UNIVERSIDADE ESTADUAL PAULISTA

“JÚLIO DE MESQUITA FILHO”

Instituto de Ciência e Tecnologia

Campus de São José dos Campos

ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2023.e3956

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3956

Success rate of silver nano-particles in comparison to silver

diamine ﬂuoride in management of deep carious lesions:

a randomized controlled clinical trial

Taxa de sucesso de nanopartículas de prata em comparação ao ﬂuoreto de diamina de prata no manejo de lesões cariosas profundas:

um estudo clínico controlado randomizado

Kareem Hamdy AHMED ALY

, Mona Ismail RIAD

, Ahmed Fawzy ABO ELEZZ



1 - Suez Canal University, Faculty of Dentistry. Ismailia, Egypt.

2 - Cairo University, Faculty of Dentistry. Cairo, Egypt.

How to cite: Ahmed Aly KH, Riad MI, Abo Elezz AF. Success rate of silver nano-particles in comparison to silver diamine uoride in management

of deep carious lesions: a randomized controlled clinical trial. Braz Dent Sci. 2023;26(4):e3956. https://doi.org/10.4322/bds.2023.e3956

ABSTRACT

Objective: Evaluate the effectiveness of nanosilver uoride in comparison to silver diamine uoride in management of deep carious lesions.

Material and Methods: This double-blinded randomized controlled clinical trial included thirty-six patients with deep carious mandibular

molars. Patients were recruited form the outpatient clinic of Suez canal university, Egypt and randomly allocated into three groups, Nanosilver

uoride group, Silver diamine uoride group and control group. For all groups, teeth were isolated by rubber dam. Access was done followed

by partial caries removal. Silver diamine uoride or Nanosilver uoride were applied, and all teeth were restored with composite resin

restorative. Patients were recalled after 3 and 6 months to follow-up the pulp vitality. R-statistical analysis software for Windows, version

4.1.1, was used to conduct the statistical analysis Results: At 3 month, for all groups, all teeth were successful. After 6 months, for silver

diamine uoride group, a single case failed. Regarding the nanosilver uoride, all cases were successful. For the control group, two cases

failed. No statistically signicant difference was found between the tested groups. Conclusion: Application of 5% Nanosilver to uoride

varnish has similar clinical efcacy as silver diamine uoride in arresting the dentin caries progression.

KEYWORDS

Dental caries; Dental pulp disease; Nanoparticles; Pulp capping; Silver diamine uoride.

RESUMO

Objetivo: Avaliar a ecácia de uoreto de nanoprata em comparação ao uoreto de diamina de prata no manejo de lesões profundas de cárie.

Material e Métodos: Este estudo clínico controlado randomizado duplo-cego incluiu trinta e seis pacientes com lesões de cárie profunda em

molares inferiores. Os pacientes foram recrutados no ambulatório da Universidade do Canal de Suez, no Egito, e alocados aleatoriamente

em três grupos de tratamento: uoreto de nanoprata, uoreto de diamina de prata e grupo controle. Para todos os grupos, os dentes foram

submetidos ao isolamento absoluto. O acesso à lesão foi feito seguido pela remoção parcial de tecido cariado. Tanto o uoreto de diamina

quanto uoreto de nanoprata foram aplicados, e todos os dentes foram restaurados com resina composta. Os pacientes foram avaliados

após 3 e 6 meses para o acompanhamento da vitalidade pulpar. O software estatístico R-statistical para Windows, versão 4.1.1, foi usado

para as análises. Resultados: Em 3 meses, para todos os grupos, todos os dentes apresentaram sucesso no tratamento. Após 6 meses, para o

grupo que utilizou o uoreto de diamina de prata um único caso falhou. Em relação ao uoreto de nanoprata, todos os casos apresentaram

sucesso. Para o grupo controle, dois casos falharam. Não houve diferença estatística entre os grupos testados. Conclusão: A aplicação de

verniz de uoreto de nanoprata a 5% tem ecácia clínica semelhante ao uoreto de diamina de prata na interrupção da progressão de cárie

no tecido dentinário.

PALAVRAS-CHAVE

Cárie; Doença da polpa dentária; Nanopartículas; Capeamento pulpar; Fluoreto de diamina de prata.

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3956

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver diamine fluoride in management of deep carious lesions: a randomized controlled clinical trial

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver

diamine ﬂuoride in management of deep carious lesions:

a randomized controlled clinical trial

INTRODUCTION

The standard treatment protocols for caries

lesions include completely removing all infected

tissue before restoring the tooth. This method

for treating deep lesions increases the danger

of pulp exposure, which frequently necessitates

endodontic therapy [1]. Deep carious lesions are

dened as cases showing radiographic evidence of

caries reaching the inner third or inner quarter of

dentine with a risk of pulp exposure [2]. For the

treatment of teeth with reversible pulp irritation

that are asymptomatic, conservative procedures of

carious dentin removal have been devised in order

to stop pulp exposure and the complications that

follow [3]. Stepwise excavation (SW) is a two-step

process that involves completely excavating

diseased tissue. However, the SW approach has

significant drawbacks associated with cavity

reopening, such as the possibility of pulp exposure

during the nal excavation or when reentering the

cavity. A different course of treatment has been

suggested because of the second intervention’s

lack of evidence and the drawbacks of the SW

approach. In this method, partial dentin removal

and placement of restorative material are carried

out in a single procedure [4]. Many uoride-based

therapeutic materials were introduced and assessed

for their effects on arresting dental caries [5].

Owing to its efciency in stopping the advancement

of dental cavities, Silver diamine uoride (SDF),

a topical fluoride preparation based on metal

ions, has recently received more attention. It was

reported that 38% SDF had a clinical efficacy

of about 65.9% in halting the advancement of

dentinal caries. The main disadvantage of SDF is

the heavy dark tissue discoloration caused by the

oxidation of the ionic silver used in its composition,

coupled with ulceration and painful oral tissue

staining. However, SDF-related soft tissue stains

are typically reversible [6].

Among the most effective antibacterial agents

is silver nanoparticles (AgNPs), whose effectiveness

against cariogenic bacteria like

S.mutans

has been

demonstrated in-vitro. AgNPs are utilized in dental

materials because of nano silver’s enhanced anti-

viral and anti-fungal properties[7]. Despite the

well established ability of nano silver uoride and

SDF in halting the carious process [8], the available

data in literature was limited to primary teeth,

invitro studies and case reports [8,9]. According to

a recent non-randomized case series, Silveruoride

demonstrated the capacity to protect the pulp in

277 permanent teeth with very deep decay [10].

Furthermore, although partial caries removal is

currently the recommended approach to preserve

pulp vitality, still the majority of dentists practice

the complete carious tissue removal to hard

dentin [2,11]. Thus by comparing the two current

cariostatic agents presented in this study, there will

be an a expansion on the current understanding in

terms of efcacy, cost and clinical decision making.

Consequently, this research was done to assess

and contrast the promising cariostatic properties

of NSF to that of SDF. The null hypothesis is that

there is no difference in clinical efcacy between

NSF and SDF in arresting deep carious lesion.

MATERIALS AND METHODS

Study design

This study was a double blinded randomized

controlled three arm study with allocation ratio

1:1:1. The patients and outcome assessors were

blinded to the study groups. The Suez Canal

University Faculty of Dentistry’s Research Ethical

Committee (226/2019) granted its approval

for this randomized clinical research. Patients

were recruited from the outpatient clinic of

the department of conservative dentistry, Suez

canal university, Ismailia Egypt. Follow up was

carried out for 6 months. The study’s protocol

was submitted into the US National Institutes

of Health protocol registry (ClinicalTrials.gov

NCT05231330). This study was reported based

on the Consolidated Standards of Reporting Trials

(CONSORT). Informed consent was obtained from

all individual participants included in the study.

Sample size calculation

Using power analysis, the total sample size

for a Chi-square test comparing three groups

was calculated. The minimum estimated sample

size was 30 individuals, and the effect size (w)

was 0.75 utilizing alpha levels of 0.05 (5%) and

beta levels of 0.10 (10%), i.e., power = 90%.

The number of subjects was increased to 36,

with 12 subjects per group, to account for a 20%

dropout rate.

Criteria of patient selection

Inclusion criteria included Cooperative

patients between 18-50 years old having vital

lower rst and second molars with class I primary

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3956

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver diamine fluoride in management of deep carious lesions: a randomized controlled clinical trial

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver

diamine ﬂuoride in management of deep carious lesions:

a randomized controlled clinical trial

deep carious lesions with no widening in the

periodontal ligaments, pain, mobility or sensitivity

to percussion. Medically unt patients, women

who were pregnant, and those with allergies to any

restorative materials, including anesthetics, were

among the exclusion criteria. Retained deciduous

teeth and teeth with previous restorations were

also excluded.

Randomization and allocation

A random sequence was created with the

use of an online tool by a coinvestigator[12].

The randomization table was then printed and

kept with the co-investigator. The operator

provided opaque envelopes with folded,

numbered papers for the patients to drag. Patients

were unaware of their treatment group. The

study groups remained anonymous at end of

study during assessment by the statistician.

All participants signed a written informed consent.

Grouping of patients

Thirty-six patients were evenly distributed

by random among three groups based on the

tested material:

• Silver Nanoparticles group (A1), (n=12):

conservative caries management (selective

caries removal to soft dentin) was carried out

to deep carious teeth followed by application

of NSF (Nano silver particles in fluoride

solution).

• SDF group (A2), (n=12): conservative caries

management (selective caries removal to soft

dentin) was carried out to deep carious teeth

followed by application of SDF.

• Control group (A3), (n=12): conservative

caries management (selective caries removal

to soft dentin) was carried out to deep carious

teeth with no additional intervention.

Intervention

AgNPs synthesis in powder form

25ml of clear silver nitrate solution was

added drop wise to the freshly prepared aqueous

solution of Sodium Borohydride (NaBH4) at 60ºC

for 30 minutes in a dark environment. The solution

was stirred to ensure homogeneity. The pH of the

mixture was then adjusted to 11 while raising

the temperature to 90ºC and continuous stirring

for 30 minutes. The resulted silver nanoparticles

suspension was exposed to simultaneous coating

with Polyvinylpyrrolidone in the early stage

of formation. It was allowed to cool at room

temperature. Besides the tiny amount produced,

the dispersion medium was freeze dried also and

affected the degree of nanosilver powder purity.

Therefore, the nanoparticles suspension was

subjected to centrifugation followed by drying

at 50ºC to produce dark greyish powder with

uniquely ne particles that representing nano-

silver powder [13].

Characterization of silver nanoparticles

In order to identify the distinctive optical

characteristics of silver nanoparticles, the generated

silver nanoparticles were examined with the aid

of ultraviolet-visible absorption spectroscopy.

The size and form of the silver nanoparticle were

assessed using a transmission electron microscope

(TEM). Once a drop of the solution has been

applied on a copper grid that has carbon coating

and allowed to dry in the air, samples were then

subjected to TEM analysis. A Gatan (DualVision

600t CCD) camera was used to capture images,

and Gatan was used to analyse the captured

images (Digital Micrograph Version 3.11.1.)

Preparation of 5% silver nanoparticles in uoride

varnish (NSF)

In a brown light-proof bottle, 10 ml of

22,600 ppm slow release sodium uoride varnish

(FLUORITOPTM-SR)3 was combined with 0.5

grammes of silver nanoparticle powder and vigorously

stirred by vortex at low speed for 30 seconds to

achieve uniform dispersion of the particles.

Diagnostic procedures

A comprehensive medical and dental history

was documented. A diagnostic chart was lled out

with the patient’s demographic information, tooth

count, and number of affected surfaces. Digital

periapical and bitewing radiographs (EzSensor

Classic, Vatec, Korea) were taken for each tooth

by the same X-ray machine (Xgenus®, De Götzen,

Italy) utilising uniform exposure conditions (70 kvp,

3.5 mAs, and 0.2 s). A cold test was performed using

EndoIce (Hygenic Endo-Ice, Coltene Whaledent,

Cuyahoga Falls, OH) and electric pulp tester

(Denjoy DY310, Denjoy, Henan, China). Scaling

and polishing were done to remove any present

dental plaque or calculus eliminating any biolms

harboring bacteria on the teeth surface.

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3956

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver diamine fluoride in management of deep carious lesions: a randomized controlled clinical trial

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver

diamine ﬂuoride in management of deep carious lesions:

a randomized controlled clinical trial

Single tooth isolation was performed for

simple occlusal lesions. Access through the cavitated

enamel was obtained, when necessary, using a

high-speed handpiece and a sterile high-speed

bur (#245 bur, Meisinger GmbH, Germany) with

copious water spray rotating at speed ranging

from 380,000-450,000 rpm. Following the

guidelines published by the International Caries

Consensus Collaboration (ICCC), selective caries

removal to soft dentine strategy was performed

using hardness criteria. Total caries removal to

hard dentine was performed for the peripheral

walls of the cavity using a sterile tungsten

carbide bur (#245 bur, 0.8 mm in diameter and

1.6 mm in length Meisinger GmbH, Germany)

and a low-speed large round bur (HM 71, size 4,

Meisinger GmbH, Germany) operated at 10000-

12000 RPM. The dentino-enamel junction (DEJ)

and cavosurface margins were inspected carefully

and made sure to be clean. For the pulpal oor

soft dentine was removed until the level at which

would put the pulp at risk of exposXure.

For the NSF group (A1) The cavity was

rinsed with copious water spray to remove any

debris then a gently compressed air ow was

done to dry the cavity followed by bending and

dipping the micro brush into NSF solution and

applying pressure to the plastic dappen dish’s

side to squeeze out extra liquid before application

over the remaining discolored soft dentin. Excess

material was removed with gauze followed by

application of a gently compressed air ow until

the medicament was dry and left for 2 minutes

for complete dryness. Selective etching of the

enamel was carried out in accordance with

the manufacturer’s instructions using a 35%

phosphoric acid gel for 15 seconds, followed by

a 15-second water rinse and a 5-second gentle

air-drying period. Using a disposable applicator

brush, a single coating of universal bond was

applied to the prepared cavity and rubbed

for 20 seconds. For about 5 seconds, a gently

stream of air passed over until it stopped moving

and the solvent had evaporated. According to

the manufacturer’s recommendations, photo

activation was carried out for 10 seconds using

the Elipar S10 light curing system (3M ESPE in

St. Paul, Minnesota, USA) at an intensity of 1200

mW/cm2. Composite resin restorative was used

to restore the cavities, the material was placed

in increments of 2 mm following the anatomic

layering technique and then light curing was done

for 40 seconds. After checking the occlusion, one-

step polishing tips and/or cups (Dimanto ®, Voco

Gmbh, Germany) and a low-speed contra-angle

handpiece (NAC-EC, NSK, Japan) with water

coolant and low pressure were used for final

polishing.

For SDF group (A2) The cavity was rinsed

with copious water spray, a gentle flow of

compressed air was done to dry the cavity followed

by application of SDF with a microbrush according

to manufacture instruction directly to the carious

tooth surface. Excess SDF was removed with gauze

followed by application of a gently compressed air

ow until medicament is dry and left for as long

as three minutes. Etching, bonding and composite

application was done as mentioned previously.

For the control group (A3) The cavity was

rinsed with ample spray of water, then a gently

compressed air ow was done to dry the cavity.

Etching, bonding and composite application was

done as mentioned previously. Postoperative

instructions and oral hygiene recommendations

for the follow-up period were given to all patients.

Patients were instructed to contact the primary

investigator if there were any symptoms of pain

or complains regarding the restoration.

Outcomes

The patients were contacted three and six

months later to evaluate the results. The outcome

of this study was the success/ failure of the tooth

expressed as a binary variable. Success requires

positive response to sensitivity pulp testing, absence

of spontaneous pain, sensitivity to percussion, sinus/

stula/swelling and radiographic abnormalities

as follows [14]:

1. Vitality pulp testing: Cold pulp testing and

electric pulp testing were performed to

conrm pulp vitality. The patient notied the

operator when he/she felt pain and when the

pain subsided. The length of the response was

recorded and compared to a control tooth.

2. Spontaneous pain: post-operative pain was

assessed as presence / absence.

3. Sensitivity to percussion: light tapping of

the occlusal surface using mirror handle

and patients were asked to report presence/

absence of pain. Test was also carried out for

adjacent and contralateral teeth.

4. Sinus/stula/swelling: using visual inspection

and tactile sensation, recorded as presence/

absence.

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3956

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver diamine fluoride in management of deep carious lesions: a randomized controlled clinical trial

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver

diamine ﬂuoride in management of deep carious lesions:

a randomized controlled clinical trial

5. Radiographic abnormalities: Indicating

presence of periapical radiolucency, widening

of lamina dura, internal and external root

resorption. Periapical radiolucency was

considered in case of widening twice the

width of the periodontal ligament space and

absence of lamina dura and was recorded as

a binary outcome as presence or absence.

If one of these tests indicated the presence

of an irreversible pulpitis or pulp necrosis

the tooth was considered as failure. Patients

who reported treating the tooth in another

healthcare facility were recorded as failure.

Statistical analysis

Using the chi-square test for the effect of

material comparison, categorical data were

presented as frequency and percentage values.

Using the Shapiro-Wilk test, the mean and standard

deviation values of the supplied numerical

data were examined for normality. One-way

ANOVA was used to analyze parametric data.

For all tests, the significance level was set at

p 0.05. R statistical analysis software for Windows,

version 4.1.1, was used to conduct the statistical

analysis.

RESULTS

The study was conducted on 36 cases that

were equally and randomly allocated to one of

the three studied groups. Consort 2010 flow

chart for the trial design is presented in Figure 1.

There were 5(41.7%) males in the control group

and 7(58.3%) females, in SDF group there was

8(66.7%) males and 4(33.3%) females, while in

silver nanoparticles group there was 7(58.3%)

males and 5(41.7%) females. The mean age of

the cases in the control group was (32.50±11.55)

years, in SDF it was (28.42±10.47) years, while in

silver nanoparticles group it was (31.25±13.30)

years. There was no signicant difference between

groups regarding sex distribution (p=0.589) and

age (p=0.690).

Figure 1 - Consort 2010 ﬂow chart for the trial design.

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3956

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver diamine fluoride in management of deep carious lesions: a randomized controlled clinical trial

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver

diamine ﬂuoride in management of deep carious lesions:

a randomized controlled clinical trial

Regarding teeth vitality, after three months,

all cases of all groups were positive. After 6 months

only one case in the control group was negative

while other cases were positive and the difference

between groups was not statistically signicant

(p=0.358). For spontaneous pain, after 3 months,

all cases were free from spontaneous pain. After

6 months, one case in the control and one in SDF

groups suffered spontaneous pain, while all cases

of silver nanoparticles group were free and there

was a non-signicant difference between groups

(p = 0.589).

Regarding the sensitivity to percussion, after

3 months, all cases were free from sensitivity to

percussion. After 6 months, 2 cases in the control

group and one case in SDF group had sensitivity

to percussion while all the cases of the silver

nanoparticles group were free but there was no

signicant difference between groups.

For both intervals, all cases in all groups

were free from presence of sinus/swelling/stula.

While for the radiographic abnormalities, after

3 months, all cases in all groups were free. After

6 months, one case in the control group had

radiographic abnormalities with no signicant

difference between groups (p=0.358) (Table I).

Overall success rate

After 3 months, all cases were successful in

all groups. After 6 months, 2 cases failed in the

control group and a single case failed in SDF, while

all cases of silver nanoparticles were successful.

No signicant difference between the materials

was found (p=0.336) (Table II, Figure 2).

Table I - Frequency and percentage values for assessed patient symptoms

Parameter Control SDF Silver nanoparticles p-value

Vitality

Negative n (%) 1 (8.3%) 0 (0.0%) 0 (0.0%)

NS 0.358

Positive n (%) 11 (91.7%) 12(100.0%) 12 (100.0%)

Spontaneous pain

Absent n (%) 11 (91.7%) 11 (91.7%) 12 (100.0%)

NS 0.589

Present n (%) 1 (8.3%) 1 (8.3%) 0 (0.0%)

Sinus/ﬁstula/swelling

Absent n (%) 12 (100.0%) 12 (100.0%) 12 (100.0%)

Present n (%) 0 (0.0%) 0 (0.0%) 0 (0.0%)

Sensitivity to percussion

Absent n (%) 10 (83.3%) 11 (91.7%) 12 (100.0%)

NS 0.336

Present n (%) 2 (16.7%) 1 (8.3%) 0 (0.0%)

Radiographic abnormalities

Absent n (%) 11 (91.7%) 12 (100.0%) 12 (100.0%)

NS 0.358

Present n (%) 1 (8.3%) 0 (0.0%) 0 (0.0%)

Signiﬁcant (p ≤ 0.05), ns; non-signiﬁcant (p>0.05). [Chi-square test x

Table II - Frequency and percentage values for outcome status for diﬀerent materials

Time Parameter Control SDF Silver nanoparticles p-value

3 months

Failure N (%) 0 (0.0%) 0 (0.0%) 0 (0.0%)

Success N (%) 12 (100.0%) 12(100.0%) 12 (100.0%)

6 months

Failure N (%) 2 (16.7%) 1 (8.3%) 0 (0.0%)

NS 0.336

Success N (%) 10 (83.3%) 11 (91.7%) 12 (100.0%)

Signiﬁcant (p ≤ 0.05), ns; non-signiﬁcant (p>0.05). [Chi-square test x

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3956

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver diamine fluoride in management of deep carious lesions: a randomized controlled clinical trial

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver

diamine ﬂuoride in management of deep carious lesions:

a randomized controlled clinical trial

DISCUSSION

This study was designed to evaluate the

success rate of silver nanoparticles in comparison

to SDF in managing deep carious permanent

teeth. SDF has been reported as a successful caries

arresting agent for up to 10 years [15]. In the

current study, the concentration of SDF was 38%.

SDF is available in solutions with 10%, 30%, and

38% silver content, although the 38% solution

appears to be the most efficient at inhibiting

caries and fostering remineralization [16].

Silver compounds transform into metallic silver,

which causes carious tissue to become darkly

stained. SDF precipitates as a black precipitate

on the surface of carious dentin as a result of

the reaction between unreacted silver ions and

the partially denatured collagen. Because of the

oxidative qualities of the ionic silver used in the

formulation, extra unreacted silver ions continue

to precipitate as silver sulphide capping, which

results in staining [17].

Silver nanoparticles have drawn attention

in the recent years in medical fields. For

gram-negative bacteria, tiny spherical silver

nanoparticles can enter the bacterial matrix

and disrupt vital cell functions including DNA

replication [18]. NSF was the experimental

prepared material in the current study for

managing deep carious lesions. The benets of

using NSF over SDF were the fact that it did not

turn the dental tissue black, and did not produce

oxides when it interacted with oxygen in the

media [19]. The experimental prepared material

was composed of nanosilver for its antimicrobial

effect and uoride to enhance remineralization.

And also, to prepare a material similar in

composition to the ready-made SDF but in

nanoscale hoping to improve its cariostatic effect

and reducing the drawbacks of black staining

caused by silver in its molecular form and without

ammonia to avoid the bad taste.

The characterization of materials containing

AgNPs is a crucial step in their development.

UV-visible spectroscopy, which has been

demonstrated to be a useful and signicant method

for the characterization of metal nanoparticles,

was used to characterise the produced AgNPs.

The UV absorption spectral test were carried out

to monitor the reduction of silver ions to AgNPs

and conrm their formation [20]. TEM was used to

visualize the particle size and shape [21]. Weight

dilution method described by Haghgoo et al.

(2014) [13] was adopted in the preparation of

5% NSF and this concentration was used as it is

the minimum nano silver concentration to kill and

inhibit growth of cariogenic microorganisms such

S.mutans and S.Salivarius

[5].

In the current study, teeth were selected

according to pre-dened clinical and radiographical

criteria which ensured to great extent the absence of

irreversible changes in the dental pulp complex [22].

Only molars with class I primary deep carious

lesions were included in the current study. This was

done to decrease the variables as much as possible

as the number of surfaces in a dental restoration has

shown to be of different inuence in different type

of studies. In addition to their easier radiographical

interpretation [23]. No dyes were utilized during

Figure 2 - Bar chart showing success percentage values for outcome status for diﬀerent groups.

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3956

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver diamine fluoride in management of deep carious lesions: a randomized controlled clinical trial

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver

diamine ﬂuoride in management of deep carious lesions:

a randomized controlled clinical trial

the caries removal process since they can lessen

visual and tactile subjective perceptions, moreover,

dyes are less specic to caries, causing excessive

removal of perfectly healthy tooth structure, and

raising the risk of mechanical pulp exposures [24].

For enhanced mechanical strength, wear

resistance, and improved aesthetics, an impervious

restoration is mandatory [25]. Additionally,

dental pulp healing is directly correlated to

the ability of both the interim and definitive

restorative material to create a biological seal,

along the entire interface, against both long-term

and short-term microleakage, rather than being

solely dependent on the purported stimulatory

effect of a particular type of medication [26].

Therefore, in the current study, all treated teeth

in all groups were restored with a light cured

composite resin to avoid bacterial leakage.

Radiographic follow up was performed

using digital radiography, in order that the

information from radiographic images would

be collected more easily and in a more objective

way, thus improving the performance of the

diagnostic process, in addition to minimize the

patient radiation. Paralleling technique was used

since it ensures image reproducibility which is

an important requisite for standardization [4].

It has been known that management of deep

carious lesions success or failure is dependent

upon accurate diagnosis at the time of treatment.

Considering the fact that more clinical failures

usually occur within the first-time interval

(3- 6 months), it is believable that improper

diagnosis may contribute to these failures. Hence,

in the present study the follow up visit were after

3 and 6 months [14,27,28].

The results of the current study showed

that, after 3 months, all cases were successful in

all groups. After 6 months, for the control group,

2 cases failed with no signicant difference between

intervals. For SDF group, a single case failed with

no signicant difference between intervals. For

NSF group, all cases were successful. Regarding

the NSF success rate in the current study all cases

were successful after 3 and 6 months. These results

come in accordance with Santos et al. (2014) [30],

who found that at ve months, the NSF group had

72.7% cases with arrested decay, and the control

group had 27.4% that might be attributed to the

synergism of the components of its formulation

(AgNPs and uoride) and the small size of the NSF

nanoparticles increasing the contact surface area.

Butrón Téllez Girón et al. (2020) [31] also found

that teeth treated with silver nanoparticles added

to fluoride varnish seemed to have enhanced

dental structure. They attributed this to the fact

that the added silver nanoparticles are more

effective in the dental remineralization thus not

only halting progression of the carious process but

also reverting it [30].

The clinical and radiographic success rate at

the end of the 6-month follow-up period in the

current study was 100% in NSF group, 91.7% in

SDF group and 83.3% in control group although

no signicant difference was found among the

three groups. This result was in accordance with

that of Tirupathi et al. (2019) [18] who compared

the success rate of 5% NSF and 38% SDF [18].

Higher success rate for NSF was observed with

no signicant differences between the 2 groups

during their 6 months follow-up. This might be

attributed to the fact that NSF is a better inhibitor

of S. mutans biofilm formation than SDF. As

these nanoparticles would easily enter the

polysaccharide matrix inside the cell, they could

prevent biofilm formation and maturation by

inhibiting the creation of exopolysaccharides [15].

The nano-sized particles of NSF are signicantly

smaller than SDF, hence the inhibition of the

bacteria with silver was stronger. As a result,

even low quantities of silver could signicantly

minimize the adverse effects of NSF while having

powerful antibacterial properties.

Regarding the success rate of SDF in this

study, after 3 months, all cases were successful

while a single case failed after 6 months

(spontaneous pain and sensitivity to percussion)

with no signicant difference between intervals,

which come in accordance with Divyashree R.

(2021) who reported that SDF seems to be a

good indirect pulp therapy (IPT) material as

it fulls the criteria for IPT procedure such as

good biological seal and maintenance of the pulp

vitality and there was no statistically signicant

difference between the clinical success rates of

SDF when used after 3 and 6 months [31]. They

hypothesized that both silver ions and uoride

ions are involved in the mechanism of action, with

uoride ions acting primarily on tooth structure

and silver ions acting primarily on cariogenic

bacteria. Santos et al. (2014) [32] compared the

effectiveness of SDF with temporary restorations

in the arrest of caries and they found that 38%

SDF was 1.73 times more effective in stopping

caries than an interim restorative approach after

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3956

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver diamine fluoride in management of deep carious lesions: a randomized controlled clinical trial

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver

diamine ﬂuoride in management of deep carious lesions:

a randomized controlled clinical trial

6 and 12 months. SDF acts as a uoride reservoir

for acid attacks by pathogenic organisms by

providing an alkaline environment that makes

CaF2 less soluble.

As for the success rate of the control group

in this study, after 3 months, all cases were

successful while 2 cases failed after 6 months

with no signicant difference between intervals

(p=0.500). The results of the control group in

this study come in accordance with a plethora

of studies that proved that if severely damaged

dentin is removed and a good interfacial seal is

created, the dentin-pulp complex’s healing and

self-repair processes can occur without the use of

a mineralization inducer [33-35]. In the current

study, the good clinical and radiographic success

reported with PCR group could be attributed to the

correct diagnosis and utilization of a well-sealed

coronal restoration to stabilize any remaining

carious dentine while reducing the availability of

exogenous nutrients thus preventing microleakage.

This study did have some limitations, rst,

even though the trial was carried out by a single

consistent operator who used the same clinical

judgement regarding degree of caries removal,

application of materials, and evaluating proximity

to pulp tissue, the investigator was not blinded to

the study groups due to noteworthy differences

in the materials used. Along with being a single

center study, this might affect the generalizability

of the study ndings. Another limitation was the

relatively small sample size and short follow up

period, which adds another burden on the external

validity of the study. Further clinical trials with

larger sample size and longer observations periods

are needed to provide a broader and more relevant

viewpoint regarding the long-term biological

effects of these materials on the dental pulp.

CONCLUSION

Under the limits of the present study, it could

be concluded that Application of 5% Nanosilver

to uoride varnish has same clinical efcacy as

SDF in preventing the progression of dentinal

caries without causing undesirable tooth staining.

However, further clinical randomized trials with

different shapes, sizes and concentrations of

Silver nanoparticles.

Author’s Contributions

KHAA: Conceptualization, Methodology,

Validation, Investigation, Formal Analysis, Data

Curation, Writing – Original Draft Preparation. MIR:

Conceptualization, Validation, Writing – Review

& Editing, Supervision. AFAE: Conceptualization,

Validation, Writing – Review & Editing, Supervision.

Conict of Interest

No conicts of interest declared concerning

the publication of this article.

Funding

The authors declare that no nancial support

was received.

Regulatory Statement

All procedures performed in the study

were in accordance with the ethical standards

of the institutional research committee of Cairo

university and with 1964 Helsinki declaration

and its later amendments.

REFERENCES

1. Pal S, Tak YK, Song JM. Does the antibacterial activity of silver

nanoparticles depend on the shape of the nanoparticle? A study

of the gram-negative bacterium Escherichia coli. Appl Environ

Microbiol. 2007;73(6):1712-20. http://dx.doi.org/10.1128/

AEM.02218-06. PMid:17261510.

2. Duncan HF, Galler KM, Tomson PL, Simon S, El-Karim I, Kundzina

R,etal. European Society of Endodontology position statement:

management of deep caries and the exposed pulp. Int Endod

J. 2019;52(7):923-34. http://dx.doi.org/10.1111/iej.13080.

PMid:30664240.

3. Ricketts D, Lamont T, Innes NPT, Kidd E, Clarkson JE.

Operative caries management in adults and children.

Cochrane Database Syst Rev. 2019;7(7):CD003808.

http://dx.doi.org/10.1002/14651858.CD003808.pub4.

PMid:31339555.

4. Stafuzza TC, Vitor LLR, Rios D, Silva TC, Machado MAAM,

Oliveira TM. Clinical and radiographic success of selective

caries removal to firm dentin in primary teeth: 18-month

follow-up. Case Rep Dent. 2018;2018:9213681. http://dx.doi.

org/10.1155/2018/9213681. PMid:29796320.

5. Soekanto SA, Marpaung LJ, Ushohwah H, Djais A, Darwita RR.

Efficacy of propolis fluoride and nano silver fluoride for inhibition

of streptococcus mutans and enterococcus faecalis biofilm

formation. Int J Appl Pharm. 2017;9(Spe 2):51-4.

6. Sayed M, Nikaido T, Abdou A, Burrow MF, Tagami J. Potential

use of silver diammine fluoride in detection of carious dentin.

Dent Mater J. 2021;40(3):820-6. http://dx.doi.org/10.4012/

dmj.2020-308. PMid:33775985.

7. Yin IX, Zhao IS, Mei ML, Li Q, Yu OY, Chu CH. Use of silver

nanomaterials for caries prevention: a concise review. Int J

Nanomedicine. 2020;15:3181-91. http://dx.doi.org/10.2147/IJN.

S253833. PMid:32440117.

8. Rady MA, Elbehery SM, Eldesouky G, Elbaz G, Mahfouz S.

Clinical evaluation of the efficacy of silver diamine fluoride

in arresting active dentin caries in primary molars. Dent Sci

Braz Dent Sci 2023 Oct/Dec; 26 (4): e3956

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver diamine fluoride in management of deep carious lesions: a randomized controlled clinical trial

Ahmed Aly KH et al.

Success rate of silver nano-particles in comparison to silver

diamine ﬂuoride in management of deep carious lesions:

a randomized controlled clinical trial

Update. 2021;2(2):197-203. http://dx.doi.org/10.21608/

dsu.2021.77947.1070.

9. Mungur A, Chen H, Shahid S, Baysan A. A systematic review on

the effect of silver diamine fluoride for management of dental

caries in permanent teeth. Clin Exp Dent Res. 2023;9(2):375-87.

http://dx.doi.org/10.1002/cre2.716. PMid:36823765.

10. Griffith M. Treating deep caries in 277 adult teeth with silver

fluoride. J Calif Dent Assoc. 2021;49(1):13-7. http://dx.doi.org/

10.1080/19424396.2021.12222658.

11. Schwendicke F, Stangvaltaite L, Holmgren C, Maltz M, Finet M,

Elhennawy K,etal. Dentists’ attitudes and behaviour regarding

deep carious lesion management: a multi-national survey. Clin

Oral Investig. 2017;21(1):191-8. http://dx.doi.org/10.1007/

s00784-016-1776-5. PMid:26971353.

12. https://www.randomizer.at/. Accessed 10 September 2020.

13. Haghgoo R, Saderi H, Eskandari M, Haghshenas H, Rezvani

MB. Evaluation of the antimicrobial effect of conventional and

nanosilver-containing varnishes on oral Streptococci. J Dent

(Shiraz). 2014;15(2):57-62. PMid:24883341.

14. Corralo DJ, Maltz M. Clinical and ultrastructural effects of

different liners/restorative materials on deep carious dentin:

a randomized clinical trial. Caries Res. 2013;47(3):243-50.

http://dx.doi.org/10.1159/000345648. PMid:23343804.

15 Mei ML, Zhao IS, Ito L, Lo ECM, Chu CH. Prevention of secondary

caries by silver diamine fluoride. Int Dent J. 2016;66(2):71-7.

http://dx.doi.org/10.1111/idj.12207. PMid:26689611.

16. Duangthip D, Wong MCM, Chu CH, Lo ECM. Caries arrest by

topical fluorides in preschool children: 30-month results. J Dent.

2018;70:74-9. http://dx.doi.org/10.1016/j.jdent.2017.12.013.

PMid:29289726.

17. Akyildiz M, Sönmez IS. Comparison of remineralising potential of

nano silver fluoride, silver diamine fluoride and sodium fluoride

varnish on artificial caries: an in vitro study. Oral Health Prev

Dent. 2019;17(5):469-77. PMid:31268047.

18. Tirupathi S, Svsg N, Rajasekhar S, Nuvvula S. Comparative

cariostatic efficacy of a novel nano-silver fluoride varnish with

38% silver diamine fluoride varnish a double-blind randomized

clinical trial. J Clin Exp Dent. 2019;11(2):e105-12. http://dx.doi.

org/10.4317/jced.54995. PMid:30805113.

19. Brignardello-Petersen R. Although silver diamine fluoride arrested

caries sooner than fluoride varnish, the overall proportion of

arrested caries was not importantly different after 30 months.

J Am Dent Assoc. 2018;149(8):e117. http://dx.doi.org/10.1016/j.

adaj.2018.02.007. PMid:29625697.

20. Gurunathan S, Han JW, Kwon DN, Kim JH. Enhanced antibacterial

and anti-biofilm activities of silver nanoparticles against

Gram-negative and Gram-positive bacteria. Nanoscale Res

Lett. 2014;9(1):373. http://dx.doi.org/10.1186/1556-276X-9-373.

PMid:25136281.

21. Corrêa JM, Mori M, Sanches HL, Cruz AD, Poiate E, Poiate

IAVP. Silver nanoparticles in dental biomaterials. Int J Biomater.

2015;2015:485275. http://dx.doi.org/10.1155/2015/485275.

PMid:25667594.

22. Ricucci D, Loghin S, Siqueira JFJ Jr. Correlation between clinical

and histologic pulp diagnoses. J Endod. 2014;40(12):1932-9.

http://dx.doi.org/10.1016/j.joen.2014.08.010. PMid:25312886.

23. Khokhar M, Tewari S. Outcomes of partial and complete

caries excavation in permanent teeth: a 18 month clinical

study. Contemp Clin Dent. 2018;9(3):468-73. http://dx.doi.

org/10.4103/ccd.ccd_344_18. PMid:30166846.

24. Croft K, Kervanto-Seppälä S, Stangvaltaite L, Kerosuo E.

Management of deep carious lesions and pulps exposed during

carious tissue removal in adults: a questionnaire study among

dentists in Finland. Clin Oral Investig. 2019;23(3):1271-80.

http://dx.doi.org/10.1007/s00784-018-2556-1. PMid:29987635.

25. Favaro JC, Peixoto YCTM, Geha O, Dias FA, Guiraldo RD, Lopes

MB,etal. Can silver diamine fluoride or silver nanoparticle-based

anticaries agents to affect enamel bond strength? Restor Dent

Endod. 2021;46(1):e7. http://dx.doi.org/10.5395/rde.2021.46.

e7. PMid:33680896.

26. Pratiwi AR, Meidyawati R, Djauharie N. The effect of MTA

application on the affected dentine remineralization after partial

caries excavation (in vivo). J Phys Conf Ser. 2017;884(1):012119.

http://dx.doi.org/10.1088/1742-6596/884/1/012119.

27. Martins DAS, Moreira KMS, Pereira MSS. Partial removal of

carious in primary teeth: a systematic review of the literature.

Oral Health Dent Manag. 2018;17(1):1-5.

28. Maltz M, Garcia R, Jardim JJ, De Paula LM, Yamaguti PM, Moura

MS,etal. Randomized trial of partial vs. stepwise caries removal:

3-year follow-up. J Dent Res. 2012;91(11):1026-31. http://dx.doi.

org/10.1177/0022034512460403. PMid:22983407.

29. Santos VE Jr, Vasconcelos A Fo, Targino AGR, Flores MAP,

Galembeck A, Caldas AF Jr,etal. A new “silver-bullet” to treat

caries in children - nano silver fluoride: a randomised clinical

trial. J Dent. 2014;42(8):945-51. http://dx.doi.org/10.1016/j.

jdent.2014.05.017. PMid:24930870.

30. Butrón Téllez Girón C, Hernández Sierra JF, DeAlba-Montero

I, Urbano Peña MDLA, Ruiz F. Therapeutic use of silver

nanoparticles in the prevention and arrest of dental caries.

Bioinorg Chem Appl. 2020;2020:8882930. http://dx.doi.

org/10.1155/2020/8882930. PMid:32855631.

31. Divyashree R. Effectiveness of silver diamine fluoride when

used as an indirect pulp therapy (IPT) material- a clinical and

radiological assessment. Int J Appl Dent Sci. 2021;7(2):466-78.

http://dx.doi.org/10.22271/oral.2021.v7.i2g.1255.

32. Santos, V. E., Targino, A. G. R., Flores, M. A. P., Pessoa, H. de

L. F., Galembeck, A., & Rosenblatt, A. (2014). Antimicrobial

activity of silver nanoparticles in treating dental caries. Revista

Da Faculdade De Odontologia - UPF, 18(3). https://doi.

org/10.5335/rfo.v18i3.3568

33. Sharma S, Logani A, Shah N. Comparative efficacy of photo-

activated disinfection and calcium hydroxide for disinfection

of remaining carious dentin in deep cavities: a clinical study.

Restor Dent Endod. 2014;39(3):195-200. http://dx.doi.

org/10.5395/rde.2014.39.3.195. PMid:25110643.

34. Franzon R, Opdam NJ, Guimarães LF, Demarco FF, Casagrande

L, Haas AN, etal. Randomized controlled clinical trial of the

24-months survival of composite resin restorations after

one-step incomplete and complete excavation on primary

teeth. J Dent. 2015;43(10):1235-41. http://dx.doi.org/10.1016/j.

jdent.2015.07.011. PMid:26231301.

35. Singh S, Mittal S, Tewari S. Effect of different liners on pulpal

outcome after partial caries removal: a preliminary 12 months

randomised controlled trial. Caries Res. 2019;53(5):547-54.

http://dx.doi.org/10.1159/000499131. PMid:31096259.

Kareem Hamdy Ahmed Aly

(Corresponding address)

Suez Canal University, Faculty of Dentistry, Ismailia, Egypt.

Email: Kareem.aly@dentistry.cu.edu.eg

Date submitted: 2023 Jul 12

Accept submission: 2023 Oct 11