Community trial of silver fluoride treatment for deciduous dentition caries in remote Indigenous communities
https://www.ncbi.nlm.nih.gov/pubmed/30883781
First published: 18 March 2019
https://doi.org/10.1111/adj.12689
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/adj.12689
Abstract
Background
Silver fluoride 40% followed by 10% stannous fluoride (AgF) has been used in dental practice in some parts of Australia for many years. This study compared the effectiveness of application of AgF with Atraumatic Restorative Technique (ART) in managing cavitated carious primary molars
Methods
The study was a community effectiveness trial in two remote Aboriginal communities where AgF has been used for some time. Children between four and eight years of age with caries on primary molars were randomised by birth date to receive AgF or ART. There were 210 children who were included in the study with 384 eligible teeth. Children were followed up for periods between nine months and four years. Negative outcomes such as dental pain, extraction, use of antibiotics and more extensive restorative treatment were considered as the primary outcomes of the study
Discussion
This study found that use of the formulation 40% silver fluoride with 10% stannous fluoride was as effective as ART in treating dental caries among young children in a real life clinical setting in remote Australia. Both types of treatments resulted in very few complications. The null hypothesis (a hypothesis used in statistics that proposes that no statistical significance exists in a set of given observations) was supported.
The strength of this study included the use of a silver fluoride formula, one which has been more commonly used in Australia and does not have an ammonia smell. Treatment was undertaken in the posterior teeth of the primary dentition whereas most studies of silver diamine fluoride have treated anterior teeth. Other strengths were the comparison with an existing treatment (ART) and the evaluation of AgF in routine clinical practice. This meant that the results show success of the AgF rather than its value.
This study used a different formula than Silver diamine fluoride which gave results similar to SDF. The need for retreatment was regarded as a disadvantage in one result in this study but is recognised that it may be required as part of the treatment regime with AgF. Recent studies of silver diamine fluoride have suggested that biannual treatments are necessary to produce the best results with that agent19. The use of the silver fluoride stannous fluoride combination enabled the maintenance of the primary dentition as well as ART.
This AgF treatment is simple and could be used by oral health therapists and hygienists. It was well accepted by children in this study. The black staining which results was not mentioned as a problem by the children in the study or their parents, and is clinically useful as an indicator of caries arrestment. Studies in vitro have raised the possibility that staining with SDF may be minimised with potassium iodide20 which could be investigated for AgF. AgF could also be used beneath glass ionomer cement fillings to reduce the appearance of staining or if the possibility of food packing was considered an issue.
In recent years the Hall Technique using preformed stainless steel crowns has been widely used to treat primary caries. This is also a treatment which does not require local anaesthetic and which reduces risk of major failure or pain compared to fillings21. Research comparing use of silver fluoride with preformed stainless steel crowns would be useful. It would also be useful to conduct a cost-effective analysis regarding number of dental general anaesthetics prevented due to provision of AgF.
Results
Those negative outcomes were infrequent in both treatment groups. If retreatment with AgF is regarded as part of routine treatment, then the prevalence ratio of negative sequelae for children treated with AgF compared with those treated with ART was lower at 0.18
Conclusions
Silver fluoride treatment for cavitated carious lesions in primary molars was as effective as the ART technique in this remote Indigenous population. It is an acceptable technique on very young and/or apprehensive patients and does not have the ammonium odour of SDF.
Comment
The negative** outcomes were infrequent in both treatment groups. However given that 275teeth were treated with CSDS and only 109 were treated with ART*; the prevalence ratio of negative sequelae treated with CSDS compared with those treated with ART* was lower at 0.18. Given that more teeth (275) were treated with CSDS than SDF (109) and the fact that negative results were lower in that group (CSDS) is more significant that the statistics suggest The treatment of cavitated lesions in primary molars was more effective than the ART* technique in this Indigenous population; furthermore, it was readily accepted by the very young apprehensive patients.
* ART technique is useful for treatment of dental caries, in areas where dental equipment and dentists are scarce. ART is relatively painless, based on removing soft diseased dentine using a sharp dental hand instrument and restoring with glass-ionomer cement. However, even ART may be problematic and regarded as intrusive for some Indigenous children. In addition the material used in ART required constant refrigeration which may not be feasible in some remote locations.
As more teeth (275) were treated with CSDS than SDF (109) and the fact that negative results were lower in that group (CSDS) is more significant that the statistics suggest.
** Negative outcome: dental pain, extraction, use of antibiotics and more extensive treatment.