ORIGINAL CONTRIBUTIONS

ARTICLE 3

Potential diversion of local anesthetics

from dental offices for use as cocaine
adulterants
Mana Saraghi, DMD; Elliot V. Hersh, DMD, MS, PhD

ocal anesthetics, with the exception of cocaine, are

devoid of psychogenic properties and usually are
not perceived to be drugs that can be abused.
However, several reports of methemoglobinemia
coincident with cocaine administration have demonstrated the potential for the diversion of the commonly
used topical anesthetic benzocaine as a cocaine adulterant.1,2 Analysis of a sample of the cocaine seized by
the authorities revealed that lidocaine also is used as
a cocaine adulterant.1,2 Adulterants are used not only
to dilute illicit drugs to increase the profits of those
who sell the drugs but also to give drug users the illusion that the drug is a more potent drug. For example,
lidocaine and benzocaine increase the nasal numbness
that accompanies snorting cocaine. When used properly,
local anesthetics have a wide safety margin.1,2 Injectable
lidocaine is the most frequently used local anesthetic
in dentistry in the United States; it is estimated that approximately 640,000 to 800,000 cartridges of lidocaine
are used daily (Paul Mondock, senior vice president of
sales and marketing, Septodont, Lancaster, Pa., written
communication, Aug. 14, 2013). In addition, benzocaine
can be used safely as a topical over-the-counter agent.3,4
However, given the potential for local anesthetics to be
used as drug adulterants, we suggest tighter surveillance
of lidocaine cartridges and benzocaine gels in the dental
office.
CASES

We conducted a PubMed search by using the following

terms: adulterants, benzocaine, cocaine, lidocaine
and methemoglobinemia. The following case illustrates
the potential misuse of lidocaine and benzocaine as
cocaine adulterants.
A 34-year-old man sought care for seizures at an

ABSTRACT
Background. Reports of lidocaine and benzocaine
in the bloodstreams of people who abuse cocaine with
accompanying reports of seizures and methemoglobinemia indicate that there is a potential that local
anesthetics are being diverted from dental offices and
being used as cocaine adulterants. These adulterants
augment the nasal numbness produced by inhaling
cocaine.
Methods. The authors conducted a PubMed search
by using the following terms: adulterants, benzocaine,
cocaine, lidocaine and methemoglobinemia.
Results. The authors identified two case reports as
a result of their PubMed search. Each case involved
a patient with symptoms of both cocaine overdose
and methemoglobinemia who sought treatment at an
emergency department. The results of urine samples
from each patient, as well as the results from an analysis of a sample of one patients cocaine, revealed the
presence of many adulterants, including lidocaine and
benzocaine.
Conclusions. Injectable lidocaine and topical benzocaine are cheap and readily available substances found
in dental offices that may be diverted by anyone
including dentists, office staff members or patientsto
adulterate cocaine.
Practical Implications. Additional research is
needed to identify whether dental offices are a common source of cocaine adulterants. The authors recommend that dentists keep track of their local anesthetic
supplies.
Key Words. Lidocaine; drugs; drug abuse; drug
contamination; drug interactions; pharmacology; local
anesthetics; topical anesthetics; dental anesthetics.
JADA 2014;145(3):256-259.
doi:10.14219/jada.2013.33

Dr. Saraghi was an instructor of dental anesthesiology, Department of Periodontics, Division of Pediatric Dentistry, and Department of Oral Surgery
and Pharmacology, School of Dental Medicine, University of Pennsylvania, Philadelphia, when this article was written. She now is a dentist anesthesiologist, Northwest Dental Anesthesia, 5528 E. Green Lake Way N., #19, Seattle, Wash. 98103, e-mail msaraghi@gmail.com. Address correspondence to Dr. Saraghi.
Dr. Hersh is a professor of oral surgery and pharmacology, Division of Pharmacology, School of Dental Medicine, University of Pennsylvania,
Philadelphia.

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ORIGINAL CONTRIBUTIONS

emergency department (ED) in England while he was in

police custody.1 He had ingested a white powder, which
he identified as cocaine, and admitted that the cocaine
seemed more potent than usual. The patient had a history of epilepsy. He developed seizures within one hour of
ingesting this batch of cocaine. The ED physician placed
him under general anesthesia to control his seizures. His
skin became cyanotic between seizure episodes. The ED
physician obtained an arterial blood sample from the
patient for arterial blood gas analysis. The blood was described as dark in color, with a partial pressure of oxygen
in arterial blood (PaO2) of 65.1 kilopascals and a fraction
of oxygenated hemoglobin (FO2Hb) of 82.5 percent (normal PaO2, 11-13 kPa; normal FO2Hb, 94-98 percent). The
high arterial oxygen tension and low fraction of hemoglobin bound to oxygen are characteristic of methemoglobinemia. Co-oximetry testing confirmed a diagnosis
of methemoglobinemia, because the methemoglobin
(metHbO2) level was 13.8 percent. Methylene blue was
not administered to the patient because his metHbO2
levels were below 20 percent. Urine mass spectrometry
was used to identify the presence of not only cocaine but
also phenytoin, lidocaine and benzocaine.
Another case of benzocaine-adulterated cocaine
has been reported in the literature.2 A 27-year-old man
had attempted suicide by consuming a large quantity of
cocaine. Noticing his altered mental status, his girlfriend called emergency services for help. The patient
was having seizures and vomiting and was mydriatic
and cyanotic by the time the paramedics arrived. His
vital signs were documented as heart rate of 120 to 130
beats per minute, blood pressure of 220/130 millimeters
of mercury and respiratory rate of 20 to 30 breaths per
minute. Such dramatic increases in blood pressure, heart
rate and respiratory rate and the onset of seizures are
characteristic of cocaine intoxication. He arrived in the
ED with a temperature of 38.3C (100.9F). The ED physician obtained an arterial blood sample from the patient
for arterial blood gas analysis. The blood was described
as chocolate brown; hemoglobin spectral analysis results
helped confirm a diagnosis of methemoglobinemia,
because the metHbO2 level was 37 percent. Methylene
blue was administered intravenously, and the patient
was discharged from the hospital after six days. Urine
mass spectrometry and gas chromatography testing were
used to identify cocaine, norcocaine, ecognine (another
cocaine metabolite) and benzocaine. The patients girlfriend also gave the physician a plastic bag containing a
white powder and claimed it was a cutting substance.
This powder underwent mass-spectral analysis, which
identified it as benzocaine.
DISCUSSION

effects from the adulterants and fillers. Illicit drugs, with

the exception of abused prescription drugs, are produced
under less-than-ideal conditions with no oversight or
regulation, and the skills of the people who produce
them are highly variable. To net a greater profit, producers often cut, or adulterate, illicit drugs with other
substances. These cutting agents may be inert diluents
or pharmacologically active adulterants.5-7 Pharmacologically inactive compounds or fillers such as sugars or
starches can dilute the illicit drug, artificially increasing
the volume and ultimately increasing profits.5-7 An adulterant, on the other hand, often is chosen as an adjunct
to the illicit drug to enhance the drugs effects, giving
adulteration of heroin with fentanyl. Both substances
are opioids; however, the inclusion of fentanyl provides
a more rapid onset of euphoria as the prodrug heroin is
metabolized to morphine.8 Another example is adulterating cocaine with local anesthetics such as lidocaine or
benzocaine. Cocaine is a local anesthetic, and the addition of lidocaine or benzocaine can give the drug user
a more profound freeze or nasal numbness when the
cocaine is snorted.6,7
The results of analyses of samples of seized cocaine
have shown that lidocaine is used as an adulterant more
frequently than is benzocaine. Fucci and De Giovanni9
reported that the most common adulterant found in
cocaine samples was lidocaine, followed by caffeine and
aminophenazone. Results of an analysis of 2,824 cocaine
samples showed that lidocaine was found in higher
percentages than was benzocaine.10 In an analysis of 471
samples of seized cocaine, investigators found lidocaine
in 128 samples and benzocaine in only two.7 Other pharmacologically active compounds found in the cocaine
samples included but were not limited to phenacetin (an
acetaminophen precursor), caffeine, diltiazem (a calcium
channel blocker), levamisole (an anticancer drug) and
hydroxyzine (an antihistamine).7 In another analysis of
343 cocaine samples, investigators detected the following
adulterants: phenacetin (in 54 percent of the samples),
caffeine (in 17 percent), acetaminophen (in 14 percent),
diltiazem (in 11 percent), lidocaine (in 11 percent),
levamisol (in 6 percent) and hydroxyzine (4 percent).11
Although these drugs were seized in western Europe, it
is possible that illicit drug producers in North America
use similar adulterants. However, not all seized cocaine is
analyzed for purity, nor are all the findings published in
the literature.
Cocaine (benzoylmethylecgonine) is an ester local
anesthetic. Local anesthetics effects are mediated by
means of a sodium channel blockade.12 A unique feature
of cocaine that distinguishes it from other local anesthetics is that it has vasoconstrictive and sympathomimetic
effects caused by means of inhibiting the reuptake of

These cases illustrate that the overall manifestation of a

drug overdose may include not only the adverse effects
of the illicit drug use but also the unintended adverse

ABBREVIATION KEY. ED: Emergency department.

MetHbO2: Methemoglobin.

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ORIGINAL CONTRIBUTIONS

norepinephrine, serotonin and dopamine and increasing

the release of norepinephrine, dopamine and serotonin.
Cocaine toxicity, therefore, manifests as increased
sympathetic nervous system effects such as increased
blood pressure and heart rate. Patients may seek care at
an ED complaining of chest pain with either myocardial
ischemia or myocardial infarction after abusing cocaine.
Drastic increases in sympathetic output also may lead to
hemorrhagic or ischemic strokes with short-term abuse.
Other effects include hyperthermia, diaphoresis, mydriasis, paranoia and increased likelihood of thrombosis.
Dopamine reuptake inhibition and release results in
increased dopamine concentrations in the brain, which
leads to euphoria and sometimes delirium. Short-term
cocaine use lowers the seizure threshold. When cocaine
is adulterated with other local anesthetics such as lidocaine, the seizure threshold is decreased further and may
precipitate a new seizure or worsen an existing seizure
disorder.12,13
Methemoglobinemia manifests with its own toxidrome as at least one of the four ferrous iron atoms in a
hemoglobin molecule become oxidized to the ferric state,
converting reduced hemoglobin to oxidized hemoglobin
or metHbO2.14 Methemoglobinemia can be acquired
or congenital; the acquired type is most common.4,14
Acquired methemoglobinemia most commonly is due to
overdose reactions to oxidizing agents such as benzocaine and prilocaine; and nitrites such as nitroglycerine,
dapsone and ciprofloxacin.3,14 The literature does not
support the use of lidocaine as a hemoglobin oxidant.14,15
When hemoglobin is oxidized to metHbO2, the molecule
has a lower affinity for oxygen. As a result, less oxygen is
delivered to tissues.3,14 In healthy people, there are physiological levels of metHbO2 (approximately 0-2 percent),
as oxygen is an oxidizing agent. Several endogenous
enzymatic systems reduce this metHbO2. When oxidizing agents exhaust the bodys capacity to reduce
metHbO2, such as in a benzocaine overdose, metHbO2
levels begin to increase. As metHbO2 rises to 10 to 15
percent, cyanosis may occur; at higher levels of 20 to
45 percent metHbO2, patients demonstrate an altered
mental status with headache, dizziness, fatigue, syncope,
tachypnea and tachycardia. MetHbO2 levels of 50 to
55 percent usually correlate with loss of consciousness,
coma, acidosis, seizures and arrhythmias. MetHbO2
levels of 70 percent usually result in death. Traditional
pulse oximeters help differentiate oxyhemoglobin and
deoxyhemoglobin by means of how they absorb two
wavelengths of light differently. MetHbO2 absorbs
equally at these two wavelengths and consequently leads
to the pulse oximeters erroneously reading between
85 and 90 percent regardless of whether supplemental
oxygen is administered. A blood test with co-oximetry
can measure the levels of metHbO2 in the blood because
co-oximetry differentiates between the absorption of two
more wavelengths of light in addition to the ones meas-

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ured by means of a pulse oximeter so that hemoglobinopathies such as metHbO2 or carboxyhemoglobin can be
measured.16 A person overdosing on cocaine adulterated
with benzocaine not only will exhibit the classic signs of
cocaine overdose but also those of benzocaine overdose.
A quick Internet search can reveal a wealth of
information, some of it inaccurate, for potential drug
producers. A search via Googles search engine for how
to make lidocaine into powder to cut cocaine led us
to several message boards and forums in which people
shared tips about how to convert ampules of lidocaine
into a powder. Suggestions included evaporation, using
a heat lamp, mixing lidocaine with bicarbonate and
experimenting with various temperatures and cooking
times. Benzocaine can be prepared by various methods,
including Fischer esterification, an organic chemistry
laboratory procedure in which para-aminobenzoic acid
and ethanol react to form benzocaine.17 With an estimated 1 million cartridges of local anesthetic used daily
in the United States, a large volume of local anesthetic
cartridges move into and out of dental offices rather
quickly (Paul Mondock, senior vice president of sales
and marketing, Septodont, written communication, June
7, 2013). Benzocaine is used topically before administering an injection, so both benzocaine and lidocaine
are easily accessible, often left unattended and rarely
accounted for as compared with controlled substances.
Benzocaine also is easily accessible as an over-thecounter drug for temporary relief of pain from apthous
ulcers, orthodontic appliances, teething and toothache,
which further increases the risk of its unapproved use as
a cocaine adulterant.3,4
Although keeping a drug log and a count of every
lidocaine cartridge may be prohibitively time consuming
and excessive, it may be prudent for dentists and office
staff members to keep an eye on office supplies. Without
proper oversight, entire boxes of local anesthetic cartridges and bottles of topical local anesthetic may vanish
easily and be diverted either by a patient, a patients
escort or an office staff member. More restrictive ways of
monitoring of local anesthetic supplies in dental offices,
such as unit-of-use bar codes and radiofrequency identification chips, could lower the incidence of lidocaine
and benzocaine diversion from dental offices. However, before such measures are undertaken, additional
research is needed to identify whether dental offices are
a common source of lidocaine and benzocaine that are
used as cocaine adulterants.
CONCLUSIONS

Topical and injectable local anesthetics are among the

most common medications administered in the dental
office. When used according to the package insert, they
are safe. However, there is a real potential for diversion
of local anesthetics, especially lidocaine and benzocaine,
from the dental office to illegal drug producers. Illegal

ORIGINAL CONTRIBUTIONS

drug producers often adulterate their drugs with other

substances to dilute their product and increase their
profits.
Case reports of methemoglobinemia coincident with
cocaine abuse and the results of subsequent analyses of
the patients urine or drug samples have revealed that
benzocaine was an adulterant. Results from forensic
analysis of cocaine samples revealed that lidocaine and
benzocaine also were drug adulterants. Local anesthetics
are used frequently in the dental office and may have a
high turnover rate. Therefore, a patient or staff member
may divert boxes of local anesthetic easily from the office. It may be wise for dentists and office staff members
to keep track of local anesthetics. Additional research is
needed to identify whether dental offices are a common
source of lidocaine and benzocaine diversion for use as
cocaine adulterants.
Disclosure. Over the preceding five years, Dr. Hersh has received grant
monies from Pfizer Consumer Healthcare and Church and Dwight, the
makers of benzocaine products used to treat tooth pain. In addition, Dr.
Hersh received grant funding from Septodont, the maker of dental injectable local anesthetic solutions including lidocaine. Dr. Saraghi did not
report any disclosures.
1. Chakladar A, Willers JW, Pereskokova E, Beaumont PO, Uncles DR.
White powder, blue patient: methaemoglobinaemia associated with
benzocaine-adulterated cocaine. Resuscitation 2010;81(1):138-139.
2. McKinney CD, Postiglione KF, Herold DA. Benzocaine-adultered
street cocaine in association with methemoglobinemia. Clin Chem
1992;38(4):596-597.
3. Hersh EV, Stoopler ET, Secreto SA, DeRossi SS. A study of benzocaine
gel dosing for toothache. J Clin Dent 2005;16(4):103-108.
4. Hersh EV, Ciancio SG, Kuperstein AS, et al. An evaluation of 10
percent and 20 percent benzocaine gels in patients with acute toothaches:
efficacy, tolerability and compliance with label dose administration
directions. JADA 2013;144(5):517-526.
5. Gostic T, Klemenc S, Stefane B. A study of the thermal decomposition
of adulterated cocaine samples under optimized aerobic pyrolytic conditions. Forensic Sci Int 2009;187(1-3):19-28.
6. Hunter L, Gordge L, Dargan PI, Wood DM. Methaemoglobinaemia
associated with the use of cocaine and volatile nitrites as recreational
drugs: a review. Br J Clin Pharmacol 2011;72(1):18-26.
7. Schneider S, Meys F. Analysis of illicit cocaine and heroin samples
seized in Luxembourg from 2005-2010. Forensic Sci Int 2011;212(1-3):
242-246.
8. Behrman AD. Luck of the draw: common adulterants found in illicit
drugs. J Emerg Nurs 2008;34(1):80-82.
9. Fucci N, De Giovanni N. Adulterants encountered in the illicit
cocaine market. Forensic Sci Int 1998;95(3):247-252.
10. Brunt TM, Rigter S, Hoek J, Vogels N, van Dijk P, Niesink RJ. An
analysis of cocaine powder in the Netherlands: content and health hazards due to adulterants. Addiction 2009;104(5):798-805.
11. Evrard I, Legleye S, Cadet-Tarou A. Composition, purity and perceived quality of street cocaine in France. Int J Drug Policy 2010;21(5):
399-406.
12. Zimmerman JL. Cocaine intoxication. Crit Care Clin 2012;28(4):
517-526.
13. Wong GT, Irwin MG. Poisoning with illicit substances: toxicology
for the anaesthetist. Anaesthesia 2013;68(suppl 1):117-124.
14. Trapp L, Will J. Acquired methemoglobinemia revisited. Dent Clin
North Am 2010;54(4):665-675.
15. Guay J. Methemoglobinemia related to local anesthetics: a summary
of 242 episodes. Anesth Analg 2009;108(3):837-845.
16. Matthews PJ Jr. Co-oximetry. Respir Care Clin N Am 1995;1(1):47-68.
17. Demare P, Regla I. Synthesis of two local anesthetics from toluene:
an organic multistep synthesis in a project-oriented laboratory course.
J Chem Educ 2012;89(1):147-149.

1.1% Sodium Fluoride

PRESCRIPTION STRENGTH TOOTHPASTE

DESCRIPTION: Self-topical neutral fluoride dentifrice containing 1.1% (w/w)

sodium fluoride for use as a dental caries preventive in adults and pediatric patients.
Active Ingredient: Sodium fluoride 1.1% (w/w)
INDICATIONS AND USAGE: A dental caries preventive; for once daily selfapplied topical use. It is well established that 1.1% sodium fluoride is safe and
extraordinarily effective as a caries preventive when applied frequently with
mouthpiece applicators. 1-4 PreviDent 5000 BoosterPlus brand of 1.1% sodium
fluoride toothpaste in a squeeze bottle is easily applied onto a toothbrush.
This prescription toothpaste should be used once daily in place of your regular
toothpaste unless otherwise instructed by your dental professional. May be used
in areas where drinking water is fluoridated since topical fluoride cannot produce
fluorosis. (See WARNINGS for exception.)
CONTRAINDICATIONS: Do not use in pediatric patients under age 6 years unless
recommended by a dentist or physician.
WARNINGS: Prolonged daily ingestion may result in various degrees of dental
fluorosis in pediatric patients under age 6 years, especially if the water fluoridation
exceeds 0.6 ppm, since younger pediatric patients frequently cannot perform the
brushing process without significant swallowing. Use in pediatric patients under age
6 years requires special supervision to prevent repeated swallowing of toothpaste
which could cause dental fluorosis. Pediatric patients under age 12 should be
supervised in the use of this product. Read directions carefully before using. Keep
out of reach of infants and children.
PRECAUTIONS:
General: Not for systemic treatment. DO NOT SWALLOW.
Carcinogenesis, Mutagenesis, Impairment of Fertility: In a study conducted
in rodents, no carcinogenesis was found in male and female mice and female rats
treated with fluoride at dose levels ranging from 4.1 to 9.1 mg/kg of body weight.
Equivocal evidence of carcinogenesis was reported in male rats treated with 2.5
and 4.1 mg/kg of body weight. In a second study, no carcinogenesis was observed
in rats, males or females, treated with fluoride up to 11.3 mg/kg of body weight.
Epidemiological data provide no credible evidence for an association between
fluoride, either naturally occurring or added to drinking water, and risk of human
cancer. Fluoride ion is not mutagenic in standard bacterial systems. It has been
shown that fluoride ion has potential to induce chromosome aberrations in cultured
human and rodent cells at doses much higher than those to which humans are
exposed. In vivo data are conflicting. Some studies report chromosome damage in
rodents, while other studies using similar protocols report negative results.
Potential adverse reproductive effects of fluoride exposure in humans have not
been adequately evaluated. Adverse effects on reproduction were reported for rats,
mice, fox, and cattle exposed to 100 ppm or greater concentrations of fluoride in
their diet or drinking water. Other studies conducted in rats demonstrated that
lower concentrations of fluoride (5 mg/kg of body weight) did not result in impaired
fertility and reproductive capabilities.
Pregnancy: Teratogenic Effects: Pregnancy Category B. It has been shown that
fluoride crosses the placenta of rats, but only 0.01% of the amount administered
is incorporated in fetal tissue. Animal studies (rats, mice, rabbits) have shown
that fluoride is not a teratogen. Maternal exposure to 12.2 mg fluoride/kg of
body weight (rats) or 13.1 mg/kg of body weight (rabbits) did not affect the litter
size or fetal weight and did not increase the frequency of skeletal or visceral
malformations. There are no adequate and well-controlled studies in pregnant
women. However, epidemiological studies conducted in areas with high levels of
naturally fluoridated water showed no increase in birth defects. Heavy exposure to
fluoride during in utero development may result in skeletal fluorosis which becomes
evident in childhood.
Nursing Mothers: It is not known if fluoride is excreted in human milk. However,
many drugs are excreted in milk, and caution should be exercised when products
containing fluoride are administered to a nursing woman. Reduced milk production
was reported in farm-raised fox when the animals were fed a diet containing a high
concentration of fluoride (98-137 mg/kg of body weight). No adverse effects on
parturition, lactation, or offspring were seen in rats administered fluoride up to 5
mg/kg of body weight.
Pediatric Use: The use of PreviDent 5000 BoosterPlus in pediatric age groups 6
to 16 years as a caries preventive is supported by pioneering clinical studies with
1.1% sodium fluoride gels in mouth trays in students age 11 to 14 years conducted
by Englander et al.2-4 Safety and effectiveness in pediatric patients below the age
of 6 years have not been established. Please refer to the CONTRAINDICATIONS and
WARNINGS sections.
Geriatric Use: Of the total number of subjects in clinical studies of 1.1% (w/v)
sodium fluoride, 15 percent were 65 and over, while 1 percent were 75 and over.
No overall differences in safety or effectiveness were observed between these
subjects and younger subjects, and other reported clinical experience has not
identified differences in responses between the elderly and younger patients, but
greater sensitivity of some older individuals cannot be ruled out. This drug is known
to be substantially excreted by the kidney, and the risk of toxic reactions to this drug
may be greater in patients with impaired renal function. Because elderly patients
are more likely to have decreased renal function, care should be taken in dose
selection, and it may be useful to monitor renal function.5
ADVERSE REACTIONS: Allergic reactions and other idiosyncrasies have been
rarely reported.
OVERDOSAGE: Accidental ingestion of large amounts of fluoride may result in
acute burning in the mouth and sore tongue. Nausea, vomiting, and diarrhea may
occur soon after ingestion (within 30 minutes) and are accompanied by salivation,
hematemesis, and epigastric cramping abdominal pain. These symptoms may
persist for 24 hours. If less than 5 mg fluoride/kg body weight (i.e., less than 2.3
mg fluoride/lb body weight) has been ingested, give calcium (e.g., milk) orally to
relieve gastrointestinal symptoms and observe for a few hours. If more than 5
mg fluoride/kg body weight (i.e., more than 2.3 mg fluoride/lb body weight) has
been ingested, induce vomiting, give orally soluble calcium (e.g., milk, 5% calcium
gluconate or calcium lactate solution) and immediately seek medical assistance.
For accidental ingestion of more than 15 mg fluoride/kg of body weight (i.e., more
than 6.9 mg fluoride/lb body weight), induce vomiting and admit immediately to
a hospital facility.
A treatment dose (a thin ribbon) of PreviDent 5000 BoosterPlus contains
approximately 2.5 mg fluoride. A 3.4 FL OZ (100 mL) bottle contains approximately
605 mg fluoride.
DOSAGE AND ADMINISTRATION: Follow these instructions unless otherwise
instructed by your dental professional:
1. Adults and pediatric patients 6 years of age or older, apply a thin ribbon of
PreviDent 5000 BoosterPlus to a toothbrush. Brush teeth thoroughly once daily for
two minutes, preferably at bedtime, in place of your regular toothpaste.
2. After use, adults expectorate. For best results, do not eat, drink, or rinse for
30 minutes. Pediatric patients, age 6-16, expectorate after use and rinse mouth
thoroughly.
Rev. 07/12

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