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Year : 2015  |  Volume : 3  |  Issue : 3  |  Page : 83-87

A case report on fluorosed teeth whitening without microabrasion - Is it possible?

Department of Restorative Dentistry, Faculty of Dentistry, Süleyman Demirel University, Isparta, Turkey

Date of Web Publication30-Oct-2015

Correspondence Address:
Prof. R Banu Ermis
Department of Restorative Dentistry, Faculty of Dentistry, Suleyman Demirel University, 32260, Campus, Isparta
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-4619.168730

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Whitening of fluorosis stains ranging from yellow to dark brown presents a great challenge to the dentists. The aim of this study was to report the clinical case of a 32-year-old female patient with moderate fluorosis, who was treated using the combination of light-assisted in-office and at-home whitening system. The in-office whitening was performed using 25% hydrogen peroxide (Zoom DayWhite, Discus Dental, Stamford, USA) for four 15-min sessions with supplemental light (Philips Zoom, Stamford, USA) immediately followed by home whitening with a take-home custom tray using 22% carbamide peroxide (Zoom NiteWhite, Discus Dental, Stamford, USA) worn for 6 h a day for 1 week. Color measurements using a dental spectrophotometer (Spectroshade, MHT Optic Research AG, Niederhasli, Switzerland) after the first week showed that the suggested combination technique provided a fast whitening result with a high degree of patient satisfaction. The in-office whitening with light exhibited to be an efficient method for removing yellow and brown fluorosis stains, while the at-home whitening was useful for obtaining a uniform tooth shade. At the 6-month and 1-year recall, the teeth shade and appearance were evaluated. The results of this case report clearly show an effective esthetic result in the long term; however, the question of whether appropriate color stability would be provided by the technique still remains to be answered.

Keywords: Color stability, dental fluorosis, spectrophotometer, supplementary light, teeth whitening

How to cite this article:
Ermis R B, Ugurlu M. A case report on fluorosed teeth whitening without microabrasion - Is it possible?. J Res Dent 2015;3:83-7

How to cite this URL:
Ermis R B, Ugurlu M. A case report on fluorosed teeth whitening without microabrasion - Is it possible?. J Res Dent [serial online] 2015 [cited 2020 Nov 24];3:83-7. Available from: http://www.jresdent.org/text.asp?2015/3/3/83/168730

  Introduction Top

Dental fluorosis is a specific disturbance in tooth formation, and is defined as a chronic, fluoride-induced condition in which enamel development is deteriorated and the enamel is hypomineralized.[1],[2] Clinically, dental fluorosis is seen as white spots or opaque white lines or the tooth surface may have a white, parchment-like appearance.[3] The brown stains sometimes seen in moderate-to-severe fluorosis are due to the uptake of extrinsic stains, mainly from the diet.[4] At higher concentrations of fluoride, discontiguous or confluent pitting of the enamel surface is seen, accompanied by extrinsic stains.[1] Dental fluorosis is distributed bilaterally, affecting mainly anterior teeth, and the severity varies among the different types of teeth.[2]

The unaesthetic discoloration of dental fluorosis is the most prominent feature, causing various psychological problems.[5],[6] The majority of patients with fluorosis have very mild and mild conditions. Depending on the severity of fluorosis and its clinical appearance, restorative treatments can change the aesthetic appearance of teeth.[4] Fluorosis staining is within the enamel and the enamel discoloration is superficial in case of mild fluorosis. For the moderate and severe fluorosis, enamel staining and mottling can penetrate deeper into enamel levels.[4],[7]

The microabrasion is an effective method for removing yellow-brown discoloration due to mild fluorosis.[2],[8] It has been shown that the combination of the office whitening with microabrasion is a successful method for whitening of the fluorosed teeth.[4] In various studies, it has been mentioned that micro-abrasion before whitening amplifies the aesthetic results as well as simplifies the treatment procedure.[6],[7],[9],[10] It has been reported that the combination of microabrasion and office whitening is more effective than microabrasion alone for the whitening of fluorosed teeth.[11] Successful aesthetic results have also been reported when combined tooth whitening technique (office and home whitening) in addition to microabrasion was applied.[6],[12]

According to the literature, the microabrasion technique usually has been used for the whitening of fluorosed teeth. This study aimed to quantitatively evaluate the clinical efficacy of combined tooth whitening technique (office whitening with supplemental light and home whitening) without microabrasion for the removal of stains caused by dental fluorosis.

  Case Report Top

A 32-year-old female patient was admitted to the Department of Restorative Dentistry of the Süleyman Demirel University with the complaint of discoloration in upper front teeth (tooth number 11-13 and 21-23). History of the patient has revealed the presence of yellowish brown and white patches on the teeth since childhood. Clinical examination showed the presence of yellow and brown patches in maxillary central incisors and white patches on the facial surface of all teeth.

The symmetrical and bilateral pattern of enamel hypomineralization and the presence of a contributory fluoride history suggest a putative diagnosis of dental fluorosis. Fluorosis was recorded using the Thylstrup and Fejerskov index (TFI = 3-4). The etiology is attributed to the early exposure to high concentrations of fluoride ingested from drinking water.

Various treatment options addressing the patient's presenting complaint were discussed with the patient and her husband. These included the use of in-office and take-home tooth whitening systems, enamel micro-abrasion, and composite veneers. The patient and her husband chose the more conservative treatment options of tooth whitening without microabrasion. The physician agreed to use combined tooth whitening technique (office whitening with supplementary light and home whitening) without enamel microabrasion to improve the appearance of the teeth and to stabilize the color of the whitened teeth.

Before the treatment, digital photographs were taken and the pretreatment shade of the teeth was recorded with a dental spectrophotometer (Spectroshade) [Figure 1], [Table 1]. An alginate impression of maxillary arch was taken, and then it was poured with dental stone and was trimmed, and thereby the resultant cast for a custom tray was prepared. A light-cured flowable composite resin was placed (Bright Light Flow, DMP, Markopoulo, Greece) to block out material on the labial surface of the cast, and it was extended 1 mm from the gingival, mesial, and distal margins. A tray was fabricated with a 0.035 inch thick, 5 × 5-inch soft tray material (Philips Zoom EVA Tray Material, Discus Dental, Stamford, Connecticut, USA) was fabricated in a heat/vacuum tray-forming machine. The tray was trimmed in a scalloped pattern to properly fit the model and the patient instructed on the proper use of the upper tray.
Figure 1: Pretreatment appearance of moderate fluorosed teeth with TFI = 3-4

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Table 1: Color parameters (L*a*b, ΔE, Vita shade) of the treated teeth at the time points

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Before starting the in-office whitening technique, the teeth were pumiced and the gingival tissue was isolated using a light-cured resin dam (Liquidam, Discus Dental, Stamford, Connecticut, USA). The 25% hydrogen peroxide gel was applied (Zoom DayWhite, Discus Dental, Stamford, Connecticut, USA) to the maxillary anterior teeth. Visible light irradiation was applied with the light-curing unit (Philips Zoom, Stamford, Connecticut, USA) for 15 min. Then, the gel was removed with gauze and the procedure was repeated three times. Immediately after the treatment, a desensitizing gel (Relief ACP, Discus Dental, Stamford, Connecticut, USA) was applied to the teeth to decrease postoperative sensitivity. After office whitening, digital photographs were taken and the teeth shade was recorded with the spectrophotometer [Figure 2], [Table 1].
Figure 2: Postoperative appearance after office whitening

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The home whitening phase of the treatment was initiated immediately. Fabricated whitening trays were delivered to the patient along with a 22% carbamide peroxide whitening gel (Zoom NiteWhite, Discus Dental, Stamford, Connecticut, USA) to be used for 6 h/day for 1 week. The patient was instructed about the proper use of the tray. After home whitening, digital photographs were taken and the teeth shade was recorded with the spectrophotometer [Figure 3], [Table 1].
Figure 3: Postoperative appearance after 1 week of home whitening

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At 6-month and 1-year recall, teeth were pumiced to remove all superficial debris and digital photographs were taken [Figure 4] and [Figure 5]. The teeth shade and appearance of teeth were evaluated and determined with the spectrophotometer. The Commission International de l'Eclairage color system (CIE L*a*b*) was used to determine the overall color difference (ΔE) as determined by the following equation: ΔE = (ΔL 2+Δa 2+Δb 2).[12],[13],[14]
Figure 4: The 6-month follow-up visit showing effective aesthetic result

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Figure 5: The 1-year follow-up visit showing effective aesthetic result

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At the end of the recalls, the patient was satisfied with the appearance of her teeth and the results of whitening treatment. No gingival problem was present. Although she experienced some degree of tooth sensitivity throughout the treatment, it was not intense enough to discontinue treatment or even use the desensitizing gel provided.

  Discussion Top

For dental fluorosis, a range of treatment strategies has been defined in the literature. The combined treatment approach, including enamel microabrasion and in-office whitening or home whitening technique, is a widely used technique for the treatment of tooth discoloration caused by fluorosis.[15] In recent years, effective aesthetic results have been reported as a result of this treatment approach for the aesthetic management of mild-to-severe fluorosis.[16]

Recently, another combined vital tooth whitening technique, including office whitening and home whitening, is also used for aesthetic management of vital nonfluorosed teeth.[17] According to our knowledge, there is no publication regarding the use of this combined tooth whitening (office whitening with supplementary light and home whitening) technique for the treatment of fluorosed teeth. This case report aims to assess whether this technique is used in the whitening of fluorosed teeth. Furthermore, the goal of the treatment for tooth discoloration is to achieve an acceptable and pleasurable aesthetic result as conservatively as possible. The present study also aims to investigate a noninvasive procedure for fluorosis with no pitting. Therefore, this clinical report described the effectiveness of light activated in-office whitening and home whitening technique without microabrasion for the treatment of fluorosed teeth.

In this study, the teeth shade was recorded with the spectrophotometer at different time points. For each tooth, the color values have been measured with both VITA and CIE L* a* b* color coordinate system that has been computed by using the internal software of the measurement system and the color value was calculated by averaging the L* a* b* and the differences were evaluated using the delta equation.

L* represents the degree of grayness and corresponds to a value of brightness or whiteness of the teeth.[13] In this case, L* values have increased in all teeth after office whitening but then those decreased with time [Table 1]. a* is a parameter in the red-green direction while b* is a parameter in the blue-yellow direction.[13] There has been a reduction in a* values over time [Table 1]. The yellowness value (b*) also decreased for all treated teeth at baseline but at 1 week and 6- and 12-month post-bleaching, the teeth showed an increase of the b* color parameter. The color of teeth did not change after one year according to VITA color parameters [Table 1].

According to Johnston and Kao, color differences are clinically visible to the naked eye in cases with ΔE* exceeding 3.7 units.[18] In this case, the mean color change ΔE* after home whitening has been more than 3.7 units [Table 1]. With this color change, teeth became noticeably white after 1 week. The ΔE* values (1 week-12 months) have been less than 3.7 units in all teeth except for the left canine [Table 1]. There has been a slight color relapse in the left canine after 1 year.

It has been reported that mild and moderate tooth sensitivity can be experienced by the patients during postoperative period of fluorosed teeth whitening.[19] In the current case with fluorosis index TFI 3-4, minimal sensitivity occurred during the office whitening treatment and a desensitizing gel was applied to the teeth immediately after the treatment to decrease postoperative sensitivity. The patient did not experience sensitivity during the recall period.

Since the introduction of in-office whitening treatments, the use of curing lights has been recommended to accelerate the action of the whitening gel.[20],[21] In a recent study, the clinical results have also indicated that light activation affects only the treatment time, and the color stability was not influenced by light after 6 months.[22] In one study, whitening of teeth with nonpitted fluorosis done by light-activated power bleaching demonstrated effective results and low sensitivity in a short time.[23] In this case report, the good shade alterations have also been acquired with the combined technique (light activated in-office and home whitening without microabrasion) in a short time and the color stability was observed after 1 year. However, more evidence is necessary to prove whether light activation is correlated with color stability of whitened fluorosed teeth.

  Conclusion Top

Although color change assessment through the use of VITA shade guide tab revealed no color change over a long period of time; there was a slight return according to spectrophotometric analysis for 1 year [Table 1]. However, it can be concluded that the combined tooth whitening technique (office whitening with supplemental light and home whitening) without microabrasion described in this case report led to effective whitening of the fluorosed teeth (TFI 3-4) and provided aesthetic improvement and patient satisfaction. This technique may be offered as a noninvasive treatment alternative for the nonpitted fluorosed teeth. Nevertheless, longer term follow-up studies with more patients are needed to evaluate the effects of the whitening technique on fluorosed teeth.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1]


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