Silver diamine fluoride to arrest caries in cavitated primary molars

caries upper arch

Globally caries of the primary teeth ranks second amongst non-communicable diseases of childhood and presents a significant public health problem. Silver diamine fluoride in concentrations ranging from 10-38% favours the remineralisation of enamel and dentine and the arrest of caries progression. A number of studies and reviews have demonstrated beneficial effects for silver diamine fluoride (SDF) on caries but the have been no reviews of SDF on its effectiveness on caries progression in cavitated primary molars.

The aim of this review was to evaluate the efficacy of silver diamine fluoride (SDF) in controlling caries progression in cavitated primary molars.


A protocol was registered with PROSPERO and searches conducted in the PubMed, Embase Scopus and OpenGrey databases Randomised controlled trials (RCTs) and non-randomized clinical studies (NRSI) comparing silver diamine fluoride (SDF) with other non-invasive or minimally invasive treatment or no treatment in children with active dentine caries in primary molars were considered. Only studies published in English, Italian and French were selected. Two reviewers independently screened and selected studies and extracted data. Risk of bias was assessed independently by 3 reviewers using the Cochrane risk of bias tools.  The success rate and odds ratios were used to calculate the effect size for the meta-analysis.


  • 9 RCTs published between 2005 and 2021 involving a total of 3168 children were included.
  • 4 studies were from China, 2 India, and one each from Brazil, Saudi Arabia, and Spain.
  • 2 studies were considered to be a low risk of bias, one at high risk and 6 at unclear risk.
  • The SDF application protocol showed a high degree of variability across the studies.
  • 5 studies contributed to the meta-analyses
    • the overall effect in preventing caries progression = 33% (95%CI; 26 to 40%)
    • 622 out of 1205 carious lesions were arrested a caries arrest rate = 51.62% ± 27.40%


The authors concluded: –

SDF 38% was found to be effective in arresting active cavitated lesions in primary molars when applied annually or biannually, evaluated at follow up ≥12 months. SDF tends to be more effective than ART technique or NaF varnish in arresting caries progression. The effectiveness of SDF greatly increases if applications are repeated over time. A lack of standardisation in the application protocol emerged from the literature.


Previously we have considered a review by Oliveira BH et al, on SDF for prevention of new caries lesions in primary teeth (Dental Elf – 15th Aug 2018) and an umbrella review by Seifo et al (Dental Elf – 17th Jul 2019) which looked at SDF in both the primary and permanent dentition and included 11 systematic reviews citing 30 unique publications. The new review focuses on the use of SDF in cavitated primary molars.  The reviewers have searched several major databases with some language restrictions which could potentially have excluded some relevant studies. While the intention was to include RCTs and NRSI in the end only 9 RCTs were included. Although the authors have assessed the risk of bias of the included studies, they have been generous as 5 of the studies considered to be at unclear risk of bias did each have one domain assessed as being at high risk of bias and both the low-risk studies had one domain presenting some risks. Consequently, a stricter interpretation means that 6 studies are at high risk and 3 were at unclear risk. Overall, the reviews findings are in line with other reviews demonstrating a beneficial caries reduction effect from the annual or biannual application of 38% SDF. Future studies should be conducted in line with international guidelines such as the SPIRIT and  CONSORT statements and use common outcomes to facilitate comparisons.


Primary Paper

Zaffarano L, Salerno C, Campus G, Cirio S, Balian A, Karanxha L, Cagetti MG. Silver Diamine Fluoride (SDF) Efficacy in Arresting Cavitated Caries Lesions in Primary Molars: A Systematic Review and Metanalysis. Int J Environ Res Public Health. 2022 Oct 9;19(19):12917. doi: 10.3390/ijerph191912917. PMID: 36232217; PMCID: PMC9566773.

Review protocol on PROSPERO

Other references

Dental Elf – 17th Jul 2019

Silver diamine fluoride for caries management?

Dental Elf – 15th Aug 2018

Silver diamine fluoride for caries prevention in primary teeth


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Derek Richards

Derek Richards is a specialist in dental public health, Director of the Centre for Evidence-Based Dentistry and Specialist Advisor to the Scottish Dental Clinical Effectiveness Programme (SDCEP) Development Team. A former editor of the Evidence-Based Dentistry Journal and chief blogger for the Dental Elf website until December 2023. Derek has been involved with a wide range of evidence-based initiatives both nationally and internationally since 1994. Derek retired from the NHS in 2019 remaining as a part-time senior lecturer at Dundee Dental School until the end of 2023.

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