Silver diamine fluoride (SDF) has emerged as a valuable tool for caries arrest, particularly in pediatric and geriatric populations where traditional restorative approaches present challenges. The AAPD updated clinical guidelines provide evidence-based direction for practitioners.

Current Evidence

38% SDF applied biannually achieves caries arrest rates of 70-90% in primary teeth, according to systematic reviews of randomized controlled trials. Higher concentrations and more frequent applications do not significantly improve outcomes while increasing silver staining.

The mechanism involves silver antimicrobial properties, fluoride remineralization effects, and ammonia penetration enhancement. Arrested lesions become hard, dark, and clinically stable.

Patient Selection

AAPD guidelines recommend SDF for: children with extensive caries who cannot tolerate traditional treatment, patients with behavioral or medical management challenges, and as interim therapy before definitive treatment.

Contraindications include silver allergy (rare but possible), active oral ulceration at application sites, and cosmetically sensitive areas where staining is unacceptable to patients and families. Pregnant and breastfeeding patients should postpone elective SDF applications.

Application Protocol

Isolate the treatment area and dry the tooth surface. Apply SDF with a micro-applicator, allowing one minute of contact time before rinsing. Protect adjacent gingiva with petroleum jelly if staining is a concern.

Documentation should include lesion location, SDF concentration used, and post-application photographs. Schedule re-evaluation at 2-4 weeks and plan biannual reapplication for active management.

Communication Matters

Patient and parent education is essential before treatment. The permanent black staining of arrested lesions surprises families who were not adequately prepared. Photographs of expected outcomes facilitate informed decision-making and reduce post-treatment dissatisfaction.