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Vol 13, No 1 (2025) 
ISSN 2167-8677 (online) 

DOI 10.5195/d3000.2025.1044  

 

	

	

http://dentistry3000.pitt.edu	

Sodium Fluoride Varnish versus Silver Diamine Fluoride Effectiveness 
to Stop Dental Decay in Primary Molars 
 
Lubna Abdulelah Abdulrahman Almallah1, Mohammed Qays Mahmoud Fahmi2, Wurood Khairallah Al-Lehaibi1  
 
1Dijah University College, Iraq 
2College of Den7stry, Musransiriyah University, Iraq

Abstract 

Objec<ve: The aim of this study was to determine how well 38% SDF and 5% NaF varnish 
inhibited primary molar decay. Materials and Methods: 84 children between the ages of 6 
and 9 who had caries without pulpal involvement in their primary teeth were included in the 
randomized controlled experiment. Children were divided between two groups at random. 
5% NaF varnish was applied to Group 1 (n = 42), and 38% SDF was applied to Group 2 (n = 
42). In both groups, the second applicaVon was completed six months later. Children were 
examined for caries arrest and recalled at 6- and 12-month. Results: AXer 6-month intervals, 
the rate of caries arrest was in group 1(NaF varnish – 40.4%) while in group 2 (SDF – 66.6%) 
and aXer 12-month intervals the rate of caries arrest was (NaF varnish – 47.6%) for group 1 
and (SDF- 88%) for group 2 (p<0.05). Conclusion: The SDF group was shown to have higher 
caries arresVng potenVal than the NaF varnish group.  

Open Access 
Cita%on: Almallah LAA, et al. (2025) Sodium Fluoride Var-
nish versus Silver Diamine Fluoride Effec%veness to Stop 
Dental Decay in Primary Molars. Den%stry 3000. 1:a001 
doi:10.5195/d3000.2025.1044 
Received: September 14, 2025  
Accepted: September 25, 2025 
Published: October 15, 2025 
Copyright: ©2025 Almallah LAA, et al. This is an open ac-
cess ar%cle licensed under a Crea%ve Commons ASribu-
%on Work 4.0 United States License. 
Email: Iubna.abd@duc.edu.iq

	

Introduc)on 
Dental	caries	begins	with	0irst	lesions,	which	
are	 dynamic	 and	 resulting	 from	 an	 imbal-
ance	between	the	dental	surface's	deminer-
alization	and	remineralization	[1].	If	remin-
eralization	is	greater	than	demineralization,	
these	 initial	 lesions	 may	 be	 reversed	 or	
stopped.	On	the	other	side,	 if	demineraliza-
tion	 is	 greater	 than	 remineralization,	 they	
may	 become	 cavitations	 [2,3].	 Active	 early	
caries	on	smooth	or	dry	occlusal	surfaces	can	
be	easily	detected	clinically	which	appears	as	
chalky	white	 lesions	 [4].	Conversely,	proxi-
mal	 surfaces	have	consistently	 shown	dif0i-
culties	 for	 early	 detection;	 the	 inability	 to	
self-clean,	 limited	salivary	access,	and	clini-
cal	diagnosis	in	the	contact	point	area	have	
all	 contributed	 to	 this	 challenge	 regarding	
the	early	diagnose	and	treatment	[5].	

The	 treatment	 modalities	 for	 these	 lesions	
include	conventional	restorations,	caries	in-
0iltration,	proximal	sealants,	 increased	0luo-
ride	 usage	 and	maintaining	 dental	 hygiene	
[6].	Many	 studies	 have	 been	 demonstrated	
that	 using	 silver	 0luoride	 (SF)	 products	 to	
treat	carious	lesions	in	both	adults	and	chil-
dren	is	an	effective	minimally	invasive	treat-
ment	option	[7].	On	the	other	hand,	sodium	
0luoride	varnish	(NaF)	has	been	shown	to	be	
useful	in	reducing	the	progression	of	dental	
cavities	by	promoting	remineralization	and	
inhibiting	 demineralization.	 According	 to	
these	 studies,	 using	 0luoride	 varnishes	 can	
prevent	caries	in	young	children	and	reduce	
cavities	by	25%	to	45%	[8-10].	
By	utilizing	caries	arresting	agents	and	ma-
terials	 with	 cariostatic	 properties	that	 re-
duce	 the	 bacterial	 load,	 such	 as	 arginine,	

sealants,	 0luoride	 varnish,	 nanosilver	 0luo-
rides,	and	silver	diamine	0luoride	(SDF),	the	
concept	of	cavity	control	by	restoration	has	
been	 replaced	 by	 prevention	with	minimal	
intervention	[8].	
In	2014,	the	United	States	Food	and	Drug	Ad-
ministration	authorized	SDF.	Since	then,	de-
mand	for	using	it	"off-label"	to	treat	carious	
lesions	in	children	has	grown	[11].		
SDF	offers	an	extensive	list	of	advantages	in	
managing	caries.	It	is	an	effective	in	stopping	
cavitated	 carious	 lesions	 [12-14].	 In	 addi-
tion,	it	is	inexpensive	and	does	not	produce	
any	 aerosol	 and	 does	 not	 need	 any	 dental	
equipment.	Nevertheless,	discoloration	is	its	
primary	drawback	[14].		
In	dentistry,	topical	0luorides,	including	0luo-
ride	varnishes,	are	commonly	utilized	to	re-
mineralize	enamel	 in	 the	 earliest	 lesions	



  Sodium Fluoride Varnish versus Silver Diamine Fluoride EffecVveness to Stop Dental Decay in Primary Molars 

Vol 13, No 1 (2025)    DOI 10.5195/d3000.2025.1044 

	http://dentistry3000.pitt.edu	
2	

without	causing	tooth	discoloration.	As	it	is	
necessary	 to	 assess	 these	 topical	 0luorides'	
ability	to	prevent	cavitated	lesions,	for	this,	
the	current	study	was	carried	to	assess	and	
compare	the	potential	of	semiannually	appli-
cation	of	both	38%	SDF	and	5%	NaF	varnish	
to	 primary	molars	 in	 stopping	 dental	 cavi-
ties.		

Materials and Methods 
The	 total	 number	 of	 participating	 children	
was	 92	 randomly	 chose	 and	 their	 parents	
from	 the	Department	 of	 Pediatric	 and	 Pre-
ventive	Dentistry	of	Dijlah	university	during	
the	academic	year	2023–2024	only	84	were	
responded.	
The	Dijlah	University	Faculty	of	Dentistry's	
Ethical	 Committee	 created	 and	 authorized	
the	informed	ethical	consent	form.	
Following	screening,	the	children	who	satis-
0ied	the	study's	inclusion	requirements	were	
given	permission	 to	participate.	During	 the	
questionnaire	 interview,	 each	 participant	
was	requested	to	sign	a	 formal	ethical	con-
sent	form.	
Children	were	 chosen	 following	 the	 CPITN	
probe	 evaluation	 of	 the	 carious	 lesion	 and	
the	 intraoral	 periapical	 radiograph,	 which	
con0irmed	 the	 depth	 of	 the	 lesion	 in	 teeth	
with	 radiolucency	 restricted	 to	 the	 outer	
third	of	the	dentin.	
A	total	of	84	child	was	randomized	into	two	
groups:	Group	1	 consisting	of	5%	NaF	var-
nish	and	Group	2	consisting	of	38%	SDF.	
Children	whose	parents	are	strongly	against	
0luoride	 staining	 with	 silver	 diamine,	 Chil-
dren	whose	medical	conditions	are	too	dif0i-
cult			to	treat	in	clinic,	Children	who	are	sen-
sitive	to	silver	products,	were	excluded.	
Children	 between	 the	 ages	 of	 6	 and	9	who	
were	cooperative	and	willing	to	take	part	in	
the	study	were	those	with	occlusal	carries	in	
primary	molar	teeth	without	any	pulpal	 in-
volvement.	
Although	 the	 socioeconomic	 status	 of	 the	
families’	 children	 whose	 participate	 was	
quite	 close	 to	 one	 another,	 the	 researcher	
matched	the	two	groups	using	the	socioeco-
nomic	 status	 (SES)	 questionnaire	 that	 was	
already	in	use	(28)	(one	of	the	parents	com-
pleted	the	questionnaire)	to	minimize	the	in-
accuracy	 of	 the	 results.	 In	 this	 study,	 oral	
health	 behaviors	 like	 cleaning	 one's	 teeth	
and	consuming	sugar	were	matched	by	age,	
gender,	 and	 SES	 status	 using	 the	 group	
matching	approach.	
After	using	a	rubber	cup	and	no	0luoridated	
pumice	 powder	 to	 clean	 the	 chosen	 teeth,	
they	were	rinsed	and	allowed	to	dry	for	0ive	
seconds.	Cotton	rollers	were	used	for	isola-
tion.	
	At	the	initial	visit	and	six	months	later,	SDF	
and	NaF	varnish	were	applied	to	every	cari-
ous	 primary	 molar	 a	 single	 operator	

performed	 every	 clinical	 operation.	 A	 tiny	
applicator	tip	was	used	to	apply	Group	1	top-
ical	 NaF	 varnish	 (Embrace	 Varnish,	
Pulpdent,	USA),	which	was	then	given	a	mi-
nute	to	dry.	The	patient	was	instructed	not	to	
eat	 or	 drink	 anything	 for	 thirty	minutes	 in	
addition	 to	 receiving	 information	 on	 good	
oral	hygiene.	The	5%	NaF	varnish	was	re-ap-
plied	 after	 6-	 and	12-month	 intervals	 from	
baseline.	To	prevent	SDF	discoloration,	vas-
eline	was	administered	around	the	tooth	and	
gingiva	in	Group	2,	then	using	a	tiny	applica-
tor	 tip,	 SDF	 (Riva	 Star,	 SDI	 Inc.,	 Australia)	
was	applied	to	the	lesion with	cavitation,	for	
approximately	 2	 minutes	 were	 allowed	 to	
pass.	A	gentle	air0low	was	used	to	accelerate	
the	drying	process.	If	possible,	the	lesion	was	
kept	 isolated	 for	 three	minutes.	 To	 reduce	
systemic	absorption,	excess	SDF	was	elimi-
nated	using	a	cotton	pellet	[11].	
On	 the	 other	 hand,	 potential	 lesions	 were	
cleaned	and	dried	by	a	piece	of	cotton	before	
examination.	 Assessing	 lesion	 activity	 was	
done	by	visual	 inspection	and	tactile	detec-
tion	using	a	0.5	mm	ball-ended	Community	
Periodontal	 Index	 (CPI)	 periodontal	 probe	
and	a	disposable	dental	mirror.	Lesions	were	
assessed	at	baseline	and	after	6	months	and	
after	 12	months,	 If	 the	 cavity	wall	 or	 0loor	
could	be	readily	pierced	with	minimal	force	
using	the	CPITN	probe,	active	caries	was	de-
tected	during	the	recall	visits.		
Hard-surfaced	 cavities	were	 categorized	 as	
stopped	 caries,	 whenever	 an	 active	
tooth	caries	 lesion	 detected	 at	 baseline	 be-
came	inactive	during	follow-up,	stopped	car-
ies	was	reported	[5].	
The	 statistical	 package	 for	 social	 sciences	
(SPSS)	(version	25)	was	used	to	analyze	the	
data.	The	chi-square	test	was	used	to	assess	
the	 collected	 data.	 Statistical	 signi0icance	
was	determined	by	considering	a	probability	
value	of	<	0.05.	

Results 
In	 this	 study,	 children’s	Participation	 is	de-
scribed	in	the	CONSORT	0low	diagram	(Fig-
ure	1).	
The	total	sample	84	child,	the	research	was	
done	during	 the	academic	year	2023–2024	
were	randomized	into	two	groups:	Group	1	
consisting	 of	 5%	NaF	 varnish	 and	Group	 2	
consisting	of	38%	SDF.	
The	potential	of	caries	arresting	for	both	ma-
terials	 at	 6-	 and	 12-month	 intervals	 as	 in-
tragroup	 comparison,	 this	 difference	 was	
found	to	be	statistically	signi0icant	in	the	SDF	
(P	<0.05)	while	not	signi0icant	 for	NaF	var-
nish	(P	>0.05)	groups	(Table	1).	
The	potential	of	caries	arresting	was	 found	
to	be	greater	for	SDF	(66.6%)	at	6-month	in-
tervals	 on	 intergroup	 comparison	 than	 for	
NaF	 varnish	 (40.4%),	 and	 the	 differences	

were	 determined	 to	 be	 statistically	 signi0i-
cant	(P	<	0.05).	
Likewise,	at	12-month	intervals,	there	was	a	
statistically	signi0icant	difference	(P	<	0.05)	
in	 the	 performance	 of	 SDF	 (88%)	 and	NaF	
varnish	(47.6%)	(Table	2).	

Discussion 
Two	approaches	 for	 treating	 active	 carious	
lesions	are	indicated.	The	two	types	of	cavity	
control	 are	 nonrestorative	 (NRCC)	 and	 re-
storative	(RCC)	[15,16].		
Since	NRCC	doesn't	include	drilling	or	anes-
thetic	and	tries	to	keep	primary	teeth	func-
tioning	 until	 they	 are	 exfoliated,	 it	 is	 re-
garded	 as	 a	 kid-friendly	 procedure	 [16].	 It	
has	an	advantage	over	conventional	restora-
tive	therapy	since	it	does	away	with	the	anx-
iety	 and	 tension	 that	 intrusive	 restorative	
therapy	frequently	causes.	
A	squamous	layer	of	silver-protein	conjugate	
forms	when	SDF	is	applied	to	a	decaying	sur-
face,	strengthening	the	tooth's	resistance	to	
enzymatic	 digestion	 and	 acid	 breakdown	
[17,18].	
As	 the	 depth	 of	 the	 lesion	 diminishes,	 the	
mineral	density	and	hardness	of	the	treated	
lesion	increase	[13].	Silver	 ions	destroy	the	
germs	causing	dental	cavities	[14,15]	by	rup-
turing	 the	 cell	 membrane,	 denaturing	 pro-
teins,	and	preventing	DNA	replication.	
When	 the	 SDF’s	 0luoride	 ingredient	 com-
bines	with	calcium	phosphate	and	hydroxy-
apatite	to	generate	0luorapatite	and	calcium	
0luoride,	it	strengthens	the	oral	hard	tissues'	
resistance	to	acid	attack	[13,17].	SDF	used	in	
the	control	group	as	it	is	a	topical	mediation	
that	has	been	shown	to	be	effective	in	stop-
ping	cavitated	caries	lesions.	
SDF	 is	 currently	 receiving	 a	 lot	 of	 interest	
from	 researchers	 and	 dentists.	 SDF	 differs	
from	other	caries-preventive	agents	in	that	it	
has	 the	 capacity	 to	 regulate	 the	 caries	pro-
cess.	
Because	0luoride	varnishes	are	so	simple	to	
use	 on	 pre-cooperative	 children	 as	well	 as	
those	with	special	needs,	they	have	become	
extremely	 popular	 in	 the	 pediatric	 dental	
community.	According	to	Virupaxi	et	al.	[18],	
0luoride	 varnish	 can	 reduce	 dental	 cavities	
by	25%	to	45%	and	helps	in	preventing	car-
ies	in	young	children.	
Since	 it	 has	 been	 determined	 from	 the	 re-
search	that	children	in	the	age	range	of	6	to	
9	 years	 old	 have	 a	 high	 frequency	 of	 un-
treated	carious	lesions,	these	children	were	
taken	 into	 consideration	 for	 the	 study.	 To	
prevent	 dentinal	 caries,	 we	 investigated	 at	
an	 application	 of	 semiannual	 regimen	 for	
SDF	and	NaF	varnish.		
According	 to	Fung	et	al.	 [19],	38%	SDF	ap-
plied	semiannually	(75.7%)	is	more	success-
ful	in	preventing	dentinal	caries	than	SDF	ap-
plied	 annually	 (66.9%).	 According	 to	 the	



  Sodium Fluoride Varnish versus Silver Diamine Fluoride EffecVveness to Stop Dental Decay in Primary Molars 

Vol 13, No 1 (2025)    DOI 10.5195/d3000.2025.1044 

	http://dentistry3000.pitt.edu	
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American	Dental	Association	Council	on	Sci-
enti0ic	Affairs,	high-risk	people	can	success-
fully	lower	their	caries	prevalence	by	admin-
istering	 0luoride	 varnish	 every	 six	 months	
[20].	
In	the	current	study,	there	was	no	attempt	to	
excavate	carious	tissue,	facilitating	an	easier	
and	faster	application	process.		
Compared	to	proximal	lesions,	occlusal	cavi-
tated	 lesions	are	more	easily	 accessible	 for	
hygiene	management.	The	darkening	of	 the	
lesions	 treated	 with	 SDF	 typically	 ranges	
from	gray	to	black.	
In	primary	molars,	SDF	was	found	to	have	a	
greater	 caries	 stopping	 capacity	 than	 NaF	
varnish	at	6-	and	12-months	periods	 in	the	
present	 investigation.	This	may	be	because	
38%	SDF	has	an	alkaline	nature	and	a	high	
concentration	of	0luoride	(44,800	ppm)	and	
silver	(253,870	ppm).	It	essentially	prevents	
bacterial	 growth	and	 then	promotes	dentin	
remineralization.	On	the	other	hand,	the	0lu-
oride	 concentration	 of	 5%	 NaF	 varnish	 is	
lower—22,600	ppm.	
These	 0indings	 are	 corresponded	 to	 a	 12-
month	 follow-up	 randomized	 controlled	
study	 on	 young	 children	 carried	 out	 by	
Mabangkhru	et	al.	[21].	They	concluded	that,	
when	applied	semiannually,	38%	SDF	had	a	
stronger	caries	arresting	potential	 than	5%	
NaF	varnish.		
In	addition,	Duangthip	et	al.	found	that	SDF	
had	a	66%	greater	ef0icacy	than	NaF	varnish	
(41%),	in	reducing	carious	lesions	[22].	Sim-
ilarly,	38%	of	SDF	has	65%–91%	caries	ar-
resting	 potential	 in	 the	 primary	 dentition,	
while	0luoride	varnish	has	38%–44%	caries	
arresting	potential,	according	to	an	umbrella	
review	by	Seifo	et	al	[23].	
Fluoride	 varnish	 showed	 a	 42%	 caries	 ar-
resting	potential	in	the	current	investigation	
at	12-month	intervals.	Fluoride	varnish	use	
was	found	to	minimize	caries	in	the	primary	
dentition	with	a	37%	preventive	percentage	
in	a	Cochrane	comprehensive	study	[19].	The	
primary	mechanism	by	which	 0luoride	 var-
nish	regulates	 the	advancement	of	caries	 is	
one.	It	raises	the	hard	tissues'	ability	to	resist	
demineralization	in	the	event	of	subsequent	
pH	 dips	 and	 restores	 the	 mineral	 content	
that	was	lost	while	the	caries	process	was	ac-
tive	[6].	
Fluoride	 varnish	 showed	 a	 42%	 caries	 ar-
resting	potential	in	the	current	investigation	
at	12-month	intervals.	Fluoride	varnish	use	
was	found	to	minimize	caries	in	the	primary	
dentition	with	a	37%	preventive	percentage	
in	a	Cochrane	comprehensive	study	[24].	The	
primary	mechanism	by	which	 0luoride	 var-
nish	regulates	the	advancement	of	caries	is	a	
single.	In	the	instance	of	additional	pH	drops,	
it	strengthens	the	hard	tissues'	resistance	to	
demineralization	 and	 brings	 back	 the	

mineral	content	lost	during	the	active	caries	
process	[13].		
In	the	current	investigation,	the	SDF	showed	
a	higher	rate	of	caries	arrest	 than	NaF	var-
nish	 groups	 at	 6-	 and	 12-month	 intervals.	
This	might	be	because	of	the	second	applica-
tion	separated	six	months	apart.	In	a	similar	
vein,	 Zhi	 et	 al.	 [25]	 found	 that	 when	 SDF	
treatment	frequency	was	raised	to	every	six	
months,	the	percentage	of	active	dentin	that	
had	 been	 arrested	 increased.	 According	 to	
Mabangkhru	et	al.	[21],	SDF	and	NaF	varnish	
had	 greater	 caries	 arrest	 rates	 at	 the	 12-
month	 time	periods	 than	 they	did	at	 the	6-
month	time	periods.	This	might	be	brought	
on	by	maintaining	proper	dental	hygiene	and	
using	 topical	 0luoride	 on	 a	 regular	 applica-
tion.	
Children	 who	 are	 uncooperative	 with	 con-
ventional	caries	therapy	can	safely	use	SDF.	
It	 takes	 less	 time	 and	 requires	 little	 equip-
ment,	making	it	easy	to	become	involved	in	a	
communal	environment.	This	facilitates	bet-
ter	 dental	 care	 accessibility	 in	 rural	 loca-
tions.	
Most	of	the	time,	using	SDF	has	more	bene-
0its	than	disadvantages,	such	as	the	staining	
of	 dentin	 lesions	 black,	 beside	 it	 can	 stop	
dental	cavities.	NaF	varnish	is	not	as	effective	
as	SDF.	Therefore,	SDF	can	be	regularly	ap-
plied	to	cavitated	primary	molars	as	a	tech-
nique	of	interim	therapy.	
The	study's	therapeutic	implications	include	
evidence	that	38%	of	SDF	successfully	stops	
caries	lesions	with	cavitation.	Therefore,	this	
can	 be	 applied	 in	 underprivileged	 areas	
where	 early	 primary	 tooth	 loss	 and	 un-
treated	dental	caries	are	common.	
Conclusion 
SDF	demonstrated	more	caries	arresting	po-
tential	than	NaF	varnish	when	applied	semi-
annually	to	cavitated	primary	molars.	
Conflict of Interest 
None.	
Acknowledgements 
The			authors			would			like			to			thank	Dijlah	
University,	Baghdad,	 Iraq,	 for	 their	support	
in	the	present	work.	
Financial Support and Sponsorship 
None.	

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Table	1.	Comparison	of	effectiveness	between	silver	diamine	0luoride	and	sodium	0luoride	varnish	at	two	different	time.	

	

	
	
	
	
	
	
	
	
	
	
	
	
	
	

Table	2.	Comparison	of	the	effectiveness	of	sodium	0luoride	varnish	and	silver	diamine	0luoride	in	arresting	caries	lesion	at	two	distinct	times.		
	
	

	
	
	
	
	
	
	
	
	
	
	
	
	
	
	

	
	
	
	
	

	
	

Group	

	
	
Time	interval	

Caries	activity	 	
	
X2	

	

P<0.05	

		Caries	arrested	 Caries	active	

	
SDF	

	
	

6	 28	(66.6%)	 14	(28.5%)	 	
5.509	

	
df	=	1	
	

critical	value	=	3.84	
12	 37	(88%)	 5	(11.9%)	

	
NaF	varnish	
	

6	 17	(40.4%)	 25	(59.5%)	 	
0.434	

12	 20	(47.6%)	 22	(52.3%)	

	
	

Time	interval	

	
	

Group	

Caries	activity	 	
	
X2	

		P<0.05	

	
Caries	arrested	 Caries	active	

	
6	

SDF	
	

28	(66.6%)	 14	(28.5%)	 	
5.791	

	
	

df	=	1	
	

critical	value	=	3.84	

NaF	varnish	
	

17	(40.4%)	 25	(59.5%)	

	
12	
	
	

SDF	
	

37	(88%)	 5	(11.9%)	 	
15.773	

NaF	varnish	
	

20	(47.6%)	 22	(52.3%)	



  Sodium Fluoride Varnish versus Silver Diamine Fluoride EffecVveness to Stop Dental Decay in Primary Molars 

Vol 13, No 1 (2025)    DOI 10.5195/d3000.2025.1044 

	http://dentistry3000.pitt.edu	
5	

	
Figure	1.	The	0low	graphic	shows	how	children	participate	in	the	study.	

	
	
	
	
	
	
	
	
	
	
	
							 	

																																																																							
	

	
	
													 	 																																																																		 	

6	months	follow	up	
	
	
	
	
	
	
12	months	follow	up		

Randomize (n=84 children) 

Group I, 5%NaF (n=42) 

Follow up17 (40.4%)	

Follow	up20	(47.6%)	

Group II, 38%SDF (n=42)	

Follow up28 (66.6%)	

Follow up 37 (88%)