## 4 Discussion
### Comparative Efficacy of SDF in Various Treatment Modalities  
The systematic review identified several studies assessing the comparative efficacy of SDF in different treatment modalities [119]. For instance, [PERSON] et al. in 2019 were pivotal in assessing the efficacy of SDF in pediatric dental caries prevention and treatment in remote Aboriginal communities. The randomized groups received an atraumatic restorative technique (ART) or SDF. The study found that SDF-treated teeth showed more retreatment needs, particularly in 5-year-olds, leading to a higher prevalence ratio (PR: 1.77). However, when retreatment was considered routine, the PR for negative outcomes was lower for SDF (PR: 0.18). This highlighted the staining issues associated with SDF but emphasized its effectiveness and simplicity compared to ART. Despite its contributions, the study faced challenges in recruitment, posing potential limitations on its generalizability [77].  
Similarly, [PERSON] et al. demonstrated comparable success rates of silver diamine fluoride-modified atraumatic restorative technique (SMART) with conventional methods, emphasizing its potential as a child-friendly alternative. They compared the use of the SDF-modified atraumatic restorative technique (SMART) with the conventional drill and fill method in treating deep asymptomatic caries in primary molars. The study, involving 226 children aged 4-8, showed that SMART had comparable success rates with the con ventional method. However, SMART demonstrated better treatment acceptance (79% vs. 56%), making it a potential alternative for uncooperative children. This underscores the significance of child-friendly approaches in pediatric dentistry, aligning with the paradigm shift towards minimally invasive techniques [78].  
However, [PERSON] et al. challenged the presumed superiority of SDF over traditional fluoride varnishes in preventing caries in high-risk preschool children, suggesting contextual effectiveness. This study involved engaging in an 18-month randomized clinical trial comparing the efficacy of two topical fluoride applications and a placebo in preventing approximal caries in the primary teeth of preschool children. Participants were assigned to three groups: placebo control, 5% sodium fluoride (NaF) varnish, and 38% SDF. Surprisingly, the study found no significant differences in the development of approximal caries among the groups, challenging the presumed superiority of SDF over traditional fluoride varnishes. This suggests that, in certain contexts, traditional fluoride varnishes may be as effective as SDF in preventing caries in high-risk preschool children [80].  
While the study by [PERSON] et al. highlighted the effectiveness of SDF in remote Aboriginal communities, it also brought attention to the need for routine retreatment and staining issues associated with SDF. [PERSON] et al.'s findings regarding SMART under-scored its comparable success rates with conventional methods, along with its superior treatment acceptance, indicating its potential as a child-friendly alternative. Additionally, [PERSON] et al.'s study challenged the presumed superiority of SDF over traditional fluoride varnishes in preventing caries in high-risk preschool children, suggesting that traditional varnishes may be equally effective in certain contexts.