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Year : 2021  |  Volume : 39  |  Issue : 3  |  Page : 316-320

Can silver diamine fluoride be an alternative to aerosol-based dentistry during the COVID scenario? A retrospective analysis

Department of Pedodontics, PGIDS, Rohtak, Haryana, India

Date of Submission02-Apr-2021
Date of Decision15-Sep-2021
Date of Acceptance05-Oct-2021
Date of Web Publication22-Nov-2021

Correspondence Address:
Dr. Ruchi Singhal
Department of Pedodontics, PGIDS, Rohtak, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisppd.jisppd_127_21

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Background: Restrictions on routine dental procedures involving aerosols during COVID-19 have resulted in a significant increase in the suffering of pediatric patients. Aim: The study reported the alternative measures followed in our department using SDF during the COVID era when routine elective dental procedures were prohibited. Materials and Methods: The retrospective data of patients aged 2–13 years with carious molar teeth who were treated with silver diamine fluoride without (Group 1) or with (Group 2) caries excavation were collected. Results: One thousand and seventy-two patients (646 males and 426 females) with 2459 carious molar were treated. On follow-up assessment at 3 months, 28 teeth in Group 1 and 21 teeth in Group 2 showed progression of carious lesion using International Caries Detection and Assessment System (ICDAS II criteria). Out of these failure cases, 32 (1.8%) teeth were primary and 17 (2.5%) were permanent. Complete relief in sensitivity/pain on stimulation was reported in 2381 teeth (96.83%), whereas in 78 (3.17%) teeth, mild sensitivity/pain on stimulation was reported. The average time consumed during treatment per tooth in Group 1 was 5.04 min and in Group 2 was 5.78 min. Conclusion: SDF application can be carried out as a nonaerosol-generating procedure and is a simple technique for children and clinicians.

Keywords: Aerosols, COVID-19, silver diamine fluoride

How to cite this article:
Singhal R, Singhal P, Namdev R, Negi S. Can silver diamine fluoride be an alternative to aerosol-based dentistry during the COVID scenario? A retrospective analysis. J Indian Soc Pedod Prev Dent 2021;39:316-20

How to cite this URL:
Singhal R, Singhal P, Namdev R, Negi S. Can silver diamine fluoride be an alternative to aerosol-based dentistry during the COVID scenario? A retrospective analysis. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2021 Dec 7];39:316-20. Available from: https://www.jisppd.com/text.asp?2021/39/3/316/330702

   Introduction Top

Coronavirus disease, commonly referred as COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in late 2019 and has been declared a global pandemic or Public Health Emergency of International Concern by the World Health Organization Director-General on the recommendation of the International Health Regulations (2005) Emergency Committee.[1],[2],[3] To control the most rapidly expanding pandemic since the Spanish flu pandemic in the early 1900s, many countries across the globe introduced lockdown measures, significantly affecting the daily lives of their citizens, including the provision of routine dental care.[4],[5]

Infected aerosols and splatter droplets generated from dental procedures during the use of high-speed handpiece, three-in-one syringe, ultrasonic scalers, air polishers, and air abrasion units known as aerosols-generating procedures (AGPs) have been implicated in the transmission of diseases through an airborne route.[6],[7] The infected aerosol can remain airborne for a few hours before landing on and contaminating surfaces for up to 72 h.[8],[9] Hence during the peak of the pandemic, AGPs were suspended and were only provided to patients requesting urgent care.[4] These implications have resulted in a significant increase in the suffering of pediatric patients in need of dental care and have placed a large burden on dental health services due to increasing waiting lists for both routine and urgent dental care. It is futile to imagine that COVID-19 will just suddenly disappear; rather, it is likely to remain an issue in the long term.[4] As a result, some traditional approaches used for the management of carious primary teeth prior to the COVID-19 pandemic will need to be adapted during the COVID-19 era and more minimally intervention techniques in caries management will need to be utilized to minimize the risk of spreading the infection to patients, dental staff, and public posed by the dental procedures. Minimal intervention dentistry is a biological approach to treat carious lesions, which covers a spectrum of techniques ranging from no carious tissue removal to selective carious tissue removal using sealants, resin infiltration, silver diamine fluoride (SDF) application, the hall technique, and atraumatic restorative technique.[1],[5],[10] SDF application can be carried out as a nonaerosol-generating procedure and is a simple technique for both children and clinicians.[11] SDF combines the antibacterial properties of silver ions and the preventive effects of fluoride.[12] The current formulation on the market, 38% SDF, has one of the highest fluoride ion concentrations of all topical applications: 44,800 ppm compared to 22,600 ppm in 5% sodium fluoride varnish.[13] A recent systematic review and guideline by the American Association of Pediatric Dentistry strongly recommended the use of SDF in the caries management of children and adolescents, including those with special health-care needs.[11],[14],[15] Therefore, this study was done to report the protocol followed in our department during the COVID era, in which routine elective dental procedures were prohibited and alternative measures were followed using SDF to relieve the grievances of pediatric patients and to reduce the waiting list of patients in need of dental treatment. The data were analyzed to evaluate the effectiveness of SDF application over conventional aerosol-based dentistry, i.e. cavity preparation and restoration. The secondary objectives of the study were to evaluate average chairside time, patient satisfaction, and to compare the effectiveness of SDF in arresting caries in primary and permanent molar teeth.

   Materials and Methods Top

The retrospective data of patients aged 2–13 years with carious molar teeth (primary/permanent) who were treated with SDF were collected from the department of pedodontics and preventive dentistry from April 1, 2020, to October 31, 2020. The teeth with scores 1–6 according to ICDAS II criteria were included. Parents who refused to give written consent; those who gave a history of spontaneous pain/abscess/sinus, carious lesion close to pulp/pulp exposure, tooth with mobility, and patient allergic to silver were excluded. The demographic details, chief complaint, and history of any previous dental treatment were collected from departmental records. All the standard precautions to prevent COVID 19 infection, including PPE kit, N95 mask, face shield, eye gear, and pretreatment mouth rinse with 1% H2O2, were followed. Teeth were divided into two groups based on the treatment approach followed.

Group 1: SDF application without caries excavation: All the children <4 years of age and older children who were uncooperative were included in this group. Thirty-eight percent of SDF solution was applied for 1 min without prior removal of carious tissue.

Group 2: SDF application with caries excavation: The children >4 years of age who displayed cooperative behavior were included in this group. Thirty-eight percent of SDF solution was applied for 1 min with prior removal of carious tissue using a spoon excavator.

Vaseline was applied to the perioral tissues and mucosal surfaces surrounding the tooth. Cotton rolls and high-volume suction were used to isolate the carious teeth. One drop of 38% SDF (FAgamin, Tedequim SRL, Bv deLos Polacos 6136 × 5147GGP, Cordoba, Argentina) was placed in a plastic dappen dish, and a disposable microbrush was used to apply the SDF to carious surfaces of teeth for 1 min. Gentle flow of compressed air was used to dry the surface. The excess was removed by gentle blotting with another cotton pellet. All the treated teeth were restored with fast-setting zinc oxide cement (Orafil G, Prevest DenPro, India). After treatment, the children were asked not to eat or drink for 30 min. The total time consumed during the procedure from patient preparation to SDF application was recorded using a stopwatch.

Patient satisfaction regarding the comfort level during the treatment was assessed and recorded using visual analog scale [Figure 1]. The patients were assessed postoperatively for relief in sensitivity/pain on stimulation after 3 months. At follow-up, the treated caries lesions were examined using the WHO probe and were classified as either active or arrested according to ICDAS II criteria after removing the temporary restoration. Caries with yellowish/brown rough wall/floor which can be easily penetrated by the probe using a light force were diagnosed as active. Carious lesions with smooth hard surfaces which cannot be penetrated were classified as arrested.
Figure 1: Patient satisfaction rating using the visual analog scale

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   Results Top

A total of 1072 patients (646 males and 426 females) with 2459 carious molar teeth were selected for the study. Patients with one carious molar were 21% (225), with two carious molars were 46% (493), with three carious molars were 18% (193), and with more than three carious molar teeth were 15% (161). Out of the total 2459 teeth, 1780 teeth were primary and 679 were permanent. ICDAS II criteria were used to categorize the carious lesion preoperatively as well as on follow-up visits [Table 1]. Teeth in Group 1 were 607 and in Group 2 were 1852. Twenty-eight teeth in Group 1 and 21 teeth in Group 2 showed progression of carious lesion [Table 2]. Out of these failure cases, 32 (1.8%) teeth were primary and 17 (2.5%) were permanent [Table 3]. Out of 1072 patients, 264 reported previous history of dental treatment (restoration using drill). Of these, 88% reported better experience in terms of time taken and comfort level during the procedure. Patient satisfaction scoring using VAS showed that 1004 patients (93.7%) were relaxed during treatment and experience no discomfort (score 0), 68 patients (6.3%) experience mild discomfort (score 1–3), and no patient experience moderate (score 4–6) and very severe (7–9) or worst discomfort (score 10) [Figure 1]. On follow-up assessment at 3 months, complete relief in sensitivity/pain on stimulation was reported in 2381 teeth (96.83%), whereas in 78 (3.17%) teeth, mild sensitivity/pain on stimulation was reported that were managed by reapplication of SDF. Forty-nine teeth (1.99%) that showed failure were subjected to definitive restorative/endodontic treatment. The average time consumed during treatment per tooth in Group 1 was 5.04 min and in Group 2 was 5.78 min [Table 4]. Mucosal and skin staining was reported in 16 patients that disappeared inadvertently within a week without any intervention.
Table 1: Distribution of teeth according to International Caries Detection and Assessment System II criteria

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Table 2: Distribution of affected teeth according to the groups

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Table 3: Distribution of affected teeth according to the type of dentition

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Table 4: Comparison of average time consumed during the procedure in different groups

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   Discussion Top

All children should be considered potential carriers of SARS-CoV-2 unless proved otherwise because of the long incubation period (2–14 days) of the virus and the clinical manifestation in children usually range from asymptomatic to mild, nonspecific symptoms leading to the uncertainty of their infectious status.[1],[16],[17] This scenario presents unprecedented challenges to pediatric dentists. Hence, all universal precautions were followed during dental treatment to reduce the risk of cross infection to children as well as health-care professionals.

Given the high proportion of children with dental caries worldwide and its negative impact on their quality of life, alternatives to conventional dental treatment of carious teeth should be reconsidered to minimize the amount of aerosols produced to maintain a healthy environment for patients and dental staff. Noninvasive approaches may present alternatives to conventional surgical treatment in arresting or slowing the progression of caries lesions in primary and permanent teeth.[18] Management using the SDF application was followed at our institute.

SDF is a topical colorless liquid whose components work synergistically for caries arrest. Silver has bactericidal properties interfering with bacterial metabolism and inhibiting biofilm formation,[19] whereas fluoride promotes remineralization and makes the dentine less susceptible to acid dissolution.[19],[20] SDF also inhibits the action of matrix metalloproteinases that break down collagen.[20] The mode of action to relieve dentin sensitivity is through the occlusion of dentinal tubules by SDF. When applied to the tooth surface, SDF is proposed to react with hydroxyapatite to form silver phosphate and calcium fluoride which acts as a reservoir of fluoride and phosphate ions in aiding remineralization.[21] The silver ions penetrate into the lesions and remain there to exert their influence.[22]

A comprehensive review evaluating the evidence from 11 systematic reviews favored the SDF in caries arrest.[23] Clinical research has consistently found that SDF effectively arrests caries in the primary dentition; however, the evidence base for coronal caries in the permanent dentition is less robust. In a study on Chinese preschool children, a yearly application of 38% SDF (44,800 ppm F) to decayed primary anterior was significantly more effective than 3 monthly applications of sodium fluoride varnish in arresting caries and preventing new carious lesions (22,600 ppm F).[24] The fluoride in SDF penetrates and retains into dentin, with 2–3 times more frequency than sodium fluoride varnish.[25] A systematic review and meta-analysis conducted in 2016 concluded that 38% SDF resulted in 81% (95% confidence interval [68%–89%] P < 0.001) caries arrest in active lesions in primary teeth with reported effectiveness of 85% at 6 months and dropping to 71% at 30 months and beyond.[26] For the permanent dentition, evidence has found that SDF promotes caries arrest in root caries. In a Cuban study, a greater percentage of efficacy in deciduous teeth (around 80%) was observed than in permanent molar (65%) teeth.[18] While there is potential for SDF to be applied in this clinical presentation, further research is required. The present study adds on to the literature regarding sparse evidence of clinical effectiveness of SDF in caries arrest in permanent teeth. We observed 97.5% effectiveness in permanent dentition and 98.21% effectiveness in primary teeth over a 3-month follow-up interval.

SDF application is indicated in carious lesions with no clinical or radiographic signs of irreversible pulpitis, dental infection, pulp exposure, or pathology. Therefore, patients with ICDAS II score 1–6 were included in the study. Treatment using SDF can be completed in a short period of time, therefore requiring a shorter fallow period (time required to allow for clearance of infectious aerosols after a particular procedure) and reduce the number of patients in waiting room.[1],[27] Both these factors may help in significant reduction in risk of viral transmission. The average duration of procedure in both groups range from 5.04 to 5.78 min which is considerably less compared to conventional restorative procedures using drilling. Children are more prone to fear and anxiety during dental treatment, so arresting caries treatment is proposed for the management of dental caries in this stratum of the community. In the present study also, 93.7% of patients were most relaxed without any discomfort during the treatment, whereas only 6.3% had mild discomfort. Clemens et al. also claimed this procedure to be more acceptable, comfortable, and relatively pain-free for the children and parents.[28]

Previous studies had reported comparable results to arrest dentin caries with or without excavation of caries prior to application of SDF.[24] In the present study, we found more failures in Group I which might be due to the inclusion of very small and uncooperative children in this group. This might have led to improper isolation and inadequate SDF application in these patients. More failures were noted in teeth with ICDAS scores 5 and 6. This may be explained by the fact that the progression of carious lesion toward pulp was more than clinically apparent. Moreover, single application of SDF was not sufficient to arrest the caries up to the total depth of lesion.

The main drawback of the treatment is that it leaves carious teeth black because of the presence of silver compounds such as silver oxide and silver phosphate, thus thorough discussion with parents prior to its use is paramount.[23] In a survey conducted on American parents with young children, only 30% of parents found anterior teeth SDF staining acceptable 68% found posterior teeth staining acceptable.[14] In our study, most of the patients and their guardians found it acceptable, which may be because of inclusion of posterior teeth only. Moreover, discoloration of SDF was masked by temporary restoration.

There can be concerns from the possible toxicity of SDF especially with the concentration of fluoride at 44,800 ppm. In an adult toxicity study of SDF, fluoride levels did not exceed the safety limits when treatment was limited to three anterior teeth. In a recent study of SDF in 888 children aged 3–4 years, only minor adverse events such as tooth and gum pain (6.6%), gum swelling (2.8%), and gum bleaching (4.7%) were reported with no major adverse events.[29],[30] In the present study, we had not found any adverse effects apart from staining of gingival and perioral tissues in 16 patients which faded within a week.

   Conclusion Top

COVID-19 has and will continue to have significant impacts on the practice of pediatric dentistry. This article emphasizes the importance of alternative treatment strategies during the global pandemic to protect dental care professionals as well as the child patient while providing clinical care for the affected children and those potential carriers of the infection

SDF application can be carried out as a nonaerosol-generating procedure and is a simple technique for the child and clinician

It is therefore a useful tool in the caries management armamentarium, particularly during the recovery phase of the pandemic, and in dealing with the unmet needs of children with caries.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]


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