Not too long ago, 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 may provide help 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 Nineteen Nineties present that even in a colophony, the fluoride uptake (bioavailability) may be very comparable between 2.5 and 5% formulations. Due to this fact, 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. Nevertheless, at this share there isn’t any 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 inside the first 4 hours, the following 24 hours as much as 10%.
That is protected 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 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 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 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 by way of saliva into the lesion regardless.
For max uptake, particularly in sufferers with xerostomia, ensure 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 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 improve fluoride uptake – this would offer the required 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’s extra floor space, so subsequently better bioavailability. Secondly, smaller particles keep in suspension longer (though it’s at all times really useful to shake the bottle earlier than software to realize an excellent distribution of particles in suspension earlier than shelling out)
Are there any elements that sufferers may have an adversarial 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 remedies 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 obtainable.
What are suggestions for getting one of the best out of the product software and conserving the bottle clear?
All the time shake the bottle 10-15 seconds – lower than that and you could 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 actually 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 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 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 is going to 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 protected 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 is going to dry and blanche tissue quickly, however this isn’t dangerous or painful.
Benefit Arrest will trigger irritation in wounded tissue. It isn’t dangerous however may be delicate. Utility of Benefit Arrest isn’t really useful in a case of ulcerative gingivitis if the applying would contact mushy 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 isn’t any proof of pulpal involvement or publicity (akin to drainage or fistulas), Benefit Arrest may be utilized. When it’s positioned close to pulp, it’s going to 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?
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 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 max 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, you could discover a slight foam on software of the acid and that is regular.
How you can 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 regular. This method is named the two day SMART (Silver Modified Atraumatic Resin Method).
How you can keep away from staining with gentle remedy merchandise?
Please word: 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 2-3 second gentle remedy to watch if Benefit Arrest has stained an esthetic space, then polish that away. Then you may proceed with restoration. A number 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 may present extra gray by means of 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’s nonetheless bond power however you could not need to use this in excessive compression areas, and so on.
How regularly 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 may 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 least two purposes. Then reassess the lesion and contemplate 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 you might want to rinse or not rinse after Benefit Arrest placement?
Both is ok. If no rinse, you could need to blot web site 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 mushy tissues and shouldn’t contact mushy tissue. AA has a pH of 10, which isn’t caustic. It might quickly 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 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 cut 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’s 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 implies decrease share of fluoride is required. The appliance is simple, 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 broadly utilized in pediatric and geriatric care. Whereas it is very important inform sufferers and caregivers in regards to the lesion altering shade, I discover affected person acceptance is excessive. Many caregivers of susceptible sufferers and folks with monetary boundaries are relieved when they’re given an reasonably priced, non-invasive choice that may arrest decay.
For dental hygienists which might be 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 might be subg or on the gingival margin can’t be sufficiently remoted for mushy tissue safety. It’s possible you’ll have to cost extra for SDF and KI to recuperate 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 evaluation of their scientific 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.
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