VOLUME 38 • NUMBER 6 • JUNE 2007 455 QUINTESSENCE INTERNATIONAL Fluorosis is a dental disease that affects 2.1% to 74.7% of the population. 1,2 Already in the 1940s, Dean et al were able to show a strong relation between fluoride concentration in drinking water and the prevalence and severity of fluorosis. 1,2 Based on the severity of enamel damage, a classification of 10 degrees of fluo- rosis has been proposed. 3 The scores range from 0, where the glossy creamy-white enamel is visible only after drying of the tooth, to 9, where the major part of the enamel is lost and a change in the shape of the tooth has occurred. Clinicians faced with this problem have different treatment options. Teeth discolored by fluorosis may be managed by bleaching, microabrasion, veneering, or artificial crowns. The choice between these treat- ments depends on the severity of the dis- ease 4 ; however, in more severe cases the proposed treatment option is often invasive. The problem with invasive treatments is that most patients demanding treatment for fluo- rosis are young adults with a life expectancy of many decades and the use of invasive pro- cedures in the form of a prosthetic approach with veneers or crowns results in an exces- sive sacrifice of tooth material, thus acceler- ating the destruction of the tooth at an early age. Furthermore, a restorative approach is time consuming and relatively expensive. The aim of this article is to describe—and illustrate with a case report—a minimally inva- sive technique that improves the esthetic aspect of teeth with severe enamel fluorosis without requiring restorative techniques. CLINICAL PROCEDURE The proposed minimally invasive technique is based on a combined approach of micro- abrasion, 5 home bleaching, 6,7 and enamel reshaping. Once enamel fluorosis is diag- nosed (Figs 1a and 1b) by case history and clinical examination, oral hygiene instruction followed by scaling and polishing is per- formed, whenever necessary. During the microabrasion treatment, the patient’s and cli- nicians’ eyes are protected from accidental spills by protective glasses. A minimally invasive treatment of severe dental fluorosis Stefano Ardu, Dr Med Dent 1 /Minos Stavridakis, Dr Med Dent 2 / Ivo Krejci, Prof Dr Med Dent 3 This article describes a minimally invasive technique to treat a severe case of enamel fluo- rosis using microabrasion to eliminate the hypermineralized, white-colored, superficial enamel layer, followed by home bleaching treatment and chairside re-creation of superfi- cial enamel microstructure. The proposed technique may improve the esthetics of fluorotic teeth without requiring other restorative procedures. Microabrasion followed by home bleaching may be an interesting alternative for the restorative treatment of teeth affected by fluorosis. (Quintessence Int 2007;38:455–458) Key words: fluorosis, microabrasion, micromorphology, minimally invasive treatment 1 Lecturer, Division of Cariology and Endodontology, Dental School, University of Geneva, Geneva, Switzerland. 2 Lecturer, Department of Operative Dentistry, School of Dentistry, University of Athens, Athens, Greece. 3 Professor and Chairman, Division of Cariology and Endodontology, Dental School, University of Geneva, Geneva, Switzerland. Reprint requests: Dr Stefano Ardu, Ecole de Medecine Dentaire, rue Barthélemy-Menn 19, 1205 Geneva, Switzerland. E-mail: [email protected]
A minimally invasive treatment of severe dental fluorosis
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Ardu.qxdQUINTESSENCE INTERNATIONAL
1940s, Dean et al were able to show a strong
relation between fluoride concentration in
drinking water and the prevalence and severity
of fluorosis.1,2 Based on the severity of enamel
damage, a classification of 10 degrees of fluo-
rosis has been proposed.3 The scores range
from 0, where the glossy creamy-white enamel
is visible only after drying of the tooth, to 9,
where the major part of the enamel is lost and
a change in the shape of the tooth has
occurred.
different treatment options. Teeth discolored
by fluorosis may be managed by bleaching,
microabrasion, veneering, or artificial
ments depends on the severity of the dis-
ease4; however, in more severe cases the
proposed treatment option is often invasive.
The problem with invasive treatments is that
most patients demanding treatment for fluo-
rosis are young adults with a life expectancy
of many decades and the use of invasive pro-
cedures in the form of a prosthetic approach
with veneers or crowns results in an exces-
sive sacrifice of tooth material, thus acceler-
ating the destruction of the tooth at an early
age. Furthermore, a restorative approach is
time consuming and relatively expensive.
The aim of this article is to describe—and
illustrate with a case report—a minimally inva-
sive technique that improves the esthetic
aspect of teeth with severe enamel fluorosis
without requiring restorative techniques.
based on a combined approach of micro-
abrasion,5 home bleaching,6,7 and enamel
reshaping. Once enamel fluorosis is diag-
nosed (Figs 1a and 1b) by case history and
clinical examination, oral hygiene instruction
followed by scaling and polishing is per-
formed, whenever necessary. During the
microabrasion treatment, the patient’s and cli-
nicians’ eyes are protected from accidental
spills by protective glasses.
A minimally invasive treatment of severe dental fluorosis Stefano Ardu, Dr Med Dent1/Minos Stavridakis, Dr Med Dent2/
Ivo Krejci, Prof Dr Med Dent3
This article describes a minimally invasive technique to treat a severe case of enamel fluo-
rosis using microabrasion to eliminate the hypermineralized, white-colored, superficial
enamel layer, followed by home bleaching treatment and chairside re-creation of superfi-
cial enamel microstructure. The proposed technique may improve the esthetics of fluorotic
teeth without requiring other restorative procedures. Microabrasion followed by home
bleaching may be an interesting alternative for the restorative treatment of teeth affected
by fluorosis. (Quintessence Int 2007;38:455–458)
Key words: fluorosis, microabrasion, micromorphology, minimally invasive treatment
1Lecturer, Division of Cariology and Endodontology, Dental
School, University of Geneva, Geneva, Switzerland.
2Lecturer, Department of Operative Dentistry, School of
Dentistry, University of Athens, Athens, Greece.
3Professor and Chairman, Division of Cariology and
Endodontology, Dental School, University of Geneva, Geneva,
Switzerland.
rue Barthélemy-Menn 19, 1205 Geneva, Switzerland. E-mail:
[email protected]
456 VOLUME 38 • NUMBER 6 • JUNE 2007
QUINTESSENCE INTERNATIONAL
Ardu et a l
Figs 1a and 1b Views of a patient with severe enamel fluorosis. Fig 1c Microabrasion procedure under rubber dam protection.
Fig 1d Chairside fluoride gel application following microabrasion procedures. Fig 1e View after microabrasion and 2 weeks of home bleaching with 10% carbamide peroxide. Note the rough aspect of the surface and the absence of enamel micromorphology.
Figs 1f and 1g Enamel reshaping to recreate micromorphology.
Figs 1h to 1j Posttreatment appearance.
Ardu.qxd 6/4/07 11:04 AM Page 456
VOLUME 38 • NUMBER 6 • JUNE 2007 457
QUINTESSENCE INTERNATIONAL
sion is performed with an abrasive paste con-
taining silicon carbide microparticles in
water-soluble paste and 6.6% hydrochloric
acid (Opalustre Ultradent). For this purpose,
a layer of about 2 to 3 mm is applied on the
affected teeth (Fig 1c) using a specific rubber
cup (Oralcups, Opalustre Ultradent) attached
to a gear-reduction contra-angle handpiece.
The tooth surface is microabraded with slight
pressure for 60 to 120 seconds. Whenever
necessary, a small water drop can be added
and the abrasion can be repeated.
Several applications may be necessary, as
in this case, where 2 applications were per-
formed. In such a case, after each applica-
tion, an optical evaluation must be done after
water rinse, before proceeding to the next
application.
Tooth Mousse, Recaldent, GC Europe) or a
fluoride gel (Binaca Natrium Fluor Gelée,
ESRO) is then applied on the treated enamel
surface (Fig 1d), left undisturbed for 5 to 15
minutes, and finally suctioned by the aspira-
tion device but not water sprayed. Because
of the dehydration of the teeth, optical evalu-
ation of the treatment must be done at the
following appointment, and, if necessary, the
treatment may be repeated.
follows to better harmonize tooth color (Fig
1e), as does enamel-surface reshaping with
fine diamonds and silicon points (Figs 1f and
1g) to recreate a natural-looking macro- and
microstructure of the surface (Figs 1h to 1j).
DISCUSSION
ing worldwide because of excessive exposure
to fluoride within the first years of life.8–10 A crit-
ical period has been identified at which teeth
are most at risk of fluorosis: 21 to 30 months
of age for females and 15 to 24 months of age
for males.8 The mechanisms responsible for
enamel fluorosis have been investigated by
several authors. Similar theories, with slight
differences among them, have been pro-
posed. It is generally accepted that the char-
acteristic opacity of fluorotic enamel results
from incomplete apatite crystal growth. Matrix
proteins, which are associated with the miner-
al phase and permit a correct crystal growth,
normally degrade and disappear during the
enamel maturation phase. In fluorotic enamel,
they are not eliminated, resulting in their reten-
tion in the enamel tissue. Fluoride and mag-
nesium concentrations increase, while the
carbonate level is reduced. Crystal surface
morphology is slightly altered. Such changes
in crystal chemistry and morphology, involv-
ing stronger ionic and hydrogen bonds, also
lead to greater binding of modulating matrix
proteins and proteolytic enzymes. This results
in reduced degradation and enhanced reten-
tion of protein components in mature tissue.
This is most likely responsible for porous fluo-
rotic tissue, since complete matrix protein
removal is necessary for “healthy” crystal
growth.11 In other words, fluorotic enamel is
characterized by retention of amelogenins in
the early maturation stage of development
and a consequent formation of a more
porous enamel with a subsurface hypomin-
eralization.12
solution or CPP-ACP paste for 5 to 15 min-
utes. This approach is justified for 2 reasons:
First, it reduces the risk of posttreatment sen-
sibility, and second, it protects teeth from
possible external demineralization. In Segura
et al’s experience,13 in fact, teeth treated with
microabrasion followed by a 4-minute appli-
cation of 1% neutral topical sodium fluoride
exhibited significantly less enamel deminer-
alization when subjected to an artificial caries
challenge than did teeth that underwent
microabrasion alone, topical fluoride treat-
ment alone, or no treatment at all.
After completion of microabrasion, a
home bleaching technique follows to better
harmonize tooth color and produce whiter
teeth, which is most often the patient’s main
objective. The home bleaching technique
can produce satisfactory esthetic improve-
ment, thus eliminating the need for direct or
indirect veneering.
QUINTESSENCE INTERNATIONAL
microabrasion is that, especially if multiple
applications are performed in 1 session or if
multiple microabrasion sessions are needed,
because of the abrasive action of the rubber
cup with the abrasive paste, the macro- and
microstructure of the buccal surface of the
teeth is sometimes lost. As a result, the teeth
show an unnaturally smooth appearance,
which is not representative of the micromor-
phology of teeth of young patients, who most
often seek treatment for enamel fluorosis.
For this reason, after the completion of the
home bleaching, a surface reshaping with
fine diamonds and silicon points is often nec-
essary to recreate a natural-looking macro-
and microstructure of the surface and to
achieve an optimal result.
appearance, dramatically decreasing the
of approach has the advantages of being
extremely conservative and very well accept-
ed by the patients. Furthermore, no special
maintenance precautions are required; thus
it may be considered an interesting alterna-
tive to conventional, more aggressive opera-
tive intervention.
REFERENCES
1. Dean HT, Jay P, Arnold FA, Elvove E. Domestic waters
and dental caries. II. A study of 2832 white children
ages 12–14 years of eight suburban Chicago com-
munities, including Lactobacillus acidophilus stud-
ies of 1761 children. Public Health Rep 1941;56:
761–792.
2. Dean HT, Arnold FA, Elvove E. Domestic water and
dental caries. V. Additional studies of the relation of
fluoride domestic waters to dental caries in 4425
white children, age 12–14 years, of 13 cities in 4
states. Public Health Rep 1942;57:1155–1179.
3. Fejerskov O, Manji F, Baelum V, Moller IJ. Dental
Fluorosis. A Handbook for Health Workers. Copen-
hagen: Munksgaard, 1988.
fluorosis. Int Dent J 2001;51:325–333.
5. Croll TP. Enamel microabrasion: The technique.
Quintessence Int 1989;20:395–400.
6. Croll TP. Tooth bleaching for children and teens: a
protocol and examples. Quintessence Int. 1994;
25:811–817.
7. Scherer W, Penugonda B, Styner D, Georgescu M. At-
home vital bleaching: Effects on stained enamel
and dentin. Pract Periodontics Aesthet Dent 1992;4:
11–15.
olism and fluorosis. J Dent 2005;33:177–186.
9. Whelton HP,Ketley CE,McSweeney F,O’Mullane DM.
A review of fluorosis in the European Union: Preva-
lence, risk factors and aesthetic issues. Community
Dent Oral Epidemiol 2004;32(suppl 1):9–18.
10. Whelton H, Crowley E, O'Mullane D, Donaldson M,
Kelleher V, Cronin M. Dental caries and enamel fluo-
rosis among the fluoridated and non-fluoridated
populations in the Republic of Ireland in 2002.
Community Dent Health 2004;21:37–44.
11. Robinson C, Connell S, Kirkham J, Brookes SJ, Shore
RC, Smith AM.The effect of fluoride on the develop-
ing tooth. Caries Res 2004;38:268–276.
12. Buzalaf MA, Granjeiro JM, Damante CA, de Ornelas F.
Fluoride content of infant formulas prepared with
deionized, bottled mineral and fluoridated drinking
water. J Dent Child 2001;68:37–41.
13. Segura A, Donly KJ, Wefel JS. The effects of
microabrasion on demineralization inhibition of
enamel surfaces. Quintessence Int 1997;28:
463–466.
Ardu.qxd 6/4/07 11:04 AM Page 458
1940s, Dean et al were able to show a strong
relation between fluoride concentration in
drinking water and the prevalence and severity
of fluorosis.1,2 Based on the severity of enamel
damage, a classification of 10 degrees of fluo-
rosis has been proposed.3 The scores range
from 0, where the glossy creamy-white enamel
is visible only after drying of the tooth, to 9,
where the major part of the enamel is lost and
a change in the shape of the tooth has
occurred.
different treatment options. Teeth discolored
by fluorosis may be managed by bleaching,
microabrasion, veneering, or artificial
ments depends on the severity of the dis-
ease4; however, in more severe cases the
proposed treatment option is often invasive.
The problem with invasive treatments is that
most patients demanding treatment for fluo-
rosis are young adults with a life expectancy
of many decades and the use of invasive pro-
cedures in the form of a prosthetic approach
with veneers or crowns results in an exces-
sive sacrifice of tooth material, thus acceler-
ating the destruction of the tooth at an early
age. Furthermore, a restorative approach is
time consuming and relatively expensive.
The aim of this article is to describe—and
illustrate with a case report—a minimally inva-
sive technique that improves the esthetic
aspect of teeth with severe enamel fluorosis
without requiring restorative techniques.
based on a combined approach of micro-
abrasion,5 home bleaching,6,7 and enamel
reshaping. Once enamel fluorosis is diag-
nosed (Figs 1a and 1b) by case history and
clinical examination, oral hygiene instruction
followed by scaling and polishing is per-
formed, whenever necessary. During the
microabrasion treatment, the patient’s and cli-
nicians’ eyes are protected from accidental
spills by protective glasses.
A minimally invasive treatment of severe dental fluorosis Stefano Ardu, Dr Med Dent1/Minos Stavridakis, Dr Med Dent2/
Ivo Krejci, Prof Dr Med Dent3
This article describes a minimally invasive technique to treat a severe case of enamel fluo-
rosis using microabrasion to eliminate the hypermineralized, white-colored, superficial
enamel layer, followed by home bleaching treatment and chairside re-creation of superfi-
cial enamel microstructure. The proposed technique may improve the esthetics of fluorotic
teeth without requiring other restorative procedures. Microabrasion followed by home
bleaching may be an interesting alternative for the restorative treatment of teeth affected
by fluorosis. (Quintessence Int 2007;38:455–458)
Key words: fluorosis, microabrasion, micromorphology, minimally invasive treatment
1Lecturer, Division of Cariology and Endodontology, Dental
School, University of Geneva, Geneva, Switzerland.
2Lecturer, Department of Operative Dentistry, School of
Dentistry, University of Athens, Athens, Greece.
3Professor and Chairman, Division of Cariology and
Endodontology, Dental School, University of Geneva, Geneva,
Switzerland.
rue Barthélemy-Menn 19, 1205 Geneva, Switzerland. E-mail:
[email protected]
456 VOLUME 38 • NUMBER 6 • JUNE 2007
QUINTESSENCE INTERNATIONAL
Ardu et a l
Figs 1a and 1b Views of a patient with severe enamel fluorosis. Fig 1c Microabrasion procedure under rubber dam protection.
Fig 1d Chairside fluoride gel application following microabrasion procedures. Fig 1e View after microabrasion and 2 weeks of home bleaching with 10% carbamide peroxide. Note the rough aspect of the surface and the absence of enamel micromorphology.
Figs 1f and 1g Enamel reshaping to recreate micromorphology.
Figs 1h to 1j Posttreatment appearance.
Ardu.qxd 6/4/07 11:04 AM Page 456
VOLUME 38 • NUMBER 6 • JUNE 2007 457
QUINTESSENCE INTERNATIONAL
sion is performed with an abrasive paste con-
taining silicon carbide microparticles in
water-soluble paste and 6.6% hydrochloric
acid (Opalustre Ultradent). For this purpose,
a layer of about 2 to 3 mm is applied on the
affected teeth (Fig 1c) using a specific rubber
cup (Oralcups, Opalustre Ultradent) attached
to a gear-reduction contra-angle handpiece.
The tooth surface is microabraded with slight
pressure for 60 to 120 seconds. Whenever
necessary, a small water drop can be added
and the abrasion can be repeated.
Several applications may be necessary, as
in this case, where 2 applications were per-
formed. In such a case, after each applica-
tion, an optical evaluation must be done after
water rinse, before proceeding to the next
application.
Tooth Mousse, Recaldent, GC Europe) or a
fluoride gel (Binaca Natrium Fluor Gelée,
ESRO) is then applied on the treated enamel
surface (Fig 1d), left undisturbed for 5 to 15
minutes, and finally suctioned by the aspira-
tion device but not water sprayed. Because
of the dehydration of the teeth, optical evalu-
ation of the treatment must be done at the
following appointment, and, if necessary, the
treatment may be repeated.
follows to better harmonize tooth color (Fig
1e), as does enamel-surface reshaping with
fine diamonds and silicon points (Figs 1f and
1g) to recreate a natural-looking macro- and
microstructure of the surface (Figs 1h to 1j).
DISCUSSION
ing worldwide because of excessive exposure
to fluoride within the first years of life.8–10 A crit-
ical period has been identified at which teeth
are most at risk of fluorosis: 21 to 30 months
of age for females and 15 to 24 months of age
for males.8 The mechanisms responsible for
enamel fluorosis have been investigated by
several authors. Similar theories, with slight
differences among them, have been pro-
posed. It is generally accepted that the char-
acteristic opacity of fluorotic enamel results
from incomplete apatite crystal growth. Matrix
proteins, which are associated with the miner-
al phase and permit a correct crystal growth,
normally degrade and disappear during the
enamel maturation phase. In fluorotic enamel,
they are not eliminated, resulting in their reten-
tion in the enamel tissue. Fluoride and mag-
nesium concentrations increase, while the
carbonate level is reduced. Crystal surface
morphology is slightly altered. Such changes
in crystal chemistry and morphology, involv-
ing stronger ionic and hydrogen bonds, also
lead to greater binding of modulating matrix
proteins and proteolytic enzymes. This results
in reduced degradation and enhanced reten-
tion of protein components in mature tissue.
This is most likely responsible for porous fluo-
rotic tissue, since complete matrix protein
removal is necessary for “healthy” crystal
growth.11 In other words, fluorotic enamel is
characterized by retention of amelogenins in
the early maturation stage of development
and a consequent formation of a more
porous enamel with a subsurface hypomin-
eralization.12
solution or CPP-ACP paste for 5 to 15 min-
utes. This approach is justified for 2 reasons:
First, it reduces the risk of posttreatment sen-
sibility, and second, it protects teeth from
possible external demineralization. In Segura
et al’s experience,13 in fact, teeth treated with
microabrasion followed by a 4-minute appli-
cation of 1% neutral topical sodium fluoride
exhibited significantly less enamel deminer-
alization when subjected to an artificial caries
challenge than did teeth that underwent
microabrasion alone, topical fluoride treat-
ment alone, or no treatment at all.
After completion of microabrasion, a
home bleaching technique follows to better
harmonize tooth color and produce whiter
teeth, which is most often the patient’s main
objective. The home bleaching technique
can produce satisfactory esthetic improve-
ment, thus eliminating the need for direct or
indirect veneering.
QUINTESSENCE INTERNATIONAL
microabrasion is that, especially if multiple
applications are performed in 1 session or if
multiple microabrasion sessions are needed,
because of the abrasive action of the rubber
cup with the abrasive paste, the macro- and
microstructure of the buccal surface of the
teeth is sometimes lost. As a result, the teeth
show an unnaturally smooth appearance,
which is not representative of the micromor-
phology of teeth of young patients, who most
often seek treatment for enamel fluorosis.
For this reason, after the completion of the
home bleaching, a surface reshaping with
fine diamonds and silicon points is often nec-
essary to recreate a natural-looking macro-
and microstructure of the surface and to
achieve an optimal result.
appearance, dramatically decreasing the
of approach has the advantages of being
extremely conservative and very well accept-
ed by the patients. Furthermore, no special
maintenance precautions are required; thus
it may be considered an interesting alterna-
tive to conventional, more aggressive opera-
tive intervention.
REFERENCES
1. Dean HT, Jay P, Arnold FA, Elvove E. Domestic waters
and dental caries. II. A study of 2832 white children
ages 12–14 years of eight suburban Chicago com-
munities, including Lactobacillus acidophilus stud-
ies of 1761 children. Public Health Rep 1941;56:
761–792.
2. Dean HT, Arnold FA, Elvove E. Domestic water and
dental caries. V. Additional studies of the relation of
fluoride domestic waters to dental caries in 4425
white children, age 12–14 years, of 13 cities in 4
states. Public Health Rep 1942;57:1155–1179.
3. Fejerskov O, Manji F, Baelum V, Moller IJ. Dental
Fluorosis. A Handbook for Health Workers. Copen-
hagen: Munksgaard, 1988.
fluorosis. Int Dent J 2001;51:325–333.
5. Croll TP. Enamel microabrasion: The technique.
Quintessence Int 1989;20:395–400.
6. Croll TP. Tooth bleaching for children and teens: a
protocol and examples. Quintessence Int. 1994;
25:811–817.
7. Scherer W, Penugonda B, Styner D, Georgescu M. At-
home vital bleaching: Effects on stained enamel
and dentin. Pract Periodontics Aesthet Dent 1992;4:
11–15.
olism and fluorosis. J Dent 2005;33:177–186.
9. Whelton HP,Ketley CE,McSweeney F,O’Mullane DM.
A review of fluorosis in the European Union: Preva-
lence, risk factors and aesthetic issues. Community
Dent Oral Epidemiol 2004;32(suppl 1):9–18.
10. Whelton H, Crowley E, O'Mullane D, Donaldson M,
Kelleher V, Cronin M. Dental caries and enamel fluo-
rosis among the fluoridated and non-fluoridated
populations in the Republic of Ireland in 2002.
Community Dent Health 2004;21:37–44.
11. Robinson C, Connell S, Kirkham J, Brookes SJ, Shore
RC, Smith AM.The effect of fluoride on the develop-
ing tooth. Caries Res 2004;38:268–276.
12. Buzalaf MA, Granjeiro JM, Damante CA, de Ornelas F.
Fluoride content of infant formulas prepared with
deionized, bottled mineral and fluoridated drinking
water. J Dent Child 2001;68:37–41.
13. Segura A, Donly KJ, Wefel JS. The effects of
microabrasion on demineralization inhibition of
enamel surfaces. Quintessence Int 1997;28:
463–466.
Ardu.qxd 6/4/07 11:04 AM Page 458
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