Recently, our team member, Martha Szczepulski (also RDH), engaged in an insightful conversation with Steve Pardue, the Managing Member at Elevate Oral Care. This company is renowned for developing groundbreaking products such as FluoriMax (2.5% Sodium Fluoride Varnish) and Advantage Arrest (Silver Diamine Fluoride). Their discussion revolved around the practical applications and benefits of these innovative caries management treatments, which are designed for in-office use.

The following is a comprehensive summary of their discussion. We trust this information will assist you in effectively incorporating these powerful treatments into your dental practice and enhancing your patients’ oral health.

FLUORIMAX

Understanding the 2.5% Sodium Fluoride Concentration in FluoriMax

Research dating back to the 1990s indicates that the fluoride uptake, or bioavailability, is remarkably similar in both 2.5% and 5% formulations when applied in a colophony base. Therefore, it is advantageous to utilize the lowest effective concentration that yields optimal results. This approach not only maintains efficacy but also minimizes potential side effects associated with higher fluoride concentrations. (1)

The Hydroxyapatite Content in FluoriMax

FluoriMax contains 3% hydroxyapatite, which serves as a vital source of calcium and phosphate. However, at this concentration, there is minimal benefit for a typical patient. The real therapeutic advantage comes primarily from the sodium fluoride component, which is instrumental in enhancing remineralization and preventing caries.

Duration of FluoriMax Retention in the Oral Cavity

FluoriMax remains effective until physically removed from the oral cavity. Approximately 90% of fluoride uptake occurs within the initial four hours after application, with an additional 10% uptake over the next 24 hours. This safety profile is attributed to the minimal quantities used; one drop equals approximately 0.1 mL, so a typical three-drop dose is around 0.3 mL. A pivotal study conducted by Dr. Beltran, published in the JADA in 2000, revealed that fluoride plasma levels following FluoriMax application were lower than those observed after using standard toothpaste. (2)

Exploring Dewaxed Food Grade Shellac

Shellac is a natural substance derived from the resinous secretion of trees, produced by a specific group of insects known as Kerria lacca. This secretion, referred to as lac, undergoes refinement to create food-grade shellac along with various other shellac products. You may recognize shellac as the glossy coating found on products like Advil or Chicklets.

Optimal Application Areas for FluoriMax

It is recommended to apply FluoriMax to the buccal surfaces in a thin, even layer, as this creates a beneficial reservoir effect. A thin application enhances bioavailability and comfort, while a thick layer may be less effective and risk sloughing off. FluoriMax can be applied directly on or near carious lesions, allowing fluoride ions to be effectively delivered into the lesion through saliva.

For optimal fluoride absorption, particularly in patients with xerostomia, it is crucial to focus on teeth adjacent to the submandibular glands (buccal and lingual sextant 5). This area produces a more fluid saliva, facilitating better fluoride ion transfer. While application near the parotid glands is also beneficial, the saliva produced there tends to be thicker and may not transport fluoride ions as effectively. In cases of severe xerostomia, encouraging patients to sip water over the hour post-application can significantly enhance fluoride uptake.

Differences in Particle Size of FluoriMax Fluoride

Indeed, there is a significant difference in the particle size of FluoriMax fluoride compared to conventional fluoride products. Typically, conventional fluoride particles measure around 150 microns, unless specially processed. In contrast, FluoriMax utilizes micronized particles that are milled and sifted to sizes of 15 microns or smaller. This reduction in particle size enhances bioavailability due to increased surface area, allowing for greater absorption. Additionally, smaller particles remain in suspension for extended periods, although it is always advisable to shake the bottle prior to application to ensure an even distribution of particles.

Potential Adverse Reactions to FluoriMax Ingredients

To the best of our knowledge, there are no known adverse reactions to the ingredients in FluoriMax. Some individuals have reported potential sensitivities to shellac; however, scientific literature does not support these claims.

High-Intensity Treatment Protocols with FluoriMax

High-intensity treatments typically involve administering three applications within a span of 5 to 7 days. This protocol has been successfully implemented in outreach programs in various countries to maximize mineralization during short-term exposure when follow-up care is not feasible.

Best Practices for FluoriMax Application and Bottle Maintenance

To ensure optimal product performance, always shake the FluoriMax bottle for 10-15 seconds. Insufficient shaking may result in a suboptimal suspension and consistency. The fluidity of FluoriMax, compared to traditional colophony varnish, is advantageous as it enables a thinner application and minimizes product usage.

Always dispense the product with the bottle held vertically. If the applicator tip becomes sticky, clean off the excess with alcohol. Should the dispenser become clogged, you can remove the cap and rinse it with water. If the orifice is obstructed, it can be unblocked with a pin. Additional dispensing caps can be requested from Oral Science for convenience.

ADVANTAGE ARREST

Strategies for Applying FluoriMax After Advantage Arrest

There are two effective methods for applying Advantage Arrest. You can either apply it and allow it to air dry for 60 seconds, or you can apply it and immediately cover it with a layer of FluoriMax to seal it in, which promotes maximum penetration. The latter method is particularly beneficial in cases of low patient compliance, and it can also help mitigate the metallic aftertaste.

While it remains uncertain whether applying FluoriMax over Advantage Arrest offers superior results, it may enhance the overall arrest rate of carious lesions.

Safety of Advantage Arrest for Soft Tissues

Advantage Arrest has a pH of 10, indicating that it is non-caustic to healthy soft tissues. While it may cause temporary drying and blanching, this effect is not harmful or painful. However, it is important to note that Advantage Arrest may irritate wounded tissues. Therefore, its application is not advisable in cases of ulcerative gingivitis where contact with soft tissue is expected.

Application of Advantage Arrest in Deep Lesions

Advantage Arrest is capable of penetrating 2-2.5 mm into the tooth structure, although penetration depth may vary depending on the specific tooth and lesion characteristics. This product can be applied to all carious lesions, including those requiring indirect pulp capping. However, direct pulp capping is contraindicated. If there is no evidence of pulpal involvement, such as drainage or fistulas, Advantage Arrest can be safely utilized. When applied near the pulp, it can encourage the pulp to shrink. The presence of silver in indirect pulp capping does not adversely affect the pulp or tooth structure.

Immediate Use of Glass Ionomer Restorative Cement After Advantage Arrest

If you plan to place a glass ionomer (GI) restorative immediately following the application of Advantage Arrest, proceed as follows:

Apply Advantage Arrest as directed, then rinse and dry the area without desiccating it. You can then place the GI restorative, but be aware that some silver will migrate into the GI, potentially causing staining. This is primarily an esthetic concern and does not compromise bond strength. For enhanced bond strength, consider applying polyacrylic acid either before or after Advantage Arrest, and remember to rinse and dry the area before finalizing the restoration. If polyacrylic acid is used, it is normal to observe slight foaming during application.

Minimizing Staining with Direct GI Placement

To effectively avoid staining, implement a two-appointment process. On the first day, apply Advantage Arrest as recommended. After a period of 24-72 hours (the longer, the better), proceed with the placement of the GI restorative as usual. This approach is known as the 2-day SMART (Silver Modified Atraumatic Resin Technique).

Avoiding Staining with Light Cure Products

It is important to note that light curing can activate staining from any Advantage Arrest present on both sound and decayed tooth structure. To mitigate staining risks, consider the following techniques:

After applying Advantage Arrest, perform a brief 2-3 second light cure to check if any staining has occurred in visible areas, and polish it away if necessary. Once this is addressed, you can continue with the restoration process. Additionally, consider these tips:

• Using an opaque GI or resin base at the restoration’s base can help mask any grey tooth structure, as translucent composites may reveal more grey.
• In bonding systems categorized as “Self etch,” where etching, priming, and bonding are done in one step, the bond strength may be weaker than in non-self-etch systems. Although there is still bond strength, caution is advised when using these in areas subject to high compression.

Recommended Frequency of Advantage Arrest Applications

The frequency of Advantage Arrest applications should be determined based on the patient’s habits and the hardness of the lesion. Patients exhibiting poor oral hygiene and high consumption of cariogenic foods may require ongoing reapplications every 3-6 months.

Conversely, patients maintaining good oral hygiene with low to moderate consumption of cariogenic foods may benefit from at least two initial applications, followed by reassessment of the lesion, and potential applications every 6 months or annually to sustain caries arrest.

Effectiveness of Advantage Arrest in Arresting Lesions

Research indicates that the first application of Advantage Arrest can effectively arrest 70-75% of the lesion. Subsequent applications can increase this effectiveness to 90-95% of the lesion being arrested, demonstrating the substantial impact of repeated treatments. (2016 study)

To Rinse or Not to Rinse After Advantage Arrest Placement?

Both options are acceptable. If you choose not to rinse, consider blotting the site post-application to absorb any excess SDF, which can help minimize any unpleasant taste.

RivaStar vs. Advantage Arrest: Key Differences

Here are some essential facts that highlight the differences between RivaStar and Advantage Arrest:

RivaStar has a pH of 13, which is caustic to soft tissues and should not come into contact with them. In contrast, Advantage Arrest has a pH of 10, making it non-caustic and safe for soft tissue, although it may cause temporary drying and blanching without harm.

Furthermore, RivaStar’s cost per application is typically 2-3 times higher than that of Advantage Arrest. RivaStar is primarily marketed for use beneath GI class I restorations, which minimizes staining risks as it is sealed within the restoration. However, if used alone or at the margins of restorations, the staining may still occur, potentially becoming noticeable within a month.

Finally, while SDF is an effective caries inhibition agent on its own, combining it with KI can significantly reduce its efficacy, demonstrating the importance of understanding the interactions between these products in clinical settings. (3)

Key Takeaways for Dental Professionals

FluoriMax offers the same protective benefits as traditional varnish but with several significant advantages: enhanced bioavailability, which allows for a lower fluoride concentration to achieve effective results. The application process is straightforward, the product is thin and pleasant, and patients can resume eating and drinking immediately after treatment. Many patients who have previously declined varnish applications have embraced FluoriMax due to its user-friendly nature.

Advantage Arrest represents a minimally invasive intervention widely utilized in both pediatric and geriatric care. It is crucial to communicate to patients and caregivers that the color of lesions may change, but acceptance is generally high. Caregivers of vulnerable patients and those facing financial challenges often appreciate having an affordable, non-invasive solution to help arrest caries progression.

For dental hygienists working with GIs, it’s important to note that most restorations using SDF combined with KI are likely to darken over time, particularly around the edges. Additionally, SDF and KI used alone will darken over time, and the caries arresting properties are significantly diminished in the presence of KI. It is also essential to consider that lesions located subgingivally or at the gingival margin are challenging to isolate for soft tissue protection effectively. Finally, be mindful that charges for SDF and KI applications may need to be adjusted to cover product costs.

References for Further Reading

1. Seppä L, Effects 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 review of their clinical use, cariostatic mechanism, efficacy and safety. J Am Dent Assoc. 2000 May;131(5):589-96. doi: 10.14219/jada.archive.2000.0232. PMID: 10832252.

3. Zhao IS, Mei ML, Burrow MF, Lo EC, Chu CH. Effect of Silver Diamine Fluoride and Potassium Iodide Treatment 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.