1. health and fitness
2. disease

Continuing Education
Course Number: 142
Management of Fluorosis
Using Macro- and
Microabrasion
Authored by Howard E. Strassler, DMD;
Autumn Griffin, DDS; and Margrit Maggio, DMD
Upon successful completion of this CE activity 2 CE credit hours may be awarded
A Peer-Reviewed CE Activity by
Dentistry Today, Inc, is an ADA CERP Recognized Provider. ADA CERP is
a service of the American Dental Association to assist dental professionals
in indentifying quality providers of continuing dental education. ADA CERP
does not approve or endorse individual courses or instructors, nor does it
imply acceptance of credit hours by boards of dentistry. Concerns or
complaints about a CE provider may be directed to the provider or to
ADA CERP at ada.org/goto/cerp.
Approved PACE Program Provider
FAGD/MAGD Credit Approval
does not imply acceptance
by a state or provincial board of
dentistry or AGD endorsement.
June 1, 2009 to May 31, 2012
AGD Pace approval number: 309062
Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of
specific product names does not infer endorsement by Dentistry Today. Information contained in CE articles and
courses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged to
contact their state dental boards for continuing education requirements.
Continuing Education
Recommendations for Fluoride Varnish Use in Caries Management
INTRODUCTION
Management of Fluorosis Using
Macro- and Microabrasion
Effective Date: 10/1/2011
Water fluoridation is considered to be one of the significant
public health measures of the 20th century.1 During tooth
development, fluoride becomes incorporated into the
enamel matrix as fluorapatite, making the enamel more
resistant to acid attack by bacteria and subsequent tooth
demineralization. Further, fluoride is protective of enamel for
erupted teeth through an equilibrium of demineralizationremineralization during early caries formation. Through the
use of water fluoridation there has been a significant decline
in dental caries in the United States.2
Despite the evidence that supports the benefits of
fluoride in caries prevention, when higher than necessary
levels of fluoride are present, enamel fluorosis can pose an
aesthetic problem for some patients. This article will
discuss enamel fluorosis, the aesthetic challenges it can
present for certain patients, and a conservative aesthetic
treatment modality for a patient who presented with mild to
moderate fluorosis.
Expiration Date: 10/1/2013
LEARNING OBJECTIVES
After reading this article, the individual will learn:
• How fluoride is protective of enamel in the carious process.
• Definition, categories, and clinical appearance of enamel
fluorosis.
• A technique for treating enamel fluorosis using micro- and
macroabrasion.
ABOUT THE AUTHORS
Dr. Strassler is a professor, in the Division of
Operative Dentistry, Department of Endodontics, Prosthodontics and Operative
Dentistry, University of Maryland Dental
School, Baltimore, Md. He can be reached
via e-mail at hstrassler@umaryland.edu.
ENAMEL FLUOROSIS
Dental fluorosis is defined as hypomineralization of enamel
resulting from excessive ingestion of fluoride during tooth
development. It is characterized by diffuse opacities on the
enamel surface. These are differentiated from other
conditions by the characteristic bilaterally symmetric
distribution of the enamel defects. The degree to which the
enamel is affected is dependent upon the duration, timing,
and intensity of the fluoride concentration.1,3 In its mild
form, most commonly the teeth present with small white
streaks and the enamel appears mottled (Figure 1). As the
severity of the condition increases, black and brown stains
develop. Moderate fluorosis will demonstrate white
Disclosure: Dr. Strassler reports no disclosures.
Dr. Griffin is a resident in the general
practice dental residency, New Haven
Hospital, Yale University, New Haven,
Conn. She can be reached at
autumn.griffin@ynhh.org.
Disclosure: Dr. Griffin reports no disclosures.
Dr. Maggio is an assistant professor,
clinician educator and the director of
operative dentistry, Department of
Preventive and Restorative Sciences,
University of Pennsylvania School of
Dental Medicine, Philadelphia, Pa. She
can be reached at mmaggio@pobox.upenn.edu.
Figure 1.
An example of mild
fluorosis discoloration.
Disclosure: Dr. Maggio reports no disclosures.
1
Continuing Education
Management of Fluorosis Using Macro- and Microabrasion
streaking with brownish staining (Figure 2). Severe fluorosis
has the appearance of very dark brown staining and in
some cases enamel surface defects (Figure 3).
For a small number of patients, the degree of fluorosis
can be an aesthetic concern.3-5 The primary author has
found over the years that in many cases, patients with very
mild and mild to moderate fluorosis are not aware of the
minor discoloration present and have no aesthetic concerns.
In those cases where patients have moderate to severe
fluorosis, the discoloration can be of aesthetic concern.
Fluorosis is a developmental phenomenon of the
enamel that presents in both primary and permanent teeth.
The origins of fluorosis are not completely understood;
however, current research suggests that superfluous
amounts of fluoride cause retention of amelogenin proteins
in the developing tooth structure, thereby inhibiting enamel
maturation. This interference results in porosities in the
enamel at the time of tooth eruption. Specifically, recent
animal and human studies indicate that the role of fluoride
is likely due to its interaction with Ca2+ ions; excess F
intake has been shown to indirectly reduce the amount of
available Ca2+ ions, which in turn limits the number of
calcium-dependent proteases available to remove enamel
matrix proteins. This elimination of enamel matrix proteins
is necessary for adequate enamel maturation.6-9
Studies in United States school children have reported
fluorosis as high as 50% to 60% in the 1980s and in the
range of 40% to 48% through the 1990s and 2000s.8,10-14
Dental fluorosis has been evaluated by the US Department
of Health and Human Services Centers for Disease Control
and Prevention (CDC) and Prevention National Center of
Health Statistics using the dental fluorosis classification
described by Dean (Table 1). The findings were characterized
as unaffected, questionable, very mild, mild, and
moderate/severe. From the data reported for dental fluorosis
for adolescents and adults from 1999 to 2002, the majority of
persons examined were either unaffected or had
questionable fluorosis (Table 2). For persons with a diagnosis
of dental fluorosis, the rate that was mild was twice as
prevalent for 16- to 19-year-olds when compared to 20- to 39year-olds (6.7% versus 3.3%). Moderate/severe fluorosis
also was higher for the 16- to 19-year-olds when compared
to the 20 to 39 year olds (4.0% versus 1.8%).14
Figure 2.
An example of moderate
fluorosis staining.
Figure 3.
An example of severe
fluorosis staining and
enamel surface defects.
MULTIPLE SOURCES OF FLUORIDE
Recommendations for fluoride supplements for children and
adolescents have been endorsed by the ADA and the
Academy of Pediatric Dentistry for many years. In 1994, a
change in the recommendations for fluoride supplements
based upon the child’s age was made in response to
concerns about the increase in the prevalence of
fluorosis.1,15,16 These changes are noted in Table 3.
The majority of fluoride ingestion is typically thought to
be through foods, beverages, and supplements.17-24 Water
is the primary provider of fluoride. Recommendations for
total dietary fluoride intake should be calculated based
upon body weight using the formula of 0.05 mg/kg/day.25 An
analysis of fluoride exposures and ingestion from multiple
sources may be responsible for higher than optimal
amounts of fluoride required for caries prevention.26,27
Even children in nonfluoridated areas benefit from foods
and beverages processed in fluoridated areas.28 Sources
of fluoride exposure and ingestion for children from dietary
and nondietary sources include toothpastes,4,26,29-32
carbonated soft drinks,22 infant formula,4,33,34 prescribed
supplements,26,28,35,36 and fluoride mouthrinses and gels.
Recent recommendations concerning use of reconstituted
infant formula and a fluoridated dentifrice point to the
recommendation that parents monitor their use.4
Heilman and coworkers22 examined the fluoride content
2
Continuing Education
Management of Fluorosis Using Macro- and Microabrasion
of 332 carbonated beverages in Iowa. Their
Table 1. Criteria for Dean’s Fluorosis Index
results revealed that fluoride levels ranged
SCORE
CRITERIA
from 0.02 to 1.28 parts per million (ppm) with
a mean level of 0.72 ppm. Fluoride levels
Normal
The enamel represents the usual translucent semivitriform
exceeded 0.60 ppm for 71% of the products.
type of structure. The surface is smooth, glossy, and usually
Further, from this study no generalization
of a pale creamy white color.
could be made about same company/same
product results. Different sites of bottling
Questionable
The enamel discloses slight aberrations from the
translucency of normal enamel, ranging from a few white
production revealed different fluoride levels.
flecks to occasional white spots. This classification is
Variation in fluoride content reflects the fact
utilized in those instances where a definite diagnosis of the
that bottling of beverages utilizes the local
mildest form of fluorosis is not warranted and a
water supply.
classification of “normal" is not justified.
It is difficult to monitor fluoride ingestion
levels for children. When one considers that
Very Mild
Small, opaque, paper-white areas scattered irregularly over
the tooth but not involving as much as 25% of the tooth
fluoride uptake can occur from the water
surface.
Frequently included in this classification are teeth
supply, prescribed fluoride supplements,
showing no more than about one to 2 mm of white opacity
infant formula, dentifrices, fluoride mouthat the tip of the summit of the cusps of the bicuspids
rinses, soft drinks, and reconstituted juices,
or second molars.
among other sources, it is not surprising
that the incidence of fluorosis in the United
Mild
The white opaque areas in the enamel of the teeth are
more extensive but do not involve as much as 50%
States has been increasing.34,37-41
of
the tooth.
Further, with the increase in new
immigrants to the United States, fluorosis
Moderate
All enamel surfaces of the teeth are affected, and the
can be observed due to endemic fluorosis
surfaces subject to attrition show wear. Brown stain is
in other countries.42-50 For example, an
frequently a disfiguring feature.
unusual source of fluoride (not from foods
Severe
Includes teeth formerly classified as “moderately severe
or beverages) has been reported in Kenya
and
severe.” All enamel surfaces are affected and
and affects other east African nations as
hypoplasia is so marked that the general form of the tooth
well. A 1986 epidemiological study of
may be affected. The major diagnostic sign of this
dental fluorosis in Kenya stated that in fact
classification is discrete or confluent pitting. Brown stains
“dental fluorosis has been endemic to
are widespread and teeth often present a
Eastern Africa and in particular Kenya for
corroded-like appearance.
many years since the Great Rift Valley,
Source: Dean HT, 1942. Health Effects of Ingested Fluoride. Washington, DC: National
which is known to have volcanic activity,
Academy of Sciences; 1993:169.
passes through Kenya.” Although it is
believed that the main source of fluoride is from the drinking
MINIMALLY INVASIVE AESTHETIC TREATMENT
water (in some rural parts of Kenya there are 2 ppm fluoride
OPTIONS FOR MILD TO MODERATE DENTAL
in the drinking water with the corresponding incidence of
FLUOROSIS
fluorosis being 100%), the volcanic soil of Kenya has been
Concerns about the aesthetic appearance of teeth with fluorosis
found to also have very high concentrations of fluoride. Durhave led to proposed new guidelines for fluoridation of drinking
ing the dry season in Kenya, the dust contains fluoride
water.52 The goal of fluoride supplements is to provide an
51
concentrations between 2,800 ppm and 5,600 ppm.
optimal amount of fluoride to reduce the risk of dental caries.
3
Continuing Education
Management of Fluorosis Using Macro- and Microabrasion
Recent recommendations reflect
Table 2. Dental Fluorosis in the United States 1999 to 2002, Based
changes from the previous levels
Upon Characteristics—CDC Data (from cdc.gov.mmwr/PDF/ss/ss5403.pdf)
of fluoride to a more optimal
Age Group Unaffected
Questionable
Very Mild
Mild
Moderate/Severe
level of fluoride of 0.7 mg/L.52
These changes reflect the fact
6 to 11
59.8%
11.8%
19.8%
5.8%
2.7%
that the ingestion of fluoride
can come from multiple
12 to 15
51.5%
12.0%
25.3%
7.7%
3.6%
sources, resulting in a need for
16 to 19
58.3%
10.2%
20.8%
6.7%
4.0%
a lower level of fluoride in
optimally fluoridated drinking
20 to 39
74.9%
8.8%
11.1%
3.3%
1.8%
water. The recommendations
also take into account that fluoride supplements need only
speckled mottling of enamel reveals a more yellow enamel
be considered for patients at moderate to high risk for
color beneath the surface. For some patients, the loss of the
dental caries and even then may be unnecessary if patients
white speckled enamel to yellow is not acceptable. For
these cases, a combined microabrasion/macroabrasion
are receiving adequate fluoride from other sources.
with vital bleaching is an aesthetically acceptable
The majority of patients with fluorosis have mild and very
treatment.59,60
mild conditions. Depending on the severity of fluorosis and its
clinical appearance, restorative treatments can change the
aesthetic appearance of teeth. Decisions for changes should
CASE REPORT
be based upon the patient’s perception regarding whether
A 20-year-old female patient was screened at the dental
there is a need for treatment. Fluorosis staining is within the
clinic for routine dental care. Her chief complaint was to
enamel. In cases of mild fluorosis, the enamel discoloration is
remove and/or minimize the noticeable brown/yellow
superficial. For moderate and severe fluorosis, the enamel
staining of her teeth. She wanted the least invasive and
staining and mottling can penetrate to deeper
Table 3. Changes in Flouride Supplement
enamel levels. For cases of mild fluorosis of
Dosage Schedule, 1979 and 1994 1,15,16
aesthetic concern to the patient, vital
bleaching can be successful in achieving a
1979
Concentration of Fluoride Ion in Drinking Water (ppm)
change that the patient desires.53 When the
Age
< 0.3
0.3 to 0.7
> 0.7
patient presents with mild-moderate flourosis,
2 weeks to 2 years
0.25 mg/day
none
none
there may be the need for a microabrasion or
macroabrasion technique.
2 to 3 years
0.50 mg/day
0.25 mg/day
none
Microabrasion refers to the use of a
3 to 16 years
1.00 mg/day
0.50 mg/day
none
hydrochloric acid abrasive paste to remove
the superficial enamel staining.54-57 In
those cases where the fluorosis may be
1994
Concentration of Fluoride Ion in Drinking Water (ppm)
deeper in the superficial enamel but still
Age
< 0.3
0.3 to 0.6
> 0.6
mild in discoloration, a combined use of a
fine abrasive diamond (50- to 75-µm grit
Birth to 6 months
none
none
none
size) in a high-speed handpiece with water
6 months to 3 years 0.25 mg/day
none
none
spray provides for a more rapid removal of
the discolored enamel and has been
3 to 6 years
0.50 mg/day
0.25 mg/day
none
58
referred to as macroabrasion. When the
6 to 16 years
1.00 mg/day
0.50 mg/day
none
superficial enamel is removed, the white
4
Continuing Education
Management of Fluorosis Using Macro- and Microabrasion
most cost effective treatment to change her smile. A review
of her medical history and past dental history revealed no
contraindications to dental treatment. In consideration of
her age, the patient was not interested in treatment options
that involved significant removal of tooth structure, such as
porcelain or composite resin veneers which had previously
been suggested to her from her previous dentist. The
patient’s desire to change the appearance of her teeth in
the aesthetic zone was to improve her smile and thereby
her confidence. From the appearance of her teeth, a
diagnosis of mild to moderate fluorosis staining
(determined by using Dean’s Fluorosis Index) was present
on the anterior and posterior teeth in the aesthetic zone
(white mottled enamel hypomineralization), with the most
significant staining occurring on the maxillary anterior teeth;
teeth Nos. 8 and 9 contained dark brown streaks in the
middle third of the facial surfaces (Figure 4).
A review of her past history and a complete dental
examination revealed her country of origin as Kenya. She
reported childhood friends as having the same discoloration
of their teeth. As previously noted, Kenya is associated with
endemic fluorosis. A treatment plan was presented to the
patient that would fulfill her request for minimally invasive
treatment which proposed macroabrasion/microabrasion of
the superficial enamel staining. Upon completion of
treatment, the tooth shade would be evaluated. If the patient
desired further whitening, it was decided that at-home
bleaching treatment would be provided.
Figure 4.
Preoperative view of
moderate
fluorosis with patient
desiring a color change
and treatment.
Figure 5.
Dental dam applied.
Figure 6.
Macroabrasion of the
facial surfaces of the
teeth using a 50-µm grit
fine diamond with a highspeed handpiece with airwater spray.
Figure 7.
Application of Opalustre
microabrasion paste
(Ultradent Products).
Phase 1: Enamel Abrasion Phase
After receiving a routine oral prophylaxis, the maxillary teeth
in the aesthetic zone (Nos. 4 to 13) were isolated with a
dental dam to protect the gingival tissues when the acidic
microabrasion paste was to be used (Figure 5). A combined
enamel macroabrasion/microabrasion technique was
decided to be the most effective way to treat the
hypomineralized defects of the maxillary first premolars,
canines, lateral and central incisors. Enamel macroabrasion
refers to the use of either medium or fine grit diamond
abrasives or multifluted finishing burs with a high-speed
handpiece with air-water spray to remove the superficial layer
of the enamel.58,60 Enamel microabrasion refers to the use
Figure 8.
Rubbing the
microabrasion paste into
the enamel surfaces of
the maxillary incisors
with specialized brush
embedded in cup at a
speed of 1,000 rpm.
of a low concentration acid combined with an abrasive agent
as a water soluble gel or paste that would be applied to the
enamel surface with an extremely low-speed rotary
5
Continuing Education
Management of Fluorosis Using Macro- and Microabrasion
handpiece pressure applicator for precise compression of the
compound on the tooth surface so that splattering of the
compound would be eliminated or minimized.
For this case, speed reduction was accomplished with
an electric handpiece (Bien-Air Dental). Specialized torque
converter speed reduction adapters can also be used. Use
of the ultra-low-speed rotary application makes the
procedure safer, easier, and quicker.60,61 The current
formulation for microabrasion pastes is a low concentration
hydrochloric acid (6.6%), silicon carbide abrasive, and silica
gel as a binding agent. This paste in fact etches the enamel
surface more aggressively than the use of phosphoric acid
used for adhesive restorative dentistry.61
To accomplish macroabrasion/microabrasion, the facial
surfaces of the treated teeth were lightly abraded with a
flame-shaped fine grit (50 µm) diamond (8862F [Brasseler
USA]) using a high-speed handpiece with air-water spray
(Figure 6) to remove the superficial enamel
dysmineralization layer to a depth of approximately 0.2 to
0.3 mm. After completion of the rotary macroabrasion, the
microabrasion paste (Opalustre [Ultradent Products]) was
applied to the facial surfaces of the treated maxillary teeth
(Figure 7). Using a right angle latch type slow-speed handpiece running the motor at 1,000 rpm, a hybrid bristle
brush-cup was used to apply the microabrasion paste for 3
separate applications of 30 to 40 seconds each (Figure 8).
Between each application the microabrasion paste was
rinsed and dried from the tooth surfaces (Figure 9). This
procedure was repeated 3 times (Figure 10). At the
completion of the macroabrasion/microabrasion technique
the etched enamel surfaces were polished with a cupshaped porcelain polishing rubber abrasive (Jazz [SS White
Burs]) to smooth and polish the enamel surface (Figure 11).
To remineralize the acid attached enamel surface the teeth
were treated with a topical sodium fluoride (NuPro
[DENTSPLY International]) in a fluoride tray. Then an
amorphous calcium phosphate paste (MI Paste Plus [GC
America]) was rubbed onto the enamel surfaces with a
gloved finger.
The dental dam was removed and the patient viewed the
result of treatment. She was pleased with the result from the
immediate removal of the dark staining on her maxillary
anterior teeth (Figure 12). The patient was informed that
Figure 9.
Appearance of teeth after
the first application.
Figure 10.
Appearance of teeth after
third application.
Figure 11.
Polishing the etched
enamel surfaces with
a porcelain polishing
rubber abrasive (Jazz
[SS White Burs]).
Figure 12.
Postoperative view of
macroabrasion/microabrasion treatment.
Figure 13.
Postoperative view
after 4 weeks of tray
bleaching.
because of the dental dam isolation and the etching process
of the microabrasion paste, evaluation of the final color and
appearance of the teeth was to be done one week after
6
Continuing Education
Management of Fluorosis Using Macro- and Microabrasion
treatment. In case there would be the need for postoperative
tooth bleaching, maxillary and mandibular impressions were
made for subsequent bleaching tray fabrication if indicated.
The patient did not return until 3 weeks after treatment
because of travel plans.
appearance was evaluated and determined to be a shade
B1 (Figure 13). The patient was pleased with the final
aesthetic result.
CONCLUSION
Tooth discoloration due to fluorosis is an aesthetic problem
for certain patients. While there is a range of restorative
interventions that can be used to change the appearance of
fluorosed teeth, the goal of minimally invasive treatment for
mild-moderate fluorosis is the one that should be evaluated
first. For the case presented in this article, a minimally
invasive treatment option of macroabrasion/microabrasion
followed by tooth whitening with bleaching trays was shown
to be a satisfactory approach for the aesthetic treatment of
moderate fluorosis. In the United States, new
recommendations for reducing the optimal level of fluoride
for water fluoridation are addressing aesthetic concerns
without putting teeth at risk for caries.
The current evidence demonstrates that when a diagnosis
of fluorosis has been made, the majority of cases are very mild
or mild and do not pose aesthetic problems that require
treatment unless it is of concern to the patient. For the primary
author, in cases where fluorosis is evident for a child, it is
typically the parent who has identified the discoloration and
has questions about the appearance of the teeth. For some
mild fluorosis discoloration and for moderate/severe fluorosis
elective treatment to change the aesthetic appearance of the
teeth can many times be accomplished with minimally invasive
treatment using vital bleaching or combinations of
macroabrasion/microabrasion with bleaching to provide the
patient with an aesthetically acceptable result. For more severe
fluorosis with dark discolorations and surface pitting, adhesive
restorative dentistry may be necessary to fulfill a patient’s
aesthetic desires.
Phase 2: Tray Bleaching
The second phase of the treatment was initiated
approximately 3 weeks later (the patient traveled back to
Kenya in the interim). Using a Classical Vita Shade Guide
(Vident) it was determined that the teeth treated were now
predominantly an A2 shade. When removing the superficial
brownish-white enamel dysmineralization hypomineralization,
it is not unusual for the final shade of the teeth to be slightly
yellower than the original appearance (whitish speckled
discoloration due to fluorosis of the teeth). This was observed
with this patient.The patient elected to whiten her teeth further
using vital tray bleaching.
Fabricated bleaching trays were delivered to the patient
along with a 15% carbamide peroxide with potassium
nitrate and fluoride bleaching gel (Opalescence 15%PF
[Ultradent Products]) to be used with overnight application
each night for 4 weeks. The patient was told that if she was
unable to bleach overnight to use the bleaching trays for at
least 2 hours each day. During bleaching, the patient
reported mild sensitivity to the initial bleaching application.
She treated the tooth sensitivity using a recommendation
of placing a desensitizing toothpaste (Sensodyne
[GlaxoSmithKline]) in the bleaching tray one hour prior to
bleaching,62 then cleaning the tray of the toothpaste and
continuing with the bleaching regimen. One week of using
the desensitizing toothpaste was all that was necessary to
control the sensitivity.
The patient reported being able to follow the overnight
regimen of bleaching. After 4 weeks, the tooth shade and
7
Continuing Education
Management of Fluorosis Using Macro- and Microabrasion
17. Berg J, Gerweck C, Hujoel PP, et al. Evidence-based clinical
recommendations regarding fluoride intake from
reconstituted infant formula and enamel fluorosis: a report of
the American Dental Association Council on Scientific
Affairs. J Am Dent Assoc. 2011;142:79-87.
REFERENCES
1.
Centers for Disease Control and Prevention. Achievements
in public health, 1900-1999: fluoridation of drinking water to
prevent dental caries. JAMA. 2000;283:1283-1286.
2.
Ismail AI, Hasson H. Fluoride supplements, dental caries
and fluorosis: a systematic review. J Am Dent Assoc.
2008;139:1457-1468.
3.
4.
18. Steinmetz JE, Martinez-Mier EA, Jones JE, et al. Fluoride
content of water used to reconstitute infant formula. Clin
Pediatr (Phila). 2011;50:100-105.
Aoba T, Fejerskov O. Dental fluorosis: chemistry and biology.
Crit Rev Oral Biol Med. 2002;13:155-170.
19. American Dental Association. Accepted Dental Therapeutics.
33rd-40th eds. Chicago, IL: Council on Dental Therapeutics
of the American Dental Association; 1969/1970-1984:399402.
Levy SM, Broffitt B, Marshall TA, et al. Associations between
fluorosis of permanent incisors and fluoride intake from
infant formula, other dietary sources and dentifrice during
early childhood. J Am Dent Assoc. 2010;141:1190-1201.
5.
Martins CC, Feitosa NB, Vale MP, et al. Parents’ perceptions
of oral health conditions depicted in photographs of anterior
permanent teeth. Eur J Paediatr Dent. 2010;11:203-209.
6.
Wright JT, Chen SC, Hall KI, et al. Protein characterization of
fluorosed human enamel. J Dent Res. 1996;75:1936-1941.
7.
Limeback H. Enamel formation and the effects of fluoride.
Community Dent Oral Epidemiol. 1994;22:144-147.
8.
Beltrán-Aguilar ED, Barker L, Dye BA. Prevalence and
severity of dental fluorosis in the United States, 1999-2004.
NCHS Data Brief. 2010;(53):1-8.
9.
Cutress TW, Suckling GW. Differential diagnosis of dental
fluorosis. J Dent Res. 1990;69(special issue):714-721.
20. Marya CM, Dhingra S, Marya V, et al. Relationship of dental
caries at different concentrations of fluoride in endemic
areas: an epidemiological study. J Clin Pediatr Dent.
2010;35:41-45.
21. Thippeswamy HM, Kumar N, Anand SR, et al. Fluoride
content in bottled drinking waters, carbonated soft drinks
and fruit juices in Davangere city, India. Indian J Dent Res.
2010;21:528-530.
22. Heilman JR, Kiritsy MC, Levy SM, et al. Assessing fluoride
levels of carbonated soft drinks. J Am Dent Assoc.
1999;130:1593-1599.
23. Levy SM, Guha-Chowdhury N. Total fluoride intake and
implications for dietary fluoride supplementation. J Public
Health Dent. 1999;59:211-223.
10. Centers for Disease Control and Prevention.
Recommendations for using fluoride to prevent and control
dental caries in the United States. MMWR Recomm Rep.
2001;50(RR-14):1-42.
24. Levy SM, Kiritsy MC, Warren JJ. Sources of fluoride intake in
children. J Public Health Dent. 1995;55:39-52.
25. Institute of Medicine. Fluoride. In: Dietary Reference Intakes
for Calcium, Phosphorus, Magnesium, Vitamin D, and
Fluoride. Washington, DC: National Academy Press;
1997:288-313.
11. Oral Health in America: A Report of the Surgeon General.
Rockville, MD: US Department of Health and Human
Services; 2000. surgeongeneral.gov/library/oralhealth.
Accessed June 20, 2011.
26. Levy SM. Review of fluoride exposures and ingestion.
Community Dent Oral Epidemiol. 1994;22:173-180.
12. Clark DC. Trends in prevalence of dental fluorosis in North
America. Community Dent Oral Epidemiol. 1994;22:148-152.
27. Rodrigues MH, Leite AL, Arana A, et al. Dietary fluoride
intake by children receiving different sources of systemic
fluoride. J Dent Res. 2009;88:142-145.
13. Rozier RG. The prevalence and severity of enamel fluorosis
in North American children. J Public Health Dent.
1999;59:239-246.
28. Levy SM, Warren JJ, Davis CS, et al. Patterns of fluoride
intake from birth to 36 months. J Public Health Dent.
2001;61:70-77.
14. Beltrán-Aguilar ED, Barker LK, Canto MT, et al; Centers for
Disease Control and Prevention. Surveillence for dental
caries, dental sealants, tooth retention, edentulism, and
enamel fluorosis—United States, 1988-1994 and 1999-2002.
MMWR Surveill Summ. 2005;54:1-43. cdc.gov.mmwr/PDF/ss/
ss5403.pdf. Accessed June 20, 2011.
29. Franzman MR, Levy SM, Warren JJ, et al. Fluoride dentifrice
ingestion and fluorosis of the permanent incisors. J Am Dent
Assoc. 2006;137:645-652.
30. Moraes SM, Pessan JP, Ramires I, et al. Fluoride intake from
regular and low fluoride dentifrices by 2-3-year-old children:
influence of the dentifrice flavor. Braz Oral Res. 2007;21:234-240.
15. Dosage schedule for dietary fluoride supplements.
Proceedings of a workshop. Chicago, Ill. January 31 to
February 1, 1994. J Public Health Dent. 1999;59:203-281.
31. de Almeida BS, da Silva Cardoso VE, Buzalaf MA. Fluoride
ingestion from toothpaste and diet in 1- to 3-year-old
Brazilian children. Community Dent Oral Epidemiol.
2007;35:53-63.
16. American Academy of Pediatrics. Committee on Nutrition.
Fluoride supplementation: revised dosage schedule.
Pediatrics. 1979;63:150-152.
8
Continuing Education
Management of Fluorosis Using Macro- and Microabrasion
48. Ermi RB, Koray F, Akdeniz BG. Dental caries and fluorosis in
low- and high-fluoride areas in Turkey. Quintessence Int.
2003;34:354-360.
32. Oliveira MJ, Paiva SM, Martins LH, et al. Fluoride intake by
children at risk for the development of dental fluorosis:
comparison of regular dentifrices and flavoured dentifrices
for children. Caries Res. 2007;41:460-466.
33. Walton JL, Messer LB. Dental caries and fluorosis in breastfed and bottle-fed children. Caries Res. 1981;15:124-137.
49. Ibrahim YE, Bjorvatn K, Birkeland JM. Caries and dental
fluorosis in a 0.25 and a 2.5 ppm fluoride area in the Sudan.
Int J Paediatr Dent. 1997;7:161-166.
34. Pendrys DG, Katz RV, Morse DE. Risk factors for enamel
fluorosis in a fluoridated population. Am J Epidemiol.
1994;140:461-471.
50. Ferreira EF, Vargas AM, Castilho LS, et al. Factors associated to
endemic fluorosis in Brazilian rural communities. Int J Environ
Res Public Health. 2010;7:3115-3128.
35. Marthaler RM. Fluoride supplements for systemic effects in
caries prevention. In: Johansen E, Taves DR, Olsen TO, eds.
Continuing Evaluation of the Use of Fluorides. Boulder, CO:
Westview Press; 1979:33-59.
51. Manji F, Baelum V, Fejerskov O. Dental fluorosis in an area
of Kenya with 2 ppm fluoride in the drinking water. J Dent
Res. 1986;65:659-662.
52. HHS and EPA announce new scientific assessments and
actions on fluoride [news release]. US Department of Health
& Human Services; January 7, 2011. hhs.gov/news/press/
2011pres/01/20110107a.html. Accessed June 20, 2011.
36. Levy SM, Kiritsy MC, Slager SL, et al. Patterns of dietary
fluoride supplement use during infancy. J Public Health Dent.
1998;58:228-233.
53. Loyola-Rodriguez JP, Pozos-Guillen Ade J, HernandezHernandez F, et al. Effectiveness of treatment with
carbamide peroxide and hydrogen peroxide in subjects
affected by dental fluorosis: a clinical trial. J Clin Pediatr
Dent. 2003;28:63-67.
37. Levy SM, Hillis SL, Warren JJ, et al. Primary tooth fluorosis
and fluoride intake during the first year of life. Community
Dent Oral Epidemiol. 2002; 30:286-295.
38. Osuji OO, Leake JL, Chipman ML, et al. Risk factors for
dental fluorosis in a fluoridated community. J Dent Res.
1988;67:1488-1492.
54. Croll TP, Cavanaugh RR. Enamel color modification by
controlled hydrochloric acid-pumice abrasion. I. Technique
and examples. Quintessence Int. 1986;17:81-87.
39. Ismail AI, Messer JG. The risk of fluorosis in students
exposed to a higher than optimal concentration of fluoride in
well water. J Public Health Dent. 1996;56:22-27.
55. Croll TP, Cavanaugh RR. Enamel color modification by
controlled hydrochloric acid-pumice abrasion. II. Further
examples. Quintessence Int. 1986;17:157-164.
40. Holm AK, Andersson R. Enamel mineralization disturbances
in 12- year-old children with known early exposure to
fluorides. Community Dent Oral Epidemiol. 1982;10:335-339.
56. Allen K, Agosta C, Estafan D. Using microabrasive material to
remove fluorosis stains. J Am Dent Assoc. 2004;135:319-323.
41. Kumar JV, Green EL, Wallace W, et al. Trends in dental
fluorosis and dental caries prevalences in Newburgh and
Kingston, NY. Am J Public Health. 1989;79:565-569.
57. Croll TP. Enamel microabrasion for removal of superficial
discoloration. J Esthet Dent. 1989;1:14-20.
42. Nirgude AS, Saiprasad GS, Naik PR, et al. An epidemiological
study on fluorosis in an urban slum area of Nalgonda, Andhra
Pradesh, India. Indian J Public Health. 2010;54:194-196.
58. Coll JA, Jackson P, Strassler HE. Comparison of enamel
microabrasion techniques: Prema Compound versus a 12fluted finishing bur. J Esthet Dent. 1991;3:180-186.
43. Gopalakrishnan P, Vasan RS, Sarma PS, et al. Prevalence of
dental fluorosis and associated risk factors in Alappuzha
district, Kerala. Natl Med J India. 1999;12:99-103.
59. Higashi C, Dall’Agnol AL, Hirata R, et al. Association of
enamel microabrasion and bleaching: a case report. Gen
Dent. 2008;56:244-249.
44. Kadir RA, Al-Maqtari RA. Endemic fluorosis among 14-yearold Yemeni adolescents: an exploratory survey. Int Dent J.
2010;60:407-410.
60. Strassler HE. Clinical case report: treatment of mild-tomoderate fluorosis with a minimally invasive treatment plan.
Compend Contin Educ Dent. 2010; 31:54-58.
45. Marya CM, Dhingra S, Marya V, et al. Relationship of dental
caries at different concentrations of fluoride in endemic
areas: an epidemiological study. J Clin Pediatr Dent.
2010;35:41-45.
61. Croll TP. Enamel microabrasion: concept development. In:
Croll TP. Enamel Microabrasion. Chicago, IL: Quintessence
Publishing; 1991:37-41.
62. Haywood VB, Cordero R, Wright K, et al. Brushing with a
potassium nitrate dentifrice to reduce bleaching sensitivity.
J Clin Dent. 2005;16:17-22.
46. Mwaniki DL, Courtney JM, Gaylor JD. Endemic fluorosis: an
analysis of needs and possibilities based on case studies in
Kenya. Soc Sci Med. 1994;39:807-813.
47. Faye M, Diawara CK, Ndiaye KR, et al. Dental fluorosis and
dental caries prevalence in Senegalese children living in a
high-fluoride area and consuming a poor fluoridated drinking
water [in French]. Dakar Med. 2008;53:162-169.
9
Continuing Education
Management of Fluorosis Using Macro- and Microabrasion
2. Water fluoridation has been described as being a
significant public health measure. Through the use of
fluoridation there has been a significant decline in what
oral pathology?
POST EXAMINATION INFORMATION
To receive continuing education credit for participation in
this educational activity you must complete the program
post examination and receive a score of 70% or better.
a.
b.
c.
d.
Traditional Completion Option:
You may fax or mail your answers with payment to Dentistry
Today (see Traditional Completion Information on following
page). All information requested must be provided in order
to process the program for credit. Be sure to complete your
“Payment,” “Personal Certification Information,” “Answers,”
and “Evaluation” forms. Your exam will be graded within 72
hours of receipt. Upon successful completion of the postexam (70% or higher), a letter of completion will be mailed
to the address provided.
3. Dental fluorosis is defined as:
a.
b.
c.
d.
Online Completion Option:
Use this page to review the questions and mark your
answers. Return to dentalcetoday.com and sign in. If you
have not previously purchased the program, select it from
the “Online Courses” listing and complete the online
purchase process. Once purchased the program will be
added to your User History page where a Take Exam link
will be provided directly across from the program title.
Select the Take Exam link, complete all the program
questions and Submit your answers. An immediate grade
report will be provided. Upon receiving a passing grade,
complete the online evaluation form. Upon submitting the
form your Letter Of Completion will be provided
immediately for printing.
Hypomineralization of enamel resulting from excessive
ingestion of fluoride during tooth development.
Hypermineralization of enamel resulting from excessive
ingestion of fluoride during tooth development.
Hypomineralization of dentin resulting from excessive
ingestion of fluoride during tooth development.
Hypermineralization of dentin resulting from excessive
ingestion of fluoride during tooth development.
4. According to the article, the degree to which enamel is
affected by fluoride causing fluorosis is dependent on
the all the following EXCEPT:
a.
b.
c.
d.
Duration of exposure to fluoride.
Timing of when fluoride is administered.
Intensity of fluoride concentration.
The patients’ gender.
5. The clinical appearance of mild fluorosis is:
a.
b.
c.
d.
General Program Information:
Online users may log in to dentalcetoday.com any time in
the future to access previously purchased programs and
view or print letters of completion and results.
Dark yellowing of the enamel.
Dark brown and black stains oriented with horizontal
streaks within the enamel.
Small white streaks with enamel mottling.
Bluish translucency to the enamel.
6. The clinical appearance of moderate fluorosis is:
a.
b.
c.
d.
POST EXAMINATION QUESTIONS
1. During tooth development fluoride becomes
incorporated into which portion of the tooth making it
more resistant to acid attack by bacteria?
a.
b.
c.
d.
Periodontal disease.
Tooth crowding and misalignment.
Tooth anomalies.
Caries.
Dark yellowing of the enamel.
Small translucent-bluish streaks on the enamel surface.
White streaking with brownish staining of the enamel.
Dark black streaks with white halos surrounding
them within the enamel surface.
7. The clinical appearance of severe fluorosis is:
a.
b.
Periodontal ligament.
Enamel.
Dentin.
Pulp.
c.
d.
10
Dark yellowing of the enamel.
Very dark brown staining with some cases having
enamel defects.
Slight white streaking of the enamel.
Bluish translucency to the enamel.
Continuing Education
Management of Fluorosis Using Macro- and Microabrasion
c.
8. The majority of patients with enamel fluorosis have mild or
very mild conditions. All conditions of mild and very mild
enamel fluorosis require an aesthetic restorative intervention.
a.
b.
c.
d.
d.
Both statements are true.
The first statement is true and the second statement
is false.
The first statement is false and the second statement
is true.
Both statements are false.
13. Because fluoride is ingested from multiple sources,
there have been recent recommendations to lower the
amount of fluoride in optimally fluoridated drinking
water. These proposed changes are to lower the optimal
level of fluoride to:
a.
b.
c.
d.
9. In cases where the patient is concerned about the
aesthetic appearance of mild-moderate fluorosis,
conservative, minimally invasive treatment technique(s)
that can be used is (are):
a.
b.
c.
d.
a.
b.
c.
d.
a.
Both statements are true.
The first statement is true and the second statement is false.
The first statement is false and the second statement is true.
Both statements are false.
b.
c.
d.
b.
A 50-µm aluminum oxide particle in an air abrasion
device to remove fluorosis discoloration.
Abrasive pumice paste with phosphoric acid with a
prophylaxis brush to remove fluorosis discoloration.
Fine abrasive diamond (50- to 75-µm grit size) in a
high-speed handpiece with water spray.
A 10% sodium peroxide gel to whiten the enamel
surfaces.
16. When treating fluorosis discoloration that has a white
speckled mottling of enamel, it is not uncommon that
once the superficial enamel discoloration has been
removed, the enamel has a more yellow appearance. In
these cases a conservative treatment to achieve an
acceptable aesthetic result as described in the article is:
Toothpaste.
Carbonated soft drinks.
Infant formula.
All the above are sources for fluoride exposure and
ingestion for children.
a.
b.
12. When evaluating children for ingestion of fluoride it is
not uncommon for the dental professional to not
include carbonated beverages as a potential source of
fluoride. From the study by Heilman and coworkers their
conclusion was that:
a.
Hydrochloric acid abrasive paste to remove superficial
enamel staining.
Hydrofluoric acid abrasive powders in a air abrasion
device to remove superficial enamel staining.
Mild fluoride rinse (1.1% sodium fluoride) to treat
mottled enamel and dentin.
Phosphoric acid gel to remove brown and black stains
in the superficial enamel and root surfaces.
15. Macroabrasion refers to an aesthetic treatment
technique that uses:
11. Source(s) for fluoride exposure and ingestion for children
from dietary and nondietary as reported in the dental
literature include:
a.
b.
c.
d.
0.005 mg/L.
0.7 mg/L.
1.1 mg/L.
7.0 mg/L.
14. Microabrasion as an aesthetic treatment technique
refers to the use of an:
Vital bleaching.
Macroabrasion-microabrasion.
Macroabrasion-microabrasion followed by vital bleaching.
All are conservative, minimally invasive treatment
techniques for mild-moderate fluorosis.
10. Microabrasion refers to the use of a hydrochloric acid
abrasive paste to remove the superficial enamel staining.
In those cases where the fluorosis may be deeper in the
superficial enamel but still mild in discoloration, a
combined use of a fine abrasive diamond (50- to 75-µm
grit size) in a high-speed handpiece with water spray
provides for a more rapid removal of the discolored
enamel and has been referred to as macroabrasion.
a.
b.
c.
d.
Variation in fluoride content reflects the fact that bottling
of beverages utilizes the local water supply.
b and c.
c.
d.
Carbonated beverages are not a source for fluoride
ingestion.
Different sites of bottling production for carbonated
beverages can reveal different fluoride levels.
11
Full-coverage all-ceramic crowns.
Combined microabrasion/macroabrasion with vital
bleaching.
No treatment is necessary, the patient will have to live
with the yellow enamel shade.
Three quarter crown preparations then restored with
zirconia veneers.
Continuing Education
Management of Fluorosis Using Macro- and Microabrasion
PROGRAM COMPLETION INFORMATION
PERSONAL CERTIFICATION INFORMATION:
If you wish to purchase and complete this activity
traditionally (mail or fax) rather than online, you must
provide the information requested below. Please be sure to
select your answers carefully and complete the evaluation
information. To receive credit you must answer at least 12 of
the 16 questions correctly.
Last Name (PLEASE PRINT CLEARLY OR TYPE)
First Name
Profession / Credentials
Street Address
Complete online at: dentalcetoday.com
Suite or Apartment Number
TRADITIONAL COMPLETION INFORMATION:
Mail or fax this completed form with payment to:
City
Dentistry Today
E-mail Address
PAYMENT & CREDIT INFORMATION:
ANSWER FORM: COURSE #: 142
Examination Fee: $40.00 Credit Hours: 2.0
Please check the correct box for each question below.
Note: There is a $10 surcharge to process a check drawn on
any bank other than a US bank. Should you have additional
questions, please contact us at (973) 882-4700.
I have enclosed a check or money order.
I am using a credit card.
My Credit Card information is provided below.
American Express Visa MC Discover
(please print clearly):
1. a b c d
9. a b
c d
2. a b c d
10. a b
c d
3. a b c d
11. a b
c d
4. a b c d
12. a b
c d
5. a b c d
13. a b
c d
6. a b c d
14. a b
c d
7. a b c d
15. a b
c d
8. a b c d
16. a b
c d
PROGRAM EVAUATION FORM
Exact Name on Credit Card
Please complete the following activity evaluation questions.
/
Rating Scale: Excellent = 5 and Poor = 0
Expiration Date
Course objectives were achieved.
Content was useful and benefited your
clinical practice.
Review questions were clear and relevant
to the editorial.
Illustrations and photographs were
clear and relevant.
Written presentation was informative
and concise.
How much time did you spend reading
the activity and completing the test?
Signature
Approved PACE Program Provider
FAGD/MAGD Credit Approval
does not imply acceptance
by a state or provincial board of
dentistry or AGD endorsement.
June 1, 2009 to May 31, 2012
AGD Pace approval number: 309062
Zip Code
Fax Number With Area Code
Fax: 973-882-3622
Credit Card #
State
Daytime Telephone Number With Area Code
Department of Continuing Education
100 Passaic Avenue
Fairfield, NJ 07004
Please provide the following
License Number
Dentistry Today, Inc, is an ADA CERP Recognized
Provider. ADA CERP is a service of the American
Dental Association to assist dental professionals in
indentifying quality providers of continuing dental
education. ADA CERP does not approve or endorse
individual courses or instructors, nor does it imply
acceptance of credit hours by boards of dentistry.
Concerns or complaints about a CE provider may be
directed to the provider or to ADA CERP at
ada.org/goto/cerp.
12