Clinical Efficacy of Resin Infiltration Technique Alone or in Combination with Micro Abrasion and in-Office Bleaching in Adults with Mild-to-Moderate Fluorosis Stains.

BACKGROUND: The present study was conducted to evaluate the clinical efficacy of resin infiltration technique alone or in combination with microabrasion and in-office bleaching in adults with mild-to-moderate fluorosis stains on permanent maxillary anterior teeth at the end of 1 month.
MATERIALS AND METHODS: A total of 30 patients with nonpitted fluorosis stains on maxillary anterior were classified as mild (n = 15) and moderate (n = 15). Each grade is subdivided into three groups as Group A, Group B, and Group C. Group 1: Mild (score 2), Subgroup A: Resin infiltration (n = 5 patients), Subgroup B: Microabrasion followed by resin infiltration (n = 5 patients), Subgroup C: Microabrasion and bleaching followed by resin infiltration after 2 weeks (n = 5 patients). Group 2: Moderate (score 3), Subgroup A: Resin infiltration (n = 5 patients), Subgroup B: Microabrasion followed by resin infiltration (n = 5 patients), and Subgroup C: Microabrasion and bleaching followed by resin infiltration after 2 weeks (n = 5 patients). Microabrasion was performed with the opalustre kit from Ultradent according to the manufacturer's instructions. Pola office bleaching from SDI and Icon infiltrant was performed. Stain score, improvement in appearance score, need for further treatment, patient satisfaction score, tooth sensitivity immediately after treatment, 24 h and 72 h were recorded.
RESULTS: The mean appearance score in Group 1A was 73.60, in Group 1B was 72.87, in Group 1C was 65.27, in Group 2A was 68.00, in Group 2Bwas 72.93 and in Group 2C was 84.73. The mean need for further treatment score in Group 1A was 72.80, in Group 1B was 78.40, in Group 1C was 68.73, in Group 2A was 71.20, in Group 2B was 79.53 and in Group 2C was 88.73. The mean patient satisfaction score in Group 1A was 91.40, in Group 1B was 95.20, in Group 1C was 98.00, in Group 2A was 90.20, in Group 2B was 99.40 and in Group 2C was 100.00. There was a significant difference in mean tooth sensitivity immediately after treatment between Groups 1A, 1B, 1C, 2A, 2B, and 2C. There was a significant difference in mean tooth sensitivity after 24 h between Groups 1A, 1B, 1C, 2A, 2B, and 2C.
CONCLUSION: Resin infiltration technique in combination with bleaching and microabrasion technique found to be effective in the management of dental fluorosis. Copyright:

INTRODUCTION

Tooth color is of esthetic importance to many individuals, especially if the discolorations are visible.[1] Dental fluorosis is a developmental disturbance of enamel caused by excessive fluoride on ameloblasts during enamel formation. Dental fluorosis is the result of chronic endogenic intake of fluorides in amounts exceeding the optimal daily dose of 1 ppm.[2]

Fluoride is an effective agent in preventing caries by inhibiting demineralization and stimulating remineralization of enamel.[3] A linear relationship exists between the amount and duration of fluoride ingested and the development and severity of dental fluorosis.[4] Long-term exposure and high doses of systemic fluorides can cause the enamel as well as dentin and cementum to become hypomineralized and more porous. Hypomineralized tissue frequently alternates with hypermineralized bands of enamel. Deeper layers of enamel can become severely hypomineralized, making the affected teeth increasingly fragile.[5]

Several treatment options, ranging from bleaching (less invasive) to full crowns (more invasive) have been used to treat dental fluorosis depending on the extent of enamel destruction.[6] Micro-and macro-abrasion have also been moderately successful, but this has the potential to remove greater amounts of tooth structure than needed or desired.[7] Treatment of moderate levels of fluorosis has been shown to be successful with veneers. More severe levels of fluorosis require more highly invasive procedures such as veneers and crowns, especially if there are mottling and loss of occlusal vertical dimension.[8] The micro-invasive resin infiltration procedure is a new technique developed as a preventive treatment to inhibit the progression of incipient white-spot carious lesions. Following the three-step process of etching, drying, and infiltrating the affected area with a resin, the end result has a positive outcome of improving the carious lesion by masking it.[9] The present study was conducted to evaluate the clinical efficacy of resin infiltration technique alone or in combination with micro abrasion and in-office bleaching in adults with mild-to-moderate fluorosis stains on permanent maxillary anterior teeth at the end of 1 month.

MATERIALS AND METHODS

This study was conducted in the department of Conservative Dentistry and Endodontics, SGT Dental College, Gurugram, Haryana. A total of 30 patients of age >18 years with nonpitted fluorosis stains, recruited from the hospital, were included in the study.

Inclusion criteria

Only the nonpitted fluorosis opacities were included for this purpose, opacities in anterior teeth shall be classified according to Russell's criteria for differentiating fluoride and nonfluoride opacities. Subjects classified/Teeth classified with Dental fluorosis score 2 and 3 according to Dean's classification of dental fluorosis 1942.

Exclusion criteria

History of allergy toward any dental material, teeth classified as nonfluoride opacities, subjects with fractured teeth maxillary central or lateral incisors, subjects with Class V carious lesions, smoking habit, pregnant, or lactating woman.

The consent form was taken from the patients after a detailed explanation of the procedure. A total of 30 patients with nonpitted fluorosis stains on the maxillary anterior were included and classified as mild (n = 15) and moderate (n = 15). Each grade is subdivided into three groups as Group A, Group B, and Group C. Group 1: Mild (score 2), Subgroup A: Resin infiltration (n = 5 patients), Subgroup B: Microabrasion followed by resin infiltration (n = 5 patients), Subgroup C: Microabrasion and bleaching followed by resin infiltration after 2 weeks (n = 5 patients). Group 2: moderate (score 3), Subgroup A: Resin infiltration (n = 5 patients), Subgroup B: Microabrasion followed by resin infiltration (n = 5 patients) and Subgroup C: Microabrasion and bleaching followed by resin infiltration after 2 weeks (n = 5 patients). All three treatment procedures were performed under rubber dam isolation. Enamel microabrasion will be performed with the opalustre kit from Ultradent according to the manufacturer's instructions. Similarly, pola office bleaching from SDI and Icon infiltrant from DMG Germany were used according to the manufacturer's instructions [Figures 1–3]. In cases of sensitivity, at the end of the procedure, topical desensitizing agents were prescribed to the patients.

Figure 1

Preoperative photograph showing moderate score 3 fluorosis

Figure 3

Postoperative photograph showing micro abrasion and bleaching followed by resin infiltration after 2 weeks

(a). Intraoperative photograph showing application of Icon Etchant. (b) Intraoperative photograph showing application of Icon Dry. (c): Intraoperative photograph showing Application of Icon resin

Stain score, improvement in appearance score, need for further treatment, patient satisfaction score, tooth sensitivity immediately after treatment, 24 h, 72 h, and 1 week were recorded. Results were tabulated and subjected to statistical analysis. Value of P < 0.05 was considered significant.

RESULTS

The mean change in stains was compared between Groups 1A, 1B, 1C, 2A, 2B, and 2C using the one-way ANOVA test. There was a significant difference in mean change in stains between Groups 1A, 1B, 1C, 2A, 2B, and 2C [Table 1].

Table 1

Change in stain score

Groups	Mean	SD	F	P
Group 1A	74.13	4.39	2.976	0.031*
Group 1B	77.27	8.83
Group 1C	70.33	8.86
Group 2A	70.27	6.89
Group 2B	77.07	12.41
Group 2C	86.93	2.72

SD: Standard deviation. *P value is significant

Table 2 shows that the mean improvement in appearance was compared between Groups 1A, 1B, 1C, 2A, 2B and 2C. There was a significant difference in mean improvement in appearance between Groups 1A, 1B, 1C, 2A, 2B, and 2C.

Table 2

Improvement in appearance

Groups	Mean	SD	F	P
Group 1A	73.60	4.49	4.564	0.005*
Group 1B	72.87	4.46
Group 1C	65.27	6.85
Group 2A	68.00	6.80
Group 2B	72.93	11.66
Group 2C	84.73	4.86

SD: Standard deviation. *P value is significant

The mean appearance score in Group 1A was 73.60, in Group 1B was 72.87, in Group 1C was 65.27, in Group 2A was 68.00, in Group 2B was 72.93 and in Group 2C was 84.73.

The mean need for further treatment score was compared between Groups 1A, 1B, 1C, 2A, 2B, and 2C [Table 3]. There was a significant difference in mean need for further treatment between Groups 1A, 1B, 1C, 2A, 2B, and 2C.

Table 3

Need for further treatment

Groups	Mean	SD	F	P
Group 1A	72.80	4.52	5.848	0.014
Group 1B	78.40	8.57
Group 1C	68.73	15.96
Group 2A	71.20	16.69
Group 2B	79.53	14.41
Group 2C	88.73	4.88

SD: Standard deviation

The mean need for further treatment score in Group 1A was 72.80, in Group 1B was 78.40, in Group 1C was 68.73, in Group 2A was 71.20, in Group 2B was 79.53 and in Group 2C was 88.73.

The mean patient satisfaction score was compared between Groups 1A, 1B, 1C, 2A, 2B, and 2C. There was a significant difference in mean patient satisfaction score between Groups 1A, 1B, 1C, 2A, 2B, and 2C. The mean patient satisfaction score in Group 1A was 91.40, in Group 1B was 95.20, in Group 1C was 98.00, in Group 2A was 90.20, in Group 2B was 99.40, and in Group 2C was 100.00 [Tables 4 and 5].

Table 4

Tooth sensitivity

Groups	After 24 h	After 72 h	1 week	P
Group 1A	0.00	0.00	0.00	0.005
Group 1B	11.40	0.00	0.00
Group 1C	30.20	8.60	0.00
Group 2A	5.20	1.40	0.00
Group 2B	19.60	15.20	0.00
Group 2C	31.40	14.60	0.00

Table 5

Patient satisfaction score

Groups	Mean	SD	F	P
Group 1A	91.40	3.44	5.012	0.003
Group 1B	95.20	3.56
Group 1C	98.00	4.47
Group 2A	90.20	7.56
Group 2B	99.40	1.34
Group 2C	100.00	0.00

SD: Standard deviation

The mean tooth sensitivity immediately after treatment was compared between Groups 1A, 1B, 1C, 2A, 2B, and 2C [Table 6]. There was a significant difference in mean tooth sensitivity immediately after treatment between Groups 1A, 1B, 1C, 2A, 2B, and 2C. The mean tooth sensitivity immediately after treatment in Group 1A was 0.00, in Group 1B was 23.40, in Group 1C was 55.80, in Group 2A was 14.20, in Group 2B was 15.40, and in Group 2C was 52.40.

Table 6

Tooth sensitivity immediately after treatment

Groups	Mean	SD	F	P
Group 1A	0.00	0.00	11.146	<0.001
Group 1B	23.40	15.08
Group 1C	55.80	17.36
Group 2A	14.20	19.60
Group 2B	15.40	14.52
Group 2C	52.40	15.18

SD: Standard deviation

The mean tooth sensitivity after 24 h, 72 h was compared between Groups 1A, 1B, 1C, 2A, 2B and 2C. The mean tooth sensitivity after 24 h in Group 1A was 0.00, in Group 1B was 11.40, in group 1C was 30.20, in Group 2A was 5.20, in Group 2B was 19.60, and in Group 2C was 31.40. There was a significant difference in mean tooth sensitivity after 24 h between groups 1A, 1B, 1C, 2A, 2B, and 2C.

DISCUSSION

Fluorosis Index, developed by H. T. Dean in 1942, is the gold standard in classifying the varying degrees of severity of dental fluorosis.[10] The six scores according to their clinical signs are 0 for normal or unaffected teeth that have a smooth, uniform, creamy white surface, 0.5 for teeth that are questionable and have some white flecks or spots, 1 for very mild where <25% of the tooth is covered with small white opaque areas, 2 for mild where no more than 50% of the tooth is covered with white opaque areas, 3 for moderate where more than 50% of the entire tooth surface is affected and may have brown staining, and 4 for teeth that are severely corroded or pitted and often have brown staining affecting 100% of the enamel surface. A single source of fluoride or usually a combination of different factors can cause different degrees of severity of dental fluorosis.[11] The present study was conducted to assess the clinical efficacy of resin infiltration technique alone or in combination with micro abrasion and in-office bleaching in adults with mild to moderate fluorosis stains on permanent maxillary anterior teeth.

In the present study, the mean stain score in Group 1A was 74.13, in Group 1B was 77.27, in Group 1C was 70.33, in Group 2A was 70.27, in Group 2B was 77.07 and in Group 2C was 86.93. Treatment of moderate levels of fluorosis has been shown to be successful with veneers. More severe levels of fluorosis require more highly invasive procedures such as veneers and crowns, especially if there is mottling and loss of occlusal vertical dimension.[12]

We found that the mean appearance score in Group 1A was 73.60, in Group 1B was 72.87, in Group 1C was 65.27, in Group 2A was 68.00, in Group 2B was 72.93 and in Group 2C was 84.73. The mean need for further treatment score in Group 1A was 72.80, in Group 1B was 78.40, in Group 1C was 68.73, in Group 2A was 71.20, in Group 2B was 79.53 and in Group 2C was 88.73.

The mean patient satisfaction score in Group 1A was 91.40, in Group 1B was 95.20, in Group 1C was 98.00, in Group 2A was 90.20, in Group 2B was 99.40 and in Group 2C was 100.00. Various studies have revealed that low-viscosity resins decreased visibility of white-spot lesions as a supplementary positive influence due to a similar refractive index to that of enamel. Few studies have also demonstrated the usefulness of this technique in monitoring incipient caries advancement and on proximal lesions and it could constrain further demineralization of white-spot lesions that developed at the time of orthodontic treatment. However, little is known about the action of the technique on the white spots of fluorosis, and the effect of this treatment is considered with other treatment modalities such as micro-abrasion and bleaching.[1314]

The mean tooth sensitivity after 24 h, 72 h was compared between Groups 1A, 1B, 1C, 2A, 2B and 2C. The mean tooth sensitivity after 24 h in Group 1A was 0.00, in Group 1B was 11.40, in Group 1C was 30.20, in Group 2A was 5.20, in Group 2B was 19.60 and in Group 2C was 31.40. Bharath et al.[15] conducted an in vitro study and compared two techniques of enamel stain removal on fluorosed teeth and concluded that both immediate and long term (6 months) esthetic enhancement attained by McInnes bleaching were greater to enamel microabrasion. There is decrease in the esthetics of dentition in both the techniques after 6 months, which was marginal with McInnes technique and substantial in enamel microabrasion. Postoperative sensitivity in both techniques was minimal. The sensitivity perceived were transitory and receded within a month postoperatively. Sensitivity was not reported by any subjects at 1, 3, and 6 months intervals.

The limitation of the study is the small sample size.

CONCLUSION

Authors found that resin infiltration technique in combination with bleaching and microabrasion technique found to be effective in the management of dental fluorosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.