Silver Diamine Fluoride for Caries Arrest in Pediatric and Special Needs Populations: A Decade of Clinical Evidence

Abstract

Graphical Abstract

In the last ten years, silver diamine fluoride (SDF) has fundamentally transformed the treatment of dental caries in two of the most susceptible groups in dentistry; young children with early childhood caries and those with special health care needs (SHCN). The review is based on clinical evidence published in the last 5 years (2014-2024) and includes randomized controlled trials, longitudinal cohort studies, systematic reviews, and qualitative research. The main conclusion is clear: one application of 38% SDF per year arrests 6070% of active dentinal lesions, and two applications exceeds 80% after 24 months (Duangthip et al., 2017; Fung et al., 2018). In children with autism spectrum disorder, cerebral palsy, or intellectual disabilities (groups where traditional restorative care might involve general anesthesia or physical restraint), SDF presents an alternative that is behavior-friendly and needle-free and highly acceptable, with most clinical setting showing over 90 percent treatment acceptance (Nelson et al., 2021; Hashim et al., 2021). Data on safety in over 4,000 children and SHCN have shown that there are no severe systemic adverse events, and transient gingival irritation is experienced in less than 10% of cases of use, with serum silver levels being well below toxicity levels (Vasquez et al., 2022). The most obvious disadvantage, irreversible black staining of arrested dentin, is the main obstacle to acceptance on anterior teeth, but it increases parental approval levels by about 35 per cent to more than 80 per cent with a short, clear description of the risk-benefit trade-off (Clemens et al., 2020). School-based SDF programs have shown to be cost-effective and can save almost 900 per child over no treatment, and the number needed to treat is only 4.2 to prevent a single episode of general anesthesia, according to the public health perspective (Ruff & Niederman, 2023). Although this is a compelling evidence, the uptake of SDF is uneven, and less than one out of three pediatric dentists in the United States regularly prescribe SDF, often citing reimbursement issues, esthetic reasons, and knowledge gaps (Seifo et al., 2022). The conclusion of this review is that SDF does not replace but is the first line of intervention of choice in caries arrest of many vulnerable patients. The next round of work should focus on implementation science, combination therapy aimed at reducing staining, and policy changes to incorporate SDF in the federally-funded dental services.