Just 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 this can assist you to combine these extremely efficient in-offices caries administration remedies.
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. 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 standard 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 throughout 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 can be 0.3mL.
In a examine by Dr Beltran, revealed in JADA in 2000, the blood plasma ranges of fluoride after FluoriMax software had 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 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 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 through saliva into the lesion regardless.
For optimum uptake, particularly in sufferers with xerostomia, be certain 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 also 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 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 may be extra floor space, so subsequently higher bioavailability. Secondly, smaller particles keep in suspension longer (though it’s all the time really useful to shake the bottle earlier than software to attain a fair distribution of particles in suspension earlier than meting out)
Are there any components that sufferers may have an hostile impact to within the FluoriMax?
To our information no. Some folks declare a response to shellac, however this has not been substantiated by scientific literature.
What are excessive depth remedies with FluoriMax?
These are 3 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 obtainable.
What are suggestions for getting the very best out of the product software 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 standard 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 possibly can take away the cap and rinse with water. If the orifice is plugged, you possibly can open it with a pin. You too can ask for extra 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 possibly can 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 would 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 comfortable tissues (subg and sophistication V functions)?
Benefit Arrest has a pH of 10 which suggests it isn’t caustic to sound comfortable tissues. It would 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 could be delicate. Utility of Benefit Arrest just isn’t really useful in a case of ulcerative gingivitis if the applying would contact comfortable 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 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 a proof of pulpal involvement or publicity (similar to drainage or fistulas), Benefit Arrest could be utilized. When it’s positioned close to pulp, it can 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?
In case 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 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 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, it’s possible 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 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 best), place the GI restorative as standard. This system is named the two day SMART (Silver Modified Atraumatic Resin Method).
Easy methods to keep away from staining with mild remedy merchandise?
Please be aware: 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 mild remedy to look at if Benefit Arrest has stained an esthetic space, then polish that away. Then you possibly can proceed with restoration. Just a few 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 means 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 energy however it’s possible you’ll not need to use this in excessive compression areas, and so on.
How incessantly ought to Benefit Arrest be utilized?
Contemplate 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 no less than two functions. 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 applying?
The primary software can arrest 70-75% of the lesion. The second software can arrest 90-95% of the lesion. (2016 examine)
Do that you must rinse or not rinse after Benefit Arrest placement?
Both is ok. If no rinse, it’s possible 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 exploit Benefit Arrest?”
Info about RivaStar vs Benefit Arrest:
RivaStar has a pH of 13 – it’s caustic to comfortable tissues and shouldn’t contact comfortable 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 software is 2-3 instances that of Benefit Arrest.
RivaStar is marketed for use beneath GI class I restorations. On this software, 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. 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 possible 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 gives 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 simple, product is skinny and nice, and sufferers can eat and drink instantly. 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 you will need to inform sufferers and caregivers concerning the lesion altering coloration, I discover affected person acceptance is excessive. Many caregivers of susceptible sufferers and other people with monetary limitations are relieved when they’re given an inexpensive, non-invasive choice that can arrest decay.
For dental hygienists which are putting GIs, most restorations with SDF plus KI will inevitably flip darkish, no 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 are subg or on the gingival margin can’t be sufficiently remoted for comfortable tissue safety. Chances are you’ll have to cost extra for SDF and KI to get better 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 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 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.
