Ruff et al.

BMC Oral Health (2022) 22:125

https://doi.org/10.1186/s12903-022-02159-5

RESEARCH Open Access

Silver diamine fluoride, atraumatic

restorations, and oral health‑related quality
of life in children aged 5–13 years: results
from the CariedAway school‑based cluster
randomized trial
Ryan Richard Ruff*, Tamarinda J. Barry Godín, Topaz Murray Small and Richard Niederman

Abstract
Objective: Silver diamine fluoride (SDF) is a non-surgical treatment for the arrest and prevention of dental caries that
results in irreversible black staining of dental decay. The objective of this study was to evaluate the short-term impact
of SDF treatment on oral health-related quality of life (OHRQoL) relative to a standard package of glass ionomer seal-
ants and atraumatic restorative treatment (ART) in children aged 5–13 years.
Methods: CariedAway is a pragmatic, longitudinal, cluster-randomized non-inferiority trial of non-surgical interven-
tions for caries. Secondary study outcomes included OHRQoL and academic performance. Oral health-related quality
of life was measured at each study visit using the Child Oral Health Impact Profile. Change in OHRQoL was assessed
using linear regression and non-inferiority was determined using t tests.
Results: 160 children with an average age of 8.7 years completed quality of life assessments. Untreated decay at
baseline (approximately 25%) was associated with significantly worse OHRQoL and treatment in both groups resulted
in incremental improvement: children receiving SDF improved their OHRQoL scores from 16.44 (SD = 11.12) to 14.62
(SD = 11.90), and those receiving traditional sealants and atraumatic restorations slightly improved from 16.65 (SD
= 10.56) to 16.47 (SD = 11.09). Quality of life in children receiving silver diamine fluoride was non-inferior to those
receiving sealants and ART at least 6 months post-treatment (mean difference = 1.85, 95% CI = − 2.10, 5.80), and
change in OHRQoL did not depend on the severity of baseline decay.
Conclusions: OHRQoL is related to untreated dental caries, and observed changes following SDF treatment were
non-inferior relative to standard preventive therapies.

Introduction caries has been shown to develop into pain and systemic
Dental caries is the most prevalent childhood disease infection, potentially resulting in functional and/or psy-
in the world [1], found across all age groups and most chosocial impairment [3]. Much of the disproportionate
prominent among low-income populations [2]. Untreated burden of disease amongst vulnerable groups, such as
low-income and minority populations, is due to lower
accessibility and utilization of traditional dental services
*Correspondence: [email protected] [4–6]. As a result, the use of non-surgical treatments
Department of Epidemiology & Health Promotion, New York University such as silver diamine fluoride (SDF) is increasing. Silver
College of Dentistry, New York, USA

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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Ruff et al. BMC Oral Health (2022) 22:125 Page 2 of 7

diamine fluoride is a noninvasive method to prevent and consent, there were no inclusion criteria for child-level
arrest caries that can be efficiently applied in community enrollment. Any subject with parental informed consent
settings [7–9], but results in permanent black staining of and child assent was randomly assigned to treatment and
dental decay and could stain sound tooth structure. received care. Exclusion criteria for individual subjects
Oral health-related quality of life (OHRQoL) is a mul- included any child whose first language was anything
tidimensional construct consisting of subjective evalu- other than English and children enrolled in special edu-
ations of oral health, functional well-being, emotional cation classrooms. Treatment was provided in scheduled
well-being, satisfaction with care, and sense of self 6-month intervals. A total of 48 schools were enrolled in
[10]. Caries may have a negative impact on oral health- the CariedAway study at the time of this report.
related quality of life in preschool children [11], chil-
dren aged 3–12 years and adults [12–14]. High caries Interventions
experience [15] and untreated caries [16] both exhibit Interventions included two separate packages of non-sur-
reduced OHRQoL, regardless of measurement used [17, gical treatments for dental caries: a “simple” combination
18]. Despite a high oral disease burden [19], research on of fluoride varnish (5% NaF, Colgate PreviDent) applied
quality of life and caries in black and Hispanic/Latino to all teeth and silver diamine fluoride (Elevate Oral Care
populations is limited [20, 21]; evidence on silver diamine Advantage Arrest 38%, 2.24 F-ion mg/dose) applied to all
fluoride and quality of life presents conflicting results pits and fissures and asymptomatic cavitated lesions of
with treatment shown to either improve or have no effect bicuspids and molars, and a “complex” combination con-
on OHRQoL in children [22–27]; and the impact on sisting of the same application of fluoride varnish, glass
OHRQoL comparing SDF to atraumatic restorative treat- ionomer sealants applied to pits and fissures of bicuspids
ment is unclear [24, 27]. and molars, and use of atraumatic restorative treatment
CariedAway is a randomized controlled trial of non- on all frank asymptomatic cavitated lesions (GC Fuji IX).
surgical interventions for the prevention and treatment For SDF application, tooth surfaces were cleaned and
of caries in children aged 5–13 years [28], specifically dried and a microbrush was used to transfer the solu-
silver diamine fluoride, sealants, and atraumatic restora- tion to all pits and fissures on bicuspids or molar teeth
tive treatment. The CariedAway study also aims to evalu- and to all posterior, asymptomatic carious lesions for a
ate the effects of treatment on quality of life, academic minimum of 30 s, followed by air drying for a minimum
performance, and school attendance. The objectives of of 60 s. Excess material was removed from teeth with a
this paper are to assess (1) the associations between oral 2 × 2 gauze or cotton roll. Caries diagnosis followed the
health-related quality of life and dental caries and (2) the International Caries Detection and Assessment System
short term effects of non-surgical treatment for caries on (ICDAS) adapted criteria and the diagnostic and treat-
oral health-related quality of life. ment protocol is previously described [28].

Methods Randomization
Ethical approval for the CariedAway clinical trial was Enrolled schools were block randomized in a 1:1 alloca-
obtained from the New York University School of Medi- tion ratio.
cine Institutional Review Board (i17-00578). A previously
published trial protocol contains additional study-related Data collection
information [28] and the trial is registered at www. At each observation, study clinicians performed a full vis-
clinicaltrials.gov (#NCT03442309). Preliminary clinical ual-tactile examination using a disposable mirror, dispos-
results are forthcoming. able explorer, and head lamp in a portable dental chair
or while using a lapboard. Teeth were assessed as being
Design present or missing intraorally. Individual tooth surfaces
CariedAway is a longitudinal, cluster-randomized, single- were assessed as being intact/sound (ICDAS II codes
blind, pragmatic trial with the primary objective of evalu- 0–4), sealed, restored, decayed (ICDAS II code 5–6), or
ating the non-inferiority of non-surgical treatments for arrested [caries]. Clinicians were standardized prior to
dental caries. Any school in New York City with a student observing subjects (see supplementary material for pro-
population of at least 80% receiving free or reduced lunch cedures). Following the oral examination and application
and at least 50% Hispanic/Latino or black was eligible to of treatments, children were asked to complete the oral
participate in the study. School-level exclusion beyond health-related quality of life survey. The clinician would
race/ethnicity and free/reduced lunch criteria included then read each question aloud to subjects who would
those with a preexisting school oral health program. All then note their answers on a provided tablet computer.
children in enrolled schools were provided informed
Ruff et al. BMC Oral Health (2022) 22:125 Page 3 of 7

Outcomes for sociodemographic variables and COHIP scores were

Oral health-related quality of life was assessed using the computed. The association between dental caries at base-
Child Oral Health Impact Profile Short Form (COHIP- line and initial quality of life was assessed using linear
SF), consisting of 19 questions assessing oral health, regression. Following baseline analyses, subjects were
functional well-being, socio-emotional well-being, school ordered sequentially by visit date and any child without
environment, and self-image domains [29, 30]. Lower two completed visits was removed from the analytic sam-
scores indicated “better” quality of life. Examiners asked ple. Within-group differences for treatment groups used
participants each COHIP-SF question (e.g., “Have you in paired samples t tests. Post-treatment analysis of the car-
the past 3 months had pain in your teeth or a toothache”), ies-QoL association was assessed using linear regression,
and children responded by touching an indicator on the adjusting for treatment group, baseline COHIP scores,
tablet or communicating their answer (“Never,” “Almost and demographic variables. The intraclass correlation
never,” “Sometimes,” “Fairly often,” “Almost all of the coefficient for subjects nested within schools was esti-
time”) to the examiner. The COHIP-SF was designed for mated using an intercept-only mixed effects multilevel
children aged 8 and up, and the average age of subjects model. All analyses adjusted for the clustering effect of
in CariedAway completing the OHRQoL instrument schools. The non-inferiority of SDF therapy compared
was 8.7 years. Additionally, 95.7% of subjects were aged to sealants/ART on oral health-related quality of life was
between 7 and 11 years at baseline and study pretesting determined by calculating the confidence interval for
suggested that children aged 7 years were capable of com- the difference in mean COHIP scores across treatment
pleting the instrument. A global quality of life indicator group. As per the original study protocol, a non-inferior-
measuring perceived change from the previous observa- ity margin of ten was used.
tion was also used. For the global QoL question, partici-
pants were asked “On a scale of 0 to 100 where 0 is worst Impact of COVID‑19
and 100 is best, how would you rate your quality of life?” Although all study subjects randomly selected to com-
Subjects were then shown a visual scale on a horizontal plete oral health-related quality of life assessments at
axis ranging from 0 to 100 in 10-point intervals, with baseline were expected to complete follow-up data col-
“worst” at the zero point, “medium” at the 50th point, lection at each successive measurement period, the
and “best” at the 100th point. Participants then tapped impact of COVID-19 required suspension of study pro-
their answer at the point of the scale directly on the tab- cedures for approximately 18 months due to the shut-
let. Not all children received the COHIP-SF instrument: down of local school systems and subsequent prohibition
in order to reduce the data collection time and maximize of any school-based health programs from operating. As
provision of clinical care, fifty percent of participants in a result, analysis was restricted to those subjects who had
the CariedAway trial were randomly assigned within completed their first 6 month follow-up assessment just
each group at baseline to receive the quality of life assess- prior to shutdown.
ment. Assigned children then received the same QoL
instrument at every successive treatment. Results
1323 subjects completed the quality of life assessment at
Covariates baseline, 160 of which (12%) completed a second-follow
Demographic information including age, sex, and race/ up at least 6 months post-treatment with either silver
ethnicity were obtained from informed consent docu- diamine fluoride or sealants/ART, prior to study suspen-
ments or school records. A unique identification number sion due to the impact of SARS-CoV-2. The analytic sam-
maintained by the Office of School Health at the New ple (N = 160) was spread across 17 schools. The baseline
York City Department Health and Mental Hygiene and sample was approximately 53% female and consisted
New York City Department of Education was similarly of 39% Hispanic/Latino, 15% black, 4% white, and 1.4%
used as the patient record number for this study. Asian (Table 1). The overall prevalence of any untreated
decay on any tooth (deciduous or permanent) was 25.8%
Statistical analysis with an average per-person number of decayed teeth of
Analysis was restricted to only those subjects between 0.45 (SD = 1.1). Baseline untreated decay prevalence was
the ages of 5 and 13 years at time of observation. Sub- 25% in the simple group and 35% in the complex group
jects were analyzed using intent to treat: any child who (analytic sample). The average time between treatments
may have switched schools that was randomized to a dif- was 189 days. The intraclass correlation was 0.0326.
ferent treatment arm was analyzed according to his or Children with untreated decay at baseline, irrespec-
her original assignment. Baseline descriptive statistics tive of treatment assignment, scored significantly worse
on oral health-related quality of life (B = 3.67, 95% CI =
Ruff et al. BMC Oral Health (2022) 22:125 Page 4 of 7

Table 1 Sample demographics and clinical outcomes post-treatment, there were no differences in OHRQoL by
Variable Baseline sample (N Analytic sample (N
treatment group (Table 3) adjusting for baseline COHIP
= 1323) = 160) scores, the number of decayed teeth, and sociodemo-
graphic factors (B = − 1.13, 95% CI = − 4.23, 1.97).
N/mean % N/mean %
Comparisons of the analytic sample at the follow-up
Sex visit indicate children receiving silver diamine fluo-
   Female 700 52.91 88 55 ride are non-inferior to those receiving traditional glass
Ethnicity ionomer sealants and ART on self-reported oral health-
   Hispanic 513 38.78 82 51.25 related quality of life (mean difference = 1.85, 95% CI
   Non-Hispanic 105 7.94 15 9.38 = − 2.10, 5.80). The point estimate favors silver diamine
   N/A 705 53.29 63 39.38 fluoride however the confidence interval is below the
Race non-inferiority margin. Additionally, there was no signifi-
   Black 203 15.34 40 25 cant interaction as no treatment differences were found
   Asian 19 1.44 3 1.88 among only subjects with baseline caries.
   Multirace 34 2.57 4 2.5
   White 56 4.23 3 1.88 Discussion
   Other 27 2.04 4 2.49 As arresting and preventive agents for dental caries, cer-
   N/A 984 74.38 106 66.25 tain materials used in atraumatic restorative treatments
Clinical indicators and glass ionomer sealants can be visually impercepti-
   Untreated decay 341 25.77 45 28.12 ble under casual observation. In contrast, application
   # Decayed teeth 0.49 1.09 (SD) 0.43 0.84 (SD) of silver diamine fluoride results in permanent black
Treatment group staining of dental decay and superficial staining of the
   Simple (vs complex) 633 47.85 111 69.38 oral mucosa. Notably, perceptions of self are affected by
facial aesthetics, being previously observed in adoles-
cents seeking orthodontic treatment and in children with
2.15, 5.18, data not shown) than those with no untreated preexisting orofacial anomalies [31, 32]. As over 25% of
decay. Adjusting for differences in race and ethnicity, CariedAway participants had untreated decay at baseline
each decayed tooth was associated with 1.34 (95% CI with significantly lower OHRQoL than caries-free chil-
= 0.69, 1.99, data not shown) point increase in COHIP dren, concerns regarding the aesthetic impact of SDF,
scores, where higher scores indicate worse OHRQoL. despite demonstrated clinical and economic benefits [9,
There were no baseline differences in OHRQoL by treat- 33], may be justified.
ment group (B = − 0.61, 95% CI = − 4.17, 2.94, data not
shown). Across both SDF and sealant/ART groups, aver-
age OHRQoL improved following treatment (Table 2): Table 3 Regression coefficients, SDF versus Sealants + ART and
COHIP scores slightly improved from an average of 16.44 covariates for OHRQoL (N = 160)
(SD = 11.12) in children receiving silver diamine fluoride Variable B 95% CI
at baseline to 14.62 (SD = 11.90) at follow-up, while those
receiving sealants and atraumatic restorative treatments SDF − 1.13 − 4.23, 1.97
improved from 16.65 (SD = 10.56) to 16.47 (SD = 11.09). Baseline OHRQoL 0.68 0.47, 0.90
In subjects with measured OHRQoL at least 6 months Total decay 0.33 − 1.47, 2.13
Models also adjusted for race and age

Table 2 COHIP-SF scale and subscale scores, pre/post, by treatment group (means and standard deviations; N = 160)
Scale/subscale SDF Sealants + ART​
Pre Post Pre Post

Oral health 4.86 (3.31) 4.38 (3.66) 5.12 (3.55) 5.61 (3.26)
Functional well-being 2.88 (2.88) 2.08 (2.83) 2.24 (2.54) 2.63 (2.85)
Socio-emotional well-being 4.25 (4.77) 3.73 (4.84) 4.49 (5.16) 3.67 (5.69)
School environment 1.09 (1.51) 0.97 (1.52) 1.39 (2.14) 0.91 (1.71)
Self-image 3.36 (2.34) 3.46 (2.73) 3.41 (3.01) 3.63 (3.03)
COHIP (overall) 16.44 (11.12) 14.62 (11.90) 16.65 (10.56) 16.47 (11.09)
Ruff et al. BMC Oral Health (2022) 22:125 Page 5 of 7

Oral health-related quality of life slightly improved fol- of untreated decay, and the average number of decayed
lowing treatment with either silver diamine fluoride or teeth, however there was a greater proportion of sub-
sealants/ART, and children receiving SDF exceeded the jects of Hispanic or black race/ethnicity. As our pri-
minimally important difference threshold of the COHIP- mary objective was on the associations between oral
SF necessary for patient-centered clinically meaningful health, non-surgical treatment, and OHRQoL, we do
change [34]. Results further suggest SDF was non-infe- not expect the racial/ethnic differences to be a concern.
rior to children receiving ART/sealants with respect to Regardless, this selection bias is still a risk to inter-
impact on OHRQoL. These results are consistent with nal validity, and the reported associations should be
other studies of SDF in children reporting similar effects interpreted with caution. Future research in CariedA-
when compared to alternative treatments, such as ART, way will seek to explore more moderate- to long-term
fluoride varnish, or placebo [22, 23, 25–27]. change in OHRQoL, which would not be as negatively
Clinical application of silver diamine fluoride in the affected by the COVID-19 pandemic.
CariedAway trial does not include anterior teeth; SDF Silver diamine fluoride can be applied in significantly
is often applied to posterior teeth in order to mitigate less time than atraumatic restorative treatments [27]
impacts on facial aesthetics. In children aged 5–9 years, and does not require the same degree of clinical train-
the global prevalence rate of caries in deciduous teeth ing, suggesting that SDF is more efficient as a pragmatic
exceeds 40% [1]. However, decay most often occurs in treatment for caries. For example, some states authorize
the occlusal surface of molars and pre-molars [35], thus a registered nurses to provide SDF under the supervision
restriction to posterior application will still treat a major- of a licensed general dentist. Additionally, the non-
ity of underlying disease. In previous studies of SDF, invasive nature of SDF as an arresting agent, combined
caregivers of children with untreated caries were more with its secondary preventive effects, make it an attrac-
accepting of the staining effect when applied to poste- tive alternative to more traditional non-surgical inter-
rior lesions, if the child had a history of behavioral issues ventions [38]. Our results suggest that children do not
when treated by a dentist, or if more invasive measures, perceive any negative impacts on oral health-related
such as anesthesia, would be required [36]. Anterior quality of life approximately 6 months following appli-
application of silver diamine fluoride may be acceptable cation. These findings, combined with documented evi-
for deciduous teeth due to expected exfoliation, but more dence of safety and clinical efficacy, further support the
aesthetically pleasing alternatives may be required for continued use of silver diamine fluoride.
permanent anterior teeth in adolescents.
Acknowledgements
The focus of this analysis was on the potential short- The authors would like to acknowledge the following members of the Caried-
term impact of SDF application on oral health-related Away project team: Rachel Whittemore, Nydia Santiago-Galvin, Haley Gibbs,
quality of life, relative to more traditional non-surgical Catherine McGowan, Priyanka Sharma, and those providing clinical care.
caries treatments. It may be the case that the staining Author contributions
effect of SDF, even when confined to posterior teeth, RRR and RN conceived of the study. TBG provided treatments, collected clini-
becomes more appreciated with longer rates of follow-up cal and OHRQoL data, and co-directed clinical team activities. TMS co-directed
clinical team activities and supervised study conduct. RRR performed all
or when children progress into adolescence where facial statistical analyses and wrote the manuscript. All authors critically reviewed
aesthetics may be of greater concern. Additionally, as the manuscript and provided edits. All authors read and approved the final
overall oral health-related quality of life has been shown manuscript.
to be responsive to the severity of dental caries [37], the Funding
long-term impact on OHRQoL following treatment with Research reported in this publication was partially funded through a Patient-
SDF may behave in a similar manner. Centered Outcomes Research Institute (PCORI) Award (PCS-1609-36824). The
content is solely the responsibility of the authors and does not necessarily
The early suspension of the CariedAway trial due to reflect the official views of the funding organization, New York University, or
the impact of the COVID-19 pandemic meant that we the NYU College of Dentistry.
were unable to obtain 6-month follow-up data for a
Availability of data and materials
substantial proportion of the baseline sample, and lon- The datasets generated and/or analysed during the current study are not
gitudinal observation beyond 6 months was not viable. publicly available due to the active nature of the trial but are available from
As a result, only a subset of those initially enrolled and the corresponding author on reasonable request.
completing OHRQoL assessments were able to be ana-
lyzed. While our initial power calculations used a total Declarations
enrollment of 396, which assumed an ICC of 0.10, our Ethics approval and consent to participate
results show that the actual cluster correlation is con- Ethical approval for the CariedAway clinical trial was obtained from the New
siderably smaller. Compared to the full baseline sample, York University School of Medicine Institutional Review Board (i17-00578).
Informed consent was obtained from every subject parent/guardian. Subjects
the analytic sample was similar in sex, the prevalence
Ruff et al. BMC Oral Health (2022) 22:125 Page 6 of 7

provided assent. All methods were performed in accordance with the relevant fluorosis on oral health-related quality of life: a cross-sectional study in
guidelines and regulations of the Declarations of Helsinki. schoolchildren receiving water naturally fluoridated at above-optimal
levels. Clin Oral Investig. 2017;21:2771–80. https://​doi.​org/​10.​1007/​
Consent for publication s00784-​017-​2079-1.
Not applicable. 18. Arrow P. Dental enamel defects, caries experience and oral health-related
quality of life: a cohort study. Aust Dent J. 2017;62:165–72. https://​doi.​
Received: 7 December 2021 Accepted: 6 April 2022 org/​10.​1111/​adj.​12449.
19. Ahluwalia KP, Sadowsky D. Oral disease burden and dental services uti-
lization by Latino and African-American seniors in northern Manhattan.
J Community Health. 2003;28:267–80. https://​doi.​org/​10.​1023/a:​10239​
38108​988.
References 20. Broder HL, Slade G, Caine R, Reisine S. Perceived impact of oral
1. Bernabe E, Marcenes W, Hernandez CR, Bailey J, Abreu LG, Alipour V, et al. health conditions among minority adolescents. J Public Health Dent.
Global, regional, and national levels and trends in burden of oral condi- 2000;60:189–92. https://​doi.​org/​10.​1111/j.​1752-​7325.​2000.​tb033​26.x.
tions from 1990 to 2017: a systematic analysis for the global burden of 21. Southward LH, Robertson A, Edelstein BL, Hanna H, Wells-Parker E, Bag-
disease 2017 study. J Dent Res. 2020;99:362–73. https://​doi.​org/​10.​1177/​ gett DH, et al. Oral health of young children in Mississippi Delta child care
00220​34520​908533. centers: a second look at early childhood caries risk assessment. J Public
2. Frencken JE, Sharma P, Stenhouse L, Green D, Laverty D, Dietrich T. Global Health Dent. 2008;68:188–95. https://​doi.​org/​10.​1111/j.​1752-​7325.​2007.​
epidemiology of dental caries and severe periodontitis—a comprehen- 00061.x.
sive review. J Clin Periodontol. 2017;44(Suppl 18):S94-105. https://​doi.​org/​ 22. Duangthip D, Gao SS, Chen KJ, Lo ECM, Chu CH. Oral health-related qual-
10.​1111/​jcpe.​12677. ity of life of preschool children receiving silver diamine fluoride therapy:
3. Mathur VP, Dhillon JK. Dental caries: a disease which needs atten- a prospective 6-month study. J Dent. 2019;81:27–32. https://​doi.​org/​10.​
tion. Indian J Pediatr. 2018;85:202–6. https://​doi.​org/​10.​1007/​ 1016/j.​jdent.​2018.​12.​004.
s12098-​017-​2381-6. 23. Sihra R, Schroth RJ, Bertone M, Martin H, Patterson B, Mittermuller BA,
4. Treadwell HM. The nation’s oral health inequities: who cares. Am J Public et al. The effectiveness of silver diamine fluoride and fluoride varnish in
Health. 2017;107:S5. https://​doi.​org/​10.​2105/​AJPH.​2017.​303957. arresting caries in young children and associated oral health-related qual-
5. Griffin SO, Wei L, Gooch BF, Weno K, Espinoza L. Vital signs: dental sealant ity of life. J Can Dent Assoc. 2020;86:k9.
use and untreated tooth decay among U.S. school-aged children. MMWR 24. Rodrigues GF, Costa TDC, Massa GDS, Vollu AL, Barja-Fidalgo F, Fonseca-
Morb Mortal Wkly Rep. 2016;65:1141–5. https://​doi.​org/​10.​15585/​mmwr.​ Goncalves A. Oral health-related quality of life in preschool children after
mm654 silver diamine fluoride versus atraumatic restorative treatments. Pediatr
6. Dye BA, Li X, Thorton-Evans G. Oral health disparities as determined by Dent. 2020;42:373–9.
selected healthy people,. oral health objectives for the united states, 25. Jiang M, Xie QY, Wong MCM, Chu CH, Lo ECM. Association between
2009–2010. NCHS Data Brief. 2020;2012:1–8. dental conditions, sliver diamine fluoride application, parental satisfac-
7. Oliveira BH, Rajendra A, Veitz-Keenan A, Niederman R. The effect of silver tion, and oral health-related quality of life of preschool children. Clin Oral
diamine fluoride in preventing caries in the primary dentition: a system- Investig. 2020. https://​doi.​org/​10.​1007/​s00784-​020-​03542-8.
atic review and meta-analysis. Caries Res. 2019;53:24–32. https://​doi.​org/​ 26. Jiang M, Wong MCM, Chu CH, Dai L, Lo ECM. Effects of restoring SDF-
10.​1159/​00048​8686. treated and untreated dentine caries lesions on parental satisfaction
8. Wierichs RJ, Meyer-Lueckel H. Systematic review on noninvasive treat- and oral health related quality of life of preschool children. J Dent. 2019.
ment of root caries lesions. J Dent Res. 2015;94:261–71. https://​doi.​org/​ https://​doi.​org/​10.​1016/j.​jdent.​2019.​07.​009.
10.​1177/​00220​34514​557330. 27. Vollu AL, Rodrigues GF, Rougemount Teixeira RV, Cruz LR, Dos Santos
9. Contreras V, Toro MJ, Elías-Boneta AR, Encarnación-Burgos A. Effectiveness Massa G, Lima Moreira JP, de, et al. Efficacy of 30. J Dent. 2019;88:103165.
of silver diamine fluoride in caries prevention and arrest: a systematic https://​doi.​org/​10.​1016/j.​jdent.​2019.​07.​003.
literature review. Gen Dent. 2017;65:22–9. 28. Ruff RR, Niederman R. Silver diamine fluoride versus therapeutic sealants
10. Ruff RR, Sischo L, Chinn CH, Broder HL. Development and validation of for the arrest and prevention of dental caries in low-income minority
the child oral health impact profile—preschool version. Community Dent children: study protocol for a cluster randomized controlled trial. Trials.
Health. 2017;34:176–82. https://​doi.​org/​10.​1922/​CDH_​4110R​uff07. 2018;19:523. https://​doi.​org/​10.​1186/​s13063-​018-​2891-1.
11. Nora AD, da Silva Rodrigues C, de Oliveira Rocha R, Soares FZM, Minatel 29. Broder HL, Wilson-Genderson M. Reliability and convergent and discrimi-
Braga M, Lenzi TL. Is caries associated with negative impact on oral nant validity of the child oral health impact profile (COHIP child’s version).
health-related quality of life of pre-school children? A systematic review Community Dent Oral Epidemiol. 2007;35(Suppl 1):20–31. https://​doi.​
and meta-analysis. Pediatr Dent. 2018;40:403–11. org/​10.​1111/j.​1600-​0528.​2007.​0002.x.
12. Moghaddam LF, Vettore MV, Bayani A, Bayat AH, Ahounbar E, Hemmat M, 30. Broder HL, Wilson-Genderson M, Sischo L. Reliability and validity testing
et al. The association of oral health status, demographic characteristics for the child oral health impact profile-reduced (COHIP-SF 19). J Public
and socioeconomic determinants with oral health-related quality of life Health Dent. 2012;72:302–12. https://​doi.​org/​10.​1111/j.​1752-​7325.​2012.​
among children: a systematic review and meta-analysis. BMC Pediatr. 00338.x.
2020;20:489. https://​doi.​org/​10.​1186/​s12887-​020-​02371-8. 31. Ruff RR, Sischo L, Broder H. Resiliency and socioemotional functioning in
13. Haag DG, Peres KG, Balasubramanian M, Brennan DS. Oral conditions and youth receiving surgery for orofacial anomalies. Community Dent Oral
health-related quality of life: a systematic review. J Dent Res. 2017;96:864– Epidemiol. 2016;44:371–80. https://​doi.​org/​10.​1111/​cdoe.​12222.
74. https://​doi.​org/​10.​1177/​00220​34517​709737. 32. Phillips C, Beal KN. Self-concept and the perception of facial appear-
14. Aimee NR, van Wijk AJ, Maltz M, Varjao MM, Mestrinho HD, Carvalho JC. ance in children and adolescents seeking orthodontic treatment. Angle
Dental caries, fluorosis, oral health determinants, and quality of life in Orthod. 2009;79:12–6. https://​doi.​org/​10.​2319/​071307-​328.1.
adolescents. Clin Oral Investig. 2017;21:1811–20. https://​doi.​org/​10.​1007/​ 33. Yeung SST, Argáez C. CADTH rapid response reports. Silver diamine fluo-
s00784-​016-​1964-3. ride for the prevention and arresting of dental caries or hypersensitivity: A
15. Chaffee BW, Rodrigues PH, Kramer PF, Vitolo MR, Feldens CA. Oral health- review of clinical effectiveness, cost-effectiveness and guidelines, Ottawa
related quality-of-life scores differ by socioeconomic status and caries (ON): Canadian Agency for Drugs; Technologies in Health Copyright 2017
experience. Community Dent Oral Epidemiol. 2017;45:216–24. https://​ Canadian Agency for Drugs; Technologies in Health; 2017.
doi.​org/​10.​1111/​cdoe.​12279. 34. Ruff RR, Sischo L, Broder HL. Minimally important difference of the Child
16. Fernandes IB, Pereira TS, Souza DS, Ramos-Jorge J, Marques LS, Ramos- Oral Health Impact Profile for children with orofacial anomalies. Health
Jorge ML. Severity of dental caries and quality of life for toddlers and their Qual Life Outcomes. 2016;14:140.
families. Pediatr Dent. 2017;39:118–23. 35. Demirci M, Tuncer S, Yuceokur AA. Prevalence of caries on individual
17. García-Pérez Á, Irigoyen-Camacho ME, Borges-Yáñez SA, Zepeda- tooth surfaces and its distribution by age and gender in university clinic
Zepeda MA, Bolona-Gallardo I, Maupomé G. Impact of caries and dental patients. Eur J Dent. 2010;4:270–9.
Ruff et al. BMC Oral Health (2022) 22:125 Page 7 of 7

36. Seifo N, Robertson M, MacLean J, Blain K, Grosse S, Milne R, et al. The use
of silver diamine fluoride (SDF) in dental practice. Br Dent J. 2020;228:75–
81. https://​doi.​org/​10.​1038/​s41415-​020-​1203-9.
37. Corrêa-Faria P, Daher A, Freire M, de Abreu M, Bönecker M, Costa LR.
Impact of untreated dental caries severity on the quality of life of pre-
school children and their families: a cross-sectional study. Qual Life Res.
2018;27:3191–8. https://​doi.​org/​10.​1007/​s11136-​018-​1966-5.
38. Horst JA, Heima M. Prevention of dental caries by silver diamine fluoride.
Compend Contin Educ Dent. 2019;40:158–63 (quiz 164).

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