SDF: Let Caries Risk Guide the Decision

Silver diamine fluoride (SDF) is an effective, minimally invasive option for managing active carious lesions. It is simple to apply, requires relatively little chairside time, and can be especially valuable when conventional restorative care is difficult, delayed or not immediately feasible. Evidence-based clinical guidance supports 38% SDF as a nonrestorative treatment option for appropriate carious lesions. (Slayton et al., 2018)

Yet SDF still appears to be under-integrated into routine clinical care.

The bigger question may no longer be:

“Does SDF work?”

It may be:

“Are we identifying the right clients for it?”

That is why SDF should begin with caries risk assessment — not with the bottle.

SCREEN. DISPENSE. ISOLATE. APPLY. PROTECT.

SCREEN

DISPENSE

ISOLATE

APPLY

PROTECT

SCREEN

Let Caries Risk Guide the Decision

Evidence-informed caries management begins by understanding the client, not simply the lesion.

Caries risk assessment considers disease indicators, biological and behavioural risk factors, and protective factors that influence whether caries is likely to develop or progress.

• Active lesions
• Root caries
• Multiple untreated lesions
• Limited treatment tolerance
• Barriers to conventional restorative care
• Delayed access to definitive treatment
• A need for interim disease stabilization
• Challenges to conventional dental treatment

The clinician should consciously ask… Could SDF be appropriate here?

Evidence-based ADA guidance supports considering 38% SDF among nonrestorative interventions for appropriate cavitated carious lesions. (Slayton et al., 2018)

Need to see some case studies? www.centrixdental.com/sdf-clinical

Where Can SDF Make a Difference?

SDF can have value as both a nonrestorative caries-arrest treatment and, in selected cases, an interim disease-stabilization strategy.

Older Adults

Older adults may face increased caries risk because of exposed root surfaces, xerostomia, polypharmacy, reduced dexterity and medical complexity.

Systematic reviews support the effectiveness of SDF for preventing and arresting root caries in older adults. Oliveira et al. examined trials involving 895 older adults, while Grandjean et al. also found evidence supporting SDF for root-caries prevention and arrest in elders. (Oliveira et al., 2018; Grandjean et al., 2021)

It may also be useful when the definitive treatment decision is not yet clear.

For example, a client may present with:

• Recurrent caries around a crown
• Caries near a failing crown margin
• Caries associated with a bridge abutment
• Root caries on a tooth with a questionable prognosis
• Multiple active lesions requiring staged treatment

The immediate question may be:

“Can we arrest or stabilize this lesion while we determine the next step?”

In an appropriate lesion, SDF may provide that interim option.

Long-Term Care and Palliative Oral Care

Residents of long-term care may face mobility limitations, transportation barriers, frailty, cognitive impairment and reduced tolerance for conventional restorative treatment.

SDF has also been studied specifically in institutionalized older adults and nursing-home populations for prevention and management of root caries, supporting its relevance in domiciliary and long-term-care environments.

For an accessible active carious lesion, SDF may provide a minimally invasive way to arrest or stabilize disease where conventional care is not immediately practical.

It may also fit within a palliative oral-care approach when treatment goals focus on comfort, disease stabilization, function and minimizing treatment burden.

An important distinction remains:

SDF arrests caries. It does not treat odontogenic infection or irreversible pulpal disease.

Swelling, uncontrolled pain, abscess or suspected pulpal involvement still require appropriate assessment and management.

Clients With Barriers to Conventional Dental Treatment

Some clients face cognitive, developmental, behavioural, physical or medical barriers that make conventional restorative treatment difficult or poorly tolerated.

Examples may include clients who have difficulty:

• Remaining still for lengthy procedures
• Tolerating local anesthesia
• Tolerating rotary instrumentation
• Managing traditional isolation techniques
• Completing complex or lengthy appointments

SDF can provide another option for disease arrest or stabilization while the clinician develops a longer-term treatment strategy that reflects the client's needs and abilities.

Its minimally invasive application may be particularly relevant for clients who cannot readily tolerate conventional procedures. A systematic review of SDF in children specifically noted its non-invasive and relatively simple application and its potential usefulness for young children and those with special care needs. (Gao et al., 2016)

Pediatric Clients with Extensive Caries

A child with multiple active lesions may require several restorative appointments.

But the lesions scheduled for later appointments do not stop progressing while earlier treatment is being completed.

For suitable lesions, SDF can provide an important interim strategy … Stabilize today while definitive treatment is completed over time.

A systematic review of clinical trials found 38% SDF effective in arresting dentinal caries in primary teeth, with pooled data from the included studies showing a high proportion of active lesions becoming arrested. (Gao et al., 2016)

The same treatment-planning principle can apply to adults with multi-appointment restorative plans.

Rather than asking only:

“Which tooth are we restoring today?”

we can also ask:

“What are we doing today about the lesions that are still waiting?”

Build SDF Into the Treatment Plan

SDF should be documented as an intentional clinical intervention.

The treatment plan should identify:

Why SDF?

What findings from the caries-risk assessment and clinical examination support the decision?

Where?

Which tooth, surface or lesion is being treated?

What is the goal?

Caries arrest? Root-caries management? Interim disease stabilization? Disease control while restorative treatment is delayed?

What happens next?

Reassessment, monitoring, reapplication where indicated, management of risk factors and definitive care when appropriate.

Assessment → Decision → Treatment → Reassessment

SDF should never become a “place it and forget it” treatment.

This fits with both evidence-based nonrestorative caries guidance and risk-based caries management, where lesion treatment remains part of a larger ongoing disease-management strategy.

The CDCP Makes This Even More Relevant

The Canadian Dental Care Plan specifically includes SDF within its covered preventive services.

The current CDCP Dental Benefits Guide, effective April 1, 2026, includes topical application to hard tissue lesion(s) of an antimicrobial or remineralization agent, including SDF, to promote caries arrest.

In all age groups, the current frequency limitation for this service is:

Coverage does not determine treatment. Coverage creates access. Assessment determines appropriateness.

The CDCP's inclusion of SDF makes it even more important that oral health professionals assess caries risk and identify which preventive and therapeutic interventions are appropriate for each client.

And that brings us right back to… SCREEN.

DISPENSE

Once SDF has been selected, prepare only the small amount required for controlled application.

Dispense only what you need into a disposable Dappen dish or mixing well that is stable and not easily tipped. Use caution when handling SDF, as it can stain hard surfaces.

ISOLATE

Create a field that allows the clinician to access the lesion, manage saliva and adequately dry the treatment site.

The isolation approach may vary according to the lesion, the client, the clinical environment and treatment tolerance. The clinician may select from isolation tools such as dry angles, cotton rolls and gauze based on the clinical situation.

Consider the use of a suction mirror to support moisture control while also improving visibility and access to the treatment site.

APPLY

SDF is used in a very small quantity, so controlled placement matters.

Application technique may vary according to lesion size, tooth location, accessibility, client tolerance and clinician preference.

The goal is deliberate placement of SDF on the intended treatment site while minimizing unnecessary contact with surrounding tissues. Only infected lesions turn darker not the adjacent healthy enamel and dentin.

Micro-applicator brushes are an ideal choice for SDF placement because their small tip size helps provide greater control of the liquid, supports precise application to the intended lesion, and reduces the risk of unintended contact with adjacent tooth surfaces and soft tissues.

PROTECT

SDF application does not mean the client's caries-management plan is complete.

The underlying disease process still requires management.

Ongoing strategies may include:

• Professional and home fluoride strategies
• Oral hygiene support
• Dietary counselling
• Biofilm management
• Monitoring the treated lesion
• Reapplication where indicated
• Reassessment of caries risk
• Restorative treatment when appropriate

This reflects a central principle of risk-based caries management: treating an individual lesion should occur within a broader strategy addressing the factors contributing to the client's disease. (Featherstone & Chaffee, 2018)

Coverage is not the driving factor in clinical decision-making. Assessment and clinical need come first. The CDCP also recognizes the importance of ongoing fluoride prevention. Topical fluoride treatment, including fluoride varnish and other eligible topical fluoride treatments, is separately covered under the current Dental Benefits Guide.

For an eligible client, a comprehensive caries-management plan may include SDF to arrest an appropriate active lesion while also incorporating topical fluoride as part of the client's ongoing preventive strategy, according to assessed risk and clinical need.

From Assessment to Armamentarium

The practical questions around SDF matter:

How do I isolate?

How do I apply it?

What applicator should I use?

But those questions come after the most important one:

Who is this treatment appropriate for?

And that is why the clinical workflow begins, and ends, with a simple equation:

SCREEN. DISPENSE. ISOLATE. APPLY. PROTECT.

SCREEN

DISPENSE

ISOLATE

APPLY

PROTECT

Michelle Aubé (Simmonds) RDH, maxill Dental Hygiene Educator

Michelle is a Dental Hygiene Speaker, Consultant and Educator with over 30 years of experience as a RDH and 4 years as a CDA. She is a professor and curriculum writer at Fanshawe College in both the dental hygiene and continuing education program sharing her knowledge in IPAC, professional practice, periodontal classification, social justice, advocacy and clinical applications. She is maxill's CE and IPAC Director and wears various IPAC hats including auditing federal correctional facilities dental clinics for IPAC standards. Michelle is ODHA's Regional Board Director and authors articles for CDHA's OH Canada professional publication and continues to practice clinically in London ON. She is a CDHO IPAC Remedial Facilitator and IPAC Expert Opinion. Her strong ethics has allowed her to serve on the Discipline Committee at Algonquin College and hold the position of a CDHO Quality Assurance Assessor for 7 years. As a lifelong learner she is completing a BA in Adult Education at Brock University. Her diverse dental background and current status as a practicing RDH offer a fulsome and realistic view of dental-related topics. As a passionate champion for the profession, she advocates for equity, professional autonomy, and systemic change, true grassroots leadership at its finest.

Michelle can be reached at [email protected]