Fluoride Varnish: Applied Correctly, It Can Change a Patient's Life

If you're leaving acidic plaque on a tooth surface and you put fluoride varnish on top of acidic plaque, that acidic plaque turns into hydrofluoric acid plaque. Now you're actually holding... hydrofluoric acid on a tooth and in what universe do you want hydrofluoric acid on tooth surface you don't and this is why those of us in clinical practice who've been doing this long enough we have seen in children's mouths fluoride bombs these little stain pit and fissure grooves where you think you're going to get into a fissurotomy you open it up and next thing you know you're in the pulp you're doing the popotomy or pulpectomy or Heaven forbid, you're saying, I think we need to extract this unless you can get your kid in for a pediatric root canal in this tooth. Welcome to the Phil Klein Dental Podcast. According to our guest, the application of fluoride varnish is hands down the most significant procedure we can do for our patients. In fact, this simple non-invasive procedure can have a profound impact on a patient's long-term oral health, particularly in protecting a child's first molars. Teeth that, if preserved, can set the stage for a lifetime of better dental outcomes. In this episode, we'll briefly explore the science behind fluoride varnish, and I promise to keep it brief. We'll discuss how fluoride interacts with enamel, the best way to apply the varnish, and the key factors that determine its effectiveness. But as with any procedure, there's a right way and a wrong way to apply fluoride varnish. Our expert will shed light on one common mistake that he calls the fluoride bomb. We'll discuss what can go wrong during application, how to avoid these pitfalls, and what steps you can take to ensure your patients receive the full benefits of this essential preventive treatment. Joining us today is Dr. Brian Novy, a practicing dentist in Boston, Massachusetts. Dr. Novy is president of the National Canberra Coalition, faculty at Harvard School of Dental Medicine and Western University of Health Sciences, and consumer representative for the U.S. Food and Drug Administration Dental Products Panel. To reach Dr. Novy, if you have some questions, you can visit his website at holymolar.com. Holy molar is W-H-O-L-L-Y, molar.com. Dr. Novy, it's a pleasure to have you on the show. Bill, it is always so much fun to talk to you. Thanks for having me. And I'll tell you, we're very honored to have someone like you, especially on a topic like this, because there are, and I'm not trying to patronize you, even though you're our guest, there are a few dentists out there that have the knowledge, expertise, experience in preventative dentistry and the research to back it and the stuff you've written and taught about. It's just really great to have someone like you on the show. And as I said, we're very honored. Before we get into the details of fluoride varnish, which is the main focus of our discussion today, I want to ask you to give us a brief overview on the evolution of fluoride varnish in dentistry, and what is the literature saying about its impact on oral health? So realizing that fluoride incorporating the tooth crystal makes them more solid and resistant to decay, in 1995, the Food and Drug Administration approved this very, very special type of fluoride that could stick to teeth a heck of a lot better. Now, you and I remember fluoride treatments that were rinses. You'd go to the dental office and you'd mix the two rinses together. You'd send the patient over the sink. They'd swish with half that cup full for one minute. And then they'd swish for the next half of the cup full for another minute after you clean their teeth. And we were using acidulated phosphate fluoride in that respect. So that was a, or sodium fluoride sometimes, but you were basically. really kind of acid etching the teeth while you were at just the right pH. You're driving just a ton of calcium and fluoride into those teeth. And then once you spit all that out, there's this reaction that happens with phosphate from the saliva and you get this really, really super, like supercharged coating on the tooth surface. And how long did that last though? How effective were those rinses back then? Well, they were effective. I mean, they were pretty darn effective. The problem was they're so highly dependent on the timing and getting the stuff off the teeth. And I think that's the problem we have today is we have sped up the process. We don't really respect the process of fluoride varnish application because we delegate it to the members of our team who aren't surgeons. And so we say, oh, it's probably not that technique sensitive a procedure. Well, may I just say to your listeners. Yes, it is. Yes, it is. And if you take nothing else away from this podcast, please realize that if you're doing a fluoride varnish application, you've got to be really sure you understand the chemistry of what's going on the tooth surface so that the patient actually gets the benefit of that. Because I've been in many... clinical settings where i hear things like plaque is a reservoir for fluoride just get it in there it doesn't matter if you get the teeth clean yes it does matter if you get the teeth clean if you don't get the teeth clean you might be doing the patient a disservice so we should probably talk about that yeah so let me ask you this in many things like i played tennis all my life i played a little bit for college i played in high school and tennis was always taught where you had to do certain techniques you know in my day where you had to bring your racket back early and step in weight transfer But the basis behind those techniques was physics. Everything about tennis was physics. How you strike the ball, everything, spin, underspin, topspin. With this, it's basically science in chemistry. And if you understand the basic chemistry of what fluoride varnish does, it certainly makes it much more interesting to treat the patient because you understand what's behind your treatment and you're not just going through an IFU sheet. you know, saying what you're supposed to do because we're doctors. I mean, it's very fundamental to you. But for those of us who are dentists, who are not familiar with the chemistry of what we're trying to achieve by using fluoride varnish, can you go over that with us and tell us how it works related to the threshold of pH, where we're trying to bring that threshold to where a lower pH, which is more dangerous to us, is tolerated by the tooth? Well, I can't think of a topic that I would... much rather discussion than the interaction of fluoride varnish with crystalline hydroxyapatite. I mean, nothing gets me more excited than that question, Phil. So thank you for teaming me up. You're not being facetious here. I can't believe I'm saying that because if you had said that to me in the first year at dental school, I'm like, oh my gosh. um shoot me now before i have to listen to this but no it actually is thank you for appreciating how really truly spectacular that's the science is because here's what we're trying to do at the end of the day we know that when tooth crystal has fluoride incorporated into it it's It's fluorapatite. And that means that the central core of the enamel rod, which is normally a hydroxyl group, has been replaced with a fluoride ion. That fluoride ion is so electronegative, it retains the calcium and the phosphate surrounding it much more tightly. It's very kind of, well, it's electronegative. It's very negative. It's supercharged. It's holding these calcium and phosphate ions really, really tightly. That means that those calcium phosphate ions will not disassociate off that enamel rod until about pH 4.5. Now, the reality is Gatorade is well below the pH of 4.5. So if you take a swig of Gatorade, you're going to demineralize fluorapatite. And one of the really cool things in cariology we know now is that, well, we have bacteria in the mouth that produce acids of pH 3.5. So we've got bacteria in the mouth that produce an acid capable of destroying fluorapatite. So we're now understanding... Yeah, fluoride helps to a certain extent, but not if you have these really bad bacteria. So more to come on those bad bacteria in an upcoming podcast, right? So the fluoride chemistry that we're talking about happening is we want to create as much fluorapatite as possible, which will dissolve with pH 4.5, gives our patients teeth the most protection from that acid challenge that... Today, you got to remember that when tooth decay was really, I mean, tooth decay is more a problem now than it ever has been in the past. But there was a date and time when the leading cause of death in our country was tooth decay, right? That was around the time of the turn of the century. Most people couldn't even serve in the military because they had such bad. oral health that's why we have such a such an oral health presence here in the united states is that we didn't we wouldn't have a military and we realized that early what was the cause of death it was a dental caries spreading to you know lepux angina and spreading okay the heart cardiac yeah it's the connection between the oral environment and the and the heart i mean that's all over the place right now yeah Yeah, you didn't want to go off on a tangential story, but don't get me talking about Willoughby Miller's 1905 address to the first year dental students at UPenn and the linkage between the mouth and systemic health and the fact that every physician in the world pointed to dentists with more respect than they had for their own colleagues because dentists knew that every disease began in the mouth. So you're trying to, when you put fluoride varnish on a tooth crystal or on the outside surface of a tooth, you are not going to get fluoride into that tooth. What you're hoping to get is some sort of synthetic spackle-like of fluorapatite on the surface of the tooth because we realize that fluoride varnish chemistry will allow us to pull calcium phosphate to that tooth surface. So what we need to realize as clinicians is that, number one, that tooth surface has to be squeaky, squeaky, squeaky, squeaky, squeaky, squeaky, squeaky clean. And if you're applying it to an un-carious-affected tooth surface, it's going to have a certain chemical reaction. If you're applying it to a... Carrie's affected tooth surface, it's going to be, and let's just say, an area of early demineralization, like a white spot lesion, an early Carrie's lesion, that E1 lesion, E2 lesion. If you put fluoride varnish on that hydroxyapatite surface, it's going to have a completely different biochemical reaction. And it's going to have a very different chemical reaction if you put it on Carrie's infected dentin that is cavitated, and you're actually now putting it on mush. you know, what G.V. Black would call the toilet of the tooth. So really we have to, we can't assume it's all the same. And I want to point out to any of our listeners who are in the habit of putting fluoride varnish on kids' teeth multiple times a day, remember that it's not as simple as just putting fluoride varnish on top of teeth. So let's talk about the clean, let's talk about the virgin enamel first. Okay. And then we'll talk about the demineralized tooth. And if we have time, we'll talk about the mush, but the mush probably should be SDF first anyway. Yeah, exactly. Exactly. Let's not worry about it. That silver diamine fluoride is another podcast. But people who don't have silver diamine fluoride do use fluoride varnish in that technique. And I would say that's great. But when you do that, my gosh, get as much of that biofilm out of there as you possibly can. If you can get a little spoon excavator and spoon it out before you get fluoride on there, all the better. So now we'll leave that for another time. Go ahead. Right. Let's talk about the fresh, clean enamel. You're doing a full mouth. fluoride varnish on a 12-year-old, for instance. Okay. All right. Well, let's talk about a six-year-old because I think that's where the true value of the fluoride varnish comes into play, right? Is that if we can get the fluoride varnish into a kiddo's mouth while the teeth are erupting and they're in that mixed dentition stage, we, I mean, really, ultimately, our goal in a fluoride varnish application in any child's mouth is to protect the first molars. Period. End of story. We've got to protect those first molars. I mean, all of us, maybe people don't realize just how important first molars are, but when those six-year molars come into a child's mouth, we've got to do everything we can to protect them, which means we want as much fluoride in that environment. Because remember, as long as we have a little bit of fluoride coming off the teeth and the teeth are demineralizing, that's okay. We can kind of deal with that damage. But the great thing about that little bit of fluoride coming off the teeth is that it drives up the solubility constants for calcium and phosphate in the saliva, which means... that you now have your liquid saliva supercharged with calcium phosphate. And if your liquid saliva is supercharged with calcium phosphate, and you've got these crystals of teeth in your mouth, it's going to gravitate to those tooth crystals as long as they're kept clean. And there's a lot of science these days about how, what exactly the pellicle does. When you and I were in school, we didn't really have an intimate understanding of the pellicle, but the pellicle is just absolutely fascinating. And we won't talk about it now, but. go read some papers on the pellicle because it's just, it's wicked, wicked, cool biochemistry. In fact, so cool that people disagree about what is the charge of the pellicle? What is the charge of the tooth? And to your point, this is why in order to become, in order to get the, do well on the DAT and get through, you know, get through your bachelor's degree before you went to dental school. This is why we had to take so much. damn chemistry was so that you would understand when you start picking up products like the most electronegative anion in the periodic table and start slathering around this tooth crystal you better be darn sure you understand what chemistry is happening there because we got lots of different types of fluoride varnish on the market and you have to have an intimate you know have to have not an intimate a doctoral level understanding of what's going on with the chemistry of the mouth the biochemistry of the biofilm and picking your team members that you respect enough to to follow through with your recommendations for what to do with these patients, which is those teeth better be damn clean when you put this stuff. And by the way, why do you like proflorid from VOCO? What is it about that varnish that separates itself? Thank you. Thanks for asking the question. We all know this in practice. When it comes down to selecting a patient, when it comes down to selecting a product for a patient, the evidence-based triad is, well, what does the research say? What is your clinical skill and experience tell you? And what does the patient need and want? How many of our patients don't want fluoride varnish because we don't give them a choice of flavor? And we just tell them, no, you're going to get this because your insurance covers it. We don't tell them what we're doing. And I was that kiddo patient who used to not be given a choice of what flavor they got for their preventive products. And I hated getting my teeth cleaned in the dental office because they always used. orange flavored prophy paste like who uses i mean even to this day who uses orange flavored prophy paste and so many so many i'm gonna just so you're telling me you're using a product from voco that does all this amazing uh remineralization strengthening the enamel because of the flavor yes Yeah. I mean, the science is so solid on fluoride varnish. You can add your enhancers to your fluoride varnish, but at the end of the day, you want your patient to say, I want that stuff. I want that stuff. I want the stuff I got last time. So you've compared the reaction of your patients to multiple different kinds of fluoride varnish on the market, and now you're telling me that you found one that the patients really enjoy, and it makes it a breeze to go through the process of applying it. The success of your fluoride varnish application, the success of the therapeutic value of your fluoride varnish application is intimately linked to the contact time of that fluoride varnish. So if your patient is leaving the office going, God, I got to get this minty stuff off my teeth, or I don't like the sticky feeling in my mouth, and they're scraping it off their teeth, they're not really, I mean, we know that the maximum benefit of fluoride varnish is reached once the fluoride varnish has been in contact with the teeth for four hours. Well, Most patients are going to go leave the office and take a sip of water or get, I mean, if you leave that gunk on their teeth, they're scraping it off. I mean, we don't think like this because we're oral health care providers. We think, well, I told them to leave it on their teeth. Well, do they really? Okay, so I see. So the flavor is directly related to their compliance with that four-hour period. And that four-hour period is very important, apparently. Tell us about that four-hour period. That is very critical. Yeah. Thank you for asking the question. And I hate the word compliance, by the way. What's another word I can use? Well, I don't know, Bill. There's got to be... All right. Well, just let me know. Send me an email. Text me because I do a lot of podcasts and I use the word compliance quite often. So the four-hour window. Once the sodium fluoride varnish hits the tooth surface, what happens is the fluoride and the sodium rapidly disassociate. And that fluoride ion is complexing with the calcium, the first calcium ion that it finds on the tooth surface. So here's what we have to appreciate happens when you put sodium fluoride varnish on clean tooth surface clean tooth not plaque covered teeth not pellicle covered teeth clean teeth service that that sodium that sodium and fluoride are so elect they're so stuck together but when you provide calcium to the mix that fluoride goes holy crap there's something like more than sodium there's some calcium i'm going to grab that calcium and saliva washes over that tooth surface and it just helps pull that sodium away from the fluoride and now that fluoride grips more tightly onto the calcium on the hydroxyapatite surface now you have calcium fluoride deposits forming on the tooth surface like these little bubbles and they look like bubbles on scan electron microscopy and then what happens is that phosphate rich saliva which is rinsed over the surface that phosphate is now complexing with the calcium fluoride crystals and it kind of stabilizes order and stabilizes those globules of calcium fluoride on the tooth and now you have this really nice homogeneous spackle of synthetic it's not you didn't create new floor appetite hydroxyapatite rods you created this spackle of calcium fluoride globules mortared and just smashed together with a whole bunch of phosphate. And now you have a sacrificial anode on the tooth. So as long as the patient, when you ask, well, how often, how long does that last? If it stays in contact with the tooth for four hours, we think that the fluoride varnish actually causes this chemical reaction to occur, which results in a layer of fluorapatite, about 90 micrometers. At least that's the research. Right on top of the enamel. Right on top of the enamel. So you basically have created, I mean, really there's no other way to think about it other than spackle. You've drywalled the tooth. It's almost a veneer of... Exactly. And actually, you have really drywalled the tooth because what is the inside of drywall? It's hydroxyapatite. That's true. I mean, that's what's inside your drywall. So before you go on, now you said it's very important to clean the teeth. If the tooth surface is not clean... How deprecated is this whole process if that surface isn't really spanking clean? If that surface is not clean, I want to say shame on you. Because if that surface is not clean, and granted, you have to appreciate that we don't really get surfaces clean with the ProfiCup. a toothbrush with a with proper modified bass action we really have to be aware of the fact that many of us in oral health care do not properly brush patients teeth even when we put it when you put a toothbrush in our own hands and we are asked and we want to brush patients teeth we just start scrubbing and rubbing every direction we possibly can think to do it we don't actually do modified baths and so i would encourage us all to sit down with your team and have each other brush each other's teeth And criticize each other's technique. Critically appraise and criticize each other's techniques. So you're saying that, okay, so the operator, the person on the dental team, whether it's a dentist, hygienist, or assistant, who's applying this material, is going to brush the patient's teeth first in order to clean it. Clean the teeth. Do not just wipe them with gauze. Get them as clean as you possibly can. What do you brush them with? Well, I love brushing them with an EDTA gel called Live Fresh. It's an edathomil gel that chelates calcium out of the biofilm, literally strips the biofilm off the teeth, gets them squeaky, squeaky clean. So you fully brush with that? Yeah. We don't even use prophy paste anymore. I brush my patients with Live Fresh. Okay, so you brush with that, and then you don't fully dry the surface because you need moisture there. Well, no, you do want to. See, this is where we have started to fall victim to IFUs that are designed around in vitro studies and this hydrophilicity of fluoride, because you're right. You're absolutely right there. Fluoride likes water. But the question we have to ask ourselves, Phil, is are our team members leaving water behind on the teeth or are they leaving saliva behind on the teeth? Because I would bet dollars, hundreds of dollars, that many of us in dentistry. Think water when it's really saliva. And so if you're leaving saliva on the teeth, that's very different than leaving water on the teeth. You can leave water on the teeth, but that means you're isolated. You've cleaned everything off. You've car wash sprayed everything. And things are just wet with water from your air water syringe. Not floppy saliva, proteinaceous, plaque-laden saliva from your patient's tongue. Okay, so what do you leave the surface? Do you want it dry when you do it? I want it dry because I want the surface dry. That fluoride is going to interact. I want the water in. the colophony in the, in the, the, or the carrier, which is usually. Colophony is rosin. That's rosin. Yeah. Right. And I want the, I want the carrier molecule, that alcohol or the hydrophilic molecule in the fluoride varnish. I want that to be the water carrying it to the, I want that to be the solvent carrying to the hydroxyapatite crystal. If you have water in there, that's fine. I mean, water's fine. But again, many people think saliva is water. Saliva is not water. How do you isolate the teeth? Otten rolls. Cotton rolls. So you do a full mouth or one arch at a time? I work as cooperative as the patient is. And if you look at the research, it says a fluoride varnish application should take no less than one minute and could take up to four minutes. And that means you could be spending a minute per quadrant isolating, getting it, getting, you know, rinsing it with water, getting it dry, putting your fluoride varnish on, then moving on the next quadrant, letting saliva wash over that quadrant you just treated. And you air dry with this air water syringe? I do. And I realized some people are like, there's no way this is going to happen in my office. Well, it will if you start talking about how you want to improve your Florida Rarnish application. So that technique, the technique is so critical here. It is. It is. Because you have to remember, we all have to remember. We are using a product off-label. We're using a product which is used for sensitivity. We're using it to prevent tooth decay. So it's off-label use. Make sure you're doing it properly because here's, Phil, you asked, well, what could go horribly wrong? What can go horribly wrong is you cause demineralization. If you're leaving acidic plaque on a tooth surface and you put fluoride varnish on top of acidic plaque, that acidic plaque turns into hydrofluoric acid plaque. Now you're actually holding... hydrofluoric acid on a tooth. And in what universe do you want hydrofluoric acid on tooth service? You don't. And this is why those of us in clinical practice who've been doing this long enough, we have seen in children's mouths, fluoride bombs, these little stain pit and fissure grooves where you think you're going to get into a fissurotomy. You open, you go, I probably should get in there and clean that out a little bit. You open it up. And next thing you know, you're in the pulp. You're doing the pulpotomy or pulpectomy or... Or heaven forbid, you're saying, I think we need to extract this unless you can get your kid in for a pediatric root canal in this tooth. And it's because someone has over misused fluoride varnish without getting those occlusal grooves cleaned. They put fluoride varnish on top of plaque and occlusal grooves. And that acidic plaque was just marinated in fluoride. And we all know from chemistry in college, what happens when you put an acid and fluoride together? You create hydrofluoric acid. You may kill off bacteria. But great, now you have a bunch of dead bacteria and a goo of hydrofluoric acid just sitting in an occlusal groove, not being cleaned. What did you think was going to happen? Well, that is a nightmare of a situation. I'm glad I asked that question. Okay, so you've cleaned the tooth. Now, you want to put a very thin... Oh, I'm sorry. May I just cut you off? May I say, though, this is also why some people are hesitant to put fluoride varnish on occlusal grooves, because they would much rather say, well, then I would much rather just put fluoride varnish on the facial surfaces where I know they're getting clean. So, yeah, if you can't get the teeth super, super clean, put the fluoride varnish where you know you've cleaned the teeth. Because the saliva will carry some fluoride and some calcium phosphate to that plaque that you're leaving undisturbed. But please don't put fluoride varnish on top of plaque you've left behind because you didn't have time to clean the tooth properly. Okay, that's a great, great point. Great point, Dr. Novy. So the teeth are clean. We're using VOCO Pro Fluoride Varnish, your favorite, because you love the flavor. We want to put a very thin coat on. Tell us how we do this. Well, when we say thin coat... I think it's because we all, if you picture in your mind, if we take our listeners to that moment when you're dragging the brush of fluoride varnish through the patient's mouth, sometimes that brush becomes wet with saliva. When that happens, have you ever noticed that when that happens, all of a sudden at the end of your brush, that fluoride turns into a booger. And that booger is now sticking to the brush and doesn't want to stick to the teeth anymore. And now you're dragging this kind of... smooth booger around the mouth, but the booger is stuck to the brush and no fluoride is coming off the brush under the tooth surface. That's happened because all the chemistry you wanted on the tooth surface is happening on the end of the brush now, and you have lost complete control of the clinical situation. What you need to do is get rid of that brush, get the saliva out of the patient's mouth. Because what's happening is all the chemistry from the saliva that you want to happen on the tooth is being pulled to the brush now. So you need to get rid of that brush. And if you've dipped that brush back in the fluoride varnish you've been using, well, now all that chemistry is happening there in your wet, goopy fluoride varnish. So this is why you want to try to not re-dip a gloppy brush that isn't working anymore. Get a new brush. So for the dentists out there, encourage your team members when they're doing this. It's okay if you want to grab a couple extra micro brushes or better yet, bend the brushes, whatever. brush you like to apply florid varnish i want you to have a couple extra ones handy because sometimes patients tongues flop over and all of a sudden when you notice that booger forming up that's when we throw away our brush we get a new brush and then we get back in control of the clinical situation all right so now you've applied this material thin coat on all the teeth if you are good enough to do it on the grooves and you felt like you were able to clean the grooves adequately you place it on the you apply them to the grooves now what is the post procedure instructions for that patient and what do they do? Can they drink fluid? I know they shouldn't be eating for four hours, but can they drink water? You know, I think everyone's IFUs probably say something along the same lines of avoid eating and drinking for 30 minutes up to four hours. I would say explaining to the patient, we just put something on your teeth that needs time to work. And the timer starts right now. So the longer you can go and let that big hand go around, you know, every hour, if you can go four times around the clock with the big hand, that would be fantastic. Do you think you can go that long without eating or drinking anything? I know it's gonna be really, really hard, but if you start to get really thirsty or something, you start thinking, oh, I want to get this taste out of my mouth because, well, hopefully you don't, hopefully you don't because you like the way it tastes. It tastes, you know, like gummy bears. however you want to explain it to the patient, to get them, not so that you're harping on them about don't drink water for four hours. When you tell a patient don't drink water for four hours, the first thing they do is go drink water in the next four hours. So, I mean, we have got to change the way we talk to patients because we don't realize the reason patients don't do what we say is because we told them what not to do. Do you have them hydrate before the procedure? Yeah, you could. That's a great idea, Phil. Have them hydrate and say, you know, you're not going to... Well, after you've been practicing, what, 30, 25 years? And I just gave it 15 years. I, you know, it's well, and I just gave you that idea. And I'm sitting here. It is. I love it. It's a great idea to bring up with your listeners because I didn't think of it to share. You look like you're out of high school about two years. You have a very, I mean, you look like you're not no more than 25, but I know you've been around teaching for quite a while. So I don't know how old you are, but you got to be practicing for at least 20 years. All right. So now the patient left the practice. and i'm not going to use the word compliant they're not compliant because you don't like that word they followed instructions and they actually didn't drink or eat for four hours during those four hours what is happening now exactly you told us quickly but tell us what's happening so now what's happening you've got created these calcium fluoride deposits stabilized by phosphate. And now there is this rapid, rapid chemical exchange that's going on where within any early demineralized areas of the tooth, the calcium, there's labile calcium in that tooth surface. And that labile calcium is not bound to anything. That's why it's labile, right? All that labile calcium, which is bouncing around inside the body of the lesion and the tooth is now weak, you're pulling that up to the surface of the tooth. And so this is where when you start putting fluoride varnish on top of early demineralized areas versus, you know, unaffected virgin teeth that you just want to hypermineralize, the thermodynamics of what's going on is it needs to really be appreciated because if you have any macro cavitations and that fluoride varnish is getting in there, you really are disrupting the mineral balance inside the body of the lesion so much so you want this rapid. destruction of the hydroxyapatite to then quickly become replaced with fluorapatite and get some sort of remineralization. So that happens for four hours. Yes. And after four hours, it's inconsequential, whatever. Well, after four hours, we believe that the fluoride varnish is gone after four hours. Not even on the tooth. You're saying it's probably not there. Like the colophony is still there, but now you've, that's, I mean, the thermodynamics of fluoride is so aggressive when it's just simply the electronegativity of the anion. it's so aggressive that it happens fairly rapidly. And then it results in this burst phenomenon that we see. Once it's incorporated in the tooth, you've got this burst phenomenon. And then, of course, usually the patient by that point has eaten or drank something, or they scratch their teeth, or they've wiped their teeth enough time with their tongue that this stuff is falling off. So this colophany, which is the rosin, could that be brushed off after four hours? Yeah, yeah. I mean, if it's irritating, they should, yeah, they can. What is it, like a sticky, slimy feeling on their teeth? Or what does it feel like to the tongue? Well, it depends on which version you're using. Pro-fluorid varnish from Voco. Okay. Well, after four hours, I don't think you're going to notice really hardly any sticky. It feels a little bit more like a waxy coating, I think, at that point than stickiness. It's really no patient wants their teeth cleaned and then to be coated in tree sap. Right. Let me ask you a question. Tell us how important it is. You mentioned the six-year-old kid with the erupting molars. They have their first molars in. How important is it, generally speaking, for the dental population to have this kind of material like profluorid varnish applied properly to the teeth for the long-term health of that patient, that oral health, if it's done regularly? I mean, we'll talk about how often we need to do this treatment, but this is such a consequential treatment in your opinion, is it not? This is going to sound trite, but there's no... more important procedure that child is going to have in a healthcare setting unless they have some severe systemic illness, which is life-threatening. A fluoride varnish application is hands down, in my opinion, the most important healthcare procedure a child can have, especially if the first molars are benefiting from that procedure. And if it's done properly, you are setting that child up to avoid the most expensive, prevalent and preventable disease that affects humanity. And if you do it right, you do an incredible service to that child. And if you do it wrong, you set up that child to get an injection at the base of their skull in the future. That's a very profound statement. I'm glad you answered it that way. What proportion of dentists that are practicing out there, I'm not talking about necessarily pediatric dentists, but just... GPs that treat kids are handling this material properly, using it properly, where the patient benefits in the way you just described. Are we doing well with this? I would like to think that all of my colleagues are monitoring what's going on in their offices to the level that our patients are reaping the maximum benefit from these preventive procedures that we can delegate. to our team members. The reality is that it doesn't happen like that in every office. And we as dentists really need to claim ownership of what's happening clinically in settings where it may not be dentist owned or where you may not be the dentist owner and start impressing upon the owners that no, no, no, no, this is a new era of oral health care. And these preventive procedures are much more important now than ever before, especially when we know that some of the population are going to lose the benefits of water fluoridation, which I get it. I get it. You should have the right to choose what's in your water. I totally understand. And none of us want any child to be poisoned. No dentist wants a child to be poisoned. Why would a dentist want that? We know, we just know that when kids get fluoridated water, and granted, most children don't reap the benefit of fluoridated water because they don't drink fluoridated water anyway. But there are going to be populations where we see tooth decay get out of control. And it's going to be the greatest public health story. ever told 20 years from now when we see what happens when we didn't have fluoride then we did have fluoride and we took it away and people are going to point fingers at the dentist say oh look the dentist got rich well none of the dentists were for this so what it allows us to do is it allows us to more judiciously use what we know works to prevent and arrest cavities and it actually paves the way for us to do to use other therapeutics in combination with fluoride or for those patients who are just so scared of fluoride which i get it i can see why you would be scared. There's a lot of scary stuff out there. But for those patients who don't want it, we will have other things that we can use. We just need to know if we realize those things aren't working, can we have permission to put one version of fluoridone that we know will work because we don't want to give your child an injection at the base of their skull to treat something we could have treated with a liquid that tasted like gummy bears. How often do you recommend a six-year-old child, for instance, since we're talking about six-year-old children, to come back to the practice, to get this reapplication of pro-fluorid varnish? Well, it depends on the child's caries risk. I mean, there are kids out there who only drink water and milk, who eat very proteinaceous breakfast, whose parents don't allow them to have anything acidic. You know, they're not chewing on orange slices all the time. They're not drinking Gatorade. That's the exception to the general population. That's more of an exception. Yeah. Those kids. Those kids, they're not going to reap the benefits of fluoride varnish every three months. But to a kiddo who has a cariogenic diet, every three months having fluoride varnish applied to your teeth would be ideal. I would say you might get pushed out every four months. But to the most high-risk kids are going to benefit if they get it quarterly. The reality is those kids don't come into the office. So that's why we really need to make sure we get it on their teeth at least every six months. And so those six-month checkups are much more important than just saying, oh, yeah, is everything developing? Are we actually stabilizing that highly carbonated hydroxyapatite that's erupting in your mouth? Are we stabilizing it by saturating your slide with calcium phosphate? And that's what we do with fluoride. Great discussion, Dr. Novy. I know you must have some closing thoughts, so tell us what they are. Well, I was just going to say, as you were talking, I want to validate the fact that for our team members who do take their clinical roles very seriously and do a preventive procedure like a topical fluoride varnish application and do it with the intention of this is your role in the office to actually provide care to a living, breathing human being. And understanding your role in healthcare delivery and getting that patient healthy and maintaining their health in the future is so critical. And so if you are the person doing fluoride varnish, it is incumbent upon you to really... realize this isn't i'm being allowed to do something to a human being to prevent the most prevalent preventable disease on the planet and if it works You're a hero. If it works and it does, you're a hero. And that child will never really know, won't remember, but you will remember the time and the effort that you put in to helping that little kiddo maintain their teeth for the rest of their life. Because that's what that, I mean, come on, that first molar has got to last the rest of our life. And we know what happens when you start losing your first molar. Decay, shifting, tilting. loss of vertical dimension and the sequela goes on and on and on. So Dr. Novy, for our audience, if they want to reach out to you, what's a good website to visit or what's the best way for them to get in touch with you? I just completed updating my website for 2025. So you can visit my new website, which is www.holymolar.com. It used to be holymolar.net. Now it's W-H-O-L-L-Y. M-O-L-A-R.com, holymolar.com. And I've got a lot of handouts on there, and I've got links to some lectures as well. You gave a tremendous webinar, Dr. Novy, on Viva Learning back in February. What was the title of that? I believe the title was The Anion's Final Bow. Yes, that's correct. So just go to vivalearning.com, type in Novy, N-O-V-Y, and you will see his lectures in chronological order. The newest ones will be on top. Check that one out. fantastic webinar. It talks about the science of fluoride varnish. If you're looking to take your fluoride varnish procedures to a level that will really optimize the results clinically on your patients, especially those young kiddos, as Dr. Novy points out, check out that webinar and enjoy it. Thank you very much, Dr. Novy. We really appreciate your time. Thank you, Phil. Always fun.