Management of dental fluorosis by amodified treatment strategy amidst a global pandemic

Introduction

Inrecent months, the dental treatment scenario has changed due to the outbreak of the Covid 19 pandemic. The virus has a predominant transmission through aerosol and droplets, making dentists and the clinical setup very vulnerable for disease transmission. Hence, most aerosol-generating procedures have been avoided, but this has resulted in patients enduring pain and anaesthetic appearances.

In such a scenario, when patients report with aesthetic complaints, we need to find alternate modalities to address the concern. Some of these include cavity preparation using micromotors, bleaching, micro and macro abrasion.

Esthetics is a primary concern among young adults, which is challenging for the dentists.¹ The immoderate and chronic intake of fluoride during enamel formation may lead to dental fluorosis, which is characterized by white opaque areas or yellow to brown streaks, at times in combination with pitting on the enamel surface. The severity of these lesions is directly proportional to the excessive fluoride ingestion. These undesirable enamel stains can be masked by conservative approaches like enamel macro/micro abrasion, bleaching or restorative and prosthetic approaches like veneers and crowns.²

Even though, there is an increase in the esthetic concern amongst patients, the treatment options are mostly considered depending on the economic conditions. Bleaching, micro abrasion and composite restorations, being economical and less time consuming are the most considered treatment options for discoloured teeth.¹

For superficial enamel stains or defects, enamel micro abrasion is preferred. This technique was introduced by Croll et al in 1986, and there have been various reports since then describing clinical approaches and related products.³

Case report

An18-year-oldmale patient reported to the Department during the nation-wide lockdown period, with a chief complaint of brownish stain son the upper front teeth. The patient’s medical history revealed no systemic conditions and was fit for dental procedures.

In consideration of his age, time factor and avoidance of aerosol generation, treatment options that involved significant removal of tooth structure using high speed handpieces were not considered.

From the appearance of his teeth with brown streaks in the middle third of the facial surfaces of the upper anteriors, a diagnosis of moderate fluorosis with a score of 3 was determined using Dean’s Fluorosis Index. An incisal third fracture was also noted with respect to 11 and 21. (Figure: 1)

After discussing the available treatment options with the patient, a minimally invasive treatment according to the patient’s request and our concern of avoidance of aerosol generation; micro abrasion of the superficial enamel followed by composite build-up of 11 and 21 was advised.

The teeth were isolated with a rubber dam which was held in place with wedjet and floss. Liquid dam was also used to seal the rubber dam and to protect the gingiva from the acid (18% HCl) used for micro abrasion. The patient was given safety goggles to prevent the spatter of slurry used. The pumice-acid slurry (18% HCl with pumice) was applied on the labial surfaces of the maxillary anteriors using cotton. Using a latch type slowspeed handpiece, a rubber cup was used to rub the pumice acid slurry. It was applied for two consecutive applications of half a minute each (Figure: 2). Between each application, the slurry was rinsed and dried from the tooth surfaces. After the micro abrasion technique, the enamel surfaces were polished with polishing discs to smoothen and polish the enamel surface. After the process was complete, remineralizing paste (MIPaste,GC) was applied on the teeth for 2 minutes and rinsed off. The rubber dam was removed and the patient was satisfied with the outcome (Figure: 3).The patient was advised for home application of the remineralizing paste twice daily for a week and was recalled. The patient didn’t complain of any postoperative sensitivity at the subsequent visit.

Tooth preparation for resin-based composite was performed with respect to 11 and 21 using a low speed micromotor handpiece. The teeth were etched for 30 seconds with 37% phosphoric acid (3M ESPE, Scotch bond Multipurpose etchant). After rinsing it with water and air drying, bonding agent was applied and light cured (Elipar,3M ESPE). Composite was placed in increments, with appropriate light curing techniques. Finishing and polishing were completed using Sof-lex discs (3M ESPE). (Figure: 4)

Discussion

Dental fluorosis is depicted by white flecks to severe brown stains in combination with pitting of the enamel surface due to the excessive intake of fluorides at the time of tooth development.⁴

Several indices are used to measure the prevalence and severity of fluorosis. Widely used is the Dean's index because of its simplicity.⁴

In this case report, moderate fluorosis with a score of 3 was graded using Dean’s Fluorosis Index.

There are various treatment options reported for cases with moderate fluorosis.

Due to the current pandemic situation, treatment modalities are to be modified according to the guidelines proposed and the desired outcome achieved.

Out of the proposed treatments for esthetic demands, effective, conservative and less aerosol generating technique of micro abrasion was used in this case

. Micro abrasion removes a layer of stained enamel with the use of abrasive and acid in gel form. This gel form uses the same principle of polishing with pumice and water after dental prophylaxis. The acid present in the gel erodes the stained enamel and it is removed using the abrasive paste activated by rubber cup mechanically. It is the most preferred treatment option for intrinsic stain as it provides high lustrous after removal of surface irregularity and brown opaque stain.³

Various case reports have reported the use of a pumice-acid slurry^1,5 a similar technique was followed in the present case report. Satisfactory results were obtained after two applications of the mixture. A remineralizing paste (MI paste), which contains CPP ACP, was applied for 2 minutes and the patient was asked to continue its use twice a day for a week. Under the acid challenge, CPP ACP maintains a supersaturated mineral environment, thereby reducing demineralization and enhances the remineralization of enamel.⁶ According to a study by Yassin O et al⁷ , CPP ACP reduced post-operative tooth sensitivity and didn’t have any adverse effects on the colour stability after bleaching.

Similarly, in this case report, MI paste (CPP ACP) was used to enhance remineralization and reduce the post-operative sensitivity.

The tooth preparation and subsequent polishing procedures for the composite restoration in this case were done using micromotor. Hence, apt for a clinical situation in the rising global pandemic.

Conclusion

Proper infection control protocols and modifying the treatment modalities appropriately, can help the clinician reduce the risk of microbial transmission, at the same time satisfy the complaints of the patients. We, dentists should aim at giving the best possible treatment option taking into account this rising pandemic.

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