Silver Diamine Fluoride (SDF)

SDF is an FDA-approved liquid compound used to stop tooth decay without needing to use a drill or anesthesia. It is a common form of minimally invasive dental care, since it is completely painless and no tooth structure is manually removed in the process. Instead, the SDF liquid is painted onto the area of decay and allowed to absorb into the tooth. This is sometimes followed by applying a layer of fluoride varnish or petroleum jelly to prevent saliva from removing the liquid before it has fully set. After applying SDF, the harmful bacteria that first caused the decay will die and the area of decay will darken. The patient may choose to follow up with something called a glass ionomer that will mask the dark spot to more closely resemble healthy tooth structure.

Who should be treated with SDF?

SDF is most often recommended for children for the sake of both time and cost. Children often have trouble sitting still for long periods of time and may be afraid of needles and drills. Children will also lose their primary teeth by early adolescence, so they don’t require restorative treatments that boast longevity. This makes minimally invasive care such as SDF a good option for children who need dental care but aren’t quite ready or able to undergo more involved or expensive procedures, or who would otherwise require sedation or general anesthesia in order to provide invasive treatment. For the same reasons, SDF is also recommended for people who are disabled, older adults, and those with limited or no insurance.

Is SDF covered by insurance?

In the state of Vermont, Medicaid fully covers dental care for eligible children and pregnant people, making SDF a very affordable treatment option for those groups. For eligible adults with capped dental coverage, preventative SDF does not count towards the financial limit, providing more flexibility for future treatment plans. Most other insurance companies offer reimbursement for the use of SDF for both prevention and as treatment for decay.

Do all dental offices administer SDF?

No, not all dental offices practice minimally invasive care on a broad scale, although most do offer fluoride varnish. The Federal Drug Administration approved the use of SDF in dental practices in 2015, so dentists and dental hygienists trained before then would rely on Continued Education to learn this skill.

Are there other forms of minimally invasive dental care?

Yes, there are several other types of minimally invasive dental care. They range from a simple fluoride varnish—which can be applied even by some pediatric primary care doctors—to premade, stainless steel crowns that fit over a decayed tooth without the need for impressions or drilling. The type of minimally invasive care offered varies by practice.

These resources will help you understand the benefits and limitations of MIC treatment options.

• Silver Diamine Fluoride (SDF) Fact Sheet from the Vermont Department of Health (PDF)

• SDF information from the American Dental Association

• Informational videos about SDF/minimally invasive care, translated to 20 languages by the Vermont Language Justice Project

Children and people with disabilities are sometimes sedated or put under general anesthesia (either partially or fully unconscious) in order to complete dental treatment. New guidelines emerged in 2019 to improve the safety of this practice, but it should still be avoided when possible due to the risks and increased costs. About 400 children under the age of 6 undergo general anesthesia in connection with dental care in Vermont each year. An instance of sedation dentistry can cost thousands of dollars. Inexpensive, effective, minimally invasive treatments like silver diamine fluoride (SDF) and Silver Modified Atraumatic Restorative Treatment (SMART) should make sedation dentistry exceedingly rare. One regional dental practice (Montshire Pediatric Dentistry) has reduced the need for general anesthesia in their patients by 90% through the use of minimally invasive care.

• Relatively few private practice dentists are using SDF. Of the 42% of children with tooth decay in 2023, only 2.1% had been treated with SDF. Public health oriented practices, like the Federally Qualified Health Centers, are more likely to use SDF in their treatment options. 
  

Questions to ask when your dentist recommends sedation:

What procedure are you proposing, and do you have to do it? Could the problem be treated with silver diamine fluoride or another minimally invasive option?

• Children’s primary teeth will loosen and fall out - sometimes an interim treatment can maintain the tooth structure and stop any infection, preventing the need for more invasive and expensive treatments like fillings. 

• SDF is the standard of care for many instances of tooth decay – especially in children, people with disabilities, and older adults – because it stops the infection that is damaging the tooth, preserves more of the tooth structure (relative to drilling and filling a cavity), does not require anesthesia, and is significantly less expensive than more invasive procedures. 

Where will the treatment take place - in the dentist office or in a hospital setting?

• What level of sedation or anesthesia will you be using? Do you hold a sedation specialty?

• According to the administrative rules that dentists practicing in Vermont must follow, dentists must be trained and meet the standard for a speciality—a type of certification—for the level of sedation above what they intend to use. That means if they plan minimal sedation, they must hold a speciality for moderate sedation. This is because sedation isn’t always precise, and patients can move to a deeper level of sedation than planned. When this happens the dentist needs to be trained and prepared to return the patient to the intended sedation level. 

• This does not apply if the procedure is being conducted in a hospital overseen by a physician or nurse anesthetist. It also does not apply to the use of nitrous oxide.

How much experience do you have caring for kids my child’s age?

• Children under 6 may be especially vulnerable to adverse effects. Studies have shown that it is common for children to pass from the intended level of sedation to a deeper, unintended level of sedation, making the concept of rescue (returning the child to the intended level of sedation) essential.

How will my child be monitored during the procedure? 

• Be sure there will be vigilant monitoring. Ask if the office has EKG, blood pressure, pulse oximetry and end tidal carbon dioxide monitors.

Who else will be in the room to monitor and respond if something goes wrong? 

• During deep sedation and/or general anesthesia of a pediatric patient in a dental office, there must be at least 2 individuals present with the patient throughout the procedure. One of these will be an independent observer not involved in performing or assisting with the dental procedure, whose role is to administer drugs and constantly observe the patient’s vital signs, depth of sedation, and breathing.

What rescue preparations will be in place?

• Depending on the level of sedation, rescue carts should include intravenous supplies, rescue drugs, breathing bags, intubation supplies, suction, defibrillators and more. The AAPD guide provides detailed information in appendixes 3 and 4.

What is the recovery setup? 

• Some sedation drugs take a long time to fully leave the system. Depending on your child’s health and age they may need extended observation. Make sure there is a plan and staff available to monitor your child. 

Resources:

American Academy of Pediatric Dentistry Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The Office of Professional Regulation manages a searchable database of decisions pertaining to complaints of unprofessional conduct. Simply choose “Dental Examiners” from the dropdown menu of professions, and enter the last name of the dentist. If the Board of Dental Examiners found that unprofessional conduct occurred, there will be a document outlining the issue, the disciplinary action, and any steps the dentist was required to take in order to keep or restore their license. 

If you experience unprofessional conduct you can also file a complaint through the Office of Professional Regulation.