Introduction

The severity of dental caries in children continues to be high, with  80% national prevalence and a decayed missing filled teeth (dmft) score of 5.0 in kingdom of Saudi Arabia [1-5]. Management of early childhood caries continues to be an enigma, due to the multifaceted nature of the problem, including  unavailability of treatment, affordability, or behavioural issues [6]. Silver diamine fluoride (SDF) has been suggested as a low cost alternative for caries management in such cases. While several countries have conducted research on the effect of SDF to arrest dental caries [7, 8], it was in 2014 that SDF was cleared by the US Food and Drug administration for commercial use [9].

SDF is topically applied to treat tooth hypersensitivity (label indication). Nevertheless, research on efficacy of SDF in adults supports its effectiveness in root caries prevention and arrest as well as remineralisation of deep occlusal lesions.

Considerable literature exists on the safety of SDF as used to treat cavitated lesions. SDF has been claimed to be an alternative to patients who are unable to receive traditional treatments, in particular for children where dental care may need to be performed under general anaesthesia. Compared with no treatment, placebo or fluoride varnish, SDF appears to effectively prevent dental caries in the entire primary dentition [10]. A review concluded that 30% and 38% SDF concentrations lead to increased caries reduction or higher capacity for arresting caries has been observed [11].

Clinically, caries can be arrested by applying SDF to the lesion without removing any infected soft dentin [12]. The mechanism of how SDF leads to caries arrest, is not completely understood. The possible mode of action could be related to its antibacterial effect, remineralization potential and inhibition of organic matrix degradation [11]. Decreased lesion depth has been observed [13] coupled with a slowing down of lesion progression [14]. SDF application leads to the formation of an insoluble precipitate of Ag3PO4 [15] and significantly reduces streptococcus mutans and lactobacillus acidophilus counts [16].

While the evidence supporting the use of SDF is overwhelming, to the best of our knowledge, dentists’ usage is not commensurate. Learning experiences of the dentist, commercial availability, and type of clinical practice, are some of the factors that may have a bearing on the adoption of SDF in clinical practice. Thus, the aim of the study was to assess Knowledge, Attitudes, and Practices, of Pediatric dentists in Saudi Arabia regarding SDF.

Materials and Methods

The adopted study design was descriptive cross-sectional. Ethical approval  was exempted for the survey by the ethical committee.  The survey was conducted amongst pediatric dentists in academic positions, clinical practitioners or both. A convenience sample, targeting at least 10% of the assumed upper limit of population of 400 pediatric dentists, was calculated to be 40 and survey was distributed to 100 practitioners and Faculties. The questions were designed to collect data on knowledge and practices of Pediatric dentists with respect to SDF. Multiple choice questions and questions with 5-point Likert scale were used to collect data in the form of a pretested questionnaire. The link for survey was created on google forms and distributed through emails and social media. Four weeks after the initial round, reminders were sent and the data collection was completed after 2 months. Response to the survey, was considered as implicit consent. The data was tabulated and Statistical analysis was performed using IBM SPSS version 23. Pearson’s correlation was used to evaluate the relationships between the indices. p< 0.05 was considered to be statistically significant.

Results and Discussion

Responses were tabulated in Microsoft Excel and were expressed as mean and standard deviation. Cronbach's alpha inter-item consistency coefficient was overall 0.82. Out of the total 58 complete responses received, 72.4 % respondents were females and 27.6% were males. The demographic data and percentage of pediatric dentists who have used/are using SDF (Table 1), has been expressed in terms of number of respondents and percentages. Table 2a shows the perceived knowledge on usage, advantages over traditional treatment and potential problems for usage on a 5-point scale (great deal to nothing at all). The responses for a great deal and quite a bit combined ranged from 55% to 68%.

Table 2b represents knowledge on general indications of SDF on a 5 point scale (strongly agree to strongly disagree). The highest scores (strongly agree and agree combined) were for medically compromised children (74%) followed by behavioural issues and anxiety (73%). Table 2c Represents knowledge on specific indications and practice of SDF. Cavitated (65%) lesions in non-aesthetic zone of primary teeth (62%) were the highest scores (strongly agree and agree combined). Table 2d shows reasons for pediatric dentists are not using/ may not use SDF. Barrier to usage due to SDF not being readily available commercially had the highest scores (49%). Factor analysis for 5 indices prepared by combining questions and the question: Have you used/currently use SDF in your clinical practice? Significant positive correlation between; (a) Usage of SDF (A) and: knowledge on how to use SDF, and (b) perceived knowledge and use in primary/permanent, aesthetic/non-aesthetic zone (Table 3).

Table 1. Demographic Data Including Gender, Age, Qualification,  and whether  Pediatric Dentists Have Used SDF in Clinical Practice.

Table 2a. Perceived Knowledge on Usage, Advantages over Traditional Treatment and Potential Problems for Usage on a 5-Point Scale

 percentages may not be 100% in all cases due to rounding

Table 2b. Knowledge on General Indications of SDF on a 5-point Scale

Table 2c. Knowledge on Specific Indications and Practice of SDF

Table 2d. Barrier to Usage of SDF Expressed as Percentage with Mean and Standard Error

Table 3. Correlations of 5 Indices Prepared by Combining Questions  and the Question: Have You Used/Currently Use SDF in your Clinical Practice?.