SDF Essentials by Dr. Roopwant Kaur

A quick guide for general practitioners

by Dr. Roopwant Kaur 

• Application: In-office treatment for root sensitivity.
• Details: Typically reported on a per-visit basis for applying topical fluoride.
• Not to be used for: Bases, liners or adhesives under restorations.
• Insurance: Suggested to include a narrative describing the patient’s sensitivity. Generally billed per visit. This can be done on all teeth or specific teeth.
• What to do: Be aware that reimbursement is often not provided, and patients may need to pay out of pocket unless PPO providers are prohibited from charging separately for the procedure.

• Application: Treatment that relieves acute/spontaneous pain but is not curative.
• Details: Used for alleviating the patient’s acute or spontaneous complaints/problems. It serves as an interim step in the restorative process—providing comfort while preventing disease progression if restoration cannot be completed immediately.
• Not to be used for: Definitive care.
• Insurance: Includes a narrative describing the patient’s complaint and actions taken to relieve discomfort. Reimbursement can vary by insurance plan, with fees based on time spent and the complexity of the procedure.

• Application: Used for primary prevention or remineralization without an active carious lesion.
• Details: Applied for preventive care on high-risk patients, including root surfaces, pits and fissures, and demineralized areas.
• Insurance: SDF is considered a medicament, not a topical fluoride. This code may apply if SDF is used for primary prevention on root or coronal surfaces without an active lesion.

• Application: Used for conservative treatment of active, non-symptomatic carious lesions by applying a caries arresting or inhibiting medicament, such as SDF, without mechanically removing sound tooth structure.
• Details: Effective for arresting active decay, particularly with 38 percent SDF. Reapplication is often recommended at least annually, preferably biannually.
• Insurance: Coverage varies by plan. A strong narrative justifying the use of D1354 over a definitive restoration—based on caries risk assessment and clinical necessity—can support the claim. If reimbursement is denied, resubmit with an emphasis on the elevated caries risk and medical necessity.

• Application: Used for caries prevention.
• Details: This code can be used for fluoride varnish treatments typically applied during a recall visit to all teeth for general caries prevention.
• Insurance: Likely reimbursed for children but often not for adults, unless a moderate to high caries risk assessment is reported. Fees may be passed on to the patient.

• Document the patient’s caries risk assessment. A thorough risk assessment that identifies the patient’s susceptibility to dental caries can help justify the use of SDF, particularly in states or insurance plans that are more restrictive.
• Narrative and justification. Always provide a well-documented clinical narrative detailing why SDF was the appropriate choice, particularly in situations where it is used instead of more invasive restorative procedures.
• Check with your state Medicaid office. Medicaid coverage for SDF can vary even within states that have approved its use. It’s important to check the local Medicaid provider manual for specific policies and reimbursements.
• Consider a pre-authorization request. In some cases, submitting a pre-authorization request with detailed clinical notes can help ensure reimbursement for SDF applications, particularly in situations where there is uncertainty about coverage.

• Step 1: Confirm the diagnosis
  Upon detecting a lesion, confirm the diagnosis and instruct your RDH to immediately apply SDF. This swift action arrests the decay and prevents it from worsening, buying you time to plan a more definitive treatment. It is beneficial to treat a high-risk patient with fluoride varnish post-SDF, as it will also help mask the metallic taste the patient may feel after SDF application.
• Step 2: Reappoint for two to four weeks
  Schedule a follow-up appointment within two to four weeks to reassess the lesion. This follow-up allows the SDF to fully arrest the decay, providing an opportunity to plan the final restorative treatment. Reappointment is optional if the patient cannot return because of their schedule or financial reasons.
• Step 3: Restoration with usual materials
  During the follow-up visit, proceed with restoration using your usual materials. Consider incorporating a GIC into your protocol for additional protection against future decay.
• Step 4: Fast and easy learning
  The SDF application process is quick and easy to learn. Familiarize yourself with the steps and educate your team to ensure smooth and efficient incorporation of SDF into your practice.

• Arresting dental caries in pediatric patients, uncooperative individuals and those with special health care needs.⁶
• Preventing caries in geriatric patients or those with limited access to dental care.⁷
• Arresting dental caries in general restorative patients to prevent progression of the lesion between diagnosis and the restorative appointment.
• Desensitizing root surfaces and preventing secondary decay in patients receiving restorations.⁸
• Using SDF as a disclosing solution to assess the presence of decay.⁹

References
1. American Academy of Pediatric Dentistry (AAPD). Chairside Guide: Silver Diamine Fluoride in the Management of Dental Caries Lesions.
2. Krämer, N., Schmidt, M., Lücker, S., Domann, E., & Frankenberger, R. (2018). Glass ionomer cement inhibits secondary caries in an in vitro biofilm model. Clinical oral investigations, 22(2), 1019–1031. https://doi.org/10.1007/ s00784-017-2184-1.
3. Crystal, Y. O., Janal, M. N., Hamilton, D. S., & Niederman, R. (2017). Parental perceptions and acceptance of silver diamine fluoride staining. Journal of the American Dental Association (1939), 148(7), 510–518.e4. https://doi. org/10.1016/j.adaj.2017.03.013.
4. Zheng, F. M., Yan, I. G., Duangthip, D., Gao, S. S., Lo, E. C. M., & Chu, C. H. (2022). Silver diamine fluoride therapy for dental care. The Japanese dental science review, 58, 249–257. https://doi.org/10.1016/j.jdsr.2022.08.001.
5. Young D. A. (2006). The use of glass ionomers as a chemical treatment for caries. Practical procedures & aesthetic dentistry: PPAD, 18(4), 248–250.
6. Crystal YO, Marghalani AA, Ureles SD, et al. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Pediatr Dent 2017;39(5): E135-E145.
7. Angst L, Nüesch N, Grandjean M-L, Watson S, McKenna GJ, Srinivasan M. Caries management using silver diamine fluoride and providing domiciliary dental care for dependent older adults: A qualitative study of Swiss dentists. Community Dent OralEpidemiol. 2023; 51: 469-482. “https://doi.org/10.1111/ cdoe.12774”
8. Castillo JL, Rivera S, Aparicio T, et al. The short-term effects of diammine silver fluoride on tooth sensitivity: a randomized controlled trial. J Dent Res. 2011;90(2):203-208.
9. Chu CH, Lo EC, Lin HC. Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children. J Dent Res. 2002;81(11):767-770.

Dr. Roopwant Kaur, BDS, MS, an associate professor and assistant dean at East Carolina University’s School of Dental Medicine, leads in cariology and operative dentistry curriculum. Kaur serves on multiple national and regional executive boards and her accolades include the ADEA Leadership Institute Award, the Heraeus Kulzer Research Award and the Health Sciences Author Recognition Award, reflecting her dedication to dental education and research in caries risk assessment and student learning methodologies.