|Year : 2021 | Volume
| Issue : 1 | Page : 85-89
Evaluation of the clinical efficacy of 38% silver diamine fluoride in arresting dental caries in primary teeth and its parental acceptance
Aparna Chaurasiya, Sushma Gojanur
Department of Pedodontics and Preventive Dentistry, KD Dental College and Hospital, Mathura, Uttar Pradesh, India
|Date of Submission||25-Jan-2021|
|Date of Decision||25-Feb-2021|
|Date of Acceptance||02-Mar-2021|
|Date of Web Publication||22-Apr-2021|
Dr. Aparna Chaurasiya
Department of Pedodontics and Preventive Dentistry, KD Dental College and Hospital, NH#2, Chattikara, Mathura - 281 006, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Early childhood caries (ECC) has been regarded as one of the most prevalent chronic diseases in children. Conventional restorative management of ECC is difficult to perform in very young and apprehensive children. Silver diamine fluoride (SDF) can be a useful tool in the management of dental caries by arresting the carious lesion in primary teeth. After SDF treatment, the dentinal staining that is associated with SDF influences the acceptance of this treatment among parents of young children. Aim: This study aimed to evaluate the clinical effectiveness of biannual application of 38% SDF followed by 5% sodium fluoride (NaF) varnish for arresting dental caries in children and its parental acceptance. Methods: Twenty-six children aged 2–5 years with 107 active caries lesions in primary teeth were enrolled. At the baseline examination, status of carious lesions was recorded and scored according to the International Caries Detection and Assessment System II. Lesion activity was assessed by visual inspection and tactile detection. Carious lesions with score 3, 4, 5, and 6 were treated with 38%SDF application, followed by 5% NaF varnish. Children were re-evaluated at 3 weeks, 3 months, 6 months, and 12 months. Parental acceptance of SDF treatment was evaluated. Results: This study demonstrated that 38% SDF was 92.31% effective in arresting dental caries in primary teeth and was well accepted by parents. Chi-square test was used to assess the significant difference among the arrested lesions which was statistically significant (P < 0.05). Conclusion: Thirty-eight percent SDF can be effectively used in arresting caries in primary teeth in young and uncooperative children.
Keywords: 38% Silver Diamine Fluoride, Dental Caries, Primary Teeth
|How to cite this article:|
Chaurasiya A, Gojanur S. Evaluation of the clinical efficacy of 38% silver diamine fluoride in arresting dental caries in primary teeth and its parental acceptance. J Indian Soc Pedod Prev Dent 2021;39:85-9
|How to cite this URL:|
Chaurasiya A, Gojanur S. Evaluation of the clinical efficacy of 38% silver diamine fluoride in arresting dental caries in primary teeth and its parental acceptance. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2021 Jun 21];39:85-9. Available from: https://www.jisppd.com/text.asp?2021/39/1/85/314359
| Introduction|| |
Early childhood caries (ECC) is a serious public health problem in both developing and industrialized countries. Consequences of untreated caries may remember the expanded danger of future caries for essential and lasting dentition, pain and infection, delayed growth and development, high treatment costs, loss of school days, and low self-esteem. Managing and treating dental caries in children and in individuals with special health care needs is challenging and the treatment often requires advanced pharmacologic behavior guidance such as sedation and general anesthesia, which can be expensive. To reduce the burden of caries in young children and to avoid possible serious consequences of untreated decay, it is important to identify an effective, low-cost method of treating caries in children. Subsequently, over the years, various other topical fluoride agents have been evolved. Fluorides have been proved to be the single most effective weapon in still limited arsenal of anticaries agents in the last 60 years.
Among the available methods, silver diamine fluoride (SDF) solution was approved for use as a therapeutic agent in Japan in the 1960s. SDF is a colorless liquid, with 25% silver, 8% ammonia, 5% fluoride, and 62% water containing 44,800 ppm fluoride ion at pH 10. SDF has been used to manage dental caries in young children, arrest root caries in elderly patients, prevent pit and fissure caries, secondary caries, and desensitize teeth with hypersensitivity. It has an anticariogenic agent inhibiting the growth of cariogenic biofilms, inhibits the demineralization of dentine, enhances remineralization, and preserves the dentine collagen from further degradation. The specific interest in SDF centers attributes that include control of pain and infection, ease and simplicity of use (paint on), affordability of material, minimal requirement for personnel time and training, and noninvasive. It is difficult to perform restorative treatments in an uncooperative child. Hence, SDF treatment will be extremely helpful in this group of vulnerable pediatric patients and their families. The black dental staining is the main barrier for the parental acceptance toward the SDF treatment into their child's teeth. Thus, the objective of this study was to evaluate the effectiveness of a 38% SDF solution in arresting dental caries in primary teeth and the parental acceptance of SDF treatment in their children.
| Methods|| |
An in vivo study was performed on 26 uncooperative children, aged 2–5 years, with 107 active, untreated dental carious lesions. Children who visited the department of pedodontics and preventive dentistry were enrolled in the study. The protocol for this study was approved by the institutional ethical board. To be included in the study, children had to have at least 1 carious lesion as defined by the International Caries Detection and Assessment System II (ICDAS II). Using ICDAS II, lesions were categorized as active (soft) cavitated carious lesions in the primary dentition, extending into the dentin (ICDAS 5 or 6), and noncavitated lesions (ICDAS 3 or 4). Exclusion criteria were children with spontaneous pain from a cavity, signs of pulpal infection, tooth mobility, nonvital tooth, developmental defects such as amelogenesis imperfecta or dentinogenesis imperfecta, and inability to cooperate for SDF treatment or return for recall visits at 3 weeks, 3 months, 6 months, and 12 months. Before participating in the study, informed consent was obtained from the child's parent/guardian regarding SDF explaining the purpose, procedure, advantages and disadvantages, and follow-up of the study. At the baseline examination, status of carious lesions was recorded and scored according to ICDAS II. Lesion activity was assessed by visual inspection and tactile detection. Cavities with yellowish/brown color considered as active and black as arrested. Gentle force was used and great care was taken to avoid damaging the teeth during probing. If the cavity wall or floor was easily penetrated by the WHO ball-end probe using gentle force, it was diagnosed as active caries. Cavities with smooth and hard surfaces were classified as arrested caries. Food debris was removed from the surface of the teeth using a cotton roll and dried the tooth surface. No carious tissues were removed from the lesions before SDF application. Petroleum jelly was applied onto the lips and gingiva to protect soft tissues from staining. Isolation was done with cotton rolls. Thirty-eight SDF (FAgamin®, Tedequim Company, Córdoba, Argentina) solution was placed in a plastic dappen dish and applied directly to the lesion with a disposable microtip applicator and it was allowed to absorb for up to 30–60 s (depending on the child's behavior). Removing any excess material with the same cotton used to isolate is routine to minimize systemic absorption. The entire dentition was treated with 5% sodium fluoride varnish (Pulpdent Embrace varnish, 5% Sodium Fluoride with CXP) after SDF treatment to help prevent caries on the teeth and sites not treated with SDF. After application, the child was asked not to drink or eat for at least 1 h. The child was advised not to use fluoridated toothpaste for the next morning. This is to avoid excessive fluoride intake to reduce fluoride toxicity. Follow-up examinations were conducted at 3 weeks, 3 months, 6 months, and 12 months to assess color and consistency changes in lesions. At either recall evaluation, if the carious lesion were not black and hard (indicating arrest), a second application of SDF was delivered. At 6-month follow-up, reapplication of 38% SDF solution was done to all the lesions including arrested (black and hard) lesions. At baseline and each recall visit, treated lesions were assessed for lesion color (yellow, black, and brown) and texture (soft, hard, chalky, and shiny) using gentle pressure with WHO ball-end probe. Parental acceptability was also recorded at every follow-up. The follow-up oral examination was done by the same examiner using the same equipment and diagnostic criteria as that were used in baseline examination. The presence or absence of pain and infection was noted at each recall visit. The efficacy of SDF was evaluated based on clinical outcomes where dark, hard, and black lesions with no pain or infection were considered positive outcomes. Parental acceptability of the SDF treatment was recorded. They accepted the discoloration of cavities after SDF treatment to their children. SPSS for Window version 23.00 (SPSS Inc, Chicago, USA) was used for analyses. A Chi-square test was used to assess the arrest rate of the carious lesions. P < 0.05 was considered statistically significant.
| Results|| |
Twenty-six children of age 2–5 years with 107 carious lesions were enrolled in the study. Four children with 15 carious lesions dropped out at the first recall visit at 3 weeks. Twenty-two children with 92 lesions completed the study. At the baseline examination by ICDAS II classification, 3.2% were score 3, 33.6% were score 4, 29.8% were score 5, and 33.6% were score 6. Assessment of the effect of 38% SDF solution in arresting carious lesions has relied on characteristics of color and consistency of the lesions. One hundred percent of lesions were black and hard so were considered arrested after one application at 3 weeks. 94.57% carious lesions were arrested at the second recall visit by the end of 3 months, five lesions were turned brown and still soft were considered not arrested. These five lesions were treated with a second application of SDF. 95.61% caries were arrested at third recall by the end of 6 months, one lesion excluded from the further analysis as it got fractured due to trauma. 92.31% carious lesions were arrested at the fourth recall visit by the end of 12 months, seven lesions were turned brown and still soft were considered not arrested, as shown in [Table 1].
|Table 1: Color, consistency, and arrested carious lesion after silver diamine fluoride application|
Click here to view
Chi-square test was used to compare the color, consistency, and caries arrest rate from baseline to different intervals, as shown in [Table 2] and [Graph 1]. All the parents (100%) accepted the SDF treatment in their child's teeth.
|Table 2: Comparison of color and consistency of the carious lesions at each interval|
Click here to view
| Discussion|| |
The present study was carried out to evaluate the clinical efficacy of biannual application of 38% SDF solution followed by 5% NaF varnish in arresting active carious lesions in the primary teeth of children aged 2–5 years. Our results showed that SDF was 92.31% effective in arresting the carious lesions at 12-month follow-up. All the parents involved in the study accepted the SDF treatment in their children. Zhi et al. found that biannual application of 38% SDF was 91% effective in arresting carious lesions. Llodra et al. and Fung et al. found 79.7% and 74% arrested carious lesions, after biannual application of 38% SDF solution, respectively. A 30-month randomized clinical trial by Chu et al. showed that biannual application of 38% SDF was 75.7% effective in arresting active caries in primary teeth. In 12 months, clinical trial by Mabangkhru et al. showed that 35.7% carious lesions were arrested with the biannual application of 38% SDF solution. A systemic review by Rosenblatt et al. stated that 38% SDF caries arrest rate was 96%.
Clinical trials have analyzed the caries arresting efficacy of SDF over varying periods of time ranging from 3 months to 3 years. Arresting caries effect of 38% SDF decreases slowly over time. We found 100% and 94.57% caries arrest rate at 3 weeks and 3 months follow–up, respectively. Crystal YO and Niederman R recommends 1 month post operative evaluation of treated lesions with optional reapplication as required to achieve arrest of all targeted lesions. Clemens et al. and Caroline et al. found 98% and 89.6% arrested lesions at 3 months after SDF application, respectively. In our study, we found a 95.61% caries arrest rate at 6-month follow-up. Yee et al. found 73% arrested carious lesions at 6 months, whereas clinical trials by Fung et al. Zhi et al., and Mabangkhru et al. showed 45.6%, 43.3%, and 20.5% arrested carious lesions at 6 months after SDF application, respectively. At the end of 12-month follow-up, we found a total of 6 teeth with pain and infection in which one tooth had an incidence of infection because of pulp exposure due to trauma. The five teeth which were scored 6 according to ICDAS II showed the incidence of pain and infection. Thus, deep dentinal caries should be evaluated radiographically before SDF application.
Twice per year application was shown to be more effective in caries control compared to once a year until the tooth is restored or exfoliates.,, The effectiveness of one-time SDF application in arresting carious lesions ranges from 47% to 90%, depending on the lesion size and the location of the tooth. An in-vivo 30-month study found that the annual application of SDF is effective in arresting dentin caries in primary teeth in Chinese preschool children. Many authors stated that a single application of 38% SDF was effective in arresting caries in primary teeth., Chu et al. stated that caries removal prior to SDF had no impact on its effectiveness in arresting caries. SDF application should not be regarded as a silver bullet to stop ECC. In fact, it is crucial to emphasize a child's oral health and encourage parents or caregivers to maintain effective plaque control and adopt healthy child-rearing practices in complement with the follow-up visits with caries risk assessment and SDF reapplication.
Several studies have highlighted the black dental stains that appear after SDF application as one of its disadvantages.,,, Thus in the present study, parental acceptance of the utilization of SDF on their child's teeth was evaluated in primary teeth. All the parents (100%) accepted the staining associated with SDF treatment on their child's primary teeth. This showed that the parents in our study were willing to compromise their child's esthetic appearance if it means the child can receive treatment without the need for more advanced behavior management techniques, especially when the child would require oral sedation or general anesthesia. A cross-sectional survey was conducted by Cernigliaro et al. who reported that 81.3% of caregivers were satisfied with SDF treatment. Kumar et al. conducted a survey and found that 79.5% of caregivers accepted SDF treatment for their children. Mabangkhru et al. and Hu et al. reported 61% and 55.6% parental acceptance, respectively. Asif and Gurunathan assessed the parental acceptance SDF treatment in Indian populations and found that 31.6% population accepted the treatment. On the other hand, Alshammari et al. stated that the majority of parents reject this type of treatment. Parents have significant concerns with respect to the color of their child's teeth. Most parents believed that the esthetic result of this treatment would result in harming psychosocial impacts to their child due to the judgments and associated behavioral responses of other individuals.
After 12 months, parental satisfaction with the children's dental appearance remained unaltered, compared to that at baseline. This study assessed caries activity using the visual-tactile examination because radiography was infeasible and impractical in young and uncooperative children. Our findings highlight the importance of following the American Academy of Pediatric Dentistry Guidelines in evaluating child and parental circumstances before introducing and providing SDF treatment, which also emphasizes the need of utilizing clear and effective informed consent with proper photos and description of the advantages and disadvantages before providing such treatment.
The results of this study could provide and strengthen clinical evidence regarding the safety of using one drop (25 μL) or less when applying 38% SDF semiannually in children and parental acceptance toward the SDF treatment. We believe that our study is a valuable contribution to existing SDF research. In particular, we assessed the use of SDF in a cohort of children aged 2–5 years, which is a population that has not been well studied and can benefit from easy anticaries treatment. Children in this age group may benefit from delayed dental treatment and overall caries arrest, thus reducing potential pain and infection, expensive future emergency room visits, the need for general anesthesia, or traumatic dental experiences on uncooperative children. Further investigation with a larger sample size and longer follow-up period is required to verify the clinical effectiveness of SDF in young children with high caries risk.
| Conclusion|| |
Biannual application of 38% SDF treatment can arrest dental caries process even when the lesion has progressed into dentin and was well accepted by parents. Since its use for caries management is painless, simple, inexpensive, and affordable in most communities, it could be widely recommended and promoted as an alternative treatment to conventional invasive caries management, especially among child patients who are too young for conventional dental care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Livny A, Assali R, Sgan-Cohen HD. Early childhood caries among a bedouin community residing in the eastern outskirts of Jerusalem. BMC Public Health 2007;7:167.
Bruen BK, Steinmetz E, Bysshe T, Glassman P, Ku L. Potentially preventable dental care in operating rooms for children enrolled in Medicaid. J Am Dent Assoc 2016;147:702-8.
Clemens J, Gold J, Chaffin J. Effect and acceptance of silver diamine fluoride treatment on dental caries in primary teeth. J Public Health Dent 2018;78:63-8.
Shah S, Bhaskar V, Venkataraghavan K, Choudhary P, Ganesh M, Trivedi K. Efficacy of silver diamine fluoride as an antibacterial as well as antiplaque agent compared to fluoride varnish and acidulated phosphate fluoride gel: An in vivo
study. Indian J Dent Res 2013;24:575-81.
] [Full text]
Yamaga R, Yokomizo I. Arrestment of caries of deciduous teeth with diamine silver fluoride. Dent Outlook 1969;33:1007-13.
Llodra JC, Rodriguez A, Ferrer B, Menardia V, Ramos T, Morato M. Efficacy of silver diamine fluoride for caries re-duction in primary teeth and first permanent molars of schoolchildren: 36-month clinical trial. J Dent Res 2005;84:721-4.
Policy on the Use of Silver Diamine Fluoride for Pediatric Dental Patients. Pediatr Dent 2018;40:51-4.
Mei ML, Ito L, Cao Y, Li QL, Chu CH, Lo EC. The inhibitory effects of silver diamine fluorides on cysteine cathepsins. J Dent 2014;42:329-35.
Use of Silver Diamine Fluoride for Dental Caries Management in Children and Adolescents, Including Those with Special Health Care Needs. Pediatr Dent 2018;40:152-61.
Zhi QH, Lo EC, Lin HC. Randomized clinical trial on effectiveness of silver diamine fluoride and glass ionomer in arresting dentine caries in preschool children. J Dent 2012;40:962-7.
Fung MH, Wong MC, Lo EC, Chu CH. Arresting early childhood caries with silver diamine fluoride-a literature review. J Oral Hyg Health 2013;1:117.
Chu CH, Gao SS, Li SK, Wong MC, Lo EC. The effectiveness of the biannual application of silver nitrate solution followed by sodium fluoride varnish in arresting early childhood caries in preschool children: Study protocol for a randomised controlled trial. Trials 2015;16:426.
Mabangkhru S, Duangthip D, Hung CC, Phonghanyudh A, Jirarattanasopha V. A randomized clinical trial to arrest dentin caries in young children using silver diamine fluoride. J Dent 2020;99:103375.
Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: A caries “silver-fluoride bullet”. J Dent Res 2009;88:116-25.
Yee R, Holmgren C, Mulder J, Lama D, Walker D, van Palenstein Helderman W. Efficacy of silver diamine fluoride for arresting caries treatment. J Dent Res 2009;88:644-7.
Crystal YO, Niederman R. Silver diamine fluoride treatment considerations in children's caries management. Pediatr Dent 2016;38:466-71.
Caroline J, Maharani DA, Adiatman M, Rahardjo A, Callea M. Effect and impact of silver diamine fluoride application in primary teeth caries on children's quality of life. J Phys Conf Ser 1073 042001.
Chu CH, Lo EC, Lin HC. Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children. J Dent Res 2002;81:767-70.
Bagher SM, Sabbagh HJ, AlJohani SM, Alharbi G, Aldajani M, Elkhodary H. Parental acceptance of the utilization of silver diamine fluoride on their child's primary and permanent teeth. Patient Prefer Adherence 2019;13:829-35.
Kumar A, Cernigliaro D, Northridge ME, Wu Y, Troxel AB, Cunha-Cruz J, et al
. A survey of caregiver acculturation and acceptance of silver diamine fluoride treatment for childhood caries. BMC Oral Health 2019;19:228.
Hu S, Meyer B, Lai BW, Chay PL, Tong HJ. Parental acceptance of silver diammine fluoride in children with autism spectrum disorder. Int J Paediatr Dent 2020;30:514-22.
Cernigliaro D, Kumar A, Northridge ME, Wu Y, Troxel AB, Cunha-Cruz J, et al
. Caregiver satisfaction with interim silver diamine fluoride applications for their children with caries prior to operating room treatment or sedation. J Public Health Dent 2019;79:286-91.
Asif A, Gurunathan D. Parental acceptance of silver diamine fluoride treatment for children. Int J Res Pharm Sci 2020;11:6432-5.
Alshammari AF, Almuqrin AA, Aldakhil AM, Alshammari BH, Lopez JN. Parental perceptions and acceptance of silver diamine fluoride treatment in Kingdom of Saudi Arabia. Int J Health Sci (Qassim) 2019;13:25-9.
[Table 1], [Table 2]