Hayley Massie presents the findings from the literature review poster she created while in the third year of her course training to become a dental therapist at the University of the Highlands and Islands.

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Aim of the review

To review the literature on silver diamine fluoride (SDF) and determine whether it leads to more favourable outcomes when compared with restorative approaches outlined by the SDCEP1 and if patients would benefit from this treatment.

What is SDF and how does it work?

SDF is a colourless, odourless solution of silver, fluoride and ammonium ions. It was first cited as being used as a cariostatic agent in Japan in 1969 and there has been a recent resurgence in its use.2

When SDF is placed on carious tooth tissue a series of chemical reactions take place that promote tooth carious lesion arrest and desensitisation by dentinal tubule blockage.2

SDF reacts with calcium and phosphate ions to produce fluorhydroxyapatite, thereby inhibiting demineralisation.3

Why is SDF relevant?

SDF has invoked interest more recently due to its remineralisation capacity and non-invasive application procedure.4

There is an increasing body of evidence that the use of SDF can help to arrest caries without the need for more invasive dental treatment.

SDF may be useful in assisting the development of non-aerosol generating procedures (AGPs) in the current COVID-19 pandemic and its recovery phase.

SDF is not presently licensed in the UK for caries arrest and so the product remains off-label. This has been raised as a potential barrier to its use. However, support for its use by societies, like the British Society of Paediatric Dentistry (BSPD), means the practitioner can use SDF with confidence.5

Method

A systematic search using numerous online databases was carried out. Specific terms, Boolean operators and truncators were applied.

The inclusion and exclusion criteria were applied to exclude any papers which did not meet the criteria.

  • 359 records identified through database searching

  • Records after duplicates removed and free full text (n = 118)

  • Records excluded (Did not meet criteria) (n = 110)

  • Records included (Met criteria) (n = 8)

  • Randomised Controlled Trial(n = 7)

  • Clinical Study (n = 1).

Results

Several papers compared SDF to atraumatic restorative technique (ART) or glass ionomer. One paper compared SDF to fluoride varnish and the another compared with a placebo. One paper compared SDF concentrations, and another paper looked at the effectiveness of SDF alone.

SDF was first cited as being a cariostatic agent in Japan in 1969 and there has been a recent resurgence in its use.

All papers, regardless of the methodology, continuously supported the effectiveness of SDF in arresting caries in primary teeth and this effect was very consistent in the literature.

Conclusion

Traditional approaches currently used to arrest caries in primary teeth have high levels of failure6 which suggests new strategies are needed. The evidence on SDF is still emerging and suggests SDF can prevent lesion progression.

Although research is limited, there is enough evidence to suggest SDF would benefit patients. It can be concluded there are gaps in the literature. However, this makes SDF an exciting avenue to explore for future research.

Recommendations

  • I would urge researchers to conduct well-designed RCTs which compare the outcomes of SDF to other treatments (ie conventional fillings and preformed metal crowns) for the arrest of carious lesions in primary teeth

  • I would make a cautious recommendation that SDF is adopted in the UK, especially during the current COVID-19 pandemic and its recovery phase.

The SDCEP1 says 'By adopting a minimally invasive approach to caries management, the risk of upsetting the child and causing treatment-induced anxiety will be minimised. Non-invasive management of early carious lesions avoids the child entering the restorative cycle'.

Useful resources

  1. 1.

    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: 63-68.

  2. 2.

    Critical Skills Appraisal Programme. CASP checklists. Available at: https://casp-uk.net/casp-tools-checklists/ (accessed 29 October 2020).

  3. 3.

    dos Santos Jr V E, de Vasconcelos F M N, Ribeiro A G Rosenblatt A. Paradigm shift in the effective treatment of caries in schoolchildren at risk. Int Dent J 2012; 62: 47-51.

  4. 4.

    Duangthip D, Chu C H, Lo E C M. A randomized clinical trial on arresting dentine caries in preschool children by topical fluorides - 18 month results. J Dent 2016; 44: 57-63.

  5. 5.

    Fung M H T, Duangthip D, Wong M C M, Lo E C M, Chu C H. Randomized Clinical Trial of 12% and 38% silver diamine fluoride treatment. J Dent Res 2018; 97: 171-178.

  6. 6.

    General Dental Council. Standards for the dental team. London, 2013.

  7. 7.

    McHugh M L. Interrater reliability: the kappa statistic. Biochem Med (Zagreb) 2012; 22: 276-282.

  8. 8.

    Milgrom P, Horst J A, Ludwig S et al. Topical silver diamine fluoride for dental caries arrest in preschool children: A randomized controlled trial and microbiological analysis of caries associated microbes an resistance gene expression. J Dent 2018; 68: 72-78.

  9. 9.

    Seifo N, Cassie H, Radford J R, Innes N P T. Silver diamine fluoride for managing carious lesions: an umbrella review. BMC Oral Health 2019; 19: doi: 10.1186/s12903-019-0830-5.

  10. 10.

    Timms L, Deery C, Stevens C, Rodd H. COVID-2019 - Time to use silver diamine fluoride for caries arrest in general dental practice? Dent Therapy Update 2020;13: 26-30.

  11. 11.

    Vollú A L, Rodrigues G F, Roberta V R T et al. Efficacy of 30% silver diamine fluoride compared to atraumatic restorative treatment on dentine caries arrestment in primary molars of preschool children: A 12-months parallel randomized controlled clinical trial. J Dent 2019; 88: doi: 10.1016/j.jdent.2019.07.003.

  12. 12.

    Zhi Q H, Lo E C M, Lin H C. Randomized Clinical Trial on effectiveness of silver diamine fluoride and glass ionomer in arresting dentine caries in preschool children. J Dent 2012; 40: 962-967.