Clinieal Communicaíion

Effect of enamel microabrasion compound on human gingiva:report of a caseTheodore P. Croll* / Constance M. Killian** / Arthur S. Miller***

A new material to be used in the proeedure of enamel microabrasion has been recentlyintroduced. Because the compound contains hydrochloric acid, the manufacturer recom-mends many safety precautions, especially use of the rubber dam. This case reportdocuments the effect of the enamel microabrasion compound on the gingiva of onehuman subject and verifies the need for careful handling of the material.(Quinfessence Int 1990:21:959-963.)

lotroduction

PRËMA compound (Premier Denfa! Producfs) is anacid-abrasive subsfance used in the procedure of eti-amel micioabrasion (Fig 1).'"' Applied wifh a lfl;1gear reduction angle and special mandrels, the sub-sfance has been used safely and successfully forhundreds of pafients in the past 4 years. Because thecompound contains hydrochlorit: acid, the manufac-turer states that enamel microabrasion with the com-pound should be performed only with rubber damisolation ofthe teeth, to prevent soft tissue contact byaccidental exposure of the material in the oral cavity.

This paper documents the effect of the microabra-sive when it was intentionally placed on the gingivaof the senior author.

* Private Practice, Pediatdc Dentistry, Doylestown. Pennsylva-nia; Clinical Associate Professor, Department of Pediatric Den-tistry, University of Pennsylvania, Schooi of Dental Medicine;Adjunct Clinical Professor, Department of Pediatric Dentistry,University of Texas, Health Science Center at Houston (DentalBranch).

" Private Practice, Pediatric Denlistrj, Doytestown, Pennsylva-nia.

" * Professor of Pathology, Temple University, School of Medi-cine, Philadelphia, Pennsylvania t9140.

Address all correspondence to Dr T. P. Croll, Georgetown Com-mcns. Suite 2, 708 Shady Retreat Road, Doylestown, Pennsylvania18901.

Methods and materials

Gingival sites in the maxilla of the senior author weredesignated as follows:

1. The labial free gingival margin of the maxillaryright lateral incisor

2. The labial free gingivai margin of the maxillaryright canine tooth

3. The attached labial gingiva above the maxillary leftlateral incisor

The pre-experimental condition of the gingiva wasunremarkable (Fig 2a). Clinicaily, there was no inflam-mation evident and gmgival color, texture, and con-sistency were within normal limits. Other oral findingswere unremarkable except for extrinsic brown sfainingof certain proximal axial enamel surfaces. The subjectadmitted to excessive coffee consumption probably re-lated to unremitting vocational stress.

The experiment proceeded as follows; The soff fis-sue exposure site was dabbed dry wifh a cotton gauzeimrnediately prior to apphcation of the compound.The barrel of a small metal amalgam carrier was filledwith PRËMA compound, and the material was ex-pressed on the gingival tissue of site 1. The portion ofcompound was gently compressed onto the gingivalsurface with a flat metal instrument (Fig 2b). After 15seconds of tissue exposure on site 1, the compoundwas rinsed with water spray for 30 seconds.

An identical procedure was used to expose site 2 toan amalgam carrier volume of PRËMA compound for30 seconds (Fig 2c). Thirty seconds of water rinsingfollowed.

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Clinieal Communication

Fig la This teenager has superficiai white décalcificationlesions associated with poor oral hygiene during past or-thodontic treatment.

Fig 1b Enamel microabrasion with PREMA compound isperformed according to the method of Croil.'-^

Fig 1c Because the white facial lesions were superficial,microabrasion has been successful in eliminating the dis-colored enamel.

Fig 2a The pre-experimental gingival condition. Experi-mental site 1 is the iabial free gingival margin of the max-illary lateral incisor. Site 2 is the free gingival margin ofthe canine tooth.

Fig 2b An amalgam carrier barrel load of PREMA com-pound is placed on the gingiva of sife 1, affer cotlon gauzehas been used to dry the tissue. The compound is com-pressed and lefl in piace for 15 seconds.

Fig 2c The compound is placed on site 2, compressed,and left for 30 seconds.

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Clinical Communication

Fig 3a Site 3 before exposure to the compound. Fig 3b The compound is applied to the cotton-dried at-tached gingiva and left in place for 30 seconds.

Site 3 (Fig 3a) was then dried and exposed to thecompound for 30 seconds (Fig 3b). A 30-second rinsewith water spray followed.

Photographs were recorded 5 minutes and 24 hourspostoperatively (Figs 4 and 5). Twenty-four hours afterexposure to the compound, the gingival lesion at site3 was excised with a No. 15 scalpel blade after admin-istration of xylocainc 2% local infiltration anesthesia(Fig 5b). The tissue specimen was placed in 10% for-malin and submitted to the Oral Pathology Labora-tory at Temple University School of Medicine for his-tologie analysis.

Results

Five minutes (Fig 4a) and 24 hours (Fig 4b) afterapplication, no visible soft tissue changes were ob-served at site 1. The subject had no sensitivity at anytime during the experiment or postoperative course.

At 5 minutes, the marginal gingiva at site 2 dem-onstrated a slight color change to white (Fig 4a},Twenty-four hours later, an ulcerated lesion with epi-thelial sloughing existed (Fig 4b). The subject had nosensitivity in the region during the procedure or at anypostexperimental time.

After 5 minutes, the gingiva exposed to the acid-abrasive compound at site 3 was slightly white, butthe subject experienced no sensitivity {Fig 5a). At 24hours, there existed an ulcerated lesiort with tissuesloughing that was similar to that at site 2 (Fig 5b).

Histologie analysis of the excised attached gingivaat site 3 revealed a surface devoid of squamous epi-thelium but covered by a fibrinous exúdate containingmany inflammatory cells. The underlying connecfive

tissue exhibited capillary dilatation and a heavy in-fiammatory cell infiltrate composed chiefly of neutro-phils (Fig 6).

Discussion

It is not surprising that 30 seconds of exposure toPRF.MA compound resulted in surface damage to gin-giva. Although the hydrochloric acid content of thecompound has been minimized in the formula, ac-cording to the manufacturer, the acid is still capableof creating soft tissue injury if the substance remainson the tissue for too long. The practitioner should useevery means to protect the patient from oral soft tissuecontact with the compound. The compound shouldbe handled in the mouth with the same precautionsthat are taken with acids used in restorative dentistry.Phosphoric acid liquid and gels in the 30% to 50%concentration range, used routinely in resin-bondingprocedures, are also known to cause soft tissue dam-age if contact is prolonged. However, it is noteworthythat 15 seconds of exposure to the microahrasioti com-pound resulted in no observable soft tissue alterationsin this case.

An experiment using one subject cannot be used tomake general claims based on the findings. However,the clinical and histologie observations in this case areconsistent with results obtained in animal mucosalexposure studies performed during product develop-ment (Kientzler G: Personal communication). Be-cause of the strong action of hydrochloric acid, evenin low concentrations, it is likely that this compoundwould react similarly on oral soft tissues of otherpeople. Therefore, the manufacturer's recommenda-

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Clinical Communication

Fig 4a Sites 1 and 2, 5 minutes after exposure to the m¡-croabrasive eompound toliowed by water rinsing. Note thewhite discoloration ot the free gingiva ot the canine tooth.

Fig 4b Sites 1 and 2, 24 hours atter exposure to ttie com-pound.

Fig 4c Sites 1 and 2, 48 hours after exposure to the com-pound.

Fig4d Sites 1 and 2, 7 days after exposure tc the com-pound.

Fig 5a Site 3, 5 minutes after a 30-second exposure foi-lowed by water rinsing. Note ttie slight white color changeof the exposed tissue.

Fig 5b Twenty-four hours after the 30-Becond exposure tothe compound, an ulcerated lesion is apparent. The lesionwas excised and submitted tor histoiogic analysis.

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Clinieal Communication

Fig 5c Three weeks after the gingival biopsy, the tissueshows excellent healing.

Fig 6a Photomicrograph showing the ulcerated surface(top center). Intact squamous epithelium is apparent at bothlateral margins. The dark blue cells in the center of thespecimen are neutrophilic infiltrates, (Hematoxylin and eos-in stain. Original magnitication '̂ 30.3.)

Fig 6b Photomicrograph showing fibrinous exúdate cov-ering the ulcerated surface (top center). Neutrophils anderythrocytes are trapped within this meshwork. Dilated cap-illaries are present in the connective tissue beneath theulcer. (Hematoxylin and eosin stain. Original magniticationX 30.3.)

tions regarding eye protection, use of rubber gloves,use of the 10:1 gear reduction handpiece angle toavoid splattenng during application, and especiallyuse of the rubber dam during the enamel microahra-siou procedure, should be followed cxactly.

Conclusions

In this subject, 15 seconds of gingival exposure toPRËMA microabrasive compound followed by 30 sec-onds of water nnsing was harmless. However, in thesame subject, 30 seconds of exposure of two gingivalsites to the compound caused soft tissue ulcérations.The gingival lesions produced by 30 seconds of ex-posure to the microabrasive compound healed withoutvisible trace within 7 days.

The manufacturer's safety recommendations aboutthe use of the compound for enamel microabrasion

are warranted. This is especially true in regard to useof the ruhber dam.

Author's NoteThe senior anthor acknowledges financial interest in PREMA com-pound by virtue of a licensing agreement with Premier Dental Prod-ucís Compati y.

Refere oces

1. Croll TP: Enamel microabrasion for removal of superficial éii-coXoízúon, J Eslhet Dent 1989:1:14^20.

2. Croll TP: Enamel microabrasion: Ihe technique. Quintessence tntÍ989;20:395^00,

Î. Croll TP: Enamel microabrasion for removal of superficial dys-mineralizulion and decalcificalion defects, / Am Dent Assoc 1950;120;411-415. Q

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