamine Fluoride and Delegated Early Childhood Caries Pathways (2026) · cites this paper as [9]

    The Abstract describes a review that compares different SDF frequencies, concentrations and durations and assesses several outcomes. The passages available from our copy do not show the review emphasizing heterogeneity in its findings or recommending against universal protocols without pathway guardrails; that part of the attributed claim is unsupported. (LLM, conf=0.70)

    Experimental — accuracy not yet measured

  • High-level syntheses conclude that SDF is effective for arresting carious lesions under many conditions, and guidelines support SDF as a non-restorative option for managing carious lesions with appropriate counseling and follow-up.

    “High-level syntheses conclude that SDF is effective for arresting carious lesions under many conditions, and guidelines support SDF as a non-restorative option for managing carious lesions with appropriate counseling and follow-up [9,10,11,12,13].”

    From Equity or Two-Tier Care? Guardrails for Silver Diamine Fluoride and Delegated Early Childhood Caries Pathways (2026) · cites this paper as [9]

    The Abstract identifies this as a review assessing SDF for arresting carious lesions, but the passage available from our copy does not report an effectiveness conclusion. Searches for the review’s conclusions and for guidance on non-restorative use, counseling, and follow-up returned no matching passages, so our copy does not establish the attributed claim. (LLM, conf=0.70)

    Experimental — accuracy not yet measured

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Authors
Worthington, H. V., Lewis, S. R., Glenny, A.-M., Huang, S. S., Innes, N. P., O'Malley, L., Riley, P., Walsh, T., Wong, M. C. M., Clarkson, J. E., & Veitz-Keenan, A.
Affiliations
  • University of Manchester (GB)
  • New York University (US)
  • Cardiff University (GB)
  • University of Hong Kong (HK)
  • Division of Oral Health Sciences; University of Dundee; Dundee UK
  • Department of Oral Maxillofacial Pathology, Radiology and Medicine; New York University College of Dentistry; New York USA
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2024-11-07
Volume
2024
Issue
11
Pages
CD012718-CD012718
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd012718.pub2
PMC
PMC11542151
OpenAlex
W4404143243
Cited by
17
References
115
Citations by year
2026: 8 · 2025: 8 · 2024: 1
FWCI
1.38
Type
journal article
Language
en
Open access
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed (publishedVersion)
  • Discovery Research Portal (University of Dundee) (publishedVersion)
  • PubMed Central (publishedVersion)
  • ORCA Online Research @Cardiff (Cardiff University) (submittedVersion)
  • Research Explorer (The University of Manchester) (submittedVersion, other-oa)
  • The HKU Scholars Hub (University of Hong Kong) (submittedVersion, cc-by-nc-nd)
Topics
  • Health Sciences › Dentistry › Periodontics › Dental Health and Care Utilization
  • Health Sciences › Dentistry › Orthodontics › Dental materials and restorations
  • Health Sciences › Dentistry › Oral Surgery › Endodontics and Root Canal Treatments
Keywords
silver diamine fluoride, dental caries, caries arrest, dental caries prevention, root caries, primary teeth, permanent teeth, topical fluoride, children, adults, dental pain, tooth discoloration, adverse effects, cost-effectiveness, caries increment, caries risk assessment, caries risk reduction
MeSH terms
Adolescent, Adult, Quaternary Ammonium Compounds, Cariostatic Agents, Child, Child, Preschool, Dental Caries, Fluorides, Topical, Humans, Tooth, Deciduous, Bias, Randomized Controlled Trials as Topic, Root Caries, Silver Compounds

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