Root caries is an increasing clinical concern in adults and older adults, particularly when gingival recession exposes root surfaces. Unlike enamel, exposed root dentin and cementum are more susceptible to acid-mediated demineralization.
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Silver diamine fluoride (SDF), particularly the 38% formulation, has emerged as a nonrestorative approach for arresting root caries. Its clinical value is based on the ability to inhibit caries progression without requiring conventional cavity preparation.
Current evidence supports SDF as an option for arresting root caries in permanent teeth, although the certainty of evidence and clinical recommendations vary according to the treatment alternative and patient circumstances.
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Root caries develops on exposed root surfaces after loss of periodontal coverage. Dentin and cementum have a higher organic content and are less mineralized than enamel, making them more vulnerable to demineralization.
Root caries management may be particularly challenging in older adults because lesions can occur in multiple teeth and may be associated with gingival recession, plaque accumulation, xerostomia, reduced manual dexterity, or difficulty maintaining oral hygiene.
Conventional restorative treatment remains appropriate when a lesion requires restoration because of structural loss, esthetic requirements, function, or other clinical considerations. However, a nonrestorative strategy can be useful when the primary objective is to arrest disease progression.
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The anticaries effects of SDF are related primarily to its silver and fluoride components.
Silver has antimicrobial properties that can inhibit cariogenic microorganisms and interfere with bacterial activity within the carious lesion. Fluoride contributes to the formation and stabilization of fluoride-containing mineral phases and increases the resistance of dental hard tissues to subsequent acid attack.
For root caries, the objective is not to restore the original anatomy of the tooth. Instead, SDF is used to inactivate the carious lesion and prevent or reduce further progression.
Clinically, an arrested lesion generally becomes harder and darker after treatment. The permanent dark discoloration is an important consequence of SDF therapy and should be incorporated into informed consent.
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Evidence from randomized clinical trials and systematic reviews supports the effectiveness of SDF for root caries in older adults.
A systematic review and meta-analysis evaluating SDF for exposed root surfaces included three controlled clinical trials involving 895 older adults. Compared with placebo, SDF significantly reduced the number of decayed or filled root surfaces at 24 months and at 30 months or longer. SDF also showed preventive effects comparable to chlorhexidine and fluoride varnish in the included studies.
A subsequent systematic review and meta-analysis published in 2021 similarly concluded that SDF was effective for the management of root caries in older adults, while emphasizing the limitations of the available evidence.
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More recent evidence further supports the caries-arresting effect of 38% SDF.
A 2026 randomized controlled trial included 186 community-dwelling older adults, with 323 root caries lesions assessed at baseline. At the 2-month follow-up, 165 participants with 286 lesions remained in the analysis.
The SDF group demonstrated substantially higher arrest rates than the control group:
▪️ Individual level: 81.2% with SDF vs. 21.3% with control
▪️ Lesion level: 84.9% with SDF vs. 20.7% with control
The study also found that SDF application, baseline lesion status, and absence of plaque on the lesion surface were positively associated with caries arrest.
Although the short follow-up limits conclusions regarding long-term effectiveness, these findings provide additional contemporary clinical evidence supporting 38% SDF for arresting root caries.
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The current evidence-based recommendations are nuanced.
The American Dental Association (ADA) guideline on nonrestorative caries treatment identifies 38% SDF as a nonrestorative option for noncavitated and cavitated root caries lesions on permanent teeth.
However, the ADA guideline prioritizes 5,000 ppm fluoride toothpaste or gel used at least once daily over other nonrestorative options, including annual 38% SDF, because of the overall evidence assessment, feasibility, and clinical considerations. The recommendation for root-surface treatment is conditional and based on low-certainty evidence.
Therefore, SDF should not be interpreted as the universally preferred treatment for every root caries lesion. Its value is particularly relevant when a nonrestorative, minimally invasive approach is appropriate.
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Several characteristics make SDF clinically attractive for selected patients:
▪️ Nonrestorative application: no conventional cavity preparation is required to arrest the lesion.
▪️ Minimal invasiveness: treatment can be performed without rotary instrumentation.
▪️ Caries-arresting activity: clinical studies demonstrate significant arrest of root caries compared with placebo.
▪️ Potential usefulness in older adults: particularly when multiple root lesions or treatment limitations are present.
▪️ Simple topical application: the procedure requires relatively limited clinical resources.
▪️ Potential public-health value: SDF may facilitate disease control in populations with barriers to conventional restorative treatment.
These advantages should be considered within a comprehensive caries-management strategy rather than as a replacement for oral hygiene measures, fluoride exposure, dietary management, or restorative treatment when clinically indicated.
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The principal limitation is permanent dark discoloration of the treated carious lesion. This can be particularly relevant when lesions are located on visible root surfaces.
SDF also does not restore lost tooth structure. An arrested lesion may remain cavitated, and the patient may still require restorative treatment when structural integrity, plaque control, function, food impaction, or esthetics are concerns.
Another limitation is the heterogeneity of the available evidence, including differences in lesion characteristics, application protocols, follow-up periods, and patient populations. The ADA therefore assigns a conditional recommendation with low certainty for nonrestorative management of root caries using SDF.
Importantly, evidence from root caries studies should not automatically be extrapolated to every form of dental caries or to every clinical situation.
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The available evidence indicates that 38% silver diamine fluoride is effective in arresting root caries, particularly in older adults. Both earlier systematic reviews and more recent randomized clinical evidence demonstrate a substantially greater likelihood of lesion arrest with SDF than with placebo or control treatment.
Nevertheless, effectiveness should be interpreted in the context of the treatment objective. SDF is primarily a disease-arresting intervention, not a restorative procedure. It can stabilize a carious root surface but does not reconstruct missing dental tissue.
The 2026 randomized trial also highlights the importance of plaque control. The absence of plaque on the lesion surface was positively associated with caries arrest, reinforcing that SDF should be integrated into broader preventive and behavioral management rather than used as an isolated intervention.
Current guidelines consequently position SDF as one component of nonrestorative root-caries management rather than a universal substitute for high-concentration fluoride toothpaste, preventive care, or restorations when indicated.
🎯 Clinical Recommendations
1. Consider 38% SDF for active root caries in permanent teeth when a nonrestorative approach is clinically appropriate.
2. Prioritize comprehensive caries management, including plaque control, appropriate fluoride exposure, dietary counseling, and management of contributing risk factors.
3. Discuss permanent discoloration before treatment, particularly for lesions on visible root surfaces, and obtain appropriate informed consent.
4. Do not regard SDF as a restorative substitute when substantial structural rehabilitation, function, esthetics, or plaque-retentive cavitation requires restoration.
5. Monitor treated lesions clinically for changes in hardness, activity, plaque accumulation, and progression.
6. Use patient-specific decision-making. The ADA currently gives a conditional recommendation with low-certainty evidence for SDF on root surfaces, while prioritizing daily 5,000 ppm fluoride toothpaste or gel as the preferred nonrestorative strategy when feasible.
✍️ Conclusion
Silver diamine fluoride, particularly 38% SDF, has demonstrated clinically significant caries-arresting activity on exposed root surfaces. Evidence from systematic reviews and a recent randomized clinical trial supports its use as a nonrestorative option, especially in older adults and patients for whom conventional restorative treatment may be difficult or undesirable.
However, SDF does not restore lost tooth structure and produces permanent dark staining of treated carious lesions. Its use should therefore be based on lesion characteristics, patient preferences, caries risk, plaque control, functional and esthetic considerations, and the feasibility of alternative preventive or restorative treatments.
📚 References
✔ American Dental Association. (2018). Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association. Journal of the American Dental Association, 149(10), 837–849.e19. https://doi.org/10.1016/j.adaj.2018.07.002
✔ Fontana, M., & Weyant, R. J. (2025). Silver diamine fluoride for caries management: An executive summary of the clinical practice guideline. Journal of the California Dental Association, 53(1), Article 2588948. https://doi.org/10.1080/19424396.2025.2588948
✔ Grandjean, M.-L., Maccarone, N. R., McKenna, G., Müller, F., & Srinivasan, M. (2021). Silver diamine fluoride (SDF) in the management of root caries in elders: A systematic review and meta-analysis. Swiss Dental Journal, 131(5), 417–424. https://doi.org/10.61872/sdj-2021-05-02
✔ Zhang, W., McGrath, C., Lo, E. C. M., & Li, J. Y. (2016). Silver diamine fluoride: A systematic review of clinical trials. Journal of Dental Research, 95(5), 512–519. https://doi.org/10.1177/0022034516630671
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