School of Public Health

What You Should Know About Silver Diamine Fluoride

APRIL 2019

Dental public health student at University of Washington writes about silver diamine fluoride and childhood cavitiesGuest Author / Kristopher A. Kerns, MPH-D will complete his Graduate Certificate in Maternal and Child Health in 2019 and his Doctoral Degree in Oral Health Sciences in 2021 at the University of Washington School of Public Health and School of Dentistry. He is currently investigating dysbiotic shifts in the oral microbiome in relation to oral diseases, focusing on dental caries and its etiology in children.

Silver diamine fluoride (SDF) is applied directly to cavities to instantly stop the process of decay—for less than a dollar per treatment. Other topical fluorides, including toothpaste and professionally-applied varnish, primarily aim to prevent future tooth decay. More invasive treatments are typically required to treat decay once the caries process has begun to erode teeth—until now. SDF is the first and only dental therapy the US Food and Drug Administration (FDA) has fast-tracked through the approval process.1

According to Dr. Peter Milgrom, one of the lead researchers for the clinical trials, SDF could help states fill gaps in their efforts to reduce childhood tooth decay, a prevalent and persistent public health problem. But the varied acceptability of SDF among dental health professionals and policy makers presents an unforeseen barrier to its widespread use.2 It is essential to continue to educate oral health professionals, policy makers, and vested community organizations about the evidence that supports use of SDF, especially among children with dental disease.


pediatric tooth decay on a back tooth child tooth decay treated with SDFTop photo: tooth decay in a young child. Bottom: the same tooth treated with SDF therapy, the decay process is stopped and a black stain remains. SOURCE: Dr. Andrew Horng.

Initially, providers didn’t think patients and/or their guardians would accept the SDF as a treatment because of its aesthetic effect. The silver ions in SDF, which disrupt the cavity-causing bacterial biofilm3, leave a permanent black stain on the decayed area of the tooth. Researchers looked for evidence to back up this concern. However, multiple studies show that when providers explain the action and benefits of the therapy—especially when compared to more invasive methods such as anesthetized surgery—the staining effect of SDF is not an insurmountable barrier to treatment.4-6 Most parents realize that the stained, treated teeth are no longer susceptible to the pain, discomfort, or sensitivity typically associated with well-established cavities. 

As of today there is no widely accepted protocol to prevent this black staining, though it is an area of active research. Rather, standard practice options include covering the stain with an opaque, tooth-colored filling material or removing the stained tooth surface and filling the area similar to a traditional filling placement. Neither option is necessary to maintain the health of the tooth in most cases and either “fix” would be temporary as primary (baby) teeth will eventually be lost naturally.

The results of the on-going clinical trials needed for full FDA approval will provide additional evidence for providers and policymakers regarding SDF. In the meantime, Dr. Milgrom and his colleagues at the University of Washington and beyond have worked diligently to help establish the foundational evidence-based guidelines for usage of 38% concentrated SDF solution. Support from the American Dental Association and the American Academy of Pediatric Dentistry7,8 will help seamlessly integrate SDF therapy in dental public health settings as well as hopefully into the general practice upon FDA approval.


States could save millions of dollars in Medicaid payments if they adopted and promoted SDF  as an alternative to more invasive treatments which cost in the hundreds of dollars by comparison.9 This has already begun in recent years with the rapid adoption of a standardized insurance billing code and growing inclusion in both state Medicaid programs and commercial insurance companies.

Public health departments could further reduce the prevalence of tooth decay by supplementing current oral health improvement strategies with SDF therapy. While the Healthy People 2020 initiative has helped states make great progress over the last 20 years in oral health there are still thousands of children who experience tooth decay, even if states meet national oral health goals. In Washington state, nearly 50% of 8-10 year old’s and 38% of 5-7 year old’s have had cavities.10,11 Even more alarming is that 12% of these children have untreated tooth decay.11

To make population-level improvements in children’s oral health, Washington and other states need to establish quality assurance metrics that incentivize inexpensive, atraumatic, non-invasive methods, including the use of SDF therapy.


1) Institute of Translational Health Sciences (ITHS), 2019. UW Dental Research Team Receives Breakthrough Therapy Designation from the FDA. Retrieved April 23rd, 2019 from:

2) Chhokar SK, Laughter L, Rowe DJ. Perceptions of Registered Dental Hygienists in Alternative Practice Regarding Silver Diamine Fluoride. J Dent Hyg. 2017 Aug;91(4):53-60. PubMed PMID: 29118084.

3) Mei ML, Lo ECM, Chu CH. Arresting Dentine Caries with Silver Diamine Fluoride:What's Behind It? J Dent Res. 2018 Jul;97(7):751-758. doi:10.1177/0022034518774783. Epub 2018 May 16. PubMed PMID: 29768975.

4) Crystal YO, Janal MN, Hamilton DS, Niederman R. Parental perceptions and acceptance of silver diamine fluoride staining. J Am Dent Assoc. 2017 Jul;148(7):510-518.e4. doi: 10.1016/j.adaj.2017.03.013. Epub 2017 Apr 27. PubMed PMID: 28457477.

5) Clemens J, Gold J, Chaffin J. Effect and acceptance of silver diamine fluoride treatment on dental caries in primary teeth. J Public Health Dent. 2018 Dec;78(1):63-68. doi: 10.1111/jphd.12241. Epub 2017 Jul 27. PubMed PMID:28749529.

6) Magno MB, Silva LPD, Ferreira DM, Barja-Fidalgo F, Fonseca-Gonçalves A. Aesthetic perception, acceptability and satisfaction in the treatment of caries lesions with silver diamine fluoride: A scoping review. Int J Paediatr Dent. 2019 Jan 14. doi: 10.1111/ipd.12465. [Epub ahead of print] Review. PubMed PMID:30637833.

7) American Dental Association (ADA), 2018. Nonrestorative Treatments for Carious Lesions Clinical Practice Guideline. Retrieved April 24th, 2019 from:

8) American Academy of Pediatric Dentistry (AAPD), 2018. Policy on the Use of Silver Diamine Fluoride for Pediatric Dental Patients. Retrieved April 24th, 2019 from:

9) Johhnson B, Serban N, Griffin PM, Tomar SL. Projecting the economic impact of silver diamine fluoride on caries treatment expenditures and outcomes in young U.S. children. J Public Health Dent. 2019 Feb 11. doi: 10.1111/jphd.12312. [Epub ahead of print] PubMed PMID: 30741498.

10) Washington State Department of Health (WSDH), 2018. Oral Health [Tooth Decay]. Retrieved April 23rd, 2019 from:

11) Washington State Department of Health (WSDH), 2017. Washington State Smile Survey 2015-16. Retrieved April 23rd, 2019 from: