CASE PRESENTATION
Minimally Invasive Caries Management Using the SMART Technique
In recent years, there has been a paradigm shift in caries management from primarily surgical techniques to evidence-based strategies that focus on addressing the causative disease process. The American Academy of Pediatric Dentistry (AAPD) believes that effective caries management should involve taking a thorough medical and dental history, performing a careful hard-tissue exam and caries risk assessment (CRA), and intervening with treatment strategies based on the individual risk status of the patient.
In 2015, silver diamine fluoride (SDF) was introduced to the U.S. market after being approved by the FDA in 2014 to treat tooth sensitivity. However, its primary use has been off-label, to arrest and prevent caries; Horst et al. have reviewed SDF’s safety and efficacy and published a protocol for its use. While repeated applications of SDF undoubtedly ensure higher predictability of caries arrest, there are situations where the patient may not have the ability to return for further treatment or to receive treatment elsewhere. As such, the Silver Modified Atraumatic Restorative Technique (SMART) has been put forth to provide the best possible treatment in these scenarios in which SDF is placed, followed by a glass ionomer cement sealant or restoration during the same appointment.
The technique confers the advantages of the antibacterial and remineralizing effects of SDF and the chemical seal provided by a glass ionomer material. Alvear Fa et al. highlighted many applications for utilizing SMART, including pediatrics, humanitarian dentistry in underserved populations, and hospital dentistry (especially when operating room wait times are long), and these authors have illustrated the use of SMART on an elderly patient with a complex medical history.
Case in Point
The following case involves a 7-year-old healthy patient who presented to the NYU Pediatric Dentistry Clinic with large carious lesions on his mandibular right primary first and second molars (S-DO, T-MO). The patient had a limited dental history and a chief complaint of pain in the mandibular right quadrant secondary to food impaction, and he presented with a high degree of anxiety.
With the use of traditional pediatric behavior management techniques (tell-show-do, positive reinforcement, and modeling), we were able to perform a thorough exam and obtain a periapical radiograph using a digital sensor and imaging unit (DEXIS Platinum, KaVo Kerr; Progeny Preva Imaging System, Midmark). The radiograph showed large carious lesions on S-DO and T-MO, but with approximately 2 mm of intact dentin between the lesions and the pulpal tissues. Given the patient’s lack of a consistent dental home, the lack of pulpal, periapical, or interradicular pathology, and the clinician’s desire to address the chief complaint and the underlying disease, the decision was made to treat the patient using SMART.
After obtaining the parent’s informed consent and the patient’s trust, gross caries removal was performed with a spoon excavator. The teeth were isolated with cotton rolls and Denovo Preformed Matrix Bands. Advantage Arrest Silver Diamine Fluoride 38% (Elevate Oral Care) was applied for 1 minute. The teeth were light-cured for 20 seconds (VALO LED Curing Light, Ultradent), and restored with a resin-modified glass ionomer (GC Fuji II LC, GC America) at the same visit. This treatment was done without local anesthesia, and without emotional distress or physical discomfort to the patient.
Although this case report was done pre-COVID, it is relevant to note the lack of aerosols produced with this technique. Consider also the additional conditioner step before placing the glass ionomer and use of a wet cotton pellet to wipe it off instead of using an air-water syringe. If not an emergency, placing the restorative material at a later visit is beneficial to allow full penetration of the SDF and better adhesion of the glass ionomer.
References
AAPD Reference Manual. Guideline on Caries-risk Assessment and Management for Infants, Children, and Adolescents. 2016–17; 38(6): 142–147.
Alvear Fa B, Jew JA, Wong A, Young D. Silver Modified Atraumatic Restorative Technique (SMART): an alternative caries prevention tool. StomaEduJ. 2016; 3(2): 18–24.
Horst JA, Ellenikiotis H, Milgrom PL. UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications, and Consent. J Calif Dent Assoc 2016; 44(1): 16–28.
Go-To Products Used in this Case
ADVANTAGE ARREST SILVER DIAMINE FLUORIDE
Indicated for dentinal hypersensitivity, Advantage Arrest Silver Diamine Fluoride kills pathogenic organisms while hardening softened dentin so it becomes more acid- and abrasion resistant. Packaged in 8-mL bottles, the tinted formula allows for easy visualization and provides approximately 250 drops.
VALO uses a custom, multiwavelength LED for producing high-intensity light at 385 nm to 515 nm that is capable of polymerizing all light-cured dental materials. The curing light’s unibody construction provides ideal heat dissipation, and its aluminum wand, machined components, and tempered glass lens make it highly durable.
WILLIAM H. LIEBERMAN, DDS, MBA
Dr. Lieberman is a clinical associate professor and Director of Pediatric Dentistry Clinical Operations at New York University College of Dentistry. He also works in private practice in Red Bank, NJ
DYLAN S. HAMILTON, DMD, MS
Dr. Hamilton completed his residency in Pediatric Dentistry at New York University College of Dentistry in June 2017. He maintains a private pediatric dental practice in Durham, NC.
