Not too long ago, a member of our group, 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 allow you 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 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. Nonetheless, at this proportion there is no such thing as a actual profit to a traditional 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 throughout the first 4 hours, the following 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 gaggle of bugs referred to as Kerria lacca. The secretion, referred to 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 finest 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 snug and extra bioavailable.
FluoriMax may be utilized on a lesion or close to a lesion – the fluoride ions might be transported through saliva into the lesion regardless.
For optimum uptake, particularly in sufferers with xerostomia, be 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 applying would assist enhance fluoride uptake – this would supply the mandatory water to assist in fluoride ion transportation.
Is there a distinction within the particle dimension 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 fifteen microns and smaller. That is executed for 2 causes. With smaller particles there may be extra floor space, so due to this fact higher bioavailability. Secondly, smaller particles keep in suspension longer (though it’s all the time really useful to shake the bottle earlier than utility to realize a good distribution of particles in suspension earlier than shelling out)
Are there any elements that sufferers may have an antagonistic 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 executed 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 retaining the bottle clear?
All the time shake the bottle 10-15 seconds – lower than that and it’s possible you’ll not get the optimum suspension and consistency. FluoriMax is runnier than typical colophony varnish and that may 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 admittedly clogged, you’ll be able to take away the cap and rinse with water. If the orifice is plugged, you’ll be able to open it with a pin. You can too 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’ll be able to apply and instantly place a layer of FluoriMax over the AA to seal it in and permit for max penetration. The second measure is finest 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 price.
Is Benefit Arrest secure for delicate tissues (subg and sophistication V purposes)?
Benefit Arrest has a pH of 10 which suggests it isn’t caustic to sound delicate 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 may be delicate. Software of Benefit Arrest isn’t really useful in a case of ulcerative gingivitis if the applying would contact delicate 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 may 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 (equivalent to drainage or fistulas), Benefit Arrest may be utilized. When it’s positioned close to pulp, it should 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 after I use Benefit Arrest then instantly place a glass ionomer restorative cement?
For those who apply Benefit Arrest and wish to do a right away 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 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, it’s possible you’ll discover a slight foam on utility of the acid and that is regular.
Find out how 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 typical. This method known as the two day SMART (Silver Modified Atraumatic Resin Approach).
Find out how to keep away from staining with gentle remedy merchandise?
Please observe: Mild 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 2-3 second gentle remedy to watch if Benefit Arrest has stained an esthetic space, then polish that away. Then you’ll be able to proceed with restoration. A number of extra issues to contemplate:
- 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 by way of it.
- In bonding techniques referred to 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 may be nonetheless bond power however it’s possible you’ll not wish to use this in excessive compression areas, and so forth.
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 might 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 at the least two purposes. Then reassess the lesion and take into account 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 utility can arrest 70-75% of the lesion. The second utility can arrest 90-95% of the lesion. (2016 examine)
Do it is advisable rinse or not rinse after Benefit Arrest placement?
Both is ok. If no rinse, it’s possible you’ll wish to blot website after placement to soak up extra SDF (to reduce 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 delicate tissues and shouldn’t contact delicate 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 value per utility is 2-3 occasions that of Benefit Arrest.
RivaStar is marketed for use beneath GI class I restorations. On this utility, it is not going to 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 cut 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 virtually half lower in effectivity. Caries inhibition is considerably much less within the presence of SDF and KI mixed. (3)
My conclusion
FluoriMax offers the identical safety as a standard varnish, however with a number of main benefits: Elevated bioavailability, which suggests decrease proportion of fluoride is required. The applying is straightforward, product is skinny and nice, and sufferers can eat and drink immediately. Sufferers which have beforehand mentioned “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 weak sufferers and other people with monetary boundaries are relieved when they’re given an inexpensive, non-invasive possibility that can arrest decay.
For dental hygienists which are inserting GIs, most restorations with SDF plus KI will inevitably flip darkish, at the least 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 are subg or on the gingival margin can’t be sufficiently remoted for delicate tissue safety. You might must cost extra for SDF and KI to recuperate 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 Might;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.
