Yes, I believe that is the case. As long as it is the Endo power setting it’s fine. They can use the polysonic tips as well with the E70 tip - I believe the PEEK tips are the E71, 72, 73, 74 

• Aseptico Units: Unfortunately, Aseptico units are not compatible due to lack of Health Canada approval here in Canada. While they do offer a lower model of compressor that is Health Canada approved, it would require purchasing a separate air compressor from a hardware store to meet the necessary air source requirements. I spoke directly with an Aseptico representative, and they advised that this setup isn’t ideal, so I wouldn’t recommend it; and it is a gray zone due to the air quality from the hardware store air compressor.
• Safari Dental Expedition XP (link) with modification in air pressure to accommodate the Woodpecker PT-B with an additional adaptor piece to minimize the number of cords in replacement of the rheostat. You will still carry the rheostat for backup in case there are any issues with the adaptor. This is for mobile units only; there are larger and less mobile compressors that will also work for the PT-B.

Xerostomia is the result of either 1.decrease from radiation induced decrease saliva from the major salivary glands as the parotid or 2. Decrease from drug induced of the minor salivary glands.Studies show that laser is effective for 1. But not 2.Our smart laser has a setting and tips for this purpose.

Frequency of visits may be impractical but recommended 3x  per week during the radiation period. 

 2-3mm

 YES, but not with LA or topical; use a device to secure the tongue like this one  

Pediatric laser safety googles such as these should be used  

The laser wavelengths are non-ionizing radiation and not cannot penetrate through walls. However, everyone within 10 feet of the laser being used must wear the safety goggles supplied. So in an open bay operatory if dental chairs are next to each other as in orthodontics,pediatric  the glasses must be worn within 10 feet. We suggest that in the situations that there be an isolated chair or operatory just for laser use.

 To test the light, you need to plug in the base, and you can test it on the base where the little circle is on top.  You can also test other lights on there as long as they are 10mm in size. 

The battery for the O-Star Pro is better than the Valo by Clinical Research: they use two batteries (400 Mah) and we use one battery (2000 Mah).

With O-Star you can do 1000 cycles of 10 second curing with one charge.   Valo can only do about 250-300 cycles which means they replace the batteries 4 times compared to a full charge of O-Star Pro. 

Normally O-Star is only required to be charged 1x/week 

 The lifespan of O-Star Battery is around 5-10 years, or 500 full charge cycles of the battery

The head of O-Star is 360 degree swivel 

After the 5-10 years if the battery dies, they could buy a new one from us and replace it.  

  It is good to charge the O-Star when it is around 20% battery life 

It is OK to keep it on the charger, but not necessary - think about how you charge your iPhone.  For all lithium batteries it is best to keep them between 20-80%.  

It takes around 2 hours to fully charge

 O-Star has 29 LED chips internally instead of 4 (3 violet and one blue) for Valo, having 29 chips gives a more homogenous light output. 

For any clients who express concerns with the safety of the use of the unit, I would remind them that this technology has been around for several decades and many countries do not require the scatter shield. It is an extra measure in place from the FDA and both of our units are fully approved. Studies show and prove that the radiation exposure while holding the unit is comparable or less than that of the wall mounted. If there is still concern, our unit comes equipped with a wired button they can use from a more comfortable distance.    Your experience may also be a bit different as I am not sure how prevalent handhelds Xray units are in Canada. In the States, probably 7-8 out of every 10 offices I call have them. If there is more we can do to increase the comfort of your clients, lets make it happen.

The AiRay will work any sensor, PSP, or even film so the client can most definitely use it with their Schick sensors

ClearDent called me and confirmed it should work without issue. It may require that we contact Cleardent after the Twain driver is installed, but we can verify post installation. It is vital the client knows, however, that the sensor will not be a DIRECT integration, rather a Twain integration. 

Yes, there is a wired remote included with the unit  

 The scatter shield is made out of composite and lead inside 

The unit is slightly heavier than some competitor due to the extra lead protection inside.  When Woodpecker opened and inspected competitors units, there was less protection. 

Ai-Ray has been on the market for almost 4 years 

It’s exactly the same, just a question of regulation, Ai Ray Lite is for us, USA, maybe other countries, in China, they promote the Mini Ray. Ai Ray (no lite) is something else. 

these units are completely safe to use as they are extremely low radiation. The scatter shield prevents any back scatter radiation and when the handheld is used properly, little to no radiation would go beyond the patient. 

  So for Dexis, yes, they will need that third party twain licensing. This licensing can be acquired through Dexis or through another major distributor (Like Schien). This is required to use the I- Sensor within Dexis. 

They will essentially work the same way, images are stored in Dexis just like normal. It will add a few seconds to each exposure, but nothing majorly noticeable (unless they are on antique computers). 

For the license, the cost can vary but it is a one time fee.

The name Hybenx is a contraction of:  Hydroxy Benzene Sulphonic Acid

Hybenx is a chemical desiccant that safely removes microbes and tissue debris from the treatment areas without harming healthy tissue and has no systemic effects. It’s action is based on EPIEN’s novel HYBENX® Desiccation Shock Technology (“DST”). Hybenx is a topical therapeutic liquid/gel that can have a variety of uses, but our key focus is to use as an adjunct to SRP.

I would refer the clients to the Isola study. I would suggest having a printed copy you can show and give them the link. The Isola RCT shows charts of how long it took for repopulation in comparison to SRP alone and as well as a bunch of other parameters measured. I have attached Isola to this email. The substantivity to keep red complex bacteria at bay is somewhere between 6-12 months.

Per Chrissy, she thinks that Hybenx would fit in towards the end of the GBT wheel. After piezon/scaling as the final cleanse. I think it could also be applied before piezon suprag for tenacious calculus. We think it would be best not to use it before airflow/perioflow, in case it may somehow predispose an area to subcutaneous emphysema. This is just our opinion at this point, we DO NOT have evidence that it will predispose to emphysema, it is just a precautionary thought at this point. Considering how effective Airflow is, using Hybenx one time at the end to cleanse the pocket makes sense.

We recommend that it be applied to a few teeth at a time (maybe a sextant) as you want to be able to efficiently rinse off the Hybenx after 10-30 seconds and you want the area to stay isolated as the product has a strong sour taste. That being said, Epien says that the full mouth can be done in one appt. But I would not apply to the entire arch at once.

I would generally suggest a quad approach, especially in cases with lots of bleeding to maximize the hemostatic effect. This also allows to monitor for any possible sensitivity and manage it quad by quad. Also, if you need Hybenx everywhere, chances are you need time for SRP and you may not finish the mouth in one appt. So quad by quad (or sextant) and definitive debridement to maximize healing.

1. The medicament should only be left in the surgical area for no longer than 30 seconds.
2. The medicament must be flushed out thoroughly, and we recommend using an ultrasonic.

Cautiously yes. Try to minimize the double application to the surrounding tissue. And as long as no longer then a 30 second application each time. We don’t want to over desiccate the healthy tissue.

• Piezon Led Handpiece -> FS-455: compatible with the Airflow Prophylaxis Master, Airflow Master Piezon (previous generation), P250/P150 (simple stand alone scalers).
• Airflow Max Handpiece -> FS-477 /US: compatible with the Airflow Prophylaxis Master, Airflow Master Piezon, Airflow Master, Airflow S2, Airflow S1 (old devices).
• Perioflow handpiece -> FS-474: compatible with Airflow Prophylaxis Master, Airflow Master Piezon, Airflow Master.

The above-mentioned handpieces are not compatible with handies.

We will need a credit card for all purchases of Airflow stations (Prophylaxis Station & Station +) and Table Tops (Airflow Master & Airflow One). For large purchases, customers will have the option of paying in installments with their credit card and / or using a financing plan from an outside company, however this will be on a case by case basis and should be discussed with Sacha and / or Daniel. Invoices can be sent “due on receipt” (if required) for all other EMS related products.

No deposit required, yes we will place the order in Netsuite and ship it out when received in stock.

Only sold in packs of 4 bottles, no possibility of dismantling and selling individually.

Brian will place an order for Aqua FX (cleaning solution) from Maxill (located in Ontario) and Renaud will add it to the order form.

There is a one year warranty on the machine and parts. When customers register their device on the EMS app, they get an additional one year warranty. (This only applies to the machines themselves, not the handpieces purchased on their own as are considered as consumables).

No, the customer should contact the distributor from whom he purchased the machine for all maintenance and repair.

Orders are shipped from Switzerland by sea and take approximately 7-8 weeks to arrive (1-2 weeks to prepare by EMS and approximately 5 weeks to ship by sea), once order is placed. In the rare event that we are out of stock and an airflow machine is urgently needed, there is a possibility to ship by air, but since this is about 3 times the cost of shipping by sea, it will be on a case-by-case basis and to be discussed with Brian.

Yes, all reps will have their own demo unit and receive it (shipped directly to their homes) in mid-February.

As a clinician you don’t want to do GBT with a handy: - these are heavy devices - they consume way too much powder - they are less efficient. In theory you can do it but you will waste your health and money.

No not at all : the powder does not stay in the mouth: it is either ingested by the patient or aspired by the suction.

(again: the powder removes biofilm mechanically, not chemically)

Go to the Options Menu and choose the Sound Tab. Then select the Sound playback language option you would like to hear. There are 35 choices total with 16 different languages. For French you could choose Male or Female or 2 additional French Canadian accents.

There are other translation options for the printouts, or even the Patient educational movies. Note there are also translation options for the on screen user, but these are rarely made quickly for a patient's needs. Most of these changes are done on setup and will be reviewed in training or advanced training. Offices that have a known foreign speaking patient base can be taught to switch from their main language to a foreign option in under 10 seconds with just a few minutes of simple practice.

Yes our installation team requests every office to sign and provide a HIPAA BAA. Before we install software to a new office, we request they provide a HIPAA or BAA agreement that they have created. If their office does not have a HIPAA agreement made, we can offer one to help protect their patient data for any work our Florida Probe installation, training or technical support team does in the future for their office. Note also that most offices are using a link from another software, so we can force any password requirements to only let Florida Probe open from a link and thus their same password used for their Practice Management software will work to open Florida Probe software. Offices should be using a screen saver or way to block patients from using or seeing computers in the office when not in use by the dental staff.

This answer depends on many variables. If you are talking to a small office with only 1 hygienist who always has a dental assist available, then the main selling point is that this person could be doing much more useful tasks in the office beyond a perio chart. Even when they are accurate and easy to locate they never annonce "Warning" or "Danger" indicators as the software can do to help increase treatment acceptance. For larger offices there is rarely an assistant for multiple hygienists at the same time, so when charting is needed in multiple rooms they either have to stagger them or wait and delay their perio charting. The busier offices get the more likely it is that hygienists never have the assistant when they were promised. Dental assistant work in the office is very valuable and we don't think of VoiceWorks as putting them out of a job, rather we value their time so much we think they can be using their time more wisely. They can only be in 1 place at a time and we know the #1 place they will be is working at the side of the dentist vs. the hygenist. If an office has 5 hygienists probing at the same time, will the office want to hire additional staff, or will perio charting not get done, or put off to a future appointment? Just pick up the headset and start charting, never needing to call and wait for the assistant again.

Desensitizing agents have been shown to be protective of the pulp when placed on crown preparations to reduce dentin permeability. Advantage Arrest, a desensitizer, has been shown safe to the pulp when placed on exposed dentin. In addition, studies have shown desensitization and efficacy in treating softened dentin before placing direct restorations. Usually the tooth is first treated with Advantage Arrest 38%. This provides the benefit of sealing tubules plus the antimicrobial benefits of both silver and fluoride. 

Treating carious areas with Advantage Arrest 38% acts as a whole mouth fluoride treatment. It can also be used in place of sealants in grooves. A protective effect has been shown to non-treated teeth and surfaces. These findings come from high quality randomized clinical trials. 

Yes.

Although there are no head to head clinical trials comparing Advantage Arrest as a cavity liner, it has been used successfully in this way.

Advantage Arrest will not discolor intact enamel or dentin. Advantage Arrest can discolor demineralized tooth structure brown/black. Some of this discoloration may shadow a restoration and can create less than optimal esthetic restorations.

Yes, it will improve aesthetics.

No excavation, decay removal or anesthesia is required. The area to be treated should be “dry tooth brush” clean, free of plaque and debris. The area should be free of saliva, so as not to dilute the material. Transfer the material from a disposable plastic dappen dish to the surface to be treated and allow time to dry, which generally occurs in 30-60 seconds. If accelerated drying is required due to patient compliance use a low/weak air stream to dry the material. 

The chemical action of the Advantage Arrest occurs almost immediately in the outer layers of the softened dentin and can be confirmed by changes in the hardness and density of the dentin surface, similar to caries that arrests naturally because of positive changes in oral hygiene, diet, or daily application of fluoride in custom trays. The darkening of the lesion occurs over 24 hours and may increase over a week. Reexamination of the lesion at the next regular recall is appropriate and reapplication of Advantage Arrest may be warranted. Repeat until the lesion has arrested. 

Caries arrest studies were conducted with Advantage Arrest applications of once and twice annually. Arrested lesions were retreated every six-months. 

Clinicians have reported that they will recall their first cohort of Advantage Arrest patients within 3-6 weeks to evaluate the application and action of the treatment. Once they have a feel for the predictability of the material with their application technique they will set recall appointments based on the risk level and caries activity of the patient with higher risk patients at 3-month intervals. Moderate to high-risk patients, where it appears that home care and diet counselling has had positive impact, are recalled at 6-months. 

This depends on the lesion.  Larger will take longer; and it could be 2-6 months. If it’s deep enough, it could also reach the pulp in that time and fail. The deeper the lesion the higher the risk of failure.

No shaking, and separation only occurs from light or evaporation (or contamination from an unknown ingredient).

Advantage Arrest will arrest secondary decay around restorations including crowns.  It wil not increase the strength of the crown cement or adhesion, but will stop the disease process and harden decayed enamel and dentin.  If the decay has compromised the strength of the restoration prior to Advantage Arrest application, replacement of the restoration should be considered. 

Yes. The arrested dentin is harder than healthy dentin.

We will be looking for changes in shape and size of the translucency.  Additionally, secondary dentin formation can and does occur through time.  Also, the 97% efficacy rate that is being quoted here is regarding Advantage Arrest as a stand alone treatment (without the use of a restoration).  When you seal Advantage Arrest in with a restoration those numbers will change.  Although, we don’t have data if it will increase or decrease.  We must also consider this question in reverse.  What is the long term success rate of a restoration?  GI vs Composite? Sandwich vs single layer?  97% is pretty damn good when you start comparing Advantage Arrest arrest rates to restoration retention rates.

On healthy tooth surfaces you will get an effect for about 6+ months depending on the patient. 

It will create silver phosphate, and silver chlorides and various other particulates on the surface as well as some in the dentinal tubules.  Here’s an image of what it looks like.

Every 6 months.

Advantage Arrest treated sites will arrest and partially remineralize (although not enough to show up radiographically).  This site will now be impregnated with silver minerals and fluoride.  The silver, although chemically bound to the tooth, is not part of the natural tooth structure and will gradually release into the mouth.  This takes years to happen (2 or 3), but if enough leaches out of the tooth, it could soften back up.  This leaching effect is why one Advantage Arrest treated site in a mouth will help protect all the other teeth.

If the patient improves their care and lowers their caries risk, it’s possible that as silver leaches out, the lesion will remineralize naturally and stay arrested.  This is dependent upon the patient and their home care.  Reapplying Advantage Arrest in either case will ensure it stays arrested.

If you cover over an Advantage Arrest treated surface, it will hold the Advantage Arrest in place and not need re applied.

When you are a new user, when first arresting very deep lesions, and/or are not applying a restoration on top.

We recommend high caries risk patients have up to 5 sites treated per visit, with reapplications at intervals greater than 1 week apart. 

Yes, Advantage Arrest is antimicrobial and even one site treated in the mouth will help reduce the caries risk for the remainder of the teeth.

Advantage Arrest is prone to evaporation and light sensitivity.  As the ammonia evaporates, silver will crash out of the system leaving black flecks at the bottom.  Typically this happens slow over the course of many hours so it's possible to dispense early and use later in the day.  Light however, will be the major issue.  Strong lights can cause it to crash in just a few minutes to hours.  So, as long as they keep it dark, it may work.  Have them experiment and see how it goes.  If they start to see black build-up, it's going bad, if not, it's still good.  Also, a significant amount of black needs to build up before it's out of specification.

These applicators will not absorb the product as it applies, and there is no risk of leaving flock portions of the applicator on the site.

Also, ideal when you are first arresting very deep lesions and/or are not applying a restoration on top.

It may not penetrate as deeply in a non dried lesion.  Many times it may require a 2nd treatment in 1 week

Arrested lesions look like a scar on radiographs. You will observe radio-opacity as the mineralization of the previously softened dentin increases. Ultimately the best test of arrest is still the color change and tactile hardness of the dentin surface. 

It is advised that you educate your referring dentist about your use of Advantage Arrest since the appearance of a treated lesion might be new and confusing for many practitioners. 

Yes it can. It may not penetrate as deeply in a non dried lesion.  Many times it may require a secondary treatment in 1-2 week.

Yes, I would be lost without my Diagnodent, especially since we started our extensive Advantage Arrest program.  I feel it gives us a very good depiction of the relative The actual effect on reducing the bacteria in a lesion with resulting much lower readings from our Diagnodent gives me, the clinician, a reference point on what is happening in the lesion. ...2. if we find a tooth or area of teeth that is NOT getting decreased numbers on follow-up evaluations, it leads us to raising our level of Oral Health Education (OHE) with that particular patient and possibly shortening the interval between applications to 3 or 4 months instead of 6. I have attached an info sheet we give to many of our patients to help with the OHE, it really seems to have a profound effect on how they perceive their problem with chronic tooth decay and better helps them understand what they need to do to help solve the problem. Jo Frencken new book on Minimal intervention dentistry feels the D2 is better than other forms of electrical evaluation devices, but did not give it a high rating.  I, on the other hand, would not practice with our mine, we have 2 in our office.

Advantage Arrest does affect Diagnodent readings.  It will lower them but I’m not sure how long it takes for that reading to change.  Diagnodent doesn’t actually look at the tooth.  It looks for porphyrins produced by bacteria during their metabolic process.  Since Advantage Arrest kills the bugs, the porphyrins get reduced

Advantage Arrest can be applied near the gingival with little concern.  If accidental contact occurs it is not harmful or caustic.  The contact will result in a temporary staining of the soft tissue that will fade to nothing in a few days.  If liquid Advantage Arrest is in contact with the soft tissue for extended periods, some blanching may occur, but it is not harmful.  Do not apply near the gingival if there are open wounds, stomatitis, or ulcerative gingivitis as Advantage Arrest will be an irritant.

Advantage Arrest can be applied at the margins of restorations to arrest or prevent secondary decay.  Some surface staining may occur on the restoration, but it can pumiced off.

Advantage Arrest can be used on non vital teeth with the same effect it will have on vital teeth.  In the mouth, the color change will happen gradually over the course of about 3-5 hours with full darkening within about 24 hours.  Some teeth darken slower or faster based on moisture, lesion and light exposure.  With extracted teeth you may find faster darkening based on the lighting conditions of where they are stored.

This is hard to pinpoint, but it could be any of those reasons.  We know that some lesions simply do not arrest with Advantage Arrest (perhaps 10% of the time??).  It could be due to the lesion arresting somewhat on its own already and there is no collagen exposed.  It could be due to not drying the lesion first, or not allowing it time to penetrate the lesion (60 second soak).  We simply don’t know.  Try two or three applications and if it doesn’t work then the site may need other treatment.

It’s ok to do either of these options.  Leave it, remove partial, remove all.  All will work fine.

It’s best to re-apply every 6 months to 1 year.  Even if it still appears hardened and arrested.  The long term success rates are almost perfect if you reapply.

It is an irritant, and will likely cause some damage.  The specific results are relatively unknown as it hasn’t been studied in depth.  For this reason I recommend only using Advantage Arrest as an indirect pulp cap and not on any exposures.  I’ve attached one study on this topic.  For indirect pulp caps, there will be secondary dentin formation due to the high pH of Advantage Arrest.

Yes.  Even if there’s only 0.1mm of dentin.  Ag and F will always reach the pulp in deep applications that that is ok.  It’s the ammonia you don’t want on the pulp (and ammonia evaporates upon contact with the tooth [boiling point of 91 degrees F]).  I’ve attached an article that clears this up.

We expect about 6 months, but again, this isn’t well studied. 

I don’t expect any negative side effects of using Advantage Arrest on these sites as long as the pulp is not exposed. It will reduce the oral bacterial load. It will likely not be a long term fix, but it should buy some time until the teeth can be extracted or treated. There aren’t many other options.

You can let them paint everywhere if they want.  That’s fine too but it uses more product, and takes more chair time.

There are IADR studies that show remineralization takes place under and near varnish applications.  You can find them by searching their abstracts for Pfarrer.

After Advantage Arrest application dry the surface as well as possible, then proceed with whatever the recommended process for restoration is that the restorative material requests.  

CAUTION: if there is a light cure step, be prepared for the material to blacken in the light cure step. 

Yes.  Very much compatible to the point it's recommended as part of the Silver Modified Atraumatic Restorative Technique (SMART).

Yes, it will improve esthetics, help to arrest remaining decay and lessen the blackening oxidation.

It can be applied very near the pulp, as long as there are no exposures.  If the Advantage Arrest leaches through infected or affected dentin to the pulp it is not a problem; only when there is exposure.  Placing Advantage Arrest over a GI will only help the margins from secondary decay, and will give you surface staining.  Under GI will provide a strong liner and protection from secondary decay.

Advantage Arrest is only corrosive in its liquid form.  Once applied and dried it is no longer corrosive.

No especially if exposure.

No.  The goal as clinicians is not to remove 100% of the decay, but to stop/prevent the disease.  Decayed surface that can be returned to function (even without restoration) is stopping the disease and restoring function.  You’re just using a chemistry instead of amputation.  Yes, leaving decay under a restoration, treated with Advantage Arrest prior to placement will leave some radiotranslucency under/around the restoration.  This must be noted in the chart and then watched for changes over time, rather than the presence or absence of translucency at any given point.  This is a change from previous thinking about restorations.

Advantage Arrest is ionic silver and ionic fluoride held in suspension by the ammonia.  It reacts with the teeth immediately upon application and tries to bind with anything that will allow it.  That’s why it works so fast.

Approximately 25 microns into enamel and 300 microns into dentin. This will seal off the surface of any lesions and cause the remainder of the lesion to arrest. In a 2002 study by Dr. Chu, 100% of lesions stained black to the outer edge of the lesion were arrested.

10.4

Fluoride varnish is sodium fluoride.  Advantage Arrest is free, ionic fluoride.  Once you factor out the weight of the sodium in fluoride varnish, the 5% works out to 22,600 ppm F rather than 50,000 ppm F that 5% denotes (fluoride makes up 45.45% of the weight of NaF).  In Advantage Arrest, 5% is free ionic fluoride, but it’s not adjusted for specific gravity.  When you do that mg/ml it works out to 44,800 ppm F.

On a healthy tooth, Advantage Arrest deposits free silver and free fluoride ions as it does anywhere.  The silver will form silver phosphate on any receptor sites on the surface of the tooth as well as some silver chlorides and silver oxides.  The oxides do not get trapped in the body of a lesion, or bind to proteins in the tooth (since they are all covered by hydroxyapatite) so they simply wash away.  Most Silver chlorides and other random mineral formations do as well and you’re left with silver phosphate bound on exposed phosphate in the hydroxyapatite outer layers (which gives you the protection).  The exposed calcium binds with fluoride to form calcium fluoride and florapatite. We know these minerals form, and there are others we are still discovering.  The short answer is that excess silver and silver oxides wash away.

Yes and no.  Advantage Arrest will denature all proteins in bacteria and fungus so it will kill both.  However, when you wipe out a biofilm, it leaves the chance to “regrow” after the kill whatever opportunistic organism gets there first.

9.5 mg would be correct, but you must also account for the specific gravity of about 1.25 or 1.26 of the product.  This brings the actual number to 7.6 mg Advantage Arrest per drop (if a drop is 0.025 ml).

Advantage Arrest does not cause secondary dentin to form.  It works by very different means when compared to other fluoride products.  Most fluoride will create fluorapatite and regrow portions of lost enamel rods and hydroxyapetite crystals.  The fluoride portion of Advantage Arrest does do this as well, but that is not the main function of how Advantage Arrest works.

The main hardening effect of Advantage Arrest comes from the silver.  Silver in its ionic form is wicked into the body of the lesion and binds to collagen and phosphate sites.  It forms silver chlorides, silver phosphates, silver oxides (the black one) and various other minerals that we don’t fully understand yet.  These minerals fill the voids where enamel rods, hydroxyapetite crystals and other tooth structure once was but was lost to the caries disease.  These “cavitations” within the lesions get filled with silver precipitates and harden.  This is why Advantage Arrest will even harden up the soft mushy dentin in lesions.  Think of it this way… if you think of the lesion having a similar structure to a sponge; fluoride will harden the sponge to make it a hard sponge but it will still have holes.  Advantage Arrest will fill in the holes in the sponge as well and harden the sponge too.

Another analogy is the galvanization process of steel.  Steel is coated with zinc to fill in the voids and reduce the likelihood of rust.

Silver, and most metals, are broad spectrum antimicrobials in that they kill a wide variety of bugs.  I think it would be effective against anything it touches.  Having said that, it’s likely limited to activity in the mouth.  It will be diluted so far if it passes into the gut that I would expect any notable activity. 

All of the research published never mentioned GI side effects which would be what is noticed first in any type of bacterial changes in the gut.

There is always oxygen present.  Perhaps not in quantities to sustain aerobic life, but to some capacity.  The tooth passes fluid through diffusion channels and tubules constantly, and oxygen can be preferentially bound to by numerous materials.

Also the restoration process itself can introduce oxygen, and sometimes energy in the form of light or other, that can cause or quicken the blackening. 

GI restorations are designed to be porous and allow some transfer.

There is always oxygen present.  Perhaps not in quantities to sustain aerobic life, but to some capacity.  The tooth passes fluid through diffusion channels and tubules constantly, and oxygen can be preferentially bound to by numerous materials.

Also the restoration process itself can introduce oxygen, and sometimes energy in the form of light or other, that can cause or quicken the blackening. 

GI restorations are designed to be porous and allow some transfer.

That's what its main use is for here; to prevent sedation or general anesthesia use in the very young patient group. It's the best reasonable option, with almost no toxicity risk; much less risk than you have with general anesthesia or sedation.

Scientific literature suggests 1-2 drops (same than for adults) per 10 kg body weight for children under 3 years old.

Reference: University of California in San Francisco Advantage Arrest Protocol

Silver diamine fluoride should not be placed on exposed pulps. Other topical fluorides (e.g. fluoride varnish) should not be used in the same appointment. Studies have shown that 38% Advantage Arrest conveys more effective protection against decay in other teeth than fluoride varnish with reduced overall fluoride exposure. 

It will have an effect on the whole mouth but not as much as if you would have applied it on all of the non-decayed occlusals.  If you’re using it with the intent to replace a sealant, I would apply it to all occlusal surfaces that you need that benefit.  The other teeth (incisal for example) will also receive a benefit.

There are no postoperative limitations. Patients may eat or drink immediately. Patients may brush their teeth with fluoridated toothpaste on their regular schedule. 

The Margin of Safety for the volume of product needed to treat six sites is within 130 times the NOAEL (no-observed-adverse-effect-level). Treating more sites in one visit will likely have little practical impact on patient safety. Like protocols for fluoride varnish application, the suspension for several days of fluoride supplements is advised.

There are no demonstrated or proven side effect on pregnant and/or breastfeeding women as per the latest studies on the matter. However, as clinicians, we still have to follow the risks vs benefits rule.

Some blackening (or a significant amount) due to exposed collagen and open dentinaltubules which will fill with silver.

Colloidal silver will provide much much higher amounts of silver than an application of Advantage Arrest.  If the patient is going to continue using colloidal silver, it would be a good idea to have them stop taking it for a few days after Advantage Arrest application just to be sure, but we don’t forsee any issues.

Advantage Arrest and fluoride varnishes that are applied once every six months or so are not notable factors when calculating fluorosis risk.  Fluoride varnishes caused fluoride blood plasma levels about the same as brushing your teeth with regular toothpaste, and Advantage Arrest has 1/10th the amount of Fluoride of a fluoride varnish application.  In short, it will be almost immeasurable. 

Daily use of F products and ingestion of fluoridated water will be the notable factors that determine fluorosis.  

The capillary action of the applicator brush supplied with Advantage Arrest reduces dripping from the brush when transferring the material from a disposable plastic dappen dish. Patients should be protected with bibs and safety glasses as in any clinical procedure. Contact to skin and oral tissue is not harmful but is likely to cause temporary tattooing. On skin and oral soft tissue the effect is not immediate, rather it will be noticed within hours. The staining will be limited to direct areas of contact and will fade over a period of 24-72 hours. If you believe you have touched the applicator to the skin of a patient it is good to advise them of possible tattooing. 

When dispensing Advantage Arrest it is a good idea to use an absorbent material that has a coated bottom, like a patient bib, under the dappen dish and applicator to avoid contact with metal trays and office countertops. If Advantage Arrest comes in contact with instruments or countertops wash immediately with water, soap, ammonia or iodine tincture and then rinse thoroughly with water. Sodium hypochlorite (household bleach) can also be used for difficult stains. 

Yes, darkening of decayed, demineralized sites occurs as the lesion arrests. This is similar to what is seen when caries arrests from changes in diet or increased use of other fluorides. A recent study showed that patients see the discoloration as a clear indication that the treatment is working. Similar to the treatment of eroded and hypersensitive dentin, the treated area can be restored using glass ionomer or with a sandwich restoration of both glass ionomer and composite. In lab studies, bond strength of composite by itself to treated surfaces is reduced but the clinical importance is unknown. 

38% Advantage Arrest should not be diluted in an attempt to reduce discoloration. Studies have shown that diluted solutions may not be effective for caries arrest. 

Ionic silver adsorbs onto almost any protein surface and is especially tenaciously bound to denatured proteins. This accounts for the specificity to carious collagen over normal collagen, but both will stain. The differentiator between these stains is that with Advantage Arrest use, intrinsic pigmentation of a carious lesion occurs and surface protein staining occurs primarily on healthy tissue. These oxides are bound to the tissue and don’t wash or polish away. This is why the blackened lesion retains its dark color for so long, and is most likely the reason the antimicrobial effect is long lasting. 

The functional indicator of effectiveness is when the silver oxide is bound to the diseased collagen. If the surface doesn’t turn black, the silver didn’t bind and the antimicrobial effect will only be short lived. 

Not if there is no active decalcification and collagen proteins exposed.

Ozone is a completely different animal.

The ozone machines try to control the environment around the tooth for a few seconds/minutes and generate ozone that gets pumped into the body of lesions.  This gas will kill bacteria in the lesion and on surrounding surfaces.  Ozone does nothing for the mineral of the tooth, or to add structural integrity to the site.  It is an effective killing tool against the bacteria.  This reduction in turn leads to natural mineralization over the next weeks/months, but it’s a slower process and then subject the patients oral habits.

Advantage Arrest uses silver as it’s antimicrobial agent that is also driven (capillary action) into the lesion.  It kills bacteria and then also binds to the proteins in the tooth.  It creates minerals that harden in the voids of the lesion and add structural integrity to the site very quickly (48-72 hrs).  It also contains Fluoride so you get fluorapatite formation too.

In short, they both “arrest” or stop the disease, but Advantage Arrest is the only one that adds structural integrity too.  


Allow to air dry, do not rinse” and don’t blast with air. Cotton pellet blotting is fine too. I doubt it will demineralize. 

They are designed to clean, but not abrade the surface.

Yes, it’s been thought about, but likely not possible.  Advantage Arrest is ionic in the liquid so it will bind with any new additives.  Blue dye is about all we could get into the liquid.

These are very different products.  Advantage Arrest can be used on resorption (to slow or stop the progress), but there is no data on this use, and I’ve heard conflicting results.  Some improved, some continued to worsen.

It puts silver in the tooth, which isn’t natural.

If nothing else can be done, it’s worth a try.

I would avoid any varnish prior to Advantage Arrest application.  Always Advantage Arrest first, then Varnish, otherwise the resin of the varnish may prevent Advantage Arrest from entering the tooth.

• Antibacterial agent 

• Fluoride

• Desensitizing

• Caries control

• It is shifting what you bill to a recurring treatment of arresting disease

• More conservative

• Patient satisfaction

• Minimize, and even avoid local and general anesthesia

• Cut down on chair time with a restoration to do other procedures

• Buy time until the treatment of choice can be done

We don’t expect any negative side effects of using Advantage Arrest on these sites as long as the pulp is not exposed. It will reduce the oral bacterial load. It will likely not be a long term fix, but it should buy some time until the teeth can be extracted or treated. There aren’t many other options.

SDF should not cause long lasting pain unless there is an exposure of the pulp or other wound.  It’s possible to get very short term zingers as the ammonia evaporates, not anything longer than a few seconds.

When applying Advantage Arrest and wiping away the excess, do we etch on top of wet SDF (after a minute of penetration) or we give it a few secondes of light cure before the etch and rinse step?

Answer:

Complete the SDF application by drying the surface before Acid etch.  Dry away excess SDF, then move to the restorative part.  Avoid light cure if possible.

Use eye protection that will work for the patient. Even swimming goggles that seal could be an option. SDF has a pH of ten so damage can occur. I don’t know he severity, and I prefer not to find out. 

Regarding the abscess, SDF will not speed that process, but can slow the process.  In most documented deep lesion cases, the outer layers arrest, the inner layers still proceed for several months until they either arrest due to being cut off from the oral environment, or they reach the pulp and abscess.  Unfortunately, it sounds like the latter took place here.

I use the Fuji line of glass ionomer cement restoratives.  Because I receive an overwhelming number of inquiries related to this topic, I have created online resources.

Please direct her to my website, YouTube channel, and comprehensive CE course via the following links

The topic of leaving decay under a restoration has been researched over several decades; even without using SDF as a liner.  Edwina Kidd did much of this research and it can be seen in PubMed just by searching her name.  She showed that bacteria may exist, but the decay doesn’t progress when cut off from the oral environment.  The hall crown technique also proved this.  SDF as a liner has proved this again.  More recently Rella Christensen has shown that bacteria exist under SDF treated sites and under restorations, but the decay doesn’t progress.

In short, you will never get a sterile environment, even if you remove all of the decay.  But, the lesion will stop in most cases.  Adding SDF is the belt and suspenders method to ensure this takes place.

Back in the Amalgam days, Silver nitrate was used in this manner which is why those amalgam restorations lasted decades.

The variation they saw in drop size and ppm F and Ag is well within the specification range of the product.  It’s effective at all of the measured points.

In short, she proved that the product should be opened, dispensed and then closed with the cap on tight when in storage.  That’s exactly what our instructions say.

In essence, the publication means nothing for SDF, but we’re glad JADA included another article on SDF.  Also, the levels tested are still 10 fold lower than fluoride varnish on toxicity, and hundreds of times lower on silver than the EPA’s limits.  The conclusion in the article makes you question that, but there is no question.

Source: https://drive.google.com/open?id=1WeS2kIpAJpW_IOR8MQhtcYhAlyH1tb2U

As you know, the X-pur Crystal is a low pH agent & so after the clinician removes the temporary restoration after the 2-week interim provisional -- I strongly suggest to use the X-pur Crystal to cleanse & re-apply to the entire crown restoration surface again & then gently air disperse the entire surface from 4 to 5 inches with brief jets of air for only a moment in order to disperse the agent & then follow with the adhesive luting system whether a 1-step agent like the Kuraray system.

Nothing documented.

It’s odd that SDF would burn one location but not another in the same patients mouth.  My guess is that there was some form of open wound at the site near 17 and not at the other site.  The issue was the wound and not the application or the product.  Ulcerative gingivitis or any wound would cause pain and irritation, potentially blanching and other local issues.  If it were an allergic reaction it would be more generalized and happen at both locations.

Sensitivity after use could be due to deep caries under the restoration, it could be due to changing the osmotic pressure in the dentinal tubules or could be wounds or pulpal involvement.

Nitric Acid is by far the best thing to remove SDF stain, however, it is very corrosive to some surfaces and skin so use extreme caution.  You can get it at hardware stores such as Home Depot in the form of Concrete Cleaner solution.

It will eat metals, marble, and remove the surface luster from some artificial surfaces, but we’ve seen it safely used on plastics, formica, corian, granite and other surfaces.

You may also try D-Lead soap (order it on line).  It’s  a soap for firearms users to remove lead residue from skin and will also lift silver.  I have not tested it so I cannot vouch for its effectiveness.

SDF has been used with retraction cord and there aren’t any known interactions with the hemostatic agent.  However, the clinicians that I know that have done this decided not to do them again after seeing the stain caused by the retraction cord.  The cord will absorb and spread the SDF all the way around the tooth, and onto the gingival, leaving black stains on the entire surrounding gingival (which is temporary).

I recommend using the retraction cord first, then removing and using SDF after while the soft tissue is still slightly retracted from the tooth, but no cord is present.

Ozone is a good way to kill bacteria, but it doesn’t harden residual decay left behind.  The statement that lesions must be decontaminated prior to restorations is not accurate.  This was proven repeatedly by the Hall Technique crown studies, and Dr. Edwina Kidd’s work in the 1990’s, again by Dr. Tencate’s work, and then again by Dr. Chu’s and Dr. Geoff Knights work with SDF.  You simply need to have sound margins when the restoration is placed and the residual decay or carious material will die and arrest.

Ozone does kill bacteria, it is effective, but SDF does that and hardens residual decay. Regarding depth of penetration, many things affect that with both techniques.  Lesion size, severity, dryness, etc. It’s hard to say one is deeper than the other, but we do have data showing SDF penetrates 2.42mm into lesions.  Likely farther in some cases.

No issue using it in children as young as their first erupting tooth.  2 drops per 10 kg.  I haven’t seen any study that demonstrated any deleterious effect on permanent dentition formation.

I forget what’s on the Canadian labeling, but our limitation of 5 sites per visit was due to the sensitivity study and claim we have in the USA.  The study only looked at five sites, so that’s what the FDA allowed.  From a toxicity perspective, you’re safe doing extensive applications, which can likely be completed with 2 drops in small children.

Yes, but a similar benefit could be achieved by placing the SDF around the margin after the crown is seated.  If you have a PFM crown, SDF darkness won’t be seen through the crown.  If you have a zirconia or milled block crown, it’s possible that the SDF black could be seen through the crown so be cautious for aesthetics.  The margin will have a black ring around it if SDF is used.

Yes there is a benefit here.  SDF on a healthy surface will provide similar benefits as a sealant, but will need reapplied every 6 months.  It won’t stop food trapping of course, but it will stop or slow demin in those areas.

I would reapply varnish as a generalized application, although SDF does provide a benefit which may be as strong or stronger than varnish.  The data supporting SDF for whole mouth prevention exists, but it’s not a lot of data yet.  To be sure, I’d apply the varnish since there is much more data supporting it’s preventive actions.

When the AA bottle is closed tightly, and the temperature fluctuates through time ammonia wants to evaporate.  The liquid ammonia becomes gas, and the bottle gets slightly pressurized, just like a soda bottle with CO2.  It can make a pop when opened. If the bottle was inverted or shaken before opening, or if dried silver is in the threads of the cap, it can cause that material to puff/spray out when opened, and cause a popping noise.  

 

The good news is that it was stored properly, in a closed container.  There’s little that can be done to stop the popping, but make sure the cap and threads are dry and clean before closing, and store the bottle upright to minimize any of this action.

For disposal of SDF:If there’s just a little left in the bottle, trash should be fine. If the office is worried about it, dispense the liquid onto cardboard in a well ventilated area and allow the liquid to dry. Then discard the bottle and cardboard.If they are concerned with F and Silver, then it can be discarded with the medical waste from the office, or it can be taken to household chemical recycling locations and placed in the miscellaneous or ammonia based product recycling.

We’ve tested SDF at 40 degrees Celsius and it’s stable. The blue tint may shift to purple and sometimes even red if it stays hot for months on end, but the SDF is still active.In regards to cold temperatures:If the product isn’t cloudy, or have a large amount of black specks in it, it will be just fine.

If SDF contacts the pulp directly it can be an irritant.  It can cause pain and swelling, although there aren’t documented cases of it causing necrosis, it is to be avoided.  We recommend SDF use in any lesion up to and including indirect pulp cap depth, and it can be used as indirect pulp cap material (the pH will create secondary dentin, although not as much as MTA or Portland Cement).  Only avoid it when the pulp is exposed.

You absolutely can use it in deep lesions. SDF will arrest the outer 2-2.5mm (every lesion is different) of a lesion by hardening the denatured proteins and adding silver and fluoride to the mineral.  The portion of a lesion deeper than that will be cut off from the oral environment, not supplied nutrients, and silver kills remaining bugs deep in the lesion.  This deep portion will arrest on it’s own, but that process takes time; months.  During that time, there’s a small chance that if the lesion was close to the pulp, it could continue to progress toward the pulp.  A small portion of cases may end up with pulpal involvement and require restorations. This is only a small portion though.  Most will arrest.  Also, a second application of SDF a few weeks after the first, will improve the arrest amount and depth.

We have plenty.  Here is a small selection.  Please download what you’d like the link will expire in 7 days.

https://elevate.egnyte.com/fl/BvcbNqcjgL

Here are some review articles that touch on the topic as well.

https://elevate.egnyte.com/fl/990lTjR4Gy

Here are pulp interaction articles for the pulp question above.

https://elevate.egnyte.com/fl/LB9Y6sWgGB

I believe that the reason why Cetacaine cannot be used on large areas of denuded or inflamed tissue is to prevent excessive systemic absorption of the anesthetic.

The good news is that Cetacaine isn’t used on large areas of denuded or inflamed tissue because it is applied drop by drop in periodontal pockets. The concern is, most likely, with the spray, as it is more difficult to control the quantity of Cetacaine being applied to the tissue which subsequently, could lead to large areas of denuded or inflamed tissue being affected which, could potentially, increase the likelihood of excessive systemic absorption.

At the dose we recommend and using the delivery method we demonstrate

(i.e. 0.4 ml syringe), Cetacaine is a safe topical anesthetic.

This is a compounded anesthetic that looks to be very powerful. Oraqix is only 2.5% each of lidocaine and prilocaine. In the USA, we also find practices using pharmacy-compounded topicals. Currently in the USA, the FDA allows pharmacies to compound unique formulas for a doctor’s prescription, that aren’t available otherwise. It is to be prescribed for, and used on, one specific patient. However, we meet dentists and hygienists all the time that tell us they use a compounded topical. There are liability concerns should there be any issues with the compound or the facility that made it. Search “FDA warning letter compounding pharmacy”. I am not sure of the FDA approval process for these compounds, if there even is one.

As to the formula and how it compares to Cetacaine? It appears to contain very high concentrations of Lidocaine and Prilocaine, I can’t see how much tetracaine HCl. Lidocaine and Prilocaine are absorbed systemically, so if an injection should also be required, the added dosing must be seriously considered.

I hope this helps. Please let me know if you have other questions or need more information.

- This product does not have manufacturer's directions and the exact dosing in unknown. Basically, they would by applying it blindly.

- The TAC 20 does have double the tetracaine at 4%. The 2% tetracaine with Cetacaine in combination of the 14% Benzocaine, and 2% butamben provides exceptional comfort for the clients that lasts for close to 1 hr. This is immediate and profound.

Cetacaine can cause allergic reactions since para-aminobenzoic acid (PABA) is the main degradation product of benzocaine, which is one of the 3 active pharmaceutical ingredients (APIs) in Cetacaine.  Information on adverse reactions is contained in the prescribing information (i.e., the package insert).

Topicals can be used with Local Anesthetic; however, when used in higher doses the MRD (Maximum Recommended Dose) calculations should be taken into consideration.

Generally speaking unless you are using the maximum dose of 11 Lidocaine cartridges, then Cetacaine would be contraindicated in the same appt; if only using a couple of Lidocaine cartridges then Cetacaine is totally fine to use at the same appointment time.

Today’s environment is characterized by heightened sensitivity to virus infection and inflection control. This new reality is the new norm.

We are introducing Cold & Flu Guard™ because Health Care Workers, and especially Dental Professionals and Pharmacy Teams are at heightened risk of viral infection due to their profession, their patients and their interactions with consumers.

There is a need for a novel, effective, convenient, safe and well tolerated options to protect themselves, their staff, their patients and their family against viruses that enters through their mouth and nose.

The CPS «Prime» are not plastic coated. The only brushes of Curaprox that are plastic coated are the CPS «Soft Implant». There is no reason for the CPS «Prime» to be plastic coated as the wire will never come in touch with the tooth surface due to the way the bristles are bound into the wire unlike the competitor brands which are spiral bound. 

The main difference between Curaprox and them is the quality of the product. Curaprox brushes last 5 times longer than the TEPE ones.

Unfortunately, we do not have any other guidelines.

However, the steel holder can be sterilized like any other metal surgical instrument in a dental office.

And the cleaning and sterilization procedure of the IAP are similar to a sterilization procedure for non-metal components.

We recommend the sterilization with 134°C for 18 minutes in the sterilizer.

I'm sorry that I can’t give you more information.

Using a damp 2x2 is a good option and so would be a slight water syringe use (with suction). Just make sure the varnish is after any flaps are closed, and after restorations are placed.  It (any fluoride varnish) will interfere with both.

It has to do with Sales and Marketing.  There is no need to reduce the percentage if the product already works and sells well.

We do not need to apply to all surfaces as this product is hydrophilic As soon as it comes in contact with moisture, the varnish will disperse and wrap around all the surfaces of the tooth.  

There is no comparison between a fluoride rinse and FluoriMax varnish.  The varnish stays on the tooth surface and releases fluoride ions over time.  The fluoride rinse will wash away.  

Yes. Application can be done on any surface of the tooth, but there is no need to do all surfaces. 

Colophony is a tree-based resin which is more flaky, tacky and is a potential allergen.  Shellac is very thin, transparent, not tacky or flaky and is made from a beetle wax which is a food grade shellac used on most product in the grocery store.

Our analysis demonstrates that since FluoriMax adheres so well to the tooth surface, the patient can rinse, eat and drink immediately.  

It is recommended that they avoid hot liquids, alcohol and citrus juices. 

The instructions on the box state to wait 4 hours, but it is only because that is the case with other varnishes.

Children is 1-2 drops and adults is 3-4 drops. 

We currently cannot mix flavours within the kits.  They come with 2 bottles of the same chosen flavour. However, you can choose to add an additional single bottle of a different flavour with your kit order

There should not be any strong taste or burning sensation.  If the patient experiences this, it means that the product has been over applied on the teeth.

FluoriMax is an alternative to using the X-PUR Opti-Rinse 0.2% daily for 21 days. If there are patient compliance issues, it can be applied three times within 5-7 days in-office instead of having the patient do a self-treatment at home with X-PUR Opti-Rinse.

There are no studies regarding the effectiveness of fluoride foam.  The literature states that fluoride varnishes are the gold standard.

Any calcium can bind with fluoride when there is water present. Without water, NaF stays as NaF rather than breaking apart into Na and F.  In FluoriMax Varnish (and all other varnishes), there is no water present so the NaF and whatever calcium source is present will not interact while in the package.  Only when the varnish is placed in the mouth does water get into the mix allowing the F and Ca to interact.  This is exactly where you want these reactions to take place.

If the child is not High Risk Caries 

Recommended application is  2x per year  ( Every 6 months)

If the Chid is High Risk Caries

Recommended application can be 6-8x per year 

Or

Shock Treatment with 3 applications within 1 week period

We do not need to apply to all surfaces as this product is hydrophillic.  As soon as it comes in contact with moisture, the varnish will disperse and wrap around all the surfaces of the tooth.  

There is no comparison between a fluoride rinse and FluoriMax varnish.  The varnish stays on the tooth surface and releases fluoride ions over time.  The fluoride rinse will wash away.  

Yes. Application can be done on any surface of the tooth, but there is no need to do all surfaces. 

Technically FluoriMax doesn't have a pH because it doesn't contain water.  Once in dissolution the pH is neutral (at or near 7.0).

No. The fluoride ion saturates the saliva in order to remineralize a lesion, whether the varnish is applied directly to the lesion or on the opposite quadrant of the mouth.

Email from Clinical Research

FluoriMax is kind of a hot topic right now. As you mentioned their claims are quite aggressive and we are looking into the validity of those claims right now. What we do know is that the way they are reporting their uptake numbers isn't the standard for the industry which causes a lot of confusion. They report their uptake in that µgF/g varnish and the standard is µgF/cm³.

FluoriMax fluoride varnish is a little bit of a different product. It's a 2.5% sodium fluoride. It's not in a resin like most varnishes and uses what they call a "shellac" in place of colophony like we do. They sell it in a 12mL bottle and unit dose ampules. This is the only varnish on the market

that uses this concept of food grade shellac as a delivery method. 

Application is pretty standard, just paint it on, but the product is a lot runnier than most resin based varnishes and you have to shake it for 10-15 seconds. Their IFU does say that if you apply to much it will cause a bitter taste and stinging sensation. Two flavors, mint and bubblegum. In their marketing materials they claim a really high fluoride uptake, but it's a little confusing because their unit of measurement is different than what we typically see with other products. 

We've tried this here in the clinic and the clinicians hated it. It's too runny and difficult to apply. You have to hold the cheek away from the teethor 3 seconds which is also kind of a pain. 

I would also point out that the fluoride uptake they report, while not incorrect, may make it look like their fluoride uptake is far superior to ours but it's only because they report in a different unit of measure. In addition, their studies do not give a timeline so if all the fluoride they claim is released happens all at once it's unlikely the tooth is actually absorbing that. Does this shellac delivery system really adhere to the tooth as well as a resin based varnish? Nothing in their marketing material would indicate that it does. Enamelast is proven to adhere to the tooth for up to 48 hours so the patient is getting fluoride uptake for a pretty long period

of time. And lastly, experience, have they actually tried it? What was their experience? Given our experience here in the office, it might not be as positive as Elevate Oral Care would have you believe. 

We are meeting in a couple weeks to formulate an official statement regarding FluoriMax which I will send to you as soon as it's ready.

Answer

First and foremost the ugF/g was a misprint.  It’s been corrected on our website, and the correct measurement is now in place.  We can also provide the supporting data/study from Therametrics (you should already have it) which has the correct measurement in it.  Test method FDA 40 is the standard and that’s what we used.

Regarding the flavor and application, if FluoriMax is applied like other varnishes, the clinician will likely not like it.  If they take the time and apply as we instruct with one swipe from posterior to anterior by quadrant with no repetitive swipes, it will be great.  They also need to leave the teeth moist, which is a departure from other products.

We find that we can tell clinicians this, and then watch them apply it and they still do it using their old method because they are so used to doing it that way.  The application process is different, and in fact its easier and faster than other products.  It’s just… different.

FluoriMax Varnish will not alter the finish on any restoration in the mouth.

It is the solvent. Alcohol in every varnish makes the varnish liquid and then evaporates upon application.  Most varnishes this takes 3-5 minutes. In ours it only takes about 5 seconds.

Wait until they brush the varnish off about 4 hrs later.

May 2000 JADA, there is a tox section in this article that shows blood plasma levels after fluoride varnish application are equal to or less than after tooth brushing with OTC pastes.  There are many others but this one came to mind first.

FluoriMax is not a vegan nor halal product. It contains shellac obtained from the secretion of the female “lac bug” on trees. To be identified as halal, a product must obtained a certification (similar to the Kosher certification).

The ADA publication was produced before FluoriMax was on the market, so, of course it wasn’t included.

We’ve spoken with the ADA and informed them we would like included and they said it will be reviewed when they revise these guidelines in a few years.

It’s also important to note the ADA does not “Approve” any product. Never have. In fact, they’ve canceled their ADA Acceptance program for professional products completely.

It’s not possible for a prescription product to get acceptance anymore.

Vanish is alcohol based (which is ethanol), and FluoriMax is alcohol based (ethanol), the same solvent. Vanishalso has a hexane additive (which has a poor toxicology profile) and has been banned (or restricted) in parts of the EU. Our product is designed to stay on the tooth for extended periods of time (about 24 hours), but designed to release most of its fluoride within 4-6 hours. We did this because that’s how long a patient typically wears a varnish coating. They brush it off at bed time so it’s a good idea to put the fluoride to use rather than spitting it down the sink.

No. There haven’t been allergic reactions that we know about, and shellac is a common ingredient in foods (specifically food preservation such as on fruit to prevent insects and mold, and as a liner inside canned foods).  It’s also a coating for candies and medicines such as ibuprofen.

NaF is not soluble in non water containing products.  There is no water in varnishes (of any type) so having calcium ingredients isn’t an issue.  This means there’s no free ionic F available until mixed into saliva.

There is ample data showing varnishes with NaF and no calcium will deposit fluoride into enamel and dentin.  Fluoride does and will bind with the tooth in the presence of water and/or saliva, and doesn’t need an additional calcium source.

Yes, we do have Hydroxyapatite in our product which is a calcium phosphate crystal (the same that the tooth is made from).  It’s not needed unless the patient has dry mouth and no saliva.

Petroleum products can dissolve latex, so if you use latex yes it is a concern.  Typically latex takes minutes to hours to weaken in petroleum.  I’m not familiar with nitrile gloves dissolving from Petroleum jelly (most offices use nitrile).

The alcohol percentage is not high.  It is normal for this type of product.  Also, the alcohol is designed to evaporate upon application.  It will dissipate within a few seconds of application, and ingestion would be negligible if any.

Every product is different.  Listerine uses alcohol as a solvent to dissolve essential oils.  Varnishes use alcohol as a solvent for the resin so it’s thin enough to apply with a brush, yet sticky enough to stay on teeth once applied.  This dictates how much alcohol is in a product.

It varies widely based on product, resin, and what other solvents are used.  Some contain alcohol, hexane, propylene glycols and other solvents.  I’d estimate a range from 40-65% for most varnishes, with some outliers.

This is actually a hold over from Duraphat when it was brought into the USA.  Durpahat included that warning because one patient in their original tests had asthma issues during testing (likely due to colophony).  All other varnishes then bear this warning still.  We don’t expect ours would cause it, but it is a FDA and Health Canada labeling requirement.

Best practice is to wait the 4hrs to do restorative work to minimize the instrumentation in the mouth.

A long nylon brush is best to be applying a thin one stroke application. We do not advise micro-brush use

It is dependent on their caries risk level. For medium to high risk yes every 3 months is recommended and is an acceptable frequency.

The bottle of FluoriMax contains a mixing ball to ensure a homogenous mixture of the solution (just as you would typically give a stir to a unit-dose of traditional varnish prior to application). It is recommended you shake the bottle for a few seconds prior to dispensing. That will ensure the mixture will not separate and will allow for a consistent dose from the first drop to the last.

• Young patients
• People who will not remember to rinse once a week but could establish a daily routine (psychologically easier for us humans)
• People that don’t like mint

Gengigel products are water based (major ingredient). Please note that Gengigel products do not contain petroleum but have a small amount of castor oil (it’s a vegetable oil) used as surfactant.

Find more info about castor oil here: http://www.cosmeticobs.com/ingredient-cosmetic/peg-40-hydrogenated-castor-oil-574

They are the same term to express the same thing. You have to use our claims on precise concentration (competitor do not normally express it) with the relative bibliography made on our concentration and with our molecolar weight (so called high).

1 - GENGIGEL  (Statut: Natural Health Product, NPN 80046557)

Medicinal ingredients:

Hyaluronic Acid

Xylitol

Claims:

1) helps to reduce plaque and supports gum health

2) helps reduce inflammation associated with gingivitis.

3) helps to relieve the pain associated with minor oral conditions (oral lichen planus).

2 - GUM Canker-X Gel (Statut: Should be classified as a NPN, link: https://www.gumbrand.com/oral-pain-relief/canker-mouth-sores/gum-canker-x-gel.html)

Medicinal ingredient:

Aleo Vera

Claims:

1) Helps treat canker sores, mouth sores, and minor cuts or abrasions by providing a protective healing barrier.

Sunstar must apply for a NPN for this product, we will send them a letter to let them know. Without a NPN, they do not have the right to advertise their product as a pain relief.

According to some medical reports the product seems to help and accelerate the normal clotting process, but we do not have any adequate scientific evidence in this regard.

Should not be taken with any di-valent cation such as calcium & magnesium and zinc,,because part of the efficacy of Periostat is its ability to bind the cation,zinc (& calcium) in the collagenase molecule thus inhibiting its activity

Should not be taken with dairy because it contains calcium which can reduce it’sefficacy, therefore it should be taken 1 hour before or after a meal or dairy (ie: milk, cheese)

Periostat helps to suppress certain tissue-destroying enzymes that the body overproduces in response to the chronic bacterial infection of the mouth. Research clearly demonstrates that enzyme suppression is essential for a stable outcome in the treatment of periodontal disease.

Controls harmful levels of tissue-destroying enzymes and helps the body to repair and rebuild damaged tissue and bone. Periostat, combined with the removal of infectious bacteria from your teeth by your dental professional (a deep-cleaning procedure called scaling & root planing), results in a periodontally stable, healthy mouth.

Take 1 Periostat capsule twice daily – morning & evening (one hour before or two hours after a meal) with a full glass of water.

Studies have shown that more stable results are achieved with longer term use such as 6-9 months.

Benefits will continue for months following Periostat therapy, and vary by individual dependent on the management of risk factors (oral hygiene, smoking, diabetes, etc). It is important to continue maintenance visits with your dental professional every 3-4 months.

Yes! The majority of insurance carriers in Canada consider Periostat therapy a covered benefit under extended health prescription plans.

No! There is no substitute or generic for Periostat.

.Evidence shows that Periostat (combined with scaling & root planing) is very effective in controlling periodontal disease in smokers and diabetics, and will actually contribute to better control of diabetes.

Pregnant or nursing women, children, Tetracycline intolerant individuals or liver disease sufferers should not take Periostat.

• Downward dosing of Coumadin may be required.

• Efficacy of oral contraceptives may be decreased.

• Do not take antacids or iron preps within 4 hours of Periostat.

• During Penicillin/antibiotic treatment, discontinue Periostat. Resume Periostat one week following Penicillin/antibiotic use.

Clinical testing has proven that Periostat is very well tolerated. Because side-effects are similar to placebo, Periostat does not cause sun sensitivity, nausea or antibiotic resistance.

Yes! Because of Periostat’s revolutionary success in controlling periodontal disease, Periostat is now being tested with continued success in treating other inflammatory diseases, such as acne, rosacea, rheumatoid arthritis, and cardiovascular disease. Recognizing the systemic link between the health of our mouth and the health of our body is at the forefront of medical technology. Treat

periodontal disease seriously!

Just resume taking the next scheduled dose. Never double up to replace the missed capsule.

Yes, there are publications on doxycycline as an MMP-inhibitor with efficacy in various skin disorders….see the following reference (page 140) for erosive lichen planus…. Monk E. et al. (2011). Clinical Applications of Non-Antimicrobial Tetracyclines in Dermatology….in,  Pharmacological Research 63 (2011): 130-145…..Special Issue:Guest Editors: Lorne M. Golub and Robert A. Greenwald; Elsevier Publishers….

Tetracyclines like doxycycline can bind to carbon-11 and carbon-12 zinc and calcium binding-sites , which are part of the molecular structure of collagenases and other matrix metalloproteinases….but these effects appear to result in beneficial  medical and dental effects which have been detailed in  published articles such as Dr. Robert A.Greenwald  (a prominent medical professor in NY) and others …see several articles in the journal: “Current Medicinal Chemistry”,2001,vol.8:pp.237-242, plus several additional articles in the same journal….also, a number of more recent articles were published by dr.jeffrey payne ,Univ. of Nebraska ,on studies  on 126 post-menopausal women who took  periostat (or placebo capsules) daily for 2- years (a study supported by the N.I.H. of the U.S. government) which did not produce  significant side-effects, typically only benefits,e.g., decreased skin inflammation etc… so the preliminary observation on type-2 diabetic patients ,showing possible reduction in hemoglobinA1C, may reflect a reduction in diabetic complications by periostat (such as decreased chronic inflammation), which could improve glycemic control in these patients

Here is what Daniel Menard suggets to use verbally or an e-mail when we are facing a dental office that is prescribing splitting pills, as for the pharmacist, if a pharmacist suggest that to a dental office or to patient that pharmacy is acting totally in illegality as there is no replacement or generic for Periostat, therefore they nap not offer a substitute.

Following to our discussion regarding prescribing 100 mg of Doxycycline and having the patients or pharmacists divide the tablets into quarters; It’s very important that we share the following;

First, the over use of antibiotic and the antibiotic resistance are some of the most challenging problems that we are presently facing worldwide. By prescribing 100mg of doxycycline and having the patients split the tablets, you are participating in this very dangerous path.

Health Canada requests from all drug manufacturers to guarantee that every tablet or pill contains the indicated quantity of the drug, with a tolerance of +- 10 % . Tablets/pills are not manufactured to be split up. Besides the active ingredient any tablet/pill contains other materials, such as fillers. As a result, the active ingredient, in this case the doxycycline, is not evenly distributed in the tablet/pill. Therefore, splitting a 100mg tablet of doxycycline in four parts can result in one quarter containing all 100mg of the doxycycline, while the other parts are just filler. You are putting yourself and your patient at risk; you taking all the responsibility. 

Please note that the use of Periostat (20 mg doxycycline hyclate) is fully supported by scientific literature and also part of the ADA evidence-based clinical practice guideline of nonsurgical treatment of patients with chronic periodontitis and is the only drug approved by Health Canada as a collagenase inhibitor for the periodontal treatment. 

Periostat is not an antibiotic, when used as prescribed, 20 mg doxycycline BID (twice a day). It cannot create any bacteria resistance as regular antibiotics do. Please note there is no replacement or generic for Periostat. 

Periostat is $3/day for the patient. The majority of extended health plans cover Periostat. When clients are educated on how Periostat can help them and they see the value in the treatment, it is very well accepted.

The AAP have redefined periodontal disease from an infectious disease to an inflammatory disease.   If we continue to choose to ignore the inflammatory component and current JADA guidelines, we are at a standstill in our treatment progress as well as placing our client’s overall health at risk.  My main point with collagen supplementation is that there are a number of different types of collagen that are available OTC.  The source is also of significant importance due to impurities etc.   If you do some of the research there is a strong and questionable doubt as to how the collagen is able to be effectively metabolized by the body.   Low dose doxycycline on the other hand is not a ‘bandaid’ approach but rather a targeted approach to address the host response.  We have the scientific evidence to support our clinical decision making.  We have the strong evidence to know that the over production of collagenase or MMP-8 is being effectively minimized and counter balanced by the administration of low dose doxy or Periostat.  These are 2 distinctly different approaches and entities.  One is a ‘hit and miss’ with no definitive scientific impact on the periodontium and the other is treating the etiologic factors that are responsible for collagen breakdown specifically in the targeted area as well as having a beneficial impact on other areas of the body as evidenced by scientific articles related to systemic health.

You are correct…an on/off approach is recommended by Dr. Golub for someone in the scenario you have presented if they are primarily using ‘off label’ long term due to a systemic illness.  We have to be careful here to approach the dental profession with evidence-based science and defer to treatment of periodontal disease as our primary objective.  For reasons mentioned in my last email, Dr. Golub does feel the immune system after long time exposure will adjust to and counteract the beneficial efficacy of the drug.

I have always said 6 – 9 months however the JADA guidelines do suggest 3 – 9 months.   This is an easier approach with our colleagues in my opinion.   We defer always to the DHPC (dental hygiene process of care) and re-evaluation strategies.  Every client is an individual with their own circumstances so must be assessed/evaluated with a client specific approach.  If at the 3 month mark they have had resolution, the clinician may wish to take them off and re-evaluate once again in 3 months.

Your question last week in the training session was of great interest to me and as promised I reached out to Dr. Golub in regards to possible ‘resistance’ after taking Periostat for a considerable length of time.  We have had a conversation today in response to my email sent last week.  I explained the scenario to him of what I knew in that the patient suffered from an autoimmune disorder and had been on Periostat for 5 years.  I also explained her concern with a recent dental visit where she felt like her periodontal health had declined and was concerned that she may be becoming ‘resistant’ to the low dose doxycycline (LDD).

Dr. Golub’s insight as always was very well thought out and I wanted to share this with you.   Renaud, please feel free to share this with your team as well.  It’s good information for us to have in the event this question arises again.

Dr. Golub suggested taking the LDD episodically….translating to the idea of taking for 3 months and then going off of the drug for 2-3 months.   He stated that the concurrent use of other meds to suppress the immune response may also be reacting with the LDD or basically the immune system has somehow adapted to its presence.  Literature also suggests that LDD may be helpful at times of flare ups; again staying on the meds for a minimum of 3 months each time and then taking a break.    I have suggested the term ‘drug holiday’ in my lectures as well.  We know that the effect is sustained in the body for a minimum of 3 months following cessation.   This elevation in the blood serum may prove to be more effective episodically then a continued sustained presence that is losing its efficacy as the immune system adapts to its continual presence.     We always have to consider the evidence based decision making model of which the science is only part of it.  This is where the critical thinking and clinical experience comes in.

FROM JO-ANNE JONES

My inquiry is related to regulations surrounding prescribing of drugs for Ontario registered dental hygienists.

I have had the privilege of studying directly with the researcher, who discovered the therapeutic benefit of low-dose doxycycline on inhibiting the excessive amounts of collagenase (MMP-8) that exist in an inflammatory response. Dr. Lorne Golub, (DMD, MSc, MD (Honorary), SUNY Distinguished Professor, Department of Oral Biology and Pathology is a fellow Canadian having received his DMD from the University of Manitoba and then attending Harvard School of Dental Medicine for Periodontics) This incidental discovery provided the ability to regulate the host response that was dictating periodontal destruction due to excessive levels of collagen breakdown caused by collagenase. This novel discovery has led to over 300 published articles in both dental and medical journals citing many positive outcomes in treating various collagenolytic diseases with periodontal disease being the most chronic inflammatory disease known to mankind.

The current ‘Guidelines for Non-Surgical Treatment of Chronic Periodontitis’ published by JADA vote ‘in favor’ of only SRP and low-dose doxycycline to non-surgically treat periodontal disease as being beneficial with a level of certainty, balanced with a net benefit rating weighed against potential harm.

The most misunderstood aspect of low-dose doxycycline or Periostat is that it is an antibiotic. Due to the low dosage it never reaches an antimicrobial or antibiotic functional level. There is no alteration to the oral, GI or other mucosal area microflora. It is challenging to capture all of the credible talking points in a short, concise email. I would be more than happy to share this information in further detail with you in a conference call or when an in-person meeting is permissible. The following link presents a high level overview of the role of low dose, non-antibiotic, doxycycline. https://drive.google.com/file/d/1jskfyPUSuJKSGJXIvndA_EYKA5nxHlIU/view

Providing the RDH with the ability to prescribe low-dose doxycycline plays an important role in helping Canadians not only achieve optimal periodontal health but also to mitigate risk of systemic inflammatory disease or exacerbation. Allowing chronic inflammation to continue to ensue, places the dental hygiene client at risk for initiation or heightening of a systemic inflammatory response. In our world today, the public has become increasingly more educated on the importance of maintenance of overall health and the desire to obtain it..

It is 300 times charge.

The settings with the wand are the same 20 seconds 4J Biostimulation, 40 seconds 8j bioinhibition. For the wand it requires a lot more power and this is a factory Preset. For you specialist the photon works as long as 810 is the right wavelength for his chemical. For the 100J/cm2 the Zolar can be set for this. He can use either the handpiece or the wand. I will check the outputs and work with him to set the unit. He can do a custom setting which can be saved inn the menu. He can contact me if he needs more detail.

Here is the answer I received from Zolar:

The volume control only affects during the manipulation of the screen MENU. But during the procedures, every time you step on the pedal, the sound is always the same, you can’t control the volume or mute. Regardless what kind of handpiece you are using, the sound is the same.  The purpose is to let the user aware that there is a power coming  from the 

Fiber, wand or bleaching hand piece and they have to be cautious of the effects if they overused or hit the wrong target.

MENU: 3 sound options (low, med, high) + mute

WHILE IN USE: only one sound, regardless of what was selected in the MENU. This is for the safety of the users. 

No

Zolar Photon products are licensed by Health Canada to include the family of devices and accessories approved for use with Zolar Photon lasers. Accessories include the handpiece, the cutting fiber and single use disposable tips. The attachment of any accessory not licensed or approved by Zolar or the use of any consumable (tips) other than those calibrated and tested by Zolar would be illegal in Canada and will immediately terminate the product warranty.

In addition the use of such unauthorized single use disposable tips may create a hazard and place the patient at serious risk of injury or death. Any incident related to the use of unlicensed and unapproved accessories will place the users (dentist) and the suppliers of the accessories open to liability and legal action.

It is imperative for all dealers that they must appraise their clients regarding the continued safe use of Zolar tested and calibrated accessories and consumables with Zolar products.

Around 3 meter in length.

Briefly -- until the early 1980’s I realized that most of the commercial desensitizers were only palliative-at best-& needed constant reapplication for any sort of patient relief.  In addition, my own pulp biology research demonstrated that the application of acidic etchants agents for adhesives were not biological toxic when placed onto vital dentine (Cox et al. Jour Pros Dent 1987)—Consequently, I immediately focused on the use of various self-etching potassium Crystal agent as a potential desensitizer & was successful after many sample batches & tests. 

Please note -- that if you read thru the attached references – you will find over 30-published articles that support the biological & clinical use of the Crystal desensitizer.

The attached documents of instructions note that as a 1-bottle agent – Crystal is easily applied & works by the chemical chelation of the calcium hydroxyapatite (HAp) of the enamel & dentine into millions of calcium oxalate acid resistant crystals that block the dentine tubules for up to 100µm deep into the tooth substrate.  

All bological systems are static–that is--they are confounded by many variables that do not always follow standard pathways. And, without my  knowing of any of the specific patients clinical comments as well as clinical diagnostic observations–It is impossible to speculate on the why of your question.  But in some of the everyday patients situations-the dental pulp or even the periodontal tissues may be irritated or inflamed–or perhaps the tooth root may be cracked & the nerves are preconditioned as hyperactive. The biological tissues of the tooth are not always responsive as might be expected–there is a lot of biological variability in the physiological nerve systems of the oral cavity.   

I am not personally aware nor have I received any comments of any contraindications–that is if the clinician have completed their diagnostic evaluation & found there is no acute or chronic tooth bleeding or other severe tissue damage.   

As a self-etching cavity desensitizer - the self-etching desensitizer may be applied directly onto all of the prepared tooth tissues (enamel, dentine of a cavity preparation & even cementum following prophylaxis).  The important point is to cover (apply over)  ALL of the restorative enamel, dentine interface with the agent immediately following all rotary & hand instrumentation.  Do NOT pre-etch the cavity (e.g. any sort of class-V, inlay, onlay or crown prep) or blow excessive water & more so excessive air onto the cavity. As this has been shown (Brannstrom, Langeland) to cause rapid fluid evaporation from the dentine tubules & then when the air chip button is released—a sort of low pressure area immediately occurs at the restorative interface--& small air bubbles are then sucked (introduced) into the tubules which cause postoperative sensitivity issues.  More importantly--our pulp biology studies on vital dentine show the tip of the syringe should be held no closer than 4” closer to the cavity & then only a gentle air jet of 1-second to disperse the cavity fluid.

As long as the surface has been gently air dispersed & the patient reports that they are now feeling no tooth sensitivity – they may proceed to eat or even drink whatever they wish.

Why place the desensitizer onto the calculus – unless the patient is experiencing sensitivity to cold or other thermal stimuli before prophylaxis.  Then place the Crystal agent before & during the clinical removal of the calculus as well as following the scaling procedure. To make sure that all of the dentine tubules are sealed after final scaling & polishing – I personally recommend to reapply the Crystal desensitizer to all tooth surfaces as well as around the gingival neck of the tooth & even around the cavosurface margins of all of the restorations ( amalgams, inlays, crowns  etc., etc.)

Please read thru the attached references that are provided on the information & reference document regarding the Crystal desensitizer as developed by Dr. Cox.  There are overwhelming published clinical data to support the effectiveness of the Crystal desensitizer when compared to other commercial agents.

YES – emphatically – the Crystal agent is a self-etching desensitizer that should be applied once the clinician has determined that they are finished with all instrumentation.  No pre-etching is recommended before placing the Crystal  desensitizer as the H3PO4 is damaging to all vital collagen of the dentine & gingiva.  

It is difficult to give an answer to a subjective comment since I do not know the specific clinical narrative for the patient or the clinician in their application procedure.  Please note that GLUMA is a toxic agent that causes necrosis of vital PDL & gingival tissues --- there is no toxicity with the Crystal.  Read Niazy articles.  

The millions of nano-crystals – once formed underneath the restoration are acid resistant – meaning that they do not normally fall-out or become washed out from normal oral fluids or drinks.  We may note in our marketing information that the nano-crystals are stable for 6-months.  Some clinicians have noted that the crystals seem to be stable for years after placement under restorations.

Is it really better??  There are a number of other desensitizers on the commercial market that claim to be the best available agent.  There are many features of the Crystal that are advantageous & I recommend that each of you take the time to read thru the references & identify those features that seem to rank one agent over another.  We may discuss this point during the communications on the 5th of April -- as my time permits.  

Several SEM studies have demonstrated that the Crystal desensitizer rapidly penetrates into the enamel lamellae as well as the dentine tubules for up to 100um & immediately chelate with the HAp of the enamel, dentine & cementum to form many millions of acid resistant nano-crystals to block the enamel defects & dentine tubules. 

YES – the Crystal agent is very effective to treat cervical erosion & any abfraction lesion as well as post bleaching or whitening procedures. 

I recommend to place the desensitizer when all of the restorative drilling is completed. If the clinician wishes to place an adhesive restoration -- they may place an acid etchant for only 5-seconds to remove the debris -- then rinse & GENTLY evacuate with light air dispersion of 1-second & at a distance of 5-cms.

Then apply the desensitizer completely onto all of the preparation surface as well as cavity walls & even onto the enamel around the cavity. Apply the agent with a microbrush or microsponge & be sure to rub the agent all over the cavity surfaces to make sure the agent contact is complete so as to permit chelation of many millions of small nano-Calcium oxalate acid resistant crystals to seal the dentine tubules as well as to create a surface layer that DOES-NOT diminish adhesive bond strengths. After the 15-20-seconds of rubbing -- Then do NOT rinse -- but evacuate the area with gentle suction & again 1-second air jets from 5-cms distance.  Make sure the syringe is NOT spraying water -- but air ONLY!!!!

The area may have a light frosted surface -- but do NOT blow the air directly onto the agent as it will cause bubbles in the tubules that lead to patient sensitivity.

In addition,  the desensitizer is very effective at the enamel-cervical area. Place it before there is any scaling or root planing as it will lightly soften the calculus before the prophylaxis as well as seal the open dentine tubules. It may be applied liberally to flow around the entire tooth-gingival area since it is not toxic like the glutaraldehyde containing agents that kill vital tissues or those HEMA agents that are antigenic to many people -- as well as clinicians. Again - gentle air jets from 5-cms with light suction.

I believe that if you look at the article #35 on the Information Document I sent to you a number of weeks ago, that you will fine the article by Firouzmandi M et al. J Clin Dent 2017-- which reported no difference in shear bond strength when an oxalate -based desensitizer was placed. 

Of course you may realize that there are other studies that have been published -- but these are with Super Seal but there are none that I am aware of with your X-PUR Crystal desensitizer agent. Perhaps the McGill operative dept or another dental schoold department might consider to complete a SEM & bonding study for Oral Sci.

You might realize that following the placement of the desensitizer -- there are many-many millions of calcium oxalate crystals that immediately form within 5-seconds, when there is no preetching with a mineral acid (H3PO4) that depeletes the HAp of the dentine substrate. And once the clinical field is gently air dispersed, the polymer is applied & will easily pass thru the spaces of the calcium oxalate crystals. Like water passing thru the particles of sand in a glass. You can persorm this test with a clear glass full of dried sand. Then pour in water & it will interdiffuse thru the sand.

A rewetting agent is generally applied after etching with a mineral based acidic system e.g. H3PO4  -- these agents were developed with the intention(s) of rehydrating the collapsed collagen so that the adhesive primer polymer could penetrate thru the collapsed collagen fibres.  In addition, some manufacterers claim that their rewetting agent also serves as a surfactant that is supposed to increase the spreading effect of the adhesive primers over the restorative interface.  From a chemical standpoint -- the X-PUR-Crystal also is a surfactant that reduces bubble formation in preparation for the taking of an impression as well as to spread the primer system.  Of course, there is NO reduction of the final bond strength when using X-PUR Crystal -- Dr. Cox.

As you know, the X-pur Crystal is a low pH agent & so after the clinician removes the temporary restoration after the 2-week interim provisional -- I strongly suggest to use the X-pur Crystal to cleanse & re-apply to the entire crown restoration surface again & then gently air disperse the entire surface from 4 to 5 inches with brief jets of air for only a moment in order to disperse the agent & then follow with the adhesive luting system whether a 1-step agent like the Kuraray system.

Yes, 30-60 seconds, then remove the lesion by scooping. Repeat if needed.  The only lesions it won’t work on are ones that you don’t have access to (pinhole caries, interproximal, etc.).

I would not cover the papacarie duo into a lesion and leave it.  You could use Papacarie Duo, remove the decay by scooping, rinse, and then do whatever they would like: temporary, GI, composite, but I wouldn’t leave the gel underneath.

Yes, exactly.  Let’s say it’s a big lesion.  You apply Papacarie duo, excavate, and feel that there’s still more decay to remove.  Perhaps the microbrush you used for application could only carry a small amount of gel to the tooth.  You apply papacarie duo again, scoop again. You can do this multiple times if the lesion is larger than the amount of Papacarie Duo applied can remove.

It's like cleaning something. You use soap and wash, if the dirt is still there after, you can use more soap and wash again, till it’s gone.  In Papacarie Duo’s case, the blue gel will get cloudy as it breaks down the decay.  If you apply the product and it stays blue, and doesn’t get cloudy, you got all the decay.

it is a mild antimicrobia aswell as a buffering agent and the activator for the papain enzyme.

No. Some lesions such as pinhole caries and interproximal lesions may not be accessible to hand instruments.  These may require the use of the drill. The dentist may elect to use handpieces to access lesions, or improve margins of various lesions at their discretion.  Papacarie Duo can be used in conjunction with handpieces to restore lesions.