How often should silver diamine fluoride be reapplied to arrest caries?

Discussion

Regimen 6 M showed lower arrest rates compared to Regimen 1 M and 4 M and also showed increased dmft between visit 1 and visits 2 and 3. The literature suggests that increasing the frequency of SDF application can increase caries arrest rates [42]. The effectiveness of lesion arrest by 38% SDF decreases over time [42, 44]. Re-activation of treated lesions has been observed in a two-year study where a single application of 38% SDF was sufficient to prevent only 50% of the arrested surfaces at six months from reverting to active lesions again over 24 months [44]. We suggest that six months between applications may not be optimal for arrest of caries in high-risk children. Other factors which could be influencing arrest rates and dmft with six months application frequency and that need to be investigated in future studies include the number of erupted teeth, diet high in fermentable carbohydrates, plaque index, amount of plaque present in lesions, medical status, and use of antibiotics.

Effects of silver diamine fluoride on oral bacteriome and mycobiome: a randomized clinical trial. © The Author(s) 2025. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Review

Favorable outcomes with SDF were observed whether it was used alone or in combination with behavioral modifications, 5% NaF, or KI. In 2014, the US Food and Drug Administration approved SDF for off-label use to arrest caries in both dentinal and enamel lesions in children. Its increasing recognition as an NRCC option in primary teeth is attributed to its cost-effectiveness, safety, minimal chair time, non-invasiveness, and lack of aerosol generation [30]. The caries-arresting mechanism of SDF primarily relies on silver's antibacterial properties and the formation of a sclerotic layer on the dentinal surface, which promotes the remineralization of enamel and dentin [31]. Consequently, the American Dental Association clinical practice guideline recommends a biannual application of 38% SDF for arresting advanced cavitated caries in primary teeth [32]; however, Maldupa et al. and Gao et al. reported that biannual SDF applications were more effective in preventing major complications and achieving higher success rates in managing ECC [22,33].

Effectiveness of the Non-restorative Cavity Control (NRCC) Approach in Managing Dentinal Caries in Primary Teeth: A Systematic Review. Copyright © 2026, Alwusaybie et al. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Discussion

The current AAPD Clinical Practice Guideline recommends monitoring carious lesions for arrest at 2–4 weeks following application of SDF with reapplication as necessary to achieve arrest of all targeted lesions and re-care monitoring based on disease activity and caries risk level at three, four, or six months [42]. SDF is known to have a reservoir effect with sustained antimicrobial effects over time [43]. Application to carious lesions is as effective in preventing caries in other teeth and surfaces as applying SDF directly [43]. In our study, the average dmft remained the same over all three visits for Regimen 4 M which is consistent with these findings. Average arrest rates were higher for all groups after two applications of SDF followed by NaF varnish, compared to one application of SDF followed by NaF varnish, however, arrest rates were higher with application frequencies of 1 month and 4 months, compared to 6 months.

Effects of silver diamine fluoride on oral bacteriome and mycobiome: a randomized clinical trial. © The Author(s) 2025. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).