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Effectiveness of Silver Diamine Fluoride in Caries Prevention and Arrest: a Systematic Literature Review

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Effectiveness of Silver Diamine Fluoride in Caries Prevention and Arrest: a Systematic Literature Review Effectiveness of silver diamine fluoride in caries prevention and arrest: a systematic literature review Violeta Contreras, DDS ¢ Milagros J. Toro, DDS, MSD, PhD ¢ Augusto R. Elías-Boneta, DMD, MSD, DHC Angeliz Encarnación-Burgos, MPL This study aimed to evaluate the scientific evidence re- ental caries is the most frequent childhood chronic 1-3 garding the effectiveness of silver diamine fluoride (SDF) disease worldwide. Early childhood caries (ECC), in preventing and arresting caries in the primary denti- the presence of 1 or more decayed, missing, or filled tion and permanent first molars. A systematic review D tooth surfaces (dmfs) in any primary tooth in a preschool-aged (SR) was performed by 2 independent reviewers using child, has been recognized by the American Dental Association 4 3 electronic databases (PubMed, ScienceDirect, and as an important public health issue. Scopus). The database search employed the following In recent years, a reduction in overall caries indicators has been 5-7 key words: “topical fluorides” AND “children” AND “clini- reported; however, an increase in ECC has been documented. cal trials”; “topical fluorides” OR “silver diamine fluoride” If ECC remains untreated, oral health–related quality of life, body AND “randomized controlled trial”; “silver diamine weight, growth, school attendance, and school performance can 8,9 fluoride” AND “children” OR “primary dentition” AND be affected. In addition, children with ECC treated under general “tooth decay”; “silver diamine fluoride” OR “sodium fluo- anesthesia have a higher predisposition to develop dental caries 10 ride varnish” AND “early childhood caries”; and “silver in the permanent dentition. Because a severe ECC experience is diamine fluoride” AND “children”. Inclusion criteria were an important predictor for adult caries, strategies to prevent and 11-13 articles published in English, from 2005 to January 2016, control ECC are important to improve general and oral health. on clinical studies using SDF as a treatment intervention Feeding habits and a variety of biological, environmental, to evaluate caries arrest in children with primary denti- and socioeconomic factors are involved in the development 14,15 tion and/or permanent first molars. Database searches of ECC. One important socioeconomic factor is the lack of provided 821 eligible publications, of which 33 met the child dental insurance. Access to dental insurance has been inclusion criteria. After the abstracts were prescreened, found to correlate with age and is inversely related to family 16 25 articles were dismissed based on exclusion criteria. income and the educational level of the mother. ECC is there- The remaining 8 full-text articles were assessed for fore exacerbated in children residing in underprivileged areas, eligibility. Of these, 7 publications were included in the where carious lesions remain untreated due to limited financial 17,18 SR. These included 1 study assessing the effectiveness resources and facilities. 19 of SDF at different concentrations; 3 studies comparing Dental caries can be prevented or arrested. Moreover, SDF with other interventions; 2 investigations comparing preventive measures for ECC are more cost effective than emer- SDF at different application frequencies and with other gency room visits or restorative treatments when the illness has 20,21 interventions; and 1 study comparing semiannual SDF been established. A variety of evidence-based approaches for applications versus a control group. The literature indi- caries prevention have been reported; however, these strategies cates that SDF is a preventive treatment for dental caries demand significant financial investment and depend on the 18 in community settings. At concentrations of 30% and availability of oral health workforces and facilities. Effective 38%, SDF shows potential as an alternative treatment for ECC preventive measures include the use of fluoride varnish— caries arrest in the primary dentition and permanent first such as 5% sodium fluoride (NaF)—and the use of fluoridated 22-25 molars. To establish guidelines, more studies are needed toothpaste. In the management of cavitated ECC, atraumatic to fully assess the effectiveness of SDF and to determine restorative treatment (ART) has been recommended. ART is the appropriate application frequency. painless, is low cost, and can be applied outside the clinical setting or when conventional treatment is not available. A disad- 26 Received: October 1, 2016 vantage of this treatment is its high rate of failure. Accepted: November 17, 2016 Interest in the use of silver diamine fluoride (SDF) has been Published with permission of the Academy of General Dentistry. growing. SDF has been used as an alternative treatment for © Copyright 2017 by the Academy of General Dentistry. 27 All rights reserved. For printed and electronic reprints of this article caries prevention and arrest. In 2014, SDF was approved by the for distribution, please contact [email protected]. US Food and Drug Administration as a treatment for dentinal 28 sensitivity. SDF had been used off-label for caries arrest; how- ever, it was recently approved (code D1354) as an interim caries- 29 arresting medicament. Exercise No. 402, p. 30 In vitro studies have demonstrated that SDF increases the pH Subject code: Operative (Restorative) Dentistry (250) of biofilm, reduces dentin demineralization, and has antimicro- 30 bial action against cariogenic bacteria. However, treated teeth 22 GENERAL DENTISTRY May/June 2017 Chart. Selection of studies for the systematic review. Materials and methods A systematic literature database search was performed by 2 independent reviewers using PubMed, ScienceDirect, and Records identified through Scopus. The search included the following sets of key words: database searches: • “Topical fluorides” AND “children” AND “clinical trials” n = 395 (PubMed) • “Topical fluorides” OR “silver diamine fluoride” AND n = 255 (ScienceDirect) “randomized controlled trial” n = 486 (Scopus) • “Silver diamine fluoride” AND “children” OR “primary dentition” AND “tooth decay” • “Silver diamine fluoride” OR “sodium fluoride varnish” Records after removal of duplicates: AND “early childhood caries” • n = 821 “Silver diamine fluoride” AND “children” The following filters were applied to these terms: clinical trial, published in the last 10 years (or since 2005), English, and jour- nal (or dental journal). Records screened: The search was conducted from August 2015 to January 2016. n = 821 Inclusion criteria were a randomized controlled trial (RCT) using SDF as 1 of the interventions, a population of children with primary dentition and/or permanent first molars, and Records excluded: manuscripts published in English from 2005 to January 2016. Based on title, n = 788 Exclusion criteria included other study designs, manuscripts in Based on abstract, n = 25 different languages or published outside the target timeframe, RCTs not using SDF as 1 of the interventions, and/or adults or children with complete permanent dentitions. The research Full-text articles assessed for eligibility: question addressed was: In children who have caries in primary n = 8 teeth and/or permanent first molars, is the use of silver diamine fluoride more effective than other strategies in the prevention and/or arrest of carious lesions? A database was developed to compare and assess each Full-text article excluded due to inconsistencies in sample size, reviewer search. Three eligibility phases were employed: titles, study design, and results: abstracts, and full-text screening. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement n = 1 36 guidelines were followed. The data extraction form included the study design, SDF concentration and frequency, other treatment interventions used, SDF application techniques, and SDF adverse Studies included in systematic review: events. The outcomes reported were mean number of surfaces n = 7 with new, active, and inactive caries at baseline and follow-up; mean numbers of arrested surfaces; the percentage of caries arrested; and caries increment. The risk of bias was assessed using a simplified analysis adapted from recommendations in the 37 Cochrane Handbook for Systematic Reviews of Interventions. sometimes develop black stains as a result of silver phosphate 31 precipitation. Ex vivo and in vivo studies on cavitated extracted Results teeth from children receiving semiannual applications of SDF A total of 1136 manuscripts were initially identified in data- have shown effectiveness in arresting lesions as well as higher base searches: 395 articles from PubMed, 255 articles from fluoride uptake compared to fluoride varnish and acidulated ScienceDirect, and 486 articles from Scopus (Chart). After 32,33 phosphate fluoride gel. duplicate records were eliminated, 821 articles remained. Of Clinical studies have demonstrated the effectiveness of SDF these, 33 met the inclusion criteria. After the abstracts were in childhood caries prevention and arrest. Semiannual applica- prescreened, 25 articles were dismissed based on the exclusion 34 tions of SDF at 38% concentration have been recommended. criteria, and the reviewers agreed to include 8 publications in SDF has been suggested for difficult-to-treat lesions and patients the full-text article assessment phase. After review of the full with high caries risk, including those with medical or behavioral text, the reviewers decided, by consensus, to exclude 1 of the complications,
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