Act as an experienced scientific editor specializing in biomedical and dental journals. My manuscript has a similarity index of 26%, and the journal requires it to be below 20%. I will upload the manuscript section by section. For each section: 1. Rewrite every sentence in original academic language. 2. Preserve the scientific meaning exactly. 3. Do not alter the methodology, results, statistics, references, tables, figure legends, or numerical values. 4. Change sentence structure, vocabulary, and paragraph flow to minimize similarity. 5. Maintain a publication-quality scientific tone. 6. Do not introduce new information or unsupported claims. 7. Highlight any sentence that may still have unavoidable similarity because it contains standard scientific terminology. 8. Aim for a version suitable for submission to an indexed journal. I have also uploaded a plagairism report for your reference.

ABSTRACT Aim & Background Indirect pulp capping (IPC) is commonly used to treat deep carious lesions close to the pulp to help maintain tooth vitality. Recently, silver diamine fluoride (SDF)—a formulation with 45,000 ppm fluoride and silver—has gained attention as a potential IPC agent in several studies. This review and meta-analysis evaluate and contrast the clinical and radiographic outcomes of IPC using SDF and calcium hydroxide in primary teeth. Materials and Methods: An extensive literature search for papers published up to December 31, 2024, was conducted across numerous electronic databases. Two independent reviewers screened and selected the eligible studies. The Cochrane Risk of Bias tool was applied to evaluate the five randomized controlled trials that fulfilled the selection requirements. Results: Four studies (two RCTs and two non-RCTs) met the inclusion criteria. The meta-analysis found no statistically significant difference in success rates between the SDF and CaOH groups. Similarly, no statistically significant difference was found in the remaining dentin thickness at 1-month and 3-month intervals between the two materials. Conclusion: Although the current evidence is limited, SDF may be a viable alternative to calcium hydroxide for IPC in deciduous teeth. Clinical Significance: This review provides pediatric dentists with current perspectives on the application of SDF as a material for indirect pulp capping in children's teeth. Keywords: Silver diamine fluoride, calcium hydroxide, indirect pulp capping, vital pulp therapy, meta-analysis, systematic review.

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Preserving the health of primary teeth affected by deep carious lesions remains a key concern in pediatric dentistry, as it is crucial to maintain their vitality until natural exfoliation occurs. Premature loss can result in malocclusion, along with compromised function and esthetics. Indirect pulp capping (IPC), a type of vital pulp therapy, is recommended when caries approaches the pulp but there are no clinical or radiographic signs of irreversible pulp damage.1 During selective caries removal, the deepest portion of decay is intentionally left to prevent pulp exposure, and an IPC material is placed.2 Historically, calcium hydroxide-based cements (e.g., Dycal, self-curing Ca(OH)₂) have been the standard choice in pediatric dentistry. However, they are non-adhesive, provide weak dentin sealing, and may form “tunnel defects” that allow bacterial penetration into the pulp. Additionally, these materials gradually disintegrate over time, increasing failure.3,4 Beyond calcium hydroxide, the literature cites other IPC agents such as mineral trioxide aggregate (MTA), Portland cement, resin-modified glass ionomer (RMGI), dentin bonding agents, zinc oxide eugenol, and biologically active molecules like enamel matrix proteins or bone morphogenetic proteins. In recent years, silver diamine fluoride (SDF) — a formulation containing 45,000 ppm fluoride with silver — has gained its popularity as an IPC material indirect pulp capping agent.5 SDF inhibits biofilm by increasing pH and provides antimicrobial action. It promotes the formation of silver phosphate, aiding remineralization and reducing demineralization.6 A notable advantage of SDF is its ease of application, even in less cooperative children. Nonetheless, its main disadvantage is the blackish appearance of carious lesions, which may cause pulpal and soft tissue irritation.7,8 As dental caries remain widespread among pediatric populations, understanding which materials offer the best therapeutic outcomes for indirect pulp capping is increasingly important. To address this need, the present systematic review investigates and contrasts the clinical performance and radiographic results of silver diamine fluoride versus calcium hydroxide when used for indirect pulp capping in primary teeth..

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SDF works by raising local pH to suppress biofilm formation and exerts a direct antimicrobial effect. It also promotes the formation of silver phosphate, which supports remineralization while slowing further mineral loss from dentin. Change the mechanism of sdf into a different language

Since dental caries continues to be one of the most prevalent conditions affecting children worldwide, knowing which IPC materials deliver the best outcomes matters greatly to clinicians. With that in mind, this systematic review was designed to examine and compare the clinical and radiographic outcomes of silver diamine fluoride versus calcium hydroxide when used for indirect pulp capping in primary teeth. Change the last paragraph

Materials and Methods This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to ensure transparency and comprehensive reporting.. Further, in order to improve methodological accountability and openness, the protocol was registered on PROSPERO (CRD42024533369). Focused Questions: 1. What are the clinical and radiographic outcomes of IPC using SDF compared to calcium hydroxide? 2. Does silver diamine fluoride demonstrate greater effectiveness than calcium hydroxide as an indirect pulp capping material in primary teeth? The research questions were structured according to the PICO framework: • Participants: Primary teeth in pediatric patients undergoing IPC • Intervention: IPC with SDF • Comparison: IPC with calcium hydroxide • Primary Outcome: Clinical and radiographic success rates of IPC • Secondary Outcome: Formation of reparative dentin Information Sources An extensive electronic search was carried out across several databases, including Web of Science, Scopus, PubMed, Embase, Google Scholar, EBSCO, Clinical Trials Registry of India, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Oral Health Group’s Trials Register, PROSPERO, and the NIH Trials Registry. The search was restricted to studies published in English or those available with a full English summary, within the timeframe of January 1, 2000 to December 31, 2023. In addition, the reference lists of both included and excluded articles were manually reviewed to identify any additional relevant studies. A set of predefined keyword combinations (Table 1) was applied in all databases to ensure comprehensive retrieval of relevant studies. Eligibility Criteria The PICOS method described in PRISMA-P 2020 was used to determine the selection criteria.(Table 2). Study Selection The research selection was conducted in two stages. Two independent reviewers screened abstracts and titles using predetermined inclusion criteria to eliminate out papers that weren't relevant.. b.Full-text evaluation of remaining articles, applying the same criteria to confirm eligibility. Any discrepancies were settled through consultation with an independent reviewer. Data Extraction Data from the eligible studies were independently extracted by two reviewers using a predefined standardized form. The extracted information included author details, year of publication, study design, participant age, sample size, grouping, methodology, duration of follow-up, and study outcomes. Any disagreements between the reviewers were discussed and resolved through consultation with a third reviewer. Quality Assessment The Cochrane Risk of Bias tool was used for randomized controlled trials, evaluating domains such as: • Sequence generation • Allocation concealment • Blinding of participants, personnel, and outcome assessors • Incomplete outcome data • Selective reporting • Other potential sources of bias (e.g., sample size estimation, examiner calibration) The risk of bias for each included study was assessed and categorized as low, high, or unclear. Data Synthesis A narrative synthesis was performed, organized by intervention type, participant characteristics, outcomes, and study design. Where data were available, a meta-analysis was conducted using: • Risk ratios for dichotomous outcomes • Standardized mean differences for continuous outcomes The choice between a fixed-effects model and a random-effects model was determined based on the level of heterogeneity among the included studies.

Results Search Results The screening and selection process of the studies is illustrated in the PRISMA flow diagram (Figure 1). The inter-reviewer agreement was excellent (κ = 0.98), indicating high consistency among the three reviewers. The electronic search initially identified 1,605 records. After removing duplicates, 828 studies remained for title and abstract screening. Based on predefined eligibility criteria, 780 studies were excluded as irrelevant. The remaining 48 articles underwent full-text assessment by two reviewers. Following this evaluation, five studies were deemed eligible for inclusion in the systematic review. Characteristics of Included Studies The review included five randomized controlled trials 9-13conducted in India between 2020 and 2024. The details of the study design, sample characteristics, interventions, and follow-up periods are summarized in Table 3. Risk of Bias Assessment The risk of bias was evaluated using the Cochrane Collaboration tool. ( Fig 2) • Random sequence generation: Not adequately described in any study → rated as unclear risk. • Allocation concealment: Only Patil et al. reported appropriate methods, but overall categorization was high risk due to insufficient details in other studies. • Blinding: Blinding of participants, investigators, or outcome assessors was not reported in any of the studies, resulting in a high risk of bias. • Incomplete outcome data: Two studies reported drop-outs, but they were balanced across groups. • Selective reporting: Study protocols were unavailable; hence, the risk was rated as unclear. • Other bias: Missing information on examiner calibration and inclusion/exclusion criteria. Although three studies mentioned sample size estimation, examiner calibration was absent in all, leading to a high risk rating. Meta-Analysis I.Success Rate: SDF vs Calcium Hydroxide- A forest plot has been used to represent the overall comparison's outcomes.(Fig 3). Meta-analysis indicated low heterogeneity (I² = 0%), allowing use of a fixed-effects model. The pooled analysis revealed no statistically significant difference between the groups (OR = 3.26, 95% CI: 0.49–21.74, Z = 1.22, p = 0.22). II. Remaining Dentin Thickness at 1 MonthTwo studies provided adequate data for analysis. (Figure 4). High heterogeneity (I² = 93%) prompted use of a random-effects model. The results showed no significant difference between SDF and calcium hydroxide (SMD = 0.27, 95% CI: -1.55 to 2.08, Z = 0.29, p = 0.77). III. Remaining Dentin Thickness at 3 MonthsTwo studies met the inclusion criteria. The comprehensive comparison results are visually shown in a forest plot(Figure 5). Low heterogeneity (I² = 0%) supported a fixed-effects model. No statistically significant difference was observed (SMD = 0.05, 95% CI: -0.38 to 0.49, Z = 0.24, p = 0.81).

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Discussion Since indirect pulp capping (IPC) attempts to maintain pulp life and proper tooth function until exfoliation, it is essential for treatment of extensively deep caries in primary teeth. The choice of medication is directly related to the success of IPC. 14. Calcium hydroxide's antimicrobial properties and superior biocompatibility have made it the "gold standard" for many years. 15 However, its limitations are well documented, including internal resorption, weak adhesion to dentin, dissolution over time, “tunnel defects,” and inadequate sealing ability. These shortcomings have prompted exploration of newer materials such as resin-modified glass ionomer cement (RMGIC), mineral trioxide aggregate (MTA), and biodentine, which exhibit improved sealing and mechanical properties.16 Silver diamine fluoride (SDF) combines antimicrobial and cariostatic effects, making it a useful option for both controlling and preventing dental caries. Upon contact with carious lesions, it releases calcium fluoride and silver phosphate, which promote remineralization and strengthen tooth structure. Silver phosphate can occlude compromised dentinal tubules, creating a barrier that limits bacterial ingress. Compared to calcium hydroxide, SDF promotes the formation of larger fluorapatite crystals in a fluoride-rich environment, resulting in a denser structure with higher microhardness.17 SDF has recently been investigated as an IPC agent largely due to its caries-arresting ability .18 It is also valued for its antibacterial action and simple application protocol, which generally causes less discomfort to pediatric patients .19 This review evaluated and compared silver diamine fluoride (SDF) and calcium hydroxide with respect to their clinical and radiographic outcomes when used for indirect pulp capping (IPC) in primary teeth.Among the five included studies, four reported clinical success rates of 96–100% for SDF, while the calcium hydroxide group ranged from 88–96%. However, variations exist in the preparation and application of these materials. SDF is commercially available in 12% and 38% concentrations, with the latter demonstrating higher efficacy in arresting caries. It consists of about 44,800 ppm of fluoride ions and 253,900 ppm of silver. 19.Most studies have used undiluted 38% SDF; for example, Shafi et al. 9 tested a diluted version (1:10 with distilled water), whereas others used undiluted solutions from different manufacturers.10,11 When reparative dentin formation was assessed, two studies 11,20 found SDF produced the least thickness increase compared to calcium hydroxide, MTA, and biodentine, yet no clinical or radiographic failures were observed. In Divyashree’s11 trial, mean dentin bridge thicknesses at six months were 0.1533 mm for Dycal, 0.116 mm for MTA, and only 0.0076 mm for SDF. Sinha et al.20 likewise observed elevated phosphate levels and increased fluoride concentration, but noted reduced calcium content in the residual dentin of the SDF group. Similar results regarding dentin thickness over time were reported by several investigations, including Leye Benoist et al. 22 and Malhotra et al. 23. Regarding failure rates, Shafi et al.9 observed 0% failure at six months and 4% at 12 months for SDF, compared to 4% and 8.33% for light-cured calcium hydroxide over the same periods. Overall, these findings suggest that SDF may have a lower failure rate than calcium hydroxide in IPC. Factors contributing to calcium hydroxide failures include poor dentin bonding, solubility, tunnel defects, pulp tissue necrosis from particle displacement, and incorrect diagnosis of pulpal status prior to treatment. Despite its high overall success, precautionary measures are necessary when using SDF because of its drawbacks. A major drawback is the dark discoloration that develops on the treated area, potentially impacting esthetics. Additionally, reports in the literature mention possible irritation of the pulp and oral mucosa.25

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Among the five clinical trials included in this review, four reported higher clinical and radiographic success rates for silver diamine fluoride (SDF) compared to calcium hydroxide; however, the overall quality of evidence was considered low. SDF was consistently linked to the least amount of reparative dentin production at six months, although this did not result in a higher rate of radiographic or clinical failure. Based on the available evidence, silver diamine fluoride (SDF) can be considered a viable and effective alternative to calcium hydroxide for indirect pulp capping in primary molars. However, additional well-designed randomized controlled trials with larger sample sizes and extended follow-up periods are required to provide more conclusive evidence regarding the comparative clinical and radiographic outcomes of these two materials in IPC. rewrite

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