Journal of Indian Association of Public Health Dentistry

: 2022  |  Volume : 20  |  Issue : 2  |  Page : 188--192

Dentists' knowledge, attitudes, and professional behavior regarding silver diamine fluoride: A cross-sectional questionnaire study

Jiksha Mehlawat, Charu Mohan Marya, Ruchi Nagpal, Sakshi Kataria, Pratibha Taneja 
 Department of Public Health Dentistry, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India

Correspondence Address:
Jiksha Mehlawat
Department of Public Health Dentistry, Sudha Rustagi College of Dental Sciences and Research, Kheri More, Sector- 89, Greater Faridabad, Faridabad - 121 002, Haryana


Background: Dental caries is a major public health problem and is handled through either treatment or prevention. Unlike other fluoride-based caries preventive agents, silver diamine fluoride (SDF) can simultaneously prevent and arrest coronal and root dentine caries. Aim: The aim of this study is to assess dentists' educational experiences, knowledge, attitudes, and professional behavior regarding SDF use for caries prevention. Methodology: For the cross-sectional survey, a prevalidated questionnaire comprising of 33 questions was being prepared through the Google survey tool of Gmail and was sent to 200 dentists in North India region through Whatsapp groups of different communities or specialties. Data analysis was done using IBM SPSS version 16. Results: The response rate of 63.5% was received from 200 dentists, among which 28.8% were general practitioners and 35.2% were both academic and clinical practitioners. Only 5.6% respondents came up having been very well educated about SDF during Bachelors in Dental Surgery and Master of Dental Surgery in the classroom setting and 3.2% in the clinical setting. There were 14.4% participants who reported that they knew very well about what SDF is used for in dentistry, and 9.6% knew how SDF is used for treatment of tooth hypersensitivity, 24.8% knew how SDF is used to treat dental caries. The attitudes of the dentists toward SDF were positive. SDF use was considered a good treatment alternative for restorations in children with behavioral problems (17.6%), for patients who were medically fragile (12%) or had severe dental anxiety (19%) and strongly agreed to it. Conclusion: Results suggested that the majority of respondents were lacking in knowledge regarding usage of SDF in dentistry.

How to cite this article:
Mehlawat J, Marya CM, Nagpal R, Kataria S, Taneja P. Dentists' knowledge, attitudes, and professional behavior regarding silver diamine fluoride: A cross-sectional questionnaire study.J Indian Assoc Public Health Dent 2022;20:188-192

How to cite this URL:
Mehlawat J, Marya CM, Nagpal R, Kataria S, Taneja P. Dentists' knowledge, attitudes, and professional behavior regarding silver diamine fluoride: A cross-sectional questionnaire study. J Indian Assoc Public Health Dent [serial online] 2022 [cited 2023 Dec 6 ];20:188-192
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Dental caries is one of the most prevalent preventable diseases worldwide, with a prevalence rate of 69%–79%.[1] It is a contagious disease that instigate by acidogenic bacteria using carbohydrates as the source of vigor. Dental cavitation can have a negative consequence on oral health-related quality of life and dental therapy as being confirmed by several studies.[2],[3],[4],[5],[6] Untreated cavitation in teeth are related with pain, eating, drinking, and difficulty sleeping. Simultaneously reduces the confidence to smile, while children in preschool encounter interrupted sleep, increased absence from school and reduced ability to learn which affects children's general health and growth.[7] Therefore, for managing dental caries, evidence-based comprehensive approaches must be developed and implemented.

At present, the various modes of dental caries management include preventive and nonpreventive modalities. The nonpreventive mode of caries management involves cessation and decline in disease progression by mechanical caries removal and restoration of decayed tooth structure, whereas the preventive methods are implemented to prevent the progression of caries and guard the teeth from the state favoring the detrimental effects of oral biofilm. It requires a support structure and patient's cooperation. Preventive measures include nutritional counseling, use of fluoride, antimicrobial agents, and oral hygiene instructions.

The use of preventive fluoride reagents such as sodium fluoride (NaF) due to remineralization and antimicrobial properties for the prevention of dental caries has been recognized long back,[8] and amongst these agents silver diamine fluoride (SDF) has acquired substantial attention recently as a caries-preventive agent of choice. SDF use for tooth sensitivity, with an off-label use in caries management and its marketing with sodium iodide was approved by Food and Drug Administration (FDA) in 2014 and 2018, respectively.[9] Various clinical studies have manifested that the usage of 38% SDF is efficacious in intercepting new coronal caries among primary and secondary dentitions of children. In addition, SDF has appeared to be successful in apprehending coronal caries in deciduous teeth and hence considered to be a replacement treatment option when restorative treatment measures are not feasible. The efficiency of 38% SDF by restricting demineralization and encouraging protection of collagen of demineralized dentine by developing a protective layer in and within the tubules of dentine in vitro was demonstrated by Mei et al.[10]

Ensuring antibacterial action of SDF, it causes blackening of the carious lesions, which is a great concern for the practitioners to satisfy patients' expectations. In addition, evidence suggests that the percentage of arrested cavitated lesions reduced over 2 years after an initial application, proposes the reapplication over time.[11] The application of 38% SDF solution twice a year had a success rate of 84.8% in impeding caries.[12] Moreover, the application of 12% SDF is less effective as compared to 38% SDF solution.[11]

There is not much research carried out in past regarding the education of SDF to the graduates in India. Survey regarding the attitude, knowledge, and experiences of dentists toward SDF would increase the curiosity in this context and also lead to increased use and a pragmatic approach. Hence, the aim of the study was to assess dentists' educational experiences, knowledge, attitudes, and professional behavior regarding SDF.


Ethical clearance and informed consent

Ethical approval was sought from the Institutional Ethical Committee on April 25, 2019. The participants were informed that the survey is voluntary. They were free to quit any time and submission of questionnaire was regarded as consent to participate. Prior to the commencement of the study, information sheet was sent to the participants to provide them the details regarding the survey.

Survey design

It was an open, prevalidated, anonymous, cross-sectional survey which focused on educational experiences, knowledge, attitude, and professional behavior regarding SDF use for caries prevention.

Study participants and sample size

Participants confidentiality and also duplicate enteries were avoided by preventing users same IP address access to the survey twice. The data were collected from May 1st to May 15th, 2019.

The sample size was determined using the following formula:


Validity and reliability

The survey was reviewed by two groups of people. From the expert on question, construction common errors such as confusing, leading or double barreled questions were confirmed and were modified. Before the survey, a pilot test was conducted in which it was forwaded to 10 dentists. The validity of the questionnaire was assessed and the value of Cronbach's alpha reported was 0.76, which was found to be acceptable.

Survey administration

The distribution of questionnaire was over a single sheet only. The data entered in excel sheet were automatically collected from the Google survey from responses.

Survey instrument

A 33-item questionnaire was prepared through Google survey tool of Gmail which was circulated to dentists in the North India region through Whatsapp groups of different communities or specialities of Delhi, Rajasthan, Uttar Pradesh, and Haryana. We chose to distribute the survey through convenience and snow ball sampling routes. The questionnaire survey was designed to be sent through e-mails only, but keeping in concern the lack of time and often usage of Whatsapp application made it a more feasible method for survey.


The questionnaire comprised of three sections.

Section 1: Patient characteristics and educational experiences (Q: 1-10)Section 2: Knowledge assessment (Q: 11-15)Section 3: Attitude and professional behavior (Q: 16-33).

Response rates

The questionnaire was sent to 200 individuals. As planned prior commencing the survey, questionnaires with incomplete responses, apparent errors, and atypical timestamps were considered invalid and excluded. The results of the survey are reported according to the CHERRIES guidelines for reporting the results of internet E-survey.

Statistical analysis

The responses of the study were transferred to the Statistical Package for Social Sciences (SPSS) version 21, IBM Inc. for analysis. Descriptive statistics such as frequency distributions and percentages were computed to provide an overview of the responses.


A total of 127 respondents engaged with the survey, from a total of 200 participants who were contacted, yielding a response rate of 63.5%. Majority of the participants (75.20%) were female with Bachelors in Dental Surgery (BDS) degree. The characteristics of the participants are presented in [Figure 1].{Figure 1}

Educational experiences of the survey showed that only 5.6% of the participants were having been very well educated about SDF during BDS and Master of Dental Surgery (MDS) in classroom setting and 3.2% in clinical setting. Educational experiences of the participants after graduation are presented in [Figure 2].{Figure 2}

Knowledge assessment

Concerning SDF, 5 questions were included in the questionnaire to measure respondents knowledge. Approximately 14.4% respondents reported of having well/very well knowledge about SDF use in dentistry and about 13.6% of the respondents have had well/very well knowledge about the advantages SDF treatment can have over traditional dental treatments. A total of 9.6% knew how SDF is used for treatment of tooth hypersensitivity, 24.8% and 12% knew how SDF is used to treat dental caries among pediatric and adult patients [Figure 3].{Figure 3}

Attitude assessment

The third section included questions regarding the dentists' attitude toward SDF usage [Figure 4]. Among the total, 34.4% participants agreed that infected soft dentin must be removed before applying SDF and SDF treatment is good for arresting caries when it's not possible to restore all lesions in one appointment. A total of 58.4% dentists agreed that SDF can be used to arrest cavitated lesions in enamel, 46.4% and 31.2% dentists in arresting dentinal and root caries lesions. A majority of dentists also agreed that SDF is a good treatment alternative among the children with behavioral issues (40.8%), when patients are medically fragile (41.6%), when patients have severe dental anxiety (36%) and the patients who are undergoing or recently undergone radiation therapy or chemotherapy (32%). SDF was comprehended as good treatment on primary teeth that are in esthetic zone by 11.2% of participants, whereas only 8.8% strongly agreed with SDF treatment on permanent teeth in the esthetic zone.{Figure 4}

When respondents' expectations regarding SDF usage in future were questioned, 21.6% depicted that it would increase a lot and 53.6% that it would increase a little [Figure 5].{Figure 5}

Professional behavior assessment

Regarding the usage of SDF among respondents, 34.4% reported that they never used SDF for treating dental caries in primary teeth, whereas 10.4% used it often in their offices. Almost similar results were reported as 38.4% never used SDF and 8% used it often in their offices for the treatment of permanent teeth [Figure 6].{Figure 6}


Dental caries is one of the most chronic and widespread oral diseases. Dental caries causes severe pain, impaired chewing and nutrition, infection, school/work absences, students with dental pain are three times more likely to have a low grade point average, difficulty sleeping, extensive and expensive dental work which often must be completed under general anesthesia.

Hence, it is mandatory to recognize the effective measures for treating the carious lesions that are causing minimal trauma and least invasive, such as fluoride application, fluoridation of water, and toothpastes containing fluorides.[13] SDF application addresses the acceptability and satisfaction in terms of treatment of carious lesions.

In the present survey, majority dentists reported that they were not at all educated about SDF during the BDS and MDS classes. The results are such since FDA cleared SDF as desensitizing agent in 2014 only and was recognized with breakthrough therapy designation for caries treatment in 2016.[14]

In spite of the poor educational experiences regarding SDF, dentists knowledge through online resources, dental journals/other publications, and dental organizations found to assist in adding the knowledge regarding SDF. Although the participants reported that they knew the usage of SDF in dentistry, few responses were not in accordance with the evidence. Approximately 40% respondents agreed that SDF can be used in the treatment of dentinal lesions. This statement is in agreement with the results of the systematic review conducted by Gao et al.[15] on clinical trials among children in arresting carious lesions using SDF concluded that overall arrested dental caries after SDF treatment was 81%. A systematic review and meta-analysis conducted by Chibinski et al.[16] reported that the results of various studies are in association with present survey that the use of SDF is 89% more effective in controlling/arresting caries than other treatments or placebos.[11],[12],[17],[18],[19],[20],[21],[22],[23],[24]

About the removal of infected dentin prior to applying SDF, participants response was not in accordance with the study carried out by Chu et al.[17] in 2002. The study carried out by Chu et al. reported that there were no statistically significant differences in the mean number of arrested carious tooth surfaces after 30 mos were found between children who had their caries excavated prior to SDF application and those who had not (95% confidence interval = 0.75 to − 1.42) and hence did not support the assumption that caries removal prior to fluoride treatment is advantageous because the bacterial load in the caries lesion is reduced. Whereas in our study, 34.4% agreed that removal of infected dentin is necessary and 39.2% were in neutral response to this statement. According to the evidence, the excavation of carious tissues before SDF application had no significant beneficial effect. However, the use of SDF without caries removal in community-based programs has the advantage of being simple and easily obtaining good cooperation from young children.

In our study, respondents showed a positive response for using SDF among the children with behavioral issues, patients who are medically fragile, those with severe dental anxiety, patients undergoing or recently undergone radiation or chemotherapy. The use of SDF among such patients has evidence in the studies conducted by Nelson et al.[25] in 2016 and in a case report,[26] 2018. Majority of the respondents agreed that SDF is a good treatment for the lesions that are not in the esthetic zone both in primary and permanent dentition, however, a recent study by Crystal et al.,[27] in 2017 found that 68% parents accepted SDF treatment in the posterior teeth and 30% as lesion is present in the anterior teeth.

The present study has various limitations as the survey included the respondents of only very few regions of North India and the results cannot be generalized on all the dentists. The accessibility of dentists with knowledge and experience over 40–50 years may be less with the web applications and might be a lacunae for our study.


SDF is the treatment modality with efficacy to arrest carious lesions. Yet, the knowledge regarding SDF is less, which may be the result of less or no involvement of SDF in the study curriculum. Continuing Dental Education programmes covering the appropriate use, benefits, and barriers of SDF are endorsed to increase the optimal utilization of SDF by dental professionals.

Clinical significance

Increase in the knowledge regarding SDF improves the attitude toward it and the frequency of utilization of this modern proposition might also rise overtime in treating the carious lesions, especially among children. SDF application has an advantage in community-based programs as it is simple and easily obtaining good co-operation from young children.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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