10. SDF can be applied to interproximal caries lesions with
the use of spongy floss. The spongy floss is inserted so the
“fuzzy” part of the floss is adjacent to the contact. A small
section next to the contact is then saturated with SDF
and pulled under the contact area. Let sit for at least one
minute when possible. (see Figure 3)
Figure 3: Placing SDF on an approximal caries lesion using Super flossTM.
(Photo courtesy of Dr. Jason Hirsch)
11. When done applying the SDF, many feel it is helpful
to cover the area immediately with fluoride varnish or
petroleum jelly to keep the SDF in contact with the caries
lesion as long as possible and to mask any taste from the
SDF. If a restoration is going to be placed on the same
day as SDF application, do NOT do this step.
12. Cleanup: Invert all used cotton, microbrush, and dappen
dish into a glove so SDF can’t drip on any surface or skin.
Dispose of materials in a trash can.
Silver-modified atraumatic restorative treat-
As stated previously, at least two applications of SDF will
dramatically improve the arrest rate. 13, 14 However, there are
instances when it is not practical to leave a gross cavitation
open while implementing SDF arrest procedures. In addition, it may not be possible for the patient to return for dental
care for multiple SDF treatments and subsequent restoration.
In either case, for purposes of this manuscript, we will define
SMART as “Silver Modified Atraumatic Restorative T
reat-ment,” because SDF is applied and immediately restored
with sealed margins and conventional GIC (self-curing) at
the same appointment. A conventional GIC restoration may
be the ideal restorative material for SMART because it is
hydrophilic and must be placed directly on a moist surface. It
does not require light curing, which will turn the restoration
dark. SMART attempts to combine three proven clinical procedures with high levels of evidence, without violating any of
the individual principles of each: 1) caries arrest with SDF11;
2) partial or incomplete caries removal16; and 3) placement
of a conventional GIC restoration. 17, 18 In the case of a deep
cavitated lesion on a vital and asymptomatic tooth, systematic
reviews demonstrate that partial/incomplete caries removal
by cleaning the perimeter of the lesion (where mechanical
pulp exposure is unlikely) while not excavating the deeper
areas of the lesion, and cutting off the nutrient source for any
remaining bacteria by placement of a sealed restoration, has
better outcomes than total caries removal. 16, 19 Partial caries
removal now has international consensus as a best practice. 20
SDF is bactericidal to remaining bacteria in the dentin, and
arrests caries and remineralizes the surface. Conventional
GIC will chemically bond to the moist surface, and enhance
remineralization and acid resistance at the tooth-restorative
interphase. 4, 18, 21 Because the perimeter of the lesion was mechanically cleaned, it ensures a chemically sealed restoration
that will arrest and remineralize the caries lesion, preserving
tooth structure and enhancing pulp vitality. Please note that
mechanically cleaning the perimeter of the lesion may not be
possible in all instances (uncooperative patients) and some
flexibility of the SMART procedure is expected.
1. Remove biofilm and pellicle with pumice or defocused air
abrasion in the surrounding area of the lesion to be treated.
(GIC has no chemical bond to biofilm or pellicle.)
2. Apply SDF as per steps 1-9 in the above Step-by-step SDF
placement (no restoration).
3. Clean the perimeter using your preferred technique (slow-
speed round bur, hard-tissue laser, air abrasion, or a spoon
4. Condition the lesion and surrounding area with 20%
polyacrylic acid by scrubbing for 10 seconds (removing the
smear layer and activating the surface for ionic exchange).
5. Rinse with water for 10 seconds.
6. Place a matrix if needed.
7. If any contamination occurs, rinse briefly again with water
and blot dry with cotton (leaving a moist “glossy” surface).
8. Mix the GIC for 10 seconds and apply immediately, avoid-
9. Shape and remove excess but do not manipulate the GIC
after about 30 seconds from start of mix.
10. When crosslinking is initiated, the wet glossy surface of the
GIC will start to look “frosty.” This means it is losing water
and should be surface sealed with the recommended resin
based surface sealant. (do not light cure as it will turn
dark from the free SDF.) An alternative to surface sealant
is to use petroleum jelly or wet the surface with water.
11. Do not disturb for 2. 5 minutes from start of mix. Once
set, place anatomy, adjust occlusion, polish with rubber
abrasives and discs, ALL with profuse water spray.
(see Figure 4)
Note: Ask the patient not to chew on the restoration for a
few days, if possible.