Silver Diamine Fluoride in Paediatric Dentistry: Arresting Caries, Building Trust and Buying Time

A large US clinical trial has provided encouraging evidence for the use of silver diamine fluoride in young children with severe early childhood caries.

The Phase III study, published online in JAMA Pediatrics, involved 830 children under six years old. Researchers assessed the use of 38% silver diamine fluoride, commonly known as SDF, as a non-invasive treatment for active dental caries.

At six months, 54% of the lesions treated with SDF had arrested, compared with 22.5% in the placebo group. At eight months, the arrest rates were 50.2% for SDF and 17.4% for the placebo.

Although the study was designed to support a potential application for approval in the United States, its findings are highly relevant to clinicians in the UK who already use SDF as part of a minimally invasive approach to caries management.

For me, however, the value of SDF goes beyond the arrest percentages.

Integrating SDF into daily practice

I work in a predominantly private dental practice that also holds an NHS paediatric contract. I have integrated SDF into my daily clinical practice, particularly when treating very young children, anxious patients and those who are not yet able to tolerate conventional restorative treatment.

Community dental services are currently under extreme pressure. Waiting lists can be particularly long for children who require additional behavioural support, sedation or specialist care.

Unfortunately, the disease process does not pause simply because a referral has been made.

SDF has allowed me to offer these children something more while they are waiting. I often describe it as “buying time”, but that time can be incredibly valuable.

In several of my paediatric patients, I have seen a reduction in caries activity and subsequent episodes of pain. By stabilising the disease, we have been able to create a window in which the child can become familiar with the dental environment and gradually develop confidence.

A child who initially tolerates little more than an examination may, after several short and positive appointments, become comfortable enough to accept more involved treatment.

In some cases, the time bought through the use of SDF has allowed us to build sufficient trust and cooperation to intervene operatively at a later appointment. That may not have been possible, or appropriate, during the child’s first visit.

Choosing the right approach for each child

I use the Frankl Behaviour Rating Scale to help guide how I approach treatment.

For a child at the lower end of the scale who is not yet ready to accept operative care, I may begin with a simple SDF application alongside tailored preventive advice and regular review.

The application itself is relatively quick and does not require local anaesthetic, drilling or sedation. This can make it a useful introduction to treatment for children who are anxious or have limited tolerance.

Where a child can accept slightly more, I may provide a SMART restoration. SMART refers to the silver-modified atraumatic restorative treatment technique, where SDF is combined with a restorative material such as glass ionomer cement.

This gives me a flexible, behaviour-led pathway rather than an all-or-nothing approach.

Treatment can begin with disease control and gradually progress as the child’s confidence develops. At recall, or as soon as the patient becomes sufficiently accepting, I may consider placing a preformed metal crown over the tooth where clinically appropriate.

The objective is not simply to complete a procedure. It is to control the disease while bringing the child with us through the treatment journey.

Discussing SDF with parents

How SDF is presented to parents is extremely important.

The British Society of Paediatric Dentistry has produced helpful videos and parent information leaflets that can support the consent process and explain why SDF may be recommended.

The most significant consideration is staining. SDF permanently darkens active carious tissue, so parents must understand the likely appearance before treatment is provided.

Where a child can tolerate the additional application, potassium iodide may be used after SDF in an attempt to reduce the immediate dark appearance. However, I still advise parents that darkening can occur and should not be considered entirely preventable.

It is also worth showing parents the existing lesion. In many cases, the tooth already has brown or dark organic staining associated with active caries.

When parents can see the area and understand that the goal is to arrest the disease, reduce the likelihood of pain and help their child avoid a more invasive experience before they are ready, they are often very receptive.

For many families, the clinical benefits outweigh the cosmetic drawback, particularly on a posterior primary tooth.

SDF is not a magic solution, and it is not a replacement for definitive treatment where that treatment is required. Appropriate case selection, informed consent, prevention, ongoing review and monitoring remain essential.

Sometimes buying time is treatment

SDF has allowed me to offer more to paediatric patients who may otherwise be left waiting while their caries continues to progress.

It gives us an opportunity to manage active disease, reduce the risk of pain and create positive dental experiences. It can also provide the time needed to develop trust and cooperation before progressing to operative treatment.

For the right child, SDF is not simply a temporary measure.

Sometimes, buying time is treatment in itself.