AAPD policy on silver diamine fluoride (2017, revised 2023): 38% SDF inside a caries management plan, with a conditional recommendation and a permanent black stain behind it

What it says#

The document at the AAPD link is the three-page Policy on the Use of Silver Diammine Fluoride for Pediatric Dental Patients (the AAPD's spelling), developed by the Council on Clinical Affairs, adopted in 2017, revised in 2018 and carrying a latest revision date of 2023 in the Reference Manual of Pediatric Dentistry. It rests on a literature review (PubMed/MEDLINE and Google Scholar, humans, English, the last 15 years; 205 articles matched) and on expert and consensus opinion, and its purpose is narrow: SDF as part of an ongoing caries management plan, consistent with the goals of a dental home.

The background carries the substance. Topical silver products have been used in Japan for over 40 years to arrest caries and reduce sensitivity. The FDA has approved SDF as a Class II medical device for reducing tooth sensitivity, and off-label use for arresting caries is described as permissible and appropriate. As marketed in the US it is 38% silver diamine fluoride, equivalent to 5% fluoride, a colorless liquid with a pH of 10; fluoride remineralizes enamel and dentin while silver acts as an antimicrobial in the treated carious dentin. The side effect is permanent black discoloration of demineralized or cavitated surfaces, and before-and-after images are suggested for consent. Trials consistently conclude that SDF arrests dentinal caries more effectively than fluoride varnish, though the stain unblinds the examiner; SDF reportedly retains approximately 2 to 3 times more fluoride than varnish, gel or foam products, has not been shown to reduce adhesion of resin or glass ionomer, is safe within dosing and application criteria, and does not appear to harm young children's quality of life. Follow-up to evaluate arrest is advisable and reapplication may be necessary.

The policy statement has five bullets. The AAPD supports SDF as part of an ongoing caries management plan aimed at individualized care in a dental home; recognizes it as a minimally invasive approach that may prevent or delay more extensive and expensive procedures; supports delegation of application to qualified allied dental personnel, with training and supervision under the state's dental practice act, by prescription or order of a dentist after a comprehensive oral examination and caries-risk assessment; supports education of students, residents, other oral health professionals and their staffs; and encourages practice-based research on efficacy and quality of life for infants, children, adolescents and individuals with special health care needs.

The evidence sits in the 2017 clinical practice guideline the policy cites, Use of Silver Diamine Fluoride for Dental Caries Management in Children and Adolescents, Including Those with Special Health Care Needs (Crystal and colleagues, Pediatric Dentistry 2017;39(5):E135-E145). A workgroup approved by the AAPD Board in December 2016 built it on a 2016 systematic review, extracted four controlled trials (three randomized) and graded the evidence with GRADE. The single recommendation: the panel supports the use of 38% SDF for the arrest of cavitated caries lesions in primary teeth as part of a comprehensive caries management program, a conditional recommendation on low-quality evidence. Approximately 68% of cavitated lesions in primary teeth would be expected to be arrested two years after once or twice yearly application (95% CI 9.7 to 97.7); with at least 30 months of follow-up (2,567 surfaces), SDF had a 48% higher success rate than controls (95% CI 32 to 66), 76% versus 51%, or 248 more arrested lesions per 1,000 surfaces; in the largest stratum (3,313 surfaces, 24 months or more) the relative risk was 1.42 (95% CI 1.17 to 1.72), 72% versus 50%. The panel rated the evidence low or very low for risk of bias and heterogeneity, found no studies in adults, and explained the conditional grade: untreated decay in young children is a public health problem, restorative care in that group often needs sedation or general anesthesia, arrest rates upward of 70% compare well with other options, and the stain is outweighed in most cases. In trials covering over 4,000 children there were no deaths or systemic adverse effects; SDF is approximately 24 to 28% silver and 5 to 6% fluoride by weight, one drop delivers less fluoride than a 0.25 mL varnish treatment, and it should not be used in patients allergic to silver compounds.

The guideline's Appendix II and the chairside guide (revised 2025) turn that into steps: indications (high caries risk, behavioral or medical management challenges, multiple lesions that cannot all be treated in one visit, hard-to-treat lesions, limited access to care, active cavitated lesions with no clinical signs of pulp involvement); consent that names staining of the lesion, skin and clothes and the likely need for reapplication; a plastic dappen dish, because SDF corrodes glass and metal; no need to excavate carious dentin, though excavation may reduce how much surface turns black; remove gross debris, protect the gingiva, dry, dab the microbrush, apply only to the lesion, air dry for at least one minute, remove excess. One drop contains approximately 1.7 mg of fluoride and 8.5 mg of silver, so age, weight and lesion count set the safe number of drops per visit. A single application arrests 47% to 90% of lesions depending on size, location and plaque; effectiveness falls with time (in one trial half the surfaces arrested at six months had reverted by 24 months); biannual application arrests more than annual; follow-up is advised at 2 weeks to 4 months; and 5% varnish up to four times a year is recommended for the rest of the dentition. The guideline lists CDT code D1354 and warns that reimbursement varies by state and carrier.

Who it applies to#

Any child or adolescent with a cavitated caries lesion where the trade of a black, hard lesion for a drill-free, sedation-free visit makes sense, including patients with special health care needs. The policy is written for the dental home: the dentist who has done the comprehensive exam and caries-risk assessment, and the hygienist or assistant who applies SDF on that dentist's order where the state practice act allows. The guideline's intended readers include general dentists, pediatricians, family physicians and payers deciding coverage.

The evidence-based recommendation stops at primary teeth. Adults and permanent teeth are expected to respond similarly but were not studied in the trials the panel used; the AAPD's fluoride therapy best practice separately recommends 38% SDF for cavitated lesions in primary and permanent teeth. Exposed pulps, symptomatic teeth and silver allergy are excluded, and neither prevention of new lesions nor root caries was the guideline's question.

What changed#

The policy was adopted in 2017 alongside the guideline and the first chairside guide, revised in 2018, and carries a 2023 revision date; its own methods paragraph still names 2018 as the last revision, so the 2023 pass reads as a reference and wording update. The chairside guide was revised in 2025 and now states the fluoride and silver content of a drop, a recheck window of 2 weeks to 4 months, a caution about staining white-spot lesions on adjacent permanent anterior teeth, and varnish up to four times a year for the rest of the mouth. The guideline said it would be updated five years after its last search unless earlier evidence warranted; the AAPD site still lists the 2017 guideline as current.

Where the source is#

The link under the title is the AAPD's page for the policy, which opens the Reference Manual PDF, Policy on the Use of Silver Diammine Fluoride for Pediatric Dental Patients, latest revision 2023, printed at pages 113 to 115 of the 2025 manual; the AAPD's How to Cite line is the citation above. The evidence grade and the pooled numbers are from the 2017 clinical practice guideline, an 11-page open-access PDF on the same site (Pediatric Dentistry 2017;39(5):E135-E145), and the application steps and the drop content are from the two-page chairside guide revised in 2025 (Reference Manual 2025:678-9). All three PDFs were downloaded and read in full for this entry. The inventory for this directory lists the entry under the guideline's title; the policy is what sits at the URL.