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SILVER MODIFIED ATRAUMATIC RESTORATIVE TECHNIQUE( SMART): AN ALTERNATIVE CARIES PREVENTION TOOL
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Figures 1A and 1B. Radiograph of distal D3 approximal lesion on tooth # 41
case, the healthcare provider has limited options: 1. no SDF placement at all( do nothing), 2. place SDF once knowing success may be limited, or
3. place SDF and a glass ionomer cement( GIC) sealant / restoration during the same appointment to limit access of fermentable carbohydrates and improve chances of SDF caries arrest. The damage from acids affecting the tooth surfaces through the process of demineralization, as well as the process of remineralization to help replenish the lost substrates from the effects of the acid damage have both been extensively studied 6. Perhaps what is more exciting are studies demonstrating that conventional GIC produces a sealed chemical bond and remineralized layer at the material-tooth interface 7.
2. Rationale The case presentation showcases steps when applying a technique called Silver Modified Atraumatic Restorative Technique( SMART)* in which SDF is placed and immediately restored or sealed with conventional GIC. Placement of SDF and GIC on the same appointment is especially useful when, for whatever reason, the patient will not be able to return for subsequent dental treatment and it is deemed advantageous to use a minimally invasive procedure rather than nothing at all. Some examples include, children, humanitarian dentistry in underserved populations, or when there are long wait times for hospital dentistry. The technique presented will combine advantages of three proven principles: 1. the antibacterial and remineralizing effects of
SDF causing caries arrest 4, 5,
2. partial / incomplete caries removal on deep caries lesions approaching a vital and asymptomatic pulp 8, 9, and
3. proper placement of a chemically sealed and bonded GIC restoration 10. By placing SMART restorations you kill bacteria and cut off the nutrient source for any remaining bacteria by placing a chemically sealed restoration that will arrest and remineralize the caries lesion, preserving tooth structure and enhancing pulp vitality.
3. Case Study SDF Placement with Immediate Restoration Using GIC A 71-year-old female with a medical history significant for hypothyroidism, osteoporosis, gastroesophageal reflux disease, and schizophrenia presented to the practice. She was taking medication for hypothyroidism, osteoporosis. Her chief concern was to address her front teeth and to avoid extraction if possible. During her clinical exam and CRA, saliva appeared thick and ropey, multiple lesions presented throughout her mouth, and hygiene was relatively fair( moderate plaque, moderate calculus, and multiple areas of bleeding upon probing). The patient was diagnosed with moderate xerostomia, generalized mild chronic periodontal disease and extreme caries risk. The treatment plan proposed to the patient was limited scaling and root planning to address the periodontal health, and placed on 4 month recall. Upon vitality testing, tooth # 41 was diagnosed as vital and a treatment formulated to address the
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