CLINICAL REPORT

Esthetic management of white spot lesions by using minimal

intervention techniques of bleaching and resin infiltration: A
clinical report
Benjamin W. Alverson, DMD,a Kim L. Capehart, DDS, MBA, PhD,b Courtney S. Babb, DMD,c and
Mario F. Romero, DDSd

Esthetics in dentistry is sub- ABSTRACT

jective, as color, imperfections,
Dental fluorosis and hypocalcification manifest as white spot lesions and/or brown discolorations.
and other perceived flaws can With dental fluorosis, mottled layers in enamel can also be present depending on severity.
be noticed by the dentist and Treatment options have varied in such situations, depending on severity, and can range from
unseen by the patient.1 How- conservative to more invasive. This clinical report focuses on a combination of bleaching and
ever, when patients are both- resin infiltration as one of the more conservative treatment options. (J Prosthet Dent 2020;-:---)
ered by something they
perceive as unesthetic, such as white spots on their teeth, the severity of the fluorosis.7,8 Patients seeking treatment
the question of treatment options arises. While treatment for dental fluorosis are often young, which makes
options ranging from conservative to invasive are avail- expensive and time-consuming invasive treatments un-
able, the etiology of the problem and the wishes of the desirable.9,10 For patients with mild-to-moderate fluo-
patient must be taken into consideration. rosis, microabrasion is a treatment option in which a
Dental fluorosis occurs because of excessive fluoride slurry of pumice and hydrochloric acid (HCl) is used to
intake and its effect on ameloblasts during enamel for- microerode the enamel surface and improve its appear-
mation. A subsurface hypomineralization defect is ance. A more contemporary treatment alternative is resin
formed, giving the enamel a white, chalky appearance infiltration, in which a higher concentration of HCl is
that can sometimes have a rough, brown stain in more used to remove the WSLs through selective etching,
severe situations. Other than affecting esthetics, fluorosis followed by infiltrating and sealing the subsurface defects
does not largely compromise the tooth.2 The extent of with an unfilled resin, impregnated with capillary ac-
affected enamel can be classified using Horowitz Tooth tion.11 This clinical report presents how a combined
3
Surface Index of Fluorosis (TSIF). (Table 1). Fluorosis in bleaching and resin infiltration protocol was used to treat
maxillary central incisors typically occurs if there was an a patient with mild fluorosis to improve the patient’s
interruption of the ameloblasts between 15 and 30 smile while preserving intact enamel.
months and between 3.5 and 6.5 years for maxillary ca-
nines.1,4,5 Treatments to improve the appearance of
white spot lesions (WSLs) range from vital bleaching, CLINICAL REPORT
microabrasion, direct composite resin restorations, por- A 25-year-old white woman presented to The Dental
celain veneers, and complete coverage crowns.6 The College of Georgia’s Department of General Dentistry for
choice among the types of treatment usually depends on a comprehensive examination. Her chief complaint was

a
Private practice, Waynesboro, Ga.
b
Assistant Professor, Department of General Dentistry, Dental College of Georgia at Augusta University, Augusta, Ga.
c
Instructor, Department of General Dentistry, Dental College of Georgia at Augusta University, Augusta, Ga.
d
Associate Professor, Department of Restorative Sciences, Dental College of Georgia at Augusta University, Augusta, Ga.

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Table 1. Tooth surface index of fluorosis (TSIF) (Horowitz et al, 19843)

Score Description
0 Enamel shows no evidence of fluorosis.
1 Enamel shows definite evidence of fluorosis with parchment-white color
on less than 1/3 of visible surface and confined only to incisional edges of
anterior teeth and cusp tips of posterior teeth.
2 Parchment-white fluorosis totals more than one-third but less than two-
thirds of surface.
3 Parchment-white fluorosis totals at least two-thirds of surface.
4 Enamel shows staining in conjunction with any of the preceding levels of
fluorosis. Staining is defined as an area of definite discoloration that may
range from light to very dark brown.
5 Discrete pitting of the enamel exists, unaccompanied by evidence of
staining of intact enamel. A pit is defined as definite physical defects in Figure 1. Before treatment. Chalky, opaque white spots on two-thirds of
the enamel surface with a rough floor that is surrounded by a wall of the enamel surface led to diagnosis of dental fluorosis with TSIF=3. TSIF,
intact enamel. The pitted area is usually stained or different in color from
the surrounding enamel. Tooth surface index of fluorosis.
6 Both discrete pitting and staining of the intact enamel exist.
7 Confluent pitting of the enamel surface exists. A large area of the enamel DMG America) was then applied on the WSLs for 2
may be missing and the anatomy of the tooth may be irregular. Dark
brown stain is usually present. minutes by using a scrubbing motion followed by a 30-
second rinse with water spray. To remove water
remaining in the microporosities in enamel, a drying
agent (Icon-Dry; DMG America) was applied for 30
“I would like to have these white spots removed.” She
seconds followed by air-drying. If any WSLs still
did not like the WSLs present on the maxillary central
remained, selective etching was repeated until the WSLs
incisors and canines because she felt they were promi-
were not visible. Once the etching step was completed,
nent in her smile (Fig. 1). She reported growing up in
the resin (Icon-Infiltrate; DMG America) was applied by
Boone, North Carolina, where her family consumed well
a rubbing motion for 3 minutes. Excess was removed
water and drank coffee on a regular basis, contributing to
with a microbrush and light polymerized for 40 seconds.
the staining. An esthetic analysis revealed an average
A second application was applied using the protocol as
smile line,12 correct axial inclination of the maxillary
recommended by the manufacturer to reduce enamel
anterior teeth, and a healthy thin periodontal biotype
porosity and light polymerized. Polishing was completed
with scalloped gingival tissue and long interdental
with medium and fine abrasive disks (Sof-Lex; 3M) until
papillae. She has a class I molar occlusal relationship
the surface had an appropriate luster. An improvement in
bilaterally with a vertical and horizontal overlap of 2 mm
the esthetic appearance could be seen immediately and
that contributed to the reduction of enamel mamelons on
at a 1-month follow-up (Fig. 3) with no relapse noted.
all incisors. Oral hygiene was excellent, and minor
One month after resin infiltration was completed, the
restorative work had been completed after orthodontic
existing composite resin restorations were removed and
treatment to increase the width of the maxillary lateral
replaced (Harmonize; Kerr Corp) (Fig. 4). Figure 5 shows
incisors. Radiographically, all teeth displayed a uniform
her smile before and after treatment.
periodontal ligament space and intact laminae dura. The
opacity, texture, and extension of the WSLs led to the
DISCUSSION
diagnosis of dental fluorosis with a TSIF score of 3.3
Restorative and nonrestorative options were pre- This report demonstrated the efficacy of a minimally
sented and discussed with her. A minimally invasive invasive protocol that produced a good esthetic outcome
treatment that combined bleaching, resin infiltration, and while preserving tooth structure. Successful treatment
replacement of the composite resin restorations on the required an accurate diagnosing of the surface extension
maxillary lateral incisors was selected. The teeth were of the lesions, for which several fluorosis indices have
first bleached with 10% carbamide peroxide (Opales- been developed. For this patient, the TSIF was used,3 but
cence PF; Ultradent Products, Inc) in a night guard others available include the Dean classification and the
bleaching tray every night for 3 months, followed by Thylstrup and Fejerskov scale.1 Limitations of these
cessation of treatment for 15 days for color stabilization classifications include that they provide little indication of
and to allow time to restore bond strength.13 The prog- the depth of the WSLs, which is crucial when it comes to
ress of the color change was monitored and recorded resin infiltration because the lesions need irradicated by
(Fig. 2). etching.
She was now ready for resin infiltration (Icon; DMG The invasive procedures of periodontal surgery to
America). Under dental dam isolation, the teeth were improve zenith location in the esthetic zone and veneers
cleaned thoroughly with prophylaxis paste (Nupro; on the maxillary incisors were considered but deemed to
Dentsply), rinsed, and air-dried. The etchant (Icon-Etch; be unnecessary given the patient’s age and chief

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Figure 2. Tooth color change with bleaching. A, 1 month. B, 2 months. C, 3 months. D, 15 days after completion of bleaching
Figure 3. Resin Infiltration. A, Immediately after the treatment. B, After 1
month.
complaint. Another option considered was micro-
abrasion,1 although if not performed properly, it can lead
to hypersensitivity. The resin infiltration protocol only
erodes 30 to 40 mm of enamel per 120 second etch
compared with around 300 mm with microabrasion.1 In
addition, the application of HCl with the resin infiltration
system appears more controllable compared with the
slurry paste with microabrasion.
The clinical steps with the system used were intuitive
and having the patient bleach over 3 months helped
Alverson et al
3
Figure 4. Teeth after restoring with Kerr Harmonize “B1”
minimize the amount of tooth surface area that required
etching by making the fluorosed areas more noticeable
and thus making the procedure more conservative and
less time consuming. The only deviation from manufac-
turer’s recommendations were the number of etching
cycles. From clinical reports and the author’s experience,
white spots typically persist and are not fully removed
after only 2 etch cycles. They are also prone to relapse
after treatment.1,9 Fluorosed lesions act differently than
carious lesions in that the hypomineralized zone is much
deeper and erosion must be performed to reach this zone
to ensure success with infiltration.1,6 While most white
spots were removed after 3 etchant cycles of 120 seconds,
some persisted. Persisting WSLs were reetched for 30
second cycles until the application of the drying agent led
to a uniform enamel color, which took 20 cycles for 1
location. The resin infiltrant was applied twice as rec-
ommended by the manufacturer to reduce subsurface
defects that are expected after acid etching and to
enhance the esthetic outcome.
Future studies could include an in-depth look at the
efficacies of HCl penetration into fluorosed teeth at
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Figure 5. Smile views. A, Before treatment. B, After treatment.
varying TSIF diagnoses to determine etching requirement
to reach depth of hypomineralized area, as it is suggested
to be why relapse can sometimes occur.3,6 While little
evidence suggests etching to the extent that was per-
formed in some spots on this patient, it was determined
that a total reduction of 30% of the enamel layer is
clinically acceptable.14
SUMMARY
In this patient with WSLs due to fluorosis, no relapse
occurred 8 months after treatment. With the combination
of bleaching and resin infiltration, the patient was fully
satisfied with the results.
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Corresponding author:
Dr Mario F. Romero
Department of Restorative Sciences
Dental College of Georgia at Augusta University
1120 15th St, GC-4265
Augusta, GA, 30912
Email: maromero@augusta.edu
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.08.010
Alverson et al