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203]

Original Article

A comparison of various minimally invasive

techniques for the removal of dental fluorosis stains in
children
Aarushi Gupta, Renuka Dhingra, Payal Chaudhuri, Anil Gupta
Department of Paedodontics and Preventive Dentistry, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India

ABSTRACT Address for correspondence:

Dr. Aarushi Gupta,
Context: Dental fluorosis is caused by successive B 389, Nirman Vihar, Vikas Marg, New Delhi ‑ 110 092, India.
exposure to high concentrations of fluoride E‑mail: aarushigupta15@ymail.com
during tooth development leading to enamel with
lower mineral content and increased porosity.
Aims: The aim of the study was to evaluate and Access this article online
compare the effectiveness of minimally invasive Quick response code Website:
techniques for the removal of dental fluorosis www.jisppd.com
stains in children in  vivo. Design: Ninety children DOI:
in the age group of 10–17  years were selected.
10.4103/JISPPD.JISPPD_138_16
Materials and Methods: The study sample was
PMID:
equally and randomly divided into three groups;
Group  1: In‑office bleaching with 35% hydrogen ******

peroxide  (HP) activated by light‑emitting

diode  (LED) bleaching unit  (35% HP), Group  2:
Enamel microabrasion  (EM) followed by in‑office
bleaching with 44% carbamide peroxide gel  (EM),
Group  3: In‑office bleaching with 5% sodium
hypochlorite  (5% NaOCl). Statistical analysis
was done using one‑way ANOVA test. Results:
Bleaching with 35% HP activated by LED bleaching
unit and EM followed by bleaching with 44%
carbamide peroxide were equally effective for the
removal of dental fluorosis stains in children in vivo.
However, bleaching with 5% NaOCl could not
completely remove moderate to severe stains. It was
effective in removing only mild stains. Bleaching
and microabrasion procedures caused slight
decrease in tooth sensitivity readings by electric
pulp vitality tester which continued to increase
over time. However, none of the patients reported
sensitivity in their teeth at any point of time.
Patients were highly satisfied with the treatment
outcome postoperatively but reported slight relapse
of color in the three groups. Conclusions: Bleaching
and microabrasion techniques can consider as an
interesting alternatives to conventional operative
treatment options.
KEYWORDS: Bleaching, color change, dental
fluorosis, enamel microabrasion, patient satisfaction,
tooth sensitivity
Introduction
Dental fluorosis, also known as mottled enamel, is a
developmental disturbance of dental enamel, caused
by successive exposure to high concentrations of
fluoride during tooth development. It is a form of
enamel hypoplasia leading to enamel with lower
mineral content and increased porosity.[1]
Nearly 12 million out of the 85 million tons of fluoride
deposits on the Earth’s crust are found in India resulting
in as many as twenty states being affected by endemic
fluorosis.[2] The highest rates of endemicity have been
reported from Andhra  Pradesh, Haryana, Karnataka,
and Tamil Nadu. This is a major public health problem
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For reprints contact: reprints@medknow.com
How to cite this article: Gupta A, Dhingra R, Chaudhuri P,
Gupta A. A comparison of various minimally invasive techniques
for the removal of dental fluorosis stains in children. J Indian Soc
Pedod Prev Dent 2017;35:260-8.

260 © 2017 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer ‑ Medknow
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as almost 85% of rural population in India depends on
groundwater for their domestic needs.[2]
Fluorosis is a result of extended exposure to fluoride
resulting in deficient formation and maturation due to
metabolic alterations in the ameloblasts during the period
of teeth formation. It is characterized by the presence of
bilateral, diffuse, thin, and horizontal white striations and
stained plaque areas. In the most severe cases, the enamel
may become discolored and/or pitted. Histologically,
the tissue presents hypomineralized subsurface
areas confined to few micrometers from the external
mineralized surface, which increases its porosity.[3]
Various methods of therapy have been advocated for
the treatment of fluorosis‑stained teeth which range
from invasive ceramic veneer bonding restorations to
abrasive chemical treatments. However, the problem
with invasive treatments is that most patients are
young adults and the use of procedures in the form
of prosthetic approach with veneers or crowns
result in an excessive sacrifice of tooth material, thus
accelerating the destruction of the tooth at an early
age. Furthermore, the restorative approach is time
consuming and expensive.[4]
Nowadays, the combination of dental bleaching
techniques and microabrasion appears an excellent
conservative solution to reestablish health in
fluorosis‑affected teeth[5] and provide highly
satisfactory results along with low cost.
Considering the high prevalence of dental fluorosis
in Gurgaon and neighboring areas, this study was
conducted to investigate the treatment modalities for the
removal of unaesthetic dental fluorosis stains in children.
Materials and Methods
The present study was conducted in the Department
of Paedodontics and Preventive Dentistry, Faculty
of Dental Sciences, SGT University, Gurgaon. The
study design was reviewed and approved by the
ethical committee. Ninety children in the age group
of 10–17  years were selected after informed written
consent from parents. Inclusion criteria included
participants should have at least two permanent
maxillary anterior teeth, should be healthy or free
from any systemic disease, and have score 4 according
to tooth surface index of fluorosis. Participants were
excluded if they had caries or periodontal disease on
anterior teeth, abscess, draining sinus, cellulitis or other
conditions requiring emergency dental treatment,
nonvital teeth, wearing of orthodontic appliances,
hypersensitive exposed tooth crevices or cracks, and if
there was any past history of bleaching therapy.
The study sample  (ninety children) was equally and
randomly divided into the three equal groups for the
treatment of dental fluorosis.
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 35 | Issue 3 | July-September 2017 |
Gupta, et al.: Treatment of dental fluorosis stains
• Group  1: In‑office bleaching with 35% hydrogen
peroxide (HP) (Pola Office® bleaching kit) activated
by light‑emitting diode  (LED) bleaching unit
(35% HP)
• Group  2: Enamel microabrasion  (EM)  (PREMA®
Enamel Microabrasion System) followed by
in‑office bleaching with 44% carbamide peroxide
gel (EM)
• Group  3: In‑office bleaching with 5% sodium
hypochlorite (5% NaOCl).
Informed written consent was taken from the parents
of the participants. They were informed of the
benefits and possible risks involved in the treatment.
After that, vitality test was done using electric pulp
vitality tester. A  baseline color evaluation was done
by taking digital photograph of the permanent
maxillary anterior teeth. L*, a*, and b* color values
were determined from the digital photographs by
which is a standard program for quantitative analysis
and management of color of digital images.
All participants received a complete oral prophylaxis
before starting of the bleaching process or EM. The soft
tissues were protected with a polymeric barrier, and
topical anesthetic was applied on the gingival margins.
For participants in Group  1  (bleaching with 35% HP
activated by LED bleaching unit), 35% HP gel was
applied on the discolored teeth surfaces, light activation
of gel was done by LED bleaching unit for three cycles
of 15 min each with 10 min resting time. The bleaching
agent was removed at the end of every 10  min and
reapplied again as before for the light activation. At the
end of the session in all cases, the teeth will be polished
with fine polishing discs or prophylaxis paste.
For participants in Group 2 (EM followed by bleaching
with 44% carbamide peroxide), the teeth were
isolated, and petroleum jelly was applied around
the cervical portion of the teeth to prevent leakage
of the hydrochloric acid and damage to the gingiva.
Approximately 1  mm layer of a microabrasive slurry
composed of 15% hydrochloric acid plus silicon
carbide was applied to the discolored labial surface
of teeth with a dispensing tip. Rotary application
was done by a slow speed handpiece with a specially
designed mandrel tip. This continued up to 60 s at a
time. The applications were repeated till the stain got
removed (up to 3 min). Between each application, the
slurry was rinsed and dried from the tooth surfaces.
The teeth were washed abundantly with water for
20 s which was drained off by suction tip. Forty‑four
percent carbamide peroxide was prepared on the spot
as it is an unstable compound. For this, carbamide
peroxide powder with 98% purity was mixed with
carboxymethylcellulose gel with glycerin as thickening
agent and catalyst in the ratio of 1:1 by weight. The
teeth were covered with 0.2 ml layer of bleaching agent
for 20  min. The bleaching procedure continued for a
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Gupta, et al.: Treatment of dental fluorosis stains
maximum of 60 min (3 × 20 min sessions). The gel was
replaced in each clinical session and was light activated
by two 40 s applications spaced by 10 min intervals.
For participants in Group  3  (bleaching with 5%
NaOCl), the discolored enamel surface was etched for
15 s with 37% phosphoric acid and rinsed. The NaOCl
was applied to the discolored surface of all teeth using
a cotton applicator, repeating the application as the
solution gets evaporated. After 10  min, teeth were
re‑etched for 60 s, rinsed, and bleached. The procedure
was done for a maximum of 20 min in one appointment.
Cases in which satisfactory results were not obtained,
the respective procedure was repeated in further
appointments as necessary. The total number of visits
was noted for each patient.
All the qualitative and quantitative values of the
parameters to be studied were recorded in individual
patient pro forma.
To achieve standardized settings, the distance
between the teeth to be evaluated and the lens,
as well as camera angle, and lighting conditions
were tried to be kept constant for all photographic
assessments. Digital images were recorded using Sony
Cyber‑Shot DSC‑WX50. The pre‑  and post‑treatment
digital photographs were taken using similar setting
and evaluated using Adobe Photoshop 7 software.
Whiteness of enamel lesions was expressed in L*,
a*, and b* color space measurements. Color change
was calculated preoperatively and immediate
postoperative. Bleaching durability was assessed by
comparing L*, a*, and b* values collected after 1 month
and 3  months to baseline data. ∆L* is the change in
lightness  (the greater the  ∆  L*, the whiter the teeth),
and ∆ a* and ∆ b* are chromaticity values (the amount
of redness and the amount of yellowness).
Color differences were calculated using the following
equation: ∆E = ([∆L*]2 + [∆a*]2 + [∆b*]2) 1/2 (International
Commission on Illumination, Paris, 1978).
Pulp vitality test was done to check for sensitivity of
teeth at the end of the treatment and during follow‑up
visits. Patients were also asked whether they felt
sensitivity of teeth or not.
Patient satisfaction score was recorded using a visual
analog scale ranging from 1 to 5.
Patients were instructed to refrain from eating or
drinking foodstuff rich in color that can stain teeth
for first 48 h after bleaching procedure. An individual
prophylactic program for all the children was
implemented including motivation and training in oral
hygiene and a food regimen. Desensitizing paste was
advised. Patients were recalled after 1 and 3 months for
reevaluation of teeth color, teeth sensitivity, and their
262 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 35 | Issue 3 | July-September 2017 |
satisfaction. The above‑mentioned techniques were
compared for effectiveness of removal of fluorosis
stains, effect on teeth sensitivity, number of visits of
the patient, and patient satisfaction.
The data obtained were subjected to statistical analysis
and compilation of the results was done. The statistical
analysis was performed with which is a widely used
program by health and educational researchers for
statistical analysis and data management developed in
1968.
Results
After evaluation of patients having score 4 according
to tooth surface index of fluorosis, ninety patients were
selected to participate in the study ranging in age from
10 to 17  years with mean  ±  SD age of 12.7  ±  1.9  years.
A  maximum number of patients in this study were in
12–14 years of age; Group 1 ‑ 60% and Group 2 and 3 ‑ 50%.
L*, a*, and b* color parameters calculated by Adobe
Photoshop 7 software were subjected to statistical
analysis using ANOVA test. Table 1 represents L*, a*, and
b* parameters at baseline, immediate postoperative, after
1 month, and after 3 months. No significant difference
was found for any of the color parameter (L*, a*, and b*)
in Group 1, Group 2, and Group 3 at baseline (P > 0.05).
Color change
Figures 1‑3 represent color change in Groups 1, 2, and 3,
respectively.
Color differences were calculated using the following
equation: ∆E =  ([∆L*]2  +  [∆a*]2  +  [∆b*]2]1/2. Results
obtained were subjected to statistical analysis using
ANOVA test.
Table  2 and Graph  1 show the color change  (ΔE)
immediate postoperative, after 1  month, and after
3 months in all the three groups.
A statistically significant difference was found in all
the three groups for immediate postoperative color
a b
c d
Figure 1: Group 1 ‑ Bleaching with Pola Office® bleaching kit activated by
light‑emitting diode bleaching unit (a) preoperative, (b) postoperative,
(c) follow‑up after 1 month, (d) follow‑up after 3 months
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Gupta, et al.: Treatment of dental fluorosis stains

Table 1: Comparison of color parameters L*, a*, and b* at baseline, immediate postoperative, after 1 month,
and after 3 months in all the three groups
Parameter Mean±SD F P
Group 1 (35% HP) Group 2 (EM) Group 3 (5% NaOCl)
L*
Baseline 47.2±8.4 48.5±13.6 49.4±7.1 0.365 0.69
Postoperative 56.8±4.8 59.2±12.5 54.2±7.6 2.4 0.09
After 1 month 55.6±6.4 57.4±12.3 53.5±8.3 1.3 0.27
After 3 months 53.9±4.2 56.2±12.1 53.1±7.6 1.07 0.35
a*
Baseline 8.6±6.2 6.7±5.2 7.2±4.4 1.13 0.32
Postoperative 1.6±3.7 3.1±5.2 3.5±2.6 1.9 0.15
After 1 month 2.8±3.0 4.5±4.8 5.6±3.4 3.9 0.02
After 3 months 3.2±3.4 4.4±5.1 5.9±3.7 3.1 0.05
b*
Baseline 17.4±6.6 16.8±10.1 15.1±10.0 0.52 0.59
Postoperative 8.7±4.9 10.6±7.6 5.5±6.3 4.9 0.009
After 1 month 9.6±4.9 11.3±9.4 7.3±6.5 2.4 0.092
After 3 months 9.9±4.8 11.1±9.8 7.6±6.3 1.75 0.18
SD=Standard deviation; EM=Enamel microabrasion; HP=Hydrogen peroxide; NaOCl=Sodium hypochlorite

Table 2: Color change (ΔE) immediate postoperative, after 1 month, and after 3 months in all the three groups
Color change (ΔE)‑calculated from baseline Mean±SD F P
Group 1 (35% HP) Group 2 (EM) Group 3 (5% NaOCl)
Postoperative 16.10±9.28 17.29±8.29 10.60±5.72 6.105 0.003
After 1 month 14.42±8.04 16.34±7.64 9.22±5.69 7.847 0.001
After 3 months 14.03±8.15 16.29±7.89 8.83±5.70 8.178 0.001
SD=Standard deviation; EM=Enamel microabrasion; HP=Hydrogen peroxide; NaOCl=Sodium hypochlorite

a b
a b

c d
Figure 2: Group 2 ‑ Microabrasion followed by bleaching with 44%
carbamide peroxide (a) preoperative, (b) postoperative, (c) follow‑up
after 1 month, (d) follow‑up after 3 months
change (P = 0.003), color change at 1 month (P = 0.001), and
3 months (P = 0.001) calculated from baseline. Immediate
postoperative, mean color change was 17.29  ±  8.28
in Group  2, followed by 16.1  ±  9.28 in Group  1 and
10.6 ± 5.72 in Group 3. After 1 month, mean color change
was 16.34 ± 7.64 in Group 2, followed by 14.42 ± 8.04 in
Group 1 and 9.22 ± 5.69 in Group 3. After 3 months, mean
color change was 16.29  ±  7.89 in Group  2, followed by
14.03 ± 8.15 in Group 1 and 8.83 ± 5.70 in Group 3.
There was no statistically significant difference in
color change immediate postoperative, 1  month,
c d
Figure 3: Group  3  ‑  Bleaching with 5% sodium hypochlorite
(a) preoperative,  (b) postoperative,  (c) follow‑up after 1  month,
(d) follow‑up after 3 months
and 3  months between Groups  1 and 2. Statistically
significant difference was found for color change
immediate postoperative, 1  month, and 3  months
between Groups 1 and 3 (P < 0.05) and Group 2 and 3
(P < 0.05).
Paired t‑test was applied to analyze color change within
each group at different points of time. In Group  1,
statistically significant difference was seen in change
in tooth color between immediate postoperative
and after 1 month (P ≤ 0.001) or 3 months (P ≤ 0.001)

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Gupta, et al.: Treatment of dental fluorosis stains

but was not statistically significant between 1 Group 2 (0.64 ± 0.79) followed by Group 1 (0.34 ± 0.61)

and 3  months  (P  =  0.117). Similarly, in Group  2,
statistically significant difference was seen in change
in tooth color between immediate postoperative
and after 1 month (P ≤ 0.001) or 3 months (P ≤ 0.001)
but was not statistically significant between 1
and 3  months  (P  =  0.747). However, in Group  3,
statistically significant difference was seen in change
in tooth color between immediate postoperative
and after 1 month (P = 0.001) or 3 months (P ≤ 0.001)
and also statistically significant between 1 and
3 months (P = 0.005). Thus, there was a slight relapse of
color in all the three groups after 1 month of treatment.
Tooth sensitivity
We computed the differences in tooth sensitivity
values obtained using electric pulp vitality tester
by subtracting the postoperative and follow‑up
measurements from baseline measurements. The
values obtained were subjected to statistical analysis
using ANOVA test.
Table 3 and Graph 2 show changes in tooth sensitivity
values immediate postoperative, after 1  month, and
after 3 months calculated from baseline.
The changes in tooth sensitivity values were
statistically significant in all the three groups
immediate postoperative, after 1  month, and after
3  months (P  <  0.05). Immediate postoperative, the
changes in tooth sensitivity values were greatest in
Group 2 (0.74 ± 0.85) followed by Group 1 (0.29 ± 0.73)
and least in Group 3 (0.14 ± 0.21). After 1 month, the
changes in tooth sensitivity values were greatest in
20.00
18.00
17.29
16.00 16.10 16.34
14.42
14.00
12.00
10.00 10.60
9.22
8.00
6.00
4.00
2.00
0.00
Postoperative After 1 month After 3 months
and least in Group 3 (0.10 ± 0.19). After 3 months, the
changes in tooth sensitivity values were greatest in
Group 2 (0.57 ± 0.76) followed by Group 1 (0.27 ± 0.53)
and least in Group 3 (0.08 ± 0.18).
Table  3 shows a comparison of changes in tooth
sensitivity values immediate postoperative, after
1  month, and 3  months among the three groups.
Immediate postoperative, the changes in tooth
sensitivity values were statistically significant between
Group  1 and Group  2  (P  =  0.025); Group  2 and
Group  3  (P  =  0.002) but not statistically significant
between Group 1 and Group 3 (0.627). After 1 month,
the changes in tooth sensitivity values were statistically
significant between Group 2 and Group 3 (P = 0.002)
but not statistically significant between Group  1 and
Group 3 (P = 0.24) and Group 1 and 2 (P = 0.135). After
3 months, the changes in tooth sensitivity values were
statistically significant between Group 1 and Group 2;
Group  2 and Group  3 but not statistically significant
between Group 1 and Group 3.
Paired t‑test was applied to analyze changes in
tooth sensitivity within each group at different
points of time [Graph  2]. In Group  1, no statistically
significant difference was seen in changes in tooth
sensitivity values immediate postoperative and after
1 month (P = 0.334) or 3 months (P = 0.786) and between
1 and 3  months  (P  =  0.125). However, in Group  2,
statistically significant difference was seen in changes
in tooth sensitivity values immediate postoperative
and after 1 month (P = 0.065) or 3 months (P = 0.044)
but was not statistically significant between 1 and
3 months (P = 0.302). In Group 3, statistically significant
difference was seen in changes in tooth sensitivity
0.80
16.29 0.74
0.70
14.03 0.64
0.60
0.57
0.50
8.83
0.40
0.34
0.30 0.29 0.27
0.20
0.14
0.10 0.10 0.08
0.00
Postoperative After 1 month After 3 months

Group 1 Group 2 Group 3 Group 1 Group 2 Group 3

Graph 1: Color change Graph 2: Tooth sensitivity changes

Table 3: Changes in tooth sensitivity values immediate postoperative, after 1 month, and after 3 months
calculated from baseline
Changes in tooth sensitivity values Mean±SD F P
Group 1 (35% HP) Group 2 (EM) Group 3 (5% NaOCl)
Postoperative 0.29±0.73 0.74±0.85 0.14±0.21 6.899 0.002
After 1 month 0.34±0.61 0.64±0.79 0.10±0.19 6.351 0.003
After 3 months 0.27±0.53 0.57±0.76 0.08±0.18 6.012 0.004
SD=Standard deviation; EM=Enamel microabrasion; HP=Hydrogen peroxide; NaOCl=Sodium hypochlorite

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values postoperative and after 1 month (P = 0.005) or
3 months (P = 0.001) but was not statistically significant
between 1 and 3 months (P = 0.103).
However, none of the patients reported any sensitivity
in their teeth in immediate postoperative period, after
1 month, or after 3 months.
Patient satisfaction score
The patient’s satisfaction score was assessed on a
visual analog scale ranging from 1 to 5.
Table  4 and Graph  3 represent the mean patient
satisfaction scores immediate postoperative, after
1 month, and after 3 months.
It was found that there was no statistically significant
difference in the patient satisfaction scores between
all the three groups at the three points of time.
Twenty‑seven patients (90%) were satisfied with their
appearance immediately after treatment in Group  1.
However, out of these, seven patients reported
slight reappearance of color at the end of 3  months.
Twenty‑five patients  (83%) were satisfied with their
appearance immediately after treatment in Group  2.
However, out of these, eight patients reported
slight reappearance of color at the end of 3  months.
Twenty‑two patients  (73%) were satisfied with their
appearance immediately after treatment in Group  3.
However, out of these, seven patients reported slight
reappearance of color at the end of 3 months.
Paired t‑test was applied to analyze patient satisfaction
score within each group at different points of time. In
Group 1, statistically significant difference was seen in
patient satisfaction score immediate postoperatively
and after 1 month (P = 0.001) or 3 months (P = 0.001)
6.00
5.00
4.83
4.47 4.23
4.00 4.00
3.00
2.00
1.00
0.00
Postoperative 1 mth
Group 1 Group 2 Group 3
Graph 3: Patient satisfaction score
Table 4: Patient satisfaction score immediate postoperative, after 1 month, and after 3 months
Patient satisfaction score
Group 1 (35% HP)
Postoperative 4.83±0.53
After 1 month 4.23±0.94
After 3 months 4.27±0.94
SD=Standard deviation; EM=Enamel microabrasion; HP=Hydrogen peroxide; NaOCl=Sodium hypochlorite
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 35 | Issue 3 | July-September 2017 |
Gupta, et al.: Treatment of dental fluorosis stains
but was not statistically significant between 1
and 3  months  (P  =  0.326). In Group  2, statistically
significant difference was seen in patient satisfaction
score immediate postoperatively and after 1  month
(P = 0.006) or 3 months (P ≤ 0.001) but was not statistically
significant between 1 and 3  months  (P  =  0.06). In
Group  3, statistically significant difference was seen
in change in patient satisfaction score immediate
postoperatively and after 1  month  (P  =  0.006) or
3  months  (P  =  0.001) and also statistically significant
between 1 and 3 months (P = 0.161).
Number of appointments
Treatment was repeated at subsequent appointments
until the patients were satisfied with the treatment.
Four patients in Group  1 required two appointments
while one patient required three appointments. Three
patients in Group  2 required two appointments
whereas one patient required three appointments.
However, all patients in Group  3 were treated in a
single appointment only.
Discussion
Critical period of 21–30 months of age for females and
15–24  months of age for males has been identified at
which teeth are at risk of fluorosis.[4] It is generally
accepted that the characteristic opacity of fluorotic
enamel results from incomplete apatite crystal growth.
Matrix proteins, which are associated with the mineral
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 retention in the enamel tissue.
In this study, central incisors were selected as teeth
for fluorosis because the major determinant of the
prevalence and severity of dental fluorosis has been
shown to be the fluoride concentration in water ingested
by children during the mineralization of permanent
4.27 teeth. Dental fluorosis may develop only during the
3.73 period of primary and secondary mineralization of
teeth. Thus, the maxillary central incisors are most
susceptible from the age of 1–5½ years of age.[6]
The technique of bleaching or whitening teeth was
3 mth first described in 1877. It was in the year 1916 that
Dr. Walter Kane used hydrochloric acid to successfully
remove the fluorosis stains. Bleaching and EM are
the minimally invasive available techniques for the
Mean±SD F P
Group 2 (EM) Group 3 (5% NaOCl)
4.47±0.90 4.47±0.90 2.123 0.126
4.00±1.02 4.00±1.02 0.555 0.576
3.73±0.98 3.87±1.01 2.417 0.095
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Gupta, et al.: Treatment of dental fluorosis stains
treatment of dental fluorosis. In this study, bleaching
with 35% HP  (Pola Office bleaching kit) and EM
followed by bleaching with 44% carbamide peroxide
were equally effective for the removal of dental fluorosis
stains in children in vivo. However, bleaching with 5%
NaOCl could not completely remove moderate to severe
stains; it was effective in removing only mild stains.
During dental bleaching, HP is capable of penetrating
the tooth by osmosis and through porosities and
cracks, subsequently acting directly on pigmented
molecules.[7,8] After coming into contact with organic
pigments impregnated in the dental tissues, it
is capable of promoting cleavage in the simpler
hydrosoluble molecular structures, reducing and
making them lighter consequently promoting color
alteration of the tooth. Peroxide and light treatment
significantly lighten the color of teeth to a greater
extent than does peroxide or light alone.[9] When light
activated, the use of high‑intensity light raised the
temperature of HP and accelerated the rate of chemical
bleaching of teeth. The light source activates peroxide
to accelerate the chemical redox reaction of the
bleaching process; the formation of hydroxyl radicals
from HP had been shown to increase. In addition, the
light source energizes the tooth stain to aid the overall
acceleration of the bleaching process.[10] In our study,
LED bleaching unit of Unicorn Denmart was used
having a wavelength of 450–480  nm and intensity of
8000‑10,000 W/cm2 having eight‑piece high LED.
However, strong controversy surrounds the success
of light sources. Some researchers believe that it is
effective in the bleaching process, while others believe
only certain lights are effective and others reported no
effect.[11] Gurgan et al.[12] investigated the effect of three
different light systems (diode laser, 810 nm on 37% HP;
plasma arc lamp, 400–490 nm on 35% HP; LED lamp
on 38% HP) and found that the diode laser system gave
the best tooth whitening and the least tooth sensitivity
as measured with a spectrophotometer. Polydorou
et al.[13] reported that a halogen light is more effective
than a laser light, whereas Hahn (2013) could not find
an improvement in tooth whitening as a result of
LED or laser light treatments.[14] Hein et al.[15] reported
no difference in the whitening effect of bleaching
gels  (25%–35% HP) with or without three different
lights. They concluded that the proprietary chemicals
added to the bleaching gels acted as catalysts in the
whitening process and were solely responsible for
activation, whereas the lights had no influence.
In this study, Prema EM system was used which is a
chemicomechanical polishing compound containing
a mild solution of hydrochloric acid with silicon
carbide in a water‑soluble slurry. The viscosity
of the acidic solution is increased by mixing 18%
hydrochloric acid with quartz particles so that the
solution takes on a water‑soluble gel‑like form, in
which the quartz and pumice particles are suspended
266 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 35 | Issue 3 | July-September 2017 |
and function as an abrasive agent. The microabraded
surface reflects and refracts light from the surface in
such a way that mild imperfections in the underlying
enamel are camouflaged. The highly polished surface
of the enamel following abrasion with hydrochloric
acid‑pumice enhances the esthetic appearance.[16]
The amount of enamel removed by the procedure is
related to the duration of applications, the number
of applications, and the pressure applied to the
tooth during microabrasion. After completion of
microabrasion, bleaching with 44% carbamide
peroxide was done to harmonize tooth color as the
teeth often appear yellow after treatment. Carbamide
peroxide effectively lightens teeth, particularly those
that have a natural yellowish shade or have darkened
with age.[17] In this study, 44% carbamide peroxide was
prepared on the spot as it is an unstable compound. The
combination of dental bleaching and microabrasion
has proved to be successful.[18] Similar to the study of
Train et al.[19] and Loguercio et al.,[20] our study showed
that EM remarkably improved the appearance of
mildly fluorosed teeth, moderately improved the
appearance of moderately fluorosed teeth, but slightly
improved the appearance of severely fluorosed teeth.
The need for further treatment was the highest in
the severely affected teeth, whereas a considerably
higher amount did not require any further treatment
among teeth with mild fluorosis. This is because the
mild fluorotic lesions as demonstrated by Thylstrup
and Fejerskov lie in the outer 80–100 μm of enamel.
If the stains are present in the outer layers of enamel,
they can be easily removed, leaving a smooth, glassy
enamel. This type of treatment does not weaken the
enamel surface, reduces colonization by Streptococcus
mutans and renders the surface more resistant to
demineralization.[21]
It is prudent to carry out microabrasion and in‑office
bleaching under strict isolation as the acid and
35% HP used in the procedures may damage the
adjacent soft tissues including burns and bleaching.[22]
Application of petroleum jelly over the gingival tissue
before placement of gingival barrier provides added
protection from the acid. Furthermore, the use of
protective eyewear during the procedure by the patient
and operator is mandatory.
In our study, NaOCl was effective in removing only
mild stains of fluorosis; moderate to severe stains were
lightened to quite an extent but could not be removed
completely. The effectiveness of NaOCl is attributed
to its ability to neutralize amino acids to form water
and salt (neutralization reaction). With the exit of the
hydroxyl ions, there is a reduction of pH. Hypochlorous
acid, a substance present in NaOCl solution, releases
chlorine when in contact with organic tissue as a
solvent that combines with the protein amino group,
forming chloramines (chloramination reaction). When
NaOCl contacts hypomineralized and discolored
enamel, it degrades and removes the chromogenic
organic material located on the enamel surface.
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In all bleaching protocols, the first critical step is the
etching of the enamel surface which took 15 s with 37%
phosphoric acid. The use of phosphoric acid denudes
the microcavities containing the organic elements,
facilitating the penetration of bleaching agents. Care
must be exercised during bleaching to reduce the risk
of mucosal irritation, skin injury, eye splashes, clothing
damage, and hypersensitivity and allergic reactions.[23]
In all the techniques, we applied neutral sodium
fluoride on completion of the process. This is to
prevent damage caused by increased frequency
of acid exposure which tends to alter the total
demineralization/remineralization amounts, resulting
in significantly greater amounts of mineral loss. The
presence of fluoride acts as a remineralizing agent, by
forming a calcium fluoride layer.[24]
In our study, bleaching and microabrasion procedures
caused a slight decrease in tooth sensitivity readings
by electric pulp vitality tester which increased over
time. Thus, the decrease in tooth sensitivity readings
could be transient which became normal afterward.
Furthermore, this can be due to the effect of dentin
desensitizing paste prescribed to patients. However,
none of the patients reported sensitivity in their teeth
at any point of time. Thus, tooth sensitivity due to
bleaching was not a problem in our study. Postbleaching
sensitivity differs from dentin hypersensitivity
because it is related directly to the penetration of the
subproducts of the bleaching gels in the dentin and
pulp tissue, through the enamel, causing reversible
pulpitis and consequent teeth thermal sensitivity but
not causing permanent damage to the pulp. This kind
of sensitivity is transient, tends to occur early in time,
and diminishes with treatment.
Carrasco et al.  (2008),[25] in an in vitro study, found
low indexes of temperature increases considered
compatible with pulp vitality maintenance when
applying a LED source or hybrid light to the gel
(35% HP). Coutinho et  al.[26] evaluated the rise of
pulp chamber temperature induced by different light
sources in in‑office bleaching with HP 35%, and they
concluded that the specific combination of color agent
and light color determines good dental bleaching with
a smaller temperature increase and consequently, less
sensitivity.
Shade tabs are commonly used for assessing dental
color changes in dental procedures.[27] However, in this
study, CIE‑L*, a*, b* colorimetry has been used which
is established to be a more objective method in recent
decades.[28,29] Color change  (ΔE) assessment made it
possible to establish color differences before and after
treatment. Under clinical conditions, the differences
must be 3.7 or above to be detectable by the human
eye. However, equal values of ΔE can correspond to
different degrees of color perception, so ΔE is not a
valid indicator for comparing different teeth. ΔE does
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 35 | Issue 3 | July-September 2017 |
Gupta, et al.: Treatment of dental fluorosis stains
make it possible, however, to follow the evolution of
color in each tooth in a convenient, simple way, thus
making it a suitable indicator for this purpose.[30]
Jarad et al.[31] compared observers’ ability using digital
imaging method as used in this study method with the
conventional one and showed a statistically significant
difference (P < 0.001) between the conventional method
and the computer method with a 43% and 61.1% correct
match, respectively. Thus, they concluded that digital
camera can be used as a means of color measurements
in the dental clinic.
Treatment was continued till the color change
was considered as satisfactory and acceptable to
the patients. In our study, the point of tooth color
saturation was found at the end of the second or third
sessions for some patients. However, in all the three
groups, change in tooth color postoperatively and after
1 month or 3 months was statistically significant. This
may be because teeth were dehydrated immediately
after bleaching, especially when sources of light or
heat were used. This caused an illusionary effect
of whitening of teeth, which tended to disappear
after rehydration as observed after 1 and 3  months
follow‑up periods.[32] However, the fluorosis stain was
much less noticeable compared to what it was before
treatment, and as their appearance of their teeth was
still acceptable to the patients even after 3  months
recall, so we did not plan to undergo another sitting of
bleaching or microabrasion to remove the slight relapse
in color. This may also be due to subject bias as majority
of patients (63%) were boys who were not concerned
much about their appearance and color of teeth, and
most of the patients were of poor socioeconomic status
selected during camps conducted in government
schools of rural areas of Gurgaon.
Thus, bleaching and microabrasion serve as painless,
fast, and easy procedures for the professional to
perform. However, further research is required
to answer questions regarding durability of these
procedures and sensitivity associated with bleaching.
Conclusions
Esthetic appearance of teeth with mild fluorosis can be
accomplished by minimally invasive treatment using
bleaching and microabrasion. In case of moderate
fluorosis, a combination of these modalities can be
used. These techniques presented favorable results
and patient satisfaction. Furthermore, no special
maintenance precautions are required; thus these
may be considered as an interesting alternative to
conventional operative treatment options.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
267
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Gupta, et al.: Treatment of dental fluorosis stains
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