Silver Diamine Fluoride: Caries Arrest

Last substantive review: 31 August 2026. Every effect estimate below is quoted from a named, linked source, most of it from a Cochrane review published in November 2024. This page is written for two readers at once: a parent or patient deciding what to ask for, and a clinician who wants the numbers and the protocol. It is not medical or dental advice.

The short answers

• What it is. Silver diamine fluoride (SDF) is a clear liquid — about a third silver nitrate plus a fluoride salt — brushed onto a decayed spot for roughly a minute and left to dry. No needle, no drill, no removal of healthy tooth.
• What it does. It can stop a cavity from progressing. It does not rebuild the hole, tighten a loose filling, or treat an infected nerve. An “arrested” lesion is a lesion that has gone hard, dry and stable — and black.
• How well, according to the best evidence. The 2024 Cochrane review of 29 randomised trials (13,036 participants) found SDF likely prevents new root-surface cavities (moderate-certainty) and may help arrest cavities in baby teeth (low-certainty), while rating much of the rest of the evidence “very uncertain” because the trials were small and at high risk of bias. Older meta-analyses report far higher single numbers — 81% of active lesions arrested (95% CI 68–89%) in one, 51.6% ± 27.4% in another. Both are real; the spread is the honest picture.
• The catch that decides most cases. Arrested decay stains permanently dark brown to black. In a survey of 120 parents, 67.5% found that acceptable on back teeth and 29.7% on front teeth — yet most of those same parents still preferred the stain to sedation or general anaesthesia.
• Money. In the US the billing code is D1354, “interim caries arresting medicament application — per tooth.” In one published snapshot of state Medicaid policy (December 2022), Utah’s listed rate was $6.00 per tooth, primary teeth only. A resin filling is a different code and typically an order of magnitude more. Whether your plan pays, how many times per year, and whether a later filling is clawed back are all plan-specific — this page tells you what to ask, not what you will be charged.

What SDF is, and why it works at all

Silver ions are antimicrobial at strikingly low concentrations — under 50 ppm kills pathogenic organisms — which is why silver nitrate, silver foil and silver sutures were used in surgery, burns, water purification and eye care for a century before anyone thought about teeth. Fluoride, meanwhile, drives remineralisation: it pushes minerals back into softened dentin and makes the surface more acid-resistant. SDF is the marriage of the two, at roughly 44,800 ppm fluoride in the 38% solution used in most trials.

The clinical effect is not “healing”. The silver kills and suppresses the bacteria living in the lesion; the fluoride hardens the demineralised dentin underneath; the organic matrix collapses and seals. The result is a lesion that no longer feels soft or leathery to a probe, no longer advances, and has turned black. That colour change is not a dye that was painted on — it is silver phosphate and silver sulphide forming inside the tooth structure, which is precisely why it cannot be polished off reliably.

Does it work? The evidence, ordered by how much it can be trusted

1. The systematic review you should lead with. Worthington and colleagues published a Cochrane review in November 2024 covering 29 randomised controlled trials and 13,036 participants (12,020 children and 1,016 older adults). Its conclusions are deliberately narrow, and the reason matters: “All studies included high risks of bias, and some findings were imprecise.” Against placebo or no treatment (14 studies, 2,695 children and 905 older adults):

• New root-surface cavities: SDF likely prevents them — mean difference -0.79 surfaces (95% CI -1.40 to -0.17; 3 studies, 439 participants; moderate-certainty). This is the single most solid finding in the SDF literature.
• Arrest of cavities in baby teeth: SDF may help — mean difference 0.86 surfaces (95% CI 0.39 to 1.33; 2 studies, 841 participants; low-certainty).
• Prevention of new cavities in baby teeth and on the crowns of permanent teeth: possible, but “the evidence is very uncertain” (each based on a single study of 373 participants).
• Secondary prevention, adverse effects and aesthetics: “very uncertain” — the aesthetics estimate rested on one study of 43 participants. Read that as: nobody has properly measured what you actually care about.

2. The pooled arrest rates you will see quoted online. A systematic review with meta-analysis of clinical trials in children (Gao et al., JDR Clinical & Translational Research, 2016) screened 1,123 publications down to 19 trials — 16 in primary teeth, 3 in permanent — with 14 studies using 38% SDF, 3 using 30% and 2 using 10%. Pooling 8 studies of 38% SDF on primary teeth gave 81% of active caries becoming arrested (95% CI 68–89%, P<0.001).

A later, more conservative meta-analysis (Zaffarano et al., Int J Environ Res Public Health, 2022) restricted itself to cavitated lesions in primary molars with follow-up longer than six months: 792 papers → 9 studies (2 low risk of bias, 6 moderate, 1 high), 5 studies pooled, moderate heterogeneity (I² = 35.69%, p = 0.18), effect size 0.35 (p < 0.01), and — across 622 arrested lesions out of 1,205 — an arrest rate of 51.62% ± 27.40%, “especially if applied biannually”.

So which number is true? Neither, exactly. 81% is “lesions that became arrested” in a broader set including smooth-surface lesions in 3-to-5-year-olds; 51.6% is “cavitated primary molars with ≥6 months follow-up,” which is the harder case and closer to what a dentist is deciding about in a 6-year-old’s molar. When someone shows you one of these numbers as proof or as hype, ask which lesions, which concentration, and what interval.

3. Direct comparison with fluoride varnish. In the same 2024 Cochrane review, across 8 studies (2,868 children, 223 older adults), SDF versus fluoride varnish for preventing new cavities in primary teeth showed little or no difference (MD 0.00, 95% CI -0.26 to 0.26; 1 study, 434 participants; low-certainty). An older systematic review (Rosenblatt et al., J Dent Res, 2009) reported much more dramatic numbers — SDF’s lowest prevented fraction for arrest 96.1% versus varnish’s highest 21.3%, with numbers-needed-to-treat of 0.8 (95% CI 0.5–1.0) for SDF arrest versus 3.7 (3.4–3.9) for varnish — but it is important to know why: of 99 human clinical trials identified from 1966–2006, only 2 met its inclusion criteria. That is a finding about the state of the literature in 2009, not a fair fight between two materials, and it should be cited as such.

4. Root cavities in older adults — the quiet success story. A systematic review in Gerodontology (2017) found three RCTs, all on root caries, none on crown caries, and reported prevented fractions of 71% (3-year study) and 25% (2-year study) for prevention versus placebo, with arrest results favouring SDF at 24 and 30 months, and no severe adverse effects. An umbrella review (Seifo et al., BMC Oral Health, 2019) gathered 11 systematic reviews citing 30 studies and reported root-caries prevention 25–71% better than placebo and coronal arrest rates of 65–91%. It also states the methodological problem plainly: study overlap across reviews was very high (corrected covered area 0.50 for root caries, 0.17 for coronal), and “high overlap and heterogeneity … precluded meta-analysis.” Which is to say: much of the confident SDF literature is the same handful of trials re-counted in different jackets.

Evidence at a glance

Source (year)	Design and size	What was measured	Headline result	What limits it
Worthington, Cochrane (2024)	29 RCTs, 13,036 people	Prevention, arrest, adverse effects, aesthetics vs placebo / vs varnish	Root-caries prevention MD -0.79 surfaces (moderate); primary-tooth arrest MD 0.86 (low); much else very uncertain	All trials at high risk of bias; aesthetics from 1 study, n=43
Gao (2016)	19 trials of 1,123 screened	Arrest of active lesions in children	81% arrested (95% CI 68–89%) with 38% SDF, 8 studies	Mixed lesion types; heterogeneous protocols
Zaffarano (2022)	9 studies, 5 pooled, 1,205 lesions	Cavitated primary molars, ≥6 months	51.62% ± 27.40% arrest; better biannually	Only 2 studies low risk of bias
Duangthip (2018)	RCT, 888 preschoolers, 4 regimens	Adverse effects and parental satisfaction	No acute systemic illness or major adverse effect; pain 6.6%, swelling 2.8%, bleaching 4.7%; blackening 36.7–76.3% by group	Parent-reported outcomes; 30-month horizon
Chu (2002)	RCT, 375 children aged 3–5	Arrested surfaces: SDF annual vs NaF varnish quarterly vs control	Mean arrested surfaces 2.5 / 2.8 vs 1.5 / 1.5 vs 1.3 (p<0.001)	Anterior primary teeth; single setting; 44,800 ppm F
Crystal (2017, JADA survey study)	Cross-sectional survey, 120 parents	Acceptance of staining	67.5% acceptable posterior vs 29.7% anterior; most preferred stain to sedation/GA	Photographs, not their own child; one US region
Seifo (2019)	Umbrella review, 11 SRs, 30 studies	Direction and magnitude across reviews	Coronal arrest 65–91%; root prevention +25–71% vs placebo; no serious adverse events	Could not meta-analyse (overlap, heterogeneity)

For clinicians: indications, protocol, documentation

Where the guideline sits. The American Academy of Pediatric Dentistry guidance (Crystal et al., Pediatric Dentistry, 2017) is a conditional recommendation, GRADE-assessed, for using 38% SDF to arrest cavitated lesions in primary teeth as part of a comprehensive caries-management programme — not as a standalone application, and the low cost was an explicit input to the decision. The ADA’s own position material frames SDF as requiring diagnosis and monitoring by a dentist, with a patient-specific plan, informed consent covering alternatives and the staining, and delegation to trained allied personnel only within state scope-of-practice law.

Regulatory reality in the US. SDF is cleared by the FDA as a Class II device for dentin hypersensitivity; using it for caries arrest is off-label and, as the UCSF protocol paper (Horst et al., J Calif Dent Assoc, 2016) states, permissible and appropriate under US law. The same paper notes a CDT code for caries-arresting medicaments was approved for 2016 specifically so the service could be documented and billed. As of 2023 the ADA lists only two commercially available dental SDF products in the US — Advantage Arrest (Elevate Oral Care), which received FDA breakthrough device designation in 2016 for caries arrest in children and adults, and Riva Star (SDI).

Application, as the trials and protocols describe it. Isolate and control moisture; gently remove plaque and loose soft debris from the lesion (several trials left dentin intact; the Chu 2002 arms differed on exactly this and it is still debated); dry; apply 38% SDF to the lesion with a microbrush for about a minute; blot; protect lips and gingivae with a barrier such as petroleum jelly before application and remove the excess afterwards; give the patient a written description of the expected colour change. Follow-up re-examination at roughly 6–8 weeks to document arrest (hardness, no progression) and reapply as indicated. The evidence on frequency points to repeated, biannual application for sustained benefit — the ADA says so explicitly, and Zaffarano’s data favoured biannual over annual. The Cochrane review’s more humbling line for protocol design: with five studies comparing concentrations, intervals and durations, “we could not combine findings … we were unsure whether any approach to SDF application was better than another.” There is no evidence-based “best regimen” — only conventions with plausible reasoning.

Case selection. Favours SDF: cavitated lesions in primary teeth near exfoliation; patients whose medical status makes sedation or lengthy restorative care undesirable; root caries in older or care-home patients (the strongest single finding in the Cochrane set); uncooperative young children; interim control of active lesions while a definitive plan is arranged; patients without access to care. Argues against: lesions where occlusal function or aesthetics dominates; cavities with pulpal symptoms or swelling; a patient who will not accept the colour and will notice it; and — a point that gets missed — a tooth where the “arrest” would only postpone a restoration that is already indicated by the amount of remaining tooth.

Documentation that survives an audit. Pre-op photos with a shade reference; lesion number, surface, baseline texture and probing findings; the specific alternatives discussed (restoration, extraction, fluoride varnish, sealant, surveillance, no treatment) and the reason SDF was chosen; explicit consent language on permanent staining, possible gingival tattoo, the need for continued monitoring, and that arrest is not repair; re-evaluation date and findings at each review; and the CDT code with tooth numbers on the claim — one tooth number per D1354 line, because claims with tooth ranges are routinely rejected.

The stain: the part that actually decides the treatment

Practically every review reports the same adverse finding, and it is not an adverse event in the pharmacological sense — it is an aesthetic one. Of the eleven systematic reviews in the 2019 umbrella review, eight reported adverse events and seven of those eight reported black staining of arrested lesions. The ADA calls the staining permanent. Temporary grey marks on gingiva or skin (gingival tattoo) can occur if the solution contacts soft tissue.

What parents do with that information is more interesting than the stain itself. In the JADA survey of 98 mothers and 22 fathers of children with caries experience (Crystal et al., 2017), 67.5% judged staining on posterior teeth aesthetically tolerable, versus 29.7% for anterior teeth (p<0.001) — and although anterior staining was disliked, most parents still preferred it to advanced behavioural management techniques such as sedation or general anaesthesia. If you are a parent reading this at 11pm, that is the trade in one sentence: a black front tooth in a child whose baby teeth will be lost anyway, versus a sedation appointment.

There is a widely shared workaround: potassium iodide (KI) applied after SDF to convert the chromophore and lighten the surface. The clinical literature supporting it in humans is thin — the reversal protocol is published as a case report (Garg et al., Operative Dentistry, 2019) describing the technique, not as a trial showing durable, predictable results with no effect on arrest. Treat it as an operator preference to discuss, not as a solution to the stain. If aesthetics dominates the decision, the honest answer is a different treatment.

Safety, in numbers rather than adjectives

The most directly relevant safety dataset is a randomised trial designed around adverse effects (Duangthip et al., J Dent Res, 2018): 888 preschool children with active dentin caries were allocated to 12% SDF annually, 12% SDF semiannually, 38% SDF annually, or 38% SDF semiannually, with 799 children (90%) remaining at 30 months. Parents were questioned within a week of each application. Findings:

• No acute systemic illness and no major adverse effect reported in any group.
• Tooth or gum pain as perceived by patients and reported by parents: 6.6% overall.
• Gum swelling: 2.8%. Gum bleaching: 4.7%.
• No statistically significant differences between the four regimens for any minor adverse effect (p>0.05) — but the dose-dependence of the aesthetic outcome was stark: lesions turning black in 36.7% / 49.5% / 65.6% / 76.3% of groups 1–4 respectively.

The 2024 Cochrane review was unable to say much about adverse effects at all (“the evidence is very uncertain”, 5 studies, 1,299 participants), which is itself the finding: safety reporting in SDF trials is poor, not alarming. The umbrella review concluded “no serious adverse events were reported.” On the specific worries patients raise: silver allergy or sensitivity is rare but worth disclosing before application; pregnancy and lactation are not covered by the paediatric and older-adult trials above (the Utah fee-schedule note even flags an age-limit override for pregnant members — a coverage signal, not a safety study); and there is no evidence base for children under the ages in these trials. If you are considering a home-applied product, note what the trials did not test: self-application, non-standard concentrations, unmonitored intervals, and no baseline diagnosis.

Cost and insurance in the United States: what to actually ask

The CDT code is D1354 — “interim caries arresting medicament application, per tooth”, defined as conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries-arresting or -inhibiting medicament, without mechanical removal of sound tooth structure. It is not brand-specific. D1355 exists for related soft-tissue application.

Coverage is state-by-state, contract-by-contract, and it changes; here is what published policy documents show, with dates attached so you can see how old the numbers are:

• Utah Medicaid, in a December 2022 compiled state-policy table: D1354 listed at $6.00 per tooth, primary teeth only, with an age-limit override noted for pregnant members; fluoride varnish (D1206) listed at $17.87 for high-risk patients. Current rates and eligibility live in the state fee schedule — verify before you plan around $6.
• Connecticut (provider bulletin, effective November 2022): $28.42 per tooth for child and adult; primary teeth once every four months until exfoliation; permanent teeth once per tooth every four months, maximum six applications per lifetime, more only with prior authorisation; prior authorisation otherwise no longer required; dentists only; explicitly not approved as a generalised fluoride treatment; and if the same provider restores the tooth within three months, the D1354 fee is recouped and applied to the restoration.
• New Mexico (supplement effective 1 October 2024): covered for Medicaid-eligible members, no prior authorisation required, up to 5 teeth per claim, maximum two treatments per tooth per 12 months, four per tooth lifetime, with a documented comprehensive dental exam required.
• Louisiana Adult Waiver dental programme (fee schedule effective 21 April 2025): D1354 at $14.63 per tooth, reimbursable every six months, four times per tooth lifetime, extendable if caries risk is high or extremely high, limited to SDF.
• How wide is coverage at all? An AAPD survey from April 2017 found 37% of state Medicaid dental plans reimbursed the procedure — the ADA has since passed a resolution that SDF should be a covered benefit by third-party payers, and that if the tooth later needs a restoration or extraction, those should remain covered too.

Six questions that convert this from an argument into a plan. Ask the person at the insurance counter, not the front desk: (1) Is D1354 a covered benefit for this member, and for which ages and tooth types? (2) How many applications per tooth per year, and is there a lifetime maximum? (3) Is prior authorisation or a written exam note required? (4) If the tooth is restored within 90 days, is the D1354 denied or recouped? (5) Does my annual maximum apply, and does this code count as preventive (which is often paid at 100% and outside the deductible) or basic? (6) If I use a dental-school or public-health clinic, what is the self-pay fee for the same code?

For the last question there are genuinely cheap settings. Dental-school and student clinics are where SDF and sealants happen in volume, because that is what the evidence supports and teaching is the point — in Utah, the two dental programmes people search for are the University of Utah College of Dentistry and Roseman University of Health Sciences. Public-health and community clinics, including FQHCs, may also bill the code (New Mexico’s guidance explicitly describes FQHCs billing D1354 on a UB-04 institutional claim as part of the encounter).

Who should choose this, and who shouldn’t

Reasonable fit. A 3-to-8-year-old with several cavitated lesions who will not tolerate restorative care, where the teeth will exfoliate within a few years. A patient with a serious medical condition, or one on sedating medication, for whom a dental visit under general anaesthesia carries real risk. An older adult with exposed, decayed root surfaces and dry mouth. A person between plans, between states, or between appointments whose only realistic option is “do nothing for a year”. A child whose parents refuse or cannot reach restoration.

Poor fit. A tooth that hurts spontaneously, wakes you at night, or has a swelling — those are pulp and infection problems that a topical medicament cannot touch. A front tooth in an adult who will see it in the mirror every day. A lesion in a permanent tooth where the operator can and will do a proper restoration, because the “arrest” may simply delay a needed repair while removing the diagnostic signal. And anyone who has been told the stain “will wash off”: it will not.

What the evidence does not support

• It does not restore a broken tooth, and it is not a substitute for a restoration where one is indicated by the remaining tooth structure.
• Arrest is not cure. Lesions need re-examination, and the trials followed patients for months to a few years, not decades.
• There is no reliable evidence that SDF prevents cavities in permanent teeth in children — the Cochrane review calls exactly this outcome “very uncertain”, as it does for prevention in primary teeth.
• No trial regimen has been proven superior: concentrations from 10% to 38%, and annual versus semiannual schedules, could not be meaningfully compared.
• Claims that SDF is “as good as a filling”, or “useless”, are both reading one number out of a spread of 51.6% to 81% and dropping the confidence intervals.
• The aesthetic and acceptability evidence is thin in absolute terms — one 43-participant study inside the Cochrane set and one survey of 120 parents. That is the whole base.

Frequently asked questions

Does it hurt?

The application itself is not painful — nothing is drilled and no injection is given. The 2018 adverse-effects trial recorded tooth or gum pain reported by parents in 6.6% of cases across all groups, and gum swelling in 2.8%.

How long does the appointment take?

Minutes. Plan on isolation, a one-minute application, and cleanup; and on a follow-up visit in six to eight weeks, which many patients skip and which is the part that makes the treatment defensible.

Can my child eat afterwards?

Clinics typically advise waiting 30 minutes to an hour before eating or drinking, avoiding the treated teeth for the rest of the day, and no brushing of those teeth for 24 hours. Follow the instructions your own clinic gives you.

Does the black stain come off?

On the lesion, no — the ADA describes it as permanent. Teeth whitening does not fix it, and it does not spread to healthy tooth structure. Marks on skin or gum from splashed solution can persist as a tattoo, which is why a barrier is used.

Can they put tooth-coloured material over it?

Some operators seal an arrested lesion with a glass-ionomer or composite, or use the KI lightening step; the evidence base for those add-ons is much thinner than for arrest itself, and it changes the cost and the code.

Is this just fluoride?

No — and insurers treat them as different services: D1206 is fluoride varnish, D1354 is the caries-arresting medicament. Fluoride varnish is the better prevention choice across a whole mouth; SDF is the better lesion-arrest tool for a specific active cavity. Cochrane found little or no difference between them for new-cavity prevention in primary teeth (MD 0.00).

Can I buy it online and do it myself?

Products are sold direct. The trials were all clinician-applied, with a diagnosis, a baseline exam and follow-up — and the ADA’s position requires dentist diagnosis and monitoring. Buying a bottle moves you out of the evidence base and into an unmonitored DIY experiment with a permanent staining risk. This is the one place where “cheap” becomes expensive.

Does Medicaid cover it?

Many state programmes do, with conditions on age, tooth type and frequency — in Utah’s 2022 compiled policy the code was listed at $6.00 per tooth for primary teeth only. Coverage is not the same as a good fit: ask the six questions above before you assume.

Does it work on adult teeth?

On adult root surfaces it is where the evidence is strongest (moderate certainty, MD -0.79 surfaces for prevention; prevented fractions of 25–71% versus placebo). On adult crown cavities, the evidence is thin and the Cochrane verdict is “very uncertain”.

Will my insurance pay for the filling afterwards anyway?

Often yes — and the ADA has explicitly resolved that if a tooth treated with SDF later needs restoration or extraction, that should remain a covered benefit. Watch for plans that recoup the arresting fee if the same provider restores within 90 days (Connecticut’s rule did exactly that).

Is it safe during pregnancy?

The trials above enrolled children and older adults; pregnancy is not represented in the evidence I reviewed, so the honest answer is “not established — discuss it with your dentist and obstetric provider”, with the caveat that untreated dental infection in pregnancy is also not benign. State programmes sometimes override age limits for pregnant members; that is a coverage decision, not safety evidence.

What if it doesn’t arrest?

Then you have lost a short appointment, not the tooth — progression means the lesion is re-evaluated and treated properly, and a failure to arrest is itself diagnostic information about caries risk, diet frequency and fluoride exposure.

Is this a “wellness” treatment?

No. It is an evidence-supported, guideline-recommended, monitored clinical intervention with a documented trade-off. Be suspicious of any office selling it as a non-medical ritual, and of any price that does not include the follow-up exam.

Mini-glossary: patient words ↔ clinical words

• “a hole” ↔ cavitated lesion — the surface has broken down; this is the point where arrest becomes a real decision rather than a default.
• “stopped / stable” ↔ arrested — hard, dry, non-progressive on probing, usually dark.
• “it will fall out anyway” ↔ exfoliation — the reason anterior-posterior and age judgments change the answer.
• “how many people need it for one to benefit” ↔ number needed to treat (NNT); in the 2009 review SDF arrest was 0.8 (95% CI 0.5–1.0) — treat that as a red flag about the underlying data rather than a miracle.
• “how much better than doing nothing” ↔ prevented fraction (PF); root-caries prevention 25–71% in the umbrella review.
• “how sure are we?” ↔ certainty of evidence (Cochrane/GRADE language): high → moderate → low → very uncertain. Most SDF findings sit at low or very uncertain, and that is the sentence people omit.
• “approval paperwork” ↔ prior authorisation; the fee-schedule line is a CDT code, D1354, per tooth.
• “the money cap” ↔ annual maximum; arrest applications may or may not count against it depending on whether your plan calls them preventive.

Alternatives, because the honest page lists them

• Definitive restoration (composite, stainless-steel crown, glass ionomer): the reference option; higher cost, higher skill and behaviour requirements, and no staining, but the tooth is rebuilt.
• Fluoride varnish every 3–6 months: better-supported for whole-mouth prevention, no staining, weaker on a specific cavitated lesion; the Cochrane comparison found little difference for prevention in primary teeth.
• Sealants (D1351) on pits and fissures of newly erupted permanent molars: strong preventive evidence, commonly covered for children — a different problem from an existing cavity, but the right answer for many 6-year-olds.
• Atraumatic restorative treatment (ART): hand-instrument excavation plus a glass-ionomer restoration; the umbrella review lists it among comparators that SDF outperformed for arrest, and it is a middle path where a restoration is possible but a drill is not.
• 10% or 12% SDF, silver diammine fluoride variants, KI co-application, casein phosphopeptide products: all present in the literature with varying and thin evidence; the trial data above shows the 12% regimens stained less and worked, broadly, less predictably.
• Diet and fluoride exposure (frequency of sugar and acid, brushing with a fluoride toothpaste and spit-not-rinse, a glass of water after medication): unglamorous, free, and the thing that decides whether the next lesion arrives. No SDF programme in the trials was run without it.
• Watchful waiting with re-examination for a lesion that may already be arrested: legitimate, and cheaper than either treatment — but only if someone actually re-examines.

How this page was built, and what it cannot tell you

Sources were selected by working down the evidence hierarchy: a Cochrane systematic review of randomised trials (2024), an umbrella review of systematic reviews (2019), two meta-analyses of clinical trials (2016, 2022), a randomised trial designed to capture adverse effects (2018), the primary RCT most often cited in this field (2002), the guideline documents that translate it (AAPD 2017, ADA position material), and, for the aesthetic and billing sections, a parental-acceptability survey (2017) and public payer policy documents with their effective dates. Bibliographic data — authors, journal, volume, pages, DOI — was pulled programmatically from Europe PMC and each PMID was checked rather than quoted from memory; a full list with DOIs is below, and every figure in this page can be traced to one of them.

What it cannot tell you: whether your tooth is arrestable (that needs an exam and radiographs), what your plan will pay (rules change; the Utah figure here is a December 2022 compiled table), whether your child will be teased about a black front tooth (no trial measures that), and what happens over ten years (no SDF trial follows patients that long). If you want the short clinical version: this is a low-cost, low-risk, imperfectly-evidenced way to stop decay that would otherwise go untreated or require sedation, and it deserves a proper diagnosis and a follow-up appointment — the two things most often skipped.

This article summarises published research for information only. It is not medical or dental advice and does not replace an examination by a licensed dentist. Seek urgent care for facial swelling, fever, difficulty swallowing or breathing, or uncontrolled pain.

Sources

Peer-reviewed evidence

• Worthington HV, Lewis SR, Glenny AM, Huang SS, Innes NP, O’Malley L, Riley P, Walsh T, Wong MCM, Clarkson JE, Veitz-Keenan A. Topical silver diamine fluoride (SDF) for preventing and managing dental caries in children and adults. Cochrane Database Syst Rev 2024-11-01;11():CD012718. doi:10.1002/14651858.cd012718.pub2 · PMID 39508296 · PMCID PMC11542151
• Seifo N, Cassie H, Radford JR, Innes NPT. Silver diamine fluoride for managing carious lesions: an umbrella review. BMC Oral Health 2019-07-01;19(1):145. doi:10.1186/s12903-019-0830-5 · PMID 31299955 · PMCID PMC6626340 · open access
• Gao SS, Zhao IS, Hiraishi N, Duangthip D, Mei ML, Lo ECM, Chu CH. Clinical Trials of Silver Diamine Fluoride in Arresting Caries among Children: A Systematic Review. JDR Clin Trans Res 2016-10-01;1(3):201-210. doi:10.1177/2380084416661474 · PMID 30931743
• 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 2022-10-01;19(19):12917. doi:10.3390/ijerph191912917 · PMID 36232217 · PMCID PMC9566773 · open access
• Duangthip D, Fung MHT, Wong MCM, Chu CH, Lo ECM. Adverse Effects of Silver Diamine Fluoride Treatment among Preschool Children. J Dent Res 2018-04-01;97(4):395-401. doi:10.1177/0022034517746678 · PMID 29237131
• Chu CH, Lo EC, Lin HC. Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children. J Dent Res 2002-11-01;81(11):767-770. doi:10.1177/0810767 · PMID 12407092
• Crystal YO, Janal MN, Hamilton DS, Niederman R. Parental perceptions and acceptance of silver diamine fluoride staining. J Am Dent Assoc 2017-07-01;148(7):510-518.e4. doi:10.1016/j.adaj.2017.03.013 · PMID 28457477 · PMCID PMC6771934
• Hendre AD, Taylor GW, Chávez EM, Hyde S. A systematic review of silver diamine fluoride: Effectiveness and application in older adults. Gerodontology 2017-12-01;34(4):411-419. doi:10.1111/ger.12294 · PMID 28812312
• Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: a caries “silver-fluoride bullet”. J Dent Res 2009-02-01;88(2):116-125. doi:10.1177/0022034508329406 · PMID 19278981
• Crystal YO, Marghalani AA, Ureles SD, Wright JT, Sulyanto R, Divaris K, Fontana M, Graham L. Use of Silver Diamine Fluoride for Dental Caries Management in Children and Adolescents, Including Those with Special Health Care Needs. Pediatr Dent 2017-09-01;39(5):135-145. doi:10.1080/19424396.2018.12221981 · PMID 29070149
• Crystal YO, Niederman R. Evidence-Based Dentistry Update on Silver Diamine Fluoride. Dent Clin North Am 2019-01-01;63(1):45-68. doi:10.1016/j.cden.2018.08.011 · PMID 30447792 · PMCID PMC6500430
• Horst JA, Ellenikiotis H, Milgrom PL. UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications and Consent. J Calif Dent Assoc 2016-01-01;44(1):16-28. doi:10.1080/19424396.2016.12220962 · PMID 26897901 · PMCID PMC4778976
• Garg S, Sadr A, Chan D. Potassium Iodide Reversal of Silver Diamine Fluoride Staining: A Case Report. Oper Dent 2019-05-01;44(3):221-226. doi:10.2341/17-266-s · PMID 31046649

Guidelines, billing and payer documents

• American Dental Association. Silver Diamine Fluoride (Oral Health Topics, ada.org; page dated 19 Sept 2023) — FDA Class II clearance for dentin hypersensitivity, off-label status for caries arrest, Advantage Arrest breakthrough designation, biannual application, permanent staining, dentist diagnosis/monitoring, resolution on coverage. ada.org
• American Academy of Pediatric Dentistry. Use of SDF for Dental Caries Management in Children and Adolescents, Including Those with Special Health Care Needs. Pediatr Dent 2017;39(5):135-145 (guideline; PMID 29070149).
• Maryland Medicaid dental state-policy compilation. Silver Diamine Fluoride — state policy table, updated 12/07/2022 — Utah line: D1354 $6.00, primary teeth only, age-limit override for pregnant women; D1206 $17.87 high-risk. medicaiddental.org (PDF)
• New Mexico Health Care Authority. Supplement: Silver Diamine Fluoride D1354, effective 1 Oct 2024 — coverage, no prior authorisation, 2 treatments/tooth/12 months, 5 teeth per claim, 4 per tooth lifetime. hca.nm.gov (PDF)
• Connecticut DSS provider bulletin pb22_73, effective 1 Nov 2022. 2022 Dental Fee Schedule Update for CDT D1354 — $28.42/tooth, intervals, 6 applications/tooth lifetime, recoupment if restored within 3 months. ctdssmap.com (PDF)
• Louisiana Medicaid. Adult Waiver Dental Program Fee Schedule, effective 21 Apr 2025 — D1354 $14.63/tooth, per 6 months, 4×/tooth lifetime. lamedicaid.com (PDF)
• DrBicuspid. Can dental hygienists apply and bill insurance for SDF? (2023) — D1354 definition, one tooth number per line, scope-of-practice notes. drbicuspid.com

Bibliographic details (authors, journal, volume, pages, DOI, PMID) were retrieved programmatically from Europe PMC for each record above; payer figures are quoted from the cited public policy documents with their effective dates and must be verified against the current schedule before you rely on them.