Treatment of Interproximal Carious Lesions on Primary Molar Teeth With SDF and Super Floss Application Versus SDF Without Super Floss Versus Fluoride Varnish Alone: a Pilot Phase 3 Randomized Controlled Trial
Phase: NA
Conditions: Dental Caries in Children, Dental Caries Class II, Dental Caries
Sponsor: Children's Hospital Los Angeles

 
PROTOCOL NUMBER: CHLA-18-00389/UP-19-00405 
 
 
TITLE: Treatment of Interproximal Carious Lesions on Primary Molar Teeth with SDF and Super 
Floss Application versus SDF without Super Floss versus Fluoride varnish alone: a pilot 
Phase 3 Randomized Controlled Trial 
 
 
STUDY PHASE: III 
 
 
 
STUDY ARMS: 
1) 38% Silver Diamine Fluoride + Superfloss + Fluoride Varnish 
2) 38% Silver Diamine Fluoride + Fluoride Varnish 
 
3) Fluoride Varnish 
 
 
 
IND OR IDE #:  N/A 
 
 
PRINCIPAL INVESTIGATOR: 
NAME: STEPHANIE SHIMIZU, DDS 
 
ADDRESS: 4650 SUNSET BLVD., #116 
 
 
LOS ANGELES, CA 90027 
 
TELEPHONE: 323-361-2130 
 
 
 
 
FACULTY ADVISER/CO-INVESTIGATOR(S): Alexander Alcaraz, DMD 
 
 
 
SPONSOR: N/A 
 
 
PARTICIPANTS/LOCATION: Children’s Hospital Los Angeles - Pediatric Dental Clinic 
Herman Ostrow School of Dentistry of USC – Pediatric Dental 
Clinic 
 
 
AMENDMENTS/REVISIONS:  N/A 
 
 
 
 
 
 
 
 
 
 
 

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TABLE OF CONTENTS 
 
 
SCHEMA, SYNOPSIS, OR STUDY SUMMARY 
 
 
 
 
 
PAGE 
 
1.0 
BACKGROUND AND HYPOTHESES _ 
__2__ 
 
2.0 
OBJECTIVES AND PURPOSE 
__4__ 
 
3.0 
STUDY DESIGN  
__4__ 
 
4.0 
DRUG/DEVICE INFORMATION 
__5__ 
 
5.0  
SELECTION AND WITHDRAWAL OF SUBJECTS 
__8__ 
 
6.0 
DESCRIPTIVE FACTORS/STRATIFICATION/RANDOMIZATION SCHEME 
 
__9__ 
 
7.0  
STUDY AGENT ADMINISTRATION OR INTERVENTION AND TOXICITY     
MANAGEMENT PLAN 
__10__
 
 
 
 
8.0 
ASSESSMENT OF EFFICACY AND SAFETY 
__11_ 
 
 
9.0 
CLINICAL AND LABORATORY EVALUATIONS 
__12_ 
 
10.0 
CRITERIA FOR EVALUATION AND ENDPOINT DEFINITIONS  
__13_  
 
11.0 
SPECIAL INSTRUCTIONS 
 
 
 
 
 
 
__13_ 
 
12.0 
DATA COLLECTION AND MONITORING 
__13_ 
 
13.0 
STATISTICAL CONSIDERATIONS  
__13_ 
 
14.0 
REGISTRATION GUIDELINES  
__15_ 
 
15.0 
BIOHAZARD CONTAINMENT 
__15_ 
 
16.0 
ETHICAL AND REGULATORY CONSIDERATIONS 
__15_ 
 
17.0 
REFERENCES 
 
 
 
 
 
 
 
 
__16_ 
 
APPENDICES 
 
 
 
 
 
 
 
 
 
__18_ 
 
 

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 1.0 
BACKGROUND AND HYPOTHESES 
1.1  The vast majority of caries observed in children ages 5 to 10 are on interproximal surfaces1,2. 
Carious lesions on these surfaces are challenging to control and arrest due to difficulty 
reaching the contact area (in between teeth), limited salivary access, and poor flossing 
compliance in children and adolescents when flossing themselves3. Currently, for initial non-
cavitated, demineralized lesions in these high caries risk patients, the standard of care has 
been to: reinforce oral hygiene instruction, advise in reducing the frequency of fermentable 
carbohydrate consumption, observe the incipient lesion at recall visits via bitewing 
radiographs every 6 months, and promote remineralization of the carious lesion with in-
office application of topical fluoride (i.e. 5% sodium fluoride varnish) over all teeth4,5. 
Depending on the patient and the circumstances of their oral health condition, the practitioner 
may consider treating these lesions with restorations but a conservative, preventive approach 
is usually the initial goal of treatment. 
 
Silver diamine fluoride (SDF) has been used for many years internationally, but in August 
2014, SDF was cleared by the FDA as a medical device to treat dental hypersensitivity.6  
More recently, the FDA granted SDF “Breakthrough Therapy Designation” on October 30, 
2016 for caries arrest in children and adults in the United States under the product: 
Advantage Arrest Silver Diamine Fluoride 38% by Elevate Oral Care.6 The current 
formulation of 38% SDF is 25% silver for its antimicrobial effects, 5% fluoride for 
remineralization, and 8% ammonia to keep the silver and fluoride in solution.6,7 It has been 
touted as a very safe6,7 and possible noninvasive alternative and/or adjunct to topical fluoride 
treatment or restorative treatment.6 SDF has been shown to remineralize demineralized 
enamel or dentin, inhibit collagenases to protect dentin collagen from destruction, and have 
bactericidal properties to cariogenic bacteria including streptococcus mutans.7,8 Additionally, 
after the silver ions have killed the bacteria, they may be re-activated to do so again against 
subsequent or neighboring bacteria in a “zombie effect” to prevent incidence of new caries as 
explained by Horst et al.7 The silver and fluoride ions can penetrate up to 25 microns into 
enamel9 and 50-200 microns in dentin10, and promote remineralization while decreasing the 
depth of lesion.11 Repeat applications, with a biannual maintenance regimen, have shown to 
arrest caries over time6.  

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Most of the existing protocols for SDF application include direct microbrush topical 
application to the exposed carious lesion. However, with interproximal caries, microbrush 
application is difficult due to the unexposed broad contact area. The decision to treat initial 
interproximal lesions in children can be difficult when weighing patient behavior, extent of 
treatment and prognosis considerations. While there are other methods to treat interproximal 
caries such as resin infiltration, Mattos-Silveira et al. reports that there was a significant 
difference in children’s discomfort when comparing resin infiltration to flossing or SDF 
application to initial interproximal caries lesions.12 Currently, there is another study by 
Mattos-Silveira et al. in progress in Brazil that looks at the application of SDF in arresting 
interproximal carious lesions.13 This study uses a lower concentration (30%) than the current 
product used in the United States. Based on another study (Mei, ML et.al.) the 38% 
concentration of SDF appears to have a greater inhibition of metalloproteinases when 
compared to the 30% SDF and potentially this could lead to a greater arresting effect14.  
Elevate Oral Care15 and others16 have suggested applying SDF to interproximal caries with 
the use of a woven or spongy floss, such as Oral-B Super Floss®. Like typical floss, Super 
Floss is made of nylon, but the non-waxed fibers have an interlocking network which gives it 
its spongy texture. Its sponginess is presumed to be more absorbent, allowing for easier 
delivery and application of SDF to interproximal carious lesions due to limited access with a 
microbrush. In 1981, Tsutsumi showed a significant reduction in the progress of existing 
caries and significant reduction in incidence of new caries in human primary molars when 
comparing flossing with plain unwaxed floss to SDF applied with unwaxed floss17. 
Therefore, Super Floss should be considered as a method for SDF delivery to interproximal 
lesions, but there is currently no information as to the efficacy of this treatment modality. 
The purpose of this study is to investigate whether 1) SDF application using Super Floss 
can halt the progression/arrest and/or reverse/remineralize the initial interproximal 
caries and 2) whether SDF applied with Super Floss is more effective in arresting or 
remineralizing incipient lesion in comparison to: 
a) SDF applied without Super Floss or 
b) Fluoride varnish applied alone 
1.2 We hypothesize that: 

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1.21  SDF applied with Super Floss can reliably arrest and/or remineralize initial 
interproximal lesions. 
1.22  SDF applied with Super Floss will be more effective than SDF applied without Super 
Floss or fluoride varnish applied alone in arresting initial interproximal caries. 
2.0 
OBJECTIVES AND PURPOSE 
2.1  The primary aim of this prospective study is to test if 38% SDF application using Super Floss 
can reliably arrest caries in superficial interproximal lesions as determined by comparing 
time lapse bitewing radiographs. 
2.2  The secondary aim is to test if SDF applied with Super Floss will be more effective than  
SDF applied without Super Floss or fluoride varnish applied alone in arresting initial  
interproximal caries also as determined by comparing time lapse bitewing radiographs. 
3.0 
STUDY DESIGN 
3.1  Caries criteria is defined into 5 groups based on the zone of radiolucency using the 
International Caries Classification and Management System (ICCMS)18. This classification 
will be used by the present study to describe whether carious lesions have progressed based 
on comparing radiographs taken over time19 and allow for statistical analysis. The 
positioning of these bitewing radiographs must be consistent in showing the contact area and 
preventing overlap in the proximal teeth in question. ICCMS Classification is described as 
follows (Appendix I):  
i. 0: No radiolucency/no caries – not included in study  
ii. RA: Initial Stages – These are the target interproximal lesions for the present 
study 
● 1: Radiolucency in the outer half of enamel,  
● 2-Dentin-enamel Junction (DEJ): lesions extending within the inner 
half of enamel but not to DEJ,  
● 2+DEJ: lesions extending within the inner half of enamel including the 
DEJ, 
● 3: lesions extending to the outer one-third of dentin past the DEJ, and  

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iii. RB: Moderate Stages and beyond – These lesions will not included in present 
study because it is currently the standard of care to provide appropriate dental 
restorative treatment to repair the caries. 
3.2  Each child with interproximal lesions on deciduous molar teeth meeting eligibility criteria 
RA Category 1, 2, or 3 will be invited to participate. Those who agree to participate will be 
randomly allocated to one of three treatments: Fluoride varnish (Control) application alone 
versus SDF application without Super Floss (Control) versus SDF application with Super 
Floss (Intervention). Daily flossing and oral hygiene instruction will be taught to patients of 
all study groups. Inclusion, Exclusion, and Withdrawal criteria are below in Section 5. 
3.3  Follow-Up: Recall examinations and treatment reapplication will be done at 3 months, 6 
months, and 12 months after the initial visit in accordance with current American Academy 
of Pediatric Dentistry (AAPD) guidelines for high caries risks patients5. Bitewing 
radiographs will be taken at 6 months and 12 months. This is in accordance with the 
“Prescribing Dental Radiographs…” guidelines as approved by the AAPD20, which state that 
bitewing radiographs in high risk children with dental caries are recommended every 6-12 
months.   
3.4  Providers: Residents and Attendings at the Ostrow School of Dentistry at USC, Pediatric 
Residency Program. All residents and attendings participating in this study will be trained 
and standardized on how to identify lesions of interest on radiographs, obtain consent, and 
apply the medications.  
3.5 Tracking of study participants: We will count the number of participants who:  
1. Those who are asked to participate  
2. Those who consent 
3. Those who drop out before randomization/after randomization 
4. Those who withdraw by their own choice for various reasons 
5. Those who are lost to follow up 
Note: We will only collect and store clinical data for those participants who continue 
throughout the duration of the project. If a participant decides to drop out of the study at any 
time, then we will no longer collect data from the medical record during their ongoing 
clinical care. We will also discard any previous data we have collected on the participants 
that drop out. 

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4.0 
DRUG/DEVICE INFORMATION 
4.1 Drug/Device Name 
4.1.1 Advantage Arrest 38% Silver Diamine Fluoride 
4.1.2 Voco ProFluorid Varnish 
4.1.3 Oral-B Super Floss 
4.2 Manufacturer:  
4.2.1 Elevate Oral Care (346 Pike Rd Suite 5, West Palm Beach, FL 33411) 
4.2.2 VOCO GmbH (Anton-Flettner-Str. 1-3 D-27472 Cuxhaven, Germany) 
4.2.3 The Procter & Gamble Company (8700 Mason-Montgomery Road Mason, OH 45040) 
4.3 Chemical makeup, based on manufacturer’s MSDS:  
4.3.1 SDF: Ag(NH3)2F.  The silver is antibacterial, the fluoride aids in remineralization of 
the tooth, and the ammonia suspends the two in solution. One drop contains 25 μL and 
9.5mg of SDF. 
CAS # 
Ingredient 
Percentage (%) 
7440-22-4 
Silver (Ag) 
24 - 27 
1336-21-6 
Ammonia (NH3) 
7.5 - 11 
16984-48-8 
Fluoride (F) 
5 - 6 
3844-45-9 
FD&C Blue #1 
<1 
7732-18-5 
Deionized Water 
≤62.5 
 
4.3.2 Fluoride varnish: 5% NaF 
CAS # 
Ingredient 
Percentage (%) 
64-17-5 
Ethanol 
10 - 25 
7681-49-4 
Sodium Fluoride 
2.5 - 5 
 
4.3.3 Super Floss: No hazardous ingredients as defined by OSHA and/or WHMIS. 
4.4 Dose/Formulation:  
4.4.1 SDF: One drop contains 25 μL and 9.5mg of SDF, which can be applied to ~5 lesions. 
4.4.2 Fluoride Varnish: 1 mL suspension contains 50 mg NaF, equivalent to 22.6 mg 
fluoride ion. 1 unit package = 0.4 mL, which is 20 mg NaF. Approximately 0.25mL is 
used for patients with primary dentition, and 0.40mL is used for adolescent patients or 
permanent dentition.  

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4.4.3 Super Floss: N/A 
4.5 Toxicity or adverse effects,:  
4.5.1 SDF: SDF is corrosive to metal and glass, and can be an eye, skin, mucosal, 
respiratory, and gastrointestinal irritant. Repeated overexposures may cause mottled 
teeth or fluorosis on teeth/bones (not in the dosage used in this study).  
 
In the UCSF Protocol by Horst et al. 2016, they found SDF to be extremely safe, citing 
not one adverse event in over 80 years of use in Japan and mild temporary side effects 
found in 3 of 1,493 subjects in 9 clinical trials.  The lethal dose (LD50) of SDF, 
determined by female and male mouse and rat studies, was found to be: 520 mg/kg by 
oral administration, and 380 mg/kg by subcutaneous administration. Considering a 
small child weighing 10kg with caries, the dose would be 0.95mg/kg (One drop of 
SDF contains 9.5mg and one drop is usually adequate to treat one patient). For that 
10kg child, the relative safety margin of using an entire drop would be: 380 mg/kg 
LD50 / 0.95 mg/kg dose = 400-fold safety margin. 
4.5.2 Fluoride varnish:  
● Sodium Fluoride: Oral rat LD50: 52 mg/kg  
● Ethanol: Oral rat LD50: 7060 mg/kg 
Fluoride varnish can be an irritant with direct eye contact and prolonged skin contact. 
If ingested, it may cause salivation, nausea, vomiting, abdominal pain, headaches, or 
dizziness. Repeated overexposures may cause fluorosis. 
For a similar calculation above for a 10kg child, the relative safety margin of using an 
entire 0.4 mL unit (one package) of fluoride varnish would be: 52 mg/kg LD50 / 2.0 
mg/kg = 26-fold safety margin. 
4.5.3 Super Floss: There are no toxic or adverse effects listed, and there are no hazards 
when used as directed. 
4.6 Non-medical Side Effects:  
4.6.1 SDF: SDF stains carious lesions. It also can have a bitter or metallic taste. It can also 
stain or darken skin with a ‘temporary tattoo’ which resolves in 2-14 days after normal 
skin exfoliation. SDF can also stain hard surfaces like table tops as well as clothing.7 
4.6.2 Fluoride Varnish: N/A 
4.6.3 Super Floss: N/A 

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4.7 Risk:  
4.7.1  SDF: Minimal 
4.7.2 Fluoride Varnish: Minimal 
4.7.3 Super Floss: N/A 
4.8  Storage:  
4.8.1 SDF: Store in a cool dry place in provided closed container.  
4.8.2 Fluoride Varnish: Store in a cool, dry place in original sealed package away from 
direct sunlight.  
4.8.3 Super Floss: N/A 
4.9 Stability, based on manufacturer’s MSDS:  
4.9.1  SDF is a light sensitive liquid. Prolonged exposure to light or evaporation will cause 
precipitation. 
4.9.2 Fluoride varnish is a stable product. 
4.9.3 Super Floss: N/A 
5.0  
SELECTION AND WITHDRAWAL OF SUBJECTS 
5.1 Inclusion Criteria:   
5.1.1  ASA I and ASA II children, aged 3-12, with interproximal decay on deciduous molars 
identified by radiographs. These teeth will not have previous restorations. 
5.1.2 Radiographic decay within enamel or extending to the dentin-enamel junction based 
on International Caries Classification and Management System (ICCMS)18 Categories 
1 through 3 – see above. Categories 1, 2 and 3 signify the extent of the "Initial Stages" 
of an interproximal carious lesion with radiolucency in the outer 1/2 of enamel, inner 
1/2 of enamel, and outer 1/3 of dentin respectively.  
5.1.3  Interproximal lesions present without existing restorations, recurrent decay, or 
adjacent teeth with existing restorations. 
5.1.4 Behavior of the children should be within a Frankl 3 or 4 category21, indicating a 
“Positive” and “Definitely Positive” behavior rating, which would allow for safe and 
controlled execution of the proposed protocol. 
5.2 Exclusion Criteria: 
5.2.1  Children who are not ASA I or ASA II. 

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5.2.2 Children who are allergic to or intolerant of SDF 
5.2.3 Children who have known sensitivity to silver or heavy metal-ions, or have abnormal 
skin sensitization. 
5.2.4 Children who have ulcerative gingivitis or stomatitis. 
5.2.5 Carious interproximal lesions on primary molars in ICCMS Category 4, 5, or 618, 
which signify the extent of the carious lesion radiographically reaching the middle 1/3 
of dentin, inner 1/3 of dentin, and into the pulp respectively. 
5.2.6 Behavior of a child within the Frankl 1 or 2 category21, indicating a “Definitely 
Negative” and “Negative” behavior, which may compromise safe application of SDF. 
5.3 Withdrawal Criteria 
5.3.1  Patients can withdrawal voluntarily at any time.  
5.3.2 Any tooth which has progression of caries beyond ICCMS Category 3 will be 
withdrawn from the study. These teeth will be treated with appropriate restorative 
dental treatment according to the standard of care. 
5.3.3 Any qualifying tooth that subsequently requires a restoration or extraction due to 
trauma or exfoliates prematurely will be withdrawn from the study. 
5.3.4 Any study tooth whose adjacent tooth exfoliates before the end of this study and 
exposes the interproximal contact will be withdrawn from the study. 
6.0 
STRATIFICATION/DESCRIPTIVE FACTORS/RANDOMIZATION SCHEME 
6.1 We have not defined any a priori stratification factors.  
6.2 Descriptive factors: Age, Gender, Race,, Date of Initial exam, Date of Recall exam/Follow-
up, , Number of posterior caries on primary teeth that qualify for this present study, DMFS, 
Which interproximal surface (mesial or distal), Which primary molar, and Radiographic 
depth of Lesion based on ICCMS Categories (see Table 1 in Appendix).  
6.3 Once participants have met eligibility criteria and have undergone the informed consent 
process (parental permission and assent, if applicable), they will be randomized to one of the 
three treatments 1:1:1 using a cluster-randomized design. That is, participants, not teeth, will 
be randomized, though multiple teeth per participant may be treated. Using the uniform 
distribution, the statistician will generate a random number sequence. We will use blocked 
randomization (blocks of six) to better ensure an even distribution across groups. Once group 

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assignments have been made, the statistician will prepare numbered, opaque envelopes 
containing the random study arm assignments, which the investigators will use sequentially, 
as study participants accrue (i.e., the study identification number will match the number on 
the envelope).   
7.0 
STUDY AGENT ADMINISTRATION OR INTERVENTION AND TOXICITY 
MANAGEMENT PLAN 
7.1 Treatment protocol after patients are randomized into one of three treatment groups:  
7.1.1 Fluoride varnish application (Control - Group 1): Bulk saliva removed with saliva 
ejector. All teeth wiped dry with cotton gauze. One unit dose (0.4 ml) of fluoride 
varnish will be applied to all dentition then interproximal surfaces of all teeth will be 
flossed.  
i. Professionally applied fluoride varnish has been shown to inhibit 
demineralization and enhance remineralization in early enamel caries.22 
Current Caries Risk Assessment (CRA) protocol indicates fluoride varnish 
applications at 3-6 months intervals for high caries risk patients.4,5  
7.1.2  SDF application with Super Floss (Intervention - Group 2): Petroleum jelly will be 
applied to lips and face to protect the skin from staining. Teeth will then be dried with 
an air-water syringe or wiped with gauze. Super Floss will be flossed through contact 
and left in place. The practitioner will apply SDF to the superfloss on the buccal or 
lingual aspect and then over the occlusal embrasure. Provider can visualize SDF being 
absorbed to the other end of the superfloss due to the blue tint of the SDF. Super floss 
will remain between the teeth, allowing the SDF to absorb, for one minute. Super floss 
is then removed and excess SDF removed with gauze or cotton roll. Fluoride varnish is 
applied over all teeth afterwards per high risk CRA protocol and current standard of 
care4,5. 
7.1.3  SDF application without Super Floss (Intervention Control - Group 3): Petroleum jelly 
will be applied to lips and face to protect the skin from staining. Teeth will then be 
dried with an air-water syringe or wiped with gauze, and teeth with interproximal 
caries isolated. SDF will be applied with microbrush over the occlusal embrasure of 
the interproximal surfaces of the target teeth. Excess SDF removed with gauze or 

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cotton roll. Fluoride varnish is applied over all teeth afterwards per high risk CRA 
protocol and current standard of care4,5. 
i. This control (secondary aim) is to determine if indirect/nearby SDF 
application can also be absorbed by the lesion and arrest caries.  
 
 
7.2 Drug studies:   
 
AGENT 
DOSE 
ROUTE 
DAY 
ReRx 
INTERVAL 
NOTES 
38% SDF 
9.5mg/drop 
1 drop = 25 μL 
Topical 
1 
3 months, 6 
months, 12 
months 
 
5% Sodium fluoride 
varnish (2.26%  
[22,600ppm] fluoride) 
22.6mg/mL 
 
1 unit = 0.4mL 
Topical 
1 
3 months, 6 
months, 12 
months 
Fluoride varnish 
will be applied 
to each group. 
 
7.3 Criteria for removal from treatment  
7.3.1 If a carious lesion is arrested or remineralizes in any treatment group, this is 
considered a stable lesion. The patient will continue on with that treatment modality 
(ie. reapplication at 3 months, 6 months, and 12 months) until the tooth exfoliates or 
other comprehensive dental treatment is required. That lesion will continue to be 
monitored for any change in progress.  
7.3.2 Treatment will be discontinued if a patient experiences any persistent eye, skin, oral 
mucosa, respiratory, and gastrointestinal irritation that are considered Grade 2 and 
above adverse events. 
7.3.3  Treatment will be discontinued if a patient experiences any allergic reactions or 
sensitivities to SDF. 
7.3.4 Patients will discontinue treatment if or when a carious lesion progresses to ICCMS 
category 4 or beyond. The patient will be notified and scheduled for routine operative 
dental procedures (ie. restorations) to treat the carious lesion. 
7.3.5 Treatment will be discontinued if patient becomes intolerant to SDF or their behavior 
does not allow for safe and proper application of protocol.  
7.3.6 A patient may always be removed from treatment whenever he/she wishes. 

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8.0 
ASSESSMENT OF EFFICACY AND SAFETY 
8.1 Assessment of Efficacy will be based on size/depth of carious lesion comparisons between 
initial (Day 1) dental radiographs and subsequent time lapse radiographs taken at 6 and 12 
month visits. This frequency (every 6 months) of radiographs is the current standard of care 
for patients with high caries risk4,5, including those with lesions being monitored. 
8.2 Side effects/Toxicities to be monitored. 
8.2.1 Side effects/toxicities that the patient is to be asked about or examined at each 
evaluation while on treatment include: Eye, skin, mucosa, respiratory, and 
gastrointestinal irritation.  
8.2.2 No long-term toxicities to be monitored after completion of therapy.   
8.3 No dosage change based on Grade 1 Adverse Events (AE)/toxicity. If the patient develops 
temporary Grade 1 AEs as listed above and parents would like to continue treatment, the 
same regimen will resume. Serious adverse events have not been documented in previous 
studies and are not expected in our study as well. 
8.4 Adverse Event Reporting:  
8.4.1 We do not foresee any morbidity or mortality associated with any of the proposed 
treatment modalities. Participants will be advised that if any adverse events do occur 
such as irritation to the eyes, skin, mucosa, respiration, and gastrointestinal tract, then 
they can call the CHLA Pediatric Dental Clinic during business hours or there will be 
a pediatric dental resident on-call after hours. We will also report the event to the IRB 
within 48 hours. 
8.4.2 Places for submitting reports: Adverse Event Reports will be submitted only to the 
IRB as there are no sponsors of the proposed research.  
9.0 
CLINICAL EVALUATIONS AND STUDY CALENDAR 
Parameter 
Treatment Day 1 
3 Month Follow-
up 
Recall Visit (6 
months and 12 
months) 
Comprehensive Medical and Dental 
History 
X 
 
 
Updated Medical and Dental History  
 
X 
X 
Oral Examination 
X 
X 
X 
Dental Radiographs 
X 
 
X 
Assessment and Treatment Planning 
X 
 
X 
Informed Consent/Assent 
X 
 
 
Treatment Day 1 
3 Month Follow-
Up 
Recall Visit (6 
months and 12 
months) 

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Dental Prophy (cleaning) 
X 
 
X 
SDF application (with or without use 
of Super Floss) 
X1 
X1 
X1 
Fluoride varnish application* 
X 
X 
X 
Parameter 
Comprehensive Medical and Dental 
History 
X 
 
 
Updated Medical and Dental History 
 
X 
X 
Oral Examination 
X 
X 
X 
Dental Radiographs 
X 
 
X 
Assessment and Treatment Planning 
X 
 
X 
Informed Consent/Assent 
X 
 
 
Dental Prophy (cleaning) 
X 
 
X 
SDF application (with or without use 
of Super Floss) 
X1 
X1 
X1 
Fluoride varnish application* 
X 
X 
X 
 
1 
SDF application with or without the use of Super Floss is determined by which treatment 
group the patient is in. 
*  
All treatment groups will get fluoride varnish application. 
 
10.0 
CRITERIA FOR EVALUATION AND ENDPOINT DEFINITIONS 
 
 
 
The primary outcome is arrest of interproximal caries on a primary molar, as measured by 
lack of change in ICCMS classification indicating caries progression on radiographic 
examination, (higher score indicates progression).  The outcome will be evaluated at three 
time points: baseline, 6 months and 12 months. As the treatments cannot be made to appear 
similar to one another, neither the treating dentist or the patient/parent(s) will be blinded to 
treatment status.  However, evaluation of the outcome will made by comparing time lapse 
(ie. comparing intial xrays vs. at 6 months vs. at 1 year) bitewing radiographs and visualizing 
if the carious lesion has remineralized, arrested, or progressed   
 
11.0 
SPECIAL INSTRUCTIONS: 
11.1 Not applicable 
12.0 
DATA COLLECTION AND MONITORING 
As the study is small and preliminary in nature, there are is no formal monitoring committee.  
However, the statistician will monitor the progress of the study to assess accrual rate and data 
quality throughout the progress of the study.  Once collected, the data will be cleaned, 

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beginning with range checks, evaluation of outliers, crosstabs between variables of interest 
and visual examinations.  
13.0 
STATISTICAL CONSIDERATIONS 
13.1 The proposed pilot Phase III randomized controlled clinical trial aims to determine which of 
the following treatments is superior in arresting dental caries among patients presenting with 
interproximal caries scoring RA1 – RA3 on the International Caries Classification and 
Management System (ICCMS): (1) Fluoride varnish (FV, current standard of care, control), 
(2) Super floss + SDF + FV, (3) SDF + FV.  We hypothesize that group 2 will have the best 
outcomes, as measured by no change or reversal in ICCMS classification indicating no caries 
progression or remineralization on radiographic examination, (higher score indicates 
progression) followed by group 3.  As we could find no data on ICCMS-defined progression 
or remineralization rates for either Super Floss or fluoride, we were unable to calculate 
power. Instead, we provide estimates of recruitment based on feasibility. We expect to accrue 
approximately 20 participants, with 2 qualifying teeth per participant, in each group.  
10% loss to follow up has increased dramatically to ~48%. Given this unexpected setback, we 
now need to continue recruiting participants to reach sufficient power. We originally planned 
to enroll 39 subjects in the study, but would now like to add 21 new participants for a total of 
60 participants. 
Descriptive statistics will be calculated for all demographic and clinical characteristics to 
assess the degree to which randomization was successful using means and standard 
deviations or medians and interquartile ranges for continuous variables and counts and 
percentages for categorical variables.  
 
The primary analysis will be by intent-to-treat.  The primary outcome is the change in 
ICCMS category, as assessed by radiographic evidence, from baseline to 12 months, with a 
planned interim analysis to evaluate the endpoint at 6 months for early indications of 
efficacy.  We will calculate the median difference at each time point and use an individual-
level model with an adjustment to the standard error to account for the clustering.  First we 
will evaluate the association between treatment groups and the change in ICCMS score from 
baseline at 6 and 12 months using a cluster-adjusted chi-squared test.  We will further assess 

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the relationship between these two variables using generalized estimating equations, 
specifying a Poisson (or negative binomial, if overdispersed) family and a log link. We will 
also specify an exchangeable correlation matrix and a robust standard error.  
 
Since the study is randomized, we do not anticipate needing to adjust for any confounders. 
However, should we find any differences in demographic or clinical variables at baseline, we 
will investigate them as potential confounders, which will be defined as those variables 
which alter the odds ratio by >15% when included in the model.  
  
For those with missing data on outcomes or other covariates to be included in the model, we 
will consider multiple imputation methods if the amount of missing data is <10%. To assess 
the impact of missing data, we will compare those with missing data to those not missing 
data with respect to demographic and clinical variables to assess comparability. Should 
imputation be utilized, a sensitivity analysis will be conducted excluding those for whom 
data was imputed to assess the impact of imputation.  
 
Model fit will be evaluated by inspection of residuals and influential points.  As we are 
conducting an interim analysis, we will use a two-sided Bonferroni-corrected p-value of 
a=.025 for statistical significance. Finally, to assess the degree to which the two raters agree 
with respect to classifying the outcome of the x-rays, we will calculate and report Kappa. All 
statistical analyses will be done using Stata 15.0 (College Station, TX). 
  
Power Analysis 
We calculated power using a cluster-randomized design.  We were unable to locate any 
previous studies examining the impact of these three treatments (or any two) using the same 
classification system as our outcome.  However, we were able to obtain an estimate of 0.0 to 
0.25 for the interclass correlation coefficient (ICC) (Honkala et al., 2011). Assuming the 
mean ICC, and assuming a clinically significant mean difference of 0.2, a standard deviation 
of 0.2, a covariance of cluster sizes of 0.65, two caries on average per child, and a two-sided 
adjusted Type I error rate of 0.025 to account for the three time points at which the data will 
be analyzed, we will have 80% power with 11-12 participants per group, for a total of 33-36 
participants (66-72 caries).  Since we anticipate significant loss-to-follow-up over the course 

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of the study, we will inflate the sample size by ~48% and recruit a total of 54-60 participants 
(108-120 caries).  Sample size was calculated using PASS Software v.14.0 (Kayesville, UT). 
 
This study is powered to detect an effect in a population of children who are predominantly 
non-white.  Therefore, the sample size as calculated is likely to result in a sample size with 
reasonable power to detect an effect near the size outlined above, if perhaps slightly larger.   
 
14.0 
REGISTRATION GUIDELINE 
14.1 Participants will be randomized as described in Section 6.3.  Randomization envelopes will 
be available to the investigators, who need only select the next one in the series to 
accomplish randomization. No stratification parameters have been specified.  
14.2 The forms and records needed for registration: Informed Consent; Assentfor Younger 
Subjects ; and Tracking Form.   
 
 
Note: At the time of registration, two copies of a signed and dated patient Informed 
Consent form with Bill of Rights must be available (a copy for patient’s dental chart; 
a copy for the subject/parent; and the original for the PI’s file).   
15.0 
BIOHAZARD CONTAINMENT 
15.1 Not applicable  
16.0 
ETHICAL AND REGULATORY CONSIDERATIONS 
 
All institutional and Federal regulations concerning the Informed Consent form will be 
fulfilled.  The study will be conducted in adherence to ICH Good Clinical Practice. 
 
 

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17.0 
REFERENCES 
 
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14. Mei ML, Li QL, Chu CH, Yiu CK, and Lo EC. The inhibitory effects of silver diamine 
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APPENDICES 
 
Appendix I: 
Table of the ICCMS Radiographic Scoring System of Carious Lesions 
 
Red box encloses Categories 1-3, which are the target lesions for this study. 
 
 

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