Answers to 17 of Your Silver Diamine Fluoride Questions

Silver diamine fluoride (SDF) has been widely recognized as an effective noninvasive tool for the prevention and management of dental caries. And it has proven to be an invaluable treatment during the COVID-19 pandemic.

As noninvasive dentistry continues to rise in popularity, CareQuest Institute of Oral Health dedicated its latest webinar to an exploration of SDF. Our expert panel explored the science behind SDF, best practices for use today and in the future, and the challenges of incorporating it into practice.

And we received lots (and lots) of questions — both before and during the show.

Because the show was only 60 minutes, our clinical experts — Jeremy Horst Keeper, DDS, PhD, director of clinical innovation at CareQuest Innovation Partners and Sharity Ludwig, EPDH, MS, director of alternative care models at Advantage Dental Oral Health Center and Affiliated Practices — didn’t have time to answer all, or even most, of the questions.

As a bonus for webinar participants and a resource for anyone interested in SDF, here, Jeremy and Sharity answer 17 questions on SDF:

1. What are the risks related to SDF?       

The short-term taste and smell can be off-putting. They go away with a little water on the tongue or, preemptively, you can add a smear of toothpaste on the tongue or gauze that is used to keep the area dry. The main side effect is that any porous tooth structure (caries or hypomineralization), will stain black. If SDF comes into contact with skin, it will cause a small dark spot that will go away on its own in 1-2 weeks. If it comes into contact with existing white fillings, it might stain the margins if they are open. And if a filling is placed the same day, it will probably stain. Lastly, note that the most severely sensitive patients might not want to be treated a second or third time.

2. Is SDF recommended once a year or twice a year? And how would one in private practice code this?

Based on my practice, for frequency, I align this with caries. If moderate risk, I’d suggest two times per year. If high risk, at least two times per year, but I will see them four times per year and use either SDF or alternate with PVP-Iodine in conjunction with fluoride varnish. For coding, it is dependent on the intended use of the SDF. If it’s for prevention, D1355 or D1208, as the lesion isn't yet cavitated. If there is breakdown in the tooth structure, then I would use D1354.

3. Are most insurances reimbursing for SDF now?        

Most insurance plans reimburse dental teams for treatment using D1354. The CDT code for prevention in healthy surfaces by tooth, D1355, just launched in 2021. D1208, for full mouth prevention should be, is almost always, reimbursed.

4. At my Indian Health clinic, SDF is not a covered procedure according to MediCal. This makes it difficult to provide the service to our community, as SDF is quite costly to buy. My clinic doesn't want to do procedures that are not covered by insurance. Most of our patients cannot or will not afford payment for SDF. Any thoughts?  

Many tribes have chosen to pay for SDF for many reasons. In IHS clinics dependent on Medicaid, the best step is to reach out to the Medicaid state dental director directly and let them know the need.

To address patients that cannot and will not pay for non-covered services: As a provider, it is our responsibility to inform the patient of their options, considering their wants, needs, and desires. Can the organization come up with a cost-effective plan that may be more accepted by patients? For example, I have heard of offices charging a one-time set fee for SDF treatments up to four visits. Also, can you have your business office figure out what cost per visit is and have the fee be a break-even dollar amount to just cover costs? Not all patients will accept, but if at least one or a few do, you’re helping them to make a difference in their oral health.

5. What is the evidence for the use of SDF as a preventative for older adults? Would you recommend it as part of a prevention protocol for adults with dry mouth?  

The evidence is strong, at 60%. (See more in CareQuest Institute’s newest infographic on SDF). I always find it interesting when providers ask me about use on adults. From my perspective, we know it is more effective then fluoride varnish, so why not use it? In my experience, it comes down to the esthetic aspect of SDF, so I approach it with patients regardless of age. I start by asking what is important to the patient for their oral health and present options that align. 

6. What are the supervision restrictions for placement of SDF in Florida (or any state)?  Can a hygienist place in a mobile dental setting without a dentist present?

You can find state-specific and supervision information in this helpful resource from the American Dental Hygienist Association. There’s also a very helpful infographic, “Application of Silver Diamine Fluoride (SDF) by Dental Hygienists,” about scope of practice from the Oral Health Workforce Research Center.

7. Does application of SDF have any effect on bondability of the remineralized tooth structure to composite if a filling is placed later in the future?          

No, not from my experience. If you rinse before bonding, you can do so to maximum strength immediately (but wait at least one minute to allow soaking in). A same-day composite will stain, though. After a week, there won’t be a problem.

8. Can you consider the stain to be a good thing for posteriors, for example, to show that the SDF is working?

Absolutely! That is what I share with my patients to put a positive spin on it.

9. When looking at bitewings, when would SDF be recommended for an interproximal lesion as compared to fluoride varnish? Should the lesion be into the dentin? Halfway through the enamel? Or some other indicator?         

SDF can be considered for the treatment of a caries lesion at any stage before irreversible pulpitis. Although SDF clinical trials have focused on prevention of new lesions and treatment of cavitated lesions, I think it is fair to assume that the greater efficiency and effectiveness of SDF over fluoride varnish for prevention could also translate to treatment of non-cavitated lesions (for example, enamel lesions). Of course, the side effects are long-term stain, short-term taste, and smell. If there’s no visible cavity, there won’t be stain.

10. Should we use SDF instead of sealants for prevention?     

You should make the determination with your patients, but it is about 20 times more cost effective to use SDF than sealants. Per tooth, SDF is about 60% preventive fraction while sealants are about 70%. Considering material and time, SDF is the more cost-effective preventive treatment.  

11. How can you tell if the caries risk has been lowered vs. the lesion being arrested?       

Speaking to caries risk, I mentioned the risk assessment used for the clinical algorithms was focused on the clinical presentation of the teeth. As changes in the teeth occurred, you would see a change in risk level. In my experience in working with dentists, arrest varies to some degree, but dark, hard, glassy appearance are common terms shared by dentists.

12. How do you use SDF preventively? Do you place it on all teeth?  

Focus on high-risk surfaces for patients — exposed roots, occlusal surfaces of newly erupted molars, proximals in teens, etc. You can learn more on the topic — see Prevention of Caries by Silver Diamine Fluoride 38% — at this link.

13. When SDF is applied for prophylaxis to surfaces with no caries — for example to an erupting molar — does the tooth turn black?

SDF will discolor teeth if there is a breakdown in tooth structure.

14. Why would you cover with fluoride if SDF, by definition, already has fluoride? Is it overkill?   

To cover the flavor and protect the decay-SDF reaction from dilution by saliva. The fluoride from varnish is not necessary. Providers have also used Vaseline in place of varnish to prevent the saliva washout.

15. Is SDF recommended for extensive decay, such as lesions that are close to the pulp? Or are there negative effects if SDF is placed too closely to the pulp chamber?     

SDF is somehow incredibly well-tolerated by the pulp. We do not put it directly on the pulp, ever, but with at least a band of dentin over the pulp, it seems to desensitize and prevent sensitivity.

16. Can you say more about interproximal caries/superfloss technique sensitive or as long as it gets "close"?

It is water based, so the drier you get the tooth/decay, the more it will wick in via capillary action. The superfloss is an option but there is no evidence that it is helpful, and there have been a few semi-formal comparisons. The floss may soak the SDF or help it in. I just dry and apply at the embrasures.

17. How is SDF detected radiographically?             

Sometimes a radiolucent line appears in the outer layer of the cavity, but usually, there is no radiographically visible change. The goal is to see no change in the size of the lesion over time.

Editor’s Note: To view the full recording of the webinar, Providing Minimally Invasive Care with Silver Diamine Fluoride (SDF), visit the CareQuest Institute webinar library.