Clinical effectiveness/child-patient and parent satisfaction of two topical fluoride treatments for caries: a randomised clinical trial

Knowledge gaps exist regarding optimal silver diammine fluoride (SDF) regimens and the efficacy of new products for arresting dental caries in young children. We evaluated the effectiveness of 38%-SDF (SDI-RivaStar), Tiefenfluorid (TF) comparing with Placebo (P), all in conjunction with behavioural modification (BM), in preventing major complications (endodontic/extractions/pain)-a patient-centred outcome-due to early childhood caries over 12 months in children under 71-months. A six-arm, patient/parent-blinded, superiority, placebo-controlled randomised control trial at the university clinic in Riga, Latvia, from 1/9/20-31/8/22 (Protocol registration ISRCTN17005348). The trial tested six protocols, using three compounds (P/SDF/TF) under two regimes: annual and biannual (P1/P2/TF1/TF2/SDF1/SDF2) for major complications. Secondary outcomes included minor complications and parental satisfaction. All groups received BM. 373/427 randomised children (87.3%) completed the study. SDF2 had a significantly lower rate and risk of major (21.5%, OR = 0.28, 95%CI [0.11, 0.72], p < 0.05) and minor complications (OR = 0.16 (95%CI [0.05, 0.50], p = 0.002). Overall satisfaction was 96% (p > 0.05). SDF biannual application with BM effectively prevented major complications of early childhood caries and was well accepted by children and their parents. Trial registration number: ISRCTN17005348, principal investigator: Ilze Maldupa, registration date: 30/06/2021.Clinical trial registration number: ISRCTN registry: ISRCTN17005348, https://doi.org/10.1186/ISRCTN17005348 , registration date: 30/06/2021.

Time-dependent structural changes and hypermineralisation of artificially demineralised dentine following treatment with silver diammine fluoride and glass ionomer cement

OBJECTIVES

This study aimed to evaluate the change of mineral content in dentine lesions over time and examine the effectiveness of the combined treatment with silver diammine fluoride (SDF) and glass ionomer cement (GIC).

METHODS

Sixty bovine dentine specimens were divided into 4 groups: cont, Fuji, Safo, and Safo+Fuji. The specimens were imaged and measured using microcomputed tomography (microCT) at 7 time points: pre-demineralisation, after demineralisation for two weeks, immediately after treatment, 1 week, 2 weeks, 1 month, and 3 months after treatment. The 3-month group was evaluated with a light microscope, attenuated total reflectance-Fourier transform infrared (ATR-FTIR) spectroscopy, and scanning electron microscope (SEM)/energy-dispersive X-ray spectroscopy (EDS). Data were analysed by Dunn's test and Wilcoxon signed rank test with Bonferroni correction for microCT, and Kruskal-Wallis test and two-way analysis of variance for EDS characterisation.

RESULTS

MicroCT images showed high mineral density beneath dentine lesions in Safo+Fuji. The mineral density at 600 μm in Safo+Fuji increased significantly over time, while Safo showed an opposite trend (adjusted p<0.005). In Safo+Fuji, EDS revealed significantly high energy of fluorine (p<0.05, at 300 μm) and a tendency towards high energy of calcium (p>0.05). However, Safo+Fuji showed lower energy of silver compared to Safo (p<0.001). ATR-FTIR revealed that phosphate groups had the highest peak at a depth between 300 and 400 μm in Safo+Fuji.

CONCLUSIONS

Safo+Fuji was effective in remineralising the deep lesion in dentine after one and three months, and a hypermineralisation zone generated beneath the lesion demonstrated additional benefit in this study.

CLINICAL SIGNIFICANCE

This long-term in vitro study showed that SDF+GIC treatment could strengthen the structure of decayed teeth when applied in the treatment of patients with advanced rampant caries.

Solid-state NMR spectroscopy measurement of fluoride reaction by bovine enamel and dentin treated with silver diammine fluoride

OBJECTIVES

The aim of this study was to investigate the formation of fluoride compounds in bovine enamel and dentin treated with silver diammine fluoride (SDF) using ¹⁹F and ³¹P solid-state magic angle spinning nuclear magnetic resonance (MAS NMR) spectroscopy.

METHODS

Enamel and dentin powder, obtained from bovine teeth, were treated with 38% SDF for four minutes and then washed thoroughly with Milli-Q water. The dehydrated SDF-treated samples were then examined. ¹⁹F solid-state MAS NMR spectra were acquired and ¹H-³¹P cross-polarization (CP) experiments were performed on SDF-treated enamel and dentin powder. The surfaces of SDF-treated enamel and dentin blocks were observed by Scanning Electron Microscope (SEM).

RESULTS

¹⁹F MAS NMR detected a more pronounced signal intensity for the dentin sample than the enamel, indicating an increased reactivity of SDF for dentin, compared with enamel. ¹⁹F NMR spectra for the SDF-treated samples showed fluorhydroxyapatite (FHAp), and other fluoride compounds such as CaF₂ and the fluoride-substituted carbonate. The ¹H-³¹P CP intensities of prominent peaks were lower for the SDF-treated samples than the non-treated sample, indicating that the F^- ion replaced the OH^- ion in the lattice tunnel. SEM observations on the SDF-treated samples showed pronounced multiple precipitation and particles in dentin compared with enamel.

SIGNIFICANCE

The solid-state MAS NMR revealed the reaction of fluoride on enamel and dentin and the identification of fluoride compounds. In particular, the formation of FHAp indicates that SDF is effective in reducing the risk of tooth decay.

Potential use of silver diammine fluoride in detection of carious dentin

This study aimed to examine whether discoloration of carious dentin after silver-diammine-fluoride (SDF) application might be used as a mean to detect demineralized-dentin. Fourty specimens were obtained from 20 human permanent teeth. Teeth were sectioned through the center of carious lesions to create 2-halves in which each half was assigned to a treatment group. Specimens were divided into two groups (n=20) (each half was assigned to one group) according to solution, namely Caries Check (CC), or SDF. SDF group was subdivided into 2 groups: light-cured and 2-day storage groups. The specimens were tested using light-microscope, microhardness test and SEM/EDS analysis. Repeated-measures ANOVA was used for statistical analysis. The light-microscope showed superficial discoloration in the CC-group while SDF (2-day storage) group showed deeper discoloration for the lesion area. SDF showed significant increase in the hardness compared with the CC-group. SDF showed potentiality to be used as an assisting-tool for caries detection.

Effect of silver diammine fluoride and glass ionomer on remineralisation of natural dentine caries

OBJECTIVES

Silver diammine fluoride (SDF) is a caries-arresting agent for dentine lesions. This study investigated the effect of application frequency of SDF when used with glass ionomer cement (GI) for remineralising carious dentine.

METHODS

Freshly extracted human posterior teeth with advanced caries were used. After superficial removal of infected dentine, single (G3), double (G4), triple (G5) applications of SDF (Advantage Arrest SDF 38 %) followed by a layer of GI (GC Fuji IX GP) were compared to no treatment (negative control-G2), and GI only (G1). All teeth were stored in artificial saliva between treatments and for 2-weeks after final treatment. Micro-computed X-ray tomography (NSI) scans were obtained at each stage and analysed to plot mineral density-depth profile, lesion depth (LD) and mineral loss (ΔZ). Data was statistically analysed at a significance level of 0.05.

RESULTS

Mean LD values were 837 μm, 735 μm, 841 μm, 1008 μm, 707 μm at baseline and 785 μm, 727 μm, 712 μm, 855 μm, 639 μm after treatment for groups G1 to G5, respectively. Mean ΔZ values were 6327 vol%μm, 5995 vol%μm, 10014 vol%μm, 7192 vol%μm, 5649 vol%μm at baseline and 3686 vol%μm, 5126 vol%μm, 5539 vol%μm, 2327 vol%μm, 3218 vol%μm after treatment for groups G1 to G5, respectively. Paired t-test showed that LD and ΔZ changed significantly within all groups from baseline to treatment weeks following storage (p < 0.05) except LD in the control (p > 0.05). ANCOVA showed significant difference among groups in net lesion depth recovery and net mineral gain (p < 0.05), and G3 and G4 showed the highest mineral gains.

CONCLUSION

One or two applications of SDF prior to placement of GI, were effective in remineralising advanced dentine lesions, while additional applications, when combined with GI, did not demonstrate additional benefit in this study.

CLINICAL SIGNIFICANCE

This short-term laboratory research study showed that one or two applications of SDF followed by GI coverage could remineralise advanced dentine caries in the presence of artificial saliva. This procedure carries potential in the treatment of difficult lesions where conventional restorations would require significant tooth structure removal through traumatic procedures.

Effect of silver diammine fluoride on micro-ecology of plaque from extensive caries of deciduous teeth - in vitro study

Background

The mechanism of action of silver diammine fluoride (SDF) on plaque micro-ecology is seldom studied. This study investigated micro-ecological changes in dental plaque on extensive caries of deciduous teeth after topical SDF treatment.

Methods

Deciduous teeth with extensive caries freshly removed from school children were collected in clinic. Unstimulated saliva collection and initial plaque sampling were done before tooth extraction, then each caries was topically treated with 38% SDF in vitro. After intervention, each tooth was stored respectively in artificial saliva at 37 °C. Repeated plaque collections were done at 24 h and 1 week post-intervention. Post-intervention micro-ecological changes including microbial diversity, microbial metabolism function as well as species correlations were analyzed and compared after pyrosequencing of the DNA from the plaque sample using Illumina MiSeq platform.

Results

After SDF application, microbial diversity decreased (P > 0.05), although not statistically significant. Microbial community composition post-intervention was noticeably different from that of supragingival and pre-intervention plaque as well as saliva. At 1 week post-intervention, the relative content of Pseudomonas, Fusobacterium and Pseudoramibacter were higher than before, while most of the other bacteria were reduced, although the changes were not statistically significant (P > 0.05). The inter-microbial associations became more complex, much more positive associations among survived bacteria were observed than negative ones. COG function classification diagram showed carbohydrate transportation and metabolic functions in the plaque were significantly reduced at 24 h and 1 week post-intervention.

Conclusions

SDF has extensive antimicrobial effect on dental plaque, which may reduce carbohydrate metabolism in dental plaque and help promote new balance of the plaque flora.

Morphological and elemental analysis of silver penetration into sound/demineralized dentin after SDF application

OBJECTIVE

The aim of this study was to evaluate the penetration depth of silver into sound and demineralized dentin after application of silver diamine fluoride (SDF).

METHODS

Two hundred and eighty-eight dentin specimens were used. The specimens were divided into 3 groups: (1) sound dentin (control), (2) 30min EDTA-treated dentin; and (3) 13h EDTA-treated dentin. SDF was applied to all specimens. Each group was divided into 3 subgroups according to storage time into: 24h, 2 weeks and 1-year storage time. Each subgroup was further divided into four subgroups (n=8) according to different examinations as optical microscope (OM) observation, scanning electron microscopic (SEM) observation, elemental analysis with energy dispersive spectroscopy (EDS) and Micro-PIXE test.

RESULTS

The OM showed discoloration in the superficial layer after 24h and keep extending deeper after 2 weeks and 1-year. SEM showed silver crystals within dentinal tubules after 2 weeks and 1-year. EDS analysis can detect silver penetration only in the 1-year group reaching around 1200μm inside dentin. Micro-PIXE test detected silver at all time intervals, confirming the EDS depth results.

SIGNIFICANCE

It can be concluded that silver ions can completely infiltrate the demineralized dentin lesion with further penetration into the underlying mineralized dentin.

Antibacterial Effect of Silver Diammine Fluoride on Cariogenic Organisms

AIM

To screen the possible antimicrobial activity of a range of clinically used, silver-based compounds on cariogenic organisms: silver diammine fluoride (SDF), silver fluoride, and silver nitrate.

MATERIALS AND METHODS

Preliminary screening disk-diffusion susceptibility tests were conducted on Mueller-Hinton agar plates inoculated with Streptococcus mutans, Lactobacillus acidophilus, and Actinomyces naeslundii, organisms known to be cariogenic. In order to identify which component of the silver compounds was responsible for any antibacterial (AB) effect, and to provide controls, the following were also investigated at high and low concentrations: sodium fluoride, ammonium fluoride, ammonium chloride, sodium fluoride, sodium chloride, and sodium nitrate, as well as deionized water as control. A volume of 10 pL of a test solution was dispensed onto a paper disk resting on the inoculated agar surface, and the plate incubated anaerobically at 37°C for 48 hours. The zones of inhibition were then measured.

RESULTS

Silver diammine fluoride, silver fluoride, silver nitrate, and ammonium fluoride had significant AB effect (p < 0.05) on all three test organisms, although ammonium fluoride had no effect at low concentration; the remaining other compounds had no effect.

CONCLUSION

Silver ions appear to be the principal AB agent at both high and low concentration; fluoride ions only have an AB effect at high concentration, while ammonium, nitrate, chloride and sodium ions have none. The anticaries effect of topical silver solutions appears restricted to that of the silver ions.

CLINICAL SIGNIFICANCE

Silver compounds, such as SDF, silver fluoride, and silver nitrate have AB effect against cariogenic organisms and these may have clinical impact in arresting or preventing dental decay. Sodium fluoride did not have AB effect under the conditions tested.