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CLINICAL RESEARCH

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VOLUME 8 NUMBER 3 AUTUMN 2013
Correspondence to: Dr Soumya Sinha
Assistant Professor, Department of Pediatric and Preventive Dentistry, M.A. Rangoonwala Dental College, Pune, Maharastra,
India, Pin: 411001; Tel: 09604208083; Email: dentistsoumya@gmail.com
Microabrasion using 18% hydro-
chloric acid and 37% phosphoric
acid in various degrees of fuorosis
an in vivo comparision
Soumya Sinha, M.D.S.
Assistant Professor, Department of Pediatric and Preventive Dentistry,
M.A. Rangoonwala Dental College and Research Center, Pune, India
Kiran Kumar Sudulukunta Vorse, M.D.S.
Assistant Professor, Department of Pediatric and Preventive Dentistry,
M.A. Rangoonwala Dental College and Research Center, Pune, India
Hina Noorani, M.D.S.
Professor and Head, Department of Pediatric and Preventive Dentistry,
Parvategouda Mallanagouda Nadagouda Memorial Dental College and Hospital,
Bagalkot, India
Shivprakash Pujari Kumaraswamy, M.D.S.
Professor, Department of Pediatric and Preventive Dentistry,
Parvategouda Mallanagouda Nadagouda Memorial Dental College and Hospital,
Bagalkot, India
Siddhartha Varma
Assistant Professor, Department of Periodontics, School of Dental Sciences,
Krishna Institute of Medical Science Deemed Univeristy, Karad, India
Haragopal Surappaneni, M.D.S.
Assistant Professor, Department of Prosthodontics, St Joseph Dental College,
Eluru, Andhra Pradesh, India
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Abstract
Aims and objectives: The aim of this
study was to assess the efcacy of 18%
hydrochloric acid and 37% phosphoric
acid by an in vivo comparison.
Methods: Sixty uorotic permanent max-
illary central incisors from 30 patients
were divided into 3 categories. The teeth
received 5 seconds (mild uorosis), 20
seconds (moderate uorosis) and 30
seconds (severe uorosis) application
of 18% hydrochloric acid on 11 and 37%
phosphoric acid on 21. Standardized in-
traoral photographies were taken imme-
diately before, after, and one month after
treatment. Vinyl polysiloxane impression
of the patient were made before and after
the treatment. A scanning electron mi-
croscopic (SEM) evaluation was carried
out on the models to judge the surface
alterations. Wilcoxon and Mann-Whitney
tests were used to verify the hypothesis.
Results: A statistically signicant result
was obtained in the reduction of white
spot opacities, intensity of stains and the
total area occupied by the stains in mild
and moderate uorosis teeth. Results of
severe uorosis had an unpredictable
outcome. An SEM evaluation revealed
good improvement in the surface texture
of mild and moderate uorosis teeth.
Teeth with severe uorosis showed only
a slight improvement.
Conclusion: A microabrasion procedure
is effective for treating mild and moder-
ate uorosis cases.
(Eur J Esthet Dent 2013;8:454465)
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Introduction
One of the most frequent reasons for
seeking dental care is discolored ante-
rior teeth. In todays society, peer group
inuences play a major role in a childs
mind. The appearance of a disgured
smile negatively affects the psycho-
emotional development of children, in-
creasing their problems with social rela-
tions.
1

Causes of tooth discoloration can be
extrinsic or intrinsic. Dental uorosis is
one of the most common causes of intrin-
sic tooth discoloration. With the recent
stress on prevention of caries, the use
of uoride has increased tremendously.
The increasing use of uoride has lead
to a higher incidence of uorosis, which
has become the impetus to search for
cosmetic solutions.
Various treatment regimens proposed
for the treatment of intrinsic tooth discol-
oration are:
Vital bleaching:
a) in ofce
b) home bleaching
Non-vital bleaching
Microabrasion
Composite resin restorations
Porcelain veneers
Each of the above mentioned techniques
come with their own set of limitations.
Porcelain veneers are recommended
only in the age group of 16 years and
above. Composite resin restorations are
not a conservative approach and also
tend to discolor over time. Many patients
report postoperative sensitivity follow-
ing vital tooth bleaching.
2
Hence a more
conservative and an interim protocol for
children is needed.
The treatment of dental uorosis
through microabrasion, being a mini-
mally invasive technique in achieving
acceptable results in the removal of
enamel stains and surface defects was
taken up for the study.
1
The primary aims
of carrying out the study were to com-
pare the efcacy of microabrasion by
using 18% hydrochloric acid and 37%
phosphoric acid in terms of:
Lightening of stains and reduction
in size of the opacities and stains by
both the acids.
Checking the surface alterations of
teeth with different degrees of uoro-
sis following microabrasion using the
two acids through a scanning elec-
tron microscope analysis.
Checking for the permanency of treat-
ment outcome via a one-month follow-
up protocol.
Recording of any postoperative sen-
sitivity or soft tissue injury during the
treatment.
Materials and methods
A sample size of 60 teeth from 30 pa-
tients with varying degree of uorosis
was included in this study.
The patients were divided into 3
groups following the Deans uorosis
index:
Group 1: mild uorosis
[1 and 2 score]: 10 patients
Group 2: moderate uorosis
[3 score]:10 patients
Group 3: severe uorosis
[4 score]:10 patients
3
Score 0 and 0.5 were not included for
the study.
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Criteria for the collection of data
Criteria for acceptability included the fol-
lowing:
Children in the age group of 7 to 14
years, suffering from dental uorosis
were included in the study.
Two permanent maxillary central inci-
sors at least two-third erupted.
Staining consistent with the appear-
ance of mild, moderate, or severe
dental uorosis on both teeth. The
Deans Fluorosis index was used for
this classication.
3
Presence of symmetrical distribution of
uorosis within the dentition and a uor-
ide history to verify systemic ingestion
as the etiology of enamel defects.
No contraindications to treatment.
The children were healthy and not suf-
fering from any systemic diseases or
nutritional deciencies.
Consent for treatment was obtained.
Method of collection of data
The children for the study were selected
from those reporting to the department
of Pediatric and Preventive Dentistry
at Parvategouda Mallanagouda Nada-
gouda Memorial (PMNM) Dental Col-
lege. Parents of selected children were
informed regarding the nature and pur-
pose of the study and an informed con-
sent was obtained from them.
A full mouth supragingival scaling
was done for the patients using ultra-
sonic scaling tips. The maxillary anterior
region was isolated using a rubber dam.
18% hydrochloric acid + pumice ap-
plication was done on 11
37% phosphoric acid + pumice ap-
plication was done on 21
A slow rotating rubber cup in a contra-
angle micromotor hand piece was used
for the application.
Criteria for standardization
Group 1:
5 seconds application with 18%
hydrochloric acid on 11.
5 seconds application with 37%
phosphoric acid on 21.
This is followed by 20 seconds
rinsing with copious water spray.
A total of 4 applications were per-
formed.
Group 2:
20 seconds application with 18%
hydrochloric acid on 11.
20 seconds application with 37%
phosphoric acid on 21.
This is followed by 20 seconds
rinsing with copious water spray.
A total of 4 applications were per-
formed.
Group 3:
30 seconds application with 18%
hydrochloric acid on 11.
30 seconds application with 37%
phosphoric acid on 21.
This is followed by 20 seconds
rinsing with copious water spray.
A total of 4 applications were per-
formed.
Following the microabrasion procedure
Casein-Phosphopeptide-Amorphous
Calcium Phosphate remineralizing solu-
tion [GC Tooth Mousse paste] was ap-
plied for 15 minutes. Photos were taken
before, immediately after and one month
post treatment. Photos were scanned
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CLINICAL RESEARCH
and analyzed in software Paint Shop Pro 7
for opacities and demarcations, followed
by an analysis in Image Pro Express 4.0
software used for the calculus of the total
opacity area.
4
Vinyl polysiloxane impres-
sions of the patient were made before and
after treatment. A scanning electron mi-
croscopic evaluation was carried out on
the models to judge the surface altera-
tions.
3
Four sets of criteria were used to
judge the photomicrographs:
Type of surface defect
Depth of surface defect
Shape/description of surface defects
Area affected by the defect as a
function of percentage of the tooth
surface
Criteria for scoring
Photographic analysis
Amount of white spot (WS) discoloration
as a function of percentage of surface of
tooth involved:
0 = none
1 = questionable
2 = less than 25%
3 = greater than 25% but less than
50%
4 = 50% or more
5 = entire surface involved or pitting
present
Intensity of yellow, orange, or brown
stain (SI):
0 = none
1 = light to medium
2 = dark
Amount of stain (SA) as a function of per-
centage of surface of tooth involved
0 = none
1 = less than 25%
2 = greater than 25% but less than
50%
3 = greater than 50%
Assessement of photomicrographs
(scanning electron microscopic
analysis)
Type of surface defect:
1 = smooth
2 = grooved
3 = pitted
4 = grooved and pitted
Depth of the surface defects:
1 = shallow
2 = medium
3 = deep
Shape/description of surface defects:
1 = discrete
2 = conuent
3 = discrete and conuent
Area affected by the defects as a func-
tion of percentage of surface of tooth:
1 = less than one-fourth
2 = greater than one-fourth but less
than half
3 = greater than half but less than
three-quarters
4 = greater than three-quarters.
Statistical analysis
Wilcoxon and Mann Whitney tests
were used to verify the hypothesis of
the immediate and nal equality of the
effect of the two pastes. Kappa statis-
tics were used to obtain the interrater
reliability.
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Results and observations
The sample consisted of 30 subjects
ranging from 7 to 14 years. They were
divided into three equal groups of mild,
moderate and severe uorosis consist-
ing of 10 children each. Male and female
children were equally distributed in each
group. Results of the present study indi-
cate the following.
Photographic analysis
Amount of white spot (WS) discolora-
tion as a function of percentage of
surface of tooth involved
There was total of 43.8% of white spot
reduction during the treatment of Group
1 using 18% hydrochloric acid. This fur-
ther improved to 61.3% reduction fol-
lowing 1-month followup. A reduction
of 61% white opacities was seen after
treatment with 37% phosphoric acid.
This improved to 70.9% after a 1-month
followup period.
White spot opacities reduced by
30.5% in Group 2 after treatment with
18% hydrochloric acid. This improved
to 55.05% after 1-month follow- up. A
reduction of 38.5% after treatment and
an improvement to 67.6% in the white
opacities was observed with 37% phos-
phoric acid.
There was a total reduction of 17.3%
of white spot opacities in Group 3 after
treatment with 18% hydrochloric acid.
An improvement to 40.34% was ob-
served after the 1-month follow- up. With
37% phosphoric acid, an improvement
of 25% was seen after treatment and an
improvement to 46.6% after a period of
1 month.
The efcacy of 37% phosphoric acid
in the removal of white spot opacities
appeared to be superior to 18% Hydro-
chloric acid. However the difference in
values was not statistically signicant.
Intensity of yellow, orange,
or brown stain (SI)
A reduction of 52.65% in the intensity
of yellow stain with an improvement to
66.4% after 1 month was observed with
18% hydrochloric acid in Group 1. A
reduction of 58% with an improvement
to 62.7% after 1 month was seen after
treatment with 37% phosphoric acid.
There was a 44.9% reduction in the
intensity of yellow and brown stain fol-
lowing treatment with 18% hydrochloric
acid in Group 2. This further reduced
to 59% during the 1-month followup
period. A reduction of 47.5% stain inten-
sity was seen after treatment with phos-
phoric acid. This improved to 73.4% af-
ter 1 month.
In Group 3, the intensity of stain re-
duced by 33.5% initially and 49.7% af-
ter 1 month following treatment with 18%
hydrochloric acid. Forty-seven per cent
lightening of the intensity of yellow and
brown stain was seen postoperative af-
ter treatment with 37% phosphoric acid.
This further improved to 51.4% reduc-
tion after 1 month. The efcacy of 18%
hydrochloric acid and 37% phosphoric
acid in reduction of the intensity of yel-
low and brown stains was similar.
Amount of stain (SA) as a function
of percentage of surface of tooth
involved
In Group 1, there was a reduction of
52.7% in the total area affected by stain
following treatment with 18% hydrochlo-
ric acid and an improvement to 71.4%
after 1 month. In teeth treated with 37%
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phosphoric acid a reduction of 67.2%
and an improvement to 81.9% after 1
month was observed.
In Group 2, there was a 37.4% reduc-
tion in the total area affected by stain
immediately after treatment with 18% hy-
drochloric acid. This further decreased
to 62.8% during the 1-month follow-up
period. For the teeth treated with 37%
phosphoric acid there was a 44.8% re-
duction postoperatively and a total of
72.6% reduction after 1 month.
For teeth treated with 18% hydrochlo-
ric acid in Group 3, a reduction of 24.2%
was observed postoperatively and an
improvement to 43.0% after 1 month. A
reduction of 35% in the total area of tooth
surface affected by stain was seen after
treatment with phosphoric acid. This fur-
ther improved to a 48.7% reduction after
a 1-month follow-up period.
The comparative difference in ef-
cacy of 18% hydrochloric acid and
37% phosphoric acid in the reduction
of the total area of stain as a percentage
of tooth surface using Mann-Whitneys
U test was not statistically signicant
(Figs 1 to 3).
Scanning electron microscopic
evaluation: 10X magnication
Group 1: mild uorosis
For the teeth in this category, the type of
surface defects changed from grooved
type to the smooth type in almost 50%
of the cases treated with 18% hydro-
chloric acid, and in 45% of the cases
treated with 37% phosphoric acid. The
rest of the cases remained unchanged.
There was a reduction in the depth of
the surface defects by 37.5% for 18%
hydrochloric acid and 44.4% reduction
with 37% phosphoric acid. There was no
appreciable change in the shape of the
surface defects. The total area affected
by the surface defects reduced by 45%
in teeth treated by 18% hydrochloric ac-
Fig 1 Preoperative photography of 11 and 21
showing moderate uorosis in a 9-year-old patient.
Fig 3 Photography after one-month follow-up.
Fig 2 Postoperative photography (after four cy-
cles of microabrasion).
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id and by 52% in teeth treated by 37%
phosphoric acid.
Group 2: moderate uorosis
The type of surface defects improved
by 53.3% after treatment with 18% hy-
drochloric acid and an improvement of
55.5% was seen after treatment with 37%
phosphoric acid. The defects changed
from the grooved and pitted type to
the smooth type. The depth of the sur-
face defects reduced by 33.33% after
treatment with 18% hydrochloric acid
and by 50% after treatment with 37%
phosphoric acid. There was no statis-
tically signicant change in the shape of
the surface defects. There was almost a
50% reduction in the total area occupied
by the surface defects in the postopera-
tive samples after treatment with 18%
hydrochloric acid and 37% phosphoric
acid. The remaining area occupied by
the defect was less than .
Group 3: severe uorosis
An improvement of only 22.5% with 18%
hydrochloric acid and 27.27% after ap-
plication of 37% phosphoric acid was
seen in the type of surface defects. The
defects changed from grooved and pit-
ted type to either grooved or pitted
type. A slight reduction in the depth was
seen: 15% with 18% hydrochloric acid
and 23.8% with 37% phosphoric acid.
There was a signicant improvement
in the shape of the surface defects with
the defects changing from discrete and
conuent and conuent to the dis-
crete type. A 34.6% change was seen
with 18% hydrochloric acid and 57.14%
change with 37% phosphoric acid.
The total area affected by the surface
defects reduced by 46% after treatment
with 18% hydrochloric acid and by 56%
after treatment with 37% phosphoric ac-
id. The nal area affected by the defects
was between and of the total tooth
surface. Though the teeth showed sub-
stantial loss of tooth structure, the initial
roughness was improved dramatically.
The performance of both 18% hydro-
chloric acid and 37% phosphoric acid
were comparable in all categories for
improvement of surface defects except
for type of surface defect in Group 2,
which 37% phosphoric acid gave super-
ior results (Figs 4 and 5)
Kappa statistics were run including all
possible combinations of comparisons
between raters. These statistics were
then averaged for inter-rater reliability,
to eliminate inter-operator bias. Kappa
values ranging from (0.24 0.00) were
obtained indicating good agreement
between the observers.
Discussion
Dental uorosis is a condition of enamel
hypomineralization due to the effects of
excessive uoride on ameloblasts during
enamel formation. The main consequence
of dental uorosis is compromised esthet-
ics, from white spots, striations or opaci-
ties on enamel in mild uorosis, to post-
operative dark brown to black staining in
moderate and severe uorosis.
5
The use of chemical agents to re-
move enamel stains is not recent. The
present study was done to compare
the efcacy of 18% hydrochloric acid
and 37% phosphoric acid in removing
uorosis stains since phosphoric acid
is a well-known substance for the dental
practitioners.
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The results of our study showed that
there is a signicant reduction of white
spot opacities, intensity of yellow, brown
and black stain and the total area affect-
ed by the stain in all the three groups.
All the three parameters seemed to im-
prove over the 1-month follow-up period.
This can be attributed to the fact that
enamel microabrasion abrades enamel
surface while compacting calcium and
phosphate into the interprismatic spac-
es. At the crystal surface level, crystal
growth occurs when two or more kink
sites (dened as two or more adjacent
surfaces) are available. A newly etched
enamel surface has proportionately
more kink sites. As the crystal growth
continues, the number of available kink
sites, progressively decreases and the
remineralization process slows. A study
done by Peariasamy et al
6
demonstrat-
ed that etching and pumicing removed
34 4 m of surface enamel but no
mineral loss was observed in the sub-
surface layer. The treatment sequence
enhanced the formation of a new rem-
ineralized layer with a mean thickness
of 22 3 m.
6
This polished surface
reects light differently (abrosion effect)
and appears whiter than normal enam-
el.
7
This is in accordance with various
studies done by Croll.
8
While the exact
reason for the color change that occurs
after microabrasion is not known, the mi-
croabraded surface reects and refracts
light from the tooth surface in such a way
that mild imperfections in the underlying
enamel are camouaged. The acid may
also penetrate and bleach the organic
compounds within the enamel, which
might explain the improvement in tooth
color. Hydration of the tooth by saliva
augments the optical properties of the
altered enamel surface and the applica-
tion of topical uoride further improves
these optical properties.
9
When success is dened as the
production of a normal, unuorosed
Fig 4 Preoperative scanning electron microscop-
ic photography evaluation for teeth treated with mi-
croabrasion procedure in a patient with moderate
uorosis.
Fig 5 Postoperative scanning electron micro-
scopic photography evaluation for teeth treated with
microabrasion procedure in a patient with moderate
uorosis.
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appearance or sufcient reduction in
uorosis so that no further treatment is
needed, the results of this investigation
are most encouraging for patients with
mild uorosis. Moderately stained teeth
improved but continued to demonstrate
white spots and staining, and severely
uorosed teeth showed only slight im-
provement. Similar results were found in
studies done by Loguercio et al
10
and
Train et al.
11
This is because the mild
uorotic lesions as demonstrated by
Thylstrup and Frejeskov
11
lie in the outer
80 -100m of enamel. The action of mi-
croabrasion is based upon the remov-
al of the rst 100 to 200 m of surface
enamel. The moderate and severe uo-
rosis lesions score greater than 4 on the
Thylstrup and Fejerskov index. These
have a pore volume of 10 to 25%, which
is considered too deep to be effectively
treated by microabrasion.
11
Strampe et al
12
reported that pumice
alone removed enamel at the rate of 3m/
min, whereas pumice with 18% hydro-
chloric acid removed enamel at the rate of
88 m/ min. Tong et al
13
reported that only
18% hydrochloric acid removed 100 m
of enamel, whereas 18% hydrochloric
acid + pumice removed up to 360 m of
enamel in the same duration. How much
enamel can be safely removed without the
subsequent need for restoring a tooth?
The rinsed tooth surface should be close-
ly inspected after each application to see
whether the site of the lesion has become
concave. If this has occurred and consid-
erable staining is still present, a bonded
resin composite restoration would be in-
dicated. Otherwise the treatment can be
considered complete once the wet tooth
surface shows no evidence of white spot
decalcication.
14
The ndings of the SEM evaluation
revealed that the degree of uorosis is
a very important predictor for surface
alteration. In mild uorosis, porosity is
found exclusively in the very outer lay-
er of enamel. As the severity of uoro-
sis increases, the pores are present in
the deeper layers; in the most severe
cases, the pore volume of enamel be-
neath the surface can be 25% or more.
In the present study the mildly uorosed
teeth were either unaffected or became
smoother. These ndings are consistent
with the study done by Train et al.
11
In
moderately uorosed teeth the surface
becomes smoother in terms of type of
defect. The defects changed from
the grooved and pitted type to the
smooth type. A decrease in the depth
of the surface defects and reduction of
the total area occupied by surface de-
fects was also observed. In the case of
severely uorosed teeth not much im-
provement was observed in terms of
type and depth of defects. However, the
shape of the defects changed from con-
uent to discrete and the total area af-
fected by the defects reduced by 50%.
The initial surface roughness was dra-
matically improved.
When comparing the two different ac-
ids used in the study, though clinically the
results of 37% phosphoric acid appear
to be superior, the difference in values
is not statistically signicant. The effects
of phosphoric and hydrochloric acid are
similar, suggesting that both can be ef-
caciously used for the microabrasion
procedure. These ndings are consist-
ent with the study done by Cristina et
al.
15
Hydrochloric acid is a very strong
acid that demands careful techniques
for its use to avoid damage on the soft
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tissues. On the other hand, phosphoric
acid could be considered as a safe and
efcient alternative; furthermore it is an
easily found substance in the dental of-
ce.
Most patients in the study tolerated
the treatment well and were pleased
with the results. Though microabrasion
caused noteworthy enamel loss, pa-
tients expressed satisfaction with the
results even though the stain was not
entirely removed, often because the pro-
cedure rendered the stain less notice-
able by blending the boundaries into the
rest of the surfaces.
Conclusion
The major conclusions drawn from the
study are:
The microabrasion procedure is ef-
fective for treating mild and moderate
uorosis cases. The best esthetic re-
sults were obtained in the mild uoro-
sis category.
Treatment of severe uorosis cases
with microabrasion gives an unpre-
dictable outcome and there is a need
for additional interventional treatment
procedures like resin restorations for
esthetic improvement.
Eight to 12 applications of the acid
and pumice mixture, for 5 seconds
application each for mild uorosis and
20 seconds application for moderate
uorosis, split into 2 to 3 appointments
were sufcient to bring about an ap-
preciable esthetic improvement in the
teeth.
The enamel surfaces acquired a
glass-like luster and an exceptionally
smooth texture following the enamel
microabrasion procedure. The results
of the treatment following microabra-
sion are stable and show a continued
improvement over time.
A good improvement in the surface
texture was seen in mild and mod-
erate uorosis cases with the type
of surface defects changing from
grooved to the smooth type. There
was a sufcient reduction in the depth
and the total area occupied by the
surface defects.
In the severe uorosis cases there
was slight improvement in the surface
topography with the type of surface
defects changing from grooved and
pitted to the pitted type. There was
also a reduction in the total area oc-
cupied by the defects. Though there
was a substantial loss of tooth struc-
ture, the initial roughness improved
dramatically.
Both hydrochloric acid and phos-
phoric acid can be effectively used
for microabrasion. Phosphoric acid
can emerge as a safe and easy alter-
native since it is easily available in the
dental ofce.
Patient satisfaction was extremely
high in the study. There was no report
of any gingival ulcerations, postoper-
ative sensitivity or loss of tooth vitality.
Researchs clinical
implications and relevence
to esthetic dentistry
One of the most frequent reasons for
seeking dental care is discolored an-
terior teeth. Microabrasion emerges as
a minimally invasive, economical and
quick in-ofce option for the treatment
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of intrinsic discoloration. Though 18%
hydrochloric acid has typically been ac-
cepted as the gold standard for micro-
abrasion procedures, through this study
we have been able to prove that 37%
phosphoric acid is equally efcacious.
This nding is very benecial since 37%
phosphoric acid is easily available to the
general practitioner in the form of etch-
ant used for composite restorations.