SDF, THE MAGIC BULLET;

Is it really a magic alternative in the caries management?

ABSTRACT:
WHO estimates oral diseases as the fourth most expensive disease to treat in most
industrialized countries where, 5% -10% of health spending is on treating dental
caries. Oral health is a basic human right. There arises a need of redefining goals of
dental care to reduce burden on population1 in developing countries which has to be
implemented right from childhood especially during Covid pandemic which has forced
the world into health and economic crisis. SDF can be considered as the need of the
hour as it is cost effective and offers biological management of caries. It fulfills the
criteria of promoting a positive dental experience in anxious pediatric patients reducing
burnout in pediatric dentists as well as improving OHRQoL in children. This article
highlights the resurgence of SDF as the Smart initiative in caries management and
suggests a model of Medical – Dental interprofessional collaborative practice.

INTRODUCTION:

The ravages of oral disease on individual as well as society includes fear, anxiety ,
pain and discomfort with sleepless nights , time off from schools impacting educational
attainment, loss of masticatory efficiency leading to malnutrition, growth retardation ,
functional limitations and treatment costs, all of which impact oral health quality of life,
general health and wellbeing of child.

A study on “Global burden of Disease” conducted by Marcenes et al,2013 and

Kassebaum et al,2017, concluded that Oral health poses a major neglected area and
presents a health challenge among the populations of the World.2

A study by Duangporn Duangthip et al,2017 ECC prevalence, in ASIA in different

countries is, Laos (96.1%), followed by Cambodia (93.1%), Myanmar (84.2%),
Malaysia (76.2%), Thailand (75.6%), India (49.6%) and the least in Japan (24.4%).
State wise prevalence of ECC from literature in Indian scenario showed a highest
occurrence in Andhra Pradesh with 63%, and least occurrence in Sikkim with 41.92%.
There was no substantial data from 16 states.3 The above trends suggest a
comprehensive approach for management of caries through Health education,
Awareness programmes and community approaches. The suggestive treatment
modalities include preventive and non- invasive measures.

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Barriers to dental care most commonly include failure to recognize the importance of
early dental visit, lack of finance, dental anxiety and not being advised by pediatrician
to seek dental care at an early age. In the prevention of dental caries the vital four
practices include plaque control, diet, fluoride and fissure sealing. The fluoride is
paramount in the treatment of caries and can be used in a variety of ways.

Philosophy of pediatric dental care - Children are future dental patients, the dental
care they receive at an early age should promote positive dental experiences which in
turn reinforce positive dental attitudes4. The adage of pediatric dentistry, sine qua non
of successful practice is realization that children are not miniature adult with respect
to their reaction to the treatment. SDF can be viewed as a reward to pediatric dentists
in management of caries as it effectively balances anxiety of children and stress of
pediatric dentists providing care.

Paradigms in Cariology:

• Infectious (mono-infectious • Dynamic process leading to

concept). mineral loss.
• Fluorides create ‘’enamel • Fluoride inhibits
resistance”. demineralization and enhances
• Operative treatment. remineralization.
• DRILL AND FILL RESTORATION • Minimum intervention
• SEAL AND HEAL OPERATION.

SDF can be de-coded as the material that satisfies WHO Millenium Development
Goals and the US Institute of Medicine criteria for 21st century, as it is safe,
patient-centered, effective, efficient, timely and equitable(Wagstaff and Claeson,
2004).

HISTORY OF SDF:

Medicinal use of silver dates long back to 1000 BCE where water is stored in silver
vessels (Russel and Hugo 1994) considering antimicrobial properties of silver5. Howe
(1917) directly applied silver nitrate to caries lesions (Howe’s solution) which
generated secondary dentin6. In-vitro studies gave the following insight of Silver
fluoride as a potential agent of caries prevention that inhibits S.mutans growth

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(Thibodeau et al ,1978; Ostela and Tenovuo ,1990), caries lesion depth progression
(klein et al ,1999) and also metabolic activity of dental plaque (Oppermann and Rolla
,1980) 5.

In vivo in primary teeth - Lateral spread of caries is inhibited by silver fluoride

(Nishino et al ,1969). Silver fluoride in combination with stannous fluoride and
stomahensive inhibits occlusal and approximal caries (craig et al, 1981). Silver and
stannous fluoride combination inhibits 95% caries progression (MC Donald and
Sheiham, 1994)5.

In vivo in permanent teeth – Silver fluoride arrests development of caries lesions

that have already been initiated (Green,1989) and inhibits approximal caries
progression (Hyde 1973 using silver nitrate)5.

These early researches lead to the use of SDF in Australia (Gotjamanos,1997), Japan
(Yamanga et al, 1969) and Mexico (Aron ,1995). Most of the available studies,
demonstrated that SDF has a phenomenal effect in preventing caries, with the
disadvantage of blacking the caries teeth. Ex vivo and in vivo studies on primary teeth
with SDF showed more effectiveness in arresting lesions than with fluoride varnish
and APF gel.

SDF was first investigated in Japan as a PHD thesis (Nishino,1969)6. This formulation
has a combined effect of high dose of fluoride and powerful antimicrobial properties of
silver. In 1970, SDF is accepted in Japan for dental treatment by Central Council of
Ministry of Health and Welfare as cariostatic agent and marketed as Saforide (Toyo
Seiyaku Kasei Co. Ltd.,Japan). Aqueous SDF 38%, has been in use for decades in
various countries for prevention and arresting of caries7,8. In India, SDF is in use since
2004. In 2014, SDF got approval from USFDA as a Class II medical advice for dentinal
hypersensitivity. In October 2016, SDF was awarded with the designation of
“breakthrough therapy” by FDA.6,9

New NOVEL Liquid

SDF differs from other fluorides agents, as the combination of silver and fluoride in an
alkaline base, has a synergistic effect in arresting dental carious lesions.Evidence

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based clinical practice guidelines on non restorative treatment of carious primary teeth
suggest, 38% SDF solution as a documented clinical pathway of management of
cavitated occlusal, approximal as well as facial or lingual lesion 10.SDF contains 25%
silver particles, 8% ammonia, 5% fluoride and 62% water. It is a colourless liquid
containing silver particles and 38% (44,800ppm) fluoride ion at a pH 10. This is refered
to as 38% SDF.5,11,12

Mechanism of action:

Silver:

It has an antimicrobial property which breaks cell walls and membranes, denatures
all proteins, inhibits DNA replication, deactivates nearly any macro molecule. It also
strengthens dentine, forms silver – protein protective layer which is acid resistant as
well as resistant to enzymatic digestion (desensitize teeth with hypersensitivity)9.

Diamine:

Stabilizes high concentration of ions in solution.

Fluoride:

Increases enamel resistance, rate of maturation, surface energy. It interferes with

micro-organisms and improves tooth morphology and plays an important role in
remineralization of incipient lesions.

SDF targets both organic and inorganic components of caries lesion. SDF when
applied locally, forms an insoluble layer of oxidized silver which increases
remineralization, obturates dentinal tubules and inhibits breakdown of enzymes such
as MMP’s and cathepsins.13 Thus, SDF highly increases resistance to acid dissolution
and decreases sensitivity of tooth. 14 SDF will interfere with biofilm formation, killing
bacteria that causes oral local environmental imbalance 15-18. Further, the dying

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bacteria releases tiny silver particles into oral environment thus, reactivating SDF to
act on live bacteria (Zombie effect)19,20.

Fluoride and Silver ions penetrate to a depth of ~25 microns and 50-200 microns
respectively into enamel,21 and dentin .22 SDF arrested lesions are 150 microns in
thickness.

Rosenblatt et al ,2009 extensively studied effects of SDF both on teeth (sound and
decayed) and bacteria. Fluoride in healthy teeth reacts with hydroxyapatite crystals to
form fluor-apatite which is less acid-soluble than hydroxyapatite, inhibiting decay
process. Silver ions reacts with thiol groups of amino acid and nucleic acids of the
bacteria. Silver amino and nucleic acids thus formed does not carry metolic and
reproductive functions, leading to killing of bacteria. However, in decayed teeth SDF
reacts with hydroxyapatite to form fluorapatite, forms calcium fluoride, ammonia
monohydrate and precipitates as silver phosphate. Silver phosphate thus, formed
subsequently reacts with bacterial amino and nucleic acid-thiol groups to form silver
amino and nucleic acids5,21,22.

Commercially available SDF products:

Rivastar (SDI)23: as a Masking discolouration of SDF

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It is commercially available as SDF and KI agent, consisting of 30-35% Silver capsule
and >60% ammonia solution and a saturated solution of KI. Rivastar is an effective
biofilm inhibitor. It’s a Silver fluoride with a two-step patented procedure which
minimises risk of staining. By applying KI over silver fluoride solution, scavenging of
free silver ions occur which prevent silver fluocculation onto dentin and forms a silver
iodide, a creamy white precipitate.

Indications for SDF

• Children with high risk of caries .

• Children unable to withstand traditional treatment due to medical or
psychological reasons (behavioural problems).
• Multiple lesions which cannot be managed at a time.

• For caries lesions which are difficult to treat.

• In those children who have difficulty in access to dental care.

• SDF can be used where the prevention of disease is not possible in clinical
situations such as special care dentistry, pre-cooperative child and current Covid
situation.

• Treatment of molar incisor hypo-mineralization and dentinal hypersensitivity.

• Partially erupted anterior carious teeth.

Contraindication of SDF

• Individuals sensitive to silver and also cavitated lesions encroaching pulp or

symptomatic teeth.
• Presence of mucositis and desquamative gingivitis that disrupt the protective
barrier of stratified squamous epithelium.
• If parents / guardians have concern regarding black stain.
• If remaining dentin thickness is less (Fancher et al ,2017).

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Tooth selection
• No history of chronic pain.
• Caries lesions that do not involve pulp.
• Cavitated carious lesions that are accessible for applying SDF with brush.
• As a cariostatic means before placement of restoration.

Precautions to be taken before the treatment (Mei ML, Chu CH,2016)

• SDF produces transient gingivitis or blackish dis-colouration. Hence, direct

contact should be avoided. Petroleum jelly or cocca butter can be coated on gingival
tissue.
• Rubber dam or cotton rolls should be used.

SDF – Inform consent (TO DO GOOD – TO DO NO HARM)

Inform consent should particularly highlight the possible staining of treated lesions,
blackening of skin, clothes with pictures and need for re-application of the treated
lesions.

Protocol for Clinical application :24,25,26,27

• The vicinity of carious teeth should be thoroughly cleansed for better contact of
SDF with denatured dentin.
• Removal of caries dentin prior to application of SDF is un-necessary.
• In order to prevent blackening with SDF treatment, necessary precautionary
measures in the form of application of petroleum jelly to lips and skin should be taken.

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• Isolate the areas, that are in vicinity of caries teeth by means of cotton rolls or
other isolation methods. Petroleum jelly should not be applied on caries surfaces that
are to be treated.
• While applying SDF to carious primary teeth adjacent to non cavitated
permanent teeth, care should be taken to avoid stain.
• To dry the lesion, compressed air should be blown very gently.
• The application of SDF on caries teeth should be carried out by a micro sponge
brush after removing the excess fluid on the brush. To minimize systemic absorption
of fluid by the child the excess fluid should be removed with gauze.
• Application of the SDF should last for a minimum of atleast 1 minute and should
be allowed to air dry for a minimum of 3 minutes.
• In order to prevent caries in untreated teeth, 5%NaF varnish should be applied
in entire dentition.

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Follow up:

• Follow up of SDF treated lesion should be carried out within a period of 2-4
weeks.
• If the teeth are not stained and hardened, reapplication of SDF is necessitated.
• After SDF treatment, if the lesions are not restored, bi annual application and
reapplication is advised.

Caries prevention- repetition is the key

Annual application of SDF resulted in better prevention of caries both in adults as well
as children than with fluoride varnish applied 4 times in a year. A systematic review
concluded that SDF application is better than NaF (Chu et al,2002; Lo et al, 2001;
Duanghip et al, 2016;)20,28 in arresting caries. This is contrary to study done by Wong
et al,2011; Wong et al, 2005). Current evidence on the efficacy of SDF (38%) for caries
arrest in children (Gao et al,2016)29 is 86% when tested after six months. It is ideal to
apply SDF periodically, preferably every six months for arrest and prevention of caries.

Adverse effects:

• SDF tastes Metallic or bitter.

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• Inadvertent contact with SDF is found to result in mucosal irritation and lesions
that resolves itself after 48 hours.
• Temporary staining of skin is found with application of SDF, that resolves with
in a period of 2-14 days.12,30
• Permanent staining of clothes is also found.12,30

Maximum Dosage and Safety margin

From the literature available, SDF gives a rare evidence of toxicity and adverse events
(Lansdown, 2002b, 2006; Lansdown & Williams,2004).
Average lethal dose LD50 – by oral administration is 520mg/kg and 380mg/ kg by
subcutaneous administration. One drop of SDF contains 9.5mg. Thus, recommended
limit of SDF is set at 1 drop (25 μL) for a 10 kg bodyweight, for every visit at an interval
of one week. This dose is in proportion with the EPA’s allowable short-term exposure
of 1.142 mg silver per litre of drinking water for 1-10 days (ATSDR, 1990).
Cumulative exposure from acute and chronic intake of silver at low level has no
bearing in causing physiological disease, but bluing of skin in argyria should be
avoided. The Environmental Protection Agency has set a lifetime exposure to silver
conservatively, at 1 gram. The highest applied dose for 3 teeth measured in the
pharmacokinetic study is 2.37 mg that would enable more than 400 applications.
Additionally, research has shown that there is a 400-fold safety norm in application
of SDF with regard to normal pulpal response and with a very few minor adverse
events like staining of gingiva and cloth.

Parent perspective:

The most frequently reported barrier for use of SDF is parental acceptance. Staining
on posterior teeth is more acceptable to parents than anterior.

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Most parents accept SDF staining in anterior teeth to avoid treatment under sedation
or general anaesthesia. Treatment with sedation or General anesthesia in children
under the age of 3 may affect the development of the brain. Hence, most parents
prefer the SDF method. This suggests that many parents are open to compromise
aesthetics in favour of less invasive approach, where child cooperation and age is a
barrier for traditional restorative care31.

How to mask discolouration

Silver nano fluoride and ammonium hexa-flurosilicate can also be used as alternatives
to SDF. Reducing agents like potassium iodide, magnesium chloride, glutathione can
be used along with SDF to mask the discoloration of teeth. SMART technique and
crowns can also be used to mask discoloration32.

Smart technique

Rivastar is a commercially available SDI (SDF + KI)33,34 which can be used to mask
the decoloration of SDF. In a systemic review, Rivastar reported clinical effectiveness
in arresting caries. They also concluded bond strength of dentine to adhesives and
GIC is not effected by its application on tooth.

Smart technique involves application of GIC on SDF applied teeth. Studies on SDF
application on the bond strength of dentine to GIC / RMGIC concluded that most
common failure mode is adhesive failure when applied SDF, also a negligible
decrease in bond strength noticed.

Effects on bonding

Studies have been carried out to find the effect of SDF on bonding of tooth by use of
GIC and resin based restorative materials. In one of the studies, it is found that rinsing
after application of SDF has decreased the bond strength between the tooth and

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restorative material by nearly 50% which contrasted with another study that showed
increase in bond strength. Further studies by Selviraj et al (2016)33,35 and Quock et al
(2012) indicated no decrease in bond strength. Decrease in shear bond strength is
observed by Kucukyilmaz et al(2016), Soeno et al (2001) and Knight et
al(2006)33.Thus, it is recommended that for direct restoration, rinsing is obligatory and
for cementing crown rinsing after application of SDF is un-necessary.

Clinical Utility
SDF as NRCC:

NRCC(Non Operative Caries Treatment) , is a novel method of treating dental carious

lesions in children. The main objective of this treatment is to manage biofilm on the
lesion surface. It is very effective in primary teeth treatment which presents with
potentially cleansable and cleansable lesions. SDF treatment as NRCC is very safe,
non-invasive, easy to perform and very economical method than other methods
performed under NRCC36.

Need for Sedation can be Avoided or Delayed in Treating Pediatric Patients

In the treatment of caries with SDF, sedation of the patient is not required. This itself
is a major advantage for the treatment of caries in children. Treatment with sedation
or General anesthesia in children under the age of 3 may effect the development of
the brain. Hence, most parents are preferring the SDF method.

Arrest of Caries in children in need of Special health care

As a pediatric dentist one can help children with special needs, such as Autism,
sensory processing disorder, Down Syndrome by treating them with SDF. This
treatment can be followed also in children who are immune-compromised, undergoing
chemotherapy, salivary dysfunction or polypharmacy, and those suffering from chronic
diseases. Laser treatment has an added benefit in promoting fluoride up take. A study

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concluded that among the 4 commercially available dental lasers CO2 and Er:YAG
lasers37 resulted in a increased fluoride uptake in the SDF-treated dentine . Hence
lasers and SDF combination has synergestic affect in treating these children38.

Caries Control in Patients with Extensive Treatment Needs

Pediatric patients who need extensive care in caries treatment may not be able to
support financially for the restorative treatment. In such cases, SDF treatment will act
as a stop-gap measure before they can afford for regular treatment.

Silver Modified Atraumatic Restorative Treatment (SMART)

SDF treatment prevents caries but does not restore form and function of the teeth. For
efficient function of the teeth affected by caries, the treatment involves application of
GIC restorative materials like HVGIC and Fuji EQUIA Forte (GC America) which is
known as SMART approach39.

Hypersensitivity

SDF also decreases dentinal hypersensitivity by occluding dentinal tubules and

produces fluoro-hydroxyapatite which will increase mineral density and hardness. The
method also does not stain healthy teeth structure and therefore is an excellent
alternative for patients suffering from hyper-sensitivity10,26.

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Treatment of Molar Incisor Hypo-mineralization (MIH)

Molar Incisor Hypo-mineralization (MIH) is a clinically challenging situation involving

20-40% of permanent first molars. These MIH teeth are more vulnerable for
developing caries involving a 10-fold risk. As, these teeth cannot be adequately
anaesthesized SDF is a better option to desensitize these teeth.

Preventing caries recurrence at restorative margins

As restoration treatment of caries involves only a finite duration of longevity, SDF

application prolongs the life of the existing restoration. It is a cost affective treatment
that is beneficial to the patients.

Interproximal incipient caries

Interproximal Incipient lesions present a clinically challenging procedure for its
treatment. SDF obstructs the growth of caries and present a suitable treatment for
interproximal incipient lesions. The procedure involves application of SDF by using
super- floss (Judy Bendit and Douglas Young ,2017)

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Treating infected root canals:
SDF due to its unique antibacterial effect is used as intracanal irrigant. Studies
concluded that 10% SDF is effective and more efficient in treating E.Faecalis
biofilm40.

SDF – community prevention

It is always an effective method in treating dental problems involving the whole

community rather than an individual approach. Treatment of oral problems with SDF
is proved to be three-fold beneficiary involving the dentist, the child and the population.
The method is most cost effective and provides inexpensive treatment for all the strata
of society. The ease of SDF treatment is phenomenal, with no requirement of patients
to visit regular dental clinics. The dentist by adapting the method has less burden in
treating caries and oral health ailments. SDF application to children involves no painful
procedures and by which the child willingly undergoes treatment41. Further, AAPD
guidelines (2017), suggest that SDF as a brush on liquid, arrests 87.7% of dental
caries lesions with success rate similar to restorations placed under general
anaesthesia. Hence, it can be advocated as school and community-based method for
caries care. SDF treatment benefits should be made to publicise extensively among
targeted population both by dental practitioners as well as non-dental activists such
as ASHA, Angalwadi and village volunteers etc and in school by teachers.

Oral health Model – Protecting and promoting oral care

It’s time to break silo-effect between Medical – Dental fraternity and create a unified
vision between Gynaecologists, Pediatricians and Pediatric Dentists to attain
“Healthy Mother- Smiling Child”.

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As medical professionals are influential due to their early access of children, we should
encourage well baby visits and early first dental visit through collaboration. Covid -19
caries management model works on integrating knowledge about Home-care,
noninvasive preventive measures such as risk assessment by ‘lift the lip’ procedure,
dietary councelling oral hygiene training, biofilm control measures and role of fluoride
varnishes, Sealants, SDF through digital platforms as CME - CDE.

Conclusion:

Prevention is the corner stone of modern holistic dentistry. Individualised oral care is
expensive but SDF can be used as affordable public health intervention thus, reducing
economic burden of cost of caries treatment. It is most safe and effective alternative
to conventional caries management across the age spectrums. Current Covid-19
pandemic has massively affected dental care and will need pediatric dentists and
policy makers to adopt new practices and protocols which are health driven rather than
treatment driven. SDF treatment efficacy, and clinical utility based on scientific
evidence from literature represents a litmus test for SDF as a promising material of
choice in achieving the Goal of SAVE 20 IN 2020 and also in years to come.

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