ADA nonrestorative caries guideline (2018): 11 recommendations sorted by lesion, surface and dentition, and the ADA's first word on SDF

What it says#

An expert panel convened by the ADA Council on Scientific Affairs and the ADA Center for Evidence-Based Dentistry ran a systematic review of randomized trials of nonrestorative treatments and formulated 11 clinical recommendations, each specific to lesion type, tooth surface and dentition, using GRADE to rate certainty and strength. Noncavitated lesions are defined as ICDAS 1 and 2; cavitated lesions as ICDAS 5 and 6, the same language as the ADA Caries Classification System.

For advanced cavitated lesions on any coronal surface, the panel prioritizes 38% silver diamine fluoride solution applied twice a year over 5% sodium fluoride varnish applied once per week for 3 weeks. In primary teeth that is a strong recommendation on moderate certainty. In permanent teeth the same prioritization is conditional on low certainty. This is where the ADA first put SDF into a clinical recommendation; the panel attaches an informed consent note that all nonrestorative and restorative options and their side effects, such as the blackened tooth surfaces SDF leaves, should be offered and explained to every patient.

For noncavitated lesions the recommendations run by surface. On occlusal surfaces, in both dentitions, the panel prioritizes sealants plus 5% sodium fluoride varnish applied every 3 to 6 months, or sealants alone, over 5% varnish alone, 1.23% acidulated phosphate fluoride gel every 3 to 6 months, or 0.2% sodium fluoride mouthrinse once per week; in primary teeth resin infiltration plus varnish is also in the list of alternatives ranked below sealants. Both are strong recommendations on moderate certainty, and they line up with the 2016 ADA and AAPD sealant guideline. On facial or lingual surfaces, the panel suggests 1.23% APF gel or 5% sodium fluoride varnish every 3 to 6 months, a conditional recommendation on moderate to low certainty. On approximal surfaces, it suggests 5% sodium fluoride varnish every 3 to 6 months, resin infiltration alone, resin infiltration plus varnish, or sealants alone, conditional on low to very low certainty.

Root surfaces get their own recommendation, for permanent teeth and for both noncavitated and cavitated lesions: prioritize 5,000 ppm fluoride (1.1% sodium fluoride) toothpaste or gel at least once per day over 5% sodium fluoride varnish every 3 to 6 months, 38% SDF plus potassium iodide solution applied annually, 38% SDF solution applied annually, or 1% chlorhexidine plus 1% thymol varnish every 3 to 6 months. That is conditional on low certainty.

One recommendation runs the other way. On noncavitated coronal surfaces in either dentition, the panel suggests clinicians do not use 10% casein phosphopeptide-amorphous calcium phosphate paste if other fluoride interventions, sealants or resin infiltration are accessible, conditional on low certainty. And a line that applies to every recommendation: where the panel ranks options, that order is a priority ranking it defined by weighing treatment effectiveness, feasibility, patients' values and preferences, and resource use, so a patient's values, special needs or insurance status should still inform the decision. The chairside pathways also require that lesions be monitored periodically for hardness or texture, color and radiographic change throughout the course of treatment.

Who it applies to#

Children and adults, primary and permanent teeth, noncavitated and cavitated lesions. The guideline names clinicians as its target audience but adds that only those authorized or trained to perform a specified intervention should do so, which in most states decides whether a hygienist can place the SDF or the sealant.

It does not cover restorative treatment. A lesion that needs a restoration is the subject of the 2023 ADA restorative guideline. The root surface recommendation is written for permanent teeth only. And the recommendations presume a lesion has been staged and a risk level recorded, which is what the ADA caries risk assessment forms and the AAPD caries risk assessment pathways are for.

What changed#

This is the ADA's first guideline on nonrestorative treatment as a category, and the first to recommend silver diamine fluoride. The ADA's 2013 topical fluoride panel had explicitly excluded SDF because it was not available in any product in the United States at the time; by 2018 it was, and the ADA put it at the top of the list for advanced cavitated coronal lesions. The AAPD's own SDF documents, its 2023 policy and its chairside guide, carry the application technique.

The other change is structural. Instead of one recommendation per product, this guideline writes one per clinical situation: lesion type by surface by dentition. That is why the same 5% sodium fluoride varnish appears as a prioritized option on one surface and as a lower-ranked alternative on another.

Where the source is#

The link under the title is the ADA's page for the guideline. Both chairside guides, the summary recommendation tables and the two clinical pathway pages were downloaded and read in full for this entry; they carry every recommendation, its GRADE certainty and its strength, the application intervals and the ICDAS definitions quoted above. The full JADA article (2018;149(10):837-849) is behind JADA access, so the narrative detail behind each recommendation was not read here, and the recommendation counts and intervention list are cross-checked against the published PubMed abstract. The chairside guides are copyright the ADA and may be used, copied and distributed for noncommercial purposes without prior approval.