More than 1,000 learners — a mix of dentists, dental hygienists, dental assistants, students, faculty, and medical professionals — spent an hour on Thursday evening learning about why, how, and when to use silver diamine fluoride (SDF) in the CareQuest Institute and MCD Global Health webinar “Silver Diamine Fluoride in Action: Evidence and Implementation.”
And they had a lot of questions.
In addition to filling nearly the full hour with an engaging and practical presentation, the all-star panel of speakers — Beau D. Meyer, DDS, MPH, Associate Professor, Division of Pediatric Dentistry, the Ohio State University; Jonathan Norris, DDS, Pediatric Dentist, Cofounder, Montshire Pediatric Dentistry; and Courtney E. Vannah, IPDH, MSDH, MPH, Senior Program Manager, MCD Global Health — provided answers to several of those questions. As a recap for those who attended and a resource for those who didn’t, the speakers reviewed the Q&A below and added a few additional thoughts on the topic.
- What are the steps for applying SDF? Do you light cure it? How often should it be reapplied?
Remove debris with an air/water syringe or toothbrush. Dry the tooth as much as possible. Scrub the SDF onto the lesion for as long as the patient will tolerate, approximately 15 seconds to 1 minute. Remove excess with a cotton roll. There is no need to light cure. Reapply every six months. The American Academy of Pediatric Dentistry (AAPD) Chairside Guide contains an application protocol with case selection criteria.
- How far apart should the two recommended annual applications be?
The studies suggest that every six months is adequate for caries arrest in primary teeth.
- Will SDF cause an abscess? When is it contraindicated?
SDF itself will not cause an abscess. However, teeth with signs of pulpal pathology or necrosis will not benefit from SDF treatment.
- If SDF is applied repeatedly, what happens to the appearance of the tooth?
If SDF is effective, the lesion will turn black and feel hard to an explorer. Reapplication won’t necessarily change the appearance of a successfully treated SDF tooth. SDF will not affect sound tooth structure, so only the actual lesion will stain.
- Why do some reimbursement policies limit treatment to a certain number of teeth when one application can treat multiple teeth?
Several explanations could exist. When SDF was first introduced into the United States, the manufacturer’s label recommended five teeth at a time. Additionally, some had concerns about SDF toxicity. Lastly, a policy that has a restriction on the number of teeth may be trying to protect against overuse or fraud, waste, and abuse.
- Is SDF similar to colloidal silver?
In some ways, yes, it is related. However, colloidal silver does not contain fluoride and is a different product than SDF, and the two should not be used interchangeably.
- Does dental insurance typically cover SDF?
Most dental insurance plans do cover SDF, although coverage varies by carrier and specific plan. Most plans cover treatment under CDT code D1354, but this may vary by carrier and plan.
- What reimbursement amount is typically covered by Medicaid?
In 2023, the mean reimbursement amount for D1354 covered by state Medicaid programs was $22.43 (SD (standard deviation) = $19.86).
- Can you use SDF as a liner in caries preparation? Does it weaken the composite bond?
You can, but it is not necessary. In preclinical studies, SDF did not appear to affect bond strength on previously SDF-treated teeth. Some studies suggest that bond strength is not as good when the tooth is restored on the same day/same visit as the SDF application.
- Can dental hygienists apply SDF? If so, can you provide examples of language they can use to support treatment acceptance?
Whether dental hygienists can apply SDF depends on the state and the requirements established by the state practice act. The American Dental Hygienists’ Association has a helpful resource summarizing state-specific policies.For guidance on discussing SDF to support treatment acceptance, the AAPD’s SDF Chairside Guide is a good resource.
- Have you heard of a protocol that uses glass ionomer sealants and SDF, instead of fluoride varnish, as a preventive measure in a school sealant program in a high-caries-risk area?
Yes, there have been several National Institutes of Health–funded studies on this topic, such as this randomized clinical trial. When the treatments were applied by school nurses, the two approaches were equivalent for first permanent molars. For additional good references, search gov for studies involving SDF applied by school nurses.
- What are the next steps when placing composite over SDF?
Consider avoiding placing composite on the same day as SDF application to avoid a gray or black discoloration shining through the composite material. If the composite is placed after caries arrest, treat the arrested lesion like a normal stained tooth. The black staining can be removed with handpieces, sometimes without the need for local anesthesia. Where aesthetics are important, complete removal of the black stain or opaque material is needed to block the black shining through the composite.
- Is SDF contraindicated for anterior teeth?
No, but informed consent is especially important. The patient or parent must understand what SDF will do to the lesion, including the expected staining. Document this understanding before applying SDF. The AAPD Chairside Guide includes before-and-after photos as examples that can be incorporated into the informed consent process.
- How would you apply SDF interproximally?
Several techniques are used. Sometimes, a microbrush can be used to gently push the liquid into the contact. Others use Super Floss to wick the liquid into the lesion. Both approaches are limited by lesion accessibility, but they may be worth trying when appropriate. SDF is most successful when it is applied directly to the lesion.
- Is there an SDF product that does not cause dark staining?
Not really. The black stain is an indicator that the treatment is working. Some products package SDF with potassium iodide, but results related to staining are mixed.
- Is there a gold standard for the frequency or number of SDF applications over the lifetime of a tooth?
The ADA nonrestorative guideline and accompanying systematic review advises that two applications per year are more effective than one. No established gold standard exists for the total number of applications over the lifetime of a tooth.
- What is the billing code for SDF, and what should providers charge?
The charge depends on the insurer and specific plan, but most insurers cover SDF under CDT code D1354.
- How does SDF affect pulpal health if it is applied after gross caries removal near the pulp?
SDF does not affect pulpal pathology. However, it should not be applied directly to the pulp because it does not treat the underlying problem in that situation. Better pulpal treatments are available. As long as there are no symptoms of irreversible pulpitis or pulpal necrosis or visible signs of direct pulp exposure, SDF can be considered as a treatment option.
- Underserved populations can be difficult to follow up with because barriers may cause missed appointments and affect continuity of treatment. Are data available on this issue?
AAPD’s clinical guideline recommends SDF as part of an individualized comprehensive caries management program. The ADA’s guideline emphasizes the need for monitoring and follow-up. There have been a number of poster presentations at national scientific meetings documenting single clinics’ dental treatment or care continuity following SDF application.
- We previously advocated for Medicaid coverage of SDF by emphasizing the low material cost. A projected cost of $44 seems high. Is this primarily related to labor and other overhead expenses?
The $44 figure represented what dentists practicing in safety net clinics recommended, not what programs covered. We were unable to determine why they recommended that amount in the study, but follow-up work is planned to explore the issue in more detail.
- What is the gold-standard SDF product?
Without recommending a particular brand, any product that contains 38% SDF aligns with the recommendations from the ADA guideline.
- What would ideal insurance coverage for SDF look like? Should it cover treatment twice per tooth per year without limitations? How should concerns about fraud, waste, and abuse be addressed?
The ideal insurance benefit for SDF treatment would cover twice per tooth per year application without limitation. Patients and parents — and providers to a degree — may provide a natural guardrail against fraud, waste, and abuse due to the black staining.
- Are primary care providers in Maine using a CPT code to bill for SDF?
Maine Medicaid chose to make the CDT code available to physicians rather than use the CPT code. Physicians are therefore currently billing with the CDT code. In other states, Medicaid is covering reimbursement to physicians applying SDF via CPT code 0792T.
Editor’s Note: View the full presentation — and download the accompanying slides — in CareQuest Institute’s webinar library.