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Corresponding author: Antonia Palankalieva ( antonia.palankalieva@mu-plovdiv.bg ) © 2024 Antonia Palankalieva, Ani Belcheva-Krivorova.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Palankalieva A, Belcheva-Krivorova A (2024) Silver compounds used in pediatric dentistry for caries arrest: A review of current materials and new technologies. Folia Medica 66(1): 19-25. https://doi.org/10.3897/folmed.66.e115790
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Silver compounds have been used in medicine and dentistry for centuries. Their use in pediatric dentistry has long been restricted because of some drawbacks, chief among them being the discoloration of teeth with black stains. However, recent advances in technology have resulted in the development of new silver agents that do not have the limitations of previously used ones. This led to the reintroduction of silver compounds in pediatric dentistry. The aim of the present review was to examine the evidence supporting the therapeutic use of silver compounds in pediatric dentistry for caries arrest, as well as the mode of action and biocompatibility, characteristics, advantages, and disadvantages of different silver-containing agents.
nanosilver fluoride, nanotechnology, non-operative treatment, silver diamine fluoride
Dental caries, which affects millions of children globally, is the most common chronic disease in children. The multifactorial etiology of this disease has been recognized as a result of the continuous efforts over the years to better understand the carious process. Although each person has a unique combination of primary and secondary etiological factors, it is generally agreed that childhood is a very dangerous time for the rapid onset and progression of carious lesions, which presents a significant problem for dental professionals.
The concepts regarding the treatment of dental caries have changed several times as pediatric dentistry has evolved, beginning with extraction as a method of treating dental caries and progressing to the principles of non-operative and minimally invasive operative treatment in childhood, which are the main focus of modern pediatric dentistry.
There is increasing interest in caries-arresting agents that can be applied directly to the carious lesion without the need for prior mechanical treatment.
Silver compounds have been used for centuries in medicine, and for over a century in dentistry. The aim of the present review was to analyze the evidence supporting the usage of silver compounds in pediatric dentistry to arrest carious lesions, as well as the biocompatibility, principle of action, characteristics, advantages and disadvantages of various silver-containing materials.
Silver (Ag+) has a significant antibacterial action. It has been used in medicine for ages and has provided numerous benefits to this field.[
Caries lesions were prevented from progressing by using a mixture of amalgam scraps and nitric acid as early as 1891. Howe PR was responsible for popularizing this silver nitrate solution, which is why it was dubbed “Howe’s solution.” It was first used in Boston, USA, to arrest caries among disadvantaged children.[
Since the early 1900s, there have been reports on the use of silver nitrate (AgNO3) to stop the progression of dental caries. Through the years, there has been fluctuations in the popularity of its use and conflicting reports on how effectively it stops dental cavities. Although references to its use date back to 1981, it is currently regarded as outdated.[
Duffin proposed the use of 25% AgNO3 solution followed by 5% NaF varnish to arrest carious lesions in dentine.[
Silver diamine fluoride is a liquid solution which has multiple scientific verifications of its powerful effect against cariogenic bacteria. Numerous in vitro studies confirm the antimicrobial effect of silver ions and the remineralizing effect of fluoride ions SDF contains. SDF can be used for caries management in young children, especially those with special care needs.[
SDF was first invented by Drs Yamaga and Nishino in Japan. They combined the actions of silver, ammonia, and fluoride producing the first silver diamine fluoride product named Saforide (Bee Brand Medico Dental Co, Ltd, Osaka, Japan).[
Organizations like the American Academy of Pediatric Dentistry (AAPD) and the World Health Organization (WHO) support the SDF application for caries management in primary dentition.[
In 2021, the WHO included SDF in the WHO Model List of Essential Medicines for both adults and children.[
Chemically, SDF is composed of diamine silver ion complex [Ag(NH3)2]+ and fluoride ion (F−). Metal amine complexes are less oxidizing and more stable than the silver ion.[
Product name | Manufacturer | Country |
Riva Star | SDI Dental Limited | Australia |
Topamine | Pharmadesign Co., Ltd. | Australia |
Advantage Arrest | Elevate Oral Care | USA |
Saforide | Toyo Seiyaku Kasei Co. Ltd. | Japan |
Ancarie | Maquira, Maringa, PR | Brazil |
Cariostatic | Inodon Laboratorio | Brazil |
Cariestop | BiodinamicaQuimica e Farmaceutica Ltda | Brazil |
Bioride | DensplyIndustria e Comericio Ltds | Brazil |
Fluoroplat | NAF Laboratorios | Argentina |
Fagamin | Tedequim SRL | Argentina |
E-SDF | Kids-e-Dental | India |
The caries-arresting mechanism of SDF is not entirely clear, but there are certain suggestions:
SDF is considered to be a material that is efficient, cost-effective, and non-invasive and may be applied for deciduous and permanent dentition.
A significant disadvantage of SDF use is the black staining of teeth, which has limited its use.[
To manage discoloration, application of potassium iodide (KI) over the SDF is suggested. This leads to white precipitate formation of silver iodide and the spare silver ions are removed. The potassium iodide is applied until the solution turns clear, then is rinsed and dried.[
Another alternative for decreasing the staining from SDF is applying glutathione after the SDF. Glutathione (GSH 20%) is a tri-peptide biomolecule that contains a thiol group which adsorbs onto metal surfaces. This makes the glutathione an ideal means to control the release of Ag+ by coating the silver particles and limiting their aggregation and therefore decreasing the color changes in teeth. Color changes in enamel lesions treated by SDF and glutathione are less than those observed in dentine lesions. This is probably because the formation of metallic silver is much less on the enamel than dentine. To minimize the discoloration in dentine lesions, it may be necessary to use higher percentage of GSH.[
The antibacterial and remineralizing effects of 38% SDF and its role as caries-arresting tool are certain. However, the major concern leading to its limited use is the unaesthetic appearance after its application. Efforts were made to find a solution for this problem. Research in the field of nanotechnology demonstrated that if the size of the bulk silver is reduced, the surface area increases considerably. In this way, bioactive molecules can be attached to improve the antimicrobial effects and prevent black staining in teeth.[
Nanotechnology is a relatively new multidisciplinary field that brings together researchers from various scientific fields, including biology, chemistry, material science, and physics, to create advanced functional nano-sized materials.[
The American physicist and Nobel Prize laureate Richard Feynman is considered the father of nanotechnology. His idea about nano-sized materials was conceived in 1959 and since then it has been implicated in different fields, including medicine.[
Some of the most popular objects of research in this field are the silver nanoparticles (AgNPs).[
There is an array of physical, chemical and biological methods that are available to synthesize nanomaterials.[
AgNPs can overcome the resistance of bacteria against antibiotics thanks to their crystallographic surface structure and large surface-to-volume ratios, which can make them alternative antimicrobial agents.[
A number of mechanisms related to the AgNPs antimicrobial activity have been proposed, but the exact modes of action aren’t fully understood.[
The development of nanoscience resulted in the start of its use in the field of dentistry and the creation of nano silver fluoride (NSF) as a new agent for caries arrest. Targino et al.[
The NSF treatment is a non-invasive option for caries management. It can be applied for caries lesions affecting enamel and dentine with a simple technique without any risk. It is considered as effective as silver diamine fluoride for caries prevention and caries arrest, but it doesn’t stain the teeth. Compared to conventional caries treatment it can be less expensive and not so time-consuming, making it economic and ergonomic. Hence, most communities can afford such treatment.[
Chitosan [poly (1,4-β-d-glucopyranosamine)] is a natural polysaccharide that is prepared by N-deacetylation of chitin. It has a great potential as a biomaterial for the creation of nanosized drug carriers and gene transfer vectors. Some of its advantages are good stability and simple preparation protocol.[
The conventional methods that produce NPs are expensive, toxic, and not eco-friendly. To eliminate these problems, researchers found out natural sources and products that could be used for the NPs synthesis.[
Of all green sources for the production of silver nanoparticles, the most frequently used ones are plants, because plant phytochemicals show greater reduction and stabilization.[
The preparation process includes collection of different plant parts from various sources, followed by washing them from debris and other unwanted materials using first ordinary water and then distilled water. Then, an extract is prepared by putting dried parts of the plant in deionized water or alcohol for a couple of hours at a temperature lower than 60°C. The plant extract is combined with solutions with different concentration of Ag salt as metal precursor, followed by heating, which leads to AgNPs synthesis. The plant extract acts as a reducing and stabilizing agent and the use of chemical stabilizers is avoided.[
Tea is one of the most commonly consumed beverages worldwide. It is the second most popular beverage in the world and is consumed for its flavor and stimulant effect. Tea made from the leaves of ‘Camellia sinensis’ (Green tea), is one of the most favored beverages worldwide.[
Silver compounds have been used in dentistry for over a century. Although SDF is not new to the dental market, it has recently made a comeback in the research field due to its positive effect on caries arrest, combined with its simple application. However, the incorporation of this product into dental practice is still limited due to its low accessibility, a lack of specific protocols for use provided by Pediatric Dentistry Associations, limited training in most universities, and the black staining effect that limits patients’ and parents’ acceptance of treatment. To explore the wider usage of silver compounds, an effort to mask the discoloration should be made. In this context, silver nanoparticles should be further investigated as a new opportunity for carries arrest.
This review paper received institutional funding from the Medical University of Plovdiv, Bulgaria under approved research project No. 18/2023.
The authors have declared that no competing interests exist.