I am writing to share an interesting observation from our recent Dentaid mission to Cambodia, in October 2025, regarding the application of silver diamine fluoride (SDF) for dental caries management in children. I represent the clinical team on the trip and we, collectively, would like to draw attention to an unexpected clinical finding. Dentaid missions offer a rare opportunity to see large numbers of children, with high rates of decay, in a compressed timeframe and under these conditions we noticed some cases of pain during SDF application. The aim of this letter is to highlight the findings and encourage further studies that Dentaid missions could potentially facilitate.

Our team, consisting of five dentists and two dental therapists, visited four schools in the Kampong Region, treating over 1,000 children aged between five and ten. The high prevalence of dental caries in this area is, in part, attributable to sugar cane cultivation and persistent traditional beliefs such as ‘tooth worms' causing decay.

During the mission, we applied SDF to 334 children. This was done as per protocol. Any teeth with visible or exposed pulps naturally did not have SDF placement. In most cases this treatment was applied to primary teeth but, due to the expeditionary nature of our clinical environment, we also needed to treat permanent molars often using SDF and glass ionomer cement together as part of the SMART treatment regime.

Despite our primary focus on treatment rather than clinical research, unexpected pain observations during SDF application emerged. 4.2% of treated children experienced sharp pain lasting up to a minute – incidences that provoked distress. Also, it was interesting to note that 78% of the painful incidents were related to first permanent molars.

This unexpected observation underscored the potential complexity of SDF application in children's teeth with large cavities. Although a low percentage, these episodes highlighted the importance of pre-emptively informing patients about possible pain to enhance patient management and comfort.

We hope that this observation opens a dialogue on refining application techniques and patient management strategies for SDF. More systematic data collection and exploration during upcoming missions in Cambodia and Uganda, where sugar cane cultivation is common, are planned. These investigations aim to improve understanding and management of pain associated with SDF applications.

While SDF is vital in settings with limited dental care, awareness of potential pain during its application is crucial. I encourage your readership to consider these findings and highlight the need for further exploration and refinement in SDF practice.