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An Evaluation of A Technique To Remove Stains From Teeth Using Microabrasion
An Evaluation of A Technique To Remove Stains From Teeth Using Microabrasion
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from enamel. The
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authors evaluated the
technique to remove
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I
C
technique by studying the A U I N G E D U
effectiveness of a propri- R 2
TICLE
stains from teeth using etary microabrasion product.
Methods. One author used microabra-
remove stains in the enamel. They then bleached using PREMA to protect the soft tissues.9,24
the teeth with 30 percent hydrogen peroxide and At the International Symposium on the Non-
heat, applied topical fluoride and polished the Restorative Treatment of Discolored Teeth in
teeth. 1996, it was concluded that microabrasion was a
In 1986, Croll and Cavanaugh2 advocated a safe and effective atraumatic method of removing
regimen to remove fluorosislike stains from the superficial enamel defects.34 In 2001, the United
teeth that consisted of up to 15 separate five- Kingdom National Clinical Guidelines in Paedi-
second applications of a thick paste made of 18 atric Dentistry recommended the use of micro-
percent HCl mixed with a fine pumice powder, abrasion to treat fluorosis, postorthodontic dem-
followed by 10-second water rinses. They used the ineralization, localized hypoplasia and idiopathic
thick paste to stop the acid from spreading over hypoplasia where the discoloration is limited to
the teeth and gingivae and to provide a vehicle for the outer enamel layer.35 Although there have
pressure-induced abrasion of the teeth. They iso- been numerous case reports,2-5,7,8,11,12,16,19,23,24,26,36-38
lated the teeth being treated with a rubber dam there have been only a few trials conducted to
sealed cervically with cavity varnish and applied study the effectiveness of enamel microabrasion
sodium bicarbonate paste around the isolated to remove stains and most of these trials were
area to help neutralize any acid overflow. They limited in size.1,9,20,39 In 2000, Ashkenazi and
applied an acid-pumice mixture to the facial sur- Sarnat39 reported the successful outcome of a two-
face of each affected tooth with a wooden stick and-one-half to four-year follow-up of the
using a gentle rubbing motion for five seconds microabrasion technique, but the sample was only
and then rinsed the tooth with water for 10 to 15 five children.
seconds and dried it with compressed air. They We conducted a controlled, blinded study to
repeated this procedure until the stains were evaluate the esthetic effectiveness of enamel
removed and the desired color correction was microabrasion using PREMA in removing white,
achieved. In most cases, they reported that dis- brown or yellow stains from secondary dentition
tinct color improvement occurred by the sixth or enamel. We hypothesized that the compound
seventh application. If no change was apparent would effectively remove the fluorosislike stains
after 12 to 15 applications, they stopped from tooth enamel and improve the appearance of
microabrasion to avoid excessive enamel loss. the teeth.
After the final application of the HCl-pumice
paste, they smoothed the tooth surface with a MATERIALS AND METHODS
paste of pumice and water in a rubber cup and After the Dalhousie University Ethics Committee,
then polished the surface with sandpaper disks. Halifax, Nova Scotia, Canada, approved the
A 1.1 percent neutral sodium fluoride gel was research project, we placed an advertisement in a
then applied for four minutes to aid remineraliza- local dental newsletter, inviting dentists to refer
tion of the enamel. This technique forms the basis patients who had mild-to-severe enamel stains in
of the PREMA compound (Premier Dental Prod- secondary dentition for a microabrasion study.
ucts, Plymouth Meeting, Pa.), which was intro- Dentists referred 32 subjects to Dalhousie Uni-
duced in 1990. versity Faculty of Dentistry. We explained the
Croll and colleagues3,4,24-33 have described exten- purpose of the study to the subjects and obtained
sively the microabrasion technique using their informed consent. The subjects received an
PREMA, which is an abrasive paste containing oral examination at no charge, and we assessed
HCl, silicon gel, silicon carbide and silica gel. The the affected teeth. The exclusion criteria were the
compound is polished onto the surface of the teeth presence of defects in the enamel surface, visible
using hand applicators and rotary mandrels using stains on the lingual and facial surfaces or caries
a 10:1 gear reduction contra-angle on a standard in teeth that required microabrasion.
slow-speed handpiece.33 Croll and colleagues32 One author (R.B.T.P.), who had more than six
reported that 15 seconds of gingival exposure to years’ experience with enamel microabrasion,
the compound followed by 30 seconds of water treated all 32 subjects using PREMA as described
rinsing was harmless. Some gingival soft-tissue by Croll.33 Before treatment, each subject received
ulceration occurred after 30 seconds of exposure, a rubber cup prophylaxis to remove any superfi-
but it healed completely in seven days. Conse- cial stain on the teeth. Next, we took standard-
quently, a rubber dam is recommended when ized pretreatment clinical slides under controlled
A B
Figure 2. Typical example of pretreatment (A) and posttreatment (B) results showing that white stains were removed
from the incisal third of both central incisors.
A B
Figure 3. A. Pretreatment view of intense white stains covering most of the central incisors. B. Posttreatment results,
showing removal of most of the white stains from both central incisors.
bility by having them unknowingly rate five face abrasion of the enamel prisms with simulta-
paired duplicate slides at the same treatment neous acid erosion compacts mineralized tissue
stage. All of the raters correctly identified that within the organic region of the enamel, replacing
there were no differences in these paired identical the outer prism-free region.42 Light reflected off of
images. We also tested intrarater reliability by and refracted through this new surface is thought
having the evaluators rate five pairs of pre- and to act differently than light from an untreated
posttreatment images twice. Since an rI of 0.6 to enamel surface.33,42 In addition, subsurface stains
0.74 represents a “good” level of correlation of rat- may be camouflaged by the optical properties of
ings,40 the rI of 0.72 for individual cases by dif- the newly microabraded surface.32 Croll33 has
ferent evaluators was good. named this phenomenon the “abrasion effect.”
Not only does microabrasion mask and remove Hydration of the tooth by saliva augments the
stained tooth structure, thus improving tooth col- optical properties of this altered enamel surface,33
oration, but the surface layer created during and the application of topical fluoride further
treatment is a highly polished, densely com- improves these optical properties.
pacted, mineralized structure.33 While the exact Using polarized light microscopy, Donly and
reason for the color change that occurs after colleagues42 examined longitudinal sections of
microabrasion is not known, the microabraded human incisors after they had received 10
surface reflects and refracts light from the tooth 20-second applications of PREMA compound.
surface in such a way that mild imperfections in They found that after microabrasion the tooth
the underlying enamel are camouflaged.33 The surface contained a dark area that demonstrated
acid also may penetrate and bleach the organic positive birefringence. After microabrasion paste
compounds within the enamel,42 which might compound was applied 20 times, this dark surface
explain the improvement in tooth color. Mild sur- layer appeared even thicker. As might be
expected after simultaneous abrasion and erosion the posttreatment slides; they found no difference
with a compound containing HCl, this surface between the control paired slides. In all but one
demonstrated an atypical enamel structure. Part subject (97 percent), the evaluators found that the
of this “abroded” surface was washed away treated teeth had an improved appearance and a
between applications of the microabrasion com- more uniform color. ANOVA revealed no differ-
pound, but a large portion of the abrasive and ences between evaluator ratings (P = .146). The rI
mineral byproducts of treatment remained as a of 0.72 for ratings of individual cases by different
dense, polished surface layer that was more evaluators, represents a good level of correlation
opaque than the untreated natural enamel.42 This of the ratings for the level of improvement or
highly polished enamel surface was not colonized degree of stain removal. Mean ratings (± SD)
as rapidly by Streptococcus mutans as were sur- were 5.38 (± 1.26) for improvement of appearance
faces that had not been microabraded.43 There and 5.06 (± 1.26) for stain removal.
also is some evidence that the treated enamel We believe that the results of this study show
may be more resistant to demineralization.44 that enamel microabrasion using the PREMA
Long-term follow-up studies, however, are compound is effective in removing stains from the
required to see if teeth treated with microabra- outermost layer of enamel and improving the
sion are more resistant to caries and to see if any appearance of the teeth. ■
relapse of the staining occurs. Dr. Price is a professor, Department of Dental Clinical Sciences, Fac-
During microabrasion, the teeth should be ulty of Dentistry, Dalhousie University, 5981 University Ave., Halifax,
Nova Scotia, B3H 3J5, Canada, e-mail “rbprice@dal.ca”. Address
properly isolated with a rubber dam, and the reprint requests to Dr. Price.
patient should wear eye protection.33 If a
Dr. Loney is a professor and the director, Graduate Prosthodontics,
microabrasion paste such as the PREMA com- Department of Dental Clinical Sciences, Faculty of Dentistry, Dal-
pound leaks under the rubber dam, some gingival housie University, Halifax, Nova Scotia, Canada.
ulceration may occur, but the tissues should heal Dr. Doyle is an assistant professor, Department of Dental Clinical
completely within one week.32 If the teeth are Sciences, Faculty of Dentistry, Dalhousie University, Halifax, Nova
Scotia, Canada.
overtreated with the compound, which can occur
if the enamel is very thin or if the stains are Dr. Moulding is a professor, Department of Restorative and Pros-
thetic Dentistry, University of Saskatchewan, Saskatoon, Canada.
severe,41 the exposed dentin may become sensi-
tive, and a direct resin-based composite restora- This study was funded by Premier Dental Products (Plymouth
tion, a porcelain veneer or a crown may be Meeting, Pa.) and the Dalhousie University Alumni Oral Health
Research Fund.
required.31 The alternative to using enamel
microabrasion to improve the esthetic appearance
of teeth is to place a direct resin-based composite, The authors thank Dr. J. Murphy, B.Ed., M.Ed., Ed.D., associate pro-
fessor, Faculty of Dentistry, Dalhousie University, for his assistance
a veneer or a crown. Therefore, we support prac- with the statistical analyses and Dr. J. Wilson, B.Sc., D.D.S., M.S., for
tice guidelines that recommend microabrasion as participating as one of the evaluators.
12. McInnes J. Removing brown stain from teeth. Ariz Dent J 1996;63(1):17-22.
1966;12(4):13-5. 31. Croll TP. Combining resin composite bonding and enamel
13. Murrin JR, Barkmeier WW. Chemical treatment of endemic microabrasion. Quintessence Int 1996;27:669-71.
dental fluorosis. Quintessence Int 1982;13:363-9. 32. Croll TP, Killian CM, Miller AS. Effect of enamel microabrasion
14. Myers D, Lyon TC Jr. Treatment of fluorosis or fluorosis-like compound on human gingiva: report of a case. Quintessence Int
lesions with calcium sucrose phosphate gel. Pediatr Dent 1986;8:213-5. 1990;21:959-63.
15. Rodd HD, Davidson LE. The aesthetic management of severe 33. Croll T. Enamel microabrasion. Chicago: Quintessence Pub-
dental fluorosis in the young patient. Dent Update 1997;24:408-11. lishing; 1991:27-60.
16. Rosenthaler H, Randel H. Rotary reduction, enamel microabra- 34. Heymann HO. Nonrestorative treatment of discolored teeth:
sion, and dental bleaching for tooth color improvement. Compend reports from an International Symposium (published correction
Contin Educ Dent 1998;19(1):62-7. appears in JADA 1997;128[6]710-1). JADA 1997;128(supplement):
17. Scherer W, Quattrone J, Chang J, David S, Vijayaraghavan T. 1S-2S.
Removal of intrinsic enamel stains with vital bleaching and modified 35. Wray A, Welbury R. UK National Clinical Guidelines in Paedi-
microabrasion. Am J Dent 1991;4(2):99-102. atric Dentistry: treatment of intrinsic discoloration in permanent ante-
18. Waggoner WF, Johnston WM, Schumann S, Schikowski E. rior teeth in children and adolescents. Int J Paediatr Dent 2001;11:
Microabrasion of human enamel in vitro using hydrochloric acid and 309-15.
pumice. Pediatr Dent 1989;11:319-23. 36. Croll TP. A case of enamel color modification: 60-year results.
19. Welbury RR, Carter NE. The hydrochloric acid-pumice microabra- Quintessence Int 1987;18:493-5.
sion technique in the treatment of post-orthodontic decalcification. Br J 37. Croll TP, Cavanaugh RR. Hydrochloric acid-pumice enamel sur-
Orthod 1993;20(3):181-5. face abrasion for color modification: results after six months.
20. Willis GP, Arbuckle GR. Orthodontic decalcification management Quintessence Int 1986;17:335-41.
with microabrasion. J Indiana Dent Assoc 1992;71(4):16-9. 38. Cvitko E, Swift EJ Jr, Denehy GE. Improved esthetics with a
21. Bailey RW, Christen AG. Effects of a bleaching technic on the combined bleaching technique: a case report. Quintessence Int
labial enamel of human teeth stained with endemic dental fluorosis. J 1992;23(2):91-3.
Dent Res 1970;49(1):168-70. 39. Ashkenazi M, Sarnat H. Microabrasion of teeth with discoloration
22. Chandra S, Chawla TN. Clinical evaluation of the sandpaper disk resembling hypomaturation enamel defects: four-year follow up. J Clin
method for removing fluorosis stains from teeth. JADA 1975;90:1273-6. Pediatr Dent 2000;25(1):29-34.
23. Elkhazindar MM, Welbury RR. Enamel microabrasion. Dent 40. Orwin RG. Evaluating coding decisions. In: Cooper H, Hedges LV,
Update 2000;27(4):194-6. eds. The handbook of research synthesis. New York: Russell Sage;
24. Croll TP. Enamel microabrasion for removal of superficial dys- 1994:139-62.
mineralization and decalcification defects. JADA 1990;120:411-5. 41. Train TE, McWhorter AG, Seale NS, Wilson CF, Guo IY. Exami-
25. Croll TP. Enamel microabrasion followed by dental bleaching: nation of esthetic improvement and surface alteration following
case reports. Quintessence Int 1992;23:317-21. microabrasion in fluorotic human incisors in vivo. Pediatr Dent
26. Croll TP, Segura A, Donly KJ. Enamel microabrasion: new con- 1996;18:353-62.
siderations in 1993. Pract Periodontics Aesthet Dent 1993;5(8):19-28. 42. Donly KJ, O’Neill M, Croll TP. Enamel microabrasion: a micro-
27. Croll TP. Hastening the enamel microabrasion procedure elimi- scopic evaluation of the “abrosion effect.” Quintessence Int
nating defects, cutting treatment time. JADA 1993;124(4):87-90. 1992;23(3):175-9.
28. Croll TP. Tooth bleaching for children and teens: a protocol and 43. Segura A, Donly KJ, Wefel JS, Drake D. Effect of enamel
examples. Quintessence Int 1994;25:811-7. microabrasion on bacterial colonization. Am J Dent 1997;10:272-4.
29. Croll TP. Enamel microabrasion: 10 years experience. Asian J 44. Segura A, Donly KJ, Wefel JS. The effects of microabrasion on
Aesthet Dent 1995;3:9-15. demineralization inhibition of enamel surfaces. Quintessence Int
30. Croll TP, Segura A. Tooth color improvement for children and 1997;28:463-6.
teens: enamel microabrasion and dental bleaching. ASDC J Dent Child