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Association of enamel microabrasion

and bleaching: A case report
Cristian Higashi, DDS Ariane Lima Dall’Agnol Ronaldo Hirata, DDS, MS
■ ■

Alessandro Dourado Loguercio, DDS, MS, PhD Alessandra Reis, DDS, PhD
■

Enamel microabrasion may be indicated for certain clinical situations,
since it is a proven method for removing superficial intrinsic enamel
discoloration defects such as fluorosis-like stains; in addition, it
is safe, conservative, and easy to perform. However, this method
removes enamel structure, causing teeth to become yellowish. This
yellowing can be treated with enamel microabrasion and bleaching.
This article describes and documents how these two methods were
utilized to correct tooth color for a young patient.
Received: May 31, 2007
Accepted: July 13, 2007

T
he etiology of intrinsic discolor-
ation of enamel may be deter-
mined by the patient’s history;
a high level of fluoride intake (1.0
ppm in drinking water) is one factor
long associated with the problem.1
To treat dental staining, one must
consider the putative cause, color,
darkness, location, and extent of the
stain; the number of teeth affected;
and the age and cooperation level
of the patient. Treatment of stains
will involve removing the stained
enamel, bleaching the stained tooth,
and/or covering the stained area.
Enamel microabrasion can
improve the appearance of teeth
dramatically, provided that the ini-
tial diagnosis of severity falls within
certain parameters. For example,
appearances can be improved when
dealing with questionable to mild
fluorosis stains or slight trauma-
induced white spots.2-4 In 2002,
Wong and Winter demonstrated
that performing the microabrasion
procedure for multi-line or diffused
enamel defects (which could be
considered as moderate or severe
fluorosis) resulted in lower levels of
patient satisfaction.4,5 The success of
microabrasion depends especially on
the type and extent of discoloration.
Microabrasion compounds, a
mixture of hydrochloric acid and
silicone carbide abrasive particles
in a water-soluble gel, are applied
over the stained enamel and rubbed.
The stained outer layer of enamel
is removed by the stripping action
of acid and the abrasive action of
pumice. In some cases, removing
the white enamel spots will give the
teeth a slightly yellowish appearance
due to the yellow dentin shade
showing through the translucent
enamel. In such cases, enamel
microabrasion can be enhanced
by generalized bleaching with
carbamide peroxide or by hydrogen
peroxide bleaching.6-9
Although both microabrasion and
bleaching techniques are designed
to improve tooth appearance, their
modes of action differ. Microabra-
sion removes the affected enamel,
while bleaching involves applying
oxidizing agents that penetrate the
enamel and dentin, resulting in tooth
lightening.10 The majority of con-
temporary studies into tooth whiten-
ing involve either hydrogen peroxide
or carbamide peroxide. The bleach-
ing treatment may be performed in
the dental office by bathing the teeth
with 35% hydrogen peroxide.10,11

Fig. 1. Preoperative views of a patient with mild fluorosis staining. Note the presence of bilateral symmetrical defects in the superior and mandibular teeth.

244 May 2008 Special Issue General Dentistry www.agd.org

 Fig. 3. Gingival tissue is protected by solid
Fig. 2. Left : An example of stains with different depths. The deepest is delimited on the labial/ Vaseline before the rubber dam and clamps
distal region. Right : An LED photocuring unit is used to examine the depth of the white spots. are placed.

Fig. 4. The labial surface of the maxillary teeth after receiving a mixture Fig. 5. The compound is rubbed into the labial surfaces of the teeth for ten
of 12% hydrochloric acid with silicone carbide particles. seconds using a contra-angle handpiece and a silicon carbide abrasive point.

Fig. 6. Treatment progress is evaluated after each application of the Fig. 7. Dry teeth are examined for white enamel spots that do not need
compound. Note that this is done while the teeth are moist. to be removed.

This article documents a case
involving a 19-year old woman
whose appearance was improved
by a microabrasion compound and
the subsequent application of 35%
hydrogen peroxide dental bleach.
Case report
A healthy 19-year-old woman sought
treatment for mild fluorosis staining
(Fig. 1). Her chief complaint was
the esthetics of her smile, which
had been affected by the presence of
white spots. The white staining was
diagnosed as dental fluorosis due to
the fact that the defect was bilaterally
symmetrical. To check the likely
depth of the white spots, anterior
teeth were subjected to transillumi-
nation using an LED photocuring
unit (Bluephase, Ivoclar Vivadent,
Amherst, NY; 800.533.6825) (Fig.
2). The fact that light could pass
through most of the white spots
suggested that they were located
superficially in the enamel.
Gingival tissue was protected
with solid Vaseline (Cheesebrough
Ponds, Englewood Cliffs, NJ;
800.243.5804) before the rubber
dam and clamps were placed (Fig.
3). The subject was given eyeglasses
to protect her eyes; at that point, an
enamel microabrasion compound
consisting of 12% hydrochloride
acid with silicone carbide particles
(Whiteness RM, FGM Dental
Products, Joinville, SC, Brazil;
55.47.3441.6100) was syringed upon
the labial surface of the left and right
premolars, canines, and lateral and
central incisors (Fig. 4). A contra-
angle handpiece fitted with a silicon
carbide abrasive point (Astropol,
Ivoclar Vivadent) and used in slow
rotation (10:1 gear reduction) rubbed
the compound firmly into the labial
surfaces of the teeth (Fig. 5).
Each tooth required approximately
seven rotary applications of ten
seconds each. After each ten-second

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5PPUI
%JTDPMPSBUJPO Enamel microabrasion and bleaching

Fig. 8. Dental polish and diamond paste are applied following the Fig. 9. A 1.23% sodium fluoride foam is applied topically for one minute.
removal of superficial stains.

Fig. 10. Left : The labial surfaces of the mandibular teeth are treated with microabrasion compound and a silicon carbide abrasive point. Right : The teeth
are rinsed with water following the microabrasion procedure.

application, the compound was
rinsed from the tooth surfaces to
assess treatment progress, which
should be done while the teeth
are moist to simulate the natural
appearance of the teeth (Fig. 6). Dry
teeth show white enamel spots (Fig.
7) that usually are camouflaged when
the enamel is saturated with saliva.
Superficial stains were removed
and the teeth were polished using
a 2.0–4.0 µm diamond paste (Dia-
mond Excel, FGM Dental Products)
and a felt disk (Diamond Flex Felts,
FGM Dental Products) (Fig. 8).
Finally, the teeth were saturated
with a sodium fluoride foam (Fluor
Care, FGM Dental Products) for one
minute (Fig. 9). The same procedure
was repeated for the mandibular
teeth (Fig. 10), which required five
rotary applications of ten seconds
each. After finishing procedures
were completed and the fluoride
foam was applied, the rubber dam
was removed (Fig. 11).
At this point, the teeth were sub-
jected to in-office bleaching using
35% hydrogen peroxide. A labial
retractor was inserted at the patient’s
mouth and a 2.0–3.0 mm wide
gingival tissue barrier was placed
along the contour of the free gingiva
to protect the gingival tissues. The
gingival barrier was photocured for
20–30 seconds (Fig. 12). Using the
mixture plate that accompanies the
kit, the peroxide liquid was mixed
with the thickener product, using a
proportion of three drops of perox-
ide for one drop of thickener (Fig.
13), an amount sufficient to cover
two teeth.
With the aid of a brush, the
vestibular surface of the teeth
(including the proximals) was cov-
ered completely with a layer of gel
approximately 0.5 mm thick (Fig.
14). The material was left undis-
turbed for one minute to penetrate
the tooth structure; at that point,
the bleaching gel was activated
using a diode-laser Whitening Lase
II (DMC Equipments, Sao Carlos,
SP, Brazil; 11.4432.0232) consisting
of three infrared diodes of 200 mW
each (wavelength 790–830 nm)
with six high-intensity blue light
emission diodes (350 mW each;
wavelength 467 nm). Each gel
application utilized three cycles of
three minutes each, with an interval
of two minutes between each cycle.
The gel remained on the tooth sur-
face for approximately 16 minutes.
The maxillary arch received three
gel applications while the mandibu-
lar arch received two. All bleached
teeth received Diamond Flex Felts
with diamond paste on the buccal
surfaces (Fig. 16), which was fol-
lowed by a 1.23% fluoride foam

246 May 2008 Special Issue General Dentistry www.agd.org

Fig. 11. The patient after the compound is applied (via ten-second rotary Fig. 12. The gingival barrier is photocured for 20–30 seconds.
applications) to the maxillary and mandibular teeth.

Fig. 13. Hydrogen peroxide and thickener are mixed. Fig. 14. Vestibular surfaces are covered completely with hydrogen
peroxide gel.

applied for one minute (Fig. 17).

Figure 18 shows the results immedi-
ately after treatment for both arches.
Figure 19 demonstrates the efficacy
of the treatment by demonstrating
that an LED light can pass through
the teeth, while Figure 20 shows the
patient’s smile following treatment.
Fig. 15. The bleaching gel is activated with a diode laser.
Discussion
While fluoride can offer consider-
able benefits, it also increases the
risk of dental fluorosis in some
populations.1 Excessive fluoride successfully removed white enamel recting fluorosis and fluorosis-like
use during tooth development can opacities by applying 18% hydro- defects. Extensive experimentation
result in mottled and pitted enamel, chloric acid and pumice for five was performed on extracted human
a condition known as fluorosis. This seconds (using wooden stick teeth by using various acids in dif-
condition usually is associated with pressure), with intermittent water ferent concentrations (combined
increased parental dissatisfaction rinsing between applications.13 with manual abrasive agents and
concerning the overall appearance, However, the inherent danger of certain gel solutions), leading to the
color, and blotchiness of their chil- using a powerful acid in the mouth creation of an enamel microabra-
dren’s teeth.12 has inspired the search for a safer, sion kit (PREMA Compound,
In 1986, Croll and Cavanaugh quicker, and easier method for cor- Premier Dental Products, Plymouth

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5PPUI
%JTDPMPSBUJPO Enamel microabrasion and bleaching
Fig. 16. Dental polishing with a felt disk and
diamond paste after the bleaching procedure.
Fig. 19. The effectiveness of the treatment can
be seen after a transillumination with an LED
photocuring unit.
Meeting, PA; 888.670.6100).3,14
Other microabrasion compounds
are available commercially, includ-
ing the one used in this article.
Previous studies have reported
the success of microabrasion
compounds for removing white
spots.4,15-17 However, the success of
microabrasion (which also can be
measured by patient satisfaction)
depends on a number of factors,
particularly the type and extent
of discoloration. Moderate and
severe fluorosis stains usually do not
respond to microabrasion treatment
as well as stains from very mild and
mild fluorosis.2,4,18
However, it is difficult to predict
when microabrasion will remove
a stain from a tooth completely,
as in the case of incipient enamel
caries around orthodontic brackets
or white spots induced by trauma.
White discolorations often are
improved, although they cannot
always be eliminated completely.
248 May 2008 Special Issue General Dentistry
Fig. 17. Topical application of 1.23% sodium
fluoride foam for one minute.
Fig. 20. The patient at the completion of
treatment.
This inability to predict the
effectiveness of microabrasion
emphasizes the need to diagnose
the depth of enamel involvement
carefully prior to the microabrasion
procedure. Although it is a very
subjective measure of evaluation,
transillumination has been used
extensively for diagnosing approxi-
mal caries lesions and can help clini-
cians to detect the degree of enamel
involvement.19-21 Demineralized
dental tissue presents a lowered
index of light transmission and
appears as a darkened shadow when
transilluminated.19 If light can pass
through the white spot easily or
partially (Fig. 2), the stain is located
superficially and can be removed,
which explains the results from the
present case report.
One disadvantage of the microbra-
sion procedure is that teeth will
have a slightly darker color once the
bright white spots are removed. As
the enamel thickness decreases, the
www.agd.org
Fig. 18. The patient immediately after
treatment of both arches.
dentin color begins to dominate
anterior tooth shade. ten Bosch and
Coops used a spectrophotometer
to measure tooth color and demon-
strated in vitro that such thinning
contributed to an increase in yellow-
ing; in addition, redness increased
at the incisal site because of occlusal
wear loss in the incisor region.22-24
Bleaching is mandatory in some cases
to eliminate the yellowing that occurs
to microabraded teeth, particularly
when treating fluorosis stains.
There are two fundamental
bleaching approaches: dentist-
supervised nightguard bleaching and
in-office/power bleaching.25,26 Typi-
cally, nightguard bleaching applies
a relatively low level of whitening
agent to the teeth via a custom-fab-
ricated mouthguard, which is worn
each night for at least two weeks.27
In-office bleaching generally uses
relatively high levels of whitening
agents (such as products containing
25–35% hydrogen peroxide) for
shorter time periods. The whitening
gel is applied to the teeth after the
soft tissues are protected and the
peroxide may be activated further
by heat or light.25,27
Two key factors determine the
overall efficacy of products contain-
ing peroxide: the concentration of
the peroxide and the length of appli-
cation. For example, Sulieman et al
compared the in vitro tooth bleach-
ing efficacy of gels with 5–35%
hydrogen peroxide and found that
higher concentrations required
fewer applications to produce uni-
form bleaching.28 This means that
while both in-office and nightguard
bleaching are clinically effective for
whitening teeth, in-office bleaching
is more practical and predictable.29,30
As a result, the present case report
employed a 35% hydrogen peroxide
gel for the in-office bleaching.
Contemporary approaches have
focused on accelerating peroxide
bleaching by illuminating the teeth
simultaneously with various light
sources, such as halogen curing
lights, plasma arc lamps, lasers, and
LEDs.31,32 The heat provided by
various light sources can accelerate
the chemical reactions of peroxide
during the bleaching process.
A recent review of the literature
revealed that in vitro and clinical
studies concerning the actual effect
of light on tooth bleaching versus a
suitable non-light control are limited
and controversial.10 Taveras et al
reported that light used with the
bleaching product was more effective
than the bleaching gel alone, but
not all studies have reached similar
conclusions.33,34 Additional research
is required to demonstrate unequivo-
cally the additional efficacy benefit
of light-activated tooth whitening
systems versus their non-light-
activated controls.
Summary
The use of a minimally invasive
technique to treat teeth with
enamel fluorosis allows the dentist
to re-establish the patient’s natural
smile. This approach has many
advantages but an extremely conser-
vative approach is more likely to be
accepted by patients. Microabrasion
and bleaching procedures can be
considered for removing superficial
intrinsic enamel defects such as
those caused by fluorosis.
Author information
Dr. Higashi is a private clinician
and graduate student, Department
of Operative Dentistry, University
Estadual de Ponta Grossa, PR–Brazil,
where Drs. Loguerico and Reis are
adjunct professors. Ms. Dall’Agnol
is an undergraduate student, Univer-
sity de Passo Fundo, RS–Brazil. Dr.
Hirata is a private clinician and PhD
student, Department of Operative
Dentistry, University Federal do Rio
de Janeiro, RJ–Brazil.
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