Understanding silver diamine fluoride’s role in modern dentistry

Silver diamine fluoride (SDF) doesn’t turn patients’ teeth black if you’re using it correctly, but many clinicians seem hesitant to adopt SDF into their practice. But why? 

Even if it doesn’t blacken teeth, can it still stain them? How can dental practices bill successfully for SDF, and how should it be presented to patients? In a recent episode of Dentistry Unmasked, Dr. Brian B. Novy, DDS, and Dr. Pamela Maragliano, DMD, break down all there is to know about SDF, answering key questions about its benefits, drawbacks, and best clinical uses. 

Shifting beyond handpieces  

Modern caries treatment is shifting beyond drills and handpieces toward noninvasive medicaments that can stop disease and give patients more options. Pam and Brian believe these types of approaches strengthen patient relationships by offering care many patients prefer over injections and drilling. 

Pam acknowledges this is a significant shift in mindset: "I know that seems like a very divisive issue to many people who have their foot glued to rheostat and their hand affixed to a handpiece — and they know that the only way an office makes money is if that handpiece is turning. But the reality is that there is a better way to take care of patients.” 

They also highlight the silver modified atraumatic restorative technique (SMART), which combines silver diamine fluoride with glass ionomer. Pam adds that dentistry should better distinguish caries as a disease process caused by oral imbalance, while a cavity is the result of that disease. She notes that implementing caries management has improved her practice and patient care, even though it has not eliminated the need for restorative processes.  

Circumventing SDF staining 

Pam and Brian explain that when silver diamine fluoride (SDF) is exposed to curing light and heat, silver particles can react and form dark precipitates that discolor the tooth. Using potassium iodide after SDF can reduce this effect by creating a white silver iodide precipitate before restoration. SDF can be paired with glass ionomer and if discoloration occurs, it often means too much SDF was used. This can later be covered with composite. Pam notes glass ionomer can act as an indicator of an acidic oral environment. 

Why dentists should incorporate SDF into their practice 

Brian says, “Dentists should incorporate silver diamine fluoride into their practice because it offers you the ability to treat caries in that moment and bring the patient back with a lesion that's the same size instead of hoping it doesn't get bigger.” 

He and Pam believe every patient should be given the option to arrest and stop their cavities, and that taking a drill to a patient’s tooth should be the last resort; ultimately, preserving tooth structure and halting the caries process is the ideal outcome. 

“Imagine a patient has a little bit of recurrent decay on the margin of a crown and yet they're 95 years old,” Brian posits. “Are you really going to tell that patient they need to redo that crown? Do you want to redo that crown on that patient? I know the dentists who are at all in production want to redo that crown, but why not just put silver diamine fluoride on that margin and stop it?” 

The complicated nature of SDF and CDT codes 

CDT codes for caries management need to be revised to become clearer, easier to use, and better aligned with modern diagnosis and treatment. The current coding does not adequately distinguish lesion location or its severity; additionally, root caries remain especially difficult to classify. 

Brian. notes that as patients keep their teeth longer and exposed root surfaces become more common, dentistry needs better codes to document treatment accurately and explain the use of therapeutic medicaments to payers. He encourages dentists to become involved in the code revision process. 

“One of the things that the code doesn't really allow for right now is understanding were you treating root caries? And how do you define if a root caries lesion is cavitated or not?  How do you determine that a root surface is cavitated or not? There is no enamel. You can say, well, I felt that it went in a little bit or I got to stick with an explorer. It's such a  gray area. And yet what is the number one problem that a lot of dentists face in this healthy population? It's root caries.” 

How AI is shaping the future 

AI is poised to transform caries management by helping dentists track treatment outcomes over time and identify which lesions need restorative care. By combining clinical data with salivary diagnostics, AI could distinguish low-risk patients from high-risk patients who may benefit from SDF. The discussion also highlights the shift away from older “drill and fill” approaches toward true disease management, while acknowledging that time and practice-setting realities can make ideal academic models difficult to implement in private practice or community clinics.  

Brian says: “AI is finally going to give us the data we need ... Did we get a health outcome at three months? Did we get a health outcome at six months? Did we get a health outcome at nine months or 12 months? Right now, we don't have any real system to track that well except for AI. And as our AI platforms get better and we can start layering in different diagnostic information like salivary testing.” 

If you are interested in learning more about SDF check out the following articles on this topic:

Could zinc replace SDF in cavity treatment? NYU scientists think so

Why is my dentist resistant to implementing SDF in the hygiene practice?

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