{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,29]],"date-time":"2026-08-29T07:17:12Z","timestamp":1787987832383,"version":"build-2784847793"},"reference-count":34,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,3,10]],"date-time":"2026-03-10T00:00:00Z","timestamp":1773100800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Children"],"abstract":"<jats:p>Early childhood caries (ECC) is a complex, multifactorial disease shaped by biofilm ecology, host susceptibility, diet and behaviors, and structural determinants of health. Silver diamine fluoride (SDF) is an effective non-restorative option for arresting cavitated lesions in many settings and can support access when definitive care is delayed. However, translating short-horizon \u201carrest\u201d outcomes into broad policy claims\u2014that SDF-first, delegated pathways can substitute for dentist-led diagnosis and comprehensive rehabilitation\u2014risks institutionalizing a two-tier standard of care for children facing the greatest access barriers. This perspective critically appraises evidence-to-implementation pathways for SDF and delegated ECC management, using risk-of-bias and reporting guidance as interpretive tools and drawing on pragmatic regimen trials, microbiome substudies, oral health-related quality of life (OHRQoL) analyses, and implementation work including the Canadian Caries Risk Assessment Tool (CCRAT) in primary care. We explicitly distinguish what studies demonstrate (e.g., feasibility and short-term arrest differences by reapplication interval) from what they do not establish (e.g., long-term tooth survival, pulpal outcomes, definitive treatment completion, and equity impacts). We propose practical guardrails that position SDF as interim management within a continuum of care: dentist-led diagnosis and escalation when pulpal risk is suspected; time-bound referral pathways with completion tracking; protocolized follow-up aligned with lesion\/risk status; outcome sets that extend beyond \u201carrest\u201d to include pain, function, OHRQoL, tooth survival, and equity stratification; and lesion-site sampling plus preregistered analyses when mechanistic claims are advanced.<\/jats:p>","DOI":"10.3390\/children13030386","type":"journal-article","created":{"date-parts":[[2026,3,10]],"date-time":"2026-03-10T08:43:31Z","timestamp":1773132211000},"page":"386","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Equity or Two-Tier Care? Guardrails for Silver Diamine Fluoride and Delegated Early Childhood Caries Pathways"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0071-9141","authenticated-orcid":false,"given":"Ziad D.","family":"Baghdadi","sequence":"first","affiliation":[{"name":"Centre for Community Oral Health, Dr. Gerald Niznick College of Dentistry, University of Manitoba, Winnipeg, MB R3B 0L8, Canada"},{"name":"Department of Preventive Dental Sciences, Division of Pediatric Dentistry, Dr. Gerald Niznick College of Dentistry, University of Manitoba, Winnipeg, MB R3E 0W2, Canada"},{"name":"TopSmiles Pediatric Dentistry and Orthodontics, Winnipeg, MB R2M 3A4, Canada"},{"name":"Butterfly Dental Group, Winnipeg, MB R3Y 1P5, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,10]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e510","DOI":"10.1542\/peds.2006-3084","article-title":"Influences on children\u2019s oral health: A conceptual model","volume":"120","author":"Gansky","year":"2007","journal-title":"Pediatrics"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1111\/omi.12152","article-title":"Advances in the microbial etiology and pathogenesis of early childhood caries","volume":"32","author":"Hajishengallis","year":"2017","journal-title":"Mol. 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