Optimizing Fluoride Retention in the Mouth of Older Adults With Distinct Salivary Flow Rates
Phase: PHASE1
Conditions: Hyposalivation
Sponsor: University of Michigan

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er 
a d ults wit h disti nct s ali v ar y fl o w r at es  
 
Pr ot oc ol N u m b er: 0 1  
N ati o n al Cli nic al Tri al ( N C T) I d e ntifi e d N u m b er:  N C T 0 4 2 3 9 8 7 2  
Pri nci p al I n v esti g at or:  Li vi a M. A. T e n ut a  
F u n d e d b y : MI C H R  
V ersi o n N u m b er:  v . 1.3  
2 0 A u g ust 2 0 2 0  
 
 

  
 
ii 
Ta bl e of C o nt e nts  
S T A T E M E N T O F C O M P LI A N C E  ............................................................................................................................ 1  
1  
P R O T O C O L S U M M A R Y  .............................................................................................................................. 1  
1. 1  
S y n o p si s  ............................................................................................................................................... 1  
1. 2  
S c h e m a  ................................................................................................................................................ 2  
1. 3  
S c h e d ul e of A cti viti e s ( S o A)  .............................................................................................................. 3  
2  
I N T R O D U C TI O N ........................................................................................................................................... 3  
2. 1  
St u d y R ati o n al e  ................................................................................................................................... 3  
2. 2  
B a c k gr o u n d  .......................................................................................................................................... 4  
2. 3  
Ri s k/ B e n efit A s s e s s m e nt  ................................................................................................................... 4  
2. 3. 1  
K n o w n P ot e nti al Ri s k s  .................................................................................................... 4  
2. 3. 2  
K n o w n P ot e nti al B e n efit s  ............................................................................................... 5  
2. 3. 3  
A s s e s s m e nt of P ot e nti al Ri s k s a n d B e n efit s  ............................................................... 5  
3  
O B J E C TI V E S A N D E N D P OI N T S  ............................................................................................................... 5  
4  
S T U D Y D E SI G N  ............................................................................................................................................ 6  
4. 1  
O v er all D e si g n  ..................................................................................................................................... 6  
4. 2  
S ci e ntifi c R ati o n al e f or St u d y D e si g n  ............................................................................................... 7  
4. 3  
J u stifi c ati o n f or D o s e  .......................................................................................................................... 7  
4. 4  
E n d of St u d y D efi niti o n  ....................................................................................................................... 7  
5  
S T U D Y P O P U L A TI O N  .................................................................................................................................. 7  
5. 1  
I n cl u si o n Crit eri a ................................................................................................................................. 7  
5. 2  
E x cl u si o n Crit eri a  ................................................................................................................................ 8  
Lif e st yl e C o n si d er ati o n s  ........................................................................................................................................ 8  
5. 3  
S cr e e n F ail ur e s  ................................................................................................................................... 8  
5. 4  
Str at e gi e s f or R e cr uit m e nt a n d R et e nti o n  ....................................................................................... 8  
6  
S T U D Y I N T E R V E N TI O N  .............................................................................................................................. 9  
6. 1  
St u d y I nt er v e nti o n( s) A d mi ni str ati o n  ................................................................................................ 9  
6. 1. 1  
St u d y I nt er v e nti o n D e s cri pti o n  ...................................................................................... 9  
6. 1. 2  
D o si n g a n d A d mi ni str ati o n  ............................................................................................. 9  
6. 2  
Pr e p ar ati o n/ H a n dli n g/ St or a g e/ A c c o u nt a bilit y  ................................................................................. 9  
6. 2. 1  
A c q ui siti o n a n d a c c o u nt a bilit y  ....................................................................................... 9  
6. 2. 2  
F or m ul ati o n, A p p e ar a n c e, P a c k a gi n g, a n d L a b eli n g  ............................................... 1 0  
6. 2. 3  
Pr o d u ct St or a g e a n d St a bilit y  ...................................................................................... 1 0  
6. 2. 4  
Pr e p ar ati o n  ..................................................................................................................... 1 0  
6. 3  
M e a s ur e s t o Mi ni mi z e Bi a s: R a n d o mi z ati o n a n d Bli n di n g  .......................................................... 1 1  
6. 4  
St u d y I nt er v e nti o n C o m pli a n c e  ....................................................................................................... 1 1  
7  
S T U D Y I N T E R V E N TI O N DI S C O N TI N U A TI O N A N D P A R TI CI P A N T 
DI S C O N TI N U A TI O N/ WI T H D R A W A L  ................................................................................................................... 1 1  
7. 1  
Di s c o nti n u ati o n of St u d y I nt er v e nti o n  ............................................................................................ 1 1  
7. 2  
P arti ci p a nt Di s c o nti n u ati o n/ Wit h dr a w al fr o m t h e St u d y  .............................................................. 1 1  
7. 3  
L o st t o F oll o w -U p  .............................................................................................................................. 1 2  
8  
S T U D Y A S S E S S M E N T S A N D P R O C E D U R E S  ..................................................................................... 1 2  
8. 1  
Effi c a c y A s s e s s m e nt s  ...................................................................................................................... 1 2  
8. 2  
A d v er s e E v e nt s a n d S eri o u s A d v er s e E v e nt s  .............................................................................. 1 5  
8. 3  
U n a nti ci p at e d Pr o bl e m s  ................................................................................................................... 1 5  
9  
S T A TI S TI C A L C O N SI D E R A TI O N S  .......................................................................................................... 1 5  
9. 1  
St ati s ti c al H y p ot h e s e s ...................................................................................................................... 1 5  

  
 
iii 
9. 2  
S a m pl e Si z e D et er mi n ati o n  ............................................................................................................. 1 6  
9. 3  
P o p ul ati o n s f or A n al y s e s  ................................................................................................................. 1 6  
9. 4  
St ati s ti c al A n al y s e s ........................................................................................................................... 1 6  
9. 4. 1  
G e n er al A p pr o a c h  ......................................................................................................... 1 6  
9. 4. 2  
A n al y si s of t h e Pri m ar y Effi c a c y E n d p oi nt( s)  ............................................................ 1 7  
9. 4. 3  
A n al y si s of t h e S e c o n d ar y E n d p oi nt( s)  ...................................................................... 1 7  
1 0  
S U P P O R TI N G D O C U M E N T A TI O N A N D O P E R A TI O N A L C O N SI D E R A TI O N S  .............................. 1 8  
1 0. 1  
R e g ul at or y, Et hi c al, a n d St u d y O v er si g ht C o n si d er ati o n s  .......................................................... 1 8  
1 0. 1. 1  
I nf or m e d C o n s e nt Pr o c e s s .......................................................................................... 1 8  
1 0. 1. 2  
St u d y Di s c o nti n u ati o n a n d Cl o s ur e  ............................................................................. 1 8  
1 0. 1. 3  
C o nfi d e nti alit y a n d Pri v a c y  ........................................................................................... 1 9  
1 0. 1. 4  
K e y R ol e s a n d St u d y G o v er n a n c e  .............................................................................. 1 9  
1 0. 1. 5  
D at a H a n dli n g a n d R e c or d K e e pi n g  ........................................................................... 1 9  
1 0. 1. 6  
Pr ot o c ol D e vi ati o n s  ....................................................................................................... 2 0  
1 0. 1. 7  
P u bli c ati o n a n d D at a S h ari n g P oli c y  .......................................................................... 2 0  
1 0. 1. 8  
C o nfli ct of I nt er e st P oli c y .............................................................................................. 2 0  
1 0. 2  
A b br e vi ati o n s  ..................................................................................................................................... 2 1  
1 1  
R E F E R E N C E S  ............................................................................................................................................. 2 2  
 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
1  
S T A T E M E N T O F C O M P LI A N C E  
T h e pr ot oc ol, i nf or m e d c o ns e nt f or m(s), r ecr uit m e nt m at eri als, a n d all p artici p a nt m at eri als will b e 
s u b mitt e d t o t h e I R B f or r evi e w a n d a p pr o v al.  A p pr o v al of b ot h t h e pr ot oc ol a n d t h e c o ns e nt f or m m ust 
b e o bt ai n e d b ef or e a n y p artici p a nt is e nr oll e d.  A n y a m e n d m e nt t o t h e pr ot oc ol will r e q uir e r evi e w a n d 
a p pr ov al by t h e I R B b ef or e t h e c h a n g es ar e i m pl e m e nt e d t o t h e st u d y.  All c h a n g es t o t h e c o ns e nt f or m 
will b e I R B a p pr ov e d; a d et er mi n ati o n will b e m a d e r e g ar di n g w h et h er  a n e w c o ns e nt n e e ds t o b e 
o bt ai n e d fr o m p artici p a nts w h o pr ovi d e d c o ns e nt, usi n g a pr evi o usl y  a p pr ov e d c o ns e nt f or m. 
1  
 
P R O T O C O L S U M M A R Y  
1. 1  
S Y N O P SI S  
Titl e:  
O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct 
s ali v ar y fl o w r at es 
 
St u d y D es cri pti o n: 
 
T his st u d y will ass ess t h e eff ect of a n i m pr ov e d fl u ori d e m o ut h r i ns e 
(c o m bi n e d wit h a c alci u m pr e ri ns e) o n e n h a nci n g t h e r et e nti o n of fl u ori d e 
i n t h e m o ut h of ol d er a d ults wit h s ali v a fl o w r a n gi n g fr o m n or m al t o 
h y p os ali v ati o n . T h e st u d y h y p ot h esis is t h at t h e c alci u m pr eri ns e  will 
i ncr e as e t h e r et e nti o n of fl u ori d e i n t h e m o ut h of ol d er a d ults, w h e n 
c o m p ar e d wit h t h e fl u ori d e ri ns e al o n e.  
  
O bj ecti v es:  
Pri m ar y O bj ecti v e: D et er mi n e t h e b e n efit of usi n g a c alci u m m o ut h ri ns e, 
b ef or e a fl u ori d e m o ut h ri ns e, t o e n h a nc e fl u ori d e r et e nti o n i n t h e m o ut h 
of i n di vi d u als wit h h y p os ali v ati o n.   
 
S ec o n d ar y O bj ecti v es: T o d et er mi n e t h e r ol e of h y p os ali v ati o n o n t h e 
r et e nti o n of fl u ori d e i n t h e m o ut h aft er a fl u ori d e ri ns e.   
 
E n d p oi nts:  
 
Pri m ar y E n d p oi nt: Fl u ori d e c o nc e ntr ati o n i n d e nt al pl a q u e ( bi ofil m) u p t o 2 
h aft er a m o ut h ri ns e  
S ec o n d ar y E n d p oi nts: Fl u ori d e c o nc e ntr ati o n i n s ali v a u p t o 2 h aft er a 
m o ut h ri ns e; C alci u m c o nc e ntr ati o n i n d e nt al pl a q u e a n d s ali v a u p t o 2 h 
aft er a m o ut h ri ns e  
 
St u d y P o p ul ati o n:  
 
T w e nt y i n di vi d u als , wit h 6 5 y e ars of a g e  or m or e , fr o m b ot h g e n d ers, wit h 
g o o d g e n er al h e alt h, i n d e p e n d e nt, wit h g o o d or al h e alt h, fr o m t h e A n n 
Ar b or, MI ar e a. At l e ast 1 0 i n di vi d u als s h o ul d h av e si g ns of h y p os ali v ati o n 
( dr y m o ut h). 
 
P h as e:  
 
1  
 
D escri pti o n of 
Sit es/ F aciliti es E nr olli n g 
P artici p a nts:  
 
P artici p a nts will b e r ecr uit e d a m o n g p ati e nts fr o m t h e Sc h o ol of D e ntistr y, 
U ni v ersit y of Mic hi g a n, i n A n n Ar b or, MI.  
 
 
D escri pti o n of St u d y 
I nt er v e nti o n: 
 
T h e st u d y will h av e 2 i nt erv e nti o ns (cr oss ov er d esi g n): a. a s o di u m fl u ori d e 
m o ut h ri ns e at a n ov er-t h e-c o u nt er c o nc e ntrati o n of 0. 0 5 % ( 2 2 6 p p m of 
fl u ori d e), us e d f or 1 mi n; b. a c alci u m m o ut h ri ns e (c alci u m l act at e at a 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
2  
c o nc e ntr ati o n of 1 5 0 m M) us e d f or 1 mi n, f oll o w e d b y t h e s o di u m fl u ori d e 
m o ut h ri ns e d escri b e d i n a. 
 
 
St u d y D ur ati o n:  
 
3 6 m o nt hs  
 
P artici p a nt D ur ati o n:  
 
1 m o nt h  
 
 
1. 2  
S C H E M A  
    
Fl o w di a gr a m  of t h e st u d y  
Pri or t o  
E nr oll m e nt  
 
 
Visit 1  
 
 
 
 
 
 
 
 
 
 
 
 
 
Visit 2  
 
 
W as h -o ut  
( at l e ast o n e w e e k) 
 
 
Visit 3  
 
 
 
 
 
N = 2 0 + p artici p a nts:  R ecr uit m e nt of  i n di vi d u als wit h  6 5 y e ars of a g e or m or e, 
wit h at l e ast 2 0 t e et h i n t h e m o ut h ( 4 i n e ac h q u a dr a nt).  
O bt ai n i nf or m e d c o ns e nt. I ntr a or al ex a m t o c h ec k f or a d diti o n al i ncl usi o n a n d 
excl usi o n crit eri a. P erf or m ass ess m e nt of u nsti m ul at e d a n d sti m ul at e d s ali v ar y 
fl o w r at e.  
Eli gi bl e i n di vi d u als will r ec ei v e st a n d ar diz e d t o ot h p ast e a n d t o ot h br us h a n d 
c o nti n u e t o f oll o wi n g visits.  
A p plic ati o n of t h e ot h er tr e at m e nt, n ot t est e d b ef or e (cr oss o v er d esi g n). 
C oll ecti o n of s ali v a a n d bi ofil m s a m pl es b ef or e a n d u p t o 2 h aft er t h e ri ns e.  
 
Tr e at m e nt B  
F ri ns e pr ec e d e d b y C a ri ns e  
N = 1 0  
Tr e at m e nt A  
F ri ns e o nl y  
N = 1 0  
A p plic ati o n of t h e tr e at m e nt assi g n e d b y r a n d o miz ati o n. C oll ecti o n of s ali v a a n d 
bi ofil m s a m pl es b ef or e a n d u p t o 2 h aft er t h e ri ns e.  
R a n d o miz e  

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
3  
1. 3  
S C H E D U L E O F A C TI VI TI E S ( S O A)  
 
Pr oc e d ur es  
B as eli n e, Visit 1  
D ay 0  
St u dy Visit 2  
D ay 7   
( + 1 m o nt h) 
St u dy Visit 3  
D ay 1 4   
( + 1 m o nt h)  
I nf or m e d c o ns e nt 
X  
 
 
D e m o gr a p hics  
X  
 
 
M e dic al hist ory  
X  
 
 
I ntr a-or al ex a m  
X  
 
 
S aliv a fl o w r at e ass ess m e nt  
X  
 
 
R a n d o miz ati o n  
X  
 
 
A d mi nist er st u dy i nt erv e nti o n  
 
X  
X  
S aliv a s a m pl es c oll ecti o n  
 
X  
X  
D e nt al bi ofil m s a m pl es c oll ecti o n  
 
X  
X  
A dv ers e ev e nts r e p orti n g 
 
X  
X  
 
 
2  
 
I N T R O D U C TI O N 
 
2. 1  
S T U D Y R A TI O N A L E   
S ali v a pl ays a m aj or r ol e i n m ai nt ai ni n g or al h e alt h. A r e d ucti o n i n s ali v a fl o w ( h y p os ali v ati o n) dr astic all y 
i ncr e as es t h e ris k f or or al dis e as es, i ncl u di n g  c aviti es. H y p os ali v ati o n ( dr y m o ut h) is a s p eci al c o nc er n f or 
ol d er i n divi d u als : a b o ut 8 0 % of A m eric a n p e o pl e o v er 6 5 y e ars of a g e h a v e at l e ast o n e c hr o nic 
c o n diti o n a n d 6 8 % h av e at l e ast t w o [ N ati o n al C o u ncil o n A gi n g, 2 0 1 5]. M a n y of t h e m e dic ati o ns us e d t o 
c o ntr ol t h es e c o n diti o ns c a us e h y p os ali v ati o n [ W olff et al., 2 0 1 7]. Als o, w it h a gi n g t h er e is a n at ur al 
ex p os ur e of t h e t e et h r o ots t o t h e or al c a vit y, a n d t h es e ar e m or e s usc e pti bl e t o c aviti es d u e t o t h e 
hi g h er s ol u bilit y of t h eir c e m e nt u m/ d e nti n w h e n c o m p ar e d wit h t h e e n a m el c ov eri n g t h e t e et h cr o w ns. 
T h er ef or e, m ai nt ai ni n g or al h e alt h i n ol d er i n di vi d u als wit h dr y m o ut h is c h all e n gi n g ; t h e r es ulti n g p ai n, 
p o or n utriti o n a n d i m p air e d s oci al f u ncti o ns a d d t o t h e ov er all r e d ucti o n i n q u alit y of lif e i n t h es e ol d er 
a d ults alr e a d y s uff eri n g fr o m dr y m o ut h.  
Fl u ori d e h as b e e n s ucc ess f ull y us e d t o m ai nt ai n or al h e alt h, es p eci all y i n dr y m o ut h p ati e nts. Y et, t h e 
ki n etics of fl u ori d e i n t h e m o ut h of ol d er a d ults, i ncl u di n g t h os e wit h h y p os ali v ati o n, is p o orl y 
u n d erst o o d. Alt h o u g h t h ey n e e d t o us e fl u ori d e i n hi g h er c o nc e ntr ati o ns, s uc h as pr escri pti o n 
t o ot h p ast es c o nt ai ni n g 5, 0 0 0 p p m of fl u ori d e ( F), t h e ext e nt of t h e eff ecti v e n ess of usi n g hi g h er fl u ori d e 
c o nc e ntr ati o ns i n h y p os ali v ati o n p ati e nts  h as sc arc el y b e e n ex pl or e d. Ev e n i n i n di vi d u als wit h n or m al 
s ali v ar y fl o w, t h e us e of a 5, 0 0 0 p p m F ri ns e d o es n ot r es ult i n t h e ex p ect e d i ncr e as e d r et e nti o n of 
fl u ori d e i n t h e m o ut h [ St a u n L ars e n et al., 2 0 1 8], s u g g esti n g t h at t h er e is a li mit f or i ncr e asi n g i ntr a or al 
fl u ori d e c o nc e ntr ati o n fr o m or al h y gi e n e pr o d ucts w h e n ai mi n g at i ncr e asi ng t h eir r et e nti o n. T his m a y 
b e d u e t o t h e li mit e d s u p pl y of p ositi v el y c h ar g e d c ati o ns, s uc h as c alci u m, t o w hic h fl u ori d e c o ul d b e 
b o u n d, t o b e r et ai n e d f or l o n g er p eri o ds i n t h e m o ut h [ V o g el 2 0 1 1]. Alt er n ati v e a p pr o ac h es ai mi n g t o 
o pti miz e t h e fl u ori d e r et e nti o n b y pr evi o usl y s u p pl yi n g a c alci u m s o urc e h a v e b e e n d ev el o p e d [ V o g el et 
al., 2 0 0 6 a, 2 0 0 6 b, 2 0 0 8 a, 2 0 0 8 b], b ut n ev er t est e d i n h y p os ali v ati o n p ati e nts. F or i nst a nc e, t h e us e of a 
c alci u m ri ns e b ef or e a fl u ori d e ri ns e ( C a →F) s ucc essf ull y e n h a nc es fl u ori d e r et e nti o n i n t h e m o ut h 
[ S o uz a et al., 2 0 1 6], u n d er n or m al s ali v ar y fl o w c o n diti o ns. T his a p pr o ac h c o ul d b e p artic ul arl y h el pf ul 
f or hy p os ali v ati o n p ati e nts, b y als o pr ovi di n g a s u p pl y of c alci u m i o ns, w hic h ar e li mit e d d u e t o t h e l o w 
s ali v a pr o d ucti on.  

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
4  
I n t h e pr es e nt tri al, t h e eff ect of s ali v ar y fl o w r at e (fr o m n or m al t o h y p os ali v ati o n) o n t h e r et e nti o n of 
fl u ori d e i n t h e m o ut h  of ol d er a d ults aft er a fl u ori d e ri ns e will b e st u di e d. W e h y p ot h esiz e t h at alt h o u g h 
a r e d ucti o n i n s ali v ar y fl o w r e d uc es t h e r at e of cl e ar a nc e of fl u ori d e fr o m t h e m o ut h, t h e l o w er 
av ail a bility of c alci u m i o ns d u e t o t h e l ac k of s ali v a als o r e d uc es fl u ori d e r et e nti o n.  Als o, t h e eff ect usi n g 
a c alci u m ri ns e b ef or e t h e fl u ori d e ri ns e t o i ncr e as e fl u ori d e r et e nti o n i n t h e m o ut h will b e t est e d i n 
ol d er i n divi d u als wit h a r a n g e of s ali v ar y  fl o w r at es. W e h y p ot h esiz e t h at t h e i ncr e as e d r et e nti o n of 
fl u ori d e o bs erv e d aft er a c alci u m pr eri ns e will b e e n h a nc e d i n i n di vi d u als wit h l o w s ali v a fl o w. 
 
2. 2  
B A C K G R O U N D   
Dry m o ut h is a s eri o us a n d pr ev al e nt pr o bl e m i n ol d er a d ults [ F ur n ess et al., 2 0 1 1] a n d is ass oci at e d wit h 
i ncr e as e d ris k f or or al dis e as es, s uc h as c ari es [N av az es h, 2 0 1 2].  T h e l ac k of s ali v a r e d uc es t h e cl e ar a nc e 
of c ari o g e nic s u g ars a n d aci ds fr o m t h e d e nt al bi ofil m, i m p airs t h e acti o n of s ali v ar y b uff eri n g a g e nts a n d 
r e d uc es t h e s u p pl y of c alci u m a n d p h os p h at e i o ns, w hic h ar e n at ur al r e mi n er alizi n g a g e nts [ E d g ar et al., 
2 0 1 2]. B as e d o n li mit e d evi d e nc e, hi g h er fl u ori d e c o nc e ntr ati o n pr o d ucts ar e us u all y r ec o m m e n d e d f o r 
ol d er a d ults wit h h y p os ali v ati o n [ Z er o et al., 2 0 1 6].  
N ev ert h el ess, p r evi o us st u di es h av e s h o w n t h at a c alci u m ( C a) pr eri ns e c a n b o ost t h e r et e nti o n of F i n t h e 
m o ut h [ V o g el et al., 2 0 0 6 a; 2 0 0 6 b; 2 0 0 8 a; 2 0 0 8 b; S o uz a et al., 2 0 1 6], e n h a nci n g its eff ect . Alt h o u g h t h e 
eff ect of t h e C a pr eri ns e o n F a v ail a bilit y i n h y p os ali v ati o n p ati e nts h as n ev er b e e n st u di e d, pr eli mi n ar y 
d at a giv e s u p p ort t o t h e e n h a nc e d eff ect ex p ect e d f or t his pr oc e d ur e. U si n g a n i n sit u m o d el, it w as s h o w n 
t h at a C a pr eri ns e us e d b ef or e a F ri ns e f or 1 4 d a ys i ncr e as e d ~ 2 2 a n d 4 -f ol d t h e F a n d C a c o nc e ntr ati o ns 
i n d e nt al bi ofil m, r es p ecti v el y [ S o uz a et al., 2 0 1 6]. T his c orr o b or at es t h e h y p ot h esis t h at t h e r et e nti o n of 
F i n t h e m o ut h c a n be e n h a nc e d, wit h o ut t h e n e e d t o i ncr e as e t h e F c o nc e ntr ati o n i n t h e m. T h e i ncr e as e d 
F a n d C a r et e nti o n m a y b e  p artic ul arl y us ef ul f or h y p os ali v ati o n p ati e nts.  
I n t h e c urr e nt pr oj ect w e ai m t o ass ess t h e eff ect of t his a p pr o ac h i n m ai nt ai ni n g i ncr e as e d a n d s ust ai n e d 
l ev els of C a a n d F i n t h e or al fl ui ds of p ati e nts wit h a r a n g e of s ali v ar y fl o w r at es, v ar yi n g fr o m n or m al t o 
hy p os aliv ati o n. T h er e ar e n o k n o w n ris ks ass oci at e d wit h t h e us e of t h es e ri ns es. 
 
 
2. 3  
RI S K / B E N E FI T A S S E S S M E N T   
  
2. 3. 1  K N O W N  P O T E N TI A L RI S K S  
N o m or e t h a n mi ni m al ris ks ar e ex p ect e d t o p artici p a nts e nr oll e d i n t his tri al. T h e disc o mf orts/ris ks ar e 
list e d b el o w: 
 
I m m e di at e disc o mf orts/ris ks: 
1. Disc o mf ort r el at e d t o r efr ai ni n g fr o m t o ot h br us hi n g fr o m t h e pr evi o us ni g ht u ntil t h e m or ni n g o f 
ri ns es a n d s a m pli n g c oll ecti o n. T his is ex p ect e d t o b e a c o m m o n disc o mf ort (i nci d e nc e > 2 5 %). T h e 
s u bj ect m a y f e el m al o d or i n t h e m or ni n g of t h e t est d u e t o t h e s us p e nsi o n of or al h y gi e n e. Aft er t h e 
s a m pli n g is c o m pl et e d, t h e s u bj ect will r ec ei v e a pr of essi o n al cl e a ni n g or s u p er vis e d t o ot h br us hi n g t o 
r e m ov e r e m n a nts of d e nt al pl a q u e. 
2. Disc o mf ort r el at e d t o c oll ecti n g s ali v a s a m pl es. T his is ex p ect e d t o b e a li k el y disc o mf ort ( 1 0 -2 5 %), as 
s o m e i n di vi d u als d o n ot f e el c o mf ort a bl e i n s pitti n g s ali v a i nt o a t u b e. T his disc o mf ort will b e mi ni miz e d 
by m ai nt ai ni n g t h e s u bj ect e d i n a pri v at e d e nt al c h air, wit h o nl y t h e tr ai n e d st u d y st aff off eri n g 
i nstr ucti o ns o n t h e pr oc e d ur e. 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
5  
3. Disc o mf ort r el at e d t o ri nsi n g wit h u nfl av or e d ri ns es. T his is ex p ect e d t o b e a li k el y disc o mf ort ( 1 0 -
2 5 %), as t h e ri ns es will b e pr e p ar e d fr o m r e a g e nt gr a d e c h e mic als, wit h n o fl av ori n g a g e nts.  
4. Disc o mf ort r el at e d t o r efr ai ni n g fr o m e ati n g or dri n ki n g f or u p t o 2 h o urs d uri n g t h e c oll ecti o n of 
s a m pl es. T his is ex p ect e d t o b e a li k el y disc o mf ort ( 1 0-2 5 %). T his m a y b e m or e dist ur bi n g f or i n di vi d u als 
wit h r e d uc e d s ali v a fl o w, if t h e y ar e us e d t o si p w at er c o nst a ntl y. If t h e s u bj ect ( es p eci all y t h os e wit h  dr y 
m o ut h) f e el t h e n e e d of dri n k w at er d uri n g t h e t w o -h o ur p eri o d aft er t h e ri ns e, h e/s h e will b e all o w e d 
t o d o s o, a n d n ot es t a k e n as pr ot oc ol d evi ati o n i n or d er t o l at er ass ess t h eir eff ect o n t h e st u d y 
o utc o m es.  
 
L o n g-r a n g e ris ks: 
1 . L oss of c o nfi d e nti alit y of t h e st u d y r ec or ds. T his ris k is ex p ect e d t o b e r ar e. T o mi ni miz e t h e ris k of 
c o nfi d e nti alit y br e ac h, d at a will b e st or e d i n p ass w or d -pr ot ect e d el ectr o nic fil es or l oc k e d st or a g e 
c a bi n ets acc essi bl e o nl y t o t h e st u d y p ers o n n el. St a n d ar ds f or d at a c oll ecti o n, m a n a g e m e nt a n d a n al ysis 
will b e f oll o w e d.  
 
2. 3. 2  K N O W N P O T E N TI A L B E N E FI T S  
T h e s u bj ects will r ec ei v e or al h y gi e n e a n d c ar e i nstr ucti o ns pr ovi d e d b y t h e st u d y p ers o n n el. Als o, i n 
c as e t h ey h av e h y p os ali v ati o n, t h ey will b e i nf or m e d a b o ut t his, b ec a us e  t his c o n diti o n is n ot n ec ess aril y 
p erc eiv e d by t h e p ati e nts a n d it i ncr e as es t h e ris k f or or al dis e as es .  
 
T h e s u bj ects m a y als o b e n efit fr o m t h e u n d erst a n di n g of t h e st u d y o bj ecti v es, m a ki n g t h e m b ett er 
a w ar e of t h e i m p ort a nc e t a ki n g c ar e of t h eir or al h e alt h. 
 
2. 3. 3  A S S E S S M E N T O F P O T E N TI A L R I S KS  A N D B E N E FI T S  
T h e ris ks/ disc o mf ort ass oci at e d wit h t his st u d y ar e n o m or e t h a n mi ni m al. T h e s u bj ects will b e i nf or m e d 
a b o ut t h e m a n d s h o ul d a gr e e t o p artici p at e b ef or e b ei n g e nr oll e d. T h ey will b e n efit fr o m l e ar ni n g a b o ut 
t h eir or al h e alt h a n d g o o d or al h y gi e n e pr actic es .  
 
By i nv esti g ati n g a n e as y a n d i n ex p e nsi v e pr oc e d ur e t o e n h a nc e t h e eff ect of fl u ori d e, t his r es e arc h will 
h el p d ev el o p a m or e eff ecti v e a n d c ost -b e n efit w a y f or fl u ori d e us e , wit h o ut t h e n e e d t o i ncr e as e t h e 
fl u ori d e c o nc e ntr ati o n. T his p ot e nti al b e n efit, es p eci all y f or v ul n er a bl e  gr o u ps li k e el d ers wit h 
hy p os aliv ati o n, o ut w ei g h  t h e mi ni m al ris ks ass oci at e d wit h t h e tri al. N o ris ks ass oci at e d wit h t h e us e of 
t h e m o ut h  ri ns es ar e ex p ect e d. 
 
3  
O BJ E C TI V E S A N D E N D P OI N T S  
 
O BJ E C TI V E S  
E N D P OI N T S  
J U S TI FI C A TI O N F O R E N D P OI N TS  
Pri m ar y  
 
 
D et er mi n e t h e b e n efit of 
usi n g a c alci u m ri ns e, b ef or e 
a fl u ori d e ri ns e, t o e n h a nc e 
fl u ori d e r et e nti o n i n d e nt al 
bi ofil m  of  i n di vi d u als wit h 
hy p os aliv ati o n.  
 
Fl u ori d e c o nc e ntr ati o n i n d e nt al 
bi ofil m (fl ui d a n d s oli d p h as e) u p 
t o 2 h aft er ri nsi n g wit h fl u ori d e. 
 
D e nt al bi ofil m c a n t a k e u p 
fl u ori d e a n d r el e as e it f or 
pr ol o n g e d p eri o ds of ti m e, li k e 
t h e h o urs i n b et w e e n or al 
h y gi e n e pr oc e d ur es.  
S ec o n d ar y  
 
 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
6  
O BJ E C TI V E S  
E N D P OI N T S  
J U S TI FI C A TI O N F O R E N D P OI N TS  
D et er mi n e t h e b e n efit of 
usi n g a c alci u m ri ns e, b ef or e 
a fl u ori d e ri ns e, t o e n h a nc e 
fl u ori d e r et e nti o n i n s ali v a of  
i n di vi d u als wit h 
hy p os aliv ati o n.  
 
1.  Fl u ori d e c o nc e ntr ati o n i n 
s ali v a u p t o 2 h aft er ri nsi n g 
wit h fl u ori d e.  
 
2.  C alci u m c o nc e ntr ati o n i n 
d e nt al bi ofil m (fl ui d a n d s oli d 
p h as e) u p t o 2 h aft er ri nsi n g 
wit h fl u ori d e.  
 
3.  C alci u m c o nc e ntr ati o n i n 
s ali v a u p t o 2 h aft er ri nsi n g 
wit h fl u ori d e.   
 
1.  S ali v ar y fl u ori d e c a n b e 
c o nsi d er e d as a s urr o g at e 
m e as ur e of fl u ori d e av ail a bilit y i n 
t h e m o ut h, b ec a us e fr o m s ali v a 
fl u ori d e fr o m ri ns es g ets t o 
d e nt al bi ofil m.  
 
2. Si nc e a c alci u m ri ns e will b e 
us e d i n o n e of t h e tr e at m e nts i n 
t his st u d y, d et er mi n ati o n of 
c alci u m c o nc e ntr ati o n i n d e nt al 
bi ofil m will b e m a d e t o i d e ntif y 
p ot e nti al s o urc es of fl u ori d e 
r et e nti o n (e. g. fl u ori d e b o u n d t o 
c alci u m i o ns, c alci u m fl u ori d e 
pr eci pit ati o n).  
 
3. S ali v ar y c alci u m c a n b e 
c o nsi d er e d as a s urr o g at e 
m e as ur e of c alci u m av ail a bilit y i n 
t h e m o ut h; si nc e a c alci u m ri ns e 
will b e us e d i n o n e of t h e st u d y 
tr e at m e nts, s ali v ar y c alci u m will 
b e d et er mi n e d.  
 
T erti ary/ Ex pl or at or y  
 
 
D et er mi n e t h e r ol e of 
hy p os aliv ati o n o n t h e 
r et e nti o n of fl u ori d e i n t h e 
m o ut h aft er a fl u ori d e ri ns e  
1.  C orr el ati o n b et w e e n s ali v ar y 
fl o w r at e a n d fl u ori d e 
c o nc e ntr ati o n i n d e nt al bi ofil m 
u p t o 2 h aft er a ri ns e.  
2.  C orr el ati o n b et w e e n s ali v ar y 
fl o w r at e a n d fl u ori d e 
c o nc e ntr ati o n i n s ali v a u p t o 2 
h aft er a ri ns e.  
 
T h e c orr el ati o n b et w e e n s ali v ar y 
fl o w r at e a n d fl u ori d e i n d e nt al 
bi ofil m a n d s ali v a  will b e 
i n v esti g at e d t o esti m at e h o w t h e 
fl o w r at e aff ect t h es e v ari abl es.  
 
 
4  
S T U D Y D E SI G N  
 
4. 1  
O V E R A L L  D E SI G N  
T h e ov er all hy p ot h esis of t his st u d y is t h at a c alci u m pr eri ns e us e d b ef or e a fl u ori d e ri ns e e n h a nc es t h e 
r et e nti o n of fl u ori d e i n t h e m o ut h. A d diti o n al h y p ot h esis t o b e t est e d is t h at t h e r e d ucti o n i n s ali v a fl o w 
( hy p os ali v ati o n) r e d uc es t h e cl e ar a nc e a n d t h er ef or e i ncr e as es t h e r et e nti o n of fl u ori d e i n t h e m o ut h.  
 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
7  
T h e st u dy will b e a si n gl e -sit e, p h as e 1 cli nic al tri al, wit h a r a n d o miz e d, bli n d e d (r e g ar di n g t h e 
i nv esti g at ors a n d l a b or at or y a n al ysts) a n d cr oss ov er d esi g n. T w o i nt erv e nti o n gr o u ps will b e t est e d: 1. 
Ri nsi n g wit h a fl u ori d e m o ut h ri ns e o nl y, b as e d o n s o di u m fl u ori d e at a n ov er -t h e-c o u nt er 
c o nc e ntr ati o n; 2. Ri nsi n g wit h t h e s a m e fl u ori d e m o ut h ri ns e as i n 1, b ut aft er a m o ut h ri ns e wit h 
c alci u m l act at e ( a f o o d a d diti v e, pr evi o usl y us e d t o e n h a nc e t h e i ntr a or al fl u ori d e r et e nti o n [ V o g el et al., 
2 0 0 6 a; 2 0 0 6 b; 2 0 0 8 a; 2 0 0 8 b; S o uz a et al., 2 0 1 6]) .  
 
F or e ac h v ol u nt e er, r a n d o miz at i o n will b e us e d t o d et er mi n e w hic h of t h e t w o i nt er v e nti o n gr o u ps t o b e 
t est e d first. V ol u nt e ers r a n d o miz e d t o st art t h e tri al i n gr o u p 1, will t est gr o u p 2 i n t h e f oll o wi n g p h as e, 
a n d vic e v ers a. D e nt al pl a q u e ( pri m ar y e n d p oi nt) a n d s ali v a (s ec o n d ar y e n d p oi nt) will b e c oll ect e d f or 
fl u ori d e a n al ysis. C alci u m c o nc e ntr ati o n i n b ot h s a m pl es will als o b e d et er mi n e d (s ec o n d ar y e n d p oi nts).  
 
4. 2  
S CI E N TI FI C R A TI O N A L E F O R S T U D Y D E SI G N  
T h e us e of a r a n d o miz e d d esi g n is j ustifi e d t o r e d uc e a n y p ot e nti al bi as i n all oc at i n g t h e tr e at m e nt t o 
t h e s u bj ects. I n a d diti o n, b y usi n g a cr oss o v er d esi g n ( all s u bj ects ex p os e d t o b ot h i nt er v e nti o ns) it is 
p ossi bl e t o i ncr e as e t h e st u d y p o w er a n d r e d uc e t h e v ari a bilit y c a us e d b y t h e v ol u nt e er. T his is 
es p eci all y i m p ort a nt i n t his tri al as p e o pl e wit h a r a n g e of s ali v ar y fl o w r at es (fr o m n or m al t o 
hy p os aliv ati o n) will b e p artici p ati n g. Si nc e ev er y s u bj ect will s erv e as its o w n c o ntr ol, t h e v ari a bilit y d u e 
t o k n o w n (s uc h as s ali v ar y fl o w) a n d u n k n o w n f act ors c a n b e mi ni miz e d. 
  
T h e i nv e sti g at or/ a n al yst will b e bli n d wit h r es p ect t o t h e all oc ati o n of tr e at m e nts w h e n a n al yzi n g t h e 
s a m pl es f or fl u ori d e a n d c alci u m c o nc e ntr ati o n. T his is t o miti g at e  i n v esti g at or/ a n al yst bi as d uri n g t h e 
a n al ysis of s a m pl es.  
 
4. 3  
J U S TI FI C A TI O N F O R D OS E  
B ot h i nt erv e nti o ns will b e us e d as m o ut h ri ns es, p erf or m e d f or 1 mi n , w hic h is t h e t y pic all y 
r ec o m m e n d e d ri nsi n g ti m e f or or al pr o d ucts. T h e c o nc e ntr ati o ns t o b e us e d ar e als o s u p p ort e d b y t h e 
cli nic al r ec o m m e n d ati o ns a n d t h e lit er at ur e: 1. T h e fl u ori d e ri ns e will b e us e d at o v er-t h e-c o u nt er 
c o nc e ntr ati o ns of 2 2 6 p p m of fl u ori d e  ( 0. 0 5 % N a F); 2. T h e c alci u m l act at e ri ns e will b e t est e d at 15 0 m M 
c o nc e ntr ati o n, w hic h h as pr evi o usl y s h o w n t h e b est p erf or m a nc e w h e n c o m bi n e d wit h fl u ori d e i n 
c o m p aris o n t o l o w er ( 3 0 m M) or hi g h er ( 3 0 0 m M) c o nc e ntr ati o ns [ V o g el et al., 2 0 0 6 a ].  
 
4. 4  
E N D O F S T U D Y D E FI NI TI O N  
A p artici p a nt is c o nsi d er e d t o h av e c o m pl et e d t h e st u d y if h e or s h e h as c o m pl et e d all p h as es of t h e 
st u d y i ncl u di n g t h e l ast visit or t h e l ast sc h e d ul e d pr oc e d ur e s h o w n i n t h e Sc h e d ul e of Acti viti es ( S o A), 
S ecti o n 1. 3 . 
 
T h e e n d of t h e st u d y is d efi n e d as c o m pl eti o n of t h e l ast visit or pr oc e d ur e s h o w n i n t h e S o A i n t h e tri al 
gl o b all y . 
 
5  
S T U D Y P O P U L A TI O N  
 
5. 1  
I N C L U SI O N C RI T E RI A 
 I n or d er t o b e eli gi bl e t o p artici p at e i n t his st u d y, a n i n di vi d u al m ust m e et all of t h e f oll o wi n g crit eri a: 
1.  Pr ovisi o n of si g n e d a n d d at e d i nf or m e d c o ns e nt f or m 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
8  
2.  St at e d willi n g n ess t o c o m pl y wit h all st u d y pr oc e d ur es a n d av ail a b ilit y f or t h e d ur ati o n of t h e 
st u d y  
3.  M al e or f e m al e, a g e d 6 5 or ol d er  
4.  I n g o o d g e n er al h e alt h as evi d e nc e d b y m e dic al hist or y  
5.  I n g o o d or al h e alt h as evi d e nc e d b y a cli nic al or al ex a m  
6.  H avi n g at l e ast 2 0 t e et h i n t h e m o ut h, b ei n g at l e a st 4 ( n at ur al or cr o w n e d) t e et h i n all f o ur 
q u a dr a nts of t h e m o ut h  
7.  H avi n g s ali v ar y fl o w r at e r a n gi n g fr o m n or m al t o h y p os ali v ati o n acc or di n g t o dir ect fl o w r at e 
d et er mi n ati o n m et h o ds  
8.  A gr e e m e nt t o a d h er e t o Lif est yl e C o nsi d er ati o n s (s e e b el o w ) t hr o u g h o ut stu d y d ur ati o n  
 
5. 2  
E X C L U SI O N C RI T E RI A  
 A n i n divi d u al w h o m e ets a n y of t h e f oll o wi n g crit eri a will b e excl u d e d fr o m p artici p ati o n i n t his st u d y:  
1.  U n a bl e t o u n d erst a n d a n d/ or f oll o w st u d y i nstr ucti o ns  
2.  Activ e p eri o d o ntitis  
3.  Or al p ai n  
4.  I n ne e d o f ur g e nt d e nt al c ar e  
  
LI F E S T Y L E C O N SI D E R A TI O N S  
D uri n g t his st u d y , p artici p a nts ar e as k e d t o:  
•  
Us e a st a n d ar diz e d t o ot h p ast e a n d t o ot h br us h, pr ovi d e d b y t h e st u d y t e a m  at t h e first visit , t o 
l ev el t h e b ac k gr o u n d ex p os ur e t o fl u ori d e, 7 d a ys pri or t o e ac h ex p eri m e nt al p h as e  
•  
R efr ai n fr o m usi n g a n y ot h er m o ut h ri ns e or pr of essi o n al pr o d ucts d uri n g t h e st u d y p eri o d  
•  
R efr ai n fr o m dri n ki n g gr e e n or bl ac k t e a ( w hic h h av e hi g h fl u ori d e c o nc e ntr ati o n) o n t h e ni g ht 
b ef or e or t h e d a y of t h eir visits 
•  
R efr ai n fr o m br us hi n g t h eir t e et h o n t h e ni g ht b ef or e a n d t h e m or ni n g of t ests/s a m pli n g  
•  
R efr ai n fr o m e ati n g or dri n ki n g f or 2 h o urs aft er t h e ri ns es, d uri n g w hic h s ali v a a n d d e nt al 
pl a q u e will b e s a m pl e d  
 
5. 3  
S C R E E N F AI L U R E S  
Scr e e n f ail ur es ar e d efi n e d as p art ici p a nts w h o c o ns e nt t o p artici p at e i n t h e cli nic al tri al b ut ar e n ot 
s u bs e q u e ntl y r a n d o ml y assi g n e d t o t h e st u d y i nt er v e nti o n or e nt er e d i n t h e st u d y. A mi ni m al s et of 
scr e e n f ail ur e i nf or m ati o n is r e q uir e d t o e ns ur e tr a ns p ar e nt r e p orti n g of scr e e n f ail ure p artici p a nts , t o 
m e et t h e C o ns oli d at e d St a n d ar ds of R e p orti n g Tri als ( C O N S O R T) p u blis hi n g r e q uir e m e nts a n d t o 
r es p o n d t o q u eri es fr o m r e g ul at or y a ut h oriti es. Mi ni m al i nf or m ati o n i ncl u d es d e m o gr a p h y, scr e e n 
f ail ur e d et ails, eli gi bilit y crit eri a, a n d a n y s eri o us a dv ers e ev e nt ( S A E).  
 
I n di vi d u als w h o d o n ot m e et t h e crit eri a f or p artici p ati o n i n t his tri al (scr e e n f ail ur e) b ec a us e of acti v e 
p eri o d o ntitis, or al p ai n or n e e d o f ur g e nt d e nt al c ar e  m a y b e r escr e e n e d  if t h e y h a v e t h e excl usi o n 
f act or tr e at e d. R escr e e n e d p artici p a nts s h o ul d b e assi g n e d t h e s a m e p artici p a nt n u m b er as f or t h e i niti al 
scr e e ni n g. 
 
5. 4  
S T R A T E GI E S F O R R E C R UI T M E N T A N D R E T E N TI O N  
P artici p a nts will b e r ecr uit e d fr o m t h e cli nics of t h e Sc h o ol of D e nt istr y, U ni v ersit y of Mic hi g a n. Pri m ar y 
crit eri a t o b e i ncl u d e d i n t h e st u d y ( h avi n g 6 5 y e ars of a g e  or m or e, at l e ast 2 0 t e et h, at l e ast 4 t e et h i n 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
9  
e ac h q u a dr a nt) will b e a n n o u nc e d t o d e nt al pr o vi d ers i n t h e cli nics of t h e Sc h o ol of D e ntistr y. If 
i d e ntifi ed s u bj ects i n dic at e t h at t h ey ar e i nt er est e d i n p artici p ati n g, t h e pr ovi d er c a n r ef er t h eir 
n a m e/ p h o n e n u m b er t o t h e st u d y t e a m f or c o nt act a n d sc h e d ul e of t h e first visit.  It is ex p ect e d t h at a 
si mil ar n u m b er of m e n a n d w o m e n, a n d a di v ers e p o p ul ati o n i n t er ms of r ac es/ et h niciti es is r ecr uit e d. 
 
P artici p a nts will b e c o m p e ns at e d f or t h eir p artici p ati o n i n t h e st u d y usi n g a r e -c h ar g e a bl e c ar d. T h ey will 
b e c o m p e ns at e d wit h $ 1 8. 0 0 f or t h e first visit (c h ec ki n g of i ncl usi o n a n d excl usi o n crit eri a), $ 1 8. 0 0 f or 
t h e s ec o n d visit (t est of first i nt er v e ntio n gr o u p) a n d $ 4 8. 0 0 f or t h e t hir d visit (t est of s ec o n d 
i nt erv e nti o n gr o u p). T h es e a m o u nts will b e tr a nsf err e d t o t h e r e-c h ar g e a bl e c ar d wit hi n 2 -5  b usi n ess 
d ay s of t h e visit b ei n g c o m pl et e d.   
 
6  
S T U D Y I N T E R V E N TI O N 
 
6. 1  
S T U D Y I N T E R V E N TI O N( S) A D MI NI S T R A TI O N  
 
6. 1. 1  S T U D Y IN T E R V E N TI O N  D E S C RI P TI O N  
Fl u ori d e -o nl y ri ns e: T his i nt erv e nti o n is a 1 -mi n m o ut h ri ns e  wit h 1 5 mL of a 0. 0 5 % s o di u m fl u ori d e ri ns e 
(2 2 6 p p m F). T his is t h e s a m e fl u ori d e c o m p o u n d a n d c o nc e ntr ati o n f o u n d i n ov er -t h e-c o u nt er fl u ori d e 
ri ns es.  
 
Fl u ori d e ri ns e f oll o wi n g a c alci u m pr eri ns e: T his i nt er v e nti o n c o nsists of t w o 1 -mi n m o ut h ri ns es  of 1 5 
mL e ac h ; t h e first will b e p erf or m e d wit h a c alci u m l act at e s ol uti o n, pr e p ar e d at t h e c o nc e ntr ati o n of 
1 5 0 m M [ V o g el et al., 2 0 0 6a ]. C alci u m l act at e is a f o o d a d diti v e a n d s af e f or h u m a n c o ns u m pti o n, 
alt h o u g h i n t h e c urr e nt st u d y it will n ot b e i n g est e d, b ut ex p ect or at e d ( us e d as a ri ns e). T h e s ec o n d 
ri ns e, t o b e p erf or m e d wit hi n 3 0 s  aft er t h e first ri ns e, will b e t h e s o di u m fl u ori d e ri ns e at 2 2 6 p p m F, as 
d escri b e d a b ov e.  
6. 1. 2  D O SI N G A N D A D MI NI S T R A TI O N  
All p artici p a nts will t est b ot h i nt er v e nti o n gr o u ps; h alf of t h e m will t est t h e gr o u ps i n o n e or d er ( 1-> 2) , 
t h e ot h er h alf i n t h e ot h er or d er ( 2-> 1) . T h e or d er will b e d et er mi n e d r a n d o ml y usi n g a c o m p ut er -
g e n er at e d r a n d o miz ati o n list i n M S Exc el.  
 
E ac h i nt erv e nti o n gr o u p will b e t est e d i n o n e ex p eri m e nt al p h as e, s p ac e d at l e ast 7 d a ys fr o m t h e 
f oll o wi n g p h as e t o av oi d a n y i nt erf er e nc e wit h t h e pr evi o us tr e at m e nt [ F er ná n d ez et al., 2 0 1 5].  
 
N o tr e at m e nt will b e p erf or m e d b y t h e p ati e nt at h o m e; b ot h i nt erv e nti o ns will b e d eli v er e d b y t h e 
st u d y t e a m at t h e st u d y visits. 
 
6. 2  
P R E P A R A TI O N / H A N D LI N G / S T O R A G E / A C C O U N T A BI LI T Y  
 
6. 2. 1  A C Q UI SI TI O N A N D A C C O U N T A BI LI T Y  
B ot h ri ns es t o b e us e d i n t h e st u d y will b e pr e p ar e d at t h e r es e arc h l a b or at or y of t h e pri nci p al 
i nv esti g at or, f oll o wi n g g ui d eli n es us e d at t h e U ni v ersit y of Mic hi g a n R es e arc h P h ar m ac y. T h e us e of 
pl ai n m o ut h ri ns es ( n o n -c o m m erci al, wit h o ut fl av ori n g a g e nts, s urf act a nts, c ol ori n g a g e nts) is r e q uir e d 
t o t est t h e r e al eff ect of t h e c h e mic als u n d er ev al u ati o n (s o di u m fl u ori d e a n d c alci u m l act at e), wit h o ut 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
1 0  
i nt erf er e nc e of i n gr e di e nts t h at ma y aff ect t h e s ali v ar y fl o w r at e (fl av ori n g a g e nts) or t h e i nt er acti o n 
b et w e e n c alci u m a n d fl u ori d e i nt e n d e d t o b e t est e d h er e  ( d et er g e nts) [ B ar kv oll et al., 1 9 8 8]. 
 
C alci u m l act at e , C at # C 8 3 5 6, Si g m a , a n d s o di u m fl u ori d e , C at # 2 0 1 1 5 4, Si g m a , will b e us e d f or pr e p ari n g 
t h e ri ns es.  
 
T h e r es e arc h l a b or at or y of t h e pri nci p al i nv esti g at or, l oc at e d at t h e U ni v ersit y of Mic hi g a n Sc h o ol of 
D e ntistry, 1 0 1 1 N U ni v ersit y Av e, r o o m 2 3 1 0i, 4 8 1 0 9 -1 0 7 8, A n n Ar b or, MI , will pr e p ar e t h e ri ns es. A n 
ex p eri e nc e d p h ar m acist fr o m R es e arc h P h ar m ac y visit e d t h e l a b or at or y a n d r ec o m m e n d e d t h e 
pr e p ar ati o n of t h e ri ns es t h er e. . T h e s o urc e of e ac h pr e p ar e d a n d dis p e ns e d ri ns e ( dr u gs l ot #) will b e 
n ot e d i n a dis p e nsi n g l o g. Als o, t h e fi n al us e (if us e d f or a m o ut h ri ns e, or disc ar d e d d u e t o a c a nc el ati o n 
i n t h e p artici p a nt ’s a p p oi nt m e nt) will b e r ec or d e d. A n al ys es of t h e c alci u m a n d fl u ori d e c o nc e ntr ati o n i n 
e ac h b atc h of pr e p ar e d ri ns es will b e m a d e a n d r ec or d e d.   
 
6. 2. 2  F O R M U L A TI O N, A P P E A R A N C E, P A C K A GI N G, A N D L A B E LI N G  
T h e ri ns es will b e pr e p ar e d t o c o nt ai n 1 5 0 m M of c alci u m l act at e a n d 0. 0 5 % of s o di u m fl u ori d e, 
r es p ectiv el y.  
 
T h e 0. 0 5 % s o di u m fl u ori d e ri ns e will b e pr e p ar e d  i n o n e, 1-L b atc h, t o b e st or e d i n a pl astic fl as k, wit h a n 
ex pir ati o n d at e of 6 m o nt hs. Fr o m t h e t ot al v ol u m e pr e p ar e d, 1 5 -mL ali q u ots t o b e us e d b y e ac h p ati e nt 
will b e dis p e ns e d b y t h e PI,  acc or di n g t o t h e p ati e nt’s sc h e d ul e.   
 
T h e 1 5 0 m M c alci u m l act at e will b e pr e p ar e d  i n b atc h es  of 1 0 0 mL , t o b e us e d b y p ati e nts sc h e d ul e d i n 
t h e f oll o wi n g 7 d a ys . If n ot us e d, t h e ri ns es will b e disc ar d e d. Fift e e n mL b atc h es t o b e us e d b y e ac h 
p artici p a nt  will b e dis p e ns e d b y PI, acc or di n g t o t h e p ati e nt’s sc h e d ul e.  
 
Fr o m pr e p ar ati o n u ntil us e, dis p e ns e d ri ns es will b e st or e d at t h e PI’s l a b, i n t h e r efri g er at or (c alci u m 
l act at e ri ns e) or i n a l oc k e d c a bi n et. All fl as ks will b e l a b el e d acc or di n gl y. 
 
6. 2. 3  P R O D U C T S T O R A G E A N D S T A BI LI T Y  
A 1 -L b atc h of t h e s o di u m flu ori d e s ol uti o n will b e pr e p ar e d a n d st or e d i n a pl astic fl as k at r o o m 
t e m p er at ur e f or 6 m o nt hs ( U S P 7 9 5) . T h e s o di u m fl u ori d e s ol uti o n s h o ul d b e st a bl e f or t his p eri o d of 
ti m e a n d n o c o nt a mi n ati o n is ex p ect e d c o nsi d eri n g t h e a nti b act eri al acti o n of fl u ori d e [v a n L ov er e n, 
1 9 9 0] . T h e fl u ori d e c o nc e ntr ati o n i n t his s ol uti o n will b e c o nfir m e d usi n g a fl u ori d e el ectr o d e, a g ai nst 
st a n d ar ds wit h k n o w n fl u ori d e c o nc e ntr ati o n [ N ó br e g a et al., 2 0 1 9]. Fift e e n mL b atc h es f or i n di vi d u al 
p ati e nt us e will b e dis p e ns e d o n e d a y pri or t o t h e a p p oi nt m e nt. Aft er 6 m o nt hs, if t h e ex p eri m e nt al 
p h as e is n ot c o m pl et e d, a n e w b atc h will b e pr e p ar e d ( a m o u nt t o b e d et er mi n e d b y t h e n u m b er of visits 
t o b e c o m pl et e d), f oll o wi n g t h e s a m e pr oc e d ur es d escri b e d a b ov e.   
 
F or t h e c alci u m l act at e s ol uti o n, 1 0 0 -mL b atc h es will b e pr e p ar e d e ac h w e e k p artici p a nts ar e sc h e d ul e d. 
T his is t o e ns ur e t h at t his s ol uti o n is fr es hl y -us e d ( 1-4 d a ys) aft er pr e p ar ati o n. O nc e pr e p ar e d, t h e 
b atc h es will b e st or e d i n t h e r efri g er at or, b ut will b e br o u g ht t o r o o m t e m p er at ur e t o b e us e d f or m o ut h 
ri nsi n g. T h e c alci u m c o nc e ntr ati o n i n all b atc h es will b e c h ec k e d usi n g t h e Ars e n az o III m et h o d f or 
d et ecti o n of c alci u m, i n a micr o pl at e r e a d er , a g ai nst st a n d ar ds wit h k n o w n c alci u m c o nc e ntr ati o n 
[ N ó br e g a et al., 2 0 1 9].  
 
6. 2. 4  P R E P A R A TI O N  

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
1 1  
T h e ri ns es will b e d eli v er e d dir ectl y t o t h e s u bj ects f or m o ut h ri nsi n g. N o ot h er mixi n g will b e p erf or m e d 
by t h e s u bj ects.  
 
6. 3  
M E A S U R E S T O MI NI MI Z E BI A S: R A N D O MI Z A TI O N  A N D B LI N DI N G  
Bli n di n g of t h e v ol u nt e ers or cli nic al st aff will n ot b e p ossi bl e b ec a us e o n e of t h e tr e at m e nts i nv ol v es 
o n e ri ns e, t h e ot h er i nv ol v es t w o ri ns es. N ev ert h el ess, t h e l a b or at or y a n al yst will b e bli n d wit h r es p ect 
wit h t h e s a m pl es t o b e a n al yz e d; f or t his, t h e s a m pl es will b e c o d e d wit h t h e p artici p a nt I D a n d 
tr e at m e nt p h as e ( 1st or 2 n d, n ot t o b e c o nf o u n d e d wit h tr e at m e nt A or B; t h e tr e at m e nt t o b e us e d i n 
e ac h p h as e will b e d et er mi n e d r a n d o ml y f or e ac h v ol u nt e er ).  
 
T h e or d er i n w hic h t h e t w o i nt erv e nti o n gr o u ps will b e t est e d will b e r a n d o miz e d usi n g t h e M S Exc el , 
usi n g a r a n d o miz ati o n t a bl e c o nt ai ni n g 3 c ol u m ns wit h 2 0 r o ws:  
1.  F irst c ol u m n: p artici p a nt I D n u m b er, fr o m 1 t o 2 0 
2.  S ec o n d c ol u m n: l ett ers A or B (t o r e pr es e nt t h e 2 i nt er v e nti o n gr o u ps; 1 0 of e ac h l ett er)  
3.  T hir d c ol u m n: r a n d o m n u m b ers cr e at e d usi n g Exc el f u ncti o n “r a n d ” 
 
T h e t hir d a n d s ec o n d c ol u m n will b e s el ect e d a n d s ort e d b y t h e t hir d c ol u m n; t his will r a n d o miz e t h e 
tr e at m e nt t o b e us e d i n t h e first p h as e, acc or di n g t o t h e p artici p a nt I D. T h e ot h er i nt erv e nti o n gr o u p will 
b e t est e d i n t h e f oll o wi n g p h as e.  
 
6. 4  
S T U D Y IN T E R V E N TI O N  C O M P LI A N C E  
T h er e will b e n o st u d y c o m pli a nc e c h ec ks i n t h e st u d y as all pr oc e d ur es will b e p erf or m e d i n t h e cli nic, 
w h e n  t h e s u bj ect will b e f oll o w e d b y  a  st u d y t e a m m e m b er. D evi ati o ns fr o m t h e pr ot oc ol d uri n g t h e 
ex p eri m e nt al p h as es ( e. g. i nt a k e of w at er i n b et w e e n s a m pl e c oll ecti o n) will b e n ot e d i n t h e pr ot oc ol. 
 
7  
S T U D Y I N T E R V E N TI O N DI S C O N TI N U A TI O N  A N D P A R TI CI P A N T  
DI S C O N TI N U A TI O N / WI T H D R A W A L  
 
7. 1  
DI S C O N TI N U A TI O N  O F S T U D Y I N T E R V E N TI O N  
D u e t o t h e s h ort -t er m ex p os ur e t o t h e i nt er v e nti o ns t o b e t est e d h er e (o n e or t w o 1 -mi n ri ns es wit h t h e 
pr o d ucts u n d er t est), n o disc o nti n u ati o n of t h e st u d y i nt erv e nti o n is ex p ect e d.  
 
7. 2  
P A R TI CI P A N T  D I S C O N TI N U A TI O N/ W I T H D R A W A L F R O M T H E S T U D Y  
P artici p a nts ar e fr e e t o wit h dr a w fr o m p artici p ati o n i n t h e st u d y at a n y ti m e u p o n r e q u est.  
A n i nv esti g at or m a y disc o nti n u e or wit h dr a w a p artici p a nt fr o m  t h e st u d y f or t h e f oll o wi n g r e as o ns: 
•  
Si g nific a nt st u d y i nt er v e nti o n n o n -c o m pli a nc e  
•  
If any cli nic al  u n a ntici p at e d  a dv ers e ev e nt ( A E)  occ urs s uc h t h at c o nti n u e d p artici p ati o n i n t h e 
st u d y w o ul d n ot b e i n t h e b est i nt er est of t h e p artici p a nt  
•  
Dis e as e pr o gr essi o n  ( or al or g e n er al) w hic h r e q uir es disc o nti n u ati o n of t h e st u d y i nt er v e nti o n 
•  
If th e p artici p a nt m e ets a n excl usi o n crit eri o n ( eit h er n e wl y d ev el o p e d or n ot pr evi o usl y 
r ec o g niz e d) t h at pr ecl u des f urt h er st u d y p artici p ati o n  
T h e r e as o n f or p artici p a nt disc o nti n u ati o n or wit h dr a w al fr o m t h e st u d y will b e r ec or d e d o n t h e 
Disc o nti n u ati o n  C as e R e p ort F or m ( C R F ). S u bj ects w h o si g n t h e i nf or m e d c o ns e nt f or m a n d ar e 
r a n d o miz e d b ut d o n ot r ec ei v e t h e st u d y i nt er v e nti o n m a y b e r e pl ac e d.  S u bj ects w h o si g n t h e i nf or m e d 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
1 2  
c o ns e nt f or m, a n d ar e r a n d o miz e d a n d r ec ei v e t h e st u d y i nt er v e nti o n, a n d s u bs e q u e ntl y wit h dr a w, or 
ar e  wit h dr a w n or disc o nti n u e d fr o m t h e st u d y will n ot b e r e pl ac e d.  
7. 3  
L O S T T O F O L L O W -U P  
 A p artici p a nt will b e c o nsi d er e d l ost t o f oll o w -u p if h e or s h e f ails t o r et ur n f or t h e t hir d st u d y visit 
(s ec o n d i nt erv e nti o n visit) a n d is u n a bl e t o b e c o nt act e d b y t h e st u d y sit e st aff.  
 
T h e f oll o wi n g acti o ns m ust b e t a k e n if a p artici p a nt f ails t o r et ur n t o t h e cli nic f or a r e q uir e d st u d y visit:  
•  
T h e sit e will att e m pt t o c o nt act t h e p artici p a nt a n d r esc h e d ul e t h e miss e d visit a n d c o u ns el t h e 
p artici p a nt o n t h e i m p ort a nc e of m ai nt ai ni n g t h e assi g n e d visit sc h e d ul e a n d asc ert ai n if t h e 
p artici p a nt wis h es t o a n d/ or s h o ul d c o nti n u e i n t h e st u d y.  
•  
B ef or e a p artici p a nt is d e e m e d l ost t o f oll o w -u p, t h e i nv esti g at or or d esi g n e e will m a k e ev er y 
eff ort t o r e g ai n c o nt act wit h t h e p artici p a nt ( w h er e p ossi bl e, 3 t el e p h o n e c alls a n d, if n ec ess ar y, 
a c ertifi e d l ett er t o t h e p artici p a nt’s l ast k n o w n m aili n g a d dr ess or l oc al e q ui v al e nt m et h o ds). 
T h es e c o nt act att e m pts s h o ul d b e d oc u m e nt e d i n t h e p a rtici p a nt’s m e dic al r ec or d or st u d y fil e.  
•  
S h o ul d t h e p artici p a nt  c o nti n u e t o b e u nr e ac h a bl e, h e or s h e will b e c o nsi d er e d t o h a v e 
wit h dr a w n fr o m t h e st u d y wit h a pri m ar y r e as o n o f l ost t o f oll o w-u p.  
 
8  
S T U D Y A S S E S S M E N T S A N D P R O C E D U R E S  
 
8. 1  
E F FI C A C Y A S S E S S M E N T S  
T h e f oll o wi n g ass ess m e nts a n d pr oc e d ur es will b e c o n d uct e d d uri n g t h e st u d y:  
 
1.  I niti al i ntr a or al ex a mi n ati o n: R ecr uit e d s u bj ects will c o m e t o a first visit i n w hic h t h e st u d y 
d et ails will b e r evis e d a n d t h ey will si g n t h e i nf or m e d c o ns e nt. S u bj ects w h o si g n e d t h e 
i nf or m e d c o ns e nt will t h en  g o t hr o u g h a n i ntr a or al ex a mi n ati o n. T h e n u m b er of t e et h i n t h e 
m o ut h ( mi ni m u m of 2 0) a n d p er q u a dr a nt ( mi ni m u m of 4) will b e c h ec k e d. T h e  pr es e nc e of 
activ e p eri o d o ntit is or a n y ot h er t o ot h-r el at e d pr o bl e m n e e di n g ur g e nt c ar e will b e us e d as 
excl usi o n crit eri a. I n t his c as e, t h e p artici p a nt will b e dis e nr oll e d fr o m t h e tri al a n d  c o nsi d er e d a 
scr e e n f ail ur e. 
 
2.  D et er mi n ati o n of s ali v ar y fl o w r at e: All s u bj ects will h av e t h eir u nsti m ul at e d a n d sti m ul at e d 
s ali v ar y fl o w r at es d et er mi n e d i n t h e first visit. T his will b e d o n e usi n g t h e dr ai ni n g a n d t h e g u m -
sti m ul at e d m et h o ds f or u nsti m ul at e d a n d sti m ul at e d s ali v ar y fl o w d et er mi n ati o n, r es p ecti v el y 
[ N av az es h & K u m ar, 2 0 0 8]. F or u nsti m ul at e d s ali v ar y fl o w , t h e s u bj ects will sit wit h t h e h e a d 
tilti n g f or w ar d, a n d all s ali v a acc u m ul ati n g i n t h eir m o ut h will b e p assi v el y dr o ol e d i nt o a pr e-
w ei g ht e d, 1 5 mL -t u b e, vi a a dis p os a bl e f u n n el. Aft er 5 mi n of c oll ecti o n, t h e v ol u m e of s ali v a will 
b e d et er mi n e d b y w ei g ht, a n d t h e fl o w r at e esti m at e d i n mL/ mi n. A v al u e l o w er t h a n 0. 1 mL  
u nsti m ul at e d s ali v a / mi n will b e c o nsi d er e d as h y p os ali v ati o n. F or sti m ul at e d s ali v ar y fl o w , a n 
i n ert g u m or p ar affi n b as e will b e us e d as a m astic at or y sti m ul us f or s ali v a pr o d ucti o n. S u bj ects 
will b e as k e d t o c h e w t h e g u m ( 0. 5 g) a n d s pit t h e s ali v a pr o d uc e d i nt o 1 5 mL t u b es, f or 5 mi n. A 
sti m ul at e d s ali v ar y fl o w r at e of less t h a n 0. 5 mL  sti m ul at e d s ali v a/ mi n will b e c o nsi d er e d 
hy p os ali v ati o n.  B ot h i n di vi d u als wit h n or m al s ali v ar y fl o w r at e a n d h y p os ali v ati o n will b e 
e nr oll e d i n t h e st u d y, b ut at l e ast h alf of t h e i n di vi d u als s h o ul d h a v e s o m e si g n of h y p os ali v ati o n 
(s e e e nroll m e nt acc or di n g t o s ali v ar y fl o w r at e).  
 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
1 3  
3.  E nr oll m e nt of p artici p a nts acc or di n g t o s ali v ar y fl o w r at e: A m axi m u m of 1 0 s u bj ects wit h 
n or m al s ali v ar y fl o w c a n b e e nr oll e d  i n t h e st u d y ( at l e ast 1 0 of t h e e nr oll e d s u bj ects s h o ul d 
h av e h y p os ali v ati o n) . T h e f oll o wi n g t a bl e ex e m plif y t h e scr e e ni n g crit eri a will b e us e d t o 
c o nsi d er a s u bj ect eli gi bl e f or t h e tri al  acc or di n g t o s ali v ar y fl o w r at e: 
 
T a bl e: Ex a m pl e of scr e e ni n g t a bl e.  O nc e 1 0 i n di vi d u als wit h n or m al s ali v ar y fl o w r at e ar e 
e nr oll e d, t h e f oll o wi n g i n di vi d u als n e e d t o h a v e b el o w n or m al s ali v ar y fl o w t o b e  eli gi bl e.  
# scr e e n e d  
s u bj ect 
S ali v ar y fl o w r at e (sti m ul at e d 
a n d / or u nsti m ul at e d)  
Eli gi b l e 
S u m of i n di vi d u als wit h n or m al 
fl o w r at e (s h o ul d n ot exc e e d 1 0) 
1  
N or m al  
Y es  
1  
2  
B e l o w n or m al 
Y es  
1  
3  
B el o w n or m al  
Y es  
1  
4  
N or m al  
Y es  
2  
5  
N or m al  
Y es  
3  
6  
B el o w n or m al  
Y es  
3  
7  
N or m al  
Y es  
4  
8  
N or m al  
Y es  
5  
9  
N or m al  
Y es  
6  
1 0  
B el o w n or m al  
Y es  
6  
1 1  
B el o w n or m al  
Y es  
6  
1 2  
N or m al  
Y es  
7  
1 3  
B el o w n or m al  
Y es  
7  
1 4  
N or m al  
Y es  
8  
1 5  
N or m al  
Y es  
9  
1 6  
N or m al  
Y es  
1 0  
 
 
 
S u bj ects e nr oll e d fr o m t his p oi nt o n 
m ust h av e h y p os ali v ati o n  
1 7  
B el o w n or m al  
Y es  
1 0  
1 8  
N or m al  
N o  
1 0  
1 9  
B el o w n or m al  
Y es  
1 0  
2 0  
N or m al  
N o  
1 0  
2 1  
B el o w n or m al  
Y es  
1 0  
2 2  
B el o w n or m al  
Y es  
1 0  
T ot al n u m b er of s u bj ects scr e e n e d: 2 2  
T ot al n u m b er of s u bj ects e nr oll e d: 2 0  
N u m b er of scr e e n f ail ur es: 2  
C o nsi d eri n g t h e p o p ul ati o n wit h 6 5 y e ars of a g e  or m or e att e n di n g t h e Sc h o ol of D e ntistr y, it  is 
ex p ect e d t h at a l o w s ali v ar y fl o w is f o u n d i n m or e t h a n h alf of t h e e nr oll e d s u bj ects  ( d u e t o t h e 
fr e q u e nt us e of m e dic ati o ns t h at c a us e h y p os ali v ati o n). T h er ef or e, t h e r ecr uit m e nt acc or di n g t o 
s ali v ar y fl o w r at e is n ot ex p ect e d t o r es ult i n m or e t h a n 5 scr e e n f ail ur es.  
 
It s h o ul d b e n ot e d t h at th e crit eri u m  of h avi n g “at l e ast  1 0 i n di vi d u als wit h h y p os ali v ati o n ” 
e nr oll e d  all o ws f or t h e r ecr uit m e nt of  2 0 i n di vi d u als wit h  h y p os ali v ati o n.  
 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
1 4  
T h e e nr oll m e nt t a bl e will b e c h ec k e d w e e kl y. If t h e n u m b er of e nr oll e d i n di vi d u als wit h n or m al 
s ali v ar y fl o w is r e ac hi n g 1 0, e m p h asis o n t h e r ecr uiti n g of i n di vi d u als wit h h y p os ali v ati o n ( as 
o bs erv e d b y t h e ir Sc h o ol of D e ntistr y pr o vi d ers) will b e e m p h asiz e d.  
 
4.  C oll ecti o n of d e nt al pl a q u e ( bi ofil m) s a m pl es: O n t h e 2 n d a n d 3 r d visits, p artici p a nts will h av e 
d e nt al pl a q u e s a m pl es c oll ect e d f or t h e a n al ysis of fl u ori d e a n d c alci u m i n t h e bi ofil m fl ui d a n d 
s oli d p h as es. T h e c oll ecti o ns will b e m a d e at t h e f oll o wi n g ti m e p oi nts:  
• 
At t h e b e gi n ni n g of t h e s essi o n  
• 
1 5 mi n ±  5 mi n  aft er ri nsi n g wit h t h e i nt erv e nti o n gr o u p  
• 
6 0 mi n ±  5 mi n aft er ri nsi n g wit h t h e i nt er v e nti o n gr o u p 
• 
1 2 0 mi n ±  5 mi n aft er ri nsi n g wit h t h e i nt erv e nti o n gr o u p  
T h e pl a q u e s a m pl es will b e c oll ect e d b y a lic e ns e d pr of essi o n al ( d e ntist). E ac h s a m pl e will b e 
c oll ect e d fr o m a diff er e nt q u a dr a nt of t h e m o ut h. A r a n d o miz e d t a bl e will b e us e d t o  d et er mi n e 
t h e or d er of c oll ecti o n fr o m e ac h q u a dr a nt.  
T h e p artici p a nt will b e as k e d t o s uc k a n d s w all o w a n y exc essi v e s ali v a i n his/ h er m o ut h a n d a 
pl astic s p at ul a will b e us e d t o scr a p e t h e b ucc al s urf ac es (f aci n g t h e c h e e k) of t h e t e et h i n t h at 
q u a dr a nt of t h e m o ut h, c oll ecti n g a n y d e nt al pl a q u e acc u m ul at e d  t h er e. T his c oll ecti o n is 
ex p ect e d t o t a k e a b o ut 1 mi n. T h e p o ol e d pl a q u e s a m pl e will b e i m m e di at el y i m m ers e d i n  
mi n er al oil t o av oi d d esicc ati o n. T h e pl a q u e s a m pl es will t h e n b e c e ntrif u g e d t o s e p ar at e t h e 
fl ui d a n d s oli d p h as es. T h e fl ui d will b e c oll ect e d usi n g a micr o pi p ett e, u n d er micr osc o p e. B ot h 
s a m pl es –  t h e fl ui d a n d t h e s oli ds –  will b e a n al yz e d f or c alci u m a n d fl u ori d e c o nc e ntr ati o n usi n g 
a c ol ori m etric m et h o d ( Ars e n az o III r e a g e nt) a n d a n i o n -s el ecti v e el ectr o d e, r es p ecti v el y. 
 
5.  C oll ecti o n of s a li v a s a m ples: O n t h e 2 n d a n d 3 r d visits, p artici p a nts will h av e u nsti m ul at e d s ali v a 
s a m pl es c oll ect e d f or t h e a n al ysis of fl u ori d e a n d c alci u m. T h e c oll ecti o ns will st art at t h e 
f oll o wi n g ti m e p oi nts: 
• 
At t h e b e gi n ni n g of t h e s essi o n, i m m e di at el y aft er bi ofi l m c oll ecti o n 
• 
1 6 mi n ±  5 mi n aft er ri nsi n g wit h t h e i nt er v e nti o n gr o u p, i m m e di at el y aft er bi ofil m 
c oll ecti o n 
• 
3 0 mi n ±  5 mi n aft er ri nsi n g wit h t h e i nt erv e nti o n gr o u p  
• 
6 1 mi n ±  5 mi n aft er ri nsi n g wit h t h e i nt erv e nti o n gr o u p , i m m e di at el y aft er bi ofil m 
c oll ecti o n 
• 
9 0 mi n ±  5 mi n aft er ri nsi n g wit h t h e i nt erv e nti o n gr o u p  
• 
1 2 1 mi n ±  5 mi n aft er ri nsi n g wit h t h e i nt erv e nti o n gr o u p, i m m e di at el y aft er bi ofil m 
c oll ecti o n 
F or s ali v a c oll ecti o n, p artici p a nts will dr o ol a n y pr o d uc e d s ali v a i nt o a f u n n el att ac h e d t o a t u b e, 
f or 5 mi n.  T h e c oll ect e d s a m pl e will b e a n al yz e d f or fl u ori d e a n d c alci u m c o nc e ntr ati o n b ef or e 
a n d aft er b ei n g c e ntrif u g e d. A n i o n -s el ecti v e el ectr o d e a n d t h e Ars e n az o III r e a g e nt will b e us e d 
i n t h e d et er mi n ati o n of fl u ori d e a n d c alci u m c o nc e ntr ati o ns, r es p ecti v el y. 
 
6.  Ri nsi n g wit h t h e i nt erv e nti o n gr o u ps: O n t h e 2 n d a n d 3 r d visits, p artici p a nts will ri ns e wit h t h e 
assi g n e d m o ut h ri ns e ( fl u ori d e o nl y or a c alci u m f oll o w e d b y a fl u ori d e ri ns e) f or 1 mi n e ac h. T h e 
ri ns es will b e p erf or m e d wit h 1 5 mL of t h e assi g n e d pr o d ucts, as a n or m al m o ut h ri ns e. All ri ns es 
will b e ex p ect or a t e d. At t h e e n d of t h e 1-mi n ri nsi n g wit h t h e fl u ori d e ri ns e , a c hr o n o gr a p h will 
b e s et u p t o d et er mi n e t h e f oll o wi n g c oll ecti o ns, st arti n g 1 5 mi n aft er t h e ri ns e a n d e n di n g at 
l e ast 2 h l at er. 
 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
1 5  
7.  D et er mi n ati o n of fl u ori d e ( F) a n d c alci u m ( C a) c o nc e ntr ati o ns i n d e nt al bi ofil m a n d s ali v a 
s a m pl es: Bi ofil m fl ui d a n d s ali v a s a m pl es will b e ass ess e d f or F a n d C a c o nc e ntr ati o ns dir ectl y. I n 
t h e s oli d p h as e of d e nt al bi ofil m, F a n d C a will b e pr evi o usl y extr act e d fr o m t h e bi ofil m wit h 0. 5 
M H Cl f or 3 h at r o o m t e m p e r at ur e [ C ur y et al., 1 9 9 7; T e n ut a et al., 2 0 0 6] b ef or e d et er mi n ati o n 
of c o nc e ntr ati o ns i n t h e aci d extr act. F c o nc e ntr ati o ns will b e d et er mi n e d usi n g a F el ectr o d e s et 
u p f or micr o a n al ysis [ V o g el et al., 1 9 9 7; T e n ut a et al., 2 0 0 6] usi n g a p pr o pri at e fl u ori d e st a n d ar ds 
a n d TI S A B III as t h e b uff er. C a c o nc e ntr ati o n i n t h e bi ofil m fl ui d a n d s ali v a s a m pl es will b e 
d et er mi n e d usi n g a c alci u m micr o el ectr o d e [ V o g el et al., 2 0 0 0; T e n ut a et al., 2 0 1 0]. I n t h e aci d 
extr act of t h e bi ofil m s oli d p h as e, t ot al c alci u m c o n c e ntr ati o n will b e d et er mi n e d usi n g a 
c ol ori m etric r e acti o n ( Ars e n az o III), i n a micr o pl at e r e a d er [L eit ã o et al., 2 0 1 8].  
N o st u d y r es ults will b e c o m m u nic at e d t o t h e p ati e nts, exc e pt f or t h eir s ali v ar y fl o w r at e, w hic h 
c a n si g nific a ntl y i ncr e as e t h eir ris k f or c ari es dis e as es i n c as e it is l o w.  
 
8. 2  
A D V E R S E E V E N T S A N D S E RI O U S A D V E R S E E V E N T S  
I R B M e d’s g ui d eli n es o n a dv ers e ev e nts ( A E) a n d s eri o us a dv ers e ev e nts ( S A E) r e p orti n g will b e f oll o w e d. 
T h es e g ui d eli n es i ncl u d e t h e d efi niti o ns of A E/ S A E a n d w h e n t o r e p ort it.  
 
8. 3  
U N A N TI CI P A T E D P R O B L E M S  
I R B M e d’s g ui d eli n es o n u n a ntici p at e d pr o bl e ms ( U a P) r e p orti n g will b e f oll o w e d. T h es e g ui d eli n es 
i ncl u d e t h e d efi niti o n of U a P a n d w h e n t o r e p ort it. 
 
9  
S T A TI S TI C A L C O N SI D E R A TI O N S   
 
9. 1  
St ati sti c al H y p ot h e s e s  
•  
Pri m ar y Effic ac y E n d p oi nt:  
•  
Fl u ori d e c o nc e ntr ati o n i n d e nt al bi ofil m  
o  N ull h y p ot h esis: A fl u ori d e ri ns e pr ec e d e d b y a c alci u m ri ns e is n ot s u p eri or t h a n a 
fl u ori d e-o nl y ri ns e i n e n h a nci n g f l u ori d e c o nc e ntr ati o n i n d e nt al bi ofil m (fl ui d a n d s oli d 
p h as e s) u p t o 2 h aft er m o ut h ri nsi n g . 
o  Alt er n ati v e h y p ot h esis: A fl u ori d e ri ns e pr ec e d e d b y a c alci u m ri ns e is s u p eri or t h a n a 
fl u ori d e-o nl y ri ns e i n e n h a nci n g fl u ori d e c o nc e ntr ati o n i n d e nt al bi ofil m (fl ui d a n d s oli d 
p h as es) u p t o 2 h aft er m o ut h ri nsi n g.  
 
•  
S ec o n d ar y Effic ac y E n d p oi nts:  
•  
Fl u ori d e c o nc e ntr ati o n i n s ali v a  
o  N ull h y p ot h esis : A fl u ori d e ri ns e pr ec e d e d b y a c alci u m ri ns e is n ot s u p eri or t h a n a 
fl u ori d e-o nl y ri ns e i n e n h a nci n g fl u ori d e c o nc e ntr ati o ns i n s ali v a u p t o 2 h aft er m o ut h 
ri nsi n g. 
o  Alt er n ati v e h y p ot h esis: A fl u ori d e ri ns e pr ec e d e d b y a c alci u m ri ns e is s u p eri or t h a n a 
fl u ori d e-o nl y ri ns e i n e n h a nci n g fl u ori d e c o nc e ntr ati o ns i n s ali v a (fl ui d a n d s oli d p h as es) 
u p t o 2 h aft er m o ut h ri nsi n g.  
•  
C alci u m c o nc e ntr ati o n i n d e nt al bi ofil m  
o  N ull h y p ot h esis: A fl u ori d e ri ns e pr ec e d e d b y a c alci u m ri ns e is n ot s u p eri or t h a n a 
fl u ori d e-o nl y ri ns e i n e n h a nci n g c alci u m c o nc e ntr ati o n i n d e nt al bi ofil m (f l ui d a n d s oli d 
p h as es) u p t o 2 h aft er m o ut h ri nsi n g.  

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
1 6  
o  Alt er n ati v e h y p ot h esis: A fl u ori d e ri ns e pr ec e d e d b y a c alci u m ri ns e is s u p eri or t h a n a 
fl u ori d e-o nl y ri ns e i n e n h a nci n g c alci u m c o nc e ntr ati o n i n d e nt al bi ofil m (fl ui d a n d s oli d 
p h as es) u p t o 2 h aft er m o ut h ri nsi n g.  
•  
C alci u m c o nc e ntr ati o n i n s ali v a  
o  N ull h y p ot h esis: A fl u ori d e ri ns e pr ec e d e d b y a c alci u m ri ns e is n ot s u p eri or t h a n a 
fl u ori d e-o nl y ri ns e i n e n h a nci n g c alci u m c o nc e ntr ati o n i n s ali v a u p t o 2 h aft er m o ut h 
ri nsi n g. 
o  Alt er n ati v e h y p ot h esis: A fl u ori d e ri ns e pr ec e d e d b y a c alci u m ri ns e is s u p eri or t h a n a 
fl u ori d e-o nl y ri ns e i n e n h a nci n g c alci u m c o nc e ntr ati o n i n s ali v a u p t o 2 h aft er m o ut h 
ri nsi n g. 
 
•  
T erti ar y / ex pl or at or y E n d p oi nts:  
•  
C orr el ati o n b et w e e n s ali v ar y fl o w r at e a n d fl u ori d e c o nc e ntr ati o n i n d e nt al bi ofil m  
o  N ull h y p ot h esis: T h er e is n o c orr el ati o n ( b et a = 0) b et w e e n s ali v ar y fl o w r at e a n d 
fl u ori d e c o nc e ntr ati o n i n d e nt al bi ofil m aft er ri nsi n g wit h a fl u ori d e m o ut h ri ns e. 
o  Alt er n ati v e h y p ot h esis: T h er e is a c orr el ati o n ( b et a ¹  0) b et w e e n s ali v ar y fl o w r at e a n d 
fl u ori d e c o nc e ntr ati o n i n d e nt al bi ofil m aft er ri nsi n g wit h a fl u ori d e m o ut h ri ns e. 
•  
C orr el ati o n b et w e e n s ali v ar y fl o w r at e a n d fl u ori d e c o nc e ntr ati o n i n s ali v a  
o  N ull h y p ot h esis: T h er e is n o c orr el ati o n ( b et a = 0) b et w e e n s ali v ar y fl o w r at e a n d 
fl u ori d e c o nc e ntr ati o n i n s ali v a aft er ri nsi n g wit h a fl u ori d e m o ut h ri ns e. 
o  Alt er n ati v e h y p ot h esis: T h er e is a c orr el ati o n ( b et a ¹  0) b et w e e n s ali v ar y fl o w r at e a n d 
fl u ori d e c o nc e ntr ati o n i n s ali v a aft er ri nsi n g wit h a fl u ori d e m o ut h ri ns e. 
 
9. 2  
S A M P L E SI Z E  D E T E R MI N A TI O N  
D at a fr o m S o uz a et al., 2 0 1 6, usi n g ri ns es si mil ar t o b e us e d i n t his st u d y, w er e us e d i n s a m pl e siz e 
c alc ul ati o n. I n t h at st u d y, a n al ysis of fl u ori d e c o nc e ntr ati o n i n d e nt al bi ofil m 1 0 h aft er usi n g t h e ri ns es 
w as av ail a b l e. ( N ot e t h at t h e ex p ect e d diff er e nc es b et w e e n t h e gr o u ps u p t o 2 h aft er t h e m o ut h ri nsi n g 
ar e ex p ect e d t o b e bi g g er, as s ali v a pr o d ucti o n ov erti m e t e n ds t o cl e ar all s u bst a nc es fr o m t h e m o ut h).  
 
C o nsi d eri n g a n  8 0 % p o w er t o d et ect diff er e nc es at t h e 5 % si g nific a nc e l ev el, a n esti m at e d s a m pl e siz e of 
1 5 w as d et er mi n e d ( St at a/ S E 1 5. 1 f or M ac). T h e s a m pl e siz e w as i ncr e as e d t o 2 0 s u bj ects c o nsi d eri n g a n 
attriti o n of 3 0 % . 
 
9. 3  
P O P U L A TI O N S F O R A N A L Y S E S  
F or t h e pri m ar y a n d s ec o n d ar y o utc o m es, o nl y p artici p a nts c o m pl eti n g t h e w h ol e st u d y will pr ovi d e 
d at a f or t h e a n al ys es ( p er -pr ot oc ol a n al ysis).  
 
F or t h e t erti ar y o utc o m es, a m o difi e d i nt e nti o n -t o-tr e at a n al ysis will b e us e d; all v ol u nt e ers c o m pl eti n g 
t h e fl u ori d e-o nl y m o ut h ri ns e tr e at m e nt will pr ovi d e d at a f or t h e c orr el ati o n a n al ys es, ev e n if t h ey di d 
n ot c o m pl et e t h e ot h er st u d y tr e at m e nt.  
 
9. 4  
S T A TI S TI C A L A N A L Y S E S  
 
9. 4. 1  G E N E R A L A P P R O A C H  
D escri pti v e st atistics:  D at a of fl u ori d e c o nc e ntr ati o n i n s ali v a a n d d e nt al bi ofil m t e n d t o h av e a n ot -
n or m al distri b uti o n. If t h at is t h e c as e i n t his st u d y, t h es e d at a will b e pr es e nt e d as t h e g e o m etric m e a n 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
1 7  
( of l o g tr a nsf or m e d d at a) a n d c o nfi d e nc e i nt erv al (c alc ul at e d fr o m l og tr a nsf or m e d d at a). D at a of 
c alci u m, if fitti n g n or m al distri b uti o n, will b e pr es e nt e d as m e a ns a n d st a n d ar d d evi ati o ns. If n ot fitti n g 
n or m al distri b uti o n, t h e s a m e a p pr o ac h f or fl u ori d e will b e us e d.  
 
I nf er e nti al t ests: T h e c o m p aris o ns b et w e e n gr o u ps wi ll b e m a d e usi n g an al ysis of v ari a nc e, h avi n g t h e 
v ol u nt e ers as st atistic al bl oc ks (s o urc e of v ari ati o n). T his is o nl y t o r e d uc e k n o w n v ari a bilit y fr o m t h e 
err or c alc ul ati o n. O n e -t ail e d t ests will b e us e d t o t est f or s u p eri orit y of o n e tr e at m e nt v ers us t h e ot h er. 
T h e p -v al u e will b e s et at 5 %.  
B ef or e t h e a n al ysis of v ari a nc e, t h e n or m alit y of err ors will b e t est e d. It is ex p ect e d t h at fl u ori d e d at a is 
n ot n or m all y distri b ut e d, a n d t h er ef or e a l o g tr a nsf or m ati o n of d at a will b e p erf or m e d ( w hic h us u all y is 
a d e q u at e t o n or m aliz e t h e d at a). T h e s a m e a p pr o ac h will b e us e d f or t h e c alci u m d at a.  
 
B esi d es t h e gr o u ps c o m p aris o ns , t h e s ali v ar y fl o w r at e will b e c orr el at e d wit h t h e fl u ori d e c o nc e ntr ati o n 
i n d e nt al bi ofil m a n d s ali v a, t o h el p u n d erst a n d t h e eff ect of fl o w r at e o n fl u ori d e s ali v ar y cl e ar a nc e. F or 
t h at, a r e gr essi o n a n al ysis will b e us e d t o c orr el at e t h e d at a of s ali v ar y fl o w wit h fl u ori d e c o nc e ntr ati o n 
( ar e a u n d er t h e c urv e of fl u ori d e c o nc e ntr ati o n ov er ti m e) i n s ali v a a n d d e nt al bi ofil m. A si g nific a nc e 
l ev el of 5 % will b e us e d i n t his a n al ysis.  
 
9. 4. 2  A N A L Y SI S O F T H E P RI M A R Y E F FI C A C Y E N D P OI N T( S)  
Fl u ori d e c o nc e ntr ati o n i n d e nt al bi ofil m ( pri m ar y effic ac y e n d p oi nt) will b e d et er mi n e d fr o m t h e 
s a m pl es c oll ect e d at b as eli n e a n d 1 5 mi n, 6 0 mi n a n d 1 2 0 mi n (±  5 mi n) aft er ri nsi n g wit h t h e assi g n e d 
m o ut h ri ns e(s). T h e c o nc e ntr ati o n at e ac h i n di vi d u al ti m e p oi nt will b e c o m p ar e d b et w e e n t h e t w o 
i nt erv e nti o n gr o u ps. Als o, t h e ar e a u n d er t h e c ur v e of fl u ori d e c o nc e ntr ati o n i n d e nt al bi ofil m v ers us 
ti m e will b e c alc ul at e d. T his si n gl e m e as ur e m e nt of fl u ori d e bi o a v ail a bilit y o v erti m e aft er t h e m o ut h 
ri ns e(s) will b e c o m p ar e d b et w e e n t h e t w o i nt erv e nti o n gr o u ps. 
 
E ac h s et of d at a will b e c h ec k e d f or n or m alit y of err ors. If t h e d at a is n ot n or m al, it will b e l o g -
tr a nsf orm e d. A n a n al ysis of v ari a nc e will b e c o n d uct e d, c o nsi d eri n g as f act ors t h e p artici p a nt 
( ex p eri m e nt al bl oc k) a n d t h e tr e at m e nt. T h e us e of t h e p artici p a nt as a s o urc e of v ari ati o n ai ms s ol el y t o 
r e d uc e u n k n o w n v ari a bilit y i n t h e err or. A n al p h a l ev el of 5 % will b e us e d t o d et er mi n e si g nific a nt 
diff er e nc es b et w e e n t h e t w o gr o u ps.  
 
I n c as e d at a w er e l o g-tr a nsf or m e d t o fit t h e st atistic al a n al ysis, t h eir g e o m etric m e a ns a n d c o nfi d e nc e 
i nt erv als (c alc ul at e d fr o m t h e l o g-tr a nsf or m e d d at a) will b e pr es e nt e d. 
 
If dat a is missi n g fr o m o n e of t h e i nt erv e nti o n gr o u ps, t h e r est of t h e p artici p a nt d at a (fr o m t h e ot h er 
i nt erv e nti o n) will b e excl u d e d fr o m t h e a n al ysis. 
 
9. 4. 3  A N A L Y SI S O F T H E S E C O N D A R Y E N D P OI N T( S)  
Fl u ori d e a n d c alci u m c o nc e ntr ati o ns i n s ali v a (s ec o n d ar y e n d p oi nts ) will b e d et er mi n e d fr o m t h e 
s a m pl es c oll ect e d at b as eli n e a n d 1 6 mi n, 3 0 mi n, 6 1 mi n, 9 0 a n d 1 2 1  mi n ( ±  5 mi n) aft er ri nsi n g wit h t h e 
assi g n e d m o ut h ri ns e(s). T h e c o nc e ntr ati o n at e ac h i n di vi d u al ti m e p oi nt will b e c o m p ar e d b et w e e n t h e 
t w o i nt erv e nti o n gr ou ps. Als o, t h e ar e a u n d er t h e c urv e of fl u ori d e  a n d c alci u m  c o nc e ntr ati o n i n s ali v a 
v ers us ti m e will b e c alc ul at e d  a n d  c o m p ar e d b et w e e n t h e t w o i nt erv e nti o n gr o u ps.  
 
C alci u m c o nc e ntr ati o n i n d e nt al bi ofil m ( pri m ar y effic ac y e n d p oi nt) will b e d et er mi n e d fr o m t h e s a m pl es 
c oll ect e d at b as eli n e a n d 1 5 mi n, 6 0 mi n a n d 1 2 0 mi n ( ±  5 mi n) aft er ri nsi n g wit h t h e assi g n e d m o ut h 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
1 8  
ri ns e(s). T h e c o nc e ntr ati o n at e ac h i n di vi d u al ti m e p oi nt will b e c o m p ar e d b et w e e n t h e t w o i nt erv e nti o n 
gr o u ps. Als o, t h e ar e a u n d er t h e c urv e of c alci u m c o nc e ntr ati o n i n d e nt al bi ofil m v ers us ti m e will b e 
c alc ul at e d a n d c o m p ar e d b et w e e n t h e t w o i nt erv e nti o n gr o u ps.  
 
E ac h s et of d at a will b e c h ec k e d f or n or m alit y of err ors. If t h e d at a is n ot n or m al, it will b e l o g -
tr a nsf or m e d. A n a n al ysis of v ari a nc e will b e c o n d uct e d, c o nsi d eri n g as f act ors t h e p artici p a nt 
( ex p eri m e nt al bl oc k) a n d t h e tr e at m e nt. T h e us e of t h e p artici p a nt as a s o urc e of v ari ati o n ai ms s ol el y t o 
r e d uc e u n k n o w n v ari a bilit y i n t h e err or. A n al p h a l ev el of 5 % will b e us e d t o d et er mi n e si g nific a nt 
diff er e nc es b et w e e n t h e t w o gr o u ps.  
 
I n c as e d at a w er e l o g-tr a nsf or m e d t o fit t h e st atistic al a n al ysis, t h eir g e o m etric m e a ns a n d c o nfi d e nc e 
i nt erv als (c alc ul at e d fr o m t h e l o g-tr a nsf or m e d d at a) will b e pr es e nt e d. 
 
If d at a is missi n g fr o m o n e of t h e i nt er v e nti o n gr o u ps, t h e r est of t h e p artici p a nt d at a (fr o m t h e ot h er 
i nt erv e nti o n) will b e excl u d e d fr o m t h e a n al ysis. 
 
 
1 0  S U P P O R TI N G D O C U M E N T A TI O N A N D O P E R A TI O N A L C O N SI D E R A TI O N S  
1 0. 1  R E G U L A T O R Y, E T HI C A L , A N D S T U D Y O V E R SI G H T C O N SI D E R A TI O N S  
 
1 0. 1. 1  I N F O R M E D C O N S E N T P R O C E S S 
A n i nf or m e d c o ns e nt  d escri bi n g i n d et ail t h e st u d y i nt erv e nti o n, st u d y pr oc e d ur es, a n d ris ks ar e gi v e n t o 
t h e p artici p a nt a n d writt e n d oc u m e nt ati o n of i nf or m e d c o ns e nt is r e q uir e d pri or t o st arti n g 
i nt erv e nti o n/ a d mi nist eri n g st u d y i nt er v e nti o n.  
 
1 0. 1. 1. 1  C O N S E N T P R O C E D U R E S A N D D O C U M E N T A TI O N  
I nf or m e d c o ns e nt is a pr oc ess t h at is i niti at e d pri or t o t h e i n di vi d u al’s a gr e ei n g t o p artici p at e i n t h e 
st u d y a n d c o nti n u es t hr o u g h o ut t h e i n di vi d u al’s st u d y p artici p ati o n. C o ns e nt f or ms will b e I nstit uti o n al 
R evi e w B o ar d ( I R B)-a p pr ov e d a n d t h e p artici p a nt will b e as k e d t o r e a d a n d r evi e w t h e d oc u m e nt. T h e 
i nv esti g at or will ex pl ai n t h e r es e arc h st u d y t o t h e p artici p a nt a n d a ns w er a n y q u esti o ns t h at m a y aris e. 
A v er b al ex pl a n ati o n will b e pr o vi d e d i n t er ms s uit e d t o t h e p artici p a nt’s c o m pr e h e nsi o n of t h e 
p ur p os es, pr oc e d ur es, a n d p ot e nti al ris ks of t h e st u d y a n d of t h eir ri g hts as r es e arc h p artici p a nts.  
P artici p a nts will h a v e t h e o p p ort u nit y t o c ar ef ull y r evi e w t h e writ t e n c o ns e nt f or m a n d as k q u esti o ns 
pri or t o si g ni n g.  T h e p artici p a nts s h o ul d h av e t h e o p p ort u nit y t o disc uss t h e st u d y wit h t h eir f a mil y or 
s urr o g at es or t hi n k a b o ut it pri or t o a gr e ei n g t o p artici p at e. T h e p artici p a nt will si g n t h e i nf or m e d 
c o ns e nt d oc u m ent pri or t o a n y pr oc e d ur es b ei n g d o n e s p ecific all y f or t h e st u d y. P artici p a nts m ust b e 
i nf or m e d t h at p artici p ati o n is v ol u nt ar y a n d t h at t h e y m a y wit h dr a w fr o m t h e st u d y at a n y ti m e, wit h o ut 
pr ej u dic e. A c o p y of t h e i nf or m e d c o ns e nt d oc u m e nt will b e gi v e n t o t h e p artici p a nts f or t h eir r ec or ds. 
T h e i nf or m e d c o ns e nt pr oc ess will b e c o n d uct e d a n d t h e f or m si g n e d, b ef or e t h e p artici p a nt u n d er g o es 
a ny st u dy -s p ecific pr oc e d ur es. T h e ri g hts a n d w elf ar e of t h e p artici p a nts will b e pr ot ect e d b y 
e m p h asizi n g t o t h e m t h at t h e q u alit y of t h eir m e dic al c ar e will n ot b e a dv ers el y aff ect e d if t h ey d ecli n e 
t o p artici p at e i n t his st u d y. 
 
1 0. 1. 2  S T U D Y DI S C O N TI N U A TI O N A N D C L O S U R E  
T his st u dy m a y b e t e m p or aril y s us p e n d e d or pr e m at ur el y t er mi n at e d if t h er e is s uffici e nt r e as o n a bl e 
c a us e.  Writt e n n otific ati o n, d oc u m e nti n g t h e r e as o n f or st u d y s us p e nsi o n or t er mi n ati o n, will b e 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
1 9  
pr ovi d e d by t h e s us p e n di n g or t er mi n ati n g p art y t o st u d y p artici p a nts.  If t h e st u d y is pr e m at ur el y 
t er mi n at e d or s us p e n d e d, t h e P ri nci p al Inv esti g at or ( PI ) will pr o m ptl y i nf or m st u d y p artici p a nts, t h e 
I nstit utio n al R evi e w B o ar d ( I R B), a n d s p o ns or a n d will pr o vi d e t h e r e as o n(s) f or t h e t er mi n ati o n or 
s us p e nsi o n.  St u d y p artici p a nts will b e c o nt act e d, as a p plic a bl e, a n d b e i nf or m e d of c h a n g es t o st u d y 
visit sc h e d ul e.  
  
Circ u mst a nc es t h at m a y w arr a nt t er mi n ati o n or s us p e nsi o n i ncl u d e, b ut ar e n ot li mit e d t o:  
•  
D et er mi n ati o n of u n ex p ect e d, si g nific a nt, or u n acc e pt a bl e ris k t o p artici p a nts  
•  
D e m o nstr ati o n of effic ac y t h at w o ul d w arr a nt st o p pi n g    
•  
I ns uffici e nt c o m pli a nc e t o pr ot oc ol r e q uir e m e nts 
•  
D at a t h at ar e n ot s uffici e ntl y c o m pl et e a n d/ or ev al u a bl e  
•  
D et er mi n ati o n t h at t h e pri m ar y e n d p oi nt h as b e e n m et  
•  
D et er mi n ati o n of f utilit y  
 
1 0. 1. 3  C O N FI D E N TI A LI T Y A N D P RI V A C Y  
P artici p a nt c o nfi d e nti alit y a n d pri v ac y is strictl y h el d i n tr ust b y t h e p artici p ati n g i n v esti g at ors, t h eir 
st aff, a n d t h e s p o ns or a n d t h eir i nt er v e nti o ns. T his c o nfi d e nti alit y is ext e n d e d t o c o v er t esti n g of 
bi ol o gic al s a m pl es i n a d diti o n t o t h e cli nic al i nf or m ati o n r el ati n g t o p artici p a nts.  T h er ef or e, t h e st u d y 
pr ot oc ol, d oc u m e nt ati o n, d at a, a n d all ot h er i nf or m ati o n g e n er at e d will b e h el d i n strict c o nfi d e nc e. N o 
i nf or m ati o n c o nc er ni n g t h e st u d y or t h e d at a will b e r el e as e d t o a n y u n a ut h oriz e d t hir d p art y wit h o ut 
pri or writt e n a p pr ov al of t h e s p o ns or.  
 
All r es e arc h acti v iti es will b e c o n d uct e d i n as pri v at e a s etti n g as p ossi bl e. 
 
T h e st u dy p artici p a nt’s c o nt act i nf or m ati o n will b e s ec ur el y st or e d at e ac h cli nic al sit e f or i nt er n al us e 
d uri n g t h e st u d y. At t h e e n d of t h e st u d y, all r ec or ds will c o nti n u e t o b e k e pt i n a s e c ur e l oc ati o n f or as 
l o n g a p eri o d as dict at e d b y t h e r evi e wi n g I R B, I nstit uti o n al p olici es, or s p o ns or r e q uir e m e nts. 
 
1 0. 1. 4  K E Y R O L E S  A N D S T U D Y G O V E R N A N C E  
 
Pri nci p al I n v esti g at or  
Li vi a M. A. T e n ut a, D D S, M Sc, P h D, Ass oci at e Pr of ess or 
U niv ersity of Mic hi g a n, Sc h o ol of D e ntistr y  
1 0 1 1 N. U ni v ersit y Av e, r o o m 2 2 1 7, A n n Ar b or, MI  
7 3 4 -7 6 3 -3 7 0 3  
lit e n ut a @ u mic h. e d u 
 
1 0. 1. 5  D A T A  H A N D LI N G  A N D R E C O R D  K E E PI N G   
 
1 0. 1. 5. 1  D A T A C O L L E C TI O N A N D  M A N A G E M E N T R E S P O N SI BI LI TI E S  
D at a c oll ecti o n is t h e r es p o nsi bilit y of t h e cli nic al tri al st aff, u n d er t h e s u p ervisi o n of t h e pri nci p al 
inv esti g at or . T h e i nv esti g at or is r es p o nsi bl e f or e ns uri n g t h e acc ur ac y, c o m pl et e n ess, l e gi bilit y, a n d 
ti m eli n ess of t h e d at a r e p ort e d. 
 
All s o urc e d oc u m e nts s h o ul d b e c o m pl et e d i n a n e at, l e gi bl e m a n n er t o e ns ur e acc ur at e i nt er pr et ati o n 
of d at a.   

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
2 0  
 
H ar dc o pi es of t h e st u d y visit w or ks h e ets will b e pr ovi d e d f or us e as s o urc e d oc u m e nt  w or ks h e ets f or 
r ec or di n g d at a f or e ac h p artici p a nt e nr oll e d i n t h e st u d y.   
 
1 0. 1. 5. 2  S T U D Y R E C O R D S R E T E N TI O N  
 
1 0. 1. 6  P R O T O C O L D E VI A TI O N S  
A pr ot oc ol d evi ati o n is a n y n o nc o m pli a nc e wit h t h e cli nic al tri al pr ot oc ol. T h e n o nc o m pli a nc e m a y b e 
eit h er o n t h e p art of t h e p artici p a nt, t h e i n v esti g at or, or t h e st u d y sit e st aff. As a r es ult of d evi ati o ns, 
c orr ectiv e acti o ns ar e t o b e d ev el o p e d b y t h e sit e a n d i m pl e m e nt e d pr o m ptl y.  
 
It is t h e r es p o nsi bilit y of t h e pri nci p al  i n v esti g at or t o us e c o nti n u o us vi gil a nc e t o i d e ntif y pr ot oc ol 
d evi ati o n s. All d evi ati o ns m ust b e a d dr ess e d i n st u d y s o urc e d oc u m e nts .  Pr ot oc ol d evi ati o ns m ust b e 
s e nt t o t h e r evi e wi n g Instit uti o n al R evi e w B o ar d (I R B)  p er t h eir p olici es . T h e pri nci p al i n v esti g at or is 
r es p o nsi bl e f or k n o wi n g a n d a d h eri n g t o t h e r evi e wi n g I R B r e q uir e m e nts.  
 
1 0. 1. 7  P U B LI C A TI O N A N D D A T A S H A RI N G P O LI C Y  
T his tri al will b e  r e gist er e d at Cli nic al Tri als. g ov, a n d r es ults i nf or m ati o n fr o m t his tri al will  b e s u b mitt e d 
t o Cli nic al Tri als. g o v. I n a d diti o n, ev er y att e m pt will b e m a d e t o p u blis h r es ults i n p e er-r evi e w e d j o ur n als.  
D at a fr o m t his st u d y m a y b e r e q u est e d  fr o m ot h er r es earc h ers 3  y e ars aft er t h e c o m pl eti o n of t h e 
pri m ary e n d p oi nt b y c o nt acti n g Li vi a M. A. T e n ut a.  
 
1 0. 1. 8  C O N F LI C T O F  IN T E R E S T  P O LI C Y  
T h e i n d e p e n d e nc e of t his st u d y fr o m a n y act u al or p erc ei v e d i nfl u e nc e, s uc h as b y t h e p h ar m ac e utic al 
i n d ustr y, is critic al.  T h er efor e , a n y act u al c o nflict of i nt er est of p ers o ns w h o h av e a r ol e i n t h e d esi g n, 
c o n d uct, a n al ysis, p u blic ati o n, or a n y as p ect of t his tri al will b e discl os e d a n d m a n a g e d. F urt h er m or e, 
p ers o ns w h o h av e a p erc ei v e d c o nflict of i nt er est will b e r e q uir e d t o h av e s u c h c o nflicts m a n a g e d i n a 
w ay t h at is a p pr o pri at e t o t h eir p artici p ati o n i n t h e d es ig n a n d c o n d uct of t his tri al.  
 
 
 
 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
2 1  
1 0. 2  A b br e vi ati o n s  
A E  
A d v ers e E v e nt  
C a  
C alci u m  
C O N S O R T  C o ns oli d at e d St a n d ar ds of R e p orti n g Tri als  
C R F  
C as e R e p ort F or m  
F  
Fl u ori d e  
F D A  
F o o d a n d Dr u g A d mi nistr ati o n  
GL P  
G o o d L a b or at or y Pr actic es  
I R B 
I nstit uti o n al R e vi e w B o ar d  
N a F  
S o di u m fl u ori d e  
N C T  
N ati o n al Cli nic al Tri al  
PI  
Pri nci p al I n v esti g at or  
S A E  
S eri o us A d v ers e E v e nt  
S O A  
Sc h e d ul e of Acti viti es  
U a P  
U n a ntici p at e d Pr o bl e m  
U S P  
U nit e d St at es  P h ar m ac o p ei a  
 
 
 

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
2 2  
1 1  R E F E R E N C E S  
B ar kv oll  P,  R øll a  G,  L a g erl öf  F.  Eff ect  of  s o di u m  l a ur yl  s ulf at e  o n  t h e  d e p ositi o n  of  al k ali -s ol u bl e 
fl u ori d e o n e n a m el i n vitr o. C ari es R es. 1 9 8 8; 2 2( 3): 1 3 9-4 4.  
C ury  J A,  R e b ell o  M A,  D el  B el  C ur y  A A.  I n  sit u  r el ati o ns hi p  b et w e e n  s ucr os e  ex p os ur e  a n d  t h e 
c o m p ositi o n of d e nt al pl a q u e. C ari es R es. 1 9 9 7; 3 1( 5): 3 5 6 -6 0.  
E d g ar M, D a w es C, O' M ull a n e D. S ali v a a n d or al h e alt h. 4. e d. St e p h e n H a nc oc ks Li mit e d, 2 0 1 2.  
F er n á n d ez C E, T e n ut a L M A, C ur y J A. W as h -o ut p eri o d f or cr oss ov er d esi g n ex p eri m e nts usi n g hi g h 
fl u ori d e c o nc e ntr ati o n d e ntifric e. R ev Cli n P eri o d I m p R e h a bil Or al. 2 0 1 5; 8( 1): 1 -6.  
F ur n ess S, W ort hi n gt o n H V, Br y a n G, Birc h e n o u g h S, Mc Mill a n R. I nt er v e nti o ns f or t h e m a n a g e m e nt 
of  dry  m o ut h:  t o pic al  t h er a pi es.  C oc hr a n e  D at a b as e  S yst  R ev.  2 0 1 1  D ec  7;( 1 2): C D 0 0 8 9 3 4.  d oi: 
1 0. 1 0 0 2/ 1 4 6 5 1 8 5 8. C D 0 0 8 9 3 4. p u b 2.  
L eit ã o TJ, C ur y J A, T e n ut a L M A. Ki n etics of c alci u m bi n di n g t o d e nt al bi ofil m b act eri a. PL o S O n e. 2 0 1 8 
J a n 3 1; 1 3( 1): e 0 1 9 1 2 8 4. d oi: 1 0. 1 3 7 1/j o ur n al. p o n e. 0 1 9 1 2 8 4. 
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Acc ess e d 
o n M ar 2 0 t h, 2 0 1 9. 
N av az es h M, K u m ar S K; U ni v ersit y of S o ut h e r n C alif or ni a Sc h o ol of D e ntistr y. M e as uri n g s ali v ar y fl o w: 
c h all e n g es a n d o p p ort u niti es. J A m D e nt Ass oc. 2 0 0 8 M a y; 1 3 9 S u p pl: 3 5 S -4 0 S.  
N av az es h, M. X er ost o mi a a n d s ali v ar y gl a n d h y p of u ncti o n; a eti ol o g y , di a g n osis, cli nic al i m plic ati o ns 
a n d  m a n a g e m e nt.  I n:  E d g ar  M,  D a w es  C,  O' M ull a n e  D,  e ds.  S ali v a  a n d  or al  h e alt h.  4. e d.  St e p h e n 
H a nc oc ks Li mit e d, 2 0 1 2. C h. 4.  
N ó br e g a D F, L eit ã o TJ, C ur y J A, T e n ut a L M A. Fl u ori d e bi n di n g t o d e nt al bi ofil m b act éri a : s y n er gistic 
eff ect wit h c alci u m q u esti o n e d. C ari es R es. 2 0 1 9; 5 3: 1 0 -5.  
S o uz a  J G,  T e n ut a  L M,  D el  B el  C ur y  A A,  N ó br e g a  D F,  B u di n  R R,  d e  Q u eir oz  M X,  V o g el  GL,  C ur y  J A. 
C alci u m pr eri ns e b ef or e fl u ori d e ri ns e r e d uc es e n a m el d e mi n er aliz ati o n: a n i n sit u C ari es St u d y. C ari es 
R es. 2 0 1 6; 5 0( 4): 3 7 2 -7. d oi: 1 0. 1 1 5 9/ 0 0 0 4 4 6 4 0 7.  
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1 5 0 0  a n d  5 0 0 0 
p p m  fl u ori d e  ex p os ur e.  Cli n  Or al  I nv esti g.  2 0 1 8  A pr; 2 2( 3): 1 1 2 3 -1 1 2 9. 
d oi: 1 0. 1 0 0 7/s 0 0 7 8 4 -0 1 7 -2 1 9 5 -y.  
T e n ut a L M, D el B el C ur y A A, B ort oli n M C, V o g el GL, C ur y J A. C a, Pi, a n d F i n t h e fl ui d of bi ofil m f or m e d 
u n d er s ucr os e. J D e nt R es. 2 0 0 6; 8 5( 9): 8 3 4 -8.  
T e n ut a  L M,  D el  B el  C ur y  A A,  T a bc h o ur y  C P,  M oi  G P,  Sil v a  WJ,  C ur y  J A.  Ki n etics  of 
m o n ofl u or o p h os p h at e h y dr ol ysis i n a b act eri al t est pl a q u e i n sit u. C ari es R es.  2 0 1 0; 4 4( 1): 5 5 -9. d oi: 
1 0. 1 1 5 9/ 0 0 0 2 7 9 4 6 6.  
v a n L ov er e n C. T h e a nti micr o bi al acti o n of fl u ori d e a n d its r ol e i n c ari es i n hi biti o n. J D e nt R es. 1 9 9 0; 6 9 
S p ec N o: 6 7 6 -8 1.  
V o g el  GL,  C h o w  L C,  C ar e y  C M,  Sc h u m ac h er  G E,  T a k a gi  S.  Eff ect  of  a  c alci u m  pr eri ns e  o n  s ali v ar y 
fl u ori d e aft er a 2 2 8-p p m fl u ori d e ri ns e. C ari es R es 2 0 0 6 a; 4 0: 1 7 8 -8 0.  
V o g el GL, C h o w L C, C ar ey C M. C alci u m pr e -ri ns e gr e atl y i ncr e as es o v er ni g ht s ali v ar y fl u ori d e aft er a 
2 2 8 p p m fl u ori d e ri ns e. C ari es R es. 2 0 0 8 a; 4 2( 5): 4 0 1 -4. d oi: 1 0. 1 1 5 9/ 0 0 0 1 5 4 7 8 6.  

O pti mizi n g fl u ori d e r et e nti o n i n t h e m o ut h of ol d er a d ults wit h disti nct s aliv ary fl o w r at es 
V ersi o n 1. 3  
Pr ot oc ol 0 1  
2 0 A u g ust 2 0 2 0  
 
 
2 3  
V o g el GL, M a o Y, C ar ey C M, C h o w L C. I ncr e as e d ov er ni g ht fl u ori d e c o nc e ntr ati o ns i n s ali v a, pl a q u e, 
a n d pl a q u e fl ui d aft er a n ov el t w o -s ol uti o n ri ns e. J D e nt R es. 1 9 9 7; 7 6( 3): 7 6 1-7.  
V o g el GL, Sc h u m ac h er G E, C h o w L C, T a k a gi S, C ar ey C M. C a pr e -ri ns e gr e atl y i ncr e as es pl a q u e a n d 
pl a q u e fl ui d F. J D e nt R es. 2 0 0 8 b; 8 7( 5): 4 6 6 -9.  
V o g el  GL,  S hi m  D,  Sc h u m ac h er  G E,  C ar ey  C M,  C h o w  L C,  T a k a gi  S.  S ali v ar y  fl u ori d e  fr o m  fl u ori d e 
d e ntifric es or ri ns e s aft er us e of a c alci u m pr e-ri ns e or c alci u m d e ntifric e. C ari es R es. 2 0 0 6 b; 4 0( 5): 4 4 9-
5 4.  
V o g el GL, Z h a n g Z, C h o w L C, C ar ey C M, Sc h u m ac h er G E, B a nti n g D W. Eff ect i n  vitr o aci dific ati o n o n 
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2 0 0 0 A pr; 7 9( 4): 9 8 3 -9 0.  
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W or ks h o p o n Or al M e dici n e VI. Dr u gs R D. 2 0 1 7 M ar; 1 7( 1): 1 -2 8. d oi: 1 0. 1 0 0 7/s 4 0 2 6 8 -0 1 6 -0 1 5 3 -9.  
Z er o D T, Br e n n a n M T, D a ni els T E, P a p as A, St e w art C, Pi nt o A, Al -H as hi mi I, N a v az es h M, R h o d us N, 
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K M;  Sj ö gr e n’s  S y n dr o m e  F o u n d ati o n  Cli nic al  Pr actic e  G ui d eli n es  C o m mitt e e.  Cli nic al  pr actic e 
g ui d eli n es  f or  or al  m a n a g e m e nt  of  Sj ö gr e n  dis e as e:  D e nt al  c ari es  pr e v e nti o n.  J  A m  D e nt  Ass oc. 
2 0 1 6; 1 4 7( 4): 2 9 5 -3 0 5. d oi: 1 0. 1 0 1 6/j. a d aj. 2 0 1 5. 1 1. 0 0 8.