Lately, a member of our crew, Martha Szczepulski (additionally RDH), met with Steve Pardue, Managing Member at Elevate Oral Care, the corporate behind the event of FluoriMax (2.5% Sodium Fluoride Varnish) and Benefit Arrest (Silver Diamine Fluoride).

Here’s a abstract of their dialogue. We hope this can aid you combine these extremely efficient in-offices caries administration therapies.

FLUORIMAX

Why is there solely 2.5% NaF in FluoriMax?

Research going again to the 1990s present that even in a colophony, the fluoride uptake (bioavailability) could be very related between 2.5 and 5% formulations. Subsequently, it’s best to make use of the bottom proportion that produces efficient outcomes. (1)

How a lot hydroxyapatite is in FluoriMax?

3%. It’s a supply of calcium and phosphate. Nevertheless, at this proportion there isn’t a actual profit to a traditional mouth, and perhaps a miniscule profit to a affected person with xerostomia. True profit is from the sodium fluoride.

How lengthy does FluoriMax stay within the oral cavity?

It stays till it’s eliminated.

Roughly 90% of the uptake is inside the first four hours, the subsequent 24 hours as much as 10%.

That is secure because of the small portions being utilized. 1 drop = 0.1mL, so a beneficiant Three drop dose could be 0.3mL.

In a research by Dr Beltran, printed in JADA in 2000, the blood plasma ranges of fluoride after FluoriMax software have been lower than an everyday toothpaste software. (2)

What’s dewaxed meals grade shellac?

Shellac is a pure product that’s produced from a resinous secretion discovered on timber, made by a bunch of bugs known as Kerria lacca. The secretion, known as lac, is refined into meals grade shellac, amongst different shellac merchandise.

You’ll have seen shellac because the shiny coating on an Advil or a Chicklet. 

The place ought to I apply FluoriMax?

The advice is to use to the buccal surfaces in a skinny layer the place it acts as a reservoir. This reservoir works greatest as a skinny layer. A thick layer is much less bioavailable and is extra more likely to slough off and be swallowed. A skinny layer is extra comfy and extra bioavailable.

FluoriMax might be utilized on a lesion or close to a lesion – the fluoride ions might be transported by way of saliva into the lesion regardless.

For optimum uptake, particularly in sufferers with xerostomia, make sure that to use to tooth in shut proximity to the submandibular glands (buccal and lingual sextant 5). This saliva is extra liquid and facilitates fluoride ion transportation. Close to the parotid glands can be good, however this saliva is usually extra ropey and doesn’t facilitate transport in addition to the extra liquid saliva from the submandibular glands.

In extreme xerostomia, sipping a glass of water over the hour after the appliance would assist enhance fluoride uptake – this would offer the required water to assist in fluoride ion transportation.

Is there a distinction within the particle measurement of FluoriMax fluoride?

Sure. Standard fluoride particles are within the vary of 150 microns (except the producer mills them first). FluoriMax has micronized particles – the fluoride particles are milled and sifted to 15 microns and smaller. That is carried out for 2 causes. With smaller particles there may be extra floor space, so due to this fact better bioavailability. Secondly, smaller particles keep in suspension longer (though it’s at all times really helpful to shake the bottle earlier than software to realize an excellent distribution of particles in suspension earlier than shelling out)

Are there any components that sufferers might have an opposed impact to within the FluoriMax?

To our information no. Some individuals declare a response to shellac, however this has not been substantiated by scientific literature.

What are excessive depth therapies with FluoriMax?

These are Three functions in 5-7 days. This has been carried out in outreach work in different nations to maximise mineralization in a brief time period publicity with no followup out there.

What are suggestions for getting the perfect out of the product software and conserving the bottle clear?

All the time shake the bottle 10-15 seconds – lower than that and chances are you’ll not get the optimum suspension and consistency. FluoriMax is runnier than standard colophony varnish and that could be a good factor as a result of it spreads very skinny and requires much less product.

All the time dispense with the bottle vertical. If the applicator tip will get sticky, wipe off extra with alcohol. If the dispenser is absolutely clogged, you may take away the cap and rinse with water. If the orifice is plugged, you may open it with a pin. You can even ask for added shelling out caps from Oral Science. 

ADVANTAGE ARREST

Ought to I apply FluoriMax after making use of Benefit Arrest?

There are two methods to use Benefit Arrest. You may apply and permit to air dry for 60 sec. Or you may apply and instantly place a layer of FluoriMax over the AA to seal it in and permit for max penetration. The second measure is greatest to make use of in conditions of low affected person compliance. It’ll additionally make the aftertaste much less metallic. 

It’s unknown whether it is superior to use FluoriMax over Benefit Arrest however it might enhance arrest price.

Is Benefit Arrest secure for smooth tissues (subg and sophistication V functions)?

Benefit Arrest has a pH of 10 which suggests it isn’t caustic to sound smooth tissues. It’ll dry and blanche tissue briefly, however this isn’t dangerous or painful. 

Benefit Arrest will trigger irritation in wounded tissue. It isn’t dangerous however might be delicate. Utility of Benefit Arrest shouldn’t be really helpful in a case of ulcerative gingivitis if the appliance would contact smooth tissue.

What about putting Benefit Arrest in deep lesions?

Benefit Arrest will penetrate 2-2.5mm into tooth construction – penetration varies in every tooth and lesion.

Benefit Arrest might be utilized in all carious lesions as much as and together with oblique pulp capping. Direct pulp cap is contraindicated. If there isn’t a proof of pulpal involvement or publicity (reminiscent of drainage or fistulas), Benefit Arrest might be utilized. When it’s positioned close to pulp, it’ll encourage pulp to shrink. Silver can go into the pulp in oblique pulp cap, however this isn’t detrimental to the pulp or tooth. 

What occurs once I use Benefit Arrest then instantly place a glass ionomer restorative cement?

When you apply Benefit Arrest and need to do a direct GI placement:

Apply it as regular, then rinse and dry (don’t dessicate). You may place the GI however some silver might be drawn into the GI, so staining of the GI will happen. That is solely an esthetic concern. It doesn’t lower the bond energy. For optimum bond energy, a polyacrylic acid could also be utilized both earlier than or after the Benefit Arrest (then rinse and dry, don’t dessicate) for max bond energy. If utilizing polyacrylic acid step, chances are you’ll discover a slight foam on software of the acid and that is regular.

The best way to keep away from GI staining with direct placement of GI (no tooth construction polish or removing)?

To keep away from staining, it’s a two-appointment course of. On first day, apply Benefit Arrest as regular. After 24-72 hours (longer is healthier), place the GI restorative as standard. This system is named the two day SMART (Silver Modified Atraumatic Resin Approach).

The best way to keep away from staining with gentle remedy merchandise?

Please notice: Gentle curing will “activate” stain of all Benefit Arrest, whether or not it’s on sound or decayed tooth construction. Useful strategies to keep away from staining are:

After placement of Benefit Arrest, do a 2-Three second gentle remedy to watch if Benefit Arrest has stained an esthetic space, then polish that away. Then you may proceed with restoration. Just a few extra issues to think about:

• An opaque GI or resin base can be utilized on the base of the restoration to masks gray tooth construction. Translucent composite might present extra gray via it. 
• In bonding techniques known as “Self etch” the place the etch, prime and bond are in a single bottle, the bond is weaker than in non self etch techniques. There’s nonetheless bond energy however chances are you’ll not need to use this in excessive compression areas, and so forth.

How regularly ought to Benefit Arrest be utilized?

Take into account your affected person habits and assess the hardness of the lesion.

Sufferers with poor oral hygiene and excessive consumption of cariogenic meals might have indefinite reapplication of Benefit Arrest each 3-6 months.

Sufferers with good oral hygiene and low to reasonable consumption of cariogenic meals ought to have at the very least two functions. Then reassess the lesion and think about making use of each 6 months or yearly to keep up arrest.

How a lot of the lesion is arrested with the appliance?

The primary software can arrest 70-75% of the lesion. The second software can arrest 90-95% of the lesion. (2016 research)

Do you must rinse or not rinse after Benefit Arrest placement?

Both is ok. If no rinse, chances are you’ll need to blot website after placement to soak up extra SDF (to attenuate style)

“I heard RivaStar doesn’t stain. Why ought to I take advantage of Benefit Arrest?”

Info about RivaStar vs Benefit Arrest:

RivaStar has a pH of 13 – it’s caustic to smooth tissues and shouldn’t contact smooth tissue. AA has a pH of 10, which isn’t caustic. It could briefly dry and blanche tissue however it isn’t dangerous to the tissue. 

RivaStar value per software is 2-Three instances that of Benefit Arrest. 

RivaStar is marketed for use below GI class I restorations. On this software, it won’t stain as a result of it’s primarily sealed in and the product was simply positioned on the ground of the restoration. Nevertheless, if SDF and KI are used alone, or the margins of the restoration include SDF and KI, the KI will scale back and decelerate the staining, however it doesn’t inhibit the staining. The staining will probably present up inside a month. 

Lastly, when SDF stands alone, it’s a very efficient caries inhibition agent. When SDF and KI are mixed, there may be an nearly half lower in effectivity. Caries inhibition is considerably much less within the presence of SDF and KI mixed. (3)

My conclusion

FluoriMax supplies the identical safety as a traditional varnish, however with a number of main benefits: Elevated bioavailability, which suggests decrease proportion of fluoride is required. The appliance is simple, product is skinny and nice, and sufferers can eat and drink straight away. Sufferers which have beforehand stated “no” to varnish love FluoriMax.

Benefit Arrest is a minimally invasive intervention that’s broadly utilized in pediatric and geriatric care. Whereas it is very important inform sufferers and caregivers concerning the lesion altering coloration, I discover affected person acceptance is excessive.  Many caregivers of susceptible sufferers and folks with monetary boundaries are relieved when they’re given an inexpensive, non-invasive choice that may arrest decay.

For dental hygienists which can be putting GIs, most restorations with SDF plus KI will inevitably flip darkish, at the very least across the edges. Utilizing SDF with KI alone will flip darkish over time, and the caries arrest properties are considerably lowered within the presence of KI. And lastly, any lesions which can be subg or on the gingival margin can’t be sufficiently remoted for smooth tissue safety. Chances are you’ll must cost extra for SDF and KI to get better product value. 

References

1. Seppä L, Results of sodium fluoride concentrations on enamel remineralization in vitro. Scand J Dent Res 1988;96:304-309.

2. Beltrán-Aguilar ED, Goldstein JW, Lockwood SA. Fluoride varnishes. A evaluation of their medical use, cariostatic mechanism, efficacy and security. J Am Dent Assoc. 2000 Could;131(5):589-96. doi: 10.14219/jada.archive.2000.0232. PMID: 10832252.

3. Zhao IS, Mei ML, Burrow MF, Lo EC, Chu CH. Impact of Silver Diamine Fluoride and Potassium Iodide Therapy on Secondary Caries Prevention and Tooth Discolouration in Cervical Glass Ionomer Cement Restoration. Int J Mol Sci. 2017 Feb 6;18(2):340. doi: 10.3390/ijms18020340. PMID: 28178188; PMCID: PMC5343875.