Tooth decay in a two- or three-year-old child can quickly progress from a small spot on the tooth into a full-blown medical problem. Pain, infection, difficulty eating, and sometimes the need for complex dental procedures are just part of the consequences. In particularly young children, performing the treatment itself can be a challenge, sometimes even requiring general anesthesia.
Now, a large clinical study published in late July in the journal JAMA Pediatrics points to a much simpler option: Applying a substance to the tooth, without drilling and without removing the decay, which managed to arrest a significant portion of decay lesions in young children. The study included 830 children aged one to six who suffered from severe early childhood caries.
The tested substance is called Silver Diamine Fluoride, or SDF, a solution containing silver and fluoride. The substance assists in remineralizing the tooth, inhibits bacterial activity, and hardens the tissue damaged by decay. The main advantage lies in its simplicity: It can be applied directly onto the lesion, without drilling or removing the decay.
It is important to understand that "arresting decay" is not synonymous with curing the tooth. SDF does not regrow the missing part and does not close a cavity that has already formed. Its goal is to turn an active decay lesion into one that no longer progresses.
830 children, and a significant difference
The researchers conducted a randomized, double-blind, placebo-controlled clinical trial. Participating in the study were 830 children aged 12 to 71 months who suffered from severe early childhood caries and active cavitated lesions.
The children were randomly divided into two groups. Half received SDF at a 38% concentration, and the others received a placebo. The substance was applied at the start of the study and once more after six months, and the teeth were examined after three, six, and eight months.
The main test was simple: Was the active decay arrested? Three months after treatment, 57.5% of the decay lesions in the SDF group were arrested, compared to 18.8% in the placebo group. After six months, 54% of the lesions treated with SDF were arrested, compared to 22.5% in the control group.
Even after eight months, a significant gap was maintained: 50.2% of the lesions in the treatment group were defined as arrested, compared to 17.4% in the placebo group.
The major advantage of the treatment: No drill required
The finding may hold special importance for young children. Standard dental treatment requires the child to sit still and cooperate with drilling and additional procedures – a task that is not always possible at age two or three.
Applying SDF is a short, non-invasive procedure. The researchers even raise the possibility that in the future, the treatment could be integrated into additional healthcare settings, provided the teams receive appropriate training.
In terms of safety, the study found no significant differences between the groups regarding events considered related to the treatment. The researchers also found no difference in pain.
However, SDF has a prominent downside: The treated decay tissue usually turns a dark to black color. From an aesthetic standpoint, this can be significant, especially on front teeth, which is why it is important to explain this to parents in advance.
Yet SDF is not the only option. In Israel, minimally invasive approaches also exist in which decay tissue is removed as targetedly as possible and the area is subsequently sealed or restored. Such treatment may require gentle drilling, and depending on the lesion depth and the child, can sometimes be performed without anesthesia. The advantage is the ability to restore the tooth structure and achieve a more aesthetic result.
On molar teeth, sealing fissures is also an option in appropriate cases. Sealing serves primarily for prevention or initial decay lesions, making it no automatic substitute for SDF when a cavity already exists.
Combination is also possible
Another option is combining SDF with restorative treatment. One approach is known as SMART, short for Silver Modified Atraumatic Restorative Treatment. In this method, SDF is used to help arrest the decay, and the area is then covered and restored with a dental material.
The idea is to combine SDF’s ability to arrest decay activity with restoring the tooth and improving its appearance. This option may suit some children and is also applied in Israel, though it is important not to present it as a one-size-fits-all solution. The research still does not allow a determination that it is universally superior to appropriate restorative treatment alone.
Choosing between SDF, sealing, minimally invasive restoration, or a combination depends on the location and depth of the decay, the child’s age, their ability to cooperate, and aesthetic considerations.
Not a magic solution for decay
Despite the impressive results, SDF did not arrest all decay lesions. After eight months, about half of the lesions in the treatment group were still not defined as arrested. Therefore, it should not be viewed as a substitute for brushing, fluoride use, proper nutrition, dental checkups, and additional treatments when needed.
The study also has limitations. The follow-up period was relatively short, and about 30% of participants did not complete it, partly due to the coronavirus pandemic. Additionally, the darkening of the treated area could have compromised blinding in some cases.
Still, this is a large, controlled trial that reinforces the role of a remarkably simple treatment in the toolkit against early childhood caries. For a two- or three-year-old child who struggles with standard dental treatment, the option to arrest part of the decay lesions through application alone can be significant.
The broader message for parents is no less important: Not every case of decay in a child necessarily requires starting with drilling and a filling. Modern dentistry currently offers methods aimed at halting the disease, preserving as much tooth structure as possible, and tailoring the treatment to the child.
The author, Dr. Eran Fermon, is a dentist and director of the Malo Clinic in Ramat Hasharon.