Overcoming the Challenges of Treating Caries in in Children

Silver diamine fluoride (SDF) has become a welcome addition to our armamentarium to effectively manage caries in cases in which we experience challenges and obstacles to traditional dentistry. SDF is a liquid or gel that can be placed efficiently and effectively to arrest caries without the use of a local anesthetic or a drill. In pediatric dentistry, SDF is widely used in situations in which traditional caries management is not practical or possible. The American Academy of Pediatric Dentistry's policy on the use of SDF supports its incorporation into ongoing caries management plans to optimize individualized patient care.¹ Although SDF has proven effective and invaluable, with its use comes two further challenges. First, SDF leaves a hallmark black stain on teeth as the arrested carious tissue darkens. Research has shown that this staining is undesirable to some patients and parents, particularly on anterior teeth where it is more visible.² In another study, parents found the results of SDF acceptable, whereas professionals did not.³ Regardless, the staining is an unpleasant result. The second challenge associated with using SDF is that it arrests the progression of the caries but does not restore the cavitation.

When restoring the cavitation of an SDF-treated tooth, we need to consider the shear bond strength that it can achieve with the restorative material. Numerous studies have examined the impact of SDF on shear bond strength, and many have found that the use of SDF on carious dentin does not negatively impact the shear bond strength between it and direct restorative materials, including resin-modified glass ionomers and conventional resin composites.^4-6 Furthermore, we need to consider what materials will best mask the undesirable stain of the SDF to provide excellent esthetics in addition to function.

The following case report details the use of a single-shade flowable composite along with an opaque blocker material to restore an SDF-treated primary cuspid.

A 5-year-old female patient presented with extensive early childhood caries. According to her parents, it was difficult to maintain her oral hygiene due to her uncooperative behavior during brushing and visits to her family dentist. The patient's parents were informed about the benefits of SDF, and they accepted a treatment plan in which SDF would be used to arrest the patient's decay and then she would undergo full mouth rehabilitation under general anesthesia. Although the examination revealed multiple caries lesions that would be treated, this case report focuses on the buccal decay found on primary tooth H (Figure 1).

To begin the caries arresting procedure, tooth H was isolated using cotton rolls and an absorbent cellulose triangle (Dri-Angle^®, Dri-Angle) to prevent saliva contamination. Next, a 38% SDF solution (Advantage Arrest^®, Elevate Oral Care) was applied to the lesion using a microbrush, ensuring thorough coverage of the decayed area (Figure 2). The SDF was allowed to sit for 1 minute before the excess was removed with a cotton pellet. The dark stain of the SDF, which is indicative of successful caries arrest, was evident immediately after application (Figure 3), and it had become even darker when the patient returned for the restorative appointment (Figure 4).

At the restorative appointment, general anesthesia was administered, and tooth H was isolated with a rubber dam (Dental Dam, Sanctuary) to ensure a dry working field. The margins of the lesion were then cleaned and prepared with a coarse diamond bur on a high-speed handpiece. After the preparation was complete, a dark stain remained at its center, illustrating that the deepest part of the lesion had been treated with SDF (Figure 5). Next, the tooth's surface was etched with a phosphoric acid etching gel for 15 seconds in a selective etch technique, rinsed, and dried. A universal bonding agent was then applied and light-cured for 10 seconds. Prior to restoring the tooth with composite, a blocking material (OMNICHROMA^® BLOCKER Flow, Tokuyama Dental) was placed over the SDF-treated area to mask the stain and then light cured (Figure 6 and Figure 7). This material is designed to effectively mask dark stains and provide a more neutral base for the overlying composite restoration. In this case, the degree of masking was insufficient after one layer due to the depth and darkness of the stain. Therefore, a second layer of the blocking material was placed to provide a greater masking effect (Figure 8). With the stain blocked, the restoration was then completed by placing a single-shade, flowable bulk-fill composite (OMNICHROMA^® Flow BULK, Tokuyama Dental). This material was selected due to its unique properties, which allow it to blend seamlessly with the shade of the surrounding tooth structure. Once placed, the composite was shaped and contoured to match the natural anatomy of tooth H (LM-Arte^™ Dark Diamond^™, LW-Dental) (Figure 9). The restoration was then finished and polished (Enhance^®, Dentsply Sirona) to achieve a smooth, glossy result, ensuring both function and esthetics (Figure 10).

This case illustrates the efficacy and efficiency of using SDF to arrest caries prior to definitive restorative treatment in pediatric patients. It enables a more minimally invasive approach; prevents further disease progression, pain, and infection; and facilitates a positive patient experience. When restoring SDF-treated caries lesions, the use of a blocking material followed by a single-shade composite permits the delivery of a functional and esthetic final restoration without the need for shade selection, which further enhances efficiency. This approach provides a solution to restore SDF-treated teeth effectively, easily, and esthetically.

Carla Cohn, DMD
Private Practice
Winnipeg, Manitoba, Canada