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Dental fluorosis is a common disease in punjab(india).it is due to an
unusually high dose of fluorides during odontogenesis causing a structural
modification of hard dental tissues and thereby resulting in a
hypomineralisation of these tissues.fluorotic enamel is a hypocalcified,
porous,brittle and most unaesthetic tissue. Bleaching has been suggested by
several authors in order to treat the unaesthetic aspect of dental fluorosis,
but many results are however unsatisfactory. This is a novel method which is
based on the structural characteristics of the fluorotic ename & organic and
exogenous nature of fluorotic enamel stains which includes four different
stages:-
1) Cleansing the enamel surface with pumice 2) Enamel etching with
hydrochloric acid 3) application of sodium hypochlorite. 4) application of
dental adhesives.
Introduction
A frequent question asked by most of patients residing in the fluorotic belt
of punjab (india) is "will my tooth turn white?" Usually the answer is
a "yes" with the explanation that the modern dental treatment
procedures are such as to esthetically synchronise the facial harmony of tooth
structure.the reason for this discoloration is a high fluoride concentration in
water in certain areas of punjab. the normal colour of permanent teeth is
greyish yellow, greyish white or yellowish white but the number of people with
this colour are usually limited owing to over aggressive tooth brushing and
abrasive cleansing materials, acidic food and drinks and last but not the
least,ageing. The elderly people thus, have more yellowish teeth as compared to
younger persons.these alterations in colour maybe physiologic or pathologic and
endogenous or exogenous in nature. the modern era is an era of esthetics. People
having teeth with normal colour also want to have whiter teeth to improve their
smile. So one cannot ignore the wishes of such patients and hence bleaching, as
we know, has emerged as the simplest, most common, least invasive and least
expensive means available to dentists to lighten discoloration.
History
Many agents have been used in the past and a number of new methods have
continued to be introduced. It was oxalic acid first by chappel in 1877 which
was followed by various forms of chlorine, until hydrogen peroxide was first
used by harlan in 1884. Many advances continued focussing basically on the ways
to facilitate the absorption of bleaching agent. The recent developments of
hi-tech computer imaging have enhanced patient understanding, expectation and
ultimately satisfaction.
Mode of action
Bleaching works by oxidation in which the bleaching agent enters the enamel
&/or dentin of the discolored tooth and reduces the molecules containing
discoloration. The bleaching depth depends on the cause of the stains and where
and how deep the stain has permeated the tooth structure plus how deep the
bleaching agent can permeate to the source of discoloration and remain there
long enough to release deep stains.
Etiology of tooth discoloration
Extrinsic discolorations are found on outer surface of teeth and are usually
Of local origin e.g. Tobacco, paan, tea, coffee, silver nitrate stains, oral
intake of iron suspensions, continuous use of mouth washes and gum paint.
Intrinsic the stains are found within the enamel and dentin and are caused by
The deposition of the substances within these structures e.g. Tetracycline,
Fluorosis stains, amelogenesis imperfecta, dentinogenesis imperfecta, pulp
necrosis etc.
Histopathology
fluorosed teeth are also called mottled teeth . Such teeth appear when child
ingests excessive fluoride during enamel formation or calcification in areas
where drinking water contains more than 1ppm of Fluoride. The higher
concentration of fluoride is believed to cause a metabolic alteration in the
ameloblasts which results in defective matrix & improper calcification. 1ppm
of fluoride has no biological side effects on The vital organs of human body
i.e. Kidney, heart & lungs. Fluoride up to 4ppm in drinking water
occasionally produces skeletal fluorosis but above 8ppm coupled with
malnutrition positively causes not only skeletal fluorosis but irreversible bone
changes & deformity as well.
Histology
histological examination shows hypomineralised, porous sub-surface enamel
below a well mineralised surface layer. The most affected teeth (in decreasing
order) are premolars, 2ndmolars, followed by maxillary incisors, canines &
1st molars. Mandibular incisors are affected least.
Stages of fluorosis
the appearance of teeth depends upon the severity of the lesion which in turn
depends upon the fluoride contents consumed by a particular individual through
the water supply.
1) the constant use of water having fluoride to the extent of 1ppm causes
mildest grade of mottling in 10% of the population.
2) as concentration of fluoride increases, the effect worsens, so much so
that when the concentration reaches 6ppm,incidence of mottling is 100%.
3) very mild :- in this type there are very small white areas occasionally
seen on the tooth surfaces, but do not involve more than 25% of tooth surfaces.
(4) mild :- in this type there is more extensive tooth involvement and
involves 50% of tooth surfaces.
(5) moderate :- more surfaces are involved here and are subjected to
attrition. They show marked wear with yellow or brown pigmentation.
(6) severe :- all enamel surfaces are involved, so much so that the tooth mor
phology is affected.there is discrete or confluent pitting of enamel surfaces.
Brown stains are widespread & the tooth often presents a corroded surface.
Optimum fluoride levels
In cold climate, recommended fluoride levels may be as high as 1.2 ppm
whereas in extremely hot climate, a level of 0.7 ppm is recommended. In moderate
climate, the optimum fluoride level is 1 ppm. High temperature causes increase
in mottling because there is increased consumption of water containing fluoride.
Distribution of mottling in various areas of teeth has no relation with periods
of mineralisation of crown. Teeth are only affected provided the child lives in
the area of fluorosis during the time of enamel mineralisation. Brown tooth
stains respond to treatment but white stains are not effectively resolved. It
has been observed that teeth in process of eruption receive maximum benefit from
optimum amount of fluoride plus teeth exposed to f shortly after eruption were
also protected although to a lesser degree.
Different f levels in punjab & other states of india
I) Punjab
1) bhatinda - 4.5 ppm
2) mansa - 4.2 ppm
3) mukatsar - 3.3 ppm
4) faridkot - 3 ppm
5) ferozepur - 2.6 ppm
6) moga - 2 ppm
7) sangrur - 1.35 ppm
8) jalandhar - 0.55 ppm
9) amritsar - 0.45 ppm
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10) hoshiarpur - 0.44 ppm
11) nawanshahar - 0.4 ppm
12) fatehgarh sahib - 0.37 ppm
13) patiala - 0.35 ppm
14) ropar - 0.3 ppm
15) kapurthala - 0.25 ppm
16) ludhiana - 0.22 ppm
17) gurdaspur - 0.15 ppm
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II) Andhra Pradesh
1) nalgonda - 20.6ppm
2)prakasan - 12.0ppm
3)vishakhapatnam - 11.0ppm
4) anantpur - 10.1ppm
5)guntar - 10 ppm
6)medak - 9.8ppm
7)kunoor - 9.6ppm
8)nellore - 8 ppm
9)mehboobnagar - 6.4 ppm
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10)warrangal - 5.8 ppm
11) kareemnagar - 4.9 ppm
12) hyderabad - 4.8ppm
13) cuddapah - 4.6ppm
14) nizamabad - 3.0ppm
15) chittoor - 2.9 ppm
16) adkabab - 2.8 ppm
17) srikakalam - 2.8 ppm
18) Godavari - 1.6 ppm
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III) Gujarat
1) kutch - 1.2 -- 11 ppm
2) bhavnagar - 1.5 - 4ppm
3) jamnagar - 1.5 - 4ppm
4) rajkot - 2.5ppm
5) saurashtra - 1.5 - 2.5 ppm
6) rajpur - 0 - 2.5 ppm
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7) banakanta - 1.5 - 2ppm
8) godar - 1.6 - 1.7ppm
9) godhra - 0 - 1.6 ppm
10) surinderanagar - 0 - 1.5 ppm
11) surat - 0 - 1.3 ppm
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IV) Tamil Nadu
1) Coimbatore 2) Dharampur 3) Madurai 4) Narkot 5) Salem 6) Trichi
all 1.5 --- 5ppm
V) Kerala
1) Allepey 2) Eranakulam 3) Quillon 4) Trichur
all 0 -- 1.5 ppm
V) Rajasthan
1) Bharatpur - 28ppm
2) Tonk - 21ppm
3) Alwar - 20.6ppm
4) Sikar - 19.1ppm
5) Ajmer - 18.4ppm
6) Bhilwara - 16.5ppm
7) Swaimadhopur - 16.1ppm
8) Jhalawar - 16ppm
9) Churu - 16ppm
10) Jodhpur -16ppm
11) Sirohi - 15.8ppm
12) Jaipur - 15ppm
13) Nalpur - 14.2ppm
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14) kota - 14.2ppm
15) dungarpur - 12ppm
16) bikaner - 10.2ppm
17) barmer - 10ppm
18) pali -- 9.1ppm
19) ganganagar - 9ppm
20) jalour -- 8ppm
21) wagpur - 7.1ppm
22) chittorgarh - 6ppm
23) bundi - 5.8ppm
24) banswara - 4.3ppm
25) jhunjhunu - 2.2ppm
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VI) Uttar Pradesh
1) Gorakhpur - 0.6-6.8ppm
2) Shahjahanpur - 4ppm
3) Lakhpur -0.1-4ppm
4) Rai bareilly - 0.6-3ppm
5) Banda - 0.6-3ppm
6) Agra - 0.2-3ppm
7) Kanpur - 0.2-3ppm
8) Varanasi - 0.2-3ppm
9) Unna - 0.1-3ppm
10) Aligarh - 0.4-2ppm
11) Allahabad - 0.2-2ppm
12) Itah -0.8-1.6ppm
13) Hamirpur - 0.6-1.6ppm
14) Azamgarh - 0.1-1.6ppm
15) Muradpur - 1.0-1.4ppm
16) Jamalpur - 1.0-1.2ppm
17) Lucknow - 0.8-1.2ppm
18) Meerut - 0.4-1.2ppm
19) Bulandshahar - 0.4-1.2ppm
20) Dijnor - 0.2-1.2ppm
21) Jhansi - 0.2-1.2ppm
22) Bareilly 0.1-0.9ppm
23) Balliya - 0.4-0.8ppm
24) Barabanki - 0.4-0.8ppm
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25) fatehgarh - 0.4-0.8ppm
26) mirzapur - 0.4-0.8ppm
27) gadhepur - 0.3-0.8ppm
28) gonda - 0.2-0.8ppm
29) basti - 0.2-0.8ppm
30) jalpum - 0.1-0.8ppm
31) dehradun - 0.1-0.8ppm
32) pratapgarh - 0.4-0.6ppm
33) manipuri - 0.4-0.6ppm
34) lahtpur - 0.1-0.6ppm
35) muzaffarnagar - 0.2-0.5ppm
36) rampur - 0.2-0.4ppm
37) pilibhit - 0.2-0.4ppm
38) bijnor - 0.1-0.4ppm
39) fatehabad - 0.1-0.4ppm
40) badari - 0.1-0.4 ppm
41) sitapur - 0.1-0.4ppm
42) saharanpur - 0.1-0.4ppm
43) mathura - 0.1-0.4ppm
44) faizabad - 0.2ppm
45) etawah - 0.1-0.2ppm
46) nainital - 0.1-0.2ppm
47) dahrich - 0.1-0.2ppm
48) sultanpur - 0.1ppm
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Treatment options
Basically for all these stains or in particular fluorotic stains the
treatment options available to us include :-
1) Veneering / laminates or placement of porcelain crowns
2) Micro / macroabrasion
3) Bleaching - a) vital tooth inoffice bleaching b) nightguard home bleaching c)
our novel method of inoffice bleaching
1) Veneering or laminates or ceramic
crowns
Advantages:
1) esthetically more acceptable
2) Long lasting
3) Durable
4) Simple
5) Can be given over endodontically treated tooth
6) more strength and resistance to forces
Disadvantages:
1) brittle
2) less shear strengh
3) causes loss of tooth structure
4) patient may not be willing
5) susceptible to fracture
6) due to tooth reduction, pulp & other tissues may face trauma
7) overcontouring may make it appear & feel unnatural
8) vitality tests cannot be done once crowns are properly fit
9) post cementation caries difficult to detect
10) lab.procedure needs precision for proper marginal seal
11) gingival irritation- may cause hyperaemia & bleeding
2) Micro/ Macro abrasion :-
This technique involves applying of 18% hcl to soften the enamel And then
abrading it with a controlled abrasive technique With pumice to remove
superficial stains / defects. Instead of pumice, even silicon carbide may be
used with 11%hcl.
Advantages:
1) improved method for superficial stains
2) safer method
3) involves physical removal of tooth structure
Disadvantages:
1) can cause sensitivity
2) causes wearing of tooth structure
3) patients might not allow cutting of tooth structure
4) defect may persist after finishing of technique for which a restorative alternative is needed
3) Bleaching :-
This procedure has many methods and techniques involving various solutions in
each technique.
Advantages:
1) easy
2) time saving
3) cheaper
4) patient acceptance better
5) can be carried out both in office & at home
Disadvantages:
1) requires patient cooperation(especially for home bleaching)
2) cannot be used where teeth have large pulps
3) cannot be used where teeth are too dark
4) cannot be used where the patient expectations are too high
5) cannot be used in impatient patients
6) causes cervical resorption
7) cannot be used in attritioned teeth which might cause sensitivity
8) cannot be used where teeth are bonded, laminated or have extensive restorations
9) not a perfect technique & merely changes colour to variable depths
10) lasts for only 1 - 3 years (short period)
A) Vital tooth inoffice power bleaching
This technique uses a combination of 37% phosphoric acid & 35%hydrogen peroxide.the oxidation reaction is
generally promoted by a heated instument or with intensive light.in this method,
one application is carried out weekly for 2 - 6 appointments with each treatment
lasting 30 minutes. Use of phosphoric acid by this technique is optional.
Advantages:
1) caustic chemicals are totally under dentist's control.
2) soft tissue protection is better achieved by dentist.
3) bleaching of tooth is achieved more rapidly
Disadvantages:
1) slightly costly procedure.
2) unpredictable results.
3) uncertain duration of treatment
4) soft tissue damage possible for both dentist & patient.
5) rubber dam causes discomfort.
6) can cause post operative sensitivity.
B) Night guard home bleaching
This procedure involves making an impression of the teeth & pouring a cast of the same, trimming of the cast, application
of a blockout resin & fabrication of a night guard tray by a vaccum former
machine. After cooling, the tray is trimmed & a 10 - 15% gel of carbamide
peroxide is recommended for the same. In this procedure the total treatment time
is 2 - 6 weeks.
Advantages:
1) use of lower concentration.
2) ease of application.
3) minimal side effects.
4) lower cost (as compared to veneers)
5) lesser chair time.
6) much lesser labour intensive.
Disadvantages:
1) have to rely a lot on patient compliance for results.
2) longer treatment time.
3) unknown potential for soft tissue changes with excessive use.
4) treatment results are time & dose dependent.
5) peroxide solution may cause irritation of gingival papilla.
6) teeth become sensitive to temperature changes.
Another method using macken's solution has been described
1 part anaesthetic ether 0.2 ml - removes surface debris 5 parts hcl 38% 1ml
--- etches 5 parts hydrogen peroxide 30% 1 ml --- bleaches
Our Approach For Inoffice Bleaching
Indications:
1) Fluorosis stains / systemic fluorosis
2) Tetracycline stains
Contra indications:
1) Hyperaemic gingiva
2) Persistant periodontal problem cases
3) Fractured incisors / anteriors
Clinical application
The various steps are
1) Cleansing
2) Isolating
3) Etching
4) Rinsing
5) Dehydration
6) Application of solution
7) Scrapping
8) Rinsing
9) Filling
The Steps in detail:
1) cleansing the tooth surface with a nylon tooth brush & a mixture of pumice and water to remove surface debris.
2) isolation is done by application of rubber dam.
3) then dry the tooth surface & do enamel etching with 35% hcl for 20 - 25 seconds.
4) copious rinsing is done to eliminate acid residues & the tooth is subjected to thorogh drying.
5) application of 95% ethyl alcohol to dehydrate the enamel surface.
6) now,the application of 30% hydrogen peroxide(h2o2) is done first for 1 minute followed by alternative application of 5.25% sodium hypochlorite (naohcl) is done for 5 minutes during which it can be
re-applied to the tooth surface to keep it wet.
7) the removal of staining molecules can be accelerated by gently scrapping the tooth surface.
8) this is followed by thorough rinsing of tooth surface.
9) this procedure is repeated at the interval of three days for successive sittings till the results are satisfactory.
10) in the end, fill the microcavities caused in the tooth by this solution with a light cure dental adhesive.
Advantages:
1) HCl etches enamel,but does not penetrate.
2) Tooth structure is not damaged.
3) Very very few chances of post - operative sensitivity of tooth.
4) No heat / application is required.
5) Very economical as all the three solutions in quantity of 50 ml. Each cost rs. 250 - 300 (total ).
6) Very low quantity of solutions required at each sitting.
Disadvantages :
1) Fluorosed teeth require larger & repeated sessions to decolorise Them.
2) Some blanching of gingiva can occur which is reversible within Half an hour.
3) Transitory decrease in bond strengh occurs when composite is applied to bleached / etched enamel.however,after a week,no decrease is seen.
4) Unknown duration of treatment.
Discussion
The different hypothesis concerning the fluorotic stains removal are:
1) if a fluorotic tooth is put into a naohcl solution,it removes all the
stains within a few hours.this confirms the organic & exogenous nature of
fluorotic tooth stains which are due to elementary impregnation of a
hypocalcified & porous tissue. said by :- triller m. Alterations des tissues
by marie curie in 1984.
2) scanning electron microscope study (sem) study shows that Posteruptive
calcified layer covers the fluorotic enamel surface ; hence the mineral layer
removal is essential.
Conclusion
In the end, i would like to conclude that this system of stains Removal seems
to be clinically applicable & satisfactory with minimal abrasion of enamel
surface.to make this technique Universally acceptable , lot of cases have to be
treated with this technique.
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