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An evaluation of a technique to remove stains from teeth using

microabrasion

Article  in  Journal of the American Dental Association (1939) · September 2003

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R E S E A R C H ABSTRACT
Background. Microabrasion using a
paste made of acid and pumice
is a technique that has been A D A
J
used to remove white,
✷ ✷

An evaluation of a yellow and brown stains ®

N
CON
from enamel. The

IO
authors evaluated the
technique to remove

T
T

A
N

I
C
technique by studying the A U I N G E D U
effectiveness of a propri- R 2
TICLE
stains from teeth using etary microabrasion product.
Methods. One author used microabra-

microabrasion sion to remove white, yellow and brown

RICHARD B.T. PRICE, B.D.S., D.D.S., M.S.,
F.D.S. R.C.S. (EDIN.), Ph.D.; ROBERT W. LONEY,
D.M.D., M.S.; M. GORMAN DOYLE, D.D.S., M.S.;
M. BRENT MOULDING, D.M.D., M.S.
number of microabrasion techniques to
stains from within the outermost layer of
the tooth enamel of 32 subjects. Standard-
ized slides of the teeth were taken before
and one week after treatment. Four
prosthodontists evaluated the paired
images, using a standardized questionnaire
and visual analog scales ranging from 1 (no
improvement in appearance or stain not
removed at all) to 7 (exceptional improve-

A improve the appearance of fluorotic teeth ment in appearance or stain totally

have been described.1-23 McCloskey reported
that Kane successfully removed fluorosis
stains by applying acid and heat in 1916.11 In
the 1960s, McInnes12 used a mixture of five parts of 36
percent hydrochloric acid, or HCl; five parts of 30 per-
cent hydrogen peroxide; and one part ether as a topical
treatment. This technique was modified slightly by
Chandra and Chawla22 who applied the solution with
cuttlebone and sandpaper disks in a rotary instrument
in the 1970s. They observed a noticeable
Microabrasion loss in mesiodistal curvature in some
teeth after the procedure. In the 1980s,
using a paste
Myers and Lyon14 reported improvement
containing when they used a calcium sucrose phos-
hydrochloric phate gel to remove tooth stains. Their
acid and procedure involved etching teeth for two
pumice is to three minutes with 37 percent phos-
effective in phoric acid, followed by a pumice abra-
sion with rotary instrumentation of the
removing
surface. They repeated these two steps
stains from the followed by a four-minute application of a
outermost layer mixture of 2 percent sodium fluoride.
of enamel and Next, they applied a 40 percent calcium
improving the sucrose phosphate gel and left it on the
appearance of tooth surface for 30 minutes. If there was
no significant improvement after four
the teeth.
weeks, they repeated the treatment.
Murrin and Barkmeier13 applied 36 per-
cent HCl mixed with pumice to the enamel surface with
a slowly rotating rubber cup for up to five minutes to
removed). The evaluators were calibrated
and blinded.
Results. The evaluators always identified
a difference between the pretreatment
slides and posttreatment slides; they found
no difference between the control slides. In
all cases but one (97 percent), the treated
teeth had improved in appearance with
more uniformity in color. Analysis of vari-
ance revealed no differences between evalu-
ator ratings (P = .146). The intraclass corre-
lation coefficient for ratings of individual
cases by different evaluators was 0.72, rep-
resenting a “good” level of correlation of the
ratings for improvement of appearance and
for stain removal. Mean (± standard devia-
tion) ratings were 5.38 (± 1.26) for improve-
ment of appearance and 5.06 (± 1.26) for
stain removal.
Conclusions. This study showed that
enamel microabrasion could remove stains
from within the outermost layer of tooth
enamel, thereby improving the appearance
of the teeth.
Clinical Implications. This study sup-
ports recommendations that enamel
microabrasion is an effective, atraumatic
method of improving the appearance of
teeth with stains in the outermost layer of
enamel.

1066 JADA, Vol. 134, August 2003

Copyright ©2003 American Dental Association. All rights reserved.

remove stains in the enamel. They then bleached
the teeth with 30 percent hydrogen peroxide and
heat, applied topical fluoride and polished the
teeth.
In 1986, Croll and Cavanaugh2 advocated a
regimen to remove fluorosislike stains from the
teeth that consisted of up to 15 separate five-
second applications of a thick paste made of 18
percent HCl mixed with a fine pumice powder,
followed by 10-second water rinses. They used the
thick paste to stop the acid from spreading over
the teeth and gingivae and to provide a vehicle for
pressure-induced abrasion of the teeth. They iso-
lated the teeth being treated with a rubber dam
sealed cervically with cavity varnish and applied
sodium bicarbonate paste around the isolated
area to help neutralize any acid overflow. They
applied an acid-pumice mixture to the facial sur-
face of each affected tooth with a wooden stick
using a gentle rubbing motion for five seconds
and then rinsed the tooth with water for 10 to 15
seconds and dried it with compressed air. They
repeated this procedure until the stains were
removed and the desired color correction was
achieved. In most cases, they reported that dis-
tinct color improvement occurred by the sixth or
seventh application. If no change was apparent
after 12 to 15 applications, they stopped
microabrasion to avoid excessive enamel loss.
After the final application of the HCl-pumice
paste, they smoothed the tooth surface with a
paste of pumice and water in a rubber cup and
then polished the surface with sandpaper disks.
A 1.1 percent neutral sodium fluoride gel was
then applied for four minutes to aid remineraliza-
tion of the enamel. This technique forms the basis
of the PREMA compound (Premier Dental Prod-
ucts, Plymouth Meeting, Pa.), which was intro-
duced in 1990.
Croll and colleagues3,4,24-33 have described exten-
sively the microabrasion technique using
PREMA, which is an abrasive paste containing
HCl, silicon gel, silicon carbide and silica gel. The
compound is polished onto the surface of the teeth
using hand applicators and rotary mandrels using
a 10:1 gear reduction contra-angle on a standard
slow-speed handpiece.33 Croll and colleagues32
reported that 15 seconds of gingival exposure to
the compound followed by 30 seconds of water
rinsing was harmless. Some gingival soft-tissue
ulceration occurred after 30 seconds of exposure,
but it healed completely in seven days. Conse-
quently, a rubber dam is recommended when
Copyright ©2003 American Dental Association. All rights reserved.
R E S E A R C H
using PREMA to protect the soft tissues.9,24
At the International Symposium on the Non-
Restorative Treatment of Discolored Teeth in
1996, it was concluded that microabrasion was a
safe and effective atraumatic method of removing
superficial enamel defects.34 In 2001, the United
Kingdom National Clinical Guidelines in Paedi-
atric Dentistry recommended the use of micro-
abrasion to treat fluorosis, postorthodontic dem-
ineralization, localized hypoplasia and idiopathic
hypoplasia where the discoloration is limited to
the outer enamel layer.35 Although there have
been numerous case reports,2-5,7,8,11,12,16,19,23,24,26,36-38
there have been only a few trials conducted to
study the effectiveness of enamel microabrasion
to remove stains and most of these trials were
limited in size.1,9,20,39 In 2000, Ashkenazi and
Sarnat39 reported the successful outcome of a two-
and-one-half to four-year follow-up of the
microabrasion technique, but the sample was only
five children.
We conducted a controlled, blinded study to
evaluate the esthetic effectiveness of enamel
microabrasion using PREMA in removing white,
brown or yellow stains from secondary dentition
enamel. We hypothesized that the compound
would effectively remove the fluorosislike stains
from tooth enamel and improve the appearance of
the teeth.
MATERIALS AND METHODS
After the Dalhousie University Ethics Committee,
Halifax, Nova Scotia, Canada, approved the
research project, we placed an advertisement in a
local dental newsletter, inviting dentists to refer
patients who had mild-to-severe enamel stains in
secondary dentition for a microabrasion study.
Dentists referred 32 subjects to Dalhousie Uni-
versity Faculty of Dentistry. We explained the
purpose of the study to the subjects and obtained
their informed consent. The subjects received an
oral examination at no charge, and we assessed
the affected teeth. The exclusion criteria were the
presence of defects in the enamel surface, visible
stains on the lingual and facial surfaces or caries
in teeth that required microabrasion.
One author (R.B.T.P.), who had more than six
years’ experience with enamel microabrasion,
treated all 32 subjects using PREMA as described
by Croll.33 Before treatment, each subject received
a rubber cup prophylaxis to remove any superfi-
cial stain on the teeth. Next, we took standard-
ized pretreatment clinical slides under controlled
JADA, Vol. 134, August 2003 1067
R E S E A R C H

between the pretreatment

slides and the posttreat-
No Exceptional ment slides; they found no
Improvement Improvement difference between the con-
trol slides. In all but one
Mean 5.38 ( 1.26 SD)
subject (97 percent of sub-
1 2 3 4 5 6 7 jects treated), the evalua-
tors found that the treated
A teeth had improved appear-
Totally ance and more uniform
Not at All Removed color. Figure 2 and Figure 3
show representative pre-
Mean 5.06 ( 1.26 SD) and posttreatment images
of the anterior teeth. On a
1 2 3 4 5 6 7
B scale of 1 (no improvement
in appearance or stain not
removed at all) to 7 (excep-
tional improvement in
appearance or stain totally
Figure 1. Visual analog scales. A. Comparing the two views on a scale of 1 to 7 to removed), mean ratings (±
rate the improvement in appearance. B. Comparing the two views on a scale of 1 to
7 to rate the degree of stain removal. SD: Standard deviation. SD) were 5.38 (± 1.26) for
improvement of appearance
lighting conditions on the same day that the and 5.06 (± 1.26) (Figure 1) for stain removal.
treating practitioner treated the teeth with Analysis of variance, or ANOVA, revealed no dif-
microabrasion. We re-evaluated the subjects at ferences between evaluator ratings (P = .146).
least one week after treatment to assess the The intraclass correlation coefficient, or rI, for
results and to take posttreatment slides. We used ratings of individual cases by different evaluators
the same background, camera, flash, ambient was 0.72.
light, exposure and batch of slide film for all of
the slides. DISCUSSION
During an evaluation session, we projected the The 32 subjects in this study were all referred to
32 paired pre- and posttreatment the Dalhousie University Faculty of
slides of the subjects side by side in Dentistry for microabrasion by their
a darkened room with the post- The evaluators dentists. The subjects had mild-to-
treatment view of the treated teeth always identified a severe enamel stains, and they all
projected randomly on either the difference between met the inclusion criteria. The
right or left side. Four calibrated the pretreatment mean ratings (± SD) of 5.38 (± 1.26)
and blinded prosthodontists for improvement of appearance and
slides and the post-
assessed the slides under standard 5.06 (± 1.26) for stain removal on a
viewing conditions using a stan- treatment slides. scale of 1 to 7 indicate that while
dardized questionnaire and visual not all of the stains had been
analog scales, or VAS, with ranges removed, the evaluators thought
of 1 to 7 (Figure 1). We used five pairs of dupli- there had been a significant improvement in
cate slides showing teeth at the same stage of appearance. We accepted the hypothesis that the
treatment and five duplicate pairs of slides microabrasion compound would be able to remove
showing teeth before and after treatment as con- the stains from enamel and improve the appear-
trols to test for intra- and interrater reliability. ance of the teeth. Similar results were reported
We calculated the intraclass correlation coeffi- in a 41-subject clinical trial by Train and col-
cient for ratings of individual cases by different leagues,41 who showed that mildly stained teeth
raters using a two-way random-effects model.40 had the greatest esthetic improvement after
microabrasion using PREMA.
RESULTS In our study, the raters were blinded and cali-
The evaluators always identified a difference brated. We assessed them for intrarater relia-

1068 JADA, Vol. 134, August 2003

Copyright ©2003 American Dental Association. All rights reserved.
 R E S E A R C H

A B
Figure 2. Typical example of pretreatment (A) and posttreatment (B) results showing that white stains were removed
from the incisal third of both central incisors.

A B
Figure 3. A. Pretreatment view of intense white stains covering most of the central incisors. B. Posttreatment results,
showing removal of most of the white stains from both central incisors.

bility by having them unknowingly rate five
paired duplicate slides at the same treatment
stage. All of the raters correctly identified that
there were no differences in these paired identical
images. We also tested intrarater reliability by
having the evaluators rate five pairs of pre- and
posttreatment images twice. Since an rI of 0.6 to
0.74 represents a “good” level of correlation of rat-
ings,40 the rI of 0.72 for individual cases by dif-
ferent evaluators was good.
Not only does microabrasion mask and remove
stained tooth structure, thus improving tooth col-
oration, but the surface layer created during
treatment is a highly polished, densely com-
pacted, mineralized structure.33 While the exact
reason for the color change that occurs after
microabrasion is not known, the microabraded
surface reflects and refracts light from the tooth
surface in such a way that mild imperfections in
the underlying enamel are camouflaged.33 The
acid also may penetrate and bleach the organic
compounds within the enamel,42 which might
explain the improvement in tooth color. Mild sur-
face abrasion of the enamel prisms with simulta-
neous acid erosion compacts mineralized tissue
within the organic region of the enamel, replacing
the outer prism-free region.42 Light reflected off of
and refracted through this new surface is thought
to act differently than light from an untreated
enamel surface.33,42 In addition, subsurface stains
may be camouflaged by the optical properties of
the newly microabraded surface.32 Croll33 has
named this phenomenon the “abrasion effect.”
Hydration of the tooth by saliva augments the
optical properties of this altered enamel surface,33
and the application of topical fluoride further
improves these optical properties.
Using polarized light microscopy, Donly and
colleagues42 examined longitudinal sections of
human incisors after they had received 10
20-second applications of PREMA compound.
They found that after microabrasion the tooth
surface contained a dark area that demonstrated
positive birefringence. After microabrasion paste
compound was applied 20 times, this dark surface
layer appeared even thicker. As might be

JADA, Vol. 134, August 2003 1069

Copyright ©2003 American Dental Association. All rights reserved.
R E S E A R C H
expected after simultaneous abrasion and erosion
with a compound containing HCl, this surface
demonstrated an atypical enamel structure. Part
of this “abroded” surface was washed away
between applications of the microabrasion com-
pound, but a large portion of the abrasive and
mineral byproducts of treatment remained as a
dense, polished surface layer that was more
opaque than the untreated natural enamel.42 This
highly polished enamel surface was not colonized
as rapidly by Streptococcus mutans as were sur-
faces that had not been microabraded.43 There
also is some evidence that the treated enamel
may be more resistant to demineralization.44
Long-term follow-up studies, however, are
required to see if teeth treated with microabra-
sion are more resistant to caries and to see if any
relapse of the staining occurs.
During microabrasion, the teeth should be
properly isolated with a rubber dam, and the
patient should wear eye protection.33 If a
microabrasion paste such as the PREMA com-
pound leaks under the rubber dam, some gingival
ulceration may occur, but the tissues should heal
completely within one week.32 If the teeth are
overtreated with the compound, which can occur
if the enamel is very thin or if the stains are
severe,41 the exposed dentin may become sensi-
tive, and a direct resin-based composite restora-
tion, a porcelain veneer or a crown may be
required.31 The alternative to using enamel
microabrasion to improve the esthetic appearance
of teeth is to place a direct resin-based composite,
a veneer or a crown. Therefore, we support prac-
tice guidelines that recommend microabrasion as
a conservative first treatment of choice for
removing superficial stains in the enamel before
proceeding to a less-conservative treatment.34,35
CONCLUSIONS
We evaluated the effectiveness of a microabrasion
compound to remove white, yellow and brown
stains from the tooth enamel of 32 subjects.
Standardized slides were taken after oral prophy-
laxis but before microabrasion treatment and
again at least one week after treatment. Four
prosthodontists evaluated the paired images
using a standardized questionnaire and VAS,
with ranges from 1 (no improvement in appear-
ance or stain not removed at all) to 7 (exceptional
improvement in appearance or stain totally
removed). The evaluators found that there was a
difference between the pretreatment slides and
1070 JADA, Vol. 134, August 2003
Copyright ©2003 American Dental Association. All rights reserved.
the posttreatment slides; they found no difference
between the control paired slides. In all but one
subject (97 percent), the evaluators found that the
treated teeth had an improved appearance and a
more uniform color. ANOVA revealed no differ-
ences between evaluator ratings (P = .146). The rI
of 0.72 for ratings of individual cases by different
evaluators, represents a good level of correlation
of the ratings for the level of improvement or
degree of stain removal. Mean ratings (± SD)
were 5.38 (± 1.26) for improvement of appearance
and 5.06 (± 1.26) for stain removal.
We believe that the results of this study show
that enamel microabrasion using the PREMA
compound is effective in removing stains from the
outermost layer of enamel and improving the
appearance of the teeth. ■
Dr. Price is a professor, Department of Dental Clinical Sciences, Fac-
ulty of Dentistry, Dalhousie University, 5981 University Ave., Halifax,
Nova Scotia, B3H 3J5, Canada, e-mail “rbprice@dal.ca”. Address
reprint requests to Dr. Price.
Dr. Loney is a professor and the director, Graduate Prosthodontics,
Department of Dental Clinical Sciences, Faculty of Dentistry, Dal-
housie University, Halifax, Nova Scotia, Canada.
Dr. Doyle is an assistant professor, Department of Dental Clinical
Sciences, Faculty of Dentistry, Dalhousie University, Halifax, Nova
Scotia, Canada.
Dr. Moulding is a professor, Department of Restorative and Pros-
thetic Dentistry, University of Saskatchewan, Saskatoon, Canada.
This study was funded by Premier Dental Products (Plymouth
Meeting, Pa.) and the Dalhousie University Alumni Oral Health
Research Fund.
The authors thank Dr. J. Murphy, B.Ed., M.Ed., Ed.D., associate pro-
fessor, Faculty of Dentistry, Dalhousie University, for his assistance
with the statistical analyses and Dr. J. Wilson, B.Sc., D.D.S., M.S., for
participating as one of the evaluators.
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