Just lately, a member of our workforce, Martha Szczepulski (additionally RDH), met with Steve Pardue, Managing Member at Raise Oral Care, the corporate in the back of the improvement of FluoriMax (2.5% Sodium Fluoride Varnish) and Merit Arrest (Silver Diamine Fluoride).
Here’s a abstract in their dialogue. We are hoping this will likely will let you combine those extremely efficient in-offices caries control therapies.
FLUORIMAX
Why is there handiest 2.5% NaF in FluoriMax?
Research going again to the Nineteen Nineties display that even in a colophony, the fluoride uptake (bioavailability) could be very an identical between 2.5 and 5% formulations. Subsequently, it’s best to make use of the bottom proportion that produces efficient effects. (1)
How a lot hydroxyapatite is in FluoriMax?
3%. This is a supply of calcium and phosphate. Then again, at this proportion there is not any actual get advantages to an ordinary mouth, and perhaps a miniscule get advantages to a affected person with xerostomia. True get advantages is from the sodium fluoride.
How lengthy does FluoriMax stay within the oral hollow space?
It stays till it’s got rid of.
Roughly 90% of the uptake is throughout the first 4 hours, the following 24 hours as much as 10%.
That is protected because of the small amounts being carried out. 1 drop = 0.1mL, so a beneficiant 3 drop dose can be 0.3mL.
In a find out about via Dr Beltran, revealed in JADA in 2000, the blood plasma ranges of fluoride after FluoriMax software have been lower than a normal toothpaste software. (2)
What’s dewaxed meals grade shellac?
Shellac is a herbal product this is made out of a resinous secretion discovered on bushes, made via a gaggle of bugs known as Kerria lacca. The secretion, known as lac, is delicate into meals grade shellac, among different shellac merchandise.
You’ll have noticed shellac because the glossy coating on an Advil or a Chicklet.
The place will have to I practice FluoriMax?
The advice is to use to the buccal surfaces in a skinny layer the place it acts as a reservoir. This reservoir works easiest as a skinny layer. A thick layer is much less bioavailable and is much more likely to slough off and be swallowed. A skinny layer is extra relaxed and extra bioavailable.
FluoriMax will also be carried out on a lesion or close to a lesion – the fluoride ions will probably be transported by way of saliva into the lesion regardless.
For max uptake, particularly in sufferers with xerostomia, be sure you practice 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 may be just right, however this saliva is in most cases extra ropey and does no longer facilitate shipping in addition to the extra liquid saliva from the submandibular glands.
In serious xerostomia, sipping a tumbler of water over the hour after the appliance would lend a hand build up fluoride uptake – this could give you the important water to help in fluoride ion transportation.
Is there a distinction within the particle dimension of FluoriMax fluoride?
Sure. Typical fluoride debris are within the vary of 150 microns (except the producer generators them first). FluoriMax has micronized debris – the fluoride debris are milled and sifted to fifteen microns and smaller. That is accomplished for 2 causes. With smaller debris there’s extra floor house, so subsequently better bioavailability. Secondly, smaller debris keep in suspension longer (even though it’s all the time beneficial to shake the bottle prior to software to reach a good distribution of debris in suspension prior to dishing out)
Are there any elements that sufferers can have an hostile impact to within the FluoriMax?
To our wisdom no. Some folks declare a response to shellac, however this has no longer been substantiated via medical literature.
What are prime depth therapies with FluoriMax?
Those are 3 packages in 5-7 days. This has been accomplished in outreach paintings in different international locations to maximise mineralization in a brief time period publicity and not using a followup to be had.
What are guidelines for buying the most productive out of the product software and holding the bottle blank?
At all times shake the bottle 10-15 seconds – lower than that and also you would possibly not get the optimum suspension and consistency. FluoriMax is runnier than standard colophony varnish and that could be a just right factor as it spreads very skinny and calls for 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 in reality clogged, you’ll take away the cap and rinse with water. If the orifice is plugged, you’ll open it with a pin. You’ll additionally ask for added dishing out caps from Oral Science.
ADVANTAGE ARREST
Must I practice FluoriMax after making use of Merit Arrest?
There are two techniques to use Merit Arrest. You’ll practice and make allowance to air dry for 60 sec. Or you’ll practice and straight away position a layer of FluoriMax over the AA to seal it in and make allowance for optimum penetration. The second one measure is easiest to make use of in scenarios of low affected person compliance. It is going to additionally make the aftertaste much less steel.
It’s unknown whether it is awesome to use FluoriMax over Merit Arrest however it will strengthen arrest charge.
Is Merit Arrest protected for comfortable tissues (subg and sophistication V packages)?
Merit Arrest has a pH of 10 this means that it’s not caustic to sound comfortable tissues. It is going to dry and blanche tissue briefly, however this isn’t destructive or painful.
Merit Arrest will purpose inflammation in wounded tissue. It isn’t destructive however will also be delicate. Software of Merit Arrest isn’t beneficial in a case of ulcerative gingivitis if the appliance would contact comfortable tissue.
What about hanging Merit Arrest in deep lesions?
Merit Arrest will penetrate 2-2.5mm into teeth construction – penetration varies in each and every teeth and lesion.
Merit Arrest will also be carried out in all carious lesions as much as and together with oblique pulp capping. Direct pulp cap is contraindicated. If there is not any proof of pulpal involvement or publicity (comparable to drainage or fistulas), Merit Arrest will also be carried out. When it’s positioned close to pulp, it is going to inspire pulp to shrink. Silver can move into the pulp in oblique pulp cap, however this isn’t adverse to the pulp or teeth.
What occurs once I use Merit Arrest then straight away position a tumbler ionomer restorative cement?
For those who practice Merit Arrest and wish to do a direct GI placement:
Observe it as customary, then rinse and dry (don’t dessicate). You’ll position the GI however some silver will probably be drawn into the GI, so staining of the GI will happen. That is handiest an esthetic worry. It does no longer lower the bond energy. For max bond energy, a polyacrylic acid could also be carried out both prior to or after the Merit Arrest (then rinse and dry, don’t dessicate) for optimum bond energy. If the usage of polyacrylic acid step, you could realize a slight foam on software of the acid and that is customary.
Tips on how to keep away from GI staining with direct placement of GI (no teeth construction polish or elimination)?
To keep away from staining, this can be a two-appointment procedure. On first day, practice Merit Arrest as customary. After 24-72 hours (longer is best), position the GI restorative as standard. This method is named the two day SMART (Silver Changed Atraumatic Resin Method).
Tips on how to keep away from staining with gentle treatment merchandise?
Please notice: Mild curing will “turn on” stain of all Merit Arrest, if it is on sound or decayed teeth construction. Useful ways to keep away from staining are:
After placement of Merit Arrest, do a 2-3 2d gentle treatment to look at if Merit Arrest has stained an esthetic house, then polish that away. Then you’ll continue with recovery. A couple of further issues to imagine:
- An opaque GI or resin base can be utilized on the base of the recovery to masks gray teeth construction. Translucent composite may display extra gray thru it.
- In bonding techniques known as “Self etch” the place the etch, high and bond are in a single bottle, the bond is weaker than in non self etch techniques. There may be nonetheless bond energy however you would possibly not wish to use this in prime compression spaces, and many others.
How ceaselessly will have to Merit Arrest be carried out?
Believe your affected person conduct and assess the hardness of the lesion.
Sufferers with deficient oral hygiene and prime consumption of cariogenic meals might want indefinite reapplication of Merit Arrest each and every 3-6 months.
Sufferers with just right oral hygiene and occasional to reasonable consumption of cariogenic meals will have to have no less than two packages. Then re-examine the lesion and imagine making use of each and every 6 months or yearly to care for arrest.
How a lot of the lesion is arrested with the appliance?
The primary software can arrest 70-75% of the lesion. The second one software can arrest 90-95% of the lesion. (2016 find out about)
Do you wish to have to rinse or no longer rinse after Merit Arrest placement?
Both is okay. If no rinse, you could wish to blot web page after placement to take in extra SDF (to attenuate style)
“I heard RivaStar doesn’t stain. Why will have to I exploit Merit Arrest?”
Info about RivaStar vs Merit Arrest:
RivaStar has a pH of 13 – it’s caustic to comfortable tissues and will have to no longer contact comfortable tissue. AA has a pH of 10, which isn’t caustic. It’ll briefly dry and blanche tissue however it’s not destructive to the tissue.
RivaStar value in keeping with software is 2-Thrice that of Merit Arrest.
RivaStar is advertised for use underneath GI magnificence I restorations. On this software, it is going to no longer stain as a result of it’s necessarily sealed in and the product was once simply positioned at the flooring of the recovery. Then again, if SDF and KI are used on my own, or the margins of the recovery include SDF and KI, the KI will scale back and decelerate the staining, nevertheless it does no longer inhibit the staining. The staining will most likely display up inside of a month.
Finally, when SDF stands on my own, this can be a very efficient caries inhibition agent. When SDF and KI are blended, there’s a virtually part lower in potency. Caries inhibition is considerably much less within the presence of SDF and KI blended. (3)
My conclusion
FluoriMax supplies the similar coverage as a traditional varnish, however with a number of main benefits: Greater bioavailability, this means that decrease proportion of fluoride is needed. The applying is straightforward, product is skinny and delightful, and sufferers can consume and drink straight away. Sufferers that experience up to now stated “no” to varnish love FluoriMax.
Merit Arrest is a minimally invasive intervention this is extensively utilized in pediatric and geriatric care. Whilst you will need to inform sufferers and caregivers concerning the lesion converting colour, I to find affected person acceptance is prime. Many caregivers of prone sufferers and folks with monetary obstacles are relieved when they’re given an reasonably priced, non-invasive choice that can arrest decay.
For dental hygienists which can be hanging GIs, maximum restorations with SDF plus KI will inevitably flip darkish, no less than across the edges. The use of SDF with KI on my own will flip darkish through the years, and the caries arrest homes are considerably lowered within the presence of KI. And finally, any lesions which can be subg or on the gingival margin can’t be sufficiently remoted for comfortable tissue coverage. You could wish to fee extra for SDF and KI to get better product value.
References
1. Seppä L, Results of sodium fluoride concentrations on tooth remineralization in vitro. Scand J Dent Res 1988;96:304-309.
2. Beltrán-Aguilar ED, Goldstein JW, Lockwood SA. Fluoride varnishes. A overview in their medical use, cariostatic mechanism, efficacy and protection. 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 Enamel Discolouration in Cervical Glass Ionomer Cement Recovery. Int J Mol Sci. 2017 Feb 6;18(2):340. doi: 10.3390/ijms18020340. PMID: 28178188; PMCID: PMC5343875.
