ManagementofFluorosis UsingMacro-and …dentifrices,ﬂuoridemouth-rinses,softdrinks,andreconstitutedjuices, amongothersources,itisnotsurprising thattheincidenceofﬂuorosisintheUnited

Continuing Education

Management of FluorosisUsing Macro- and

MicroabrasionAuthored by Howard E. Strassler, DMD;

Autumn Griffin, DDS; and Margrit Maggio, DMD

Course Number: 142

Upon successful completion of this CE activity 2 CE credit hours may be awarded

A Peer-Reviewed CE Activity by

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.

Dentistry Today, Inc, is an ADA CERP Recognized Provider. ADA CERP isa service of the American Dental Association to assist dental professionalsin indentifying quality providers of continuing dental education. ADA CERPdoes not approve or endorse individual courses or instructors, nor does itimply acceptance of credit hours by boards of dentistry. Concerns orcomplaints about a CE provider may be directed to the provider or toADA CERP at ada.org/goto/cerp.

Approved PACE Program ProviderFAGD/MAGD Credit Approvaldoes not imply acceptanceby a state or provincial board ofdentistry or AGD endorsement.June 1, 2009 to May 31, 2012AGD Pace approval number: 309062

LEARNING OBJECTIVESAfter 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 AUTHORSDr.Strassler is a professor, in theDivision ofOperative Dentistry, Department of Endo-dontics, Prosthodontics and OperativeDentistry, University of Maryland DentalSchool, Baltimore, Md. He can be reachedvia e-mail at [email protected].

Disclosure: Dr. Strassler reports no disclosures.

Dr. Griffin is a resident in the generalpractice dental residency, New HavenHospital, Yale University, New Haven,Conn. She can be reached [email protected].

Disclosure: Dr. Griffin reports no disclosures.

Dr. Maggio is an assistant professor,clinician educator and the director ofoperative dentistry, Department ofPreventive and Restorative Sciences,University of Pennsylvania School ofDental Medicine, Philadelphia, Pa. She

can be reached at [email protected].

Disclosure: Dr. Maggio reports no disclosures.

INTRODUCTIONWater fluoridation is considered to be one of the significantpublic health measures of the 20th century.1 During toothdevelopment, fluoride becomes incorporated into theenamel matrix as fluorapatite, making the enamel moreresistant to acid attack by bacteria and subsequent toothdemineralization. Further, fluoride is protective of enamel forerupted teeth through an equilibrium of demineralization-remineralization during early caries formation. Through theuse of water fluoridation there has been a significant declinein dental caries in the United States.2

Despite the evidence that supports the benefits offluoride in caries prevention, when higher than necessarylevels of fluoride are present, enamel fluorosis can pose anaesthetic problem for some patients. This article willdiscuss enamel fluorosis, the aesthetic challenges it canpresent for certain patients, and a conservative aesthetictreatment modality for a patient who presented with mild tomoderate fluorosis.

ENAMEL FLUOROSISDental fluorosis is defined as hypomineralization of enamelresulting from excessive ingestion of fluoride during toothdevelopment. It is characterized by diffuse opacities on theenamel surface. These are differentiated from otherconditions by the characteristic bilaterally symmetricdistribution of the enamel defects. The degree to which theenamel is affected is dependent upon the duration, timing,and intensity of the fluoride concentration.1,3 In its mildform, most commonly the teeth present with small whitestreaks and the enamel appears mottled (Figure 1). As theseverity of the condition increases, black and brown stainsdevelop. Moderate fluorosis will demonstrate white


1

Recommendations for Fluoride Varnish Use in Caries Management

Management of Fluorosis UsingMacro- and MicroabrasionEffective Date: 10/1/2011 Expiration Date: 10/1/2013

Figure 1.An example of mildfluorosis discoloration.

streaking with brownish staining (Figure 2). Severe fluorosishas the appearance of very dark brown staining and insome cases enamel surface defects (Figure 3).

For a small number of patients, the degree of fluorosiscan be an aesthetic concern.3-5 The primary author hasfound over the years that in many cases, patients with verymild and mild to moderate fluorosis are not aware of theminor discoloration present and have no aesthetic concerns.In those cases where patients have moderate to severefluorosis, the discoloration can be of aesthetic concern.

Fluorosis is a developmental phenomenon of theenamel that presents in both primary and permanent teeth.The origins of fluorosis are not completely understood;however, current research suggests that superfluousamounts of fluoride cause retention of amelogenin proteinsin the developing tooth structure, thereby inhibiting enamelmaturation. This interference results in porosities in theenamel at the time of tooth eruption. Specifically, recentanimal and human studies indicate that the role of fluorideis likely due to its interaction with Ca2+ ions; excess Fintake has been shown to indirectly reduce the amount ofavailable Ca2+ ions, which in turn limits the number ofcalcium-dependent proteases available to remove enamelmatrix proteins. This elimination of enamel matrix proteinsis necessary for adequate enamel maturation.6-9

Studies in United States school children have reportedfluorosis as high as 50% to 60% in the 1980s and in therange of 40% to 48% through the 1990s and 2000s.8,10-14

Dental fluorosis has been evaluated by the US Departmentof Health and Human Services Centers for Disease Controland Prevention (CDC) and Prevention National Center ofHealth Statistics using the dental fluorosis classificationdescribed by Dean (Table 1).The findings were characterizedas unaffected, questionable, very mild, mild, andmoderate/severe. From the data reported for dental fluorosisfor adolescents and adults from 1999 to 2002, the majority ofpersons examined were either unaffected or hadquestionable fluorosis (Table 2). For persons with a diagnosisof dental fluorosis, the rate that was mild was twice asprevalent for 16- to 19-year-olds when compared to 20- to 39-year-olds (6.7% versus 3.3%). Moderate/severe fluorosisalso was higher for the 16- to 19-year-olds when comparedto the 20 to 39 year olds (4.0% versus 1.8%).14

MULTIPLE SOURCES OF FLUORIDERecommendations for fluoride supplements for children andadolescents have been endorsed by the ADA and theAcademy of Pediatric Dentistry for many years. In 1994, achange in the recommendations for fluoride supplementsbased upon the child’s age was made in response toconcerns about the increase in the prevalence offluorosis.1,15,16 These changes are noted in Table 3.

The majority of fluoride ingestion is typically thought tobe through foods, beverages, and supplements.17-24 Wateris the primary provider of fluoride. Recommendations fortotal dietary fluoride intake should be calculated basedupon body weight using the formula of 0.05 mg/kg/day.25 Ananalysis of fluoride exposures and ingestion from multiplesources may be responsible for higher than optimalamounts of fluoride required for caries prevention.26,27

Even children in nonfluoridated areas benefit from foodsand beverages processed in fluoridated areas.28 Sourcesof fluoride exposure and ingestion for children from dietaryand nondietary sources include toothpastes,4,26,29-32

carbonated soft drinks,22 infant formula,4,33,34 prescribedsupplements,26,28,35,36 and fluoride mouthrinses and gels.Recent recommendations concerning use of reconstitutedinfant formula and a fluoridated dentifrice point to therecommendation that parents monitor their use.4

Heilman and coworkers22 examined the fluoride content


2

Management of Fluorosis Using Macro- and Microabrasion

Figure 2.An example of moderatefluorosis staining.

Figure 3.An example of severefluorosis staining andenamel surface defects.

of 332 carbonated beverages in Iowa. Theirresults revealed that fluoride levels rangedfrom 0.02 to 1.28 parts per million (ppm) witha mean level of 0.72 ppm. Fluoride levelsexceeded 0.60 ppm for 71% of the products.Further, from this study no generalizationcould be made about same company/sameproduct results. Different sites of bottlingproduction revealed different fluoride levels.Variation in fluoride content reflects the factthat bottling of beverages utilizes the localwater supply.

It is difficult to monitor fluoride ingestionlevels for children.When one considers thatfluoride uptake can occur from the watersupply, prescribed fluoride supplements,infant formula, dentifrices, fluoride mouth-rinses, soft drinks, and reconstituted juices,among other sources, it is not surprisingthat the incidence of fluorosis in the UnitedStates has been increasing.34,37-41

Further, with the increase in newimmigrants to the United States, fluorosiscan be observed due to endemic fluorosisin other countries.42-50 For example, anunusual source of fluoride (not from foodsor beverages) has been reported in Kenyaand affects other east African nations aswell. A 1986 epidemiological study ofdental fluorosis in Kenya stated that in fact“dental fluorosis has been endemic toEastern Africa and in particular Kenya formany years since the Great Rift Valley,which is known to have volcanic activity,passes through Kenya.” Although it isbelieved that the main source of fluoride is from the drinkingwater (in some rural parts of Kenya there are 2 ppm fluoridein the drinking water with the corresponding incidence offluorosis being 100%), the volcanic soil of Kenya has beenfound to also have very high concentrations of fluoride. Dur-ing the dry season in Kenya, the dust contains fluorideconcentrations between 2,800 ppm and 5,600 ppm.51

MINIMALLY INVASIVE AESTHETIC TREATMENTOPTIONS FOR MILD TO MODERATE DENTALFLUOROSISConcerns about the aesthetic appearance of teeth with fluorosishave led to proposed new guidelines for fluoridation of drinkingwater.52 The goal of fluoride supplements is to provide anoptimal amount of fluoride to reduce the risk of dental caries.


3


SCORE CRITERIA

Normal The enamel represents the usual translucent semivitriformtype of structure. The surface is smooth, glossy, and usuallyof a pale creamy white color.

Questionable The enamel discloses slight aberrations from thetranslucency of normal enamel, ranging from a few whiteflecks to occasional white spots. This classification isutilized in those instances where a definite diagnosis of themildest form of fluorosis is not warranted and aclassification of “normal" is not justified.

Very Mild Small, opaque, paper-white areas scattered irregularly overthe tooth but not involving as much as 25% of the toothsurface. Frequently included in this classification are teethshowing no more than about one to 2 mm of white opacityat the tip of the summit of the cusps of the bicuspidsor second molars.

Mild The white opaque areas in the enamel of the teeth aremore extensive but do not involve as much as 50%of the tooth.

Moderate All enamel surfaces of the teeth are affected, and thesurfaces subject to attrition show wear. Brown stain isfrequently a disfiguring feature.

Severe Includes teeth formerly classified as “moderately severeand severe.” All enamel surfaces are affected andhypoplasia is so marked that the general form of the toothmay be affected. The major diagnostic sign of thisclassification is discrete or confluent pitting. Brown stainsare widespread and teeth often present acorroded-like appearance.

Source: Dean HT, 1942. Health Effects of Ingested Fluoride. Washington, DC: NationalAcademy of Sciences; 1993:169.

Table 1. Criteria for Dean’s Fluorosis Index

Recent recommendations reflectchanges from the previous levelsof fluoride to a more optimallevel of fluoride of 0.7 mg/L.52

These changes reflect the factthat the ingestion of fluoridecan come from multiplesources, resulting in a need fora lower level of fluoride inoptimally fluoridated drinkingwater. The recommendationsalso take into account that fluoride supplements need onlybe considered for patients at moderate to high risk fordental caries and even then may be unnecessary if patientsare receiving adequate fluoride from other sources.

The majority of patients with fluorosis have mild and verymild conditions. Depending on the severity of fluorosis and itsclinical appearance, restorative treatments can change theaesthetic appearance of teeth. Decisions for changes shouldbe based upon the patient’s perception regarding whetherthere is a need for treatment. Fluorosis staining is within theenamel. In cases of mild fluorosis, the enamel discoloration issuperficial. For moderate and severe fluorosis, the enamelstaining and mottling can penetrate to deeperenamel levels. For cases of mild fluorosis ofaesthetic concern to the patient, vitalbleaching can be successful in achieving achange that the patient desires.53 When thepatient presents with mild-moderate flourosis,there may be the need for a microabrasion ormacroabrasion technique.

Microabrasion refers to the use of ahydrochloric acid abrasive paste to removethe superficial enamel staining.54-57 Inthose cases where the fluorosis may bedeeper in the superficial enamel but stillmild in discoloration, a combined use of afine abrasive diamond (50- to 75-µm gritsize) in a high-speed handpiece with waterspray provides for a more rapid removal ofthe discolored enamel and has beenreferred to as macroabrasion.58 When thesuperficial enamel is removed, the white

speckled mottling of enamel reveals a more yellow enamelcolor beneath the surface. For some patients, the loss of thewhite speckled enamel to yellow is not acceptable. Forthese cases, a combined microabrasion/macroabrasionwith vital bleaching is an aesthetically acceptabletreatment.59,60

CASE REPORTA 20-year-old female patient was screened at the dentalclinic for routine dental care. Her chief complaint was toremove and/or minimize the noticeable brown/yellowstaining of her teeth. She wanted the least invasive and


4


Age Group Unaffected Questionable Very Mild Mild Moderate/Severe

6 to 11 59.8% 11.8% 19.8% 5.8% 2.7%

12 to 15 51.5% 12.0% 25.3% 7.7% 3.6%

16 to 19 58.3% 10.2% 20.8% 6.7% 4.0%

20 to 39 74.9% 8.8% 11.1% 3.3% 1.8%

Table 2. Dental Fluorosis in the United States 1999 to 2002, BasedUpon Characteristics—CDC Data (from cdc.gov.mmwr/PDF/ss/ss5403.pdf)

1979 Concentration of Fluoride Ion in Drinking Water (ppm)

Age < 0.3 0.3 to 0.7 > 0.7

2 weeks to 2 years 0.25 mg/day none none

2 to 3 years 0.50 mg/day 0.25 mg/day none


1994 Concentration of Fluoride Ion in Drinking Water (ppm)

Age < 0.3 0.3 to 0.6 > 0.6

Birth to 6 months none none none

6 months to 3 years 0.25 mg/day none none



Table 3. Changes in Flouride SupplementDosage Schedule, 1979 and 19941,15,16

most cost effective treatment to change her smile. A reviewof her medical history and past dental history revealed nocontraindications to dental treatment. In consideration ofher age, the patient was not interested in treatment optionsthat involved significant removal of tooth structure, such asporcelain or composite resin veneers which had previouslybeen suggested to her from her previous dentist. Thepatient’s desire to change the appearance of her teeth inthe aesthetic zone was to improve her smile and therebyher confidence. From the appearance of her teeth, adiagnosis of mild to moderate fluorosis staining(determined by using Dean’s Fluorosis Index) was presenton the anterior and posterior teeth in the aesthetic zone(white mottled enamel hypomineralization), with the mostsignificant staining occurring on the maxillary anterior teeth;teeth Nos. 8 and 9 contained dark brown streaks in themiddle third of the facial surfaces (Figure 4).

A review of her past history and a complete dentalexamination revealed her country of origin as Kenya. Shereported childhood friends as having the same discolorationof their teeth. As previously noted, Kenya is associated withendemic fluorosis. A treatment plan was presented to thepatient that would fulfill her request for minimally invasivetreatment which proposed macroabrasion/microabrasion ofthe superficial enamel staining. Upon completion oftreatment, the tooth shade would be evaluated. If the patientdesired further whitening, it was decided that at-homebleaching treatment would be provided.

Phase 1: Enamel Abrasion PhaseAfter receiving a routine oral prophylaxis, the maxillary teethin the aesthetic zone (Nos. 4 to 13) were isolated with adental dam to protect the gingival tissues when the acidicmicroabrasion paste was to be used (Figure 5). A combinedenamel macroabrasion/microabrasion technique wasdecided to be the most effective way to treat thehypomineralized defects of the maxillary first premolars,canines, lateral and central incisors. Enamel macroabrasionrefers to the use of either medium or fine grit diamondabrasives or multifluted finishing burs with a high-speedhandpiece with air-water spray to remove the superficial layerof the enamel.58,60 Enamel microabrasion refers to the use

of a low concentration acid combined with an abrasive agentas a water soluble gel or paste that would be applied to theenamel surface with an extremely low-speed rotary


5


Figure 4.Preoperative view ofmoderatefluorosis with patientdesiring a color changeand treatment.

Figure 5.Dental dam applied.

Figure 6.Macroabrasion of thefacial surfaces of theteeth using a 50-µm gritfine diamond with a high-speed handpiece with air-water spray.

Figure 7.Application of Opalustremicroabrasion paste(Ultradent Products).

Figure 8.Rubbing themicroabrasion paste intothe enamel surfaces ofthe maxillary incisorswith specialized brushembedded in cup at aspeed of 1,000 rpm.

handpiece pressure applicator for precise compression of thecompound on the tooth surface so that splattering of thecompound would be eliminated or minimized.

For this case, speed reduction was accomplished withan electric handpiece (Bien-Air Dental). Specialized torqueconverter speed reduction adapters can also be used. Useof the ultra-low-speed rotary application makes theprocedure safer, easier, and quicker.60,61 The currentformulation for microabrasion pastes is a low concentrationhydrochloric acid (6.6%), silicon carbide abrasive, and silicagel as a binding agent. This paste in fact etches the enamelsurface more aggressively than the use of phosphoric acidused for adhesive restorative dentistry.61

To accomplish macroabrasion/microabrasion, the facialsurfaces of the treated teeth were lightly abraded with aflame-shaped fine grit (50 µm) diamond (8862F [BrasselerUSA]) using a high-speed handpiece with air-water spray(Figure 6) to remove the superficial enameldysmineralization layer to a depth of approximately 0.2 to0.3 mm. After completion of the rotary macroabrasion, themicroabrasion paste (Opalustre [Ultradent Products]) wasapplied to the facial surfaces of the treated maxillary teeth(Figure 7). Using a right angle latch type slow-speed hand-piece running the motor at 1,000 rpm, a hybrid bristlebrush-cup was used to apply the microabrasion paste for 3separate applications of 30 to 40 seconds each (Figure 8).Between each application the microabrasion paste wasrinsed and dried from the tooth surfaces (Figure 9). Thisprocedure was repeated 3 times (Figure 10). At thecompletion of the macroabrasion/microabrasion techniquethe etched enamel surfaces were polished with a cup-shaped porcelain polishing rubber abrasive (Jazz [SSWhiteBurs]) to smooth and polish the enamel surface (Figure 11).To remineralize the acid attached enamel surface the teethwere treated with a topical sodium fluoride (NuPro[DENTSPLY International]) in a fluoride tray. Then anamorphous calcium phosphate paste (MI Paste Plus [GCAmerica]) was rubbed onto the enamel surfaces with agloved finger.

The dental dam was removed and the patient viewed theresult of treatment. She was pleased with the result from theimmediate removal of the dark staining on her maxillaryanterior teeth (Figure 12). The patient was informed that

because of the dental dam isolation and the etching processof the microabrasion paste, evaluation of the final color andappearance of the teeth was to be done one week after


6


Figure 9.Appearance of teeth afterthe first application.

Figure 10.Appearance of teeth afterthird application.

Figure 11.Polishing the etchedenamel surfaces witha porcelain polishingrubber abrasive (Jazz[SS White Burs]).

Figure 12.Postoperative view ofmacroabrasion/micro-abrasion treatment.

Figure 13.Postoperative viewafter 4 weeks of traybleaching.

treatment. In case there would be the need for postoperativetooth bleaching, maxillary and mandibular impressions weremade for subsequent bleaching tray fabrication if indicated.The patient did not return until 3 weeks after treatmentbecause of travel plans.

Phase 2: Tray BleachingThe second phase of the treatment was initiatedapproximately 3 weeks later (the patient traveled back toKenya in the interim). Using a Classical Vita Shade Guide(Vident) it was determined that the teeth treated were nowpredominantly an A2 shade. When removing the superficialbrownish-white enamel dysmineralization hypomineralization,it is not unusual for the final shade of the teeth to be slightlyyellower than the original appearance (whitish speckleddiscoloration due to fluorosis of the teeth). This was observedwith this patient.The patient elected to whiten her teeth furtherusing vital tray bleaching.

Fabricated bleaching trays were delivered to the patientalong with a 15% carbamide peroxide with potassiumnitrate and fluoride bleaching gel (Opalescence 15%PF[Ultradent Products]) to be used with overnight applicationeach night for 4 weeks. The patient was told that if she wasunable to bleach overnight to use the bleaching trays for atleast 2 hours each day. During bleaching, the patientreported mild sensitivity to the initial bleaching application.She treated the tooth sensitivity using a recommendationof placing a desensitizing toothpaste (Sensodyne[GlaxoSmithKline]) in the bleaching tray one hour prior tobleaching,62 then cleaning the tray of the toothpaste andcontinuing with the bleaching regimen. One week of usingthe desensitizing toothpaste was all that was necessary tocontrol the sensitivity.

The patient reported being able to follow the overnightregimen of bleaching. After 4 weeks, the tooth shade and

appearance was evaluated and determined to be a shadeB1 (Figure 13). The patient was pleased with the finalaesthetic result.

CONCLUSIONTooth discoloration due to fluorosis is an aesthetic problemfor certain patients. While there is a range of restorativeinterventions that can be used to change the appearance offluorosed teeth, the goal of minimally invasive treatment formild-moderate fluorosis is the one that should be evaluatedfirst. For the case presented in this article, a minimallyinvasive treatment option of macroabrasion/microabrasionfollowed by tooth whitening with bleaching trays was shownto be a satisfactory approach for the aesthetic treatment ofmoderate fluorosis. In the United States, newrecommendations for reducing the optimal level of fluoridefor water fluoridation are addressing aesthetic concernswithout putting teeth at risk for caries.

The current evidence demonstrates that when a diagnosisof fluorosis has beenmade, the majority of cases are very mildor mild and do not pose aesthetic problems that requiretreatment unless it is of concern to the patient. For the primaryauthor, in cases where fluorosis is evident for a child, it istypically the parent who has identified the discoloration andhas questions about the appearance of the teeth. For somemild fluorosis discoloration and for moderate/severe fluorosiselective treatment to change the aesthetic appearance of theteeth can many times be accomplished with minimally invasivetreatment using vital bleaching or combinations ofmacroabrasion/microabrasion with bleaching to provide thepatient with an aesthetically acceptable result.For more severefluorosis with dark discolorations and surface pitting, adhesiverestorative dentistry may be necessary to fulfill a patient’saesthetic desires.


7


REFERENCES1. Centers for Disease Control and Prevention. Achievements

in public health, 1900-1999: fluoridation of drinking water toprevent dental caries. JAMA. 2000;283:1283-1286.

2. Ismail AI, Hasson H. Fluoride supplements, dental cariesand fluorosis: a systematic review. J Am Dent Assoc.2008;139:1457-1468.

3. Aoba T, Fejerskov O. Dental fluorosis: chemistry and biology.Crit Rev Oral Biol Med. 2002;13:155-170.

4. Levy SM, Broffitt B, Marshall TA, et al. Associations betweenfluorosis of permanent incisors and fluoride intake frominfant formula, other dietary sources and dentifrice duringearly childhood. J Am Dent Assoc. 2010;141:1190-1201.

5. Martins CC, Feitosa NB, Vale MP, et al. Parents’ perceptionsof oral health conditions depicted in photographs of anteriorpermanent teeth. Eur J Paediatr Dent. 2010;11:203-209.

6. Wright JT, Chen SC, Hall KI, et al. Protein characterization offluorosed 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 andseverity of dental fluorosis in the United States, 1999-2004.NCHS Data Brief. 2010;(53):1-8.

9. Cutress TW, Suckling GW. Differential diagnosis of dentalfluorosis. J Dent Res. 1990;69(special issue):714-721.

10. Centers for Disease Control and Prevention.Recommendations for using fluoride to prevent and controldental caries in the United States.MMWR Recomm Rep.2001;50(RR-14):1-42.

11. Oral Health in America: A Report of the Surgeon General.Rockville, MD: US Department of Health and HumanServices; 2000. surgeongeneral.gov/library/oralhealth.Accessed June 20, 2011.

12. Clark DC. Trends in prevalence of dental fluorosis in NorthAmerica. Community Dent Oral Epidemiol. 1994;22:148-152.

13. Rozier RG. The prevalence and severity of enamel fluorosisin North American children. J Public Health Dent.1999;59:239-246.

14. Beltrán-Aguilar ED, Barker LK, Canto MT, et al; Centers forDisease Control and Prevention. Surveillence for dentalcaries, dental sealants, tooth retention, edentulism, andenamel 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.

15. Dosage schedule for dietary fluoride supplements.Proceedings of a workshop. Chicago, Ill. January 31 toFebruary 1, 1994. J Public Health Dent. 1999;59:203-281.

16. American Academy of Pediatrics. Committee on Nutrition.Fluoride supplementation: revised dosage schedule.Pediatrics. 1979;63:150-152.

17. Berg J, Gerweck C, Hujoel PP, et al. Evidence-based clinicalrecommendations regarding fluoride intake fromreconstituted infant formula and enamel fluorosis: a report ofthe American Dental Association Council on ScientificAffairs. J Am Dent Assoc. 2011;142:79-87.

18. Steinmetz JE, Martinez-Mier EA, Jones JE, et al. Fluoridecontent of water used to reconstitute infant formula. ClinPediatr (Phila). 2011;50:100-105.

19. American Dental Association. Accepted Dental Therapeutics.33rd-40th eds. Chicago, IL: Council on Dental Therapeuticsof the American Dental Association; 1969/1970-1984:399-402.

20. Marya CM, Dhingra S, Marya V, et al. Relationship of dentalcaries at different concentrations of fluoride in endemicareas: an epidemiological study. J Clin Pediatr Dent.2010;35:41-45.

21. Thippeswamy HM, Kumar N, Anand SR, et al. Fluoridecontent in bottled drinking waters, carbonated soft drinksand fruit juices in Davangere city, India. Indian J Dent Res.2010;21:528-530.

22. Heilman JR, Kiritsy MC, Levy SM, et al. Assessing fluoridelevels of carbonated soft drinks. J Am Dent Assoc.1999;130:1593-1599.

23. Levy SM, Guha-Chowdhury N. Total fluoride intake andimplications for dietary fluoride supplementation. J PublicHealth Dent. 1999;59:211-223.

24. Levy SM, Kiritsy MC, Warren JJ. Sources of fluoride intake inchildren. J Public Health Dent. 1995;55:39-52.

25. Institute of Medicine. Fluoride. In: Dietary Reference Intakesfor Calcium, Phosphorus, Magnesium, Vitamin D, andFluoride. Washington, DC: National Academy Press;1997:288-313.

26. Levy SM. Review of fluoride exposures and ingestion.Community Dent Oral Epidemiol. 1994;22:173-180.

27. Rodrigues MH, Leite AL, Arana A, et al. Dietary fluorideintake by children receiving different sources of systemicfluoride. J Dent Res. 2009;88:142-145.

28. Levy SM, Warren JJ, Davis CS, et al. Patterns of fluorideintake from birth to 36 months. J Public Health Dent.2001;61:70-77.

29. Franzman MR, Levy SM, Warren JJ, et al. Fluoride dentifriceingestion and fluorosis of the permanent incisors. J Am DentAssoc. 2006;137:645-652.

30. Moraes SM, Pessan JP, Ramires I, et al. Fluoride intake fromregular and low fluoride dentifrices by 2-3-year-old children:influence of the dentifrice flavor.Braz Oral Res. 2007;21:234-240.

31. de Almeida BS, da Silva Cardoso VE, Buzalaf MA. Fluorideingestion from toothpaste and diet in 1- to 3-year-oldBrazilian children. Community Dent Oral Epidemiol.2007;35:53-63.


8


32. Oliveira MJ, Paiva SM, Martins LH, et al. Fluoride intake bychildren at risk for the development of dental fluorosis:comparison of regular dentifrices and flavoured dentifricesfor children. Caries Res. 2007;41:460-466.

33. Walton JL, Messer LB. Dental caries and fluorosis in breast-fed and bottle-fed children. Caries Res. 1981;15:124-137.

34. Pendrys DG, Katz RV, Morse DE. Risk factors for enamelfluorosis in a fluoridated population. Am J Epidemiol.1994;140:461-471.

35. Marthaler RM. Fluoride supplements for systemic effects incaries prevention. In: Johansen E, Taves DR, Olsen TO, eds.Continuing Evaluation of the Use of Fluorides. Boulder, CO:Westview Press; 1979:33-59.

36. Levy SM, Kiritsy MC, Slager SL, et al. Patterns of dietaryfluoride supplement use during infancy. J Public Health Dent.1998;58:228-233.

37. Levy SM, Hillis SL, Warren JJ, et al. Primary tooth fluorosisand fluoride intake during the first year of life. CommunityDent Oral Epidemiol. 2002; 30:286-295.

38. Osuji OO, Leake JL, Chipman ML, et al. Risk factors fordental fluorosis in a fluoridated community. J Dent Res.1988;67:1488-1492.

39. Ismail AI, Messer JG. The risk of fluorosis in studentsexposed to a higher than optimal concentration of fluoride inwell water. J Public Health Dent. 1996;56:22-27.

40. Holm AK, Andersson R. Enamel mineralization disturbancesin 12- year-old children with known early exposure tofluorides. Community Dent Oral Epidemiol. 1982;10:335-339.

41. Kumar JV, Green EL, Wallace W, et al. Trends in dentalfluorosis and dental caries prevalences in Newburgh andKingston, NY. Am J Public Health. 1989;79:565-569.

42. Nirgude AS, Saiprasad GS, Naik PR, et al. An epidemiologicalstudy on fluorosis in an urban slum area of Nalgonda, AndhraPradesh, India. Indian J Public Health. 2010;54:194-196.

43. Gopalakrishnan P, Vasan RS, Sarma PS, et al. Prevalence ofdental fluorosis and associated risk factors in Alappuzhadistrict, Kerala. Natl Med J India. 1999;12:99-103.

44. Kadir RA, Al-Maqtari RA. Endemic fluorosis among 14-year-old Yemeni adolescents: an exploratory survey. Int Dent J.2010;60:407-410.

45. Marya CM, Dhingra S, Marya V, et al. Relationship of dentalcaries at different concentrations of fluoride in endemicareas: an epidemiological study. J Clin Pediatr Dent.2010;35:41-45.

46. Mwaniki DL, Courtney JM, Gaylor JD. Endemic fluorosis: ananalysis of needs and possibilities based on case studies inKenya. Soc Sci Med. 1994;39:807-813.

47. Faye M, Diawara CK, Ndiaye KR, et al. Dental fluorosis anddental caries prevalence in Senegalese children living in ahigh-fluoride area and consuming a poor fluoridated drinkingwater [in French]. Dakar Med. 2008;53:162-169.

48. Ermi RB, Koray F, Akdeniz BG. Dental caries and fluorosis inlow- and high-fluoride areas in Turkey. Quintessence Int.2003;34:354-360.

49. Ibrahim YE, Bjorvatn K, Birkeland JM. Caries and dentalfluorosis in a 0.25 and a 2.5 ppm fluoride area in the Sudan.Int J Paediatr Dent. 1997;7:161-166.

50. Ferreira EF, Vargas AM, Castilho LS, et al. Factors associated toendemic fluorosis in Brazilian rural communities. Int J EnvironRes Public Health. 2010;7:3115-3128.

51. Manji F, Baelum V, Fejerskov O. Dental fluorosis in an areaof Kenya with 2 ppm fluoride in the drinking water. J DentRes. 1986;65:659-662.

52. HHS and EPA announce new scientific assessments andactions 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.

53. Loyola-Rodriguez JP, Pozos-Guillen Ade J, Hernandez-Hernandez F, et al. Effectiveness of treatment withcarbamide peroxide and hydrogen peroxide in subjectsaffected by dental fluorosis: a clinical trial. J Clin PediatrDent. 2003;28:63-67.

54. Croll TP, Cavanaugh RR. Enamel color modification bycontrolled hydrochloric acid-pumice abrasion. I. Techniqueand examples. Quintessence Int. 1986;17:81-87.

55. Croll TP, Cavanaugh RR. Enamel color modification bycontrolled hydrochloric acid-pumice abrasion. II. Furtherexamples. Quintessence Int. 1986;17:157-164.

56. Allen K, Agosta C, Estafan D. Using microabrasive material toremove fluorosis stains. J Am Dent Assoc. 2004;135:319-323.

57. Croll TP. Enamel microabrasion for removal of superficialdiscoloration. J Esthet Dent. 1989;1:14-20.

58. Coll JA, Jackson P, Strassler HE. Comparison of enamelmicroabrasion techniques: Prema Compound versus a 12-fluted finishing bur. J Esthet Dent. 1991;3:180-186.

59. Higashi C, Dall’Agnol AL, Hirata R, et al. Association ofenamel microabrasion and bleaching: a case report. GenDent. 2008;56:244-249.

60. Strassler HE. Clinical case report: treatment of mild-to-moderate fluorosis with a minimally invasive treatment plan.Compend Contin Educ Dent. 2010; 31:54-58.

61. Croll TP. Enamel microabrasion: concept development. In:Croll TP. Enamel Microabrasion. Chicago, IL: QuintessencePublishing; 1991:37-41.

62. Haywood VB, Cordero R, Wright K, et al. Brushing with apotassium nitrate dentifrice to reduce bleaching sensitivity.J Clin Dent. 2005;16:17-22.


9


POST EXAMINATION INFORMATION

To receive continuing education credit for participation inthis educational activity you must complete the programpost examination and receive a score of 70% or better.

Traditional Completion Option:You may fax or mail your answers with payment to DentistryToday (see Traditional Completion Information on followingpage). All information requested must be provided in orderto process the program for credit. Be sure to complete your“Payment,” “Personal Certification Information,” “Answers,”and “Evaluation” forms. Your exam will be graded within 72hours of receipt. Upon successful completion of the post-exam (70% or higher), a letter of completion will be mailedto the address provided.

Online Completion Option:Use this page to review the questions and mark youranswers. Return to dentalcetoday.com and sign in. If youhave not previously purchased the program, select it fromthe “Online Courses” listing and complete the onlinepurchase process. Once purchased the program will beadded to your User History page where a Take Exam linkwill be provided directly across from the program title.Select the Take Exam link, complete all the programquestions and Submit your answers. An immediate gradereport will be provided. Upon receiving a passing grade,complete the online evaluation form. Upon submitting theform your Letter Of Completion will be providedimmediately for printing.

General Program Information:Online users may log in to dentalcetoday.com any time inthe future to access previously purchased programs andview or print letters of completion and results.

POST EXAMINATION QUESTIONS

1. During tooth development fluoride becomesincorporated into which portion of the tooth making itmore resistant to acid attack by bacteria?

a. Periodontal ligament.

b. Enamel.

c. Dentin.

d. Pulp.

2. Water fluoridation has been described as being asignificant public health measure. Through the use offluoridation there has been a significant decline in whatoral pathology?

a. Periodontal disease.

b. Tooth crowding and misalignment.

c. Tooth anomalies.

d. Caries.

3. Dental fluorosis is defined as:

a. Hypomineralization of enamel resulting from excessiveingestion of fluoride during tooth development.

b. Hypermineralization of enamel resulting from excessiveingestion of fluoride during tooth development.

c. Hypomineralization of dentin resulting from excessiveingestion of fluoride during tooth development.

d. Hypermineralization of dentin resulting from excessiveingestion of fluoride during tooth development.

4. According to the article, the degree to which enamel isaffected by fluoride causing fluorosis is dependent onthe all the following EXCEPT:

a. Duration of exposure to fluoride.

b. Timing of when fluoride is administered.

c. Intensity of fluoride concentration.

d. The patients’ gender.

5. The clinical appearance of mild fluorosis is:

a. Dark yellowing of the enamel.

b. Dark brown and black stains oriented with horizontalstreaks within the enamel.

c. Small white streaks with enamel mottling.

d. Bluish translucency to the enamel.

6. The clinical appearance of moderate fluorosis is:


b. Small translucent-bluish streaks on the enamel surface.

c. White streaking with brownish staining of the enamel.

d. Dark black streaks with white halos surroundingthem within the enamel surface.

7. The clinical appearance of severe fluorosis is:


b. Very dark brown staining with some cases havingenamel defects.

c. Slight white streaking of the enamel.

d. Bluish translucency to the enamel.


10


8. The majority of patients with enamel fluorosis have mild orvery mild conditions. All conditions of mild and very mildenamel fluorosis require an aesthetic restorative intervention.

a. Both statements are true.

b. The first statement is true and the second statementis false.

c. The first statement is false and the second statementis true.

d. Both statements are false.

9. In cases where the patient is concerned about theaesthetic appearance of mild-moderate fluorosis,conservative, minimally invasive treatment technique(s)that can be used is (are):

a. Vital bleaching.

b. Macroabrasion-microabrasion.

c. Macroabrasion-microabrasion followed by vital bleaching.

d. All are conservative, minimally invasive treatmenttechniques for mild-moderate fluorosis.

10. Microabrasion refers to the use of a hydrochloric acidabrasive paste to remove the superficial enamel staining.In those cases where the fluorosis may be deeper in thesuperficial enamel but still mild in discoloration, acombined use of a fine abrasive diamond (50- to 75-µmgrit size) in a high-speed handpiece with water sprayprovides for a more rapid removal of the discoloredenamel and has been referred to as macroabrasion.

a. Both statements are true.

b. The first statement is true and the second statement is false.

c. The first statement is false and the second statement is true.

d. Both statements are false.

11. Source(s) for fluoride exposure and ingestion for childrenfrom dietary and nondietary as reported in the dentalliterature include:

a. Toothpaste.

b. Carbonated soft drinks.

c. Infant formula.

d. All the above are sources for fluoride exposure andingestion for children.

12. When evaluating children for ingestion of fluoride it isnot uncommon for the dental professional to notinclude carbonated beverages as a potential source offluoride. From the study by Heilman and coworkers theirconclusion was that:

a. Carbonated beverages are not a source for fluorideingestion.

b. Different sites of bottling production for carbonatedbeverages can reveal different fluoride levels.

c. Variation in fluoride content reflects the fact that bottlingof beverages utilizes the local water supply.

d. b and c.

13. Because fluoride is ingested from multiple sources,there have been recent recommendations to lower theamount of fluoride in optimally fluoridated drinkingwater. These proposed changes are to lower the optimallevel of fluoride to:

a. 0.005 mg/L.

b. 0.7 mg/L.

c. 1.1 mg/L.

d. 7.0 mg/L.

14. Microabrasion as an aesthetic treatment techniquerefers to the use of an:

a. Hydrochloric acid abrasive paste to remove superficialenamel staining.

b. Hydrofluoric acid abrasive powders in a air abrasiondevice to remove superficial enamel staining.

c. Mild fluoride rinse (1.1% sodium fluoride) to treatmottled enamel and dentin.

d. Phosphoric acid gel to remove brown and black stainsin the superficial enamel and root surfaces.

15. Macroabrasion refers to an aesthetic treatmenttechnique that uses:

a. A 50-µm aluminum oxide particle in an air abrasiondevice to remove fluorosis discoloration.

b. Abrasive pumice paste with phosphoric acid with aprophylaxis brush to remove fluorosis discoloration.

c. Fine abrasive diamond (50- to 75-µm grit size) in ahigh-speed handpiece with water spray.

d. A 10% sodium peroxide gel to whiten the enamelsurfaces.

16. When treating fluorosis discoloration that has a whitespeckled mottling of enamel, it is not uncommon thatonce the superficial enamel discoloration has beenremoved, the enamel has a more yellow appearance. Inthese cases a conservative treatment to achieve anacceptable aesthetic result as described in the article is:

a. Full-coverage all-ceramic crowns.

b. Combined microabrasion/macroabrasion with vitalbleaching.

c. No treatment is necessary, the patient will have to livewith the yellow enamel shade.

d. Three quarter crown preparations then restored withzirconia veneers.


11


PROGRAM COMPLETION INFORMATION

If you wish to purchase and complete this activitytraditionally (mail or fax) rather than online, you mustprovide the information requested below. Please be sure toselect your answers carefully and complete the evaluationinformation.To receive credit you must answer at least 12 ofthe 16 questions correctly.

Complete online at: dentalcetoday.com

TRADITIONAL COMPLETION INFORMATION:Mail or fax this completed form with payment to:

Dentistry TodayDepartment of Continuing Education100 Passaic AvenueFairfield, NJ 07004

Fax: 973-882-3622

PAYMENT & CREDIT INFORMATION:

Examination Fee: $40.00 Credit Hours: 2.0

Note: There is a $10 surcharge to process a check drawn onany bank other than a US bank. Should you have additionalquestions, 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 provide the following (please print clearly):

Exact Name on Credit Card

Credit Card # Expiration Date

Signature

PROGRAM EVAUATION FORMPlease complete the following activity evaluation questions.

Rating Scale: Excellent = 5 and Poor = 0

Course objectives were achieved.Content was useful and benefited yourclinical practice.Review questions were clear and relevantto the editorial.Illustrations and photographs wereclear and relevant.Written presentation was informativeand concise.How much time did you spend readingthe activity and completing the test?



ANSWER FORM: COURSE #: 142Please check the correct box for each question below.

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

PERSONAL CERTIFICATION INFORMATION:

Last Name (PLEASE PRINT CLEARLY OR TYPE)

First Name

Profession / Credentials License Number

Street Address

Suite or Apartment Number

City State Zip Code

Daytime Telephone Number With Area Code

Fax Number With Area Code

E-mail Address

/

Dentistry Today, Inc, is an ADA CERP RecognizedProvider. ADA CERP is a service of the AmericanDental Association to assist dental professionals inindentifying quality providers of continuing dentaleducation. ADA CERP does not approve or endorseindividual courses or instructors, nor does it implyacceptance of credit hours by boards of dentistry.Concerns or complaints about a CE provider may bedirected to the provider or to ADA CERP atada.org/goto/cerp.

Approved PACE Program ProviderFAGD/MAGD Credit Approvaldoes not imply acceptanceby a state or provincial board ofdentistry or AGD endorsement.June 1, 2009 to May 31, 2012AGD Pace approval number: 309062

12

Documents

ManagementofFluorosis UsingMacro-and …dentifrices,ﬂuoridemouth-rinses,softdrinks,andreconstitutedjuices, amongothersources,itisnotsurprising thattheincidenceofﬂuorosisintheUnited