NHS Borders clinical guidelines
- All GDC registered dentists
- All GDC registered hygienists and therapists
- It is the responsibility of those working to this guidance to highlight any deficiencies in the SOP to the appropriate line manager.
Silver Diamine Fluoride (Dental Guidelines)
Warning
Objectives
The objective is to provide guidance on a safe, effective use of silver diamine fluoride for NHS Borders Public Dental Service.
This Standard Operating Procedure (SOP) outlines the clinical guidance for the use of Silver Diamine Fluoride (SDF) within NHS Borders Public Dental Service. It is intended for all GDC-registered dental professionals involved in patient care and aims to support safe, effective, and evidence-based application of SDF as part of caries management. The SOP includes patient selection criteria, contraindications, clinical procedures, follow-up protocols, and training requirements to ensure consistent practice and optimal patient outcomes.
Scope
This guidance outlines the use of Silver Diamine Fluoride (SDF) Riva Star Acqua by SDI (SDI, Bayswater, Victoria) for arresting dental caries in both primary and permanent dentitions, as well as for managing tooth sensitivity in children and adults.
SDF is a colourless, odourless solution of silver, fluoride and ammonium ions. SDF 38% contains 44,800ppm fluoride ions, available in the UK as Riva Star Acqua and can be ordered from Dental Directory.
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.
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 Aqua 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, based on the available evidence.
Many scientific studies from around the world have shown that SDF is effective in reducing the decay rate in children when used in addition to brushing teeth regularly with fluoride toothpaste. SDF has been evidence to have benefits in the following groups:
- Pre-cooperative children whose behaviour/medical conditions limit invasive restorative treatment.
- Children where there is need to delay treatment with sedation or general anaesthesia
Silver Diamine Fluoride (SDF) offers a range of clinical benefits for adult patients, particularly in the management of root caries, dentine hypersensitivity, and non-restorable lesions. Its non-invasive, pain-free application makes it especially valuable for:
- Older adults
- Medically compromised individuals
- Patients with limited access to dental services
SDF arrests caries progression without the need for drilling or anaesthesia, making it an ideal option for patients who may not tolerate conventional treatment. It is also suitable for use in domiciliary settings, providing a practical solution for housebound individuals. Additionally, SDF is beneficial for high caries risk patients whose medical or psychological conditions—such as disabilities, chronic illnesses, dental phobia, or anxiety—limit the feasibility of other treatment modalities.
Audience
- All GDC registered dentists
- All GDC registered hygienists and therapists
- It is the responsibility of those working to this SOP to highlight to the appropriate line manager any deficiencies in the SOP
General Criteria
- Pre-cooperative children whose behaviour or medical conditions limit invasive restorative treatment
- Children or adults with additional care needs where treatment with sedation or general anaesthesia needs to be delayed
- Patients at high caries risk with medical or psychological conditions that limit other treatment modalities (e.g. disabilities, medical conditions, dental phobia/anxiety)
- As part of a biological caries management plan where carious lesions are brushed twice daily with fluoridated toothpaste and appropriate dietary modifications have been made.
- Signs or symptoms of irreversible pulpitis, dental abscess, or fistula
- Radiographic evidence of peri-radicular radiolucency or pulpal involvement
- Infection or pain from pulpal origin or food packing
- Allergy to silver, fluoride, iodine, or ammonia
- Active ulceration, mucositis, or stomatitis
- Pregnant or breastfeeding patients
- Patients undergoing thyroid gland therapy or taking thyroid medication
- Poor or non-compliance with toothbrushing, where parents or carers are unable or unwilling to take responsibility for oral hygiene and diet.
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 requiring extended treatment visits
- Sensitive tooth surfaces, including those with Molar Incisor Hypomineralisation
- Limited or no capacity for patient cooperation without general anaesthesia or sedation
- Acclimatisation prior to cooperation.
Restorative-Based Cavity Control
- Alongside Silver Modified Atraumatic Restorative Treatment (SMART)
- Alongside the Hall Technique (SMART Hall).
- Avoid accidental staining of hands or surfaces by donning surgical gloves and protecting clinical surfaces
- Ensure PPE is worn by the operator, dental nurse, and patient
- Obtain valid informed consent from the patient or parent/carer
- Where practical, take baseline photographs and radiographs to assess the status of carious lesions.
- Prepare the tooth surface by removing debris from the cavitated lesion or area to be treated.
- Apply petroleum jelly to the patient’s peri-oral region to reduce staining from inadvertent SDF contact.
- Isolate the area with cotton wool rolls or dental dam and apply a gingival barrier using petroleum jelly or alternative.
- Dry the carious lesion or tooth tissue using a 3-in-1 syringe or cotton wool roll.
- Pierce the foil on the silver capsule using a micro-brush.
- Apply SDF directly onto the lesion or area of tooth to be treated using the micro-brush.
- Wait a minimum of 1 minute to allow adsorption; maintain isolation for up to 3 minutes if possible.
- Blot away excess solution. If providing a silver-modified ART restoration, encourage the patient to rinse after SDF application prior to GIC placement.
- Apply 5% NaF (fluoride varnish or tooth mousse) to promote remineralisation.
- Review 2–4 weeks after the first application to assess lesion activity. If the lesion remains active, reapplication of SDF may be indicated
- Restore cavitated lesions following SDF application or provide bi-annual SDF reapplication.
Reinforce the importance of maintaining excellent oral hygiene:
- Brush twice daily with 1450ppm fluoride toothpaste
- Limit sweet treats to mealtimes and keep them to a minimum
- All clinical team members must be familiar with the NHS Borders incident reporting system (InPhase)
- All incidents involving fluoride varnish application must be reported via InPhase and escalated to the relevant clinical and operational line manager
- All actions must be documented in the patient’s case notes.
- All staff must comply with NHS Borders statutory and mandatory training requirements
- All GDC registered hygienist therapists, dentists, dental nurses, and orthodontic/dental therapists performing clinical procedures must read and understand this SOP
- All new staff required to carry out clinical procedures must read and understand this SOP as part of their induction.