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Inside Dentistry
September 2017
Volume 13, Issue 9

Delivery of Fluoride Solutions to Proximal Tooth Surfaces

Part II: Caries interception with silver diamine fluoride

Theodore P. Croll, DDS | Joel H. Berg, DDS, MS

In Part I of this article, recommendations were presented for the delivery of certain fluoride solutions (in the dental office and at home) to proximal tooth surfaces in at-risk patients, using soft dental picks with a textured design.1 However, in cases in which the dental caries process has advanced from decalcification to bacterial breakdown of the tooth structure, employing “interceptive” measures in addition to preventative ones becomes more productive. For these cases, the delivery of silver diamine fluoride (SDF) to the affected proximal surfaces would be a logical treatment approach.

The use of silver solutions to treat dental caries has been advocated since the mid-1800s, but has gained much new interest with the introduction of an SDF solution.2-5 In 1924, in their respective textbooks, Hogeboom and Black described the use of silver nitrate for treatment of caries lesions,6,7 and in 1916, Prinz wrote about documented support for the use of silver nitrate dating back to 1846.8

Case Reports

The first five case reports below show the use of 38% SDF (Advantage Arrest™, Elevate Oral Care - (Figure 1) in young patients and offer a rationale for each treatment approach. The sixth case report presents evidence of how the SDF solution can stain soft tissues and skin surfaces, albeit harmlessly.

Case 1

A 10-year-old girl presented with caries lesions on the distal surface of her primary canine tooth and both proximal surfaces of the adjacent primary first molar. SDF solution was applied and agitated over the carious dentin and enamel (Figure 2 through Figure 5).

Rationale: Because the teeth would exfoliate within a year, as determined by radiographic evaluation, the parents had no objection to black discoloration. Three months later, a second SDF application was completed during a brief follow-up appointment (Figure 6).

Case 2

An eight-year-old girl was receiving a disto-occlusal resin-modified glass ionomer restoration of her mandibular primary second molar. Concurrently, caries lesions were diagnosed on the mesial and distal surfaces of her maxillary primary first molar (Figure 7). While local anesthesia took effect for the mandibular molar, SDF was applied by soft dental pick in the mesial and distal interproximal sites of the carious maxillary first molar (Figure 8). The patient returned for renewed SDF application in three months.

Rationale: Disto-occlusal resin-modified glass ionomer restoration of the mandibular primary second molar was completed because a caries lesion abutted the mesial surface of the permanent first molar. The use of a fluoride containing restorative material can be beneficial to the newly established contact region.9 Prospectively, SDF could cease caries progression in the maxillary primary first molar.

Case 3

A teenage girl presented with incipient caries lesions on the mesial and distal surfaces of her maxillary left second premolar (Figure 9). She also had occlusal caries of the adjacent first molar that required restoration. After renewed flossing instructions, the patient and parent were told about SDF, and consent was obtained for SDF application. SDF was applied by soft interdental pick into mesial and distal interproximal sites (Figure 10). The radiolucencies on the mesial cervical region of the maxillary and mandibular first premolars and distal cervical site of the mandibular canine tooth proved to be radiographic artifact. The patient was scheduled to return in 3 months for another SDF application and in 6 months for new bitewing films to be recorded. Per the Croll/Berg protocol, recommendations were also made for at-home interproximal fluoride delivery, and the patient was supplied with stannous fluoride tooth gel (ENAMELON, Premier Dental Products).1

Rationale: At this stage in caries development, there is nothing to lose by attempting this preventative approach rather than a restorative intervention. If the lesions do not progress, then the tooth has been structurally preserved for an indefinite amount of time.

Case 4

The parents of a teenage girl who underwent orthodontic treatment had not scheduled her for routine recall visits for more than two years. Large Class I caries lesions developed in multiple permanent molars, and proximal decalcification and beginning caries lesions were diagnosed in multiple other posterior teeth (Figure 11). The Class I carious molar sites were restored with ACTIVA™ BioACTIVE-RESTORATIVE™ material (Pulpdent®, TheraCal LC® resin-modified calcium silicate liners (BISCO, were used in regions of deep caries penetration. In addition, the mandibular left first molar required a disto-occlusal restoration. Proximal sites showing radiolucencies were saturated with the SDF solution using soft interdental picks (Figure 12). A 3-month follow-up appointment was scheduled for another interproximal application of SDF, and the patient was supplied with Enamelon stannous fluoride gel (Enamelon® Preventive Treatment Gel, Premier Dental Products) for daily, at-home application. The radiolucencies on the mesial cervical regions of the mandibular first premolars were artifacts.

Rationale: As in Case 3, a preventative approach was preferred over an immediate restorative intervention. If the lesions progress, tooth restoration will become necessary.

Case 5

The teenager in this case underwent Class I restoration of a permanent second molar using ACTIVA BioACTIVE-RESTORATIVE material 3 months before (Figure 13). Instead of using 5% glutaraldehyde/HEMA disinfectant, the cavity preparation was swabbed with SDF, agitated with a small brush applicator tip for 60 seconds, and then air dried.10 The black stain showing through the translucent restorative material is of minimal aesthetic consequence due to the posterior position of the second molar.

Rationale: Cavity disinfection not only decreases or eliminates postoperative tooth sensitivity, but also has been shown to significantly decrease bacteria count in cavity preparations.10 It is logical that SDF would have a similar effect to that of commercial glutaraldehyde/resin disinfectants, but additional research is needed to compare the relative effectiveness of the two agents.

Case 6

To intercept small proximal caries lesions detected on bitewing radiographs, this 10-year-old boy had SDF delivered between the mandibular primary first and second molars (Figure 14). During the procedure, some of the fluid was inadvertently wiped on the lip and skin surfaces. Attempts to remove the silver stain with mild facial soap and gentle rubbing with petrolatum were unsuccessful. Although stains caused by SDF are harmless and will disappear in a few days, until they do, they are quite unsightly. Therefore, extreme care must be taken to restrict the SDF solution to the carious tooth regions and avoid such contact as seen here.


The use of SDF solution should not be limited just to patients who have no access to routine restorative dentistry procedures. The concept of “intercepting” evolving dental caries using SDF while “preventing” the formation of new decalcification and dental caries lesions using judicious topical fluoride delivery in the dental office and at home could be considered part of the foundation for true minimally invasive dentistry.


1. Croll TP, Berg JH. Delivery of fluoride solutions to proximal tooth surfaces. Part I: Caries prevention with fluoride varnish and gel. Inside Dent. 2017;13(7):90-91.

2. Yee R, Holmgren C, Mulder J, Lama D, Walker D, van Palenstein W. Efficacy of silver diamine fluoride for arresting caries treatment. J Dent Res. 2009;88(7):644–647.

3. Crystal YO, Niederman RN: Silver diamine fluoride treatment considerations in children’s caries management. Pediatric Dentistry. 2016;38(7):466-471.

4. Mei ML, Lo EC, Chu CH. Clinical use of silver diamine fluoride in dental treatment. Compend Contin Educ Dent. 2016;37(2):93-98.

5. Christensen R. Focus on: Silver diamine fluoride. Dentistry Today. 2017;36(2):18

6. Hogeboom FE. Filling materials used in deciduous teeth. In: Hogebooom FE, eds. Practical Pedodontia or Juvenile Operative Dentistry and Public Health Dentistry, St. Louis, MO: The C.V. Mosby Company; 1924: 60-61.

7. Black GV, Black AD: Management of children’s teeth. In: Black GV, eds. A work on operative dentistry, Vol. One, The Pathology of the Hard Tissues of the Teeth, Sixth Edition, Chicago: Medico-Dental Publishing Co., London: Claudius Ash, Sons & Co., Ltd; 1924:247-257.

8. Prinz H. Dental Materia Medica and Therapeutics. 4th ed. St. Louis, MO: C.V. Mosby Company; 1916: 217-230.

9. Croll TP, Berg JH, Donly KJ. Dental repair material: A resin-modified glass-ionomer bioactive ionic resin-based composite. Compendium Contin Educ Dent. 2015;36(1):602-607.

10. Christensen R. Disinfection of tooth preparations – Why and how? Clinicians Report. 2009;2(11):1-2.


Neither author has any financial interest in any product or company mentioned in this article, and there was no remuneration of any kind for the production of this work.

About the Authors

Theodore P. Croll, DDS
Private Practice
Doylestown, Pennsylvania
Affiliate Professor
Department of Pediatric Dentistry, UW School of Dentistry
Seattle, Washington
Adjunct Professor
Department of Pediatric Dentistry, UT Health Science Center
San Antonio, Texas

Joel H. Berg, DDS, MS
University of Washington
School of Dentistry
Seattle, Washington

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