Microabrasion for the

treatment of intrinsic
discolorations from
fluorosis
Beatriz Bezerra

Intrinsic stains
Types of intrinsic stains
Change in composition/thickness of dental hard
tissues during odontogenesis or after eruption
Systemic
Genetic
Amelogenesis imperfecta, dentinogenesis imperfecta
Drug-related
Tetracyclines
Fluoride

Local
Pulp remnants in pulp horns
Root resorption
Ageing
Watts & Addy, 2001; Plotino et al., 2008

Fluorosis
Result of excess fluoride ingestion
Severity related to concentration and
duration of exposure
Plasma levels of F- are indicative of severity
Total fluoride intake, renal function, rate of bone
metabolism, metabolic activity, genetic factors
(Angmar-Mansson, et al., 1990)

3-10 mol/L plasma concentration in humans

Bone as a reservoir > plasma levels <1.5mol/L can
induce mild fluorosis (in rats) Angmar-Mansson et al.,
1976; 1990

Fluorosis
Prevalence

Beltrn-Aguilar et al.,

Fluorosis
Aesthetic problem
Psychological effects
Parents perception
Adolescents' perception
Sujak et al., 2004; Martinez-Mier et al., 2004; Sigurjons et al.,
2004; Levy et al., 2005; McGrady et al., 2012

Seek treatment for severe forms

Lymeback et al., 2006; Chankanka et al., 2010

Fluorosis
Enamel characteristics of fluorosed
teeth
Hypomineralized subsurface
Well-mineralized outer enamel surface
Wide gaps between enamel rods
Enlarged intercrystalline spaces
Fejerskov et al., 1974; Thylstrup & Fejerskov, 1978

Pitting is known to occur after eruption

due to mechanical breakdown of the
surface
Fejerskov et al., 1991; Richards et al, 1992

Fluorosis
Clinical characteristics
Mild: white opaque with increased
porosity
Thin horizontal lines running across teeth

Moderate: well-defined and thicker

white lines
Entire tooth can be chalky white and loose
transparency

Severe: yellow to brown staining

Enamel is porous, poorly mineralized (< mineral
and > protein)

Fluorosis
Indices
Dean (1942)
Classification based on water fluoride levels

Fluorosis
Indices
Thylstrup & Fejerskov (1978)
Based on correlation between visual
assessment with polarized and light
microscopic analysis

Dr. Limebacks blog

http://cof-cof.ca/2012/09/dr-hardy-limeback-bsc-phd-biochemistry-dds-dental-fluorosis-permanent-tooth-scarring-

Enamel Microabrasion
Conservative technique
Removal of superficial layer of affected enamel with acid
and abrasive powder (Croll, 1989)
18% HCl + pumice

Promotes minimal loss of surface enamel

Removes the first 100-200m
Waggoner et al. 1989

(Sinha et al., 2013)

12m after 1st application

26m after subsequent applications

Tong et al., 1993

Up to 360m with rotary prophy cup

After each application enamel should be evaluated to check

if site is concave
If area is concave with considerable staining present composite
restoration is indicated
Croll, 2000

Enamel Microabrasion
HCl in different concentrations
Commercial products
Opalustre (Ultradent) 6.6%
PREMA (Premiere Dental) 1.4%
Abrasive component Silicon carbide

Alternative treatments
Phosphoric acid + pumice
Microabrasion + bleaching

Enamel Microabrasion
Split-mouth design

(Loguercio et al., 2007)

Opalustre x PREMA
no differences in results
Opalustre achieved results faster

Outcome of microabrasion technique

seems to be affected by fluorosis
severity
Mild to moderate stains have better
outcome
Train et al.,1996; Wong & Winter, 2002; Celik et al., 2013, Sinha

Enamel Microabrasion
Application of commercially available
kits or slurry of phosphoric acid+pumice
can achieve similar results
Da Silva et al., 2002; Bezerra et al., 2005; Bassir & Bagheri, 2013; Sinha et al.,
2013

Microabrasion has shown stable results:

Lynch & McConnell, 2003 6mos

Kilpatrick & Welburry, 1993- 2.7yrs
Wong & Winter, 2002 6mos
Da Silva et al., 2002 12mos

Enamel Microabrasion
Association of microabrasion and
bleaching show a more effective
management of fluorosed teeth
Allows for a more uniform shade
Bertassoni et al., 2008; Ardu et al., 2009; Pontes et al., 2012;
Celik et al., 2013

Microabrasion alone did not promote

acceptable improvement in
appearance
Cannot achieve uniform tooth shade as
bleaching does
Celik et al., 2013

Enamel Microabrasion
In vitro studies show that microabrasion promotes increased
surface roughness, and it varies with acid concentration
Paic et al., 2008; Fragoso et al., 2012; Rodrigues et al., 2013

Phosphoric acid promotes less demineralization than HCl, with

selective conditioning etching
Meirelles et al., 2009

Phosphoric acid promotes increased roughness in mild to

moderate fluorotic enamel, but decrease in severe fluorosis
Concerns when treating severe fluorosis with adhesive restorations
Torres-Gallegos et al., 2012

Polishing after microabrasion increased surface hardness and

smoothness
Fragoso et al., 2012

Clinical question
Is the microabrasion technique
effective in removing intrinsic
discoloration from Fluorosis and
achieving good clinical results?

Dr. RiveraRamos

Dr. RodriguezJorda
J Esthet Restor Dent 25:422432, 2013

Dr. Salazar

Conclusions
HCl and phosphoric acid can achieve
similar results
Phosphoric acid is readily available in the
dental office and safer than HCl > easy
alternative to expensive kits

Mild and moderate fluorosis stains show

better results
Bleaching can be used as a complement
to achieve a more uniform shade