|Year : 2017 | Volume
| Issue : 3 | Page : 260-268
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
|Date of Web Publication||31-Jul-2017|
B 389, Nirman Vihar, Vikas Marg, New Delhi - 110 092
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Dental fluorosis is caused by successive exposure to high concentrations of fluoride during tooth development leading to enamel with lower mineral content and increased porosity. Aims: The aim of the study was to evaluate and compare the effectiveness of minimally invasive techniques for the removal of dental fluorosis stains in children in vivo. Design: Ninety children in the age group of 10–17 years were selected. Materials and Methods: The study sample was 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
|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
|How to cite this URL:|
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 [serial online] 2017 [cited 2019 Dec 11];35:260-8. Available from: http://www.jisppd.com/text.asp?2017/35/3/260/211839
| 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.
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. The highest rates of endemicity have been reported from Andhra Pradesh, Haryana, Karnataka, and Tamil Nadu. This is a major public health problem as almost 85% of rural population in India depends on groundwater for their domestic needs.
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.
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.
Nowadays, the combination of dental bleaching techniques and microabrasion appears an excellent conservative solution to reestablish health in fluorosis-affected teeth  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.
- 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 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. ΔL* is the change in lightness (the greater the Δ L*, the whiter the teeth), and Δ a* and Δ b* are chromaticity values (the amount of redness and the amount of yellowness).
Color differences were calculated using the following equation: ΔE = ([ΔL*]2 + [Δa*]2 + [Δb*]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 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).
|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|
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[Figure 1], [Figure 2], [Figure 3] represent color change in Groups 1, 2, and 3, respectively.
|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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|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|
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|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|
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Color differences were calculated using the following equation: ΔE = ([ΔL*]2 + [Δa*]2 + [Δb*]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.
|Table 2: Color change (ΔE) immediate postoperative, after 1 month, and after 3 months in all the three groups|
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A statistically significant difference was found in all the three groups for immediate postoperative color 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, 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) but was not statistically significant between 1 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.
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.
|Table 3: Changes in tooth sensitivity values immediate postoperative, after 1 month, and after 3 months calculated from baseline|
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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 Group 2 (0.64 ± 0.79) followed by Group 1 (0.34 ± 0.61) 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 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.
|Table 4: Patient satisfaction score immediate postoperative, after 1 month, and after 3 months|
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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) 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. 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 teeth. Dental fluorosis may develop only during the 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.
The technique of bleaching or whitening teeth was 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 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., 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. 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. 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. Gurgan et al. 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. 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. Hein et al. 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 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. 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. 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. Similar to the study of Train et al. and Loguercio et al., 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.
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. 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.
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.
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.
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), 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. 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. However, in this study, CIE-L*, a*, b* colorimetry has been used which is established to be a more objective method in recent decades., 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 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. Jarad et al. 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. 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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Alvarez AJ, Rezende KM, Marocho SM, Alves FB, Celiberti P, Ciamponi AL. Dental fluorosis: Exposure, prevention and management. J Clin Exp Dent 2009;1:14-8.
Kumar Garg V, Singh B. Fluoride signatures in groundwater and dental fluorosis in permanent teeth of school children in rural areas of Haryana state, India. Int J Occup Environ Med 2013;4:107-8.
Peariasamy K, Anderson P, Brook AH. A quantitative study of the effect of pumicing and etching on the remineralisation of enamel opacities. Int J Paediatr Dent 2001;11:193-200.
Ardu S, Stavridakis M, Krejci I. A minimally invasive treatment of severe dental fluorosis. Quintessence Int 2007;38:455-8.
Croll TP. Esthetic correction for teeth with fluorosis and fluorosis-like enamel dysmineralization. J Esthet Dent 1998;10:21-9.
Ishii T, Suckling G. The appearance of tooth enamel in children ingesting water with a high fluoride content for a limited period during early tooth development. J Dent Res 1986;65:974-7.
Buchalla W, Attin T. External bleaching therapy with activation by heat, light or laser – A systematic review. Dent Mater 2007;23:586-96.
Kawamoto K, Tsujimoto Y. Effects of the hydroxyl radical and hydrogen peroxide on tooth bleaching. J Endod 2004;30:45-50.
Chhabra N, Singbal KP. Viable approach to manage superficial enamel discoloration. Contemp Clin Dent 2010;1:284-7.
] [Full text]
Venkatesan SM, Narayan GS, Ramachandran AK, Indira R. The effect of two bleaching agents on the phosphate concentration of the enamel evaluated by Raman spectroscopy: An ex vivo
study. Contemp Clin Dent 2012;3 Suppl 2:S172-6.
Hayward R, Osman Y, Grobler SR. A clinical study of the effectiveness of a light emitting diode system on tooth bleaching. Open Dent J 2012;6:143-7.
Gurgan S, Cakir FY, Yazici E. Different light-activated in-office bleaching systems: A clinical evaluation. Lasers Med Sci 2010;25:817-22.
Polydorou O, Hellwig E, Hahn P. The efficacy of three different in-office bleaching systems and their effect on enamel microhardness. Oper Dent 2008;33:579-86.
Hahn P, Schondelmaier N, Wolkewitz M, Altenburger MJ, Polydorou O. Efficacy of tooth bleaching with and without light activation and its effect on the pulp temperature: An in vitro
study. Odontology 2013;101:67-74.
Hein DK, Ploeger BJ, Hartup JK, Wagstaff RS, Palmer TM, Hansen LD. In-office vital tooth bleaching – What do lights add? Compend Contin Educ Dent 2003;24:340-52.
Donly KJ, O'Neill M, Croll TP. Enamel microabrasion: A microscopic evaluation of the “abrosion effect”. Quintessence Int 1992;23:175-9.
Cvitko E, Swift EJ Jr., Denehy GE. Improved esthetics with a combined bleaching technique: A case report. Quintessence Int 1992;23:91-3.
Bertassoni LE, Martin JM, Torno V, Vieira S, Rached RN, Mazur RF. In-office dental bleaching and enamel microabrasion for fluorosis treatment. J Clin Pediatr Dent 2008;32:185-7.
Train TE, McWhorter AG, Seale NS, Wilson CF, Guo IY. Examination of esthetic improvement and surface alteration following microabrasion in fluorotic human incisors in vivo
. Pediatr Dent 1996;18:353-62.
Loguercio AD, Correia LD, Zago C, Tagliari D, Neumann E, Gomes OM, et al.
Clinical effectiveness of two microabrasion materials for the removal of enamel fluorosis stains. Oper Dent 2007;32:531-8.
da Silva SM, de Oliveira FS, Lanza CR, Machado MA. Esthetic improvement following enamel microabrasion on fluorotic teeth: A case report. Quintessence Int 2002;33:366-9.
Dahl JE, Pallesen U. Tooth bleaching – A critical review of the biological aspects. Crit Rev Oral Biol Med 2003;14:292-304.
Cárdenas Flores A, Flores Reyes H, Gordillo Moscoso A, Castanedo Cázares JP, Pozos Guillén Ade J. Clinical efficacy of 5% sodium hypochlorite for removal of stains caused by dental fluorosis. J Clin Pediatr Dent 2009;33:187-91.
Darshan HE, Shashikiran ND. The effect of McInnes solution on enamel and the effect of Tooth mousse on bleached enamel: An in vitro
study. J Conserv Dent 2008;11:86-91.
] [Full text]
Carrasco TG, Carrasco-Guerisoli LD, Fröner IC.In vitro
study of the pulp chamber temperature rise during light-activated bleaching. J Appl Oral Sci 2008;16:355-9.
Coutinho DS, Silveira L Jr., Nicolau RA, Zanin F, Brugnera A Jr. Comparison of temperature increase in in vitro
human tooth pulp by different light sources in the dental whitening process. Lasers Med Sci 2009;24:179-85.
Fani G, Vichi A, Davidson CL. Spectrophotometric and visual shade measurements of human teeth using three shade guides. Am J Dent 2007;20:142-6.
CIE. Colorimetry: Official Recommendations of the International Commission on Illumination. Publication CIE. Paris, France: Bureau Central de la CIE; 1978. p. 15-30.
Knösel M, Attin R, Jung K, Brunner E, Kubein-Meesenburg D, Attin T. Digital image color analysis compared to direct dental CIE (L*, a*, b*) colorimeter assessment under different ambient conditions. Am J Dent 2009;22:67-72.
Llambés G, Llena C, Amengual J, Forner L.In vitro
evaluation of the efficacy of two bleaching procedures. Med Oral Patol Oral Cir Bucal 2011;16:e845-51.
Jarad FD, Russell MD, Moss BW. The use of digital imaging for colour matching and communication in restorative dentistry. Br Dent J 2005;199:43-9.
Almeida LC, Riehl H, Santos PH, Sundfeld ML, Briso AL. Clinical evaluation of the effectiveness of different bleaching therapies in vital teeth. Int J Periodontics Restorative Dent 2012;32:303-9.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]