Silver Modified Atraumatic Restorative Technique: For Pediatric Patients

Dr. Carla Cohn


Whether you call them primary teeth, milk teeth, baby teeth, first teeth, or deciduous teeth, one thing is certain—children’s teeth matter! The primary dentition serves a critical role in the growth and development of our children, allowing them a healthy, confident smile with the ability to chew and eat nutritious food and to thrive. Deciduous teeth hold space and make way for their permanent successors, permitting proper speech development. Yet, with all of these important functions, the respect for the primary dentition is simply not there. Many people have difficulty understanding why so much time, effort, and resources go into caring for “teeth that are simply going to fall out anyway.” Sadly, the care of primary dentition also takes a back seat in the practices of many dental professionals. The truth is, from a dental professional standpoint, that the management of children’s behavior in the dental office can be challenging at times. Add to that the fact that caries are epidemic, with early childhood caries and severe early childhood caries being the most common of chronic childhood diseases. Furthermore, another hurdle is that access to care for many children is poor. Whether it is the disadvantaged population right here in North America or the much larger child population in other countries, getting to a dentist or accessing and/or affording dental treatment, to many children, is simply not possible (Figure 1). What would be truly beneficial would be a non-invasive, inexpensive, and effective way to treat caries. Enter glass ionomer restoratives and silver diamine fluoride.

Figure 1. Kids’ teeth matter: gross decay in early mixed dentition.

Glass Ionomer Restorative Materials
Glass ionomers were first introduced as a dental material in the 1970s.1 Since their introduction, glass ionomers have evolved and have improved immensely. They are easier to handle and have better wear resistance and aesthetics.1,2 Glass ionomers are an ideal restorative option for our pediatric patients due to their inherent material properties. A glass ionomer has the ability to bond chemically to dentin and enamel, thereby eliminating the need to phosphoric-acid-etch and bond. Glass ionomers are biocompatible, and this restorative material can act as a fluoride release and then recharge and act as a reservoir. A significant property of glass ionomers is hydrophilicity, and, as a result, glass ionomers are ideal for the pre-cooperative or uncooperative child patient. Glass ionomers have been used routinely for the atraumatic restorative technique (ART) or the intermediate/interim restorative technique (IRT). In these techniques, hand instrumentation or slow-speed rotary instruments are used to remove decay, most often without the use of local anesthetic.

Glass ionomers are used as the restorative material of choice. A preparation with a solid periphery, no pulpal exposure, and a complete seal is imperative for clinical success. According to the American Academy of Pediatric Dentistry (AAPD), “there is strong evidence from a meta-analysis, that employing ART/IRT techniques using high viscosity glass ionomer cements has value as single surface temporary restoration for both primary and permanent teeth. Additionally, ITR may be used for caries control in children with multiple open carious lesions, prior to definitive restoration of the teeth.”1 ART and IRT are useful as techniques, and yet they still fall short. Clinically, we encounter situations in which it is not even possible to complete an ART or IRT procedure. This may be the case due to poor patient cooperation, the speed necessary to treat many children who may have poor access to care, or financial limits. In these situations, we must seek a more powerful tool.

Silver Diamine Fluoride
Silver diamine fluoride (SDF) is that powerful tool. SDF is a topical agent that arrests dental caries. It is supplied as a colorless or blue liquid that is as simple to apply as a drop of liquid. When left in contact with the carious tissue for one full minute, it is capable of arresting caries to a depth of 25 µm into enamel and 200 to 300 µm into dentin. The application of SDF requires no use of local anesthesia, and no drilling or removal of tooth structure. The silver ion acts as an antimicrobial that denatures proteins and breaks down cell walls, inhibiting DNA replication, and as a coagulant that occludes dentinal tubules. The fluoride ion promotes mineralization, creates fluorohydroxyapatite, inhibits demineralization, and inhibits bacteria. SDF is inexpensive and allows for treatment of many patients in a fast and easy manner. Silver diamine at a 38% concentration, applied biannually, is found to be the most effective.2 However, even a single application of 38% SDF was found to be effective in reducing caries after 6 months.3 From all available evidence, there is no doubt that SDF is effective.4-9 SDF has been available in the United States since 2014 and has also been approved as an agent to treat dentin sensitivity. SDF has been available in Canada since 2016 and has been approved as a caries-arresting agent. The SDF panel from the AAPD states indications and usage as a “conditional recommendation, with low-quality evidence” and the use of 38% SDF for the arrest of cavitated carious lesions in primary teeth as part of a comprehensive caries management program.1 The hallmark of SDF is that it leaves the arrested lesion with a black stain, or scar. This is unsightly, and, in many instances, the aesthetics are unacceptable to the patient or parent. The other downside to treatment with SDF is that, although it arrests the caries, it does not fill the lesion and, therefore, cannot restore the form of the tooth.

The SMART (silver modified atraumatic restorative treatment) technique marries the 2 aforementioned materials. The carious lesion is treated first with SDF and then restored with a glass ionomer. This serves to effectively arrest caries, without removal of additional tooth structure, and then restore tooth form with a glass ionomer.9 The added benefit here is that the glass ionomer will also mask the black stain caused by the SDF. In an in vitro study, it was found that SDF does not adversely affect the bond strength between glass ionomer cement (GIC) and carious primary dentin.10 This SMART technique can be carried out with placement of the GIC immediately after placement of the SDF in a single appointment or after 2 applications of the SDF, as recommended biannually to arrest the lesion,2 and then placement of the GIC.

Case 1

This patient was anxious, and his ability to cooperate in the dental office was found to be unpredictable at best. He presented with a lesion on the distal lower left primary molar and an incipiency on the neighboring first permanent molar (Figures 2 and 3). SDF treatment was deemed an ideal solution, as it would treat both the primary and permanent neighbors. SDF (Advantage Arrest [Elevate Oral Care]) was placed on the lesion with cotton roll isolation for one full minute. The lesion was washed and dried, but not desiccated. A glass ionomer (IonoStar Molar [VOCO]) was placed and allowed to set to achieve a SMART restoration. IonoStar Molar, a self-cure glass ionomer, is a nonsticky and immediately packable material. The improved handling allows for better adaptation to the cavity preparation. In addition, IonoStar Molar has improved aesthetics over previous glass ionomers (Figure 4).

Case 2
An uncooperative patient presented with a large lesion involving the distal-occlusal surface of the upper left first primary molar. This case required arrest of the lesion and restoration of the cavitation due to problems with food impacting in the cavity (Figure 5). The teeth were isolated with cotton rolls, and SDF was placed on the lesion with cotton roll isolation for one full minute. The lesion was washed and dried, but not desiccated. A glass ionomer was placed and allowed to set in this SMART restoration (Figure 6).

Case 3
This 3-year-old patient was a challenging behavior-management case. She presented with occlusal caries on both mandibular second molars. Figure 7 shows the preoperative mandibular right molar. At her very young age, she was unable to sit in the dental chair and cooperate for local anesthesia or an invasive procedure or for extended periods of time. After isolation with cotton rolls, SDF (Figures 8 and 9) was placed at appointment one and coated with fluoride varnish (Profluorid Varnish [VOCO]) (Figure 10). She was set up for a 4-month follow-up appointment. At that appointment, a glass ionomer was placed directly on top of the SDF, creating the SMART restoration (Figure 11).

Case 4
A patient presented with a large carious lesion on his mandibular right first permanent molar. The patient resided in an area with poor access to care. He was seen in the operating room, and this procedure was carried out under general anesthesia. The area was isolated with a slot-style rubber dam (Figure 12). Caries were then excavated to a reasonable depth, and care was taken to not have a mechanical carious pulp exposure (Figure 13). In this case, Riva Star (SDI), an SDF desensitizer newly released in North America, was applied as the base of the SMART restoration. Riva Star consists of the placement of SDF, followed by potassium iodide to mask the silver- black scar (Figure 14). The lesion was washed and dried, but not desiccated. The enamel was etched and bonded with Futurabond U (VOCO) universal adhesive. The cavity was filled to the dentin enamel junction with layers of glass ionomer at the base of the cavitation directly on top of the Riva Star (Figure 15), followed by a resin-modified glass ionomer, Ionolux (VOCO) (Figure 16). Ionolux is an aesthetic resin-modified glass ionomer that also does not stick to instruments and is immediately packable. All layers were co-cured, and then a final layer of GrandioSO Flow (VOCO) flowable composite was applied (Figure 17).

Primary teeth are often deemed to be unimportant and expendable, children’s behavior in dental offices can be unpredictable and difficult to manage, caries is a rampant chronic disease, and poor access to care makes treatment for early childhood and severe early childhood caries very difficult. A perfect storm is created.

Traditional caries management requiring surgical intervention to remove the diseased tooth structure, followed by placement of a restorative material to restore form and function, is both invasive and expensive. Barriers to traditional restorative treatment (ie, behavioral issues, limited cooperation, access to care, or financial constraints) call for alternative caries management modalities.

SDF and glass ionomers have become common materials in my office. I have seen many children saved from a potentially traumatic dental experience because of these materials. I have been able to treat many otherwise uncooperative children and save them from the pain of a toothache. Glass ionomers and SDF have become invaluable tools for treating children. As materials and technology evolve, we must as well. In the author’s opinion, this could be the “silver lining” that we have all been looking for! After all, children’s teeth do matter!


  1. AAPD reference manual. Recommendations: best practices. Pediatr Dent. 2017;39:312-324.
  2. Fung MHT, Duangthip D, Wong MCM, et al. Arresting dentine caries with different concentration and periodicity of silver diamine fluoride. JDR Clin Trans Res. 2016;1:143-152.
  3. Yee R, Holmgren C, Mulder J, et al. Efficacy of silver diamine fluoride for Arresting Caries Treatment. J Dent Res. 2009;88:644-647.
  4. Clemens J, Gold J, Chaffin J. Effect and acceptance of silver diamine fluoride treatment on dental caries in primary teeth. J Public Health Dent. 2018;78:63-68.
  5. Chu CH, Lo EC, Lin HC. Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children. J Dent Res. 2002;81:767-770.
  6. Llodra JC, Rodriguez A, Ferrer B, et al. Efficacy of silver diamine fluoride for caries reduction in primary teeth and first permanent molars of schoolchildren: 36-month clinical trial. J Dent Res. 2005;84:721-724.
  7. Crystal YO, Niederman R. Silver diamine fluoride treatment considerations in children’s caries management. Pediatr Dent. 2016;38:466-471.
  8. Crystal YO, Marghalani AA, Ureles SD, et al. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Pediatr Dent. 2017;39:E135-E145.
  9. Alvear Fa B, Jew JA, Wong A, et al. Silver Modified Atraumatic Restorative Technique (SMART): an alternative caries prevention tool. Stomatology Edu Journal. 2016;3:243-248.
  10. Puwanawiroj A, Trairatvorakul C, Dasanavake AP, et al. Microtensile bond strength between glass ionomer cement and silver diamine fluoride-treated carious primary dentin. Pediatr Dent. 2018;40:291-295.

Dr. Cohn is a general dentist, devoted solely to the practice of dentistry for children. She maintains a private practice at Kids Dental in Winnipeg, Man, Canada. She is a proud member of the American Academy of Pediatric Dentistry Speakers Bureau, Catapult Education Speakers Bureau, and Pierre Fauchard Academy and is a cofounder of the Women’s Dental Network. Dr. Cohn has been named as one of Dentistry Today’s Leaders in Continuing Education for multiple years in a row. She has published several articles and webinars and enjoys lecturing on all aspects of children’s dentistry for the general practitioner both nationally and internationally. She can be reached via email at

Disclosure: Dr. Cohn receives educational support from VOCO.

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