4. SDF can be used for patients with limited access to dental
care or limited financial resources for traditional care, e.g.,
patients in developing countries, nursing homes, rural
5. SDF is an excellent desensitizer and often reduces or
eliminates the need for local anesthesia.
6. Regardless of financial status, SDF should be considered as
an option when the patient requests more conservative care.
Contraindications and precautions
SDF is contraindicated if there is a history of silver allergy and
should be used with caution with ulcerations or stomatitis.
While SDF is safe, clinicians should exercise caution with
a tooth that is symptomatic, partially necrotic, or otherwise
pulpally involved. With careful application, SDF should not go
beyond treated caries sites, but patients and providers should
be aware that SDF may cause stinging if it contacts soft tissue,
ulcerations, or lacerations. SDF will soon be available in a blue
tint, making it much easier to visualize upon placement.
Patients who are concerned about fluoride must be made
aware that SDF contains fluoride. The patient can be educated
that there is ten times less fluoride in one drop of SDF than 0.5
ml unit-doses of fluoride varnish because so little is actually
used. Patients are reminded that SDF is not ingested but merely
placed topically on the caries lesion.
It should be noted that multiple applications (minimum of two
applications annually) of SDF are required for predictable caries
arrest. 13, 14 In 2016, a suggested SDF protocol was published by
Horst. 3 There are some updates on this protocol based on studies and clinical observation since those protocols were originally
proposed. Many clinicians are reporting they no longer see the
need for rinsing off the SDF after placement, given its margin
of safety and lack of clinical complaints from patients. It is also
reported that it is no longer mandatory to protect the gingiva
with petroleum jelly since adverse reactions are few and very
minor regarding SDF contacting the gingiva. In contrast, there
is a greater risk that the petroleum jelly can get on the caries
lesion and affect SDF uptake and glass ionomer cement (GIC)
bonding. Originally, clinicians were concerned that SDF would
affect bond strength or restoration retention. This has not been
reported with conventional GIC restorations, nor does it seem to
compromise the integrity of crown adhesion. At least one study
reported that SDF will not weaken bond strength of composite. 15
Light curing SDF is not necessary or recommended and will
cause darkening of resin-based restorations.
Side effects and precautions
Placement of SDF should be restricted to the caries lesion be-
ing treated. Predictable side effects include darkening of the
treated lesion (it will not usually stain healthy tooth structure)
and a short-lived, bitter metallic taste. A dab of toothpaste on
the tongue may help with the taste. If SDF contacts soft tissue,
a temporary stinging and/or staining may occur (usually brown
in color on the skin and white or gray in appearance on the oral
tissues). Any staining or soft tissue irritation will be temporary,
typically disappearing in several days. Caution should also be
taken with clinical surfaces and uniforms as staining can occur and will not come off. There are several existing informed
consent forms available on the internet. A consent form should
be read and signed by the patient prior to placing SDF.
Step-by-step SDF placement (no restoration)
The following example is based on clinical experience and it
is important for the reader to understand that at this time,
there is no scientific evidence to support one method of
placing SDF over another. The research base for SDF use is
evolving rapidly. What we know today may be disproved or
modified tomorrow. The information presented is accurate to
the best of our knowledge as of June 2017.
1. Wear standard personal protective equipment (PPE),
and make sure the patient is wearing safety glasses and a
2. Dispense SDF into a plastic dappen dish. One drop treats
3. If you wish, you may apply extraoral protection for
the lips and surrounding area using petroleum jelly or lip
balm. Some patients, with a keen sense of smell, find a
scented lip balm will mask the odor of SDF as it is placed
in the mouth. It is critical to make sure that no petroleum
jelly or lip balm gets on the caries lesion or it will inhibit
uptake of the SDF and affect bonding of any dental restorative materials placed that day.
4. Use of a saliva ejector and/or suction bite-block device can
5. If a suction bite-block device is not used, try to isolate
the tongue and cheek from the affected teeth using gauze,
cotton rolls, or absorbent triangles.
6. Petroleum jelly is not normally needed to protect the
intraoral soft tissues given the safety of SDF and the risk of
detrimental effects of getting it on the lesion. Some feel it is
helpful when there are already irritations on surrounding
soft tissues such as ulcerations or mucositis. See critical
note in No. 3.
7. Desiccate the carious surface with air or a cotton swab if air
is not available.
8. Immerse a stiff microbrush into the SDF in the dappen
dish and saturate the lesion with SDF using a scrubbing
motion. This is best done with a dental assistant to avoid
SDF contact with other unintended structures.
9. While scrubbing, allow the SDF to absorb for at least
one minute, if possible. For uncooperative patients, one
minute may not be achievable; for cooperative patients,
longer exposure time may be advantageous.