Frontiers in Dentistry

Silver Modified Atraumatic Restorative Technique: A Way

towards “SMART” Pediatric Dentistry during the COVID-19
Pandemic
Divya Natarajan
Department of Pedodontics and Preventive Dentistry, Chettinad Dental College and Research Institute,
Kancheepuram District, Tamil Nadu, India

Article Info ABSTRACT

Article type: As the coronavirus disease-2019 pandemic outbreak continues to be a global public
Review Article health concern, dentists should seek means to provide oral health care with minimal
risk. To meet the recommendations of the Center for Disease Control, alternative
Article History: non-aerosol generating techniques have been proposed to minimize the risk of
Received: 24 May 2021 disease transmission to patients and dental healthcare personnel. Among recent
Accepted: 23 Dec 2021 materials, silver diammine fluoride (SDF) has been shown to be effective in
Published: 12 Mar 2022 preventing and arresting caries. This along with an atraumatic restorative treatment
with glass ionomer cements (GICs) makes it a potentially attractive adjunctive
therapy for caries management in pediatric patients. In this technique, SDF is applied
* Corresponding author: over carious tissue and the lesion is restored with auto-polymerizing GIC. This
Department of Pedodontics and Preventive review article aims to provide a practical background and clinical guide for the
Dentistry, Chettinad Dental College and
application of silver-modified atraumatic restorative technique (SMART) as a safe
Research Institute, Kancheepuram District,
Tamil Nadu, India
way to provide dental services to children during the pandemic.
Keywords: SARS-CoV-2; COVID-19; Silver Diamine Fluoride; Dental Atraumatic
Email: dr.divya@outlook.in
Restorative Treatment; Silver Fluoride; Fluorides, Topical; Pediatric Dentistry

 Cite this article as: Natarajan D. Silver Modified Atraumatic Restorative Technique: A way towards “SMART” Pediatric
Dentistry during the COVID-19 Pandemic. Front Dent. 2022;19:12.

INTRODUCTION with hand instruments in areas of COVID-19

The coronavirus disease-2019 (COVID-19) community transmission [1].
pandemic has significantly impacted dental In recent years, there has been a changing
services due to the high risk of infection trend in the management of carious lesions
transmission through the aerosol-generating especially in children worldwide. The current
procedures. Dental procedures have the evidence suggests that removal of all infected
potential to generate aerosols (usually < 5 μm) dentin in deep carious lesions is not necessary
and droplets (usually > 5 μm) that can spread provided that a well-sealed restoration is
the respiratory pathogens including the given [2]. A 10-year landmark clinical study
severe acute respiratory syndrome showed that bonded and sealed composite
coronavirus 2 (SARS-CoV-2). The World restorations placed over frank cavitated
Health Organization (WHO), even after 6 lesions arrested the clinical progress of the
months of declaring the COVID-19 outbreak as lesions [3]. We know that affected or arrested
a global pandemic, still advises to avoid or dentin has lower bacterial activity than does
minimize oral health care services that involve the infected dentin [4]. If we could arrest the
aerosol production, and emphasizes on infected dentin and provide a well-sealed
prioritizing minimally invasive procedures restoration, it could serve dual benefits. One

Copyright © 2022 The Authors. Published by Tehran University of Medical Sciences.

This work is published as an open access article distributed under the terms of the Creative Commons Attribution 4.0 License
(http://creativecommons.org/licenses/by-nc/4). Non-commercial uses of the work are permitted, provided the original work is properly cited.
Silver Modified Atraumatic Restorative Technique

such procedure could be done using silver the tooth with adhesive restorative material;
diammine fluoride (SDF) and glass ionomer thereby, removing the sensory triggers and
cement (GIC) by atraumatic restorative reducing dental anxiety [9]. One modification
treatment (ART). This new paradigm in caries of the ART proposed by Massara et al. [10]
intervention and management using SDF and included the use of a rotary handpiece on the
ART together is called the silver-modified enamel only, followed by placement of a
atraumatic restorative technique (SMART). traditional restoration and termed it the
This technique offers children an interim “modified atraumatic restorative treatment”.
alternative to traditional restorative tech- This enhanced visualization of the lesion,
niques providing the dual benefit of arresting saved time, and caused less manual fatigue.
the carious lesion and restoring the tooth But Frencken clarified that ART consisted of
without the risk of aerosols. the use of hand instruments only, and the use
of adhesive materials and hence advocated the
EVOLUTION “adherence to the original description”
Silver has been used in dentistry for many [10,11]. In the SMART technique described
years because of its antimicrobial properties; here, the use of hand instruments or
whereas, fluoride has been used to prevent modification by using high speed handpiece
and arrest caries. In 1917, silver was used by depends on the patient, clinical scenario, and
Howe in the form of silver nitrate to treat dental setting.
caries lesions as “Howe’s solution” [5]. Later
in 1972, 38% SDF was developed in Japan. It MATERIAL
was approved by the Food and Drug SDF is a topical fluoride solution that has been
Administration in 2014 as a class-II medical used at a concentration of 38% and contains
device to treat dentin hypersensitivity in 44,800 ppm fluoride. Its fluoride concentra-
patients over the age of 21 years, and its use tion is the highest among all the commercially
for caries arrest was off-label [6]. Since then, available fluoride agents in dentistry. It
SDF (Ag[NH3]2F) has been a popular caries contains around 25% silver, 8% ammonia, and
management tool in pediatric dentistry. SDF 5% fluoride [12]. SDF is available as e-SDF
has been commonly misspelled as “diamine (India), FAgamin (Argentina), Fluoroplat
silver fluoride” or “silver diamine fluoride” (Argentina), Bioride (Brazil), Saforide (Japan),
and “ammoniated silver fluoride”. The term Advantage Arrest (United States), Topamine
“silver diammine fluoride” is a more accurate (Australia) and Riva Star (Australia) at a
description of its chemical structure since SDF concentration of 38%. It is also available as
contains two ammine (NH3) groups and not Cariestop (Brazil) at a concentration of 12%
amine (NH2) groups [7]. In October 2016, it and 30% and Creighton Dental CSDS –
was recognized by the Food and Drug ammonia free (Australia) at 40%. It is
Administration as a breakthrough designation odorless, with a pH ranging from 10-13 and is
therapy for caries arrest. The breakthrough available as clear or tinted blue liquid
therapy status does not mean approval; (Advantage Arrest) based on the manufac-
rather, it is designated for drugs to treat a turer for an easier application. Among these,
serious or life threatening disease or condition Riva Star is the only commercially available
that demonstrate substantial improvement product containing both silver diammine
over available therapy. It has a unique ability fluoride and potassium iodide (SDF + KI), but
to be a “silver-fluoride bullet” because of its because of the high pH of 13, the use of a
potential to arrest and prevent caries [8], and gingival barrier or rubber dam should be
has since been widely employed as part of considered to avoid chemical burn of the soft
non-restorative cavity control. tissue [13]. One bottle of SDF provides 250
The ART was pioneered in the mid-1980s in drops, and each drop could be used for
Tanzania by Jo Frencken. It encompasses a applying on up to 5 tooth surfaces.
minimal intervention approach to remove The saturated solution of potassium iodide
carious tissue using hand instruments and seal (SSKI) or Lugol’s solution contains 1g of

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 Natarajan D.

potassium iodide per milliliter of solution demineralized dentin. In the bacterial cell, the
which helps eliminate the black staining of released silver ions react with the thiol groups
SDF on carious tissue [14]. of amino-acids and nucleic acids and the silver
High-viscosity auto-cure GIC has been amino and nucleic acid conjugates are unable
advocated in ART because it would chemically to carry out metabolic and reproductive
bond to the moist surface being hydrophilic functions. The silver ions also interact with the
providing seal, and acid resistance and sulfhydryl groups of proteins and DNA of
enhancing remineralization at the tooth- microorganisms, altering the hydrogen
restorative interphase. In the SMART bonding and inhibiting the respiratory
restorations, auto-cure GIC is preferred over process, DNA unwinding, cell-wall synthesis
the light-cure as the light could cause and cell division. It inactivates the glucosyl-
darkening of the SDF [15]. transferase enzyme activity and hence the
synthesis of glucans, thereby, inhibiting the
RATIONALE sucrose-dependent adhesion of the bacteria to
The basis for the SMART comes from the fact tooth surfaces and the viability of
that by biologically sealing the tooth with Streptococcus mutans [21]. This results in
caries, the viable bacteria present in the bacterial killing and inhibition of biofilm
remaining carious dentin lose their viability by formation [8].
being deprived of their sucrose substrate. Another theory by Wakshlak et al. [20]
Thus, if the organisms were made nonviable proposed that the biocidal metal-like silver
using SDF and the staining was eliminated by slowly releases cations which are toxic to
the use of KI, prior to placement of a bacteria. The bacteria killed by silver showed
restorative material like GIC as placed in ART, biocidal activity against the viable bacteria of
it would significantly improve the prognosis of the same species. This metal-induced biocidal
the tooth [15]. Placement of a restoration action was called the “zombie effect”. An in
following SDF would eliminate imminent vivo study established a >95% reduction in
fracture of the remaining tooth structure, total viable counts of anaerobes in carious
prevent space loss [16], provide easy access dentin treated with SDF+KI [25]. In addition,
for biofilm removal [17], and eliminate the fluoride from SDF and GIC binds to bacterial
need for advanced behavior guidance [12] cell constituents and influences the enzymes
while satisfying the parents’ demands or such as enolase and proton-extruding adeno-
needs [18]. sine triphosphatase; the latter inhibits sugar
uptake and the carbohydrate metabolism of
MECHANISM OF ACTION acidogenic oral bacteria, thereby, inhibiting
The mechanism of carious lesion arrest by SDF biofilm formation [26].
has been explained by the dual action of both Cariostatic activity
silver and fluoride. The silver acts by its The arresting action of SDF on caries could be
bactericidal “zombie” effect [19,20], enzy- explained by its high concentration of fluoride,
matic inhibition of biofilm [21], inhibition of its alkaline property, and presence of silver.
dentinal collagen degradation [22], and loss of When SDF or SDF+KI is applied over
mineral content [23]; thereby, inhibiting demineralized enamel or dentin, insoluble
demineralization. The fluoride inhibits biofilm protective precipitates of calcium fluoride,
and facilitates apatite nucleation and silver chloride, silver protein layer and
remineralization [8]. metallic silver are formed. These precipitates
Bactericidal and Biofilm inhibition of silver and fluoride were found in higher
SDF has a strong antibacterial and antifungal levels in demineralized dentin than in sound
effect inhibiting Streptococcus mutans, dentin which explains why SDF application is
Lactobacillus acidophilus, Streptococcus more effective as a means of arresting the
sobrinus, Actinomyces naeslundii [19] and existing dentin caries than preventing caries
Candida Albicans [24] biofilm formation on initiation on sound dentin surfaces. An in vitro

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Silver Modified Atraumatic Restorative Technique

study by Seto et al. [27] showed silver thereby, preventing the caries process [8]. In
microwires that filled the voids in the carious addition, limited detectable silver particles
lesion, permeating the dentinal tubules, and were found on the sound enamel surface
distributing forces throughout the lesion and treated with SDF, which explains why the
into intact dentin, resulting in reinforced hard sound tooth surfaces are not stained black
dentin. Thus, the inhibitory effect on loss of [35]. Clinical trials have shown SDF to be
mineral content, dentin demineralization [19], efficient in preventing caries in both primary
collagen degradation and biofilm formation and permanent dentition [36]. Furthermore,
contributed to the increased microhardness of the fluoride from GIC has also shown to be
caries dentin [28] and thereby caries arrest effective in preventing the progression of
[21,22,29,30]. Evidence shows that SDF at a incipient carious lesions.
concentration of 38% is more effective than Desensitization
12% for caries arrest [31]. Likewise, Dos The silver from SDF forms microwires within
Santos et al. [32] found 30% SDF to be more the dentinal tubules and these precipitates of
effective than GIC used as an interim silver and calcium fluoride prevent fluid flow
restorative treatment for caries arrest. A through the tubules, blocking them, and
systematic review by Chibinski et al. [33] thereby diminishing pain and clinically
established that SDF is 89% more effective in reducing dentin hypersensitivity [13,27,37].
arresting caries than other active treatments Synergistic action of SDF and GIC
in primary teeth. When SDF is applied to carious tissue, it reacts
Remineralization with the hydroxyapatite to form calcium
During the caries process, there is loss of fluoride and silver phosphate. In addition to
minerals and breakdown of collagen fibrils silver phosphate, silver oxide and silver
resulting in high porosity occupied by water. sulfide are formed, which convert the silver
On SDF application, silver and fluoride from ions to metallic silver nanoparticles when
SDF combine with the phosphate group of exposed to light. This results in black staining
proteins and calcium ions to form silver when SDF is applied to the surface of carious
phosphate and calcium fluoride, respectively. lesions. The silver particles penetrate into the
The calcium fluoride acts as a fluoride dentinal tubules to form a silver enriched
reservoir and there is subsequent dissociation “zone” at the end of demineralized sites,
of calcium and fluoride and formation of increasing the hardness of carious dentin [35].
fluorapatite [8]. It also enhances mineral When potassium iodide solution is applied
deposition in the spaces filled with water over this layer of SDF, the free silver ions react
forming a more resistant hybrid layer by with the iodide to form a creamy white
increasing adhesive diffusion, and thereby, precipitate of silver iodide. This will remove
enhancing the microhardness of superficial free silver ions that would potentially stain the
dentin [34]. SDF, being alkaline, facilitates the surface [38]. But the pitfall is that silver iodide
phosphate in the saliva to attach to dentin is believed to be highly photosensitive, and
collagen, inhibits the proteolytic enzymes, may dissociate into metallic silver and iodine
matrix metalloproteinases and cysteine by exposure to light [39]. This could be the
cathepsins and protects them from being reason for the conflicting evidence regarding
exposed, thereby, inhibiting collagen discoloration when KI is used.
breakdown. This serves as a binding site for Furthermore, in carious lesions, SDF initially
calcium ions, thereby facilitating the apatite reacts with the hydroxyapatite to form
nucleation onto the collagen [28]. unstable calcium fluoride, which is washed out
Caries Prevention over time. The calcium and phosphate ions
When SDF is applied to healthy teeth from the odontoblastic processes combined
unaffected by caries, the fluoride anions from with fluoride from SDF and strontium and
the SDF substitute the hydroxyl ions of the fluoride ions from the GIC to form a caries
hydroxyapatite crystal, forming fluoro- resistant base beneath the GIC. The infected
hydroxyapatite which is less acid-soluble, dentin with broken collagen matrix will form

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 Natarajan D.

fluoride-rich arrested caries with an intact panel and clinical experience of clinicians who
collagen matrix; this enhances the formation have successfully used the SMART technique
of stable fluoroapatite which is resistant to [38-42] (Box 1).
acid dissolution [30,40]. The GIC, used after
SDF application, controls caries progression FACTORS AFFECTING SMART RESTORATIONS
by providing proper conditions for Biocompatibility
reorganization of carious dentin. Although GIC When SDF is left in contact with the carious
also releases fluoride, this release is very low tissue for one full minute, it is capable of
when compared with SDF. Thus, the GIC in arresting caries to a depth of 25 µm into
SMART restorations probably controls the enamel and 200 to 300 µm into dentin. The
caries lesions by preventing biofilm retention silver formed microwires in voids caused
and cavity sealing but not predominantly by during demineralization and concentrated at
fluoride release [33]. Thus, these SMART the end of demineralized sites create a self-
restorations kill bacteria and cut off the limiting “zone” or “shield” [27,35]. In a study
nutrient source for any remaining bacteria by done on dogs by Russo et al, histological
placing a chemically sealed restoration that analysis of the teeth lined with 38% SDF and
will arrest and remineralize the caries lesion, restored with amalgam showed that SDF acts
enhancing pulp vitality and preserving the as pulp tissue irritant with presence of
tooth structure [15]. lympho-histio-plasmacytic infiltrate and dark
colored granules inside the cytoplasm of
CLINICAL APPLICATIONS macrophages [41]. Contrastingly, studies by
The indications and contraindications for Bimstein et al, [42] and Korwar et al. [43]
SMART are listed in Table 1. found evidence of silver deposits and no
bacteria within the dentinal tubules, tertiary
CLINICAL TECHNIQUE dentin deposition and absence of pulpal
The clinical protocol for SMART is based on inflammation in deep carious primary teeth
the chairside recommendations by expert treated with SDF.

Table 1. Indications and contraindications for SMART

Indications Contraindications
Asymptomatic carious lesions with no clinical signs of
Symptomatic carious lesions involving pulp
pulpal inflammation or reports of spontaneous pain.
Patients with ulcerative gingivitis or stomatitis
Non-cleansable carious lesions in posterior teeth
or undergoing thyroid gland therapy
Patients at high risk of caries with rampant caries or
Parents who do not consent to SDF
severe-early childhood caries OR active cavitated caries
treatment or color changes
lesions in anterior or posterior teeth
Multiple cavitated caries lesions that may not all be treated
Known silver allergy
in one visit
Symptomatic molar incisor hypomineralization Potassium iodide contraindications
Prevent caries
Root caries
Cavity liner
Dentinal hypersensitivity
Behavioral, special needs, medical conditions, dental
phobia, anxiety management challenges
Patients without access to or with difficult access to dental care
Non aerosol generating treatment
Outreach community programs

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Silver Modified Atraumatic Restorative Technique

Box 1. Step-by-step clinical technique for SMART

Silver Modified Atraumatic Restorative Technique: Step by Step Clinical Technique
1. Language appropriate informed consent inclusive of color clinical pictures of SDF treated lesions should
be obtained prior highlighting the risk, benefits and alternate treatment options for parents, particularly
for caregivers with low oral health literacy. It should include that caregiver understands that the decayed
part of the tooth may stain black. This is emphasized to make them aware of the staining and partial
appearance of the stains at the restoration-tooth interface [44-46].
2. Wear standard personal protective equipment, and make sure the patient is wearing safety glasses and a
plastic-lined bib.
3. Apply cocoa butter or petroleum jelly to perioral areas and/soft tissues that would possibly come in
contact with SDF. Care should be taken that the petroleum jelly dos not contact the caries lesion as it
could inhibit the uptake of SDF and affect bonding.
Clinical tip: A scented lip balm would mask the ammonia odor of SDF
4. Remove gross debris, biofilm and pellicle with pumice, non-fluoride prophylaxis paste or moist cotton
pellet from the cavity to enhance direct contact of SDF to the carious dentin [6].
Clinical tip: Alternatively, etch with 37% phosphoric acid for 5-15 seconds, rinse and dry. Do not
desiccate.
5. Isolate with isodry or isolite, saliva ejector, suction bite-block, gauze, cotton rolls, finger guard, absorbent
triangles or dri-angle and dry with a cotton pellet.
Clinical Tip: Alternatively, dry the tooth both prior and after SDF placement using a clean and dry
microbrush.
6. No operative intervention (e.g., affected or infected dentin removal) is necessary to achieve caries arrest.
7. Dispense 1 drop of SDF into a disposable plastic dappen dish and use a micro-brush to apply on the lesion
with scrubbing motion. Leave SDF in place for 1 minute. The arrested lesion should be matte black in
color and firm on using a periodontal probe.
Clinical Tip: Use a plastic dappen dish as SDF corrodes glass and metal and digital timer for
application time. The dentist’s finger could be used to block for the child’s tongue when applying SDF
on lower posterior teeth, which augments tooth isolation and prevents a metallic taste [46].
8. Excess should then be appropriately removed with cotton wool or a gauze.
Clinical Tip: Avoid rinsing post SDF application to reduce the chance of staining soft tissues and
metallic taste [46].
9. KI is placed on a separate dish, and a separate microbrush fully immersed in the KI should be applied to
the SDF treated carious tissue. KI should be repeatedly applied one to three times until the white
precipitate turns colorless. Wait for 5 to 10 seconds between applications and remove excess with cotton.
Rinse with water and air-dry [47].
10. If required, the cavosurface margins could be prepared with a high-speed handpiece, slow-speed round
bur, hard-tissue laser, air abrasion, or a spoon excavator.
11. Remove debris and condition with 20% polyacrylic acid for 10 seconds, then rinse for 10 seconds and
blot dry with cotton leaving a moist glossy surface. This is essential to remove the smear layer and ensure
good chemical bond to the tooth structure activating the surface for ionic exchange.
12. Place matrix system if required. GIC is mixed and placed into the cavity. Do not disturb the GIC for 2.5
minutes from the start of the mix. Use “finger push” technique wherein a gloved finger lubricated with
unfilled resin or manufacturer’s coat is used to push the GIC and at the same time removing excess
material. Excessive GIC should be removed from unwanted areas using an instrument lubricated with a
thin film of unfilled resin.
13. If restoring with resin modified GIC or composite, a layer of auto-cure GIC is placed up to the
dentinoenamel junction, bonding agent is applied to the surface, bulk fill composite or resin modified GIC
is condensed into the cavity and light cured. This is indicated only when using SDF+KI [48].
14. Finishing and polishing should be accomplished with light pressure with high-speed finishing burs and
polishing cups, respectively. Manufacturer’s coat or unfilled resin (without light cure to avoid blackening
of tooth and restoration) should be used post restoration.
15. Invert all used cotton, microbrush, and dappen dish into a glove so SDF does not drip on any surface or skin.

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 Natarajan D.

Conditioning vs. etching BENEFITS

When the carious tissue is conditioned using The most notable aspects of SMART
polyacrylic acid, it does not facilitate SDF technique are its ease of use, efficacy, low-
penetration into demineralized dentin. cost, biocompatibility, and less chairside
Contrastingly, application of 37% phosphoric time. It is not technique-sensitive and offers a
acid removes the smear layer, which non-aerosol generating alternative to
decreases the surface bioload and thereby traditional caries management with a high-
facilitating deeper penetration of the SDF [49]. speed handpiece. The ART-based approach
Bond strength increases the children’s cooperation being
Pre-etching aids in deeper penetration of SDF less painful and less time consuming [55].
or SDF+KI by inhibition of matrix With the added benefit of decreased tooth
metalloproteinases and cysteine cathepsins, sensitivity, the brushing procedure becomes
which enhances the interlocking within the less painful and this enhances the adherence
dentinal tubules, thereby, increasing the to oral hygiene procedures in children [37].
overall bond strength [49,50]. Whereas, post- Thus, from a practical standpoint, this
etching resulted in an increase in bond technique offers a simple and good value-for-
strength of the adhesive restorative material money intervention that does not require
like GIC or resin modified GIC. In agreement, specialist referral for use in resource-limited
etch-and-rinse adhesive showed higher bond health care systems and community dental
strength than self-etch adhesive on SDF service.
treated carious dentin [4]. Unfortunately, the
bond strength of GIC was significantly reduced SIDE EFFECTS
when SDF was allowed to dry and SDF+KI Despite the numerous benefits, the unesthetic
precipitate was left on the surface without black staining of the carious tissue hampers
rinsing. This is due to the deposition of silver the broader acceptance of SDF. An in vitro
iodide precipitate, and rinsing the SDF treated study by Nguyen et al. [56]] found that teeth
dentin eliminates this precipitate; thus treated with SDF+KI showed minimal or no
favoring adhesion and thereby improving the staining irrespective of being restored with
bond strength of GIC [51,52]. It is important to auto-cure GIC, resin modified GIC, or
understand that application of KI over SDF composite. New research on bovine teeth has
does not affect the bond strength of GIC or shown 20% glutathione to be effective for
resin modified GIC to dentin [39,53]. eliminating the stains predominantly on the
Light curing enamel only [57]. In 2019, a scoping review by
When SDF is applied to carious dentin, Magno et al. [58] concluded that esthetic
metallic silver is formed, and its production is perception of staining by SDF was influenced
accelerated when exposed to light and high by lower acceptance by dentists and not by
temperature, producing a black stain. In patients and parents. Further studies are
addition, light curing of SDF-treated dentin required to assess the acceptability of SMART
does not affect the depth of penetration of technique and this one pitfall would not
silver particles into the dentin tubules of undermine the numerous benefits of this
primary teeth [54]. technique.
Microleakage Based on the follow-up of 888 preschool
A study reported that SDF+KI+GIC showed the children in a clinical study, transient tooth and
highest resistance to microleakage. This could gingival pain (6.6%), gingival swelling (2.8%)
be attributed to the anti-matrix and gingival bleaching (4.7%) were only
metalloproteinase action of SDF causing reported [59]. Previous clinical studies have
decreased collagen degradation and reported metallic taste and a small, mildly
promotion of remineralization, and this painful white lesion in the mucosa, which
resulted in improved chemical bond of GIC to disappeared in 2 days without any treatment
the collagen fibrils [53]. [8,36,38]. Furthermore, it causes permanent

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Silver Modified Atraumatic Restorative Technique

staining of counter top surfaces, floors, to its antimicrobial activity and inhibition of
instruments and clothing which may be demineralization [19], and it has proven to be
treated with sodium hypochlorite [8]. Any more effective than fluoride varnish [8].
staining of skin would disappear when Wright and White [12] suggested that if SDF
keratinocytes are shed over a period of 14 was used for the management of early
days. The white discoloration or surface childhood caries, it would decrease the need
changes on the oral mucosa would resolve in for sedation and general anesthesia, and the
2 days [36,60,61]; whereas, a long-term cost implications for delivery of care.
mucosal stain would be evident if SDF Alternatively, if SDF was used only as a
contacts an intraoral wound. Hence, temporary means to stabilize the disease until
desquamative gingivitis or mucositis is a conventional restorative treatment could be
relative contraindication [47]. implemented, then the oral health care costs
might actually increase [12]. By implication
SAFETY AND TOXICITY with the right technique and choice of
SDF has been reported to be completely safe restorative material, SMART restorations
for use in preschool children with no could offer promising permanent results. In
adverse effects or reports of acute or serious the current pandemic scenario, the use of
systemic illness [59,62]. The recommended aerosol-generating procedures in SMART
limit of SDF is one drop (25 μL) containing restorations could be avoided. Furthermore,
9.5 mg of SDF per 10 kg per treatment visit when KI is unavailable for use, the use of an
corre-sponding to 0.95 mg/kg. The average auto-cure opaque GIC or an opaquer prior to
median lethal dose (LD 50) of SDF observed in GIC placement is advised to avoid grayish
rat studies is approximately 520 mg/kg [47] discoloration of restoration. While the clinical
by oral administration providing a 547-fold effectiveness of SDF and ART have been
safety margin. The average amount of SDF documented in scientific literature separately,
applied to 3 teeth was found to be 7.6 mg or there are no published trials investigating the
2.5 mg per tooth [47]. This corresponds to success of SMART technique in pediatric
1.5 mg of silver (0.5 mg per tooth) and 0.33 dentistry to date.
mg of fluoride (0.11 mg per tooth) [63].
Thus, a child of 10 kg with 20 decayed teeth CONCLUSION
treated with 38% SDF would receive a In summary, the SMART procedure ensures the
maximum dose of 10 mg (1 mg/kg) silver continued viability of dental practice during the
and 2.2 mg fluoride (0.22 mg/kg), which is COVID-19 pandemic. The synergistic benefits of
within the safety margin. Considering, the antimicrobial activity and caries arrest of
toxic dose of fluoride which is 5 mg/kg [64], SDF+KI and a well-sealed restoration in a single
there would be a 23-fold safety margin. technique could potentially be the reason for
Similarly, the no-observable-adverse-effect clinical success of the SMART technique. The
level of ingested silver for rats is 181 technique offers an efficient and economical way
mg/kg/day and it is 10 g for a total lifetime for management of caries in young and highly
for humans; thus, toxicity is of low concern anxious children and could help break the cycle
for silver [65,66]. A randomized controlled of dental caries. The SMART technique could be
trial investigating the effectiveness and a revolutionary approach to caries management
safety of 38% SDF in 2-to-3-year old children with more clinical trials and longer follow-up to
showed no consistent changes in relative provide more information on its clinical
abundance of caries-associated outcomes.
microorganisms, nor emergence of
antibiotic or metal resistance gene ACKNOWLEDGMENTS
expression [67]. None.

EVIDENCE AND PRACTICE PERSPECTIVE CONFLICT OF INTEREST STATEMENT

The SDF’s clinical success has been attributed None declared.

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 Natarajan D.

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