CLINICAL APPLICATION

Re-establishing Esthetics
of Fluorosis-Stained Teeth
Using Enamel Microabrasion and
Dental Bleaching Techniques
Danielson Guedes Pontes, PhD
Professor of Operative Dentistry, Course of Dentistry, Nilton Lins University,
Manaus, Amazonas, Brazil;
Professor of Operative Dentistry, Superior School of Health Sciences,
State University of Amazonas, Manaus, Amazonas, Brazil;
Lieutenant, Subdivision of Dentistry, HMAM, 12aRM, Brazilian Army

Ketlen Michele Leite Correa, DDS

Course of Dentistry, Nilton Lins University, Manaus, Amazonas, Brazil

Flávia Cohen-Carneiro, PhD

Professor of Operative Dentistry, Faculty of Dentistry,
Federal University of Amazonas, Manaus, Amazonas, Brazil

Correspondence to: Danielson Guedes Pontes

Rua Rio Mar, 1203 – apto. 901, Nossa Sra. das Graças, 69053-120, Manaus, AM, Brazil

E-mail: danielsonpontes@hotmail.com; Tel: +55-92-8855-7577 / +55-92-3584-2056

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Abstract microabrasion technique with 6% hydro-

chloric acid associated with silica car-
Dental fluorosis manifests itself as white bide showed to be a safe and efficient
stains on the enamel of teeth exposed to method for removing white fluorosis
excessive doses of fluoride during their stains, while dental bleaching was use-
formation. Fluorosis usually occurs as ful for obtaining a uniform tooth shade.
a result of the ingestion of dentifrices, The association of these techniques
gels and fluoridated solutions. It may presented excellent results and the pa-
be diagnosed as mild, moderate or se- tient was satisfied. Both techniques are
vere, and in some cases, it may cause painless, fast and easy to perform, in ad-
the loss of the surface structure of den- dition to preserving the dental structure.
tal enamel. The aim of this study was to Treatment showed immediate and per-
report the clinical case of a female pa- manent results; this technique must be
tient of 18 years with moderate fluorosis, divulged among professionals and their
whose smile was reestablished by the patients.
use of an enamel microabrasion tech-
nique, followed by in-office bleaching. A (Eur J Esthet Dent 2012;7:130–137)

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Clinical significance or restorations with direct resin compos-

ite. However, all these procedures are
The association of enamel microabra- considered invasive, since they require
sion and dental bleaching techniques significant wear of the dental structure.3
has been shown to be efficient elements Problems due to intrinsic color chang-
for the recovery of the esthetics of teeth es in the enamel surface, which were
with moderate fluorosis. It occupies an previously resolved by wearing the tooth
outstanding place among treatment op- and later reconstructing it with direct and
tions, especially as it is a conservative indirect materials, are now esthetically
treatment alternative to preserve the solved by means of more conservative
dental structure. techniques, using abrasive substances
associated with chemical solutions for
the purpose of correcting surface irregu-
Introduction larities present in the tooth enamel.
A study conducted by Ardu S et al4
Tooth color change may be a result of described an easy technique to solve
intrinsic or extrinsic causes. Changes small surface defects in cases of mild
in enamel as a result of external factors to moderate fluorosis. Surface abrasion
are more frequent, and occur due to the of enamel with an esthetically pleasing
deposition of substances such as tea, result could be achieved by in-office
coffee and tobacco. The intrinsic caus- bleaching.
es are inherent to defects in tooth devel- Nowadays, the most popular tech-
opment and systemic conditions, such nique used to improve the esthetic ap-
as: dental traumatism, which may lead pearance of teeth with fluorosis is enamel
to hemorrhage inside the pulp chamber microabrasion. This type of treatment,
and tooth darkening; enamel hypoplas- which is easily performed, associates
ia; amelogenesis imperfect; dentinogen- the use of acid with abrasive particles to
esis imperfect, and systemic ingestion remove the stains from the tooth struc-
of antibiotics (tetracycline) during tooth ture superficially, offering a more con-
formation as well as dental fluorosis.1 servative approach, with minimal loss of
Fluorosis is the result of chronic fluo- enamel surface structure.5-7
ride intoxication, caused by excess in- The first report that described apply-
gestion going beyond tolerable limits for ing acid to remove fluorosis stains was
a prolonged period of time. The severity by Dr Walter Kane in 1916, who used
of this chronic intoxication will depend 18% hydrochloric acid and pumice
on the quantity of fluoride ingested, the stones, without the use of heat, until the
duration of this exposure and the stage desired shade was obtained.1
of tooth development in which the expo- One study presented a product
sure occurred.2 (Opalustre®; Ultradent Products, South
There are several resources in den- Jordan, UT, USA) composed of 6.6%
tistry to correct esthetic alterations hydrochloric acid associated with silica
caused by staining, either with the use carbide microparticles which, among
of porcelain laminate veneers, crowns other advantages, offered both the

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professional and the patient a good

safety margin during application.8 The
use of 37% phosphoric acid or 18%
hydrochloric acid has been effective for
removing enamel opaque spots caused
by fluorosis.9 However, the use of phos-
phoric acid results in increased surface
roughness and lower depth of enamel
demineralization, when compared with
hydrochloric acid.10
Microabrasion is usually performed
Fig 1 Initial image of a patient with opaque stains
before bleaching when white surface
of fluorosis with moderate degree of severity, affect-
discolorations are eliminated and the ing both maxillary and mandibular teeth.
enamel surface becomes brighter and
shinier. White spots due to demineral-
ization or decalcification defects are not
improved by dental bleaching, but they
may often be permanently eliminated
with enamel microabrasion.4 A smile with pleasant esthetics can
be extremely important in an individual’s
interpersonal relationships. As the pa-
Case report tient was extremely young, and taking
into consideration the predictability and
The patient, a female university student longevity of traditional restorative treat-
of 18 years, presented at the restorative ments, for this study a more conserva-
dental clinic with the main complaint of tive esthetic treatment was chosen with
the presence of white spots, suggest- this clinical case. This consisted of using
ive of fluorosis, in all the maxillary and enamel microabrasion techniques with
mandibular teeth (Fig 1). The patient 6% hydrochloric acid and in-office den-
reported having used fluoridated den- tal bleaching, using 35% hydrogen per-
tifrice (Tandy®; Kolynos do Brasil, São oxide.
Paulo, Brazil) containing a large amount Dental prophylaxis was performed to
of fluoride (1.100 ppm) throughout her remove biofilm. After this, the operative
entire childhood, and that she frequently field was isolated with a rubber dam.
ingested it. The ingestion of fluoridated The aim was to protect the gingival tis-
toothpaste quite possibly had an im- sues while enamel abrasion was being
portant role in the development of den- performed (Fig 2). Special attention was
tal fluorosis, since the town in which the paid to protecting both the patient and
patient resided at the time had not incor- professional with the use of protective
porated fluoride in the public water sup- goggles and individual protective equip-
plies. During the patient’s clinical evalu- ment since highly corrosive materials
ation, no caries could be detected and were being used, which are aggressive
the diagnosis of fluorosis was confirmed. to human tissues.

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Fig 2 After dental prophylaxis, the teeth were iso- Fig 3 Insertion of material selected for the micro-
lated with a rubber dam to protect gingival tissues. abrasion technique containing 6% hydrochloric
Note the greater evidence of stains after dehydra- acid and silica carbide (Whiteness RM – FGM).
tion of teeth due to isolation of the operating field.

Fig 4 The product was rubbed over the tooth and Fig 5 The product was rubbed over the tooth and
stained area for 10 s with the aid of a plastic spatula, stained area for 10 s with the aid of a plastic spatula,
alternately using a low speed rubber cup for 10 s. alternately using a low speed rubber cup for 10 s.

A mild wear was performed on the sive. The material was rubbed over the
enamel surface affected by fluorosis tooth and stained area for 10 s with the
using an ultra-fine diamond bur (3195FF, aid of a plastic spatula, alternately using
30 μm; KG Sorensen, São Paulo, Bra- a low speed rubber cup for 10 s (Figs 4
zil), under water-cooling. Later, a small and 5). After this the material was re-
amount of the material selected for the moved from the tooth surface with water.
microabrasion technique was applied The process was repeated eight times
on the tooth surface (Whiteness RM; on each tooth. Two clinical sessions
FGM DentsCare, Joinville, SC, Brazil) were performed at intervals of one week
(Fig 3). This material contains 6% hy- (Fig 6). At the end of each consultation,
drochloric acid and silica carbide in its the teeth were polished with paste (ACI
composition, and it is extremely corro- and ACII; FGM DentsCare, Joinville, SC,

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Brazil) and felt disks. Afterwards, 2%

neutral sodium fluoride gel was topically
applied for 4 mins, with the purpose of
reducing postoperative sensitivity.11
One week after finishing microabra-
sion, the patient was submitted to den-
tal bleaching with 35% hydrogen perox-
ide bleaching gel (Whiteness HP Maxx;
FGM DentsCare, Joinville, SC, Brazil)
due to the yellowish aspect of the teeth.
With the aid of a lip retractor, a gin-
Fig 6 Esthetic result achieved one week after the
gival protective barrier (Topdam; FGM,
first microabrasion clinical session. Central incisors
DentsCare, Joinville, SC, Brazil) was with significant improvement, but with quite evident
made and the bleaching gel was ap- staining in the cervical region of the crown.

plied, and submitted to light activation

(LED at a wavelength of 450 nm) for 90 s,
twice consecutively. The teeth remained
in contact with the gel for a total time
period of 30 min, before it was removed
with an endodontic suction cannula. The
teeth were then washed with water. This
bleaching process was repeated three
times in a single clinical session if the
patient did not complain of tooth sensi-
tivity, which was not observed in any of
the consultations. A total of three clinical Fig 7 Esthetic result achieved one week after the
bleaching consultations were performed second microabrasion clinical session. Central inci-
sors do not show perceptible fluorosis stains.
until the patient was satisfied with the re-
sults achieved (Figs 7 and 8).

Discussion
Esthetic changes, such as dental fluor-
osis, which result from intrinsic stain-
ing of dental enamel and/or dentin,
can be controlled or mitigated by more
conservative methods, such as bleach-
ing and/or an enamel microabrasion
technique.12 Fig 8 Final esthetic result of treatment with enam-
el microabrasion and dental bleaching. This figure
The result obtained by the application
shows the final aspect, two weeks after the end of
of the microabrasion technique should the clinical bleaching sessions, with a high degree
be observed after allowing teeth to go of patient satisfaction

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through a period of hydration, because ever, after treatment, the following effects
during the clinical stage of treatment, are expected: some loss of structure,
dehydration occurs as a result of the use increase in enamel surface roughness
of absolute isolation. This could lead to and color change of the tooth submitted
both the professional and patient hav- to microabrasion.7,10,16 Color change
ing a mistaken impression of the result after the procedure may occur due to
achieved. This observation is in agree- loss of enamel structure (thickness), re-
ment with the findings of another study sulting in a more yellowish result. This
that reported an improvement in the color setback can be solved by performing
of teeth submitted to microabrasion after an in-office dental bleaching treatment
a period of time due to the remineraliza- after conclusion of the microabrasion
tion of enamel provided by the minerals sessions.8 Another expected effect of
present in the saliva.8 In the present clin- enamel microabrasion may be the need
ical case, the results were satisfactory to perform a restorative procedure with
due to an improvement in the appear- resin composite, and if this is the case, it
ance of enamel, in which considerable, will require a longer period of acid etch-
almost complete stain removal occurred ing to obtain a reliable bond to enamel.17
(Fig 7). This brought considerable ben- With regard to the extension of white
efits to the esthetics of the smile and to spots caused by fluorosis, it is known
the patient, resulting in a great change in that the depth of stained enamel can-
her interpersonal relationships with her not be determined before treatment
social groups, as well as her family. begins.18 The enamel microabrasion
The desire for excellence in esthetic technique can only be considered a
dental treatments has led to great sci- definite treatment for teeth with mild or
entific and technological advances, and moderate fluorosis.19 If there is no im-
thus more satisfactory results have been provement in color after 12 to 15 appli-
found.13,14 The microabrasion technique cations of the acid, another procedure
has its space in this context, and al- must be chosen such as, for example,
though there are several microabrasion dental wear with burs and resin compos-
techniques described in related litera- ite restoration. Therefore, professionals
ture, products used for this type of treat- who use this technique must be always
ment are basically composed of an acid aware of possible failures. This must be
associated with an abrasive. Normally, explained to the patient before starting
the majority of commercial products de- esthetic treatment with the microabra-
veloped for enamel microabrasion con- sion technique. However, in favor of this
tain different concentrations of hydro- technique, fluorosis stains are usually
chloric acid. However, since this type of confined to the enamel surface layer,
acid is quite corrosive, it has been used which allows microabrasion to remove
at lower concentrations. these stains efficiently.18
In most clinical situations, the mi- In the present case report, eight ap-
croabrasion technique used to remove plications of the abrasive material for a
fluorosis stains is capable of promoting period of 10 s were performed on each
an esthetically satisfying result.15 How- tooth in each clinical session. Final suc-

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cess was obtained after three micro- 7. Higashi C, DallÁgnol AL, Hirata R, Loguercio
AD, Resi A. Association of enamel microabra-
abrasion sessions. Thus, as observed in sion and bleaching: a case report. Gen Dent
this case report, a combination of treat- 2008;56: 244–249.
8. Paic M, Sener B, Schug J, Schmidlin PR.
ment methods such as microabrasion
Effects of microabrasion on substance
and dental bleaching, for example, play loss, surface roughness, and colorimetric
a relevant role when esthetic excellence changes on enamel in vitro. Quintessence Int
2008;39:517–522.
with maximum tissue preservation is de- 9. Bezerra AC, Leal SC, Otero SA, Gravina DB,
sired.20,21 Ayrton de Toledo O. Enamel opacities removal
using two different acids: an in vivo compari-
son. J Clin Pediatr Dent 2005;29:147–150.
10. Meireles SS, Andre Dde A, Leida FL, Bocan-

Conclusion gel JS, Demarco FF. Surface roughness and

enamel loss with two microabrasion tech-
niques. J Contemp Dent Pract 2009;10:58–65.
The microabrasion technique with 6% 11. de Macedo AF, Tomazela-Herndi S, Corrêa MS,
Duarte DA, Santos MT. Enamel microabrasion
hydrochloric acid associated with silica
in an individual with Cohen syndrome. Spec
carbide was shown to be a safe and effi- Care Dentist 2008; 28:116–119.
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Aranha AC. A minimally invasive procedure for
stains, while dental bleaching was use- esthetic achievement: enamel microabrasion of
ful for obtaining a uniform tooth shade. fluorosis stains. Gen Dent 2010;58:225–229.
13. da Silva VA, de Oliveira FS, Lanza CR, Macha-
The association of these techniques
do MA. Esthetic improvement following enamel
presented excellent results and the pa- microabrasion on fluorotic teeth: a case report.
tient was satisfied; both techniques pre- Quintessence Int 2002;33:366–369.
14. Peruchi CMS. O uso da microabrasão do
served the dental structure, and were esmalte para remoção de manchas brancas
painless, fast and easy for the profes- sugestivas de fluorose dentária: caso clinico.
Rev Odontol Araçatuba 2004;25:72–77.
sional to perform.
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Esthet Dent 1998;10:21–29.
16. Zuanon AC, Santos-Pinto L, Azevedo ER, Lima
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