ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Silver Diamine Fluoride May Be Better Than Sodium Fluoride Varnish In Arresting and Preventing Cavitated Caries Lesions
Clinical Question In high caries risk children, is Silver Diamine Fluoride solution compared to Sodium Fluoride varnish, more effective in preventing/arresting caries?
Clinical Bottom Line Both annual application of 38% Silver Diamine Fluoride (SDF) solution and biannual application of 5% Sodium Fluoride varnish (NaF) are clinically effective in arresting and preventing progression of caries lesions in the primary dentition and pits/fissures of permanent first molars, with no significant difference from one another in their effectiveness. There is some evidence supporting the use of SDF over NaF varnish with most studies performed on primary teeth, but the evidence was insufficient and limited. Most of the studies suggested higher efficacy of SDF in the primary dentition, however one study demonstrated that SDF promotes a faster arrestment of caries lesions in permanent first molars. This is supported by a systematic review of 2 well-conducted clinical trails and other trails. SDF is highly effective, inexpensive and easy to apply. It was suggested by WHO to use it when dental resources are limited.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 22736448Liu/2012501 children, mean age 9.1 years. With at least one sound permanent first molar with deep fissures or with early signs of caries.Randomized Controlled Trial
Key resultsAll treatment options including: sealant, NaF varnish, and SDF are effective in preventing pit and fissure caries in permanent molars. The three treatment groups had significantly lower risks of caries than did the controls (p < 0.05). Proportions of pit and fissures with caries were not significantly different (p > 0.05) with the sealant, NaF varnish, SDF, and control groups were 1.6%, 2.4%, 2.2%, and 4.6%, respectively. The percentage of sites with caries in the control group (4.6%) was significantly higher than those in the three treatment groups (p = 0.002) at the 24-months follow up. The prevented fractions (PF) were 65%, 48%, and 52% for sealant, NaF varnish, and SDF solution, respectively.
#2) 19278981Rosenblatt/2009Children: 1- 375 children aged 3-5 years, with carious upper anterior teeth (Chu et al 2002). 2- Llodra et al. (2005)Systematic review of randomized trials
Key resultsThe results indicate that SDF was more effective than NaF varnish in both arresting and preventing caries. The lowest prevented fractions (PF) for caries arrest and caries prevention for SDF were 96.1% and 70.3%, respectively. On the other hand, fluoride varnish’s highest prevented fractions for caries arrest and caries prevention were 21.3% and 55.7%, respectively. The number needed to treat (NNT) also demonstrated the benefit of SDF when compared with NaF varnish. Similarly, SDF’s highest NNT for caries arrest and caries prevention were 0.8 (95% CI = 0.5-1.0) and 0.9 (95% CI = 0.4-1.1), respectively. For NaF varnish, the lowest NNT for caries arrest and prevention were 3.7 (95% CI = 3.4-3.9) and 1.1 (95% CI = 0.7-1.4), respectively.
Evidence Search (Silver Diamine) AND sodium Fluoride Varnish
Comments on
The Evidence
Validity: In the first article the enrolled subjects were assigned to either treatment or control groups with no bias using computer generated numbers. 97% of the subjects were followed for 24 months. Two years is a reasonable time length for caries to form. The number of dropouts was reasonable and for uncontrollable reasons with the study having a 10% dropout rate. Intra-examiner reproducibility was tested. Treatment was carried out in a standardized technique. SDF was compared to the more frequently use NaF varnish and other effective and common caries prevention techniques. A drawback of the study was that no blinding of investigators was undertaken. On the systematic review, the search strategy was sufficient, searching multiple online libraries and in multiple languages for a long time window between 1966 to 2006, using good inclusion and exclusion criteria. One of the studies examined only the primary maxillary anterior teeth (Chu et al., 2002) while the second one extended to permanent molars. It is a good diversity but might limit the strength of evidence of clinical application choice. The effect on permanent teeth might be different than on the primary dentition, due to different structural biology between primary and permanent enamel and dentin. The two studies applied SDF either annually or biannually, and obtained similar results, suggesting that one application is sufficient. Perspective: In my opinion, both studies were well-conducted. According to my search, only one systematic review of 2 randomized clinical trails was available. More RCT studies are needed. Results were inconclusive. Both treatment options are effective in arresting and preventing caries with some evidence suggesting the use of SDF to be more effective.
Applicability Although most clinicians will focus on permanently restoring caries lesions, topical fluorides including SDF and NaF varnish provides an excellent alternative to arrest caries and buy some time until more definitive treatment is undertaken. SDF is effective, inexpensive, and has minimal side effects. WHO support the use of topical fluoride to arrest caries especially when access to dental care services is limited. Also, it’s a valuable option to arrest early childhood caries, when final treatment cannot be carried out due to the patient’s young age and inability to cooperate in the dental office.
Specialty/Discipline (Public Health) (General Dentistry) (Pediatric Dentistry)
Keywords Arrest, Dental Caries, Fluoride, Prevention, Silver Diamine Fluoride, Sodium Fluoride Varnish
ID# 2924
Date of submission: 10/13/2015spacer
E-mail Abudawood@livemail.uthscsa.edu
Author Shahad Abudawood, DDS
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Kevin J. Donly, DDS, MS
Faculty mentor/Co-author e-mail Donly@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
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Comments on the CAT
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