Management of Fluorosis Using Macro- and ... - DentalCEToday

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 

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Recommendations for Fluoride Varnish Use in Caries Management 

Management of Fluorosis Using 

Macro- and Microabrasion 

Effective Date: 10/1/2011 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. 

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. 

Disclosure: Dr. Maggio reports no disclosures. 

INTRODUCTION 

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. 

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 

Figure 1. 

An example of mild 

fluorosis discoloration. 

1


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 Ca 2+ ions; excess F 

intake has been shown to indirectly reduce the amount of 

available Ca 2+ 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 39- 

year-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 coworkers 22 examined the fluoride content 

2

of 332 carbonated beverages in Iowa. Their 

results revealed that fluoride levels ranged 

from 0.02 to 1.28 parts per million (ppm) with 

a mean level of 0.72 ppm. Fluoride levels 

exceeded 0.60 ppm for 71% of the products. 

Further, from this study no generalization 

could be made about same company/same 

product results. Different sites of bottling 

production revealed different fluoride levels. 

Variation in fluoride content reflects the fact 

that bottling of beverages utilizes the local 

water supply. 

It is difficult to monitor fluoride ingestion 

levels for children. When one considers that 

fluoride uptake can occur from the water 

supply, prescribed fluoride supplements, 

infant formula, dentifrices, fluoride mouthrinses, 

soft drinks, and reconstituted juices, 

among other sources, it is not surprising 

that the incidence of fluorosis in the United 

States has been increasing. 34,37-41 

Further, with the increase in new 

immigrants to the United States, fluorosis 

can be observed due to endemic fluorosis 

in other countries. 42-50 For example, an 

unusual source of fluoride (not from foods 

or beverages) has been reported in Kenya 

and affects other east African nations as 

well. A 1986 epidemiological study of 

dental fluorosis in Kenya stated that in fact 

“dental fluorosis has been endemic to 

Eastern Africa and in particular Kenya for 

many years since the Great Rift Valley, 

which is known to have volcanic activity, 

passes through Kenya.” Although it is 

believed that the main source of fluoride is from the drinking 

water (in some rural parts of Kenya there are 2 ppm fluoride 

in the drinking water with the corresponding incidence of 

fluorosis being 100%), the volcanic soil of Kenya has been 

found to also have very high concentrations of fluoride. During 

the dry season in Kenya, the dust contains fluoride 

concentrations between 2,800 ppm and 5,600 ppm. 51 



Table 1. Criteria for Dean’s Fluorosis Index 

SCORE 

Normal 

Questionable 

Very Mild 

Mild 

Moderate 

Severe 

CRITERIA 

The enamel represents the usual translucent semivitriform 

type of structure. The surface is smooth, glossy, and usually 

of a pale creamy white color. 

The enamel discloses slight aberrations from the 

translucency of normal enamel, ranging from a few white 

flecks to occasional white spots. This classification is 

utilized in those instances where a definite diagnosis of the 

mildest form of fluorosis is not warranted and a 

classification of “normal" is not justified. 

Small, opaque, paper-white areas scattered irregularly over 

the tooth but not involving as much as 25% of the tooth 

surface. Frequently included in this classification are teeth 

showing no more than about one to 2 mm of white opacity 

at the tip of the summit of the cusps of the bicuspids 

or second molars. 

The white opaque areas in the enamel of the teeth are 

more extensive but do not involve as much as 50% 

of the tooth. 

All enamel surfaces of the teeth are affected, and the 

surfaces subject to attrition show wear. Brown stain is 

frequently a disfiguring feature. 

Includes teeth formerly classified as “moderately severe 

and severe.” All enamel surfaces are affected and 

hypoplasia is so marked that the general form of the tooth 

may be affected. The major diagnostic sign of this 

classification is discrete or confluent pitting. Brown stains 

are widespread and teeth often present a 

corroded-like appearance. 

Source: Dean HT, 1942. Health Effects of Ingested Fluoride. Washington, DC: National 

Academy of Sciences; 1993:169. 

MINIMALLY INVASIVE AESTHETIC TREATMENT 

OPTIONS FOR MILD TO MODERATE DENTAL 

FLUOROSIS 

Concerns about the aesthetic appearance of teeth with fluorosis 

have led to proposed new guidelines for fluoridation of drinking 

water. 52 The goal of fluoride supplements is to provide an 

optimal amount of fluoride to reduce the risk of dental caries. 

3

Recent recommendations reflect 

changes from the previous levels 

of fluoride to a more optimal 

level of fluoride of 0.7 mg/L. 52 

These changes reflect the fact 

that the ingestion of fluoride 

can come from multiple 

sources, resulting in a need for 

a lower level of fluoride in 

optimally fluoridated drinking 

water. The recommendations 

also take into account that fluoride supplements need only 

be considered for patients at moderate to high risk for 

dental caries and even then may be unnecessary if patients 

are receiving adequate fluoride from other sources. 

The majority of patients with fluorosis have mild and very 

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 

be based upon the patient’s perception regarding whether 

there is a need for treatment. Fluorosis staining is within the 

enamel. In cases of mild fluorosis, the enamel discoloration is 

superficial. For moderate and severe fluorosis, the enamel 

staining and mottling can penetrate to deeper 

enamel levels. For cases of mild fluorosis of 

aesthetic concern to the patient, vital 

bleaching can be successful in achieving a 

change that the patient desires. 53 When the 

patient presents with mild-moderate flourosis, 

there may be the need for a microabrasion or 

macroabrasion technique. 

Microabrasion refers to the use of a 

hydrochloric acid abrasive paste to remove 

the superficial enamel staining. 54-57 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. 58 When the 

superficial enamel is removed, the white 



Table 2. Dental Fluorosis in the United States 1999 to 2002, Based 

Upon Characteristics—CDC Data (from cdc.gov.mmwr/PDF/ss/ss5403.pdf) 

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% 

speckled mottling of enamel reveals a more yellow enamel 

color beneath the surface. For some patients, the loss of the 

white speckled enamel to yellow is not acceptable. For 

these cases, a combined microabrasion/macroabrasion 

with vital bleaching is an aesthetically acceptable 

treatment. 59,60 

CASE REPORT 

A 20-year-old female patient was screened at the dental 

clinic for routine dental care. Her chief complaint was to 

remove and/or minimize the noticeable brown/yellow 

staining of her teeth. She wanted the least invasive and 

Table 3. Changes in Flouride Supplement 

Dosage Schedule, 1979 and 1994 1,15,16 

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 



4



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. 

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 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). 

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



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



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. 

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 

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. 

7



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. 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 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. 

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. 

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. 

12. Clark DC. Trends in prevalence of dental fluorosis in North 

America. Community Dent Oral Epidemiol. 1994;22:148-152. 

13. Rozier RG. The prevalence and severity of enamel fluorosis 

in North American children. J Public Health Dent. 

1999;59:239-246. 

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. 

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. 

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 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. 

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. 

19. American Dental Association. Accepted Dental Therapeutics. 

33rd-40th eds. Chicago, IL: Council on Dental Therapeutics 

of the American Dental Association; 1969/1970-1984:399- 

402. 

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. 

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. 

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 fluoride 

intake by children receiving different sources of systemic 

fluoride. J Dent Res. 2009;88:142-145. 

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. 

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. 

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. 

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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. 

34. Pendrys DG, Katz RV, Morse DE. Risk factors for enamel 

fluorosis in a fluoridated population. Am J Epidemiol. 

1994;140:461-471. 

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. 

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. 

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. 

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. 

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. 

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. 

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. 

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. 

44. Kadir RA, Al-Maqtari RA. Endemic fluorosis among 14-yearold 

Yemeni adolescents: an exploratory survey. Int Dent J. 

2010;60:407-410. 

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. 

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. 

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. 

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. 

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. 

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. 

53. Loyola-Rodriguez JP, Pozos-Guillen Ade J, Hernandez- 

Hernandez 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. 

54. Croll TP, Cavanaugh RR. Enamel color modification by 

controlled hydrochloric acid-pumice abrasion. I. Technique 

and examples. Quintessence Int. 1986;17:81-87. 

55. Croll TP, Cavanaugh RR. Enamel color modification by 

controlled hydrochloric acid-pumice abrasion. II. Further 

examples. Quintessence Int. 1986;17:157-164. 

56. Allen K, Agosta C, Estafan D. Using microabrasive material to 

remove fluorosis stains. J Am Dent Assoc. 2004;135:319-323. 

57. Croll TP. Enamel microabrasion for removal of superficial 

discoloration. J Esthet Dent. 1989;1:14-20. 

58. Coll JA, Jackson P, Strassler HE. Comparison of enamel 

microabrasion 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 of 

enamel microabrasion and bleaching: a case report. Gen 

Dent. 2008;56:244-249. 

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. 

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. 

9



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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. Periodontal ligament. 

b. Enamel. 

c. Dentin. 

d. Pulp. 

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 

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 excessive 

ingestion of fluoride during tooth development. 

b. Hypermineralization of enamel resulting from excessive 


c. Hypomineralization of dentin resulting from excessive 


d. Hypermineralization of dentin resulting from excessive 


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. 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 horizontal 

streaks 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 surrounding 

them within the enamel surface. 

7. The clinical appearance of severe fluorosis is: 


b. Very dark brown staining with some cases having 

enamel 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 or 

very mild conditions. All conditions of mild and very mild 

enamel fluorosis require an aesthetic restorative intervention. 

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. 

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. Vital bleaching. 

b. Macroabrasion-microabrasion. 

c. Macroabrasion-microabrasion followed by vital bleaching. 

d. 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. 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 children 

from dietary and nondietary as reported in the dental 

literature include: 

a. Toothpaste. 

b. Carbonated soft drinks. 

c. Infant formula. 

d. All the above are sources for fluoride exposure and 

ingestion for children. 

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. Carbonated beverages are not a source for fluoride 

ingestion. 

b. Different sites of bottling production for carbonated 

beverages can reveal different fluoride levels. 

c. Variation in fluoride content reflects the fact that bottling 

of 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 the 

amount of fluoride in optimally fluoridated drinking 

water. These proposed changes are to lower the optimal 

level 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 technique 

refers to the use of an: 

a. Hydrochloric acid abrasive paste to remove superficial 

enamel staining. 

b. Hydrofluoric acid abrasive powders in a air abrasion 

device to remove superficial enamel staining. 

c. Mild fluoride rinse (1.1% sodium fluoride) to treat 

mottled enamel and dentin. 

d. 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: 

a. A 50-µm aluminum oxide particle in an air abrasion 

device to remove fluorosis discoloration. 

b. Abrasive pumice paste with phosphoric acid with a 

prophylaxis brush to remove fluorosis discoloration. 

c. Fine abrasive diamond (50- to 75-µm grit size) in a 

high-speed handpiece with water spray. 

d. 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: 

a. Full-coverage all-ceramic crowns. 

b. Combined microabrasion/macroabrasion with vital 

bleaching. 

c. No treatment is necessary, the patient will have to live 

with the yellow enamel shade. 

d. Three quarter crown preparations then restored with 

zirconia veneers. 

11



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