Silver Diamine Flouride in Paediatric Dentistry
M3 India Newsdesk Sep 09, 2024
This article explores the effectiveness of silver diamine fluoride (SDF) in managing paediatric dental caries, highlighting its ability to arrest caries progression without invasive procedures, making it a child-friendly alternative during the COVID-19 pandemic.
Key points
- Untreated dental caries of primary teeth was the 10th most common of 291 health problems assessed in the Global Burden of Disease 2010 Study [Marcenes et al., 2013].
- The traditional conservative treatment of dental caries requires clinical skills, costly instruments, materials, and patient cooperation.
- In young children, behavioural issues or lack of cooperation often complicate this kind of treatment and often lead to disease progression and subsequent loss of teeth.
- In developed countries, uncooperative children have the option of conscious sedation or general anaesthesia, whereas in many developing countries due to barriers to accessing dental care, low socioeconomic populations go through life with untreated dental caries.
- Many preventive interventions can be used as an alternative to traditional restorative procedures, and one of them is the use of silver diamine fluoride.
- It can halt caries progression and prevent new lesion development. Compared to fluoride varnish, it seems to be nearly twice as effective.
Evolution
What is SDF
- SDF (Ag [NH3] F2) is a colourless or blue alkaline topical fluoride solution consisting of silver (254,709 ppm) and fluoride (44,860 ppm) ions.
- A steady pH of 10.4 & a specific gravity of 1.25
Mechanism of action
Effects
1. Tooth Structure
2. Effect on microbes
- Disrupts the membrane of microorganisms
- Denatures proteins
- Inhibits DNA replication
- Decrease Streptococcus mutans(SM) and Lactobacillus counts(LB)
- Inhibits adherence of SM to tooth structure
- Prolonged action of SDF - ZOMBIE EFFECT Wakshlak et al – 2015
Silver is re-activated when bacteria killed by silver ions are added to living bacteria so that the dead bacteria effectively kills living bacteria in a “zombie effect.”
3. Effect on pulp
- Gotjamanos in 1997 showed a favorable pulpal response when SDF was applied to deep caries in primary teeth of children.
- It was found that it induced the presence of abundant reparative dentin and a wide odontoblast layer.
Indications
- Uncooperative/Anxious child.
- Adults who have dental phobia
- Special health care needs children
- Asymptomatic (lesions close to a pulp)
Contraindications
- Silver allergy
- High esthetic concerns
- Carious lesions close to the pulp
Clinical application guidelines
Excavation of carious dentin is not necessary before SDF application
- Remove gross debris from the affected area.
- Apply Vaseline to lips to avoid discolouration.
- Isolate tooth surface - cotton rolls and gauze.
- The solution is applied with a micro brush – rest for 1 min.
- A 5ml solution of SDF provides approx. 100 drops.
- 1 drop ample for 5 teeth.
- Rinse excess with water/air dry.
Follow-up
- Done at 2-4 weeks
- The effectiveness of caries lesion arrest decreases over time [Yee R et al, 2009]
- Reapplication may be necessary
- Based on the size and location of the lesion
SDF effectiveness ranges from 47-90%.[Gao SS, Zhang et al 2016]
Side effects and toxicity
- Metallic taste
- Transient gingival irritation
- Minor gingival irritations heal within a couple of days
- Prevalence of tooth and gum pain
- Gum swelling and gum bleaching in 6.6% of subjects- [Duangthip D, 2018]
- Black staining of teeth (Due to metallic silver formation)
Knight et al. (2006) proposed Potassium iodide after the application of SDF to the tooth structure.
The remaining free silver ions in the solution will react with Potassium Iodide to precipitate creamy white silver iodide crystals. Hence, free silver ions are no longer available to react with sulfur and other reagents in the mouth to form black precipitates in the teeth.
Contraindications
In pregnant and lactating women [Horst et al 2016]
Current Evidence of Efficacy of SDF
1. Caries arrest in children: (41-91%)
- Based on the various comparisons – i.e. either with GIC, fluoride varnish.
- 66% higher caries arrest (Chibinski et al 2017).
- 154% higher when no treatment was given.
- Larger lesions have less likelihood of arrest.
- Anterior teeth have a higher arrest rate than posterior teeth.
2. Caries arrest on permanent teeth in children – only 1 study (Llodra and colleagues 2006).
- Preventive fraction – 100%.
- A large proportion of active caries became inactive at 12 months follow-up.
3. Caries arrest and prevention in the elderly [Hendre et al 2017]
- Limited data on coronal caries.
- Recommended for root caries.
Silver Modified Atraumatic Restorative Technique (SMART) – Alvear 2016
The SMART procedure helps to eradicate cariogenic bacteria by sealing the restoration whilst enhancing pulp vitality and promoting the remineralisation of carious lesions.
Conclusion
In times of the COVID-19 pandemic, interruption of aerosol-generating procedures is a step that is unavoidable for the safety of dental health professionals and patients.
Silver diamine fluoride is the magic alternative for paediatric caries management. It supports the conservative and contemporary “biological approach” requiring no caries removal with caries lesion arrest rates being >70%. It is child-friendly as it requires no anaesthesia and no drills, thereby reducing the chair side time.
Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.
About the author of this article: Dr Neha Kalantri is a practising dentist from Nashik.
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