• All Highland HSCP
  • Primary Care Public Dental Services staff; GDC registered dentists. 
  • It is the responsibility of those working to this guideline to highlight to the appropriate manager any deficiencies in the guidance.  


Key considerations for use of Silver Diamine Flouride in NHS Highland

Patient selection criteria

  • Pre-cooperative children whose behaviour/medical conditions limit invasive restorative treatment.
  • Children where there is need to delay treatment with sedation or general anaesthesia.
  • High caries risk with medical or psychological conditions that limit other treatment modalities i.e. disabilities, medical conditions, dental phobia/anxiety.
  • As part of a biological caries management plan where carious lesions are also brushed twice daily using fluoridated toothpaste and appropriate dietary modifications have been made.

Exclusion criteria 

  • Signs/symptoms of irreversible pulpitis or dental abscess/fistula.
  • Radiographic peri-radicular radiolucency or signs of pulpal involvement.
  • Infection/pain from pulpal origin or food packing.
  • Allergy to silver, fluoride, iodine, ammonia.
  • Active ulceration, mucositis, stomatitis.
  • Pregnant or breastfeeding. 
  • Patients undergoing thyroid gland therapy or on thyroid medication.
  • Poor/non-compliance with tooth brushing where parents unable/unwilling to take responsibility for child tooth brushing and diet.

Quick reference guide


Silver diamine fluoride

Many scientific studies from around the world have shown that silver diamine flouride is effective in reducing the decay rate in children when used in addition to brushing teeth regularly with fluoride toothpaste.

Chemical reactions on contact with carious tooth tissue promote desensitisation via dentinal tubule occlusion,

bacterial death, remineralisation and inhibition of collagen degradation. This mechanism of action:

  • Promotes arrest and remineralisation of active carious lesions, dentinal caries and teeth with exposed root surfaces causing hypersensitivity.
  • Promotes reduced sensitivity in permanent molar teeth with molar incisor hypomineralisation via occlusion of dentinal tubules.

Silver diamine fluoride (SDF) is a colourless, odourless solution of silver, fluoride and ammonium ions.

SDF 38% contains 44,800ppm fluoride ions. It is available in the UK as Riva Star by SDI (SDI, Bayswater, Victoria) and can be ordered from Dental Directory.

SDF is licensed in the UK for management of dentine hypersensitivity and would also seem to be useful for managing hypomineralised molars that are sensitive.

There is now a body of evidence to support its use off-label as a cariostatic agent either on open carious lesions or under restorations in primary and permanent teeth.

Use of Riva Star SDF for caries arrest remains off-label in the UK, in the same way that some fluoride varnish

preparations are. This means that, although it is not licensed for use for caries arrest, it can be used off-label by

licenced professionals when judged by the prescriber to be in the best interests of the patient, on the basis of the available evidence.

Please note the increased responsibility to those prescribing, supplying and administering a product outside of its product licence, see here.


Selection criteria for SDF use in non-restorative cavity control 
  • Inadequate tooth tissue remaining for a restorative solution or non-restorable dentinal lesions. 
  • Asymptomatic cavitated dentine carious lesions in primary teeth. 
  • Lesions that have been made cleansable.
  • Multiple carious lesions that require extended treatment visits. 
  • Sensitive tooth surfaces including those in Molar Incisor Hypomineralisation. 
  • Limited or no capacity for patient cooperation without general anaesthesia/sedation. 
  • Acclimatisation prior to cooperation
Selection criteria for SDF in restorative-based cavity control 
  • Alongside atraumatic restorative treatment (ART)
  • Alongside the Hall Technique (SMART Hall)
Pre-operative consideratins 
  • Ensure avoidance of accidental staining of hands or surfaces via donning surgical gloves and protection of clinical surfaces. 
  • Ensure personal protective equipment (PPE) is worn by operator, dental nurse and patient.
  • Ensure valid informed consent (checking the child’s name, DOB, address) has been gained by patient or parent/carer. 
  • Where practical baseline photographs and radiographs should be taken to record and assess status of carious lesion
Clinical application method 
  1. Preparation of tooth surface via removal of debris from cavitated lesion/area of tooth to be treated.
  2. Application of petroleum jelly to patient peri oral region to reduce staining via inadvertent SDF contact. 
  3. Isolate area with cotton wool roll/dental dam and application of gingival barrier with petroleum jelly or alternative (systematic approach working from upper right quadrant clockwise or beginning with tooth with largest cavity).
  4. Dry carious lesion/tooth tissue gently with 3in1 airflow or cotton wools roll/ball or gauze.
  5. Pierce foil on silver capsule with micro-brush (each capsule is for 1 patient only and a maximum of 1 capsule should be used per visit). 
  6. Apply SDF directly onto lesion/area of tooth to be treated with micro-brush.
  7. Wait 1 minute minimum to allow adsorption, keep isolation in place for up to 3 minutes if possible. 
  8. Blot away excess solution. (If providing a silver modified ART restoration, encourage patient to rinse after SDF application prior to GIC placement. 
  9. Apply potassium iodide (from green capsule with green microbrush provided or new microbrush) if this has been agreed with parent as part of consent process (research shows results from reduction in staining mixed but efficacy of SDF reduced). a. Pierce foil of green capsule b. Apply solution to treatment site c. Continue application until creamy white solution present on lesion turns clear 10. Apply 5% NaF (Fluoride varnish/Tooth mousse) to promote remineralisation (a silver diamine fluoride capsule contains 3mg fluoride therefore toxic dose will not be exceeded provided Duraphat® varnish measured out as per 0.25ml or 0.4ml on pad) 11. Remove gingival barrier if used
Follow up 
  • 2-4 weeks following first application to determine activity of carious lesion, if lesion remains active, reapplication of SDF may be indicated. 
  • Restore cavitated lesion following SDF application or provide bi-annual SDF reapplication
Post application instructions 
  • Reinforce the requirement for the patient/parent to maintain excellent oral hygiene by brushing 2*daily with 1450ppmF toothpaste and keeping sweet treats to a minimum and after meals only.
Incident reporting 
  • All members of the clinical team will be familiar with NHSH’s incident reporting system (DATIX). All incidents involving application of fluoride varnish will be reported on DATIX and escalated to the relevant clinical and operational line manager. 
  • All actions must be documented in patients’ case notes.
  • All staff are required to demonstrate compliance with NHSH statutory and mandatory training requirements. 
  • All undergraduate, postgraduate, GDC registered hygienist therapy students, dentists, dental nurses and orthodontic/dental therapists who carry out clinical procedures as part of their role are required to read and understand this guideline.
    • All new staff that will be required to carry out a clinical procedure on a patient as part of their role are required to read and understand this guideline as part of their induction.


Abbreviation  Meaning 
SDF  silver diamine flouride

Last reviewed: 01/12/2022

Next review date: 31/12/2025

Version: 1

Approved By: TAMSG of the ADTC

Reviewer name(s): John Lyon, Director of dentistry and clinical director (Public dental service) .

Document Id: TAM540

Internal URL: https://rightdecisions.scot.nhs.uk/umbraco#/content/content/edit/28748

Related resources

Further information for Health Care Professionals

(Scroll down to see all references)


Further information for Patients

  • All patients/carers must be issued with written guidance and must have signed consent form prior to application.

Self-management information