Comparison of caries preventive efficacy and parent perception of silver diamine fluoride and glass ionomer cement in atraumatic restorative treatment: 12 month follow up study.

To assess the effectiveness of atraumatic restorative treatment (ART) performed 4years ago in babies suffering from early childhood caries (ECC), and to compare the clinical performance of ART atraumatic restorations performed with two different high-viscosity glass ionomer cements (GIC). This was a longitudinal follow-up of a randomized, double-blind, split-mouth-type clinical trial. The initial sample was composed of 100 deciduous molars with occlusal lesions in 25 children with ages between 18 and 36months who received ART with two different GICs: Ketac Molar Easymix® (3M ESPE) and Vitro Molar® (DFL). The clinical assessments were performed by a trained, blind examiner gauged by the parameters assessed in 1, 2, and 4years (ART and USPHS criteria). For the analysis of the clinical performance of ARTs between the different GICs, the chi-square and Mann-Whitney tests were applied (p < 0.05). In the 4years of evaluation, the sample was composed by 76 ARTs and 19 children, with 94.7% of the treatments having inactivated the cavity process. The total success percentage of the ARTs was 94%, 87.5%, and 82.9%, in 1, 2, and 4years of follow-up, respectively. Moreover, among the GICs studied, this difference was not statistically significant (p > 0.05) ( ClinicalTrials.gov NCT03756025). ART was effective in handling ECC, with an excellent clinical performance of ART restorations, for both GICs, during the 4years of follow-up. ART, with both GIC studied, is an alternative therapy for ECC.

BackgroundUntreated tooth decay (caries) is the most common global health condition and one of the largest preventable disease burdens for society. It concerns both children and adults, particularly in low resource settings whereout of pocket expenditures for oral care often cause catastrophic health expenditures. The 2021 WHO Oral Health Resolution emphasized the relevance of developing so-called “Best Buys” for oral health. The purpose of this study was to identify the cost-effectiveness of Atraumatic Restorative Treatment (ART) and Silver Diamine Fluoride (SDF) as potential treatments to reduce the caries burden worldwide.MethodsLeaning on WHO CHOICE methodology, evidence scoping and an expert consensus were facilitated to extract model input parameters which were then fed into cost-effectiveness-analyses (CEA) for ART and SDF. The cost-effectiveness of the interventions was expressed as Cost per DALY averted.ResultsThe evidence scoping revealed relevant, information on the effectiveness and costs of ART and SDF. The CEA identified both ART and SDF to be potentially cost-efficient treatment strategies in settings with limited resources. SDF was found to provide a cost-efficient treatment alternative in settings where the comparably larger (human) resource requirements for ART cannot be met.ConclusionsThe findings suggest that ART and SDF represent potentially cost-efficient strategies to reduce the caries burden in settings with limited resources. While ART has previously been proposed as part of WHO’s essential package of oral care, SDF could provide a comparably inexpensive treatment alternative.Key messages• Untreated tooth decay (caries) is the most common global health condition and one of the largest preventable disease burdens for society.• The CEA identified both ART and SDF to be potentially cost-efficient treatment strategies in settings with limited resources.

Dental caries is the world's most prevalent noncommunicable disease and a source of health inequity; school dental sealant programs are a common preventive measure. Silver diamine fluoride (SDF) may provide an alternative therapy to prevent and control caries if shown to be noninferior to sealant treatment. To determine whether school-based application of SDF is noninferior to dental sealants and atraumatic restorative treatment (ART) in the prevalence of dental caries. The Silver Diamine Fluoride Versus Therapeutic Sealants for the Arrest and Prevention of Dental Caries in Low-Income Minority Children (CariedAway) study was a pragmatic noninferiority cluster-randomized clinical trial conducted from February 2018 to June 2023 to compare silver diamine fluoride vs therapeutic sealants for the arrest and prevention of dental caries. Children at primary schools in New York, New York, with at least 50% of the student population reporting as Black or Hispanic and at least 80% receiving free or reduced lunch were included. This population was selected as they are at the highest risk of caries in New York. Students were randomized to receive either SDF or sealant with ART; those aged 5 to 13 years were included in the analysis. Treatment was provided at every visit based on need, and the number of visits varied by child. Schools with preexisting oral health programs were excluded, as were children who did not speak English. Of 17 741 students assessed for eligibility, 7418 were randomized, and 4100 completed follow-up and were included in the final analysis. Participants were randomized at the school level to receive either a 38% concentration SDF solution or glass ionomer sealants and ART. Each participant also received fluoride varnish. Primary study outcomes were the prevalence and incidence of dental caries. A total of 7418 children (mean [SD] age, 7.58 [1.90] years; 4006 [54.0%] female; 125 [1.7%] Asian, 1246 [16.8%] Black, 3648 [49.2%] Hispanic, 153 [2.1%] White, 114 [1.5%] multiple races or ethnicities, 90 [1.2%] other [unspecified], 2042 [27.5%] unreported) were enrolled and randomized to receive either SDF (n = 3739) or sealants with ART (n = 3679). After initial treatment, 4100 participants (55.0%) completed at least 1 follow-up observation. The overall baseline prevalence of dental caries was approximately 27.2% (95% CI, 25.7-28.6). The odds of decay prevalence decreased longitudinally (odds ratio [OR], 0.79; 95% CI, 0.75-0.83) and SDF was noninferior compared to sealants and ART (OR, 0.94; 95% CI, 0.80-1.11). The crude incidence of dental caries in children treated with SDF was 10.2 per 1000 tooth-years vs 9.8 per 1000 tooth-years in children treated with sealants and ART (rate ratio, 1.05; 95% CI, 0.97-1.12). In this school-based pragmatic randomized clinical trial, application of SDF resulted in nearly identical caries incidence compared to dental sealants and ART and was noninferior in the longitudinal prevalence of caries. These findings suggest that SDF may provide an effective alternative for use in school caries prevention. ClinicalTrials.gov Identifier: NCT03442309.

To compare the efficacy of silver diamine fluoride (SDF) and atraumatic restorative treatment (ART) in arresting caries lesions. Variables such as treatment time, adverse effects/parental aesthetic perception, anxiety and patients' behavior were also evaluated. Children (3.53 ± 1.03 years) with dentin caries lesions on the occlusal surface of primary molars were randomized into test (SDF) and control (ART) groups. To determine the presence of caries, dmf-t and ICDAS indexes were used. Caries lesions were also classified according to activity (active or inactive). The time required to perform treatments was recorded and the children's anxiety was assessed by a Facial Image Scale. The adverse events/aesthetic perception were registered by the operator and caregivers. The Frankl Behavioral Scale assessed patients' behavior. The chi-square/Fisher's exact and Mann-Whitney tests were used for comparisons between the groups. Of the 118 participants who received treatment (SDF, n = 59; ART, n = 59), after 12-month follow-up, 91.5% (43/47) of caries lesions in the SDF and 90.2% (46/51) in the ART group were arrested (p = 1.000). After 24 months, 72% (18/25) were arrested in the SDF group and 95.2% (20/21) in the ART. The treatment times were 6.08 ± 1.72 and 13.58 ± 4.83, for SDF and ART, respectively (p < 0.001). No statistically significant difference of adverse effects, aesthetic perception, anxiety, and patients' behavior were found between the groups. SDF was similar to ART in arresting caries lesion but required less time for treatment. The anxiety, adverse effects/aesthetic perception and patients' behavior were also similar between the groups. CLINICAL RELEVANCE: The use of SDF may be a faster and less invasive alternative for the treatment of caries lesions. Clinical trial registration number and date of registration: NCT03063307. September 2016.

Background: Despite the effectiveness of silver diamine fluoride (SDF) in arresting caries, black staining of carious lesions is a major drawback. Objective: To assess parental satisfaction after using SDF versus atraumatic restorative treatment (ART) to manage ECC in their children. Materials & Methods: A randomized controlled clinical trial with patient reported outcomes; 100 children with ECC (2-5 years) were equally and randomly divided into two groups; Experimental group (N=50, n=268) received 38% SDF; Control group received ART (N=50, n=286). Parental satisfaction was assessed after 2 weeks using 4-item, 5-level, Likert-scale questionnaire. Quantitative data were represented using mean, and standard deviation (SD). Qualitative variables were displayed using frequency and percentages. Monte Carlo simulation method for Pearson's chi square statistics was applied to compare both groups regarding parental satisfaction. Significance level was set at P value ≤ 0.05. Results: Eighty percent of parents/guardians strongly agreed, agreed or were neutral regarding their children’s esthetics after SDF versus 98% after ART (P=0.06). All SDF parents/guardians strongly agreed or agreed it was an easy procedure versus 30% among ART group (P<0.0001). Among SDF parents/guardians, 96% reported the procedure to be pain free versus 74% in ART group (P= 0.008). Among SDF parents/guardians, 88% “strongly agreed” that the taste of received treatment was acceptable to their children versus 82% in ART group. (P= 0.614). Conclusion: Parental satisfaction regarding esthetics and taste was comparable after SDF and ART. Significantly more SDF parents/guardians viewed the procedure easy and pain free.

Effects of silver diammine fluoride on microtensile bond strength of GIC to dentine

Dental caries is a pervasive and inequitable chronic disease stemming from a lack of access to preventive and therapeutic care. Minimally invasive interventions may be provided in schools to treat caries in children. To compare the effectiveness of silver diamine fluoride (SDF) with atraumatic restorative treatment (ART) in the control of dental caries among US schoolchildren. The CariedAway study was a cluster randomized clinical trial conducted from February 1, 2019, to June 1, 2023, in 48 primary schools in New York City. Participants were followed up for up to 4 years. Schools with a student population of at least 50% Black and/or Hispanic or Latino students and 80% receiving free or reduced-cost lunch were eligible. Within enrolled schools, any child with parental informed consent was eligible. Treatment was provided biannually. Analysis was restricted to children aged 5 to 13 years who completed at least 1 follow-up observation and had at least 1 tooth surface with dental caries. Participants were randomized at the school level to receive SDF or ART. Any surface lesion with an International Caries Detection and Assessment System score of 5 or 6 was recorded as caries. The primary outcome was the number of carious surfaces that had a recurrence of caries. Analysis was performed on an intent-to-treat basis. Of the 17 741 children eligible, 7418 were randomized (mean [SD] age at baseline, 7.6 [1.9] years; 4006 girls [54.0%]), and 1668 were analyzed (mean [SD] age at baseline, 6.8 [1.5] years; 881 girls [52.8%]; 861 in the SDF group and 807 in the ART group). The total surface-level failure in the SDF group was 38.3% (2167 of 5651 carious surfaces) compared with 45.5% (2116 of 4647) in the ART group. There were 2167 surface failures observed among SDF participants over 1372 person-years compared with 2116 ART surface failures over 1291 person-years (incidence rate ratio, 0.96 [95% CI, 0.91-1.02]). At the person level, 45.5% of SDF recipients (392 of 861) experienced at least 1 surface failure compared with 53.3% of ART recipients (430 of 807; odds ratio, 0.51 [95% CI, 0.39-0.66]). There were no significant differences in the risk of recurrent surface failure between treatments (hazard ratio, 0.92 [95% CI, 0.82-1.04]). In this study of treatments for caries, similar failures in surface control were observed among children receiving SDF or ART. These results support the use of secondary preventive therapies for caries in schools. ClinicalTrials.gov Identifier: NCT03442309.

This clinical trial investigated the effectiveness of three minimal intervention dentistry protocols in arresting dentin caries in primary molars of preschool children. Treatment time, anxiety in children, adverse events, and parents' esthetic perception were all assessed. One hundred thirty-five 3-5-year-old children with active dentin caries lesions on the occlusal surface of primary molars were randomly allocated to the control group receiving atraumatic restorative treatment (ART) and two test groups receiving 38% silver diamine fluoride (SDF) or ultraconservative treatment (UCT). The existence and activity of caries were assessed using the International Caries Detection and Assessment System II (ICDAS II) criteria. Children were followed up at 3, 6, and 12 months. The time required to perform the treatments was recorded, and a facial image scale (FIS) was applied to assess anxiety. Questions posed to caregivers were used to investigate adverse events and esthetic assessment. After a year, the overall success rates of UCT, SDF, and ART were 61.6, 87.2, and 84.6%, respectively, with a statistically significant difference (p < 0.05). The time required to treat with SDF was significantly lower than that needed for ART and UCT (p < 0.01). Anxiety levels were significantly lower in the SDF group (p = 0.003). There was no difference in the percentage of adverse events and parental esthetic perception (p = 0.604). After 3 months, the arrest rates of ART, SDF, and UCT were similar. However, after 1 year, the arrest rate of UCT was significantly lower. Silver diamine fluoride takes significantly less chair time and has success rates comparable to ART. Ultraconservative treatment has a short-term successful application. It was confirmed that there were no variations in adverse events between SDF, ART, and UCT. NCT05314660. Hamza BE, Attia NM, Abdellatif AM, et al. Arresting Active Carious Lesions Using Minimal Intervention Dentistry among a Group of Preschool Children: A Randomized Controlled Clinical Trial. Int J Clin Pediatr Dent 2024;17(9):1018-1024.

Early childhood caries (ECC) is a significant global health problem affecting millions of preschool children worldwide. In general, preschool children from families with 20% of the lowest family incomes suffered about 80% of the ECC. Most, if not all, surveys indicated that the great majority of ECC was left untreated. Untreated caries progresses into the dental pulp, causing pain and infection. It can spread systemically, affecting a child’s growth, development and general health. Fundamental caries management is based on the conventional restorative approach. Because preschool children are too young to cope with lengthy dental treatment, they often receive dental treatment under general anaesthesia from a specialist dentist. However, treatment under general anaesthesia poses a life-threatening risk to young children. Moreover, there are few dentists in rural areas, where ECC is prevalent. Hence, conventional dental care is unaffordable, inaccessible or unavailable in many communities. However, studies showed that the atraumatic restorative treatment had a very good success rate in treating dentine caries in young children. Silver diamine fluoride is considered safe and effective in arresting dentine caries in primary teeth. The aim of this paper is to review and discuss updated evidence of these alternative approaches in order to manage cavitated ECC.

The latest national survey found that 70% of 5-year-old children in China had dental caries. The prevalence of early childhood caries (ECC) may not only be attributed to poor oral hygiene and unhealthy diet, but also to limited access to and availability of dental care. The prevailing preventive measures adopted by industrialised countries for ECC management are neither practical nor affordable in China. Hence, an alternative approach to ECC management is necessary. Atraumatic restorative treatment (ART) has been advocated because the simple and short operative time renders ART affordable. However, the success rate of ART in restoring anterior primary teeth is unfavourable. Although there is no water fluoridation in China, topical fluorides may be used to manage ECC. Tooth brushing with fluoride toothpaste is effective for caries control, but not all toothpastes in China are fluoridated. Professionally applied fluorides such as sodium fluoride varnish can be a cost-effective treatment for managing the high prevalence of ECC in China. Silver diamine fluoride (SDF) at 38% is suggested to be effective in arresting ECC in China. It can be a simple, non-invasive and low-cost treatment. However, it stains caries black. Children and their parents must be well informed before SDF treatment.

The aim of this clinical trial was to investigate the efficacy of 38% silver diamine fluoride (SDF) in the arrestment of dentine caries in primary molars of preschool children. The time required for treatment, anxiety, adverse events, parental aesthetic perception and oral health related to quality of life (OHRQoL) were also assessed. Sixty, 3–5 years old children, were assigned randomly to SDF test group or atraumatic restorative treatment (ART) control group. The ICDAS criteria determined the presence of caries and its activity. The treatment time was recorded, and the child’s anxiety was evaluated using the facial image scale before and after treatment. The caregivers were asked about any adverse events and the questions regarding esthetic perception were addressed to them. The OHRQoL was evaluated through the A-ECOHIS questionnaire before and 3 months after treatment. The overall success rates of SDF and ART after 12 months were 86.7% and 80%, respectively. There was no significant difference in arrestment of caries between SDF and ART (P value &gt; 0.05). The time required to treat with SDF was significantly shorter (p &lt; 0.001). The percentage of adverse events revealed no significant difference (p=0.604).

We aimed to appraise the comparative clinical efficacy of atraumatic restorative treatment (ART) versus conventional restorative treatment (CT) using a meta-analysis, and assessed the robustness of evidence by trial sequential analysis (TSA). Due to its simplified clinical approach, ART may be advantageous over CT for restoration of root caries lesions in institutionalised older patients. Three electronic databases (PubMed, Embase and Cochrane CENTRAL) were screened, and hand searches and cross-referencing performed to identify randomised controlled trials reporting on survival of ART vs CT for restoration of root caries in older patients. Trial selection, data extraction and risk of bias assessment were performed by two independent reviewers. ART and CT were compared using fixed- or random-effects pairwise meta-analysis for per-protocol (PP), intention-to-treat (ITT) and best-case scenarios. TSA was used to control for risk of random errors. A total of 235 studies were identified, and three trials involving 130 patients (463 restorations) were included. Risk of bias was high or moderate in all but one trial. ART was associated with a significantly increased risk of failure (OR [95% CI] 2.06 [1.06/4.00]) in PP- but not in ITT analysis (1.36 [0.92/2.02]). Analyses for best-case scenarios found great uncertainty introduced by attrition. No firm evidence was reached according to TSA. For restoration of root caries, there is insufficient data to clearly rule out whether differences between ART and CT exist. Limited available data indicate there might be an increased risk of failure for ART.

The aim of the present study was to evaluate the percent mean mineral density (MD) change of early caries lesions after the application of silver diamine fluoride (SDF) or glass ionomer cement (GIC). This double-blind, crossover study involved two experimental phases of 28days each. Thirty-two pairs of enamel slabs were created from the proximal surfaces of 16 premolars. Each pair of artificial carious slabs was randomly divided into the control or test group (38% SDF or GIC). The slabs were attached to orthodontic brackets and bonded to the maxillary first permanent molars of 16 subjects for 28days. After a 7-day washout period between phases, the subjects received the other material for the second phase. The mean MD of the lesions was measured by microcomputed tomography. SDF yielded a percent mean MD increase at a depth of 0-84μm, although increase in the GIC group was observed at a depth of 24-108μm. The percent mean MD changes of the SDF and GIC groups were similar (p = 0.100) and significantly higher than in control (p < 0.001, p = 0.003, respectively). The two materials increased the percent mean MD change of early proximal caries lesions to a similar extent, but with different spatial patterns. Due to deeper level of GIC remineralization, the refractive index of the GIC applied enamel might be closer to sound enamel. Hence, GIC is recommended for remineralization of anterior teeth. SDF staining makes it unsuitable for use in anterior teeth; thus, it is reserved for use in posterior teeth.

ABSTRACTIntroduction:The objective was to compare the clinical efficacy of silver diamine fluoride (SDF) and atraumatic restorative treatment (ART) in arresting active caries in primary teeth and first permanent molars in children.Materials and Methods:The study protocol was registered in PROSPERO (CRD42020205675). A systematic search was performed in PubMed, Scopus, Embase, Cochrane Library, and gray literature for randomized controlled trials (RCTs) published in English language with a minimum follow-up of 6 months, comparing the caries arrest potential of SDF with ART in primary teeth and first permanent molars in children. The risk of bias and quality assessment of the studies was done using the Cochrane Collaboration Tool and Joanna Briggs Institute Critical Appraisal Tool. Data analysis was performed using RevMan software; the outcomes were summarized in meta-analysis (MA) using the random-effects model, and the odds ratio (OR) at 95% confidence interval (CI) was computed.Results:A total of 1059 studies were identified, out of which 562 remained after removal of duplicates. Eight studies were considered for full-text eligibility, and four studies were included in the qualitative review. Three out of four studies were conducted on primary dentition, whereas one study was done on erupting first permanent molars in children. MA of the two studies compared 30% SDF with ART in primary molars at 12 months and revealed the OR to be 2.02 (95% CI: 0.86–4.71; I2 = 62%; P = 0.10).Conclusion:The current review points to the lack of solid evidence comparing SDF with ART for arresting active caries in primary teeth, especially in the first permanent molars. No statistically significant difference between 30% SDF and ART in primary molars at 12 months was found in the present review. Well-designed RCTs are required to determine a minimum concentration of SDF which is effective and safe for caries arrest in children.

Objective: To assess children’s anxiety before, during and after dental treatment with minimally invasive approaches: Atraumatic Restorative Treatment (ART) and Silver diamine fluoride (SDF) application. Material and Methods: This analytical cross-sectional study, in which 1306 children were initially examined, and from these, those that had at least one deciduous molar with dentin caries (score 5 ICDAS) were selected, being indicated to ART and SDF treatments. The final sample consisted of 94 children, 46 girls and 48 boys, aged between 6 and 8 years old. Each child received an ART or SDF procedure, and in all interventions, operators and treatments were randomized. Dental anxiety was assessed by facial image scale (FIS) before, during and after minimally invasive approaches. Results: Dental anxiety prevalence was of 34% before the minimally invasive approaches. Children showed a higher anxiety level during interventions (ART and SDF). And, after the service was finished, there was an increase in children with high anxiety, which ranged from 3.1% (before treatment) to 9.6% (after treatment). However, there was no statistically significant difference in the anxiety related to the types of treatment and conformation of the cavities (class I and II). Conclusion: Both child groups had higher anxiety levels during treatments, both in ART and SDF approaches.