RESEARCH ARTICLE

Assessment of Bacterial Load Using 3.8% SDF as an Irrigant

in Pulpectomized Primary Molars: A Randomized
Controlled Trial
Viral Maru1 , Dimple Padawe2, Shilpa Naik3, Vilas Takate4, Kishor Sarjeraodighe5, Sayali Mali6

A b s t r ac t
Aim and objective: The aim of the present study was to evaluate the reduction in bacterial loading using 3.8% as an irrigating solution in
pulpectomized primary molars.
Study design: A randomized, controlled clinical trial was performed that included primary molars with pulp necrosis. Sixty necrotic canals were
included, 30 irrigated with 3.8% SDF (experimental group) and 30 with 1% NaOCl solution (control group); in all cases, two microbiological
samples from within the canals were taken with sterile paper points, the first after the canal opening and before the first irrigation, and the
second after instrumentation and final irrigation, before obturation. All samples were evaluated by Agar plate method.
Results: The results were statistically analyzed by student “t“ test. After analyzing samples before and after irrigation in the control group
(NaOCl), we found a strong significant decrease of bacterial load (p = < 0.001). The same occurred in the 3.8% SDF group samples (p = < 0.001).
When both groups were compared post irrigation, a statistically significant difference was observed in favor of 3.8 % SDF.
Conclusion: 3.8% SDF can be suggested as an alternative irrigant for pulpectomy of necrotic teeth.
Keywords: 3.8% SDF, Endodontic irrigation, NaOCl, Primary molars.
International Journal of Clinical Pediatric Dentistry (2022): 10.5005/jp-journals-10005-2130

Introduction 1,2,4–6
Department of Pediatric Dentistry, Government Dental College
For effective endodontic treatment, an exhaustive cleaning, a and Hospital, Mumbai, Maharashtra, India
precise diagnosis, and a predictable disinfection protocol that 3
Department of Microbiology, Govt. Grant Medical College; JJ Group
utilizes different irrigating solutions and intracanal medicaments of Hospital, Mumbai
are necessary.1 In spite of noteworthy advancements in all domains
Corresponding Author: Viral Maru, Department of Pediatric Dentistry,
of dentistry, the quest for the perfect irrigant solution is still going Government Dental College and Hospital, Mumbai, Maharashtra,
on in pediatric endodontics.2 India, Phone: +91 9867220417, e-mail: [email protected] n
It is desirable to emphasize irrigants for cleaning primary teeth
How to cite this article: Maru V, Padawe D, Naik S, et al. Assessment
than removing dentin. Sodium hypochlorite is an extensively of Bacterial Load Using 3.8% SDF as an Irrigant in Pulpectomized
used endodontic irrigant, since its antimicrobial and solvent Primary Molars: A Randomized Controlled Trial. Int J Clin Pediatr
characteristics are adequate at 0.5-5.25% concentration levels for Dent 2022;15(S-1):S47–S51.
treating tissue,3 however, it might damage periradicular tissue even Source of support: Nil
if it enters at relatively mild concentrations.4,5
Conflict of interest: None
Intracanal irrigation using a 3.8% w/v solution of silver diamine
fluoride (SDF) has been implemented. It represents a 10-times Dentistry, Government Dental College and Hospital, Mumbai,
more diluted variant of the SDF used for performing root canal Maharashtra, India. The Institutional Ethics Committee gave its
treatment.6 Research suggests that 3.8% SDF exerts antibacterial approval to the research. A total of 60 necrotic canals of both
characteristics against an E. faecalis biofilm and can be employed genders, falling in the age group of 3–7 years, partook in this
as a root canal irrigant to reduce bacteria.7-10 controlled, randomized clinical testing after acquiring written
In contrast, the results of 3.8% SDF for irrigating primary teeth permission from their parents and/or guardians. The present
during endodontic therapy must be evaluated. Consequently, the trial had eligibility criteria of good overall health, a primary molar
present research objective was to ascertain and contrast the changes having necrosis in one or more pulp canals, presence of an abscess,
in bacterial activity after using 1% NaOCl and 3.8% SDF solutions for two-thirds or more intact root structure, and adequate tooth
endodontic irrigation of primary teeth. The null hypothesis indicates structure to hold a dental dam. The trial disqualified children
that there will be an absence of a noteworthy difference among the allergic to silver or sodium hypochlorite, systemic illness, pulp
two solutions with regards to the lower bacterial count. floor perforations, extensive mobility, or nonrestorable molar.
Sixty root canals were split in a random manner into two
M at e r i a l s and Methods categories, which are as follows:
The present research was carried out in collaboration with the • Experimental group (30 root canals): 3.8% silver diamine fluoride
Department of Microbiology, Grant Medical College and Hospital, (FAgamin; Argentina)
Mumbai, Maharashtra, India and Pediatrics and Preventive • Control group (30 root canals): 1% NaOCl solution

© The Author(s). 2022 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
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 Bacterial Load of 3.8% SDF Endodontic Irrigant

Disinfected distilled water was used to prepare a 1% NaOCl solution Laboratory Procedures
from a 3% concentration level (Neelkanth, India).11 SDF was similarly Specimens (post- and pre-irrigations) were transported using
diluted to 3.8% from 38% using disinfected distilled water.12 The 1 mL thioglycolate broth that was inoculated for one day at 37°C.
pulpectomy process required only one sitting. The sample size It was followed by plating 1,000 mL broth using Soyabean Caesin
was ascertained from a pilot study comprising ten microbiological Digest Agar medium (HIMEDIA, India), which underwent anaerobic
samples extracted from necrotic root canals (five samples per incubation for 3 days at a 37°C temperature. The overall microbial
irrigant); however, these were not included for statistical analysis load (per mL) was determined through the Colony Forming Unit
in this research. (CFU) count on Trypticase Soy Agar comprising 400 g of L-cysteine
Likewise, reliability and uniformity testing for diagnostic and mL, 0. 5 g of hemin mL, 5% sheep blood, as well as 1 g of menadione
outcomes assessment was conducted independently; a Kappa test mL (Amyl Media, Australia).17
score of 0.90 was obtained.13 The irrigant for every case was selected Clinical and radiological follow-up was performed on all
randomly from a catalog of computer-generated random numbers. 120 pulpectomy-treated primary molars at 3 months, 6 months,
Patient sampling was carried out in a non-probabilistic mode. 9 months, and 12 months. No failures were reported in either group
at the end of the 12-month follow-up.
Preclinical Laboratory Procedures
Hemin (5 mg L-1) and menadione (1 mg L-1) could retain sampled Statistical Analysis
bacteria vitality; therefore, these substances were augmented using Samples (before and after irrigation) were assessed between and
pre-reduced thioglycolate tubes and were employed as growth across groups. The Student “t“ measure helped ascertain study
and movement media.14 aspect significance using continuous measurements between the
two sets based on metric parameters (independent, two-tailed).
Isolation and Disinfection of Operative Domain
Leven’s test was conducted to ascertain variance homogeneity.
One pediatric dentist conducted the research who obtained
periapical radiographs of the identified teeth using the conventional
paralleling method. The patients’ oral cavity was disinfected using
R e s u lts
a 60-second rinse with 0.12% chlorhexidine. Local anesthesia Children who underwent treatment had a 5-year average age; A
was used for the procedure, and the primary mandibular teeth total of 120 microbiological samples were gathered, with 60 from
were numbed using an inferior alveolar nerve block. In contrast, the control group (30 pre- and 30 postirrigation) and 60 from the
infiltration (palatal and buccal) was used for the primary maxillary experimental group (30 pre- and 30 postirrigation). Preirrigation
teeth. Teeth were cleaned using pumice, and a rubber dam was baselines were similar concerning bacterial load in necrotic canals
used to prepare the working area. Petroleum jelly was used on across both groups. Preirrigation specimens were identified and
the gingiva of the infected tooth. Provisit (CasaIdea, Mexico) was contrasted for colony formation characteristics (Table 1).
used at the tooth-damn junction to prevent saliva entering the Experimental group: before versus after irrigation
operating area. The tooth crown, dam, operative area, and clamp The pre- and postirrigation samples used for the experiment
were disinfected using 30% hydrogen peroxide for 60 seconds. had mean values of 2.64 ± 0.31 × 106 CFU/mL and 2.14 ± 0.41 ×
Subsequently, 5.25% NaOCl was used for 60 seconds, followed by 106 CFU/mL. Bacterial load (CFU/mL) was significant (p = < 0.001)
inactivation using 10% sodium thiosulfate.15,16 pre- and postirrigation (Fig. 1).
Caries tissue was removed using a sterile saline solution cooled Control group: before versus after irrigation
number 3 round carbide bur. The operative area and tooth cavity The control samples before and after irrigation had mean values
were again sterilized. The roof of the pulp was then extracted using of 3.40 ± 0.10 × 106 CFU/mL and 3.29 ± 0.05 × 106 CFU/mL. The
a similar-sized new bur. The root canal was then accessible using a changes in bacterial load before and after irrigation (CFU/mL) were
disinfected cotton pellet, which was kept on the base of the pulp statistically significant (p = < 0.001) (Fig. 2).
chamber to disallow disinfectants from entering tooth canals. After irrigation: experimental group versus control
Once irrigation was completed, the antimicrobial efficacy of
Preparation of Microbiological Samples the irrigants was contrasted by quantifying bacteria (CFU/mL).
Microbiological samples were extracted from tooth canals before The assessment suggested that the experimental sample was
irrigation. Three different absorbent paper points were sterilized significantly superior to the control sample (p = 0.300) (Fig. 3).
and used for different canal sizes. These points were inserted in
canals for 30 seconds after the canals were accessible. An intraoral Discussion
periapical radiograph was used preoperatively to determine the Pulpectomy helps to reduce premature primary tooth loss. Losses
workable length of the tooth canals. Some sterile saline solution was might cause inadequate area for permanent teeth, reduced arch
used to irrigate the canals, if they were dry before the points were length, impact on premolars, and molar mesial tipping next
inserted. The paper points used for the roots were placed in a tube to the infected primary molar. This process is a conservative
containing thioglycolate. Conventional teeth treatment followed approach.18,19 The objective behind cleaning and shaping of the
sample collection. FlexoFiles (Dentsply, Switzerland) instruments root canal is the removal of tissue remnants, toxins, and bacteria
were used with 0.5 mL of the identified irrigant after filing. The from the root canal setup. Mechanical processes solely are not
canal was wetted and dried one last time after instrumentation and adequate for exhaustive canal cleaning. The remaining pulp tissue,
before sealing the tooth. A postirrigation sample was obtained from dentin particles, and bacteria might remain due to irregular canal
the canals using another set of three sterilized paper points. Lastly, structures. Hence, irrigants must complement and aid endodontic
iodoform paste (Vitapex) was inserted in the canal. An intraoral treatment. Such solutions must remove dentin particles, break
periapical radiograph was obtained after the operation. Stainless down organic tissue, sterilize the canals, and lubricate the system
steel crowns (3M) were employed for after-treatment restoration. during the procedure without irritating nearby tissues.20

S48 International Journal of Clinical Pediatric Dentistry, Volume 15 Special Issue 1 (Pediatr Endodont)
 Bacterial Load of 3.8% SDF Endodontic Irrigant

Table 1: Comparison of colony forming units per mL in experimental and control group
Colony forming unit per mL Experimental Group Control Group Total p value
Pre-Irrigation 2.64 ± 0.31 x 106 3.40 ± 0.10 x 106 3.02 ± 0.45 x 106 < 0.001*
After Irrigation 2.14 ± 0.41 x 106 3.29 ± 0.05 x 106 2.72 ± 0.65 x 106 < 0.001*
difference 0.492 0.107 0.300 –
p value < 0.001* < 0.001* < 0.001* –
*Statistically significant

Fig. 1: Comparison of colony forming unit per mL x 106 – pre- and Fig. 3: Comparison of colony forming units per mL x 106 pre- and
postirrigation in experimental group. postirrigation in experimental and control group

an uncomfortable taste and smell .21,22 Hence, there are continuous

efforts to find a sodium hypochlorite substitute.
Records indicate that silver was perhaps used for medicine
around 1000 BC. Presently, silver compounds are used for medicinal
use in sutures, nitrate, and foil forms. Silver diamine fluoride (SDF)
is claimed to be stable at 38% concentration (pH = 8-9) and its
concentration can be maintained. Several nations, including Japan
and China, have used it to slow dental caries. This compound does
not need a reducing substance. 23 Mei et al. asserted that 38%
SDF slowed the demineralization process and protected collagen
disintegration from demineralized dentin. 24 SDF also possesses
cariostatic properties concerning the tooth mineral constituents
and itself. It possesses anti-enzymatic properties on the substances
formed when Ag(NH3)2F and tooth organic tissue react. The
reagent has antibacterial characteristics because it reduces enzyme
activation and dextran-facilitated agglutination of Streptococcus
mutans cariogenic strains.25 SDF is available under the trade names
Fig. 2: Comparison of colony forming unit per mL x 106 – pre- and mentioned below: 38% SDF solution, Fluoroplat (NAF Laboratories,
postirrigation in control group Buenos Aires, Argentina), 38% SDF solution, FAgamin, Bv. of the
Poles 6136, Córdoba, Argentina, 38% SDF solution, Saforide (Toyo
Seiyaku Kasei Co. Ltd., Osaka, Japan), 38% SDF solution, Advantage
Henry Dakin was the first person to propose sodium Arrest (Elevate Oral Care LLC, West Palm Beach, Florida, US), and 38%
hypochlorite as an antiseptic solution in 1915. In 1920, Crane SDF solution, e-SDF (5 mL bottle, Kids-e-dental Llp, Mumbai, India).
outlined its usage for root canal debridement as well as sterilization. A solution comprising ammoniated silver nitrate has been
It has since attained popularity as an effectual root canal usually utilized for treating the affected root canal. It has been
irrigant. Typical usage concentration is 0.5–5.25%; however, such demonstrated by Tanaka26 that a liquid solution of AgF has strong
concentrations have high hypertonic and alkaline characteristics, antibiotic and protein-coagulating properties, and also has a
corresponding to an 11–13 pH range. It possesses oxidative and substantially potent action, which chokes up the dentinal pipettes
proteolytic characteristics that might cause the healthy and necrotic of root canal wall with respect to the electric resistance. Okamoto
pulp to disintegrate, apart from eliminating microbes. Though et al.27 discovered that applying SDF solution reduced significantly
NaOCl is an efficacious antibacterial substance, it causes toxicity the number of treatments needed. Hiraishi et al.12 stated that 3.8%
when the periradicular tissues are exposed to it; moreover, it has SDF is enough to function as an antimicrobial root canal agent

International Journal of Clinical Pediatric Dentistry, Volume 15 Special Issue 1 (Pediatr Endodont) S49
 Bacterial Load of 3.8% SDF Endodontic Irrigant

or interappointment dressing, particularly in locations where considerable tissue dissolution ability and were effective in
potential blackening/browning of dentin by metallic silver is a cleansing root canals.36 Baumgartner and Cuenin37 demonstrated
minor concern. Mathew et al. (2012)28 discovered that SDF solution that each concentration of NaOCl was similarly efficient in removing
as an endodontic irrigant can efficiently eliminate the microbes loose debris and entirely eliminating predentin and pulpal remnants
found in the circumpulpal dentin and canal. Thus, the present from nonprocessed canal walls. Necrotic pulpal tissues and smear
research found 3.8% SDF to be better in comparison to 1% NaOCl layers were subjected to dissolution equally fine by 5.25%, 2.6%,
in bacterial load following pulpectomy process in primary molars. and 1.3% NaOCl.38
This deduction is confirmed by study carried out by Mathew and
colleagues who stated that 3.8% SDF exhibits inhibitory effect on
synthesis of bacterial cell wall, cell division, and DNA unwinding,
C o n c lu s i o n
therefore, effectively decreasing microbial load inside the root More controlled clinical trials are required to support the
canal.28 Noriko et al. investigated the impact of NaOCl and 38% SDF effectiveness of 3.8% SDF as an irrigant solution, the results
on in vitro E. faecalis biofilm and observed 100% effectiveness of 3.8% reported by this study are highly encouraging in terms of being a
SDF against E. faecalis following a direct 60 minute contact.9 The suitable and potent alternative for irrigation of endodontic canals
review of literature did not find any other research evaluating 3.8% of primary teeth.
SDF solution as an irrigant in pulpectomy treatments.
The SDF advantage over other irrigants such as sodium Orcid
hypochlorite is that besides having similar antibacterial
Viral maru http://orcid.org/0000-0002-5649-1780
characteristics, the interaction between teeth and SDF causes
reciprocal formation of fluoroapatite. The quantity of fluoride
release is twice of that observed in other fluoridating substances.
This increases the antibacterial activity and may lead to increased
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