Lately, a member of our staff, 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 it will enable 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 Nineties present that even in a colophony, the fluoride uptake (bioavailability) may be very comparable between 2.5 and 5% formulations. Subsequently, it’s best to make use of the bottom share that produces efficient outcomes. (1)
How a lot hydroxyapatite is in FluoriMax?
3%. It’s a supply of calcium and phosphate. Nonetheless, at this share there isn’t any 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 following 24 hours as much as 10%.
That is secure because of the 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 software had been lower than a daily 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 should 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 could be utilized on a lesion or close to a lesion – the fluoride ions will likely be transported by way of saliva into the lesion regardless.
For optimum uptake, particularly in sufferers with xerostomia, be sure 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 also 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 applying would assist enhance fluoride uptake – this would supply the required water to help in fluoride ion transportation.
Is there a distinction within the particle measurement of FluoriMax fluoride?
Sure. Typical fluoride particles are within the vary of 150 microns (until the producer mills them first). FluoriMax has micronized particles – the fluoride particles are milled and sifted to fifteen microns and smaller. That is finished for 2 causes. With smaller particles there may be extra floor space, so subsequently larger bioavailability. Secondly, smaller particles keep in suspension longer (though it’s all the time beneficial to shake the bottle earlier than software to realize a fair distribution of particles in suspension earlier than dishing out)
Are there any elements 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 3 purposes in 5-7 days. This has been finished in outreach work in different international locations to maximise mineralization in a brief time period publicity with no followup out there.
What are suggestions for getting one of the best out of the product software and protecting 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 may 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 admittedly clogged, you possibly can take away the cap and rinse with water. If the orifice is plugged, you possibly can open it with a pin. You may as well ask for added dishing 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 possibly can 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 could enhance arrest charge.
Is Benefit Arrest secure for gentle tissues (subg and sophistication V purposes)?
Benefit Arrest has a pH of 10 which implies it isn’t caustic to sound gentle 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 could be delicate. Utility of Benefit Arrest will not be beneficial in a case of ulcerative gingivitis if the applying would contact gentle tissue.
What about inserting Benefit Arrest in deep lesions?
Benefit Arrest will penetrate 2-2.5mm into tooth construction – penetration varies in every tooth and lesion.
Benefit Arrest could be utilized in all carious lesions as much as and together with oblique pulp capping. Direct pulp cap is contraindicated. If there isn’t any proof of pulpal involvement or publicity (equivalent to drainage or fistulas), Benefit Arrest could 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?
Should you 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 will likely be drawn into the GI, so staining of the GI will happen. That is solely an esthetic concern. It doesn’t lower the bond power. For optimum bond power, 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 power. If utilizing polyacrylic acid step, chances are you’ll discover a slight foam on software of the acid and that is regular.
Easy methods to keep away from GI staining with direct placement of GI (no tooth construction polish or elimination)?
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 method known as the two day SMART (Silver Modified Atraumatic Resin Method).
Easy methods to keep away from staining with gentle treatment merchandise?
Please observe: Gentle curing will “activate” stain of allBenefit Arrest, whether or not it’s on sound or decayed tooth construction. Useful methods to keep away from staining are:
After placement ofBenefit Arrest, do a 2-3 second gentle treatment to look at if Benefit Arrest has stained an esthetic space, then polish that away. Then you possibly can proceed with restoration. A couple of 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 by way of 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 power however chances are you’ll not need to use this in excessive compression areas, and so on.
How often ought to Benefit Arrest be utilized?
Think about your affected person habits and assess the hardness of the lesion.
Sufferers with poor oral hygiene and excessive consumption of cariogenic meals may have indefinite reapplication of Benefit Arrest each 3-6 months.
Sufferers with good oral hygiene and low to average consumption of cariogenic meals ought to have not less than two purposes. Then reassess the lesion and think about making use of each 6 months or yearly to take care of arrest.
How a lot of the lesion is arrested with the applying?
The primary software can arrest 70-75% of the lesion. The second software can arrest 90-95% of the lesion. (2016 examine)
Do it’s essential to rinse or not rinse after Benefit Arrest placement?
Both is okay. 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?”
Information about RivaStar vsBenefit Arrest:
RivaStar has a pH of 13 – it’s caustic to gentle tissues and mustn’t contact gentle 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 2-3 instances that ofBenefit Arrest.
RivaStar is marketed for use underneath GI class I restorations. On this software, it won’t stain as a result of it’s basically sealed in and the product was simply positioned on the ground of the restoration. Nonetheless, 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, but it surely doesn’t inhibit the staining. The staining will doubtless 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 implies decrease share of fluoride is required. The applying is straightforward, product is skinny and nice, and sufferers can eat and drink immediately. Sufferers which have beforehand stated “no” to varnish love FluoriMax.
Benefit Arrest is a minimally invasive intervention that’s extensively utilized in pediatric and geriatric care. Whereas it is very important inform sufferers and caregivers in regards to the lesion altering coloration, 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 choice that can arrest decay.
For dental hygienists which might be inserting 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 decreased within the presence of KI. And lastly, any lesions which might be subg or on the gingival margin can’t be sufficiently remoted for gentle tissue safety. It’s possible 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 assessment 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.
