AAPD chairside guide for silver diamine fluoride (2025 revision): the two-page protocol you can laminate, from case selection to the recheck

What it says#

The chairside guide is two pages in the Resources section of the Reference Manual of Pediatric Dentistry, titled Chairside Guide: Silver Diammine Fluoride in the Management of Dental Caries Lesions, latest revision 2025, printed at pages 678 and 679. It carries no abstract, no methods paragraph and no How to Cite line. It is a bulleted protocol with two clinical photographs, one of active cavitated lesions before application and one of SDF-treated lesions with temporary gingival staining, and a footnote directing the reader to the 2017 clinical practice guideline for the evidence behind it.

The opening frames the problem and the trade. Dental caries affects more than 1 of every 5 children ages 2 through 5 years in the US. Silver diammine fluoride is efficacious in arresting caries lesions and may be included as part of a caries management plan. Caries lesions treated by SDF usually turn black and hard, and multiple applications over time may be necessary to sustain arrest.

Case selection is split in two. Patients who may benefit are those with high caries risk, with behavioral or medical management challenges, who may need multiple restorative treatment visits, with teeth that are difficult to restore, and with difficulty accessing dental care. Tooth selection criteria are cavitated lesions that are not encroaching on the pulp and have no signs or symptoms of pulpal involvement, naming unprovoked, lingering or spontaneous pain as the disqualifiers, with radiographs taken if possible to assess lesion depth; and cavitated lesions on any surface as long as they are accessible with a brush, with orthodontic separators suggested to gain access to proximal lesions. The guide adds that SDF can be used before restoration placement as well as within caries control therapy, and recommends obtaining informed consent that covers permanent staining of treated lesions, potential staining of skin and clothes, the unknown duration of caries arrest with a possible need for reapplication, and the role of SDF within a comprehensive preventive plan.

The clinical application section is eight bullets, and they read like a setup card. Age and weight of the child, along with the number of lesions requiring treatment, should be considered when determining how many drops can be safely applied in one visit; one drop of SDF contains approximately 1.7 mg of fluoride and 8.5 mg of silver. Remove gross debris from the cavitated lesion so SDF contacts decayed dentin. Carious dentin excavation before application is not necessary, though it may be considered for esthetic purposes because excavation may reduce the proportion of the tooth surface that turns black. A protective coating may be applied to the lips and skin to prevent a temporary henna-appearing tattoo where SDF contacts soft tissue. Isolate the teeth with cotton rolls or other isolation methods, and if a protective coating is applied to the surrounding gingiva, take care to avoid coating the lesion surfaces. Use caution applying SDF on primary teeth adjacent to permanent anterior teeth that may have noncavitated white-spot lesions, to avoid inadvertent staining. Bend the microbrush, dip it in SDF and dab it on the side of the plastic dappen dish to remove excess before application, restricting direct application to only the affected dentin lesion. Application time should be at least 1 minute if possible, in contact with all areas of the lesion and especially in large posterior lesions, because shorter application times may result in lower arrest rates. Remove excess SDF with gauze, a cotton roll or a cotton pellet to minimize ingestion.

Follow-up and monitoring is the shortest section and the one most offices skip. Estimations of effectiveness in arresting lesions range from 47% to 90% with a one-time application, depending on size of the cavity, tooth location and presence of plaque, and anterior teeth have higher rates of arrest than posterior teeth; therefore follow-up to evaluate arrest is advised. Recommendations for follow-up range from 2 weeks to 4 months after initial treatment. Reapplication may be indicated if the treated lesions do not appear arrested, which the guide defines as dark and hard, with biannual reapplication showing an increased caries arrest rate versus a single application. Application of 5% sodium fluoride varnish up to 4 times per year is recommended to prevent new lesions and to arrest noncavitated enamel lesions not treated with SDF, and dietary and oral hygiene counseling should be reinforced at those visits.

Who it applies to#

This is a staff document more than a doctor document. The dentist makes the diagnosis, the caries-risk assessment and the case selection; the person who then bends the microbrush, dabs it on the dappen dish and counts the minute is usually a hygienist or an assistant. That is the reason to treat the two pages as a posted protocol rather than reading material: every number in it is a number somebody has to hit at the chair.

What the guide does not carry is equally important. The strength of the recommendation, the pooled arrest rates from the trials, the off-label status of caries arrest under the FDA's clearance for tooth sensitivity, and the rules on delegating application to allied personnel on a dentist's order all sit in the AAPD's SDF policy and the 2017 clinical practice guideline. The guide does not discuss coding or reimbursement. It also assumes, rather than states, the exclusions the policy makes explicit, such as silver allergy.

What changed#

The version on the AAPD site carries a latest revision date of 2025 and a reference list accessed June 29, 2025. Two things in that list are recent enough to matter: a 2022 randomized trial of 38% SDF against restorative treatment at 12 months, and a 2024 open-label randomized trial of different SDF application intervals. The 1.7 mg fluoride and 8.5 mg silver figures trace to a 2019 Journal of the American Dental Association analysis of the silver and fluoride content and short-term stability of 38% SDF. This entry did not compare the 2025 text to earlier printings line by line, so treat the revision date as the source of truth rather than any claim about what moved.

Where the source is#

The link under the title is the AAPD's page for the resource, which opens a two-page PDF, Chairside Guide: Silver Diammine Fluoride in the Management of Dental Caries Lesions, latest revision 2025, printed at pages 678 to 679 of the Reference Manual of Pediatric Dentistry. The AAPD page shows the 2025-2026 edition. Unlike the AAPD's best practices and policies, this resource carries no How to Cite line, which is why the citation field here is empty; cite the Reference Manual pages instead. The PDF was downloaded and read in full for this entry, along with the SDF policy, the 2017 clinical practice guideline and the fluoride therapy best practice, all free to download from the same site and copyrighted by the Academy. This directory carries a separate entry on the SDF policy and the 2017 guideline, and the pathway illustration lives there; this entry deliberately carries no figure of its own, because the AAPD's two pages are already the one-page figure.