Free Silver Diamine Fluoride (SDF) Note Template (D1354)
An SDF note has three jobs: list every tooth treated, show the lesions were active and symptom-free, and record that the patient or parent understood the treated lesions will turn black. This D1354 template covers all three, plus isolation, application, and the follow-up plan.
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
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Silver diamine fluoride (38%) application (D1354), teeth: [#A, #B, #J, #K]. Lesions: [cavitated, active occlusal lesions]; teeth non-symptomatic with no clinical signs of pulpal involvement. Caries risk: [high]. Treatment options reviewed with [parent]; permanent black staining of treated lesions and temporary staining of skin or soft tissue explained, [pre-operative photos taken], consent obtained. No known silver allergy. Lips and gingiva protected with [petroleum jelly]; teeth isolated with [cotton rolls] and dried. SDF applied directly to each lesion with a microbrush and allowed to absorb for [1] minute; excess removed. [Fluoride varnish applied over treated and remaining teeth.] Patient tolerated procedure well. Next visit: [re-check arrest in 2-4 weeks; reapply SDF in 6 months].
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When to use this template
Use this silver diamine fluoride note template when you apply 38% SDF to arrest active carious lesions, most often in young children, patients with special health care needs, patients who cannot tolerate conventional restorative care, and older adults with root caries. CDT D1354 is application of caries arresting medicament, reported per tooth, for conservative treatment of an active, non-symptomatic carious lesion without mechanical removal of sound tooth structure. The note should match that definition: list each tooth and surface, and record that the lesions were active and the teeth had no signs of pulpal involvement.
Consent is the sentence that matters most. Arrested lesions stain permanently black, which limits SDF in esthetic areas, and the ADA advises that patients or guardians be told about treatment options, side effects, and the need for follow-up. Record that the staining was explained (a before photo helps) and who consented. Note any contraindication you screened for, such as a silver allergy.
Document the technique briefly: isolation, drying, direct application to the lesion, and removal of excess while protecting the gingiva and lips. SDF is not a one-time treatment. The ADA notes that a single application is not enough and that biannual application is recommended for sustained benefit, so close with the plan to re-check the lesions and reapply. Payers vary widely on how often D1354 is covered per tooth. D1355 (caries preventive medicament) is a different code for prevention on teeth without an active lesion, so do not use it for SDF arrest.
Step by step: how to document this silver diamine fluoride application
- 1
Confirm the indication
Identify active carious lesions on non-symptomatic teeth with no signs of pulpal involvement; record caries risk.
- 2
Consent
Explain permanent black staining of treated lesions and other options; take photos if possible; record who consented.
- 3
Protect and isolate
Protect lips and gingiva, isolate with cotton rolls, and dry the lesions.
- 4
Apply
Apply 38% SDF directly to each lesion with a microbrush, allow it to absorb, then remove excess.
- 5
Record per tooth
List each tooth (and surface) treated so the note matches the per-tooth claim.
- 6
Plan follow-up
Schedule a check of lesion arrest and the reapplication interval.
Tips for using this template
- check_circleList every tooth (and ideally the surface). D1354 is reported per tooth, so the note has to match the claim line for line.
- check_circleRecord that each lesion was active and the tooth non-symptomatic. The code describes treatment of an active, non-symptomatic lesion, and a tooth with pulpal signs needs a different plan.
- check_circleDocument the staining conversation and who consented. Permanent black staining of the lesion is the side effect families remember, and the consent line is your protection.
- check_circleTake pre-operative photos when you can. They make the staining conversation concrete and give you a baseline for judging arrest.
- check_circleScreen for and record contraindications, such as a known silver allergy.
- check_circlePlan the follow-up in the note. The ADA notes a single application is not enough and recommends biannual application for sustained benefit.
- check_circleDo not report D1355 for SDF arrest. D1355 is a caries preventive medicament code for teeth without an active lesion.
- check_circleIf a treated tooth is later restored, note the arrested lesion in the restorative note so the history reads clearly.
Standards & references
- ADA Oral Health Topics: Silver Diamine Fluoride: Indications, permanent black staining of arrested lesions, informed consent, and biannual application.
- ADA Evidence-Based Clinical Practice Guideline on Nonrestorative Treatments for Caries Lesions: ADA guideline (JADA 2018) with the ADA's first recommendations for 38% SDF to arrest cavitated lesions.
- AAPD Policy on the Use of Silver Diamine Fluoride for Pediatric Dental Patients: AAPD supports SDF within an ongoing caries management plan, prescribed after an exam and caries-risk assessment.
- ADA Code on Dental Procedures (CDT): D1354 (application of caries arresting medicament, per tooth) and D1355 (caries preventive medicament).
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