Review Article

Silver Modified Atraumatic Restorative Technique: A Way Towards “SMART” Pediatric Dentistry During the COVID-19 Pandemic


As the coronavirus disease-2019 pandemic outbreak continues to be a global public health concern, dentists should seek means to provide oral health care with minimal risk. To meet the recommendations of the Center for Disease Control, alternative non-aerosol generating techniques have been proposed to minimize the risk of disease transmission to patients and dental healthcare personnel. Among recent materials, silver diammine fluoride (SDF) has been shown to be effective in preventing and arresting caries. This along with an atraumatic restorative treatment with glass ionomer cements (GICs) makes it a potentially attractive adjunctive therapy for caries management in pediatric patients. In this technique, SDF is applied over carious tissue and the lesion is restored with auto-polymerizing GIC. This review article aims to provide a practical background and clinical guide for the application of silver-modified atraumatic restorative technique (SMART) as a safe way to provide dental services to children during the pandemic.

1. World Health Organization (WHO). Considerations for the provision of essential oral health services in the context of COVID-19: interim guidance. Geneva (CH): World Health Organization; 2020.
2. Kidd E, Fejerskov O, Nyvad B. Infected Dentine Revisited. Dent Update. 2015 Nov;42(9):802-9.
3. Mertz-Fairhurst EJ, Curtis JWJ, Ergle JW, Rueggeberg FA, Adair SM. Ultraconservative and cariostatic sealed restorations: results at year 10. J Am Dent Assoc. 1998 Jan;129(1):55-66.
4. Quock RL, Barros JA, Yang SW, Patel SA. Effect of silver diamine fluoride on microtensile bond strength to dentin. Oper Dent. 2012 Nov-Dec;37(6):610-6.
5. Howe PR. A Study of the Microorganisms of Dental Caries. J Med Res. 1917 Jul;36(3):481- 92.5.
6. Crystal YO, Niederman R. Silver diamine fluoride treatment considerations in children's caries management. Pediatr Dent. 2016 Nov;38(7):466-71.
7. Sarvas E. The history and use of silver diamine fluoride in dentistry: A review. J Calif Dent Assoc. 2018 Jan;46(1):19-22.
8. Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: a caries "silver-fluoride bullet". J Dent Res. 2009 Feb;88(2):116-25.
9. Frencken J, Van Amerogen E, Phantumvanit P, Songpaisan Y, Pilot T. Manual for the atraumatic restorative treatment approach to control dental caries. 3rd ed. Groningen: WHO Collaborating Centre for Oral Health Research; 1997.
10. Massara MLA, Bönecker M. Modified ART: why not? Braz Oral Res. 2012 May-Jun;26(3):187-9.
11. Frencken JE, Leal SC. The correct use of the ART approach. J Appl Oral Sci. 2010 Jan-Feb;18(1):1-4.
12. Wright JT, White A. Silver Diamine Fluoride: Changing the Caries Management Paradigm and Potential Societal Impact. N C Med J. 2017 Nov-Dec;78(6):394-7.
13. Seifo N, Robertson M, MacLean J, Blain K, Grosse S, Milne R, et al. The use of silver diamine fluoride (SDF) in dental practice. Br Dent J. 2020 Jan;228(2):75-81.
14. Garg S, Sadr A, Chan D. Potassium iodide reversal of silver diamine fluoride staining: A case report. Oper Dent. 2019 May/Jun;44(3):221-6.
15. Alvear Fa B, Jew JA, Wong ADY. Silver modified atraumatic restorative technique (SMART): an alternative caries prevention tool. Stoma Edu J. 2016;3(2):18-24.
16. American Academy of Pediatric Dentistry. Pediatric restorative dentistry. In: The Reference
Manual of Pediatric Dentistry 2020-2021. Chicago (ILL): American Academy of Pediatric Dentistry; 2020:371-83.
17. Schwendicke F, Frencken JE, Bjørndal L, Maltz M, Manton DJ, Ricketts D, et al. Managing Carious Lesions: Consensus Recommendations on Carious Tissue Removal. Adv Dent Res. 2016 May;28(2):58-67.
18. Jiang M, Wong MCM, Chu CH, Dai L, Lo ECM. Effects of restoring SDF-treated and untreated dentine caries lesions on parental satisfaction and oral health related quality of life of preschool children. J Dent. 2019 Sep;88:103171.
19. Chu CH, Mei L, Seneviratne CJ, Lo EC. Effects of silver diamine fluoride on dentine carious lesions induced by Streptococcus mutans and Actinomyces naeslundii biofilms. Int J Paediatr Dent. 2012 Jan;22(1):2-10.
20. Wakshlak RB, Pedahzur R, Avnir D. Antibacterial activity of silver-killed bacteria: the "zombies" effect. Sci Rep. 2015 Apr; 5:9555. doi: 10.1038/srep09555.
21. Knight GM, McIntyre JM, Craig GG, Mulyani, Zilm PS, Gully NJ. Differences between normal and demineralized dentine pretreated with silver fluoride and potassium iodide after an in vitro challenge by Streptococcus mutans. Aust Dent J. 2007 Mar;52(1):16-21.
22. Mei ML, Ito L, Cao Y, Li QL, Lo EC, Chu CH. Inhibitory effect of silver diamine fluoride on dentine demineralization and collagen degradation. J Dent. 2013 Sep;41(9):809-17.
23. Mei ML, Li QL, Chu CH, Lo EC, Samaranayake LP. Antibacterial effects of silver diamine fluoride on multi-species cariogenic biofilm on caries. Ann Clin Microbiol Antimicrob. 2013 Feb;12:4.
24. Fakhruddin KS, Egusa H, Ngo HC, Panduwawala C, Pesee S, Venkatachalam T, et al. Silver diamine fluoride (SDF) used in childhood caries management has potent antifungal activity against oral Candida species. BMC Microbiol. 2020 Apr;20(1):95.
25. Karched M, Ali D, Ngo H. In vivo antimicrobial activity of silver diammine fluoride on carious lesions in dentin. J Oral Sci. 2019 Mar;61(1):19-24.
26. Koo H. Strategies to enhance the biological effects of fluoride on dental biofilms. Adv Dent Res. 2008 Jul;20(1):17-21.
27. Seto J, Horst JA, Parkinson DY, Frachella JC, DeRisi JL. Enhanced Tooth Structure Via Silver Microwires Following Treatment with 38 Percent Silver Diamine Fluoride. Pediatr Dent. 2020 May;42(3):226-31.
28. Mei ML, Ito L, Cao Y, Lo EC, Li QL, Chu CH. An ex vivo study of arrested primary teeth caries with silver diamine fluoride therapy. J Dent. 2014 Apr;42(4):395-402.
29. Yu OY, Mei ML, Zhao IS, Li QL, Lo EC, Chu CH. Remineralization of enamel with silver diamine fluoride and sodium fluoride. Dent Mater. 2018 Dec;34(12):e344-e52.
30. Mei ML, Nudelman F, Marzec B, Walker JM, Lo ECM, Walls AW, et al. Formation of fluorohydroxyapatite with silver diamine fluoride. J Dent Res. 2017 Sep;96(10):1122-8.
31. Fung MHT, Duangthip D, Wong MCM, Lo ECM, Chu CH. Arresting Dentine Caries with Different Concentration and Periodicity of Silver Diamine Fluoride. JDR Clin Trans Res. 2016 Jul;1(2):143-52.
32. Dos Santos VE, Jr., de Vasconcelos FM, Ribeiro AG, Rosenblatt A. Paradigm shift in the effective treatment of caries in schoolchildren at risk. Int Dent J. 2012 Feb;62(1):47-51.
33. Chibinski AC, Wambier LM, Feltrin J, Loguercio AD, Wambier DS, Reis A. Silver diamine fluoride has efficacy in controlling caries progression in primary teeth: A systematic review and meta-analysis. Caries Res. 2017 Nov;51(5):527-41.
34. Siqueira FSF, Morales LAR, Granja MCP, de Melo BO, Monteiro-Neto V, Reis A, et al. Effect of silver diamine fluoride on the bonding properties to caries-affected dentin. J Adhes Dent. 2020;22(2):161-72.
35. Li Y, Liu Y, Psoter WJ, Nguyen OM, Bromage TG, Walters MA, et al. Assessment of the silver penetration and distribution in carious lesions of deciduous teeth treated with silver diamine fluoride. Caries Res. 2019 Feb;53(4):431-40.
36. Llodra JC, Rodriguez A, Ferrer B, Menardia V, Ramos T, Morato M. Efficacy of silver diamine fluoride for caries reduction in primary teeth and first permanent molars of schoolchildren: 36-month clinical trial. J Dent Res. 2005 Aug;84(8):721-4.
37. Willershausen I, Schulte D, Azaripour A, Weyer V, Briseño B, Willershausen B. Penetration potential of a silver diamine fluoride solution on dentin surfaces. An ex vivo study. Clin Lab. 2015;61(11):1695-701.
38. Greenwall-Cohen J, Greenwall L, Barry S. Silver diamine fluoride - an overview of the literature and current clinical techniques. Br Dent J. 2020 Jun;228(11):831-8.
39. Zhao IS, Chu S, Yu OY, Mei ML, Chu CH, Lo ECM. Effect of silver diamine fluoride and potassium iodide on shear bond strength of glass ionomer cements to caries-affected dentine. Int Dent J. 2019 Oct;69(5):341-7.
40. Lou YL, Botelho MG, Darvell BW. Reaction of silver diamine [corrected] fluoride with hydroxyapatite and protein. J Dent. 2011 Sep;39(9):612-8.
41. Russo M, Komatsu J, Takayama S, Júnior CH, Sundfeld RH, Castro MAM, et al. Saforide: resposta pulpar à sua aplicação em dentina.[Saforide: pulp response to its application in dentin]. Revista de Odontologia da UNESP. 1989;18:27-32. Portugese.
42. Bimstein E, Damm D. Human primary tooth histology six months after treatment with silver diamine fluoride. J Clin Pediatr Dent. 2018 Jan;42(6):442-4.
43. Korwar A, Sharma S, Logani A, Shah N. Pulp response to high fluoride releasing glass ionomer, silver diamine fluoride, and calcium hydroxide used for indirect pulp treatment: An in-vivo comparative study. Contemp Clin Dent. 2015 Jul-Sep;6(3):288-92.
44. Uchil SR, Suprabha BS, Suman E, Shenoy R, Natarajan S, Rao A. Effect of three silver diamine fluoride application protocols on the microtensile bond strength of resin-modified glass ionomer cement to carious dentin in primary teeth. J Indian Soc Pedod Prev Dent. 2020 Apr-Jun;38(2):138-44.
45. Firouzmandi M, Mohaghegh M, Jafarpisheh M. Effect of silver diamine fluoride on the bond durability of normal and carious dentin. J Clin Exp Dent. 2020 May;12(5):e468-e73.
46. Knight GM, McIntyre JM, Mulyani. The effect of silver fluoride and potassium iodide on the bond strength of auto cure glass ionomer cement to dentine. Aust Dent J. 2006 Mar;51(1):42-5.
47. Fröhlich TT, Rocha RO, Botton G. Does previous application of silver diammine fluoride influence the bond strength of glass ionomer cement and adhesive systems to dentin? Systematic review and meta-analysis. Int J Paediatr Dent. 2020 Jan;30(1):85-95.
48. Gupta J, Thomas MS, Radhakrishna M, Srikant N, Ginjupalli K. Effect of silver diamine fluoride-potassium iodide and 2% chlorhexidine gluconate cavity cleansers on the bond strength and microleakage of resin-modified glass ionomer cement. J Conserv Dent. 2019 Mar-Apr;22(2):201-6.
49. Lau L, Quock RL, Wu DI, Harrington DA, Patel SA, Barros JA. Effect of surface preparation and light curing on penetration of silver particles from 38% silver diamine fluoride in dentin of primary teeth: An in vitro evaluation. Am J Dent. 2021 Feb;34(1):44-8.
50. Tonmukayakul U, Arrow P. Cost-effectiveness analysis of the atraumatic restorative treatment-based approach to managing early childhood caries. Community Dent Oral Epidemiol. 2017 Feb;45(1):92-100.
51. Nguyen V, Neill C, Felsenfeld J, Primus C. Potassium iodide. The solution to silver diamine fluoride discoloration? Adv Dent Oral Health. 2017 Jun;5(1):555655.
52. Sayed M, Matsui N, Hiraishi N, Nikaido T, Burrow MF, Tagami J. Effect of glutathione bio-molecule on tooth discoloration associated with silver diammine fluoride. Int J Mol Sci. 2018 Apr;19(5):1322.
53. 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 May;29(3):257-66.
54. Duangthip D, Fung MHT, Wong MCM, Chu CH, Lo ECM. Adverse effects of silver diamine fluoride treatment among preschool children. J Dent Res. 2018 Apr;97(4):395-401.
55. Chu CH, Lo EC. Promoting caries arrest in children with silver diamine fluoride: a review. Oral Health Prev Dent. 2008;6(4):315-21.
56. Crystal YO, Marghalani AA, Ureles SD, Wright JT, Sulyanto R, Divaris K, et al. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Pediatr Dent. 2017 Sep;39(5):135-45.
57. Horst JA, Ellenikiotis H, Milgrom PL. UCSF protocol for caries arrest using silver diamine fluoride: Rationale, indications and consent. J Calif Dent Assoc. 2016 Jan;44(1):16-28.
58. Lin YS, Rothen ML, Milgrom P. Pharmacokinetics of 38% topical silver diamine fluoride in healthy adult volunteers. J Am Dent Assoc. 2019 Mar;150(3):186-92.
59. Vasquez E, Zegarra G, Chirinos E, Castillo JL, Taves DR, Watson GE, et al. Short term serum pharmacokinetics of diammine silver fluoride after oral application. BMC Oral Health. 2012 Dec;12:60.
60. Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Fluorides, Hydrogen Fluoride, and Fluorine. Atlanta (GA): U.S. Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry; 2003.
61. Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological profile for silver. Atlanta (GA): U.S. Department of Health and Human Services, Agency for Toxic Substances and Disease Registry; 1990.
62. World Health Organization (WHO). Silver as a drinking-water disinfectant. Alternative drinking-water disinfectants: bromine, iodine and silver. Geneva (CH): World Health Organization; 2018.
63. Milgrom P, Horst JA, Ludwig S, Rothen M, Chaffee BW, Lyalina S, et al. Topical silver diamine fluoride for dental caries arrest in preschool children: A randomized controlled trial and microbiological analysis of caries associated microbes and resistance gene expression. J Dent. 2018 Jan;68:72-8.
64. 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):510-8.e4.
65. American Academy of Pediatric Dentistry. Policy on the use of silver diamine fluoride for pediatric dental patients. In: The Reference Manual of Pediatric Dentistry 2020-2021. Chicago (ILL): American Academy of Pediatric Dentistry; 2020:66-9.
66. Burgette JM, Weintraub JA, Birken SA, Lewis TA, White BA. Development of a silver diamine fluoride protocol in safety net dental settings. J Dent Child (Chic). 2019 Jan;86(1):32-9.
67. Rivastar. Situations with and without Clinical Site Restoration. [Internet]. Itasca (IL): Riva Star; 2020. Available at: Accessed Oct 05, 2020.
IssueVol 19 (Continuously Published Article-Based) QRcode
SectionReview Article
SARS-CoV-2 COVID-19 Silver Diamine Fluoride Dental Atraumatic Restorative Treatment Silver Fluoride Fluorides Topical Pediatric Dentistry

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Natarajan D. Silver Modified Atraumatic Restorative Technique: A Way Towards “SMART” Pediatric Dentistry During the COVID-19 Pandemic. Front Dent. 2022;19.