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Silver diamine fluoride:

The newest tool in your caries
management toolkit
A Peer-Reviewed Publication
Written by Judy Bendit, RDH, BS, and Douglas A. Young, DDS, EdD, MBA, MS

Abstract Educational Objectives Authors’ Profiles

Silver diamine fluoride (SDF) has been used worldwide At the conclusion of this educational Judy Bendit, RDH, BS, has more than 45 years of experience in dentistry. She is a speaker, author,
since 1970 to arrest decay. In the United States, activity participants will be able to: clinician, faculty member at the Temple University School of Dentistry, an alumni board member
the product received FDA clearance in 2014 as a 1. Understand the mechanism of of the University of Pennsylvania Dental School, and an advisory board member for Palm Beach
desensitizing agent (similar to fluoride varnish) and in action of Silver Diamine Fluoride State College’s dental hygiene program. She is also a longstanding member of the American Dental
October 2016 it was recognized by the Food and Drug 2. Discuss indications/ Hygienists’ Association and a distinguished academy member of the Pennsylvania Dental Hygienists’
Administration with breakthrough therapy designation contraindications for use Association, and she is a volunteer clinician both at home and abroad.
for caries treatment. This course will look at the latest 3. Identify challenges associated Douglas A. Young DDS, EdD, MBA, MS, is a professor at the University of the Pacific where he is
tool in the caries management toolkit to help the reader with Silver Diamine Fluoride an active and ardent educator in the field of minimally invasive dentistry and cariology. He was one
incorporate this new technology into clinical practice. 4. List steps for Non-Restorative and of the founders of the CAMBRA (caries management by risk assessment) Coalition, ADEA Cariology
Keeping in mind that SDF is relatively new to the US, SMART placement Section, and the American Academy of Cariology (AAC). Dr. Young served on the ADA Council of
and research/protocols are still evolving, clinical findings Scientific Affairs (2012-2016) and is currently a cariology consultant for the ADA. Dr. Young has
and guidelines for SDF currently being used for patients presented at congresses and universities around the world. He has been published in numerous
of all ages will be discussed. peer-reviewed dental journals and textbooks focusing on minimally invasive dentistry, glass
ionomer, and cariology.
Authors’ Disclosure
Judy Bendit and Douglas A. Young have no commercial ties with the sponsors or the providers of the
unrestricted educational grant for this course.
INSTANT EXAM CODE 15217
Go Green, Go Online to take your course
Publication date: Jul. 2017 Supplement to PennWell Publications
Expiration date: Jun. 2020
This educational activity was made possible through an unrestricted educational grant by Elevate Oral Care, LLC.
This course was written for dentists, dental hygienists and assistants, from novice to skilled.
Educational Methods: This course is a self-instructional journal and web activity.
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Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required
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“This course meets the Dental Board of California’s requirements for 3 units of continuing education.” and clinical experience that allows the participant to develop skills and expertise.
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program provider are accepted by the AGD for Fellowship, Mastership and membership Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the
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data and information contained in reference section. The research data is extensive and provides direct benefit to the patient
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Educational Objectives
At the conclusion of this educational activity participants will
be able to:
1. Understand the mechanism of action of Silver Diamine
Fluoride
2. Discuss indications/contraindications for use
3. Identify challenges associated with Silver Diamine
Fluoride
4. List steps for Non-Restorative and SMART
placement
Abstract
Silver diamine fluoride (SDF) has been used worldwide since
1970 to arrest decay. In the United States, the product re-
ceived FDA clearance in 2014 as a desensitizing agent (simi-
lar to fluoride varnish) and in October 2016 it was recognized
by the Food and Drug Administration with breakthrough
therapy designation for caries treatment. This course will
look at the latest tool in the caries management toolkit to help
the reader incorporate this new technology into clinical prac-
tice. Keeping in mind that SDF is relatively new to the US,
and research/protocols are still evolving, clinical findings
and guidelines for SDF currently being used for patients of
all ages will be discussed.
Background
Dental caries is a complex, multifactorial disease which
remains a significant problem across all age groups.1 Caries
management by risk assessment (CAMBRA) is an evidence-
based strategy to prevent and treat the underlying disease
causing caries lesions. CAMBRA uses caries risk assessment
(CRA) to identify pathologic risk factors that are unique to
the patient in order to develop treatment options to reduce
the progression of caries disease. These options include
chemical therapeutics coupled with behavioral modification
targeted at altering biofilm behavior, halting further demin-
eralization, and supporting remineralization.2 Recently, SDF
has demonstrated great promise in the United States when
used as a chemotherapeutic option for caries management3
and when used alone or in combination with glass ionomer
cement restorations.4
The ADA Caries Classification System (ADA CCS) was
published to provide US oral health-care professionals the
terminology needed to discern when caries lesions should be
treated chemically and when surgical restoration would be in-
dicated.5 The ADA CCS addresses all stages of caries lesions
(non-cavitated and cavitated) based on the site, extent, and
when possible, activity.5
What is SDF?
Silver diamine fluoride is chemically 38% weight/volume
Ag(NH3)2F. The silver acts as an antimicrobial with substan-
tivity, preventing reinvasion of cariogenic bacteria after ap-
2 www.DentalAcademyOfCE.com
plication.6 The fluoride provides remineralization,7 and the
silver diamine is a metal complex that dramatically stabilizes
the high concentrations of silver and fluoride in solution.7
SDF has the highest fluoride concentration (44,800 ppm
fluoride ion) of any available material and is about twice that
of fluoride varnish. (Table 1) Upon application of SDF to a
demineralized or infected surface, a silver-protein conjugate
layer forms, increasing resistance to acid dissolution and en-
zymatic digestion.8,9 Treated lesions remineralize, increasing
mineral density and hardness while decreasing the deminer-
alization layer.10 A 2016 systematic review with meta-analysis
by Gao and colleagues demonstrated the efficacy of SDF at
arresting dentinal caries.11
Why use SDF?
The possibility of avoiding more invasive treatments involv-
ing dental injections, dental drills, and even general anes-
thesia are just a few of the significant advantages of using
SDF to chemically arrest an active caries lesion. SDF has
been shown to be especially advantageous in populations
such as young children; the elderly; those with multiple car-
ies; those with caries lesions with problematic access where
treatment by conventional means is not possible; special
needs patients; and phobic patients. SDF can transform a
child’s first dental experience from traumatic to pleasant,
instilling trust and making subsequent interactions with
dental professionals more successful. Most significantly,
SDF may save lives. Many patients are being scheduled
for IV sedation or general anesthesia simply because they
are not manageable in the normal clinical setting. Sedation
and general anesthesia techniques are not without risk and
deaths have been reported. Even when there is a medical
reason for general anesthesia in a hospital setting, there is
often one- to two-year waiting periods for nonurgent care
for some populations. SDF is invaluable in these situations
by arresting disease progression without sedation or general
anesthesia. If necessary, for medical reasons, more compre-
hensive treatment in a hospital setting can be scheduled once
the lesions are arrested.
Usually, to effectively arrest and remineralize caries le-
sions, a comprehensive dental examination, caries risk assess-
ment, access to dental equipment, products, and interventions
to modify the oral chemistry and behavior of the patient are
required. A trained clinician and a high level of patient motiva-
tion and cooperation to implement these curative strategies are
needed. When patient cooperation is less than ideal, SDF can
now offer an alternative.
SDF is minimally invasive and preserves tooth structure.7
Therefore, once the caries lesion is arrested and disease pro-
cess has been halted,7 one could argue that an arrested caries
lesion (non-cavitated or cavitated) may not require a dental
restoration to maintain health unless the patient wants to
improve form, function, or esthetics.
Table 1 Comparison of common fluoride products
Fluoride concentration Parts per million (ppm)
Silver diamine fluoride 44,800 ppm
5% fluoride varnish 22,600 ppm
APF (in office) 12,300 ppm
NaF 2 (Rx) 9,000 ppm
Rinse (Rx) 3,300 ppm
SnF 2 w/ACP 970 ppm
CPP ACP with fluoride 900 ppm
OTC .05% NaF 2 rinse 200 ppm
Safety and toxicity
The safety profile of SDF is remarkable. The maximum dose
was determined to be one drop (25 uL) of SDF per 10kg (~ 22
lbs.) per treatment visit, based on LD50 rat studies required
for FDA clearance using a 400-fold safety margin.3 LD
stands for “Lethal Dose.” LD50 is the amount of a material,
given all at once, which causes the death of 50% (one half) of
a group of test animals. The LD50 is one way to measure the
acute toxicity of a material.12
Topical application of SDF to teeth with caries lesions is
very safe. One drop of SDF is roughly equivalent to drinking
a liter of fluoridated water or using fluoridated toothpaste.
Also, a good proportion of the material on the brush remains
on the brush and is never bioavailable, further reducing the
dose and potential for toxicity.
Classification, coding, and cost
In 2014, SDF was cleared by the US Food and Drug Admin-
istration for marketing as a Class II medical device to treat
tooth sensitivity. Like fluoride varnish, SDF is used off label
to treat caries lesions.
SDF became commercially available in the US in 2015
and is marketed as Advantage Arrest by Elevate Oral Care
LLC (West Palm Beach, Fla.). In January of 2016, the Cur-
rent Dental Terminology (CDT) billing code 1354 became
active. It is interesting to note that this process took only
one year as compared to fluoride varnish that took 16 years.
CDT 1354 can be used for “Conservative treatment of an
active, asymptomatic caries lesion by topical application of a
caries-arresting or inhibiting medicament without mechani-
cal removal of sound tooth structure.” With the introduction
of CDT 1354, some third-party payers have started to reim-
burse for the application of SDF, but reimbursement has yet
to become widespread. SDF is cost effective at $.60 per drop
(one drop treats approximately five surfaces). In fact, some
state Medicaid programs are currently reimbursing for CDT
1354.
In October 2016, SDF attracted further attention by be-
ing awarded breakthrough therapy designation by the FDA
because it demonstrated “substantial improvement over
existing therapies.”
www.DentalAcademyOfCE.com 3
Table2: CDT codes used for fluoride
D1354 - Interim caries arresting medicament application
D1208 - Topical application of fluoride
D9910 - Application of a desensitizing medicament, per visit
D1999 - Unspecified preventive procedure by report
Note: In March 2017, the ADA Code Revision Committee approved the change from “per application”
to “per tooth” beginning January 1, 2018.
Who can place SDF?
A licensed dentist in any state can apply SDF. We advise all
other clinicians to examine their states’ dental board practice
acts to determine if they can place SDF. For hygienists, this
web site may be helpful: http://www.adha.org. Many state
regulatory agencies consider SDF under existing guidance for
the use of topical fluorides.
Indications
1. SDF is used for the treatment of high or extreme caries risk
patients, especially those with xerostomia or severe early
childhood caries (SECC).6-9, 11 (see Figure 1)
Figure 1: Pre-and post-operative SDF on a xerostomic patient
(no restoration).
(Photos courtesy of Dr. Angela Lee)
Arresting a lesion before conservative caries removal and
final restoration, if needed, will preserve tooth structure
and reduce mechanical pulp exposures. It is also
indicated for patients with multiple caries lesions that
may not all be treated in one visit, or will likely get worse
before treatment can be completed (e.g., long waiting
time for hospital dentistry under general anesthesia).
2. SDF is warranted when traditional treatment is chal-
lenged by behavioral or medical management.
3. SDF may access areas impossible to reach with
traditional approaches, including partially erupted
third molars, furcations, and under and around existing
restorations. (see Figure 2)
Figure 2: SDF Application in difficult to reach locations.
(Photo courtesy Monica
Savalli RDH, DDS)

4. SDF can be used for patients with limited access to dental
care or limited financial resources for traditional care, e.g.,
patients in developing countries, nursing homes, rural
areas, etc.
5. SDF is an excellent desensitizer and often reduces or
eliminates the need for local anesthesia.
6. Regardless of financial status, SDF should be considered as
an option when the patient requests more conservative care.
Contraindications and precautions
SDF is contraindicated if there is a history of silver allergy and
should be used with caution with ulcerations or stomatitis.
While SDF is safe, clinicians should exercise caution with
a tooth that is symptomatic, partially necrotic, or otherwise
pulpally involved. With careful application, SDF should not go
beyond treated caries sites, but patients and providers should
be aware that SDF may cause stinging if it contacts soft tissue,
ulcerations, or lacerations. SDF will soon be available in a blue
tint, making it much easier to visualize upon placement.
Patients who are concerned about fluoride must be made
aware that SDF contains fluoride. The patient can be educated
that there is ten times less fluoride in one drop of SDF than 0.5
ml unit-doses of fluoride varnish because so little is actually
used. Patients are reminded that SDF is not ingested but merely
placed topically on the caries lesion.
Clinical observation
It should be noted that multiple applications (minimum of two
applications annually) of SDF are required for predictable caries
arrest.13,14 In 2016, a suggested SDF protocol was published by
Horst.3 There are some updates on this protocol based on stud-
ies and clinical observation since those protocols were originally
proposed. Many clinicians are reporting they no longer see the
need for rinsing off the SDF after placement, given its margin
of safety and lack of clinical complaints from patients. It is also
reported that it is no longer mandatory to protect the gingiva
with petroleum jelly since adverse reactions are few and very
minor regarding SDF contacting the gingiva. In contrast, there
is a greater risk that the petroleum jelly can get on the caries
lesion and affect SDF uptake and glass ionomer cement (GIC)
bonding. Originally, clinicians were concerned that SDF would
affect bond strength or restoration retention. This has not been
reported with conventional GIC restorations, nor does it seem to
compromise the integrity of crown adhesion. At least one study
reported that SDF will not weaken bond strength of composite.15
Light curing SDF is not necessary or recommended and will
cause darkening of resin-based restorations.
Side effects and precautions
Placement of SDF should be restricted to the caries lesion be-
ing treated. Predictable side effects include darkening of the
treated lesion (it will not usually stain healthy tooth structure)
4 www.DentalAcademyOfCE.com
and a short-lived, bitter metallic taste. A dab of toothpaste on
the tongue may help with the taste. If SDF contacts soft tissue,
a temporary stinging and/or staining may occur (usually brown
in color on the skin and white or gray in appearance on the oral
tissues). Any staining or soft tissue irritation will be temporary,
typically disappearing in several days. Caution should also be
taken with clinical surfaces and uniforms as staining can oc-
cur and will not come off. There are several existing informed
consent forms available on the internet. A consent form should
be read and signed by the patient prior to placing SDF.
Step-by-step SDF placement (no restoration)
The following example is based on clinical experience and it
is important for the reader to understand that at this time,
there is no scientific evidence to support one method of
placing SDF over another. The research base for SDF use is
evolving rapidly. What we know today may be disproved or
modified tomorrow. The information presented is accurate to
the best of our knowledge as of June 2017.
1. Wear standard personal protective equipment (PPE),
and make sure the patient is wearing safety glasses and a
plastic-lined bib.
2. Dispense SDF into a plastic dappen dish. One drop treats
five surfaces.
3. If you wish, you may apply extraoral protection for
the lips and surrounding area using petroleum jelly or lip
balm. Some patients, with a keen sense of smell, find a
scented lip balm will mask the odor of SDF as it is placed
in the mouth. It is critical to make sure that no petroleum
jelly or lip balm gets on the caries lesion or it will inhibit
uptake of the SDF and affect bonding of any dental restor-
ative materials placed that day.
4. Use of a saliva ejector and/or suction bite-block device can
be helpful.
5. If a suction bite-block device is not used, try to isolate
the tongue and cheek from the affected teeth using gauze,
cotton rolls, or absorbent triangles.
6. Petroleum jelly is not normally needed to protect the in-
traoral soft tissues given the safety of SDF and the risk of
detrimental effects of getting it on the lesion. Some feel it is
helpful when there are already irritations on surrounding
soft tissues such as ulcerations or mucositis. See critical
note in No. 3.
7. Desiccate the carious surface with air or a cotton swab if air
is not available.
8. Immerse a stiff microbrush into the SDF in the dappen
dish and saturate the lesion with SDF using a scrubbing
motion. This is best done with a dental assistant to avoid
SDF contact with other unintended structures.
9. While scrubbing, allow the SDF to absorb for at least
one minute, if possible. For uncooperative patients, one
minute may not be achievable; for cooperative patients,
longer exposure time may be advantageous.
10. SDF can be applied to interproximal caries lesions with
the use of spongy floss. The spongy floss is inserted so the
“fuzzy” part of the floss is adjacent to the contact. A small
section next to the contact is then saturated with SDF
and pulled under the contact area. Let sit for at least one
minute when possible. (see Figure 3)
Figure 3: Placing SDF on an approximal caries lesion using Super flossTM.
(Photo courtesy of Dr. Jason Hirsch)
11. When done applying the SDF, many feel it is helpful
to cover the area immediately with fluoride varnish or
petroleum jelly to keep the SDF in contact with the caries
lesion as long as possible and to mask any taste from the
SDF. If a restoration is going to be placed on the same
day as SDF application, do NOT do this step.
12. Cleanup: Invert all used cotton, microbrush, and dappen
dish into a glove so SDF can’t drip on any surface or skin.
Dispose of materials in a trash can.
Silver-modified atraumatic restorative treat-
ment (SMART)
As stated previously, at least two applications of SDF will
dramatically improve the arrest rate.13,14 However, there are
instances when it is not practical to leave a gross cavitation
open while implementing SDF arrest procedures. In addi-
tion, it may not be possible for the patient to return for dental
care for multiple SDF treatments and subsequent restoration.
In either case, for purposes of this manuscript, we will define
SMART as “Silver Modified Atraumatic Restorative Treat-
ment,” because SDF is applied and immediately restored
with sealed margins and conventional GIC (self-curing) at
the same appointment. A conventional GIC restoration may
be the ideal restorative material for SMART because it is
hydrophilic and must be placed directly on a moist surface. It
does not require light curing, which will turn the restoration
dark. SMART attempts to combine three proven clinical pro-
cedures with high levels of evidence, without violating any of
the individual principles of each: 1) caries arrest with SDF11;
2) partial or incomplete caries removal16; and 3) placement
www.DentalAcademyOfCE.com 5
of a conventional GIC restoration.17,18 In the case of a deep
cavitated lesion on a vital and asymptomatic tooth, systematic
reviews demonstrate that partial/incomplete caries removal
by cleaning the perimeter of the lesion (where mechanical
pulp exposure is unlikely) while not excavating the deeper
areas of the lesion, and cutting off the nutrient source for any
remaining bacteria by placement of a sealed restoration, has
better outcomes than total caries removal.16,19 Partial caries
removal now has international consensus as a best practice.20
SDF is bactericidal to remaining bacteria in the dentin, and
arrests caries and remineralizes the surface. Conventional
GIC will chemically bond to the moist surface, and enhance
remineralization and acid resistance at the tooth-restorative
interphase.4,18,21 Because the perimeter of the lesion was me-
chanically cleaned, it ensures a chemically sealed restoration
that will arrest and remineralize the caries lesion, preserving
tooth structure and enhancing pulp vitality. Please note that
mechanically cleaning the perimeter of the lesion may not be
possible in all instances (uncooperative patients) and some
flexibility of the SMART procedure is expected.
Step-by-step SMART
1. Remove biofilm and pellicle with pumice or defocused air
abrasion in the surrounding area of the lesion to be treated.
(GIC has no chemical bond to biofilm or pellicle.)
2. Apply SDF as per steps 1-9 in the above Step-by-step SDF
placement (no restoration).
3. Clean the perimeter using your preferred technique (slow-
speed round bur, hard-tissue laser, air abrasion, or a spoon
excavator).
4. Condition the lesion and surrounding area with 20%
polyacrylic acid by scrubbing for 10 seconds (removing the
smear layer and activating the surface for ionic exchange).
5. Rinse with water for 10 seconds.
6. Place a matrix if needed.
7. If any contamination occurs, rinse briefly again with water
and blot dry with cotton (leaving a moist “glossy” surface).
8. Mix the GIC for 10 seconds and apply immediately, avoid-
ing voids.
9. Shape and remove excess but do not manipulate the GIC
after about 30 seconds from start of mix.
10. When crosslinking is initiated, the wet glossy surface of the
GIC will start to look “frosty.” This means it is losing water
and should be surface sealed with the recommended resin
based surface sealant. (do not light cure as it will turn
dark from the free SDF.) An alternative to surface sealant
is to use petroleum jelly or wet the surface with water.
11. Do not disturb for 2.5 minutes from start of mix. Once
set, place anatomy, adjust occlusion, polish with rubber
abrasives and discs, ALL with profuse water spray.
(see Figure 4)
Note: Ask the patient not to chew on the restoration for a
few days, if possible.
Figure 4: Immediate post-op. SDF application 1 minute and GIC restoration. However, if a stainless-steel crown is indicated, SDF could
also be used as a pretreatment before the crown is cemented.
SDF treatment could be a substantial benefit for patients if
it helps retain the deciduous tooth until natural exfoliation
or if SDF prevents a tooth from being extracted in an aging
or medically challenged adult. An attempt to mask the dark-
ened area with conventional GIC can also be considered for
improved esthetics. (see Figure 6)

Figure 6: Intra- and post-operative SMART #7,8, & 10, showing clean
perimeters and final GIC restorations. Note: tooth #10 had incomplete
stain removal on internal margin.
(Photo courtesy of Dr. Kenneth Han)

Perception of dental professionals

A very common barrier for the use of SDF on children or adults
is the perception of dental professionals that parents and patients
would never accept SDF treatment because of the discoloration.
Yet, when properly educated and informed about the pros and
cons of the SDF procedure, many patients choose to have SDF
despite the tooth darkening. Is it possible that health-care
providers are bothered by the idea of teeth darkening
more than patients? A recently published study by Crystal
and colleagues looked into parental perceptions of the dark
staining of SDF.22 They found that the dark staining on posterior
teeth was more acceptable than staining on anterior teeth, with
67.5% judging the staining as esthetically tolerable in the poste-
rior compared to 29.7% in the anterior (P<.001). However, as
the number of children’s behavioral issues increased, so did the
parents’ level of acceptance of the staining. Although staining
on anterior teeth was undesirable, most of the parents preferred
this option to advanced behavioral techniques such as sedation
or general anesthesia. Yet, almost one-third of the parents still (Photo courtesy of Dr. Douglas A. Young)
found the SDF staining unacceptable under any situation.22
With regard to esthetics on deciduous teeth, the SDF option Conclusion
could be in many cases presented as an alternative to a stainless The supporting science and clinical use of SDF presents
steel crown. (see Figure 5) a very strong case for the utilization of SDF in appropriate
patients and should be in every clinician’s caries management
Figure 5: Image of SDF vs. Stainless Steel crown toolkit. The placement of SDF does not preclude additional
options that include subsequent placement of restorations for
purposes of restoring form, function, or esthetics. Remem-
ber that SDF has unique disinfection and remineralization
properties that can halt the caries process rapidly and perhaps
reduce the need for traditional, more invasive operative pro-
cedures. By combining the compatibilities of SDF and con-
ventional GIC, we can offer new ways to medically manage
our patients as well as energize and motivate health providers
to transform disease to health.

References:
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for Disease Control MMWR Surveillance Summaries
(Photo courtesy of Dr. Jason Hirsch) August 26, 2005 / 54(03);1-44. Surveillance for Dental

6 www.DentalAcademyOfCE.com
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excavation or partial removal: a critical review. J Am Dent
Assoc 2008;139(6):705-12.
17. Mickenautsch S, Yengopal V. Caries-preventive effect
of high-viscosity glass ionomer and resin-based fissure
sealants on permanent teeth: a systematic review of
clinical trials. PLoS One 2016;11(1):e0146512.
18. Peumans M, Kanumilli P, De Munck J, et al.
Clinical effectiveness of contemporary adhesives: a
systematic review of current clinical trials. Dent Mater
2005;21(9):864-81.
19. Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete
or ultraconservative removal of decayed tissue in unfilled
teeth. Cochrane Database Syst Rev 2006;3:CD003808.
20. Schwendicke F, Frencken JE, Bjorndal L, et al. Managing
carious lesions: consensus recommendations on carious
tissue removal. Adv Dent Res 2016;28(2):58-67.
21. Ngo H, Ruben J, Arends J, et al. Electron probe
microanalysis and transverse microradiography studies
of artificial lesions in enamel and dentin: a comparative
study. Adv Dent Res 1997;11(4):426-32.
22. Crystal YO, Janal MN, Hamilton DS, Niederman R.
Parental perceptions and acceptance of silver diamine
fluoride staining. J Am Dent Assoc 2017.
Authors’ Profiles
Judy Bendit, RDH, BS, has more than 45 years of experience in
dentistry. She is a speaker, author, clinician, faculty member at the
Temple University School of Dentistry, an alumni board member
of the University of Pennsylvania Dental School, and an advisory
board member for Palm Beach State College’s dental hygiene pro-
gram. She is also a longstanding member of the American Dental
Hygienists’ Association and a distinguished academy member
of the Pennsylvania Dental Hygienists’ Association, and she is a
volunteer clinician both at home and abroad.
Douglas A. Young DDS, EdD, MBA, MS, is a professor at
the University of the Pacific where he is an active and ardent educa-
tor in the field of minimally invasive dentistry and cariology. He
was one of the founders of the CAMBRA (caries management
by risk assessment) Coalition, ADEA Cariology Section, and the
American Academy of Cariology (AAC). Dr. Young served on the
ADA Council of Scientific Affairs (2012-2016) and is currently a
cariology consultant for the ADA. Dr. Young has presented at con-
gresses and universities around the world. He has been published
in numerous peer-reviewed dental journals and textbooks focusing
on minimally invasive dentistry, glass ionomer, and cariology.
Authors’ Disclosure
Judy Bendit and Douglas A. Young have no commercial ties with
the sponsors or the providers of the unrestricted educational grant
for this course.
Online Completion INSTANT EXAM CODE 15217
Use this page to review the questions and answers. Return to www.DentalAcademyOfCE.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete
the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers.
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Questions

1. SDF stands for? 9. Which of the following FDA 16. Clinicians should exercise
a. Sodium Dioxide Fluoride statement is correct? caution with placing SDF in what
b. Stannous Diamine Fluoride a. The FDA classifies SDF as a Class I instance/s?
c. Silver Diamine Fluoride medical device a. If the tooth is symptomatic
d. Silver Dioxide Fluoride b. The FDA classifies SDF as a Class II b. Partially necrotic
2. FDA clearance (which of the cosmetic device c. Pulpally involved
c. The FDA classifies SDF as a Class II d. All of the above
following are correct?)
medical Device
a. Cleared in 1970
d. The FDA classifies SDF as a Class III
17. Which of the following statements
b. Cleared for caries management are correct?
medical Device
c. Same breakthrough designation as fluoride a. SDF will not stain countertops and upholstery?
varnish 10. The CDT 1354 code covers which b. SDF will stain the entire tooth, even if there is
d. Cleared for treating sensitivity of the following: no decay?
a. Inactive lesion, asymptomatic
3. Which of the statements are correct c. SDF will only stain where there is decay or
b. Active lesion, symptomatic
regarding caries disease? demineralization?
c. Inactive lesion, symptomatic d. SDF will wash out of uniforms if it gets on them?
a. It is a multifactorial disease.
d. Active lesion, asymptomatic
b. Risk assessment is an integral part 18. Ideally, the minimum
c. Goal is halting demineralization, supporting 11. The definition of the CDT 1354
recommended time for the solution
remineralization. code is:
of SDF to contact the lesion is:
d. All of the above a. Interim caries arresting medicament application
a. 10 seconds
b. Topical application of Fluoride
4. All of the following are required to c. Application of a desensitizing medicament, per
b. 30 seconds
place SDF EXCEPT: visit
c. 1 minute
a. proper isolation (i.e. cotton rolls) d. Unspecified preventive procedure by report d. 2 minutes
b. microbrush and product (SDF) 19. The steps for placing SDF include
c. Dental chair, compressed air, cuspidor, and 12. Which of the following is NOT an
indication for SDF? all of the following except:
suction
a. Patients with low risk of caries with no caries a. Making sure the patient is sitting up for the
d. a caries lesion procedure
lesions
5. SDF may decrease the need for b. Patients with high risk of caries b. Wearing personal protective equipment (PPE)
which of the following: c. Patients with extreme risk of caries c. Placing safety glasses and plastic lined bib on
a. Injections d. Patients with xerostomia or severe early patient
b. Drills childhood caries (SECC) d. Have an assistant help if possible
c. General Anesthesia 20. The following statements about
d. All the above
13. Other indications for SDF include?
a. Patients with active caries lesions with petroleum jelly and lip balm are true
6. What is the mechanism of action for behavioral issues EXCEPT:
SDF? b. Patients with active caries lesions with medical a. Helps prevent staining of extra-oral structures
a. Silver acts as an antimicrobial management issues b. Potentially masks the smell of the solution if
b. Fluoride promotes remineralization c. Patients with active caries lesions with limited placed on lips
c. A silver-protein conjugate layer forms, access to care c. It is OK to get into the caries lesion as it
increasing resistance to acid dissolution and d. All of the above will not effect the bonding of any restorative
enzyme digestion. 14. The contraindications for SDF material
d. All of the above d. Helpful when there are irritations on
include:
7. Which of the following statements a. Peanut allergy surrounding soft tissues such as ulcerations or
are true about SDF b. Silver allergy mucositis
a. It is minimally invasive c. Sodium Lauryl Sulfate (SLS) allergy 21. Which of the following statements
b. It preserves tooth structure d. None of the above best describes the clean-up of SDF:
c. It halts the disease process 15. All of the following support a. Just throw everything in the biohazard red trash
d. All of the above use of SDF in the nursing home can
8. SDF is which of the following: environment EXCEPT: b. Only invert the gauze in the glove
a. 36% weight/volume Ag(NH3)2F a. Easy to place c. Put any excess aside so you can use it on the next
b. 28% weight/volume Ag(NH3)2F b. Must have suction to place SDF patient
c. 38% weight/volume Ag(NH3)2F c. Takes just a few minutes d. Invert all cotton, microbrushes and dappen dish
d. 12% weight/volume Ag(NH3)2F d. Cost effective into glove and dispose in trash can.

8 www.DentalAcademyOfCE.com
 Questions

22. Instructions following placement of 26. In cleaning the perimeter of 29. Informed consent is indicated:
SDF should include: the lesion for SMART which of a. When you have multiple teeth to treat
a. Brush teeth immediately after treatment the following techniques was not b. On every patient
b. No eating or drinking for 30 minutes mentioned in the article? c. Only if the patient complains about the dark
c. Must use a RX toothpaste after SDF treatment a. Slow speed round bur staining
d. No alcohol for 1 week after treatment b. Ultrasonic insert d. Only when treating the anterior teeth that are
23. What does SMART stand for? c. Hard tissue laser visible to the patient
a. silver modified atraumatic restorative treatment d. Air abrasion 30. Which statement is correct
b. Stannous mediator for atraumatic restorative a. With the Breakthrough Therapy Designation
27. Which statement represents
treatment forthcoming from the FDA, widespread
c. Sodium modified atraumatic restorative
reasonable post-op instructions for
SMART? adaptation is forthcoming.
treatment b. With the Breakthrough Therapy Designation
d. Strontium material atraumatic restorative a. Ask the patient not to chew on the GIC
forthcoming from the EPA, widespread
treatment restoration immediately after placement and
adaptation is imminent.
ideally for a few days if possible.
24. Based on this article what is the ideal c. With the Breakthrough Therapy Designation
b. Ask the patient to not chew on the restoration
restorative material for SMART? forthcoming from the FDA, widespread
for 2 years
a. Resin modified glass ionomer (RMGI) adaptation is unlikely.
c. No eating drinking or rinsing for 24 hours
b. Conventional GIC d. With the Breakthrough Therapy Designation
c. Composite d. Do not brush the restoration with a toothbrush
forthcoming from the ADA, widespread
d. IRM for the first few days
adaptation is imminent.
25. SMART attempts to combine three 28. All of the following are positive
proven clinical procedures, which one perceptions reported by patients
of the following is NOT one of them? after the SDF procedure EXCEPT:
a. Caries arrest with SDF a. Easy to place
b. Complete caries removal b. Did not object to taste or discoloration
c. Partial or incomplete caries removal c. Very costly
d. Placement of a conventional GIC restoration d. Painless

Notes

www.DentalAcademyOfCE.com 9
INSTANT EXAM CODE 15217 ANSWER SHEET

Silver diamine fluoride: The newest tool in your caries management toolkit
Name: Title: Specialty:

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City: State: ZIP: Country:

Telephone: Home ( ) Office ( )

Lic. Renewal Date: AGD Member ID:

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information
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Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 800-633-1681
If not taking online, mail completed answer sheet to
Educational Objectives PennWell Corp.
Attn: Dental Division,
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1421 S. Sheridan Rd., Tulsa, OK, 74112
2. Discuss indications/contraindications for use or fax to: 918-831-9804
3. Identify challenges associated with Silver Diamine Fluoride
For IMMEDIATE results,
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INSTANT EXAM CODE 15217
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