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 show you how to combine these extremely efficient in-offices caries administration therapies.
FLUORIMAX
Why is there solely 2.5% NaF in FluoriMax?
Research going again to the Nineteen Nineties present that even in a colophony, the fluoride uptake (bioavailability) could be very related between 2.5 and 5% formulations. Due to this fact, 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 is no such thing as a actual profit to a standard mouth, and possibly 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 4 hours, the subsequent 24 hours as much as 10%.
That is secure as a result of small portions being utilized. 1 drop = 0.1mL, so a beneficiant 3 drop dose could be 0.3mL.
In a examine by Dr Beltran, printed in JADA in 2000, the blood plasma ranges of fluoride after FluoriMax utility have been lower than an everyday toothpaste utility. (2)
What’s dewaxed meals grade shellac?
Shellac is a pure product that’s produced from a resinous secretion discovered on bushes, 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 prone 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 shall be transported through saliva into the lesion regardless.
For optimum uptake, particularly in sufferers with xerostomia, make sure that to use to enamel 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 often 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 improve fluoride uptake – this would supply the required water to help in fluoride ion transportation.
Is there a distinction within the particle dimension of FluoriMax fluoride?
Sure. Typical 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 fifteen microns and smaller. That is carried out for 2 causes. With smaller particles there’s extra floor space, so subsequently larger bioavailability. Secondly, smaller particles keep in suspension longer (though it’s all the time really useful to shake the bottle earlier than utility to attain an excellent distribution of particles in suspension earlier than meting out)
Are there any elements that sufferers may have an opposed impact to within the FluoriMax?
To our data no. Some folks declare a response to shellac, however this has not been substantiated by scientific literature.
What are excessive depth therapies with FluoriMax?
These are 3 purposes 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 most effective out of the product utility and conserving the bottle clear?
At all times 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.
At all times 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 too can ask for added meting 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 optimum 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 could enhance arrest fee.
Is Benefit Arrest secure for mushy tissues (subg and sophistication V purposes)?
Benefit Arrest has a pH of 10 which implies it isn’t caustic to sound mushy tissues. It’ll dry and blanche tissue briefly, however this isn’t dangerous or painful.
Benefit Arrest will trigger irritation in wounded tissue. It’s not dangerous however might be delicate. Software of Benefit Arrest will not be really useful in a case of ulcerative gingivitis if the appliance would contact mushy 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 is no such thing as a proof of pulpal involvement or publicity (comparable to 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?
For those who apply Benefit Arrest and need to do an instantaneous GI placement:
Apply it as regular, then rinse and dry (don’t dessicate). You may place the GI however some silver shall 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 optimum bond energy. If utilizing polyacrylic acid step, chances are you’ll discover a slight foam on utility of the acid and that is regular.
Learn how 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 typical. This system is known as the two day SMART (Silver Modified Atraumatic Resin Approach).
Learn how to keep away from staining with mild remedy merchandise?
Please observe: Gentle curing will “activate” stain of allBenefit Arrest, whether or not it’s on sound or decayed tooth construction. Useful strategies to keep away from staining are:
After placement ofBenefit Arrest, do a 2-3 second mild remedy to watch if Benefit Arrest has stained an esthetic space, then polish that away. Then you may proceed with restoration. A couple of further 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 may present extra gray via it.
- In bonding methods 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 methods. There may be nonetheless bond energy however chances are you’ll not need to use this in excessive compression areas, and many others.
How continuously 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 not less than two purposes. Then reassess the lesion and take into account 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 utility can arrest 70-75% of the lesion. The second utility can arrest 90-95% of the lesion. (2016 examine)
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 ofBenefit Arrest?”
Info about RivaStar vsBenefit Arrest:
RivaStar has a pH of 13 – it’s caustic to mushy tissues and mustn’t contact mushy tissue. AA has a pH of 10, which isn’t caustic. It might briefly dry and blanche tissue however it isn’t dangerous to the tissue.
RivaStar price per utility is 2-3 instances that ofBenefit Arrest.
RivaStar is marketed for use below GI class I restorations. On this utility, 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 comprise 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’s 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 standard varnish, however with a number of main benefits: Elevated bioavailability, which implies decrease proportion of fluoride is required. The applying is straightforward, product is skinny and nice, and sufferers can eat and drink instantly. Sufferers which have beforehand mentioned “no” to varnish love FluoriMax.
Benefit Arrest is a minimally invasive intervention that’s extensively utilized in pediatric and geriatric care. Whereas you will need to inform sufferers and caregivers concerning the lesion altering shade, I discover affected person acceptance is excessive. Many caregivers of susceptible sufferers and other people with monetary boundaries are relieved when they’re given an inexpensive, non-invasive possibility that may arrest decay.
For dental hygienists which might be putting GIs, most restorations with SDF plus KI will inevitably flip darkish, not less than across the edges. Utilizing SDF with KI alone will flip darkish over time, and the caries arrest properties are considerably diminished within the presence of KI. And lastly, any lesions which might be subg or on the gingival margin can’t be sufficiently remoted for mushy tissue safety. You could must cost extra for SDF and KI to get well product price.
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 overview 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 Remedy 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.