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Q U I N T E S S E N C E I N T E R N AT I O N A L

A minimally invasive treatment of severe dental

fluorosis
Stefano Ardu, Dr Med Dent1/Minos Stavridakis, Dr Med Dent2/
Ivo Krejci, Prof Dr Med Dent3

This article describes a minimally invasive technique to treat a severe case of enamel fluo-
rosis using microabrasion to eliminate the hypermineralized, white-colored, superficial
enamel layer, followed by home bleaching treatment and chairside re-creation of superfi-
cial enamel microstructure. The proposed technique may improve the esthetics of fluorotic
teeth without requiring other restorative procedures. Microabrasion followed by home
bleaching may be an interesting alternative for the restorative treatment of teeth affected
by fluorosis. (Quintessence Int 2007;38:455–458)

Key words: fluorosis, microabrasion, micromorphology, minimally invasive treatment

Fluorosis is a dental disease that affects 2.1%
to 74.7% of the population.1,2 Already in the
1940s, Dean et al were able to show a strong
relation between fluoride concentration in
drinking water and the prevalence and severity
of fluorosis.1,2 Based on the severity of enamel
damage, a classification of 10 degrees of fluo-
rosis has been proposed.3 The scores range
from 0, where the glossy creamy-white enamel
is visible only after drying of the tooth, to 9,
where the major part of the enamel is lost and
a change in the shape of the tooth has
occurred.
Clinicians faced with this problem have
different treatment options. Teeth discolored
by fluorosis may be managed by bleaching,
microabrasion, veneering, or artificial
crowns. The choice between these treat-
ments depends on the severity of the dis-
ease4; however, in more severe cases the
proposed treatment option is often invasive.
The problem with invasive treatments is that
most patients demanding treatment for fluo-
rosis are young adults with a life expectancy
of many decades and the use of invasive pro-
cedures in the form of a prosthetic approach
with veneers or crowns results in an exces-
sive sacrifice of tooth material, thus acceler-
ating the destruction of the tooth at an early
age. Furthermore, a restorative approach is
time consuming and relatively expensive.
The aim of this article is to describe—and
illustrate with a case report—a minimally inva-
sive technique that improves the esthetic
aspect of teeth with severe enamel fluorosis
without requiring restorative techniques.
CLINICAL PROCEDURE

The proposed minimally invasive technique is

based on a combined approach of micro-
1
Lecturer, Division of Cariology and Endodontology, Dental
abrasion,5 home bleaching,6,7 and enamel
School, University of Geneva, Geneva, Switzerland. reshaping. Once enamel fluorosis is diag-
2Lecturer, Department of Operative Dentistry, School of nosed (Figs 1a and 1b) by case history and
Dentistry, University of Athens, Athens, Greece. clinical examination, oral hygiene instruction
3Professor and Chairman, Division of Cariology and followed by scaling and polishing is per-
Endodontology, Dental School, University of Geneva, Geneva,
formed, whenever necessary. During the
Switzerland.
microabrasion treatment, the patient’s and cli-
Reprint requests: Dr Stefano Ardu, Ecole de Medecine Dentaire,
rue Barthélemy-Menn 19, 1205 Geneva, Switzerland. E-mail:
nicians’ eyes are protected from accidental
stefano.ardu@medecine.unige.ch spills by protective glasses.

VOLUME 38 • NUMBER 6 • JUNE 2007 455

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Q U I N T E S S E N C E I N T E R N AT I O N A L
Ardu et al

Figs 1a and 1b Views of a patient with severe enamel fluorosis.

Fig 1c Microabrasion procedure under rubber dam protection.

Fig 1d Chairside fluoride gel application following microabrasion procedures.

Fig 1e View after microabrasion and 2 weeks of home bleaching with 10% carbamide peroxide.
Note the rough aspect of the surface and the absence of enamel micromorphology.

Figs 1f and 1g Enamel reshaping to recreate micromorphology.

Figs 1h to 1j Posttreatment appearance.

456 VOLUME 38 • NUMBER 6 • JUNE 2007

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Ardu.qxd 6/4/07 11:04 AM Page 457
After rubber dam application, microabra-
sion is performed with an abrasive paste con-
taining silicon carbide microparticles in
water-soluble paste and 6.6% hydrochloric
acid (Opalustre Ultradent). For this purpose,
a layer of about 2 to 3 mm is applied on the
affected teeth (Fig 1c) using a specific rubber
cup (Oralcups, Opalustre Ultradent) attached
to a gear-reduction contra-angle handpiece.
The tooth surface is microabraded with slight
pressure for 60 to 120 seconds. Whenever
necessary, a small water drop can be added
and the abrasion can be repeated.
Several applications may be necessary, as
in this case, where 2 applications were per-
formed. In such a case, after each applica-
tion, an optical evaluation must be done after
water rinse, before proceeding to the next
application.
A casein phosphopeptide–amorphous
calcium phosphate (CPP-ACP) paste (GC
Tooth Mousse, Recaldent, GC Europe) or a
fluoride gel (Binaca Natrium Fluor Gelée,
ESRO) is then applied on the treated enamel
surface (Fig 1d), left undisturbed for 5 to 15
minutes, and finally suctioned by the aspira-
tion device but not water sprayed. Because
of the dehydration of the teeth, optical evalu-
ation of the treatment must be done at the
following appointment, and, if necessary, the
treatment may be repeated.
A home bleaching technique eventually
follows to better harmonize tooth color (Fig
1e), as does enamel-surface reshaping with
fine diamonds and silicon points (Figs 1f and
1g) to recreate a natural-looking macro- and
microstructure of the surface (Figs 1h to 1j).
DISCUSSION
The prevalence of enamel fluorosis is increas-
ing worldwide because of excessive exposure
to fluoride within the first years of life.8–10 A crit-
ical period has been identified at which teeth
are most at risk of fluorosis: 21 to 30 months
of age for females and 15 to 24 months of age
for males.8 The mechanisms responsible for
enamel fluorosis have been investigated by
several authors. Similar theories, with slight
differences among them, have been pro-
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Q U I N T E S S E N C E I N T E R N AT I O N A L
Ardu et al
posed. It is generally accepted that the char-
acteristic opacity of fluorotic enamel results
from incomplete apatite crystal growth. Matrix
proteins, which are associated with the miner-
al phase and permit a correct crystal growth,
normally degrade and disappear during the
enamel maturation phase. In fluorotic enamel,
they are not eliminated, resulting in their reten-
tion in the enamel tissue. Fluoride and mag-
nesium concentrations increase, while the
carbonate level is reduced. Crystal surface
morphology is slightly altered. Such changes
in crystal chemistry and morphology, involv-
ing stronger ionic and hydrogen bonds, also
lead to greater binding of modulating matrix
proteins and proteolytic enzymes. This results
in reduced degradation and enhanced reten-
tion of protein components in mature tissue.
This is most likely responsible for porous fluo-
rotic tissue, since complete matrix protein
removal is necessary for “healthy” crystal
growth.11 In other words, fluorotic enamel is
characterized by retention of amelogenins in
the early maturation stage of development
and a consequent formation of a more
porous enamel with a subsurface hypomin-
eralization.12
In the proposed technique we suggest the
use of microabrasion to remove the unes-
thetic whitish enamel under rubber dam pro-
tection followed by application of a fluoride
solution or CPP-ACP paste for 5 to 15 min-
utes. This approach is justified for 2 reasons:
First, it reduces the risk of posttreatment sen-
sibility, and second, it protects teeth from
possible external demineralization. In Segura
et al’s experience,13 in fact, teeth treated with
microabrasion followed by a 4-minute appli-
cation of 1% neutral topical sodium fluoride
exhibited significantly less enamel deminer-
alization when subjected to an artificial caries
challenge than did teeth that underwent
microabrasion alone, topical fluoride treat-
ment alone, or no treatment at all.
After completion of microabrasion, a
home bleaching technique follows to better
harmonize tooth color and produce whiter
teeth, which is most often the patient’s main
objective. The home bleaching technique
can produce satisfactory esthetic improve-
ment, thus eliminating the need for direct or
indirect veneering.
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Ardu et al
One problem the clinician may face after
microabrasion is that, especially if multiple
applications are performed in 1 session or if
multiple microabrasion sessions are needed,
because of the abrasive action of the rubber
cup with the abrasive paste, the macro- and
microstructure of the buccal surface of the
teeth is sometimes lost. As a result, the teeth
show an unnaturally smooth appearance,
which is not representative of the micromor-
phology of teeth of young patients, who most
often seek treatment for enamel fluorosis.
For this reason, after the completion of the
home bleaching, a surface reshaping with
fine diamonds and silicon points is often nec-
essary to recreate a natural-looking macro-
and microstructure of the surface and to
achieve an optimal result.
CONCLUSIONS
The use of the proposed minimally invasive
technique to treat teeth with enamel fluorosis
allows for recovering of a natural tooth
appearance, dramatically decreasing the
unhealthy whitish enamel aspect. This kind
of approach has the advantages of being
extremely conservative and very well accept-
ed by the patients. Furthermore, no special
maintenance precautions are required; thus
it may be considered an interesting alterna-
tive to conventional, more aggressive opera-
tive intervention.
458
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