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Title Insufficient Evidence Exists to Determine if Application of Silver Diamine Fluoride (SDF) to Deep Carious Lesions Provokes an Inflammatory Pulpal Response
Clinical Question In teeth with deep dentinal caries, does silver diamine fluoride (SDF) application produce an inflammatory pulpal response as compared to no treatment?
Clinical Bottom Line Insufficient evidence exists to determine if application of silver diamine fluoride (SDF) to deep carious lesions provokes an inflammatory pulpal response. AAPD guidelines contraindicate application of SDF to cariously exposed pulps, but suggest monitoring application to deep carious lesions. Since SDF was FDA approved in 2014, few high-quality studies have been conducted concerning its effect on the dental pulp. At this time, high quality randomized controlled trials or cohort studies are needed to determine if application of SDF to deep carious lesions without pulpal exposure is contraindicated.
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) 28688180Rossi/2017Extracted human primary teeth (ex vivo) and 12 rat molarsLaboratory study
Key resultsIn the ex vivo model, SDF was found to occlude dentinal tubules at the site of application, with minimal penetration beyond the obtunded tubules. The laboratory animal model showed chronic inflammatory infiltrate and tertiary dentin formation, but no silver precipitation beyond the site of application. SDF induces minimal adverse effects to the pulp.
#2) 34323107Sulyanto/202111 carious primary teeth Laboratory study
Key resultsSDF interaction with the pulp-dentin complex promotes an immediate hard barrier to carious stimuli at the site of application, followed by tertiary dentin formation. SDF may induce an adaptive pulpal response by odontoblasts to promote mineral deposition as a protective defense against bacterial insult.
#3) 26321822Korwar/20159 adolescents with premolars indicated for orthodontic extraction (N =36)In vivo study
Key resultsSDF and glass ionomer cement (GIC) do not induce inflammatory reactions in the dental pulp and promote tertiary dentin formation. SDF and GIC can be recommended as indirect pulp treatment materials.
Evidence Search (Silver diamine fluoride) AND (dental pulp OR pulp inflammation OR pulp response)
Comments on
The Evidence
Few studies have been conducted to directly address the clinical question of concern. No systematic reviews, randomized controlled trials, or cohort studies have been conducted to date concerning whether SDF produces a pulpal inflammatory response in adult human dentition. The evidence cited in this review primarily demonstrates protective sequelae of SDF application to deep dentinal caries via tertiary dentin formation; however, other studies (Kim et. al. 2021) in animal models have shown cytotoxicity to pulpal-like cells and silver penetration into the pulp chamber (Li et. al. 2019)
Applicability SDF application to gross carious lesions is common in pediatric, public health, and geriatric dentistry. Some clinicians argue that application of SDF in deep carious lesions approximating the dental pulp can produce an inflammatory response and should be avoided. This belief is derived from historic application of silver nitrate, a related but fundamentally different medicament. No evidence exists to contraindicate application of SDF to deep carious lesions without pulpal exposure, and limited evidence exists to suggest that SDF may promote tertiary dentin formation, indicating its use as an indirect pulp therapeutic. Therefore, a clinical recommendation to refrain from SDF application to deep carious lesions is not evidence-based and more research is currently needed.
Specialty/Discipline (Public Health) (Endodontics) (General Dentistry) (Pediatric Dentistry)
Keywords Silver Diamine Fluoride, SDF, Dental Pulp, Inflammation, Tertiary Dentin
ID# 3466
Date of submission: 11/12/2021spacer
E-mail jamesz@livemai.uthscsa.edu
Author Zak James, DMD
Co-author(s) Thais Phillips, DDS
Co-author(s) e-mail phillipst5@livemail.uthscsa.edu
Faculty mentor/Co-author Anibal Diogenes, DDS, MS, PhD
Faculty mentor/Co-author e-mail diogenes@uthscsa.edu
Basic Science Rationale
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Comments and Evidence-Based Updates on the CAT
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by Cindy Huynh (San Antonio) on 10/01/2022
I have conducted a PubMed search on this topic in October 2022. A systematic review has been published: Zaeneldin 2022, PubMed ID 35139409. The review concluded that direct SDF application causes pulp necrosis, while indirect application has a mild inflammatory response, increased odontoblastic activity and tertiary dentin formation. The review also mentioned that future studies are still needed with larger sample size to truly understand the biological activity that SDF treatment has on the pulp.

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