Sunteți pe pagina 1din 84

Pavel GNATIUC, Corneliu NĂSTASE, Alexei TEREHOV, Oxana SIREŢEANU

DENTAL
FLUOROSIS

Chișinău, 2015
CZU

Aprobat de Consiliul metodic central al USMF Nicolae Testemiţanu;


proces-verbal nr. 2 din 17 noiembrie 2011

Autori: Pavel Gnatiuc - dr. med., conferenţiar universitar


Corneliu Năstase - asistent universitar, traducere engleză pp.64-68
Alexei Terehov - dr. med., conferenţiar universitar
Oxana Sireţeanu - medic, traducere engleză

Redactor literar: Valeriu OJOG - lector superior,


catedra Limbi moderne şi latină, USMF Nicolae Testemiţanu

Recenzenţi: Gheorghe Nicolau - dr. hab. med., profesor universitar,


Nicolai Cojuhari - dr. med., doctor conferenţiar.

“DENTAL FLUOROSIS”
Monografie
pentru studenţi, rezidenţi şi medici stomatologi
Ediţia a II-a, adăugită şi corectată

În această lucrare sunt tratate unele elemente fundamentale ale fluorozei dentare, ipoteze şi
date generale, şi sunt examinate amănunţit cele mai complexe şi dificile de înţeles subiecte studiate în
procesul didactic. Figurile inserate în context simplifică înţelegerea informaţiilor. Este utilă atât stu-
denţilor şi rezidenţilor, cât şi medicilor stomatologi.

Descrierea CIP a Camerei Naţionale a Cărţii

DENTAL FLUOROSIS /Monografie/ P. Gnatiuc, C. Năstase,


A. Terehov, O. Sireţeanu. -Ch.: S.n., 2015 (Î.S.F.E.-P. «Tipografia
Centrală»). - 84 p
Bibliogr. p. 74 (97 tit.)
ISBN
CZU
50 ex.

Com. ***
Î. S. Firma editorial-poligrafică “Tipografia Centrală”,

ISBN
© Pavel Gnatiuc, Corneliu Năstase,
Alexei Terehov, Oxana Sireţeanu, 2015
2
Cuprins
GENERAL ASPECTS............................................................................................................................ 4

CLINICAL MANIFESTATIONS OF FLUOROSIS........................................................................... 4

FLUORINE CONCENTRATION IN VEGETABLES....................................................................... 7

FLUORINE CONCENTRATION IN ANIMAL PRODUCTS.......................................................... 8

FLUORINE CONCENTRATION IN HUMAN BODY...................................................................... 8

FLUOROSIS EPIDEMIOLOGY........................................................................................................ 13

THE STATUS OF DENTAL FLUOROSIS IN MOLDOVA............................................................. 14

THE ETIOLOGY AND PATHOGENESIS OF DENTAL FLUOROSIS........................................ 16

RISK FACTORS................................................................................................................................... 19

THE SENSITIVITY AND RESISTANCE TO FLUORIDE OF THE HUMAN TEETH............. 20

FLUOROSIS CLASSIFICATION...................................................................................................... 21

THE CLINICAL PICTURE OF FLUOROSIS.................................................................................. 23

DIFFERENTIAL DIAGNOSIS........................................................................................................... 33

PSYCHO-EMOTIONAL IMPACT AND SOCIOLODICAL ASPECTS

OF DENTAL FLUOROSI IN YOUNG PEOPLE IN MODERN SOCIETY ( STUDY )......... 36

DENTAL FLUOROSIS TREATMENT.............................................................................................. 42

COMBINED CONSERVATIVE TREATMENT OF THE SUPERFICIAL TEETH

DISCOLORATIONS...................................................................................................................... 47

ENAMEL MICROABRASION HISTORY STAGES IN REPUBLIC OF MOLDOVA................ 51

MODERN BLEACHING SYSTEMS AND PROCEDURES FOR FLUOROSIS TEETH........... 58

VENEERS.............................................................................................................................................. 64

DENTAL FLUOROSIS PREVENTION............................................................................................. 70

CONCLUSIONS................................................................................................................................... 73

BIBLIOGRAPHY................................................................................................................................. 74

ANNEX.................................................................................................................................................. 81

3
GENERAL ASPECTS

In the last 2-3 decades, with the advent of new technologies in


dentistry, appeared the problem in the tooth fillings with restoration
of the primary aspect, as the prosthetic crowns golden era has expired
a long time ago.
An increasing number of patients want to have not only functional
restorations, but also a Hollywood smile. Dental defects, especially
those in the front, inhibit and depress patients, making them unsafe,
to communicate and to smile less. Moreover, they determine various
psycho-emotional disorders and the difficulty of integration in the social
environment.
Researchers in the country and abroad have recently made a number
of scientific studies analyzing the interrelation between the quality of
life and the maxillary system status. Modern man is associated with
visibly healthy teeth, with good health, success in life and career.
One of the diseases that lead to damage the aesthetics is fluorosis.

CLINICAL MANIFESTATIONS OF FLUOROSIS

Fluorosis is a systemic tissue disturbance that develops after ingestion


of water and food with a high content of fluorine.
Endemic fluorosis is a disease of humans and animals in the animal
zootechnic sphere, being caused by excess of fluoride in natural waters
– the main source of water supply to the population. The color and
relief changes of the dental hard tissues are the first and sometimes the
only visible clinical manifestation of fluorosis. These morbid signs are
manifested by the change of the normal enamel color, and in severe
cases – by its integrity.
4
Depending on the severity of the disorder, the enamel coloring
changes from barely noticeable white mate patches to tan and dark
brown, there are possible erosions and adamantine destructions, changes
in the mechanical properties of dental hard tissues – softness, brittleness,
increased abrasion.
The first scientific works devoted to dental fluorosis describe cases
of “black teeth” (Kins, 1888) and Vanicker’s report (1891) on the case
of “erosion of dental enamel” to residents of the city Naples (Italy).
“Speckled enamel” was described by JM Eager (1901), when he
discovered pathological changes of dental hard tissues, manifested by
spotted enamel in the Italian emigrants in the USA.
In 1908, G. Black for the first time thoroughly described the clinical
manifestation of dental fluorosis, illustrating the text with drawings
of teeth with varying degrees of involvement by fluorosis, made with
colored pencils.
In 1916, this disease was described in the State of Colorado (USA),
macules on the enamel being called “Colorado brown stain”. Underlying
cause was the excess of fluoride in drinking water.
There are different hypotheses regarding the etiology of dental
fluorosis. Only in 1928 it was determined that the etiological factor of
fluorosis is the fluoride in the drinking water. Since then it is considered
that the affection has an endemic tempt.
The title of the element fluorine (F simb.) comes from the Greek word
“ftoris” – Destroyer (in Latin – fluorum). It occupies the 13th position of
elements that are part of the earth’s crust (0.08%), exceeding 10 times the
amount of zinc and 30 times – the amount of lead (Vinogradov, 1957).
The free fluoride is a colorless or yellow-green, pungent, irritating
(penetrating) gas. At very low temperatures (-188 ° C) fluoride is
condensed to a yellow-orange fluid, and solidifies at –220 ° C, the
relative weight is 1.513 g/cm3.
In Mendeleev’s periodic system, the serial number of fluorine is 9,
the atomic weight – 19.
Of all the minerals, fluoride is the most active metalloid, possessing a
special reactivity. It reacts with almost all the elements in direct contact,
5
at room temperature or a higher one. It forms compounds with inert gas
even.
In many acids, a polymer molecule is capable of replacing oxygen.
With most organic compounds, fluoride reacts with explosion. All
reactions involving fluorine are characterized by high thermal effect
(calorie).
The most important fluoride compound is the hydrate fluoride
– a colorless fluid, unstable, which is easily vaporized, the boiling
temperature +20 ° C.
An unusual feature of fluoride is high volatility of its compounds.
There are currently over 100 known minerals containing fluorine.
A group of simple fluorides includes NaF, MgF2, AlF3H2O. The most
important mineral containing fluorine is fluoritis – natural calcium
fluoride (CaF2) which contains 48.7% of fluorine.
Fluoride gets in soil after the disintegration of the rocks. With the
increasing amount of clay particles in the soil, which is increases,
the concentration of water-soluble fluorine, soluble in citric acid and
hydrochloric acid. In most of the soils, the concentration of fluorine
increases with depth.
An enormous amount of fluorine gets back into the atmosphere, and
then back in the ground as a result of volcanic acid fumes and industrial
pollution – in as fluorine hydride and the salt of hydrofluoric acid.
The concentration of fluoride in natural waters varies a lot, being
dictated largely by the solubility of its compounds. In water, fluoride
binds usually the sodium, potassium, aluminum. The presence of these
compounds in groundwater determines fluoride accumulation in plants.
A decisive importance has the concentration and accessibility in
plants.

6
FLUORINE CONCENTRATION IN VEGETABLES
The amount of fluorine in vegetables varies a lot. Plants like wheat,
barley, rice, peas, cabbage, watercress, parsley are able to gather
microelements, including fluorine. A very big concentration of fluorine
is in the green parts of the plant, which contains from 30 to 140 mg/l of
dry matter.
It is shown that agricultural products grown on rich in fluorine soils
contain this element in greater quantity. The amount of fluorine in
spinach and in other plants used as condiments is quite high – 21 mg /
kg. In the tea leaves – a fluorine warehouse – cultivated in an endemic
area of fluorosis, the amount of fluoride can reach 1757.8 mg / kg.
It is very important not only the absolute amount of fluorine in the
food, but also in spices and water, in the technology of food preparation.
The absorption degree by the boiling products of fluoride from water
is varied. Some vegetables get more fluorine from the water, and other
get less. Potatoes, unlike beans and carrots, do not gather fluorine during
cooking.
Sometimes fluoride accumulation in plants is accompanied by a
devastating effect.
In the plants that are sensitive to environmental air pollution with
fluorine, cultivated near industrial factories, there is a low concentration
of fluorine-chlorophyll in the areas of necrosis of the leaves and an
increased amount of fluorine. The color of the leaves changes, they
become more stiff, bigger, covered with white-gray deposits. The excess
amount of fluorine determines the fruit deformation: apples, instead of
being round, are oval, and its central part – green. Walnuts are deformed
and have a yellowish color, and their bark is crushed easily. Vine leaves
have rust spots and areas of necrosis. Also it delays grapes’ ripening.
There have been detected plants resistant to fluorine – cherry, sugar
beet, potato, astra, roses etc.
7
FLUORINE CONCENTRATION IN ANIMAL PRODUCTS

The fluoride circulation in nature involves not only the plant world,
but also the animal. In this connection, a special interest presents data
on the amount of fluoride in various animal tissues. Fluoride content in
food of animal origin vary within the following limits:
• in the meat – from 0.16 to 2.0 mg / kg;
• butter – 0.4 to 0.45 mg / kg;
• in milk and dairy products – from 0.3 to 0.71 mg / kg;
• in eggs – 0.00 to 1.48 mg / kg;
• in freshwater fish – from 0.09 to 0.26 mg / kg;
• in sea fish – from 0.02 to 84.47 mg / kg.
The sea fish contains more fluorine than freshwater fish, because the
fluorine concentration in the sea is considerably bigger.

FLUORINE CONCENTRATION IN HUMAN BODY

Usually, the clinical manifestations of fluorosis are analyzed from


the dentistry point of view – the form and the visible modifications in
enamel, and also the teeth features in their relationship with external
factors.
Serious adverse effects of fluoride on different human organs and
tissues have been reported in India, China, countries with endemic
fluorosis areas in which natural levels of fluoride in drinking water and
food are very high. These shocking data were obtained not following
basic scientific researches, but as empirical-statistical findings.
But the logical question is: If an individual has minor dental fluorosis
manifestations, does this mean, by extension, that other organs and
tissues remain more or less unaffected by chronic fluoride poisoning?
The answer requires extensive and thorough investigation.
High concentrations of fluoride can affect the bones, brain, endocrine
system, etc.
Fluoride, characterized by cumulative properties, gradually
accumulates in the skeleton. The concentration of fluorine in the bone is
8
linear, this means that with the increase in the amount of drinking water
the accumulation in the bones increases.
Drinking water containing increasing concentrations of fluoride
serves as the predominant source of supply of the human body with
fluoride as the main cause of dental fluorosis.
It is known that mineral substances, in particular fluorine, are
distributed especially in the skeleton. The accumulation of fluoride in
bones and teeth is approximately equal: it depends on the following
factors:
1. individual’s age;
2. the amount of the elements that get into the body with water, food
and oral hygiene remedies and air.
The concentration of fluorine varies in different parts of the tooth,
and different groups of teeth.
Fluoride has a very big importance in tooth decay protection. This is
why the determination of the amount of flouride in the teeth in relation
to age is very important.

Fig. 1. Fluorosis impairment of the skeleton.


9
The researches led by Avcin A.P, Javoroncov A.A. proved that in the
regions of endemic fluorosis, milk teeth have a lower fluorine concentration
than the permanent ones. Decayed tooth enamel contains much less fluoride
than the intact ones. From the age of 30 years, the concentration of fluoride
in enamel of all teeth increases and at 50 years – is doubled.
Alcalaev K.K. showed that the maximum amount of fluoride is
determined in the third molars, canines and then gradually decreases in
incisors, molars I and II and premolars I and II.
The content of fluorine in different layers of the enamel is not equal,
the highest concentration is in the surface layers (with a thickness of
up to 160 mk), and then it gradually decreases to a constant level in the
deeper layers.
The amount of fluoride in temporary teeth dentin grows to a certain
age and depends on the type of teeth (the incisors – up to 5 years in
canines and molars – up to 7 years).
In the period of the teeth changing, fluoride concentration decreases from
the reduction of the layer lining the pulp. This is due to active osteoclastic
process, typical in the period of the physiological exchange of teeth.
According to some authors (Nicolaeva T.A., Beletkii A.S.) fluoride
content in deciduous teeth affected by fluorosis was from 0.082 to 0.28
%, while in the permanent ones – 0.3-0.7 %.
It was proved that fluorine accumulates faster and more in growing
teeth than in the permanent mature ones and, in particular in dentin.
After stopping the intake, fluoride rapidly disappears in growing teeth,
but is retained for a long period in permanent teeth. Thus, with age,
increases the concentration of fluorine in both bone and teeth .
The concentration of fluorine of 8.0 mg/liter in drinking water causes
skeletal fluorosis to 10% of the population.
Given the fact that in 13 districts of the Republic of Moldova fluoride
content in drinking water is higher than accepted, and that it is found in
large quantities in plants and animal bodies with food, the population of
these districts can occur not only dental fluorosis but bone fluorosis, too.
Besides the accumulation of the fluorine in the dental hard tissues
and bones, large accumulations of fluoride were noticed in the skin, hair,
10
nails. Fluoride concentration in the hair of children in endemic fluorosis
regions is ten times higher than of children in localities with average
concentration of fluoride in the environment. Soft tissues contain little
amount of fluoride. Certain organs such as the aorta and pancreas have
substantial amounts of fluorine.
The content of fluoride in biological fluids is influenced by the
overall amount of this element that enters the body. It is shown that as
the contribution of fluorine in the body of a significant amount in blood
is short-living. When the concentration of fluoride in drinking water
increases 23 times, the concentration of the fluoride in the urine increases
19 times, and in blood – only 3 times , indicating rapid elimination and
the active role of the kidneys.
In growing body, fluoride is filed more than in adults, and elimination
of urine is, on the contrary, higher in adults than in children.
The mechanism of action of fluoride on the animal body can be
explained by:
• formation of complexes with calcium fluoride, magnesium and
other enzymatic activator systems;
• inhibitory action of fluoride on a number of enzymes, which is
accompanied by dysfunction in the tissues’ interstitial exchange;
• the chemical activity of fluorine is higher than iodine, after which the
fluorine can be an iodine competitor in the thyroid hormones formation,
and therefore, may interfere with its normal function;
• the important role of fluoride in the exchange (metabolism) of
vitamins.
Fluoride is unevenly distributed in the tissues of the animal body,
different in function and morphology, showing a special affinity to
the calcified tissues, in which the fluoride molecules are accumulated
throughout life.
Under physiological conditions, the role of fluoride is linked to the
formation of the fluorapatite – a component of the bone and teeth structure.
Currently it is shown that fluoride has an important role not only in
the development and normal condition of teeth and bones, and in the
normal growth and overall development of the body. Fluoride can fulfill
11
specific metabolic functions in tissues even in low concentrations, like
in soft tissues.
A special interest is paid to the information of fluoride accumulation
in the milk of a breastfeeding woman because it is the only food for little
babies.
It was established that in the milk of the breastfeeding women who
were living in endemic fluorosis zones, the amount of fluoride in the milk
is lower than in the milk of the women living outside the endemic zone.
Therefore, an important role in preventing fluorosis is the checking
of the fluoride amount in the child’s body from the mother’s milk during
the most intense growth and formation of the skeleton and teeth.
It is obvious that the breastfeeding woman’s body is working a
physiological mechanism that maintains the concentration of fluoride in
milk at the optimum level for the child. The concentration of the fluoride
in the milk of cows from fluorosis endemic zones varies from 0.01 to
0.7 mg/l. This demonstrates that the mammary glands serve as a natural
barrier for fluoride molecules and the elimination from the body with the
milk does not play a significant role.
Our research showed that children from the fluorosis endemic zones
who were breastfed for a year or more, and then consumed milk products,
were less exposed to fluorosis.
Out of 60 children in the village Pârliţa, Ungheni who had clinical
manifestations of fluorosis, 22 had various diseases of internal organs:
hepatitis (13), gastritis (4), pyelonephritis (3) cardiac system disorders (2).
The worsening of the fluorosis manifestation in children was favored by
daily consumption of 2-3 glasses of tea and milk deficit (Gnatiuc P.I., 1988).
•••
Currently is established that fluoride deficiency in drinking water and
in the body is manifested by the increase of the dental caries. Deficiency
of fluoride in the body is accompanied not only by the increased tooth
decay, but also by the metabolic disorders. In areas with the fluoride
insufficiency in drinking water, the deaf morbidity in children is
approximately twice more often than in areas with normal fluoride
content in drinking water.
12
Medical condition due to a long and excessive intake of fluoride was
called fluorosis. The most sensitive to fluoride poisoning are the children,
especially in the age of high growth and formation of bone and teeth.
The role of fluoride in the drinking water concentration:
• 1 mg/l – is optimal and has an active prophylactic effect against
caries;
• 2 mg/l – causes fluorosis teeth;
• 8 mg/l – skeletal fluorosis in 10% of the population;
• 20-80 mg/l – during the 10-20 years – serious crippling skeletal
fluorosis;
• more than 50 mg/l – changes in structure and function of the thyroid;
• 100 mg/l – growth retardation;
• more than 125 mg/l – the manifestation of functional-structural
changes in the kidney;
• from 2.5 to 5.0 g is lethal to humans.

FLUOROSIS EPIDEMIOLOGY
Environmental Protection Agency (USA) considers fluorosis as a
“cosmetic defect” and not a “disease” and the World Health Organization
(WHO) – as a disease that affects millions of people worldwide (WHO
Information , 2001, 2002).
The prevalence of endemic fluorosis is directly related to the
distribution of fluoride in the environment, particularly water. In 1931,
it was found that in areas where residents had macular enamel, drinking
water had an increased content of fluoride.
Teeth fluorosis is the dental hard tissues pathology that occurs
during the formation of the teeth. The condition is the result of increased
content of fluoride in drinking water, food and so on, which enters the
child’s body during the formation and mineralization of the dental hard
tissues. The excess of fluorine contained in food is less toxic than in
drinking water.
13
The literature describes endemic impairment, in mass of the
population with fluorosis.
Endemic fluorosis is in more than a thousand zones, it can be noticed
in Norway, Sweden, Finland, Denmark, UK, Spain, Italy, USA, Poland,
Kazakhstan, Ukraine, Russia, Turkmenistan, Azerbaijan, Canada, China,
Mexico, Chile, Australia, India, Sri Lanka, Saudi Arabia, South Africa,
Kenya, Nigeria, Tanzania, Sudan, Morocco, etc.
It is generally accepted that when the fluoride content in water is :
< 0.5 mg/l , fluorosis does not occur ;
= 0.8-1.2 mg/l , fluorosis affects 10 to 12% percent of the population ;
= 1.2-1.5 mg/l, – 20-30% of the population ;
= 1.5-1.8 mg/l , – about 40 % of the population ;
> 2-2.5 mg/l, – about 50 % of the population ;
> 2.5 mg/l , the percentage of people suffering from fluorosis (
“enamel maculation” ) increases sharply, sometimes, the disease affects
almost the entire population consuming water from that source.

The status of dental fluorosis in Moldova

The aesthetic problem of the affected teeth with dental fluorosis


is actual to Moldova, because, according to the National Centre of
Preventive Medicine, in the country there are some areas with high
concentration (> 1.5 mg/l) of fluoride in drinking water :
• Glodeni ≈ 5-11 mg/l in water natural reservoirs and 1.2-1.7 mg/l – in
ordinary wells.
• Făleşti ≈ 4-8 and 1.0-1.8 mg/l in water natural reservoirs;
• Ungheni ≈ 4-8 and 0.85 to 1.5 mg/l in water natural reservoirs;
• Călăraşi ≈ 3-5 and 0.8-1.5 mg/l in water natural reservoirs;
• Nisporeni, Anenii Noi, Hânceşti ≈ 2,0-4,0 and the range of 0.8-1.5
mg/l;
• Căinari, Taraclia Basarabeasca ≈ 3.0 to 8.0 and 0.8-1.2 mg/l;
• Ceadâr-Lunga ≈ 11.0 to 16.0 and from 1.0 to 1.6 mg/l;
• Floreşti, Criuleni ≈ 2,0-4,0 and 0,8-1,2 mg/l.
14
In many residents in the
affected areas have been detected
clinical manifestations of dental
fluorosis, such as color and texture
changes of the teeth.
Dental fluorosis is the most
frequent non carious disease of
dental hard tissues.
The damage and the
frequency of the endemic
fluorosis (morbidity) of the teeth
to the minor population of an
endemic zone depend largely
on the concentration of fluoride
in drinking water. The higher
is the amount of fluoride in
water, more evident the clinical
manifestations are in the affected
Fig. 2. The map of fluorosis en- teeth in the growing period and
demic areas in Moldova. the more children are suffering
from fluorosis.
However, it was noticed that in
the fluorosis endemic regions not all children are affected by fluorosis.
The morbidity depends on the health of the mother during pregnancy,
the alimentation of the child (breastfeeding), the nature of the food,
duration of water consumption, which contains increased amounts of
fluoride, and the overall body strength.
In fluorosis endemic regions, the morbidity is 50-96 % of children.

15
THE ETIOLOGY AND PATHOGENESIS
OF DENTAL FLUOROSIS

In regions with hot climates can be observed dental fluorosis


manifestations in the presence of moderate content of fluoride in drinking
water (0.5-0.7 mg/l). This is due to the active consumption of water.
The presence of significant quantities of calcium in water reduces the
development of fluorosis.
Clinical researches have shown that the optimal concentration of
fluoride in the drinking water should be – 1 mg/l. At such concentrations,
fluorosis is rare (or present in mild forms), also being noticed strong
cariostatic effect.
For a long time fluorosis was considered an endemic disease, related
to fluoride concentration in drinking water. The mechanism of action of
fluoride in endemic fluorosis pathogenesis has not yet been fully elucidated.
I.G. Lucomskii (1940) said that fluorosis is the result of the
interaction of the fluoride with calcium, magnesium, manganese and
other microelements of hard dental tissue, affecting their participation
in histophysiology processes, which ultimately lead to damages in the
enamel during training. Fluoride is a calcium antagonist. According to
some authors, fluoride binds calcium and removes it from the body, and
on this background fluorosis occurs.
I.O. Novik (1951) explained the occurrence of fluorosis by the fact
that the chemical activity of the fluoride is greater than that of iodine,
which causes suppression of thyroid function, accompanied by the
disturbance of formation of dental hard tissues.
The most plausible theory is the toxic action of fluoride on ameloblasts
during the genesis of the enamel, causing subsequent structural disorders
(PO Pedersen, Scott D. В., 1959; Patrikeev V.K. 1968 A. Matsuo, 1998).
16
Other authors think that fluoride inactivates the alkaline phosphatase,
cholinesterase, etc., leading to impaired mineralization of dental hard
tissues.
According to the hypothesis of А.К. Nikolishin (1996) during tooth
development (amelogenesis), the excess of fluoride, between the follicular
sac vessels and intracellular spaces get to the ameloblasts and form close
links with the protein retaining calcium of the immature enamel.
As a result, in the differentiation of the hard tissue is formed the
hidroxifluorapatite. Complete substitution of hydroxyl groups with
fluorine cannot occur because the fluoride ions penetrate the epithelial
cells (ameloblasts) of the internal and external layers of the enamel
organ in limited quantities necessary for vital processes and to maintain
cellular metabolism. In the process of mineralization the epithelial
barrier function of the ameloblasts (property of retaining excess fluoride
ions to pass through biological membranes) are gradually depleted.
For this reason, after calcification of the ameloblasts and reducing
the amount of fluoride in the blood, the development of fluorosis at
this stage is stopped. This development is characteristic of early forms
of dental fluorosis. But, if a high concentration of the fluoride in the
body, the long-acting on the surface of the hard tissues (teeth, bones)
determines the fluoride sedimentation as insoluble calcium compounds
in water. The process manifests with epistaxis: on the surface of the
enamel fluorapatite is formed calcium fluoride.
This can last throughout intramaxillary tooth development. In
addition, during the intramaxillary development of the permanent teeth
follicles occurs the process of root and the alveolar bone resorption.
It can be assumed that the fluoride released from the alveolar bone is
included in the new compounds of calcium (calcium fluoride) and settles
on the surface of the enamel. These processes are typical to advanced
forms of dental fluorosis. The most intensive period of formation of the
calcium fluoride in the enamel is at the age of 2-4 years.
It is possible that the formation of CaF2 on the enamel surface may
continue after the tooth erupts, due to the high concentrations of fluoride in
drinking water and oral fluid of the children in endemic fluorosis regions.
17
The connection between the CaF2 from the superficial layers and the
CaF2 from the fluorapatite layers in the severe forms of fluorosis is not
lasting. From the structural point of view calcium fluoride is loose and
fragile.
Therefore, the action of mechanical factors, on the surface of the
enamel can be formed cavities, defects. Clinically it was determined
that dental hard tissue destruction in severe forms of fluorosis occurs
particularly evident during enamel mineralization immediately after
permanent teeth erupt. The degree of damage is determined by the
thickness of the enamel deposition of CaF2 on the surface of the enamel,
the nature of food and saliva mineralization properties.
According to the data of the local and foreign researchers at
concentrations of 0.8-1.0 mg/l of fluoride in drinking water mild fluorosis
can occur in 10-20% of the population, to 1.0-1.5 mg/l 20-30% of the
population is affected, at 1.5-2.5 mg/l – 30-45% at 2.5 mg/l and more,
the rate reached 50% of those affected.
A study of the Pediatric Dentistry Department researchers of the
SMFU “Nicolae Testemiţanu” demonstrated that, with increasing
concentration of fluoride in drinking water, increases the frequency and
extent of damage to the teeth with fluorosis. In children of 6 years, the
frequency of dental fluorosis was 81.77%, in 12 years – in 82.57% and
those 15 years – 89.87%. The average degree of damage by fluorosis
was 2.01 ± 0.33: in the children 6 years – 1.73 ± 0.53, in children 12
years – 2.22 ± 0.47 and in children 15 years – 2.24 ± 0.77.
Some scientists indicate anticarious action of fluoride. The works
of other authors, however, and our research shows that fluoride has an
anticarious effect only in small quantities and only in the shaded and
macula forms of fluorosis.

18
RISK FACTORS
Currently, it is demonstrated that fluorosis is the result of a cumulative
effect of intake of fluoride from various sources.
The main risk factors are:
• fluoride toothpaste and frequency of its use;
• Fluoridation of drinking water;
• the use of tablets containing fluorine;
• the use of fluorinated salt.
Fluorosis affects teeth during their formation. Recent studies have
shown that fluoride, the parenteral administration (or local) quickly
penetrates the blood and disturbs the thyroid function, leading ultimately
to adverse effects on enamel mineralization.
Fluoride that entered the body, act on enameloblasts, leading to
imperfect enamelogenesis. It is unlikely the microelement to act
locally, as changes occur also in parenteral administration of fluoride
preparations.
Voynar A.V. (1953) believes that fluoride reduces alkaline phosphatase
activity, and this negatively affects the enamel mineralization.
In a series of studies performed in different countries, it was found
that the critical period for developing fluorosis of permanent teeth is at
the age of 20-36 months of life, although the study by Erdal S., Buchanan
SN indicates significant risks to children of 3-5 years because at this age
remains a risk of excessive intake of fluoride. According to Erdal S. and
Buchanan SN, in children from 3 to 5 years, the fluoride tablets and
toothpaste increase the daily intake of fluoride (EDI) from 2-6 times.
It should be mentioned that, with increasing age at which children
start to drink water that contains fluoride, they decrease the frequency
19
and severity of damage. This is manifested most intensely at the age
of 6-7 years, when it is already completed the crown calcification of
permanent teeth except molars two and three.
When the enamel is already formed, the use of even long-term, high
water-containing fluoride does not result in change of color enamel.
However, if the amount of fluorine will be more than 6 mg/l, it can
produce changes in the tissues of teeth already formed.
High concentrations of fluoride in drinking water can produce
macules in milk teeth, although much less frequently than in permanent
ones. This is because their complete mineralization is finished in the
intrauterine period. Fluoride, that enters the mother’s body is stopped by
the placenta, which protects the fetus from intoxication.

THE SENSITIVITY AND RESISTANCE


TO FLUORIDE OF THE HUMAN TEETH

It is considered that the population prevalence of dental fluorosis


in endemic regions increases in accordance with the increasing
concentration of fluoride in drinking water.
In most people the clinical manifestations of fluorosis are significant,
and in some – only minor changes. Moreover, in such areas live children
whose teeth are perfectly healthy. This is due to the fact that at the same
concentration of fluoride in water, the body may respond differently to
that micro-nutrient intake.
The severity of dental fluorosis depends on the body’s sensitivity to
fluoride poisoning and its ability to resist the harmful effects of this
microelement.

20
FLUOROSIS CLASSIFICATION

The clinical picture of endemic fluorosis is varied. All the authors


classify fluorosis, from smaller events and progressing to larger ones,
for an appropriate examining and assessing, a comfortable and not
cumbersome classification is needed.
The results of our clinical work of more than 30 years have
strengthened the view, in that fluorosis can affect or the two central
incisors of the upper jaw and the first molars, or all the permanent teeth
of both jaws, although in a variable severity.
Some classifications are:
Dean (1937), which contains seven degrees of dental fluorosis;
Patrikeev (1956), Thylstrup and Fejerskow (1978), Horowitz (1984),
Pendrys (1990) – 5 degrees:
Maksimenko and Nicolishin (1976) – 4 degrees, etc..
The degree of damage can vary from striped to destructive form.
Therefore, we believe it is useful to classify the local and generalized
fluorosis.
Local dental fluorosis is characterized by the lack of yellow-brown or
brown pigmentations, characteristic to generalized form of the disease,
and generalized fluorosis – the enamel looking “dead”. In addition to
pigmented macules, erosions and defects of the crowns of the teeth are
often detected because of the abrasion and fracturing.
We present you the USMF “Nicolae Testemiţanu” classification of
the dental fluorosis (1986-2011), which includes five ascending degrees
of the enamel damage.
• Level I – vestibular hatches on the enamel surface of the anterior
crowns, in the cervical region of the teeth – fine chalky strips, barely
visible, but easily detectable with converging lens. Sometimes these
hatches confluence in chalky macules.
21
• Level II – yellow or yellow patches. Incisors’ enamel is affected, but
can be affected all the teeth. Enamel color intensity is more pronounced
in the central part of the macula passing without clear demarcations to a
normal enamel. Macules are spread over the entire tooth, including the
incisal edge.
• Level III – beige patches, reddish-brown to chocolate and pinching
of the tooth enamel, which occupies more than a half of the tooth surface.
• Level IV – dark brown patches and erosions on dental enamel.
• Level V – enamel destroyed. Such teeth are fragile and the abrasion
is easily. Enhanced abrasion is usually associated with tainted enamel,
leading to rapid destruction of the tooth.
These events were observed both in local fluorosis and in the general
forms of dental fluorosis.
WHO (1965) recommended the classification of fluorosis after I.
Müller, which includes five forms of dental fluorosis:
• Questionable – A few white flecks or white spots
• Very Mild – Small opaque, paper white areas covering less than
25% of the tooth surface
• Mild – Opaque white areas covering less than 50% of the tooth
surface
• Moderate – All tooth surfaces
affected; marked wear on biting
surfaces; brown stain may be present
• Severe – All tooth surfaces
affected; discrete or confluent pitting;
brown stain present.
Fig. 3. Severe forms of dental fluorosis

22
THE CLINICAL PICTURE OF FLUOROSIS

Depending on the concentration of the fluoride in drinking water


and consumed food, can occur both dental caries and fluorosis. Low
content of fluoride in drinking water leads to tooth decay and the high
concentration – to the occurrence of fluorosis.
Patients complain of the presence of patches, lines and chalky, yellow
or brown bands on the tooth surface.
The changings in the normal enamel staining intensity states the
severity of the disease of the dental hard tissues. Usually, dark brown
coloration of the macules, erosions and enamel damage are signs of
severe forms of fluorosis.
The variety of the macroscopic picture of teeth affected by fluorosis
in children from Ungheni in our study presents a particular interest.
After detection of the disease frequency, the teeth groups were distributed
in the following order: incisors, premolars, molars. In severe cases the
damages can be noticed in all the teeth – both maxilla and mandible.
Grade I – the presence of the hatches on the maxilla incisors’ enamel.
Grade II – the presence of a pale yellow spots or yellow, located on
the incisors and premolars and molars. Stains are oriented horizontally
along the equator tooth or cutting edge region of the incisors, rarely,
pigmented bands are arranged vertically along the axis of the tooth .
Grade III – the presence of inclusions and brown spots (light brown),
located on the enamel of a group of teeth or of all the teeth.
Grade IV – the presence of spots and brown enamel erosions (dark) on
all the teeth. The size and shape of erosion varies, often they are solitary,
but more often multiple, sometimes the enamel defects confluence. The
edges are irregular, the bottom – rough and usually pigmented .
Grade V – the presence of the enamel destructions of isolated groups
of teeth. At this stage, the teeth are gradually destroyed after increasing
their brittleness.
23
Teeth with mild degrees (I, II) of fluorosis maintain functional
properties: strength, abrasion, shape. The possibility of these teeth to be
attacked by caries is very low.
Teeth with significant levels (III , IV, V) of fluorosis are characterized
by marked disturbances of mineralization, as a result they are more
fragile, brittle and are easily exposed to abrasion. All this leads to
accelerated destruction.
A particularity of teeth damaged from fluorosis is that mandibular
teeth are much less affected by erosive and destructive forms.
In the cervical region, normal enamel loses its luster and gets milky
matte color.
The higher is the severity of fluorosis, the enamel affected area
expands. Sometimes, all teeth have a matte milky tint all at the same
level.
Children of the same age have varying degrees of fluorosis. Of 376
children investigated from the regions of endemic fluorosis in 59 children
living permanently in that place were not detected signs of fluorosis of
the teeth, although they had the same living conditions as the children
with fluorosis.
In this context we find that individual susceptibility of the organism is
the decisive factor for the manifestation of fluoride lesions.
In the case of low fluoride concentrations (1.5-2.0 mg/l) in the
drinking water can be detected enamel changes in the form of small
individual “porcelain” patches, or coated , transverse ribbed (that can be
longitude, too), which normally occupy a small part of the surface of the
dental crown, located on any of the surfaces of the tooth.
Such changes are most commonly seen on the vestibular surfaces
of the teeth and are noticed especially in incisors and first molars, the
mineralization of which occurs simultaneously.
If supplying water contains high fluoride concentrations (2.0 – 2.5
mg/l), in the enamel are noticed yellow colored patches, especially in
children who were not breastfed or were weakened by illness.
When consuming water containing 2.5-3.0 mg/l fluoride besides the
yellow patches, can be noticed intense dark yellow or brown pigmentations.
24
These pigmented patches can be located in any part of the tooth. In dark
pigmented macules there may be observed and some inclusions.
If children drink the water containing high concentrations of fluoride
(3-4 mg/l) usually they develop severe forms of enamel damage –
erosions, which are arranged usually erratic and scarcely on the surface
of the dental crown. The erosions unite with pigmented or chalky
macules and they assign to the teeth the “pinched” look. In more serious
cases, the dotted erosions confluence and this may lead to changes in the
tooth crown.
The concentration above 4.0 mg/l of fluoride in the drinking water
leads to the destruction of the tooth enamel. Most often, this form of
fluorosis occurs in children weakened by chronic illness and living in
inadequate and unfavorable living conditions.
As a characteristic sign of the enamel fluorosis damage is the
symmetrical location of the macules on the surface of dental crowns.
Homonymous teeth are affected by the same form of fluorosis, repeating
the exact macular drawing in the symmetrical teeth. In the same person,
different dental groups may be affected by fluorosis in different degree
and form.
One form of fluorosis may not, in the future, move to a different form,
even if the child starts to use water which contains a bigger amount of
fluorine.
So a form of fluorosis is kept throughout their life. And conversely,
people that began drinking water containing a lower fluoride
concentration noted sometimes that macules on their teeth become less
obvious, getting a dimmed look.
In fluorosis, the teeth that have already erupted have a poppy aspect,
of one degree or another.
It is well known that dental fluorosis occurs after consumption of
water with high content of fluoride during the tooth development. The
consumption of drinking water containing even very high concentrations
of fluoride during the finished tooth calcification does not cause fluorosis.
Usually, fluorosis macules locate in the permanent teeth, most often
– incisors and first molars.
25
This is because the time of calcification of the permanent central
incisors and first molars coincide.
The damage causes to these teeth are:
• the amount of water consumed by the infant per 1 kg of weight, with
time is reduced;
• the child’s body is more susceptible to various diseases in the first
years of life when these teeth mineralization occurs.
The mineralization of upper central incisors and first molars begin at
5-6 months after birth and ends at 4-5 years.
The mineralization of lateral incisors and canines start over 8-10
months after childbirth and ends: the lateral incisors – 4-5 years, and the
canines – from 6-7 years.
The premolars mineralization starts in the second year of life, and
ends at 6-7 years.
Molars begin mineralization at 6 years and the mineralization process
ends at 7-8 years; molars III – 12-16 years.
The later starts the mineralization of a group of teeth, the more
rarely these teeth are affected by fluorosis. Periods of mineralization
disturbances correspond to the location of morbid fluoride changes.
Our researches carried out in a number of regions of endemic
fluorosis allow us to support the hypothesis that clinical picture of dental
fluorosis is not the same in all outbreaks, even at the same concentration
of fluoride in drinking water.
Even in the same outbreak not all the children are affected by the
same form of fluorosis.
It depends on pregnancy period complications, infant feeding –
natural or artificial – and further feeding of the child.
Children that consumed food with large amounts of calcium and
phosphorus were less affected by caries.
The consumption of water containing high fluoride concentration
(3-4 mg/l) reduces the buffer action of favorable environmental factors
and almost all the children are affected by fluorosis.
In case of very high concentrations of fluoride, the number of serious
forms of fluorosis grows.
26
The older children are from an endemic outbreak, the less clinical
manifestations are observed, and the fluorosis form is easier. This
phenomenon manifests itself at 6-7 years when the mineralization of
permanent teeth crowns ends, excluding the third molars.
When the concentration of fluoride in drinking water is very high, the
deciduous teeth are also affected by fluorosis, although, less frequently
than the permanent ones.
The investigation of 136 primary school pupils in Pârliţa, Ungheni,
where water fluoride concentration is 13 mg/l, has revealed that the
incidence of fluorosis in the deciduous teeth is 23.7%, the macular form
was diagnosed at 94.4%.
Fluorosis attacked especially the IV-th and the V-th maxilla and
mandible teeth, and only 4 cases have revealed impairment of all the
teeth. Colouring macules vary from chalky to tan-dark.
In all the children who had fluorosis of the temporary teeth was
detected and a severe fluorosis form of permanent teeth.
The distribution of decay among the first grade pupils constituted
57.4%, of which only temporary teeth decay – 46% of cases, temporary
and permanent teeth – 7.4%, the first permanent molar tooth decay –
4%. Decay intensity amounted to 1.3, the intensity of fluorosis – 4.0.
In the specialized literature there are reported facts that fluorosis
teeth show a high fragility and increased abrasion. These features are
probably related to modification of the enamel.
It should be noted that the inhabitants of endemic outbreaks often
occur minor enamel chipping. Almost always enamel chipping is
accompanied by the increased tooth abrasion. Bare surface after
chipping becomes, over time, smooth, hard and glossy, with a yellowish
tint. Crowns fractures can be observed in anterior teeth.
Analyzing the clinical manifestations of dental fluorosis: increased
tooth abrasion, enamel chipping, relatively high susceptibility to injuries
– we can conclude about functional incompetence of teeth affected by
severe forms of fluorosis.
The presence of enamel macules on tooth can be seen in other diseases
of the teeth.
27
Therefore, the differential diagnosis of fluorosis should be done with
the decay in the macula stage and dental hypoplasia.
These pathological processes are characterized by the following
differential-diagnostic signs:
1. Chalky macules in decays are usually solitary, and in fluorosis –
multiple.
2. Chalky macules in decays are a sign of an acute evolution of the
disease, and the pigmented – a sign of chronic evolution. In fluorosis,
the presence of chalky or pigmented patches is an index of the severity
of the process, and not of its intensity.
3. Chalky macules in decays are characterized by a tendency to
change (pigmentation, the formation of a defect). Fluorosis enamel
macules are stable.
4. In macula decays, the pigmentation has a dirty greyish indefinite
unhealthy looking, in fluorosis, pigmentation has a stable yellow-brown
color.
5. In macula decays, the tooth has a bluish tint, the enamel appears
transparent; in fluorosis, the macules are noted on white enamel
background.
6. Macula decays are arranged typically in the vicinity of the contact
surfaces of the tooth crown and the fissure region. Fluorosis macules are
localized on the vestibular and lingual surfaces of the teeth and on the
cusps of the lateral teeth.
7. The symmetrical localization of the teeth decay can happen, but
affects it only singular teeth. Fluorosis macules are localized strictly
symmetrical, affecting homonymous teeth of the right side and the left
with patches of the same shape and color. Even if decay macules are
localized symmetrically, the design is not strictly repeated as in fluorosis.
8. Chalky decay macules is the symptom of acute severe caries and
is characterized by the presence of cavities in teeth. In fluorosis, cavities
are missing or are solitary.
9. The decay primarily affects the first molars; in fluorosis, macules
are observed in all groups of teeth, although most often they locate in
the central incisors.
28
10. In case of caries, both – temporary and permanent teeth are
affected; and in fluorosis – mainly is affected the permanent dentition.
11. In fluorosis, the enamel surface is smooth, glossy, and painless when
probing; in dental caries, the enamel surface is matt, rough, sometimes
sensitive when probing, there may be present a decrepit wall cavity.
12. In caries, the reaction to thermal factors is positive, and in
fluorosis – is negative.
13. Decay occurs after the tooth eruption; in fluorosis – when tooth
erupts.
14. In decay, the coloration with methylene blue is positive, while in
fluorosis – negative.
15. In fluorosis it is detected a high concentration of fluoride in the
drinking water, while in caries – a low concentration.
The clinical picture of dental fluorosis is extremely varied – through
its forms and nature of the external manifestations of the tooth enamel,
but also the teeth features in their relationship with external factors. The
drawing of the enamel macules is also multiform.
Depending on the shape and extent of damage, changes the character
of the macula – from small, chalky (white) spots (or warped) barely
perceptible to the naked eye on the labial surface of the enamel, to
multiple confluent macules and erosions, that disfigure or destroy the
tooth crown.

Chalky solitary patches (Fig.


4)

Small solitary patches with


chalky or “porcelain” aspect and
sometimes with transverse stripes,
which usually occupy a small part
of the surface of the tooth crown are
common. These kinds of changes
are rarely noticed simultaneously Fig. 4. Chalky solitary patches
29
on several sides of the same tooth. When there is a slight damage, the
“porcelain” macules can be observed having an intense natural light, in
more severe cases, the chalky macules are easily detected. These types
of macules are a little similar to the hypoplasia macules. Such mild
fluorosis forms (enamel maculation) are unnoticeable and some people
(even the dentists) do not pay attention.

Yellowish patches (Fig. 5)


In some cases, on the enamel are
encountered pale yellow patches.
This yellow macular pigmentation
gives a “tiger aspect” to the tooth.

Fig. 5. Yellowish patches

Yellow or brown patches (Fig.


6)
This is a more severe form
of fluorosis and is characterized
by intense dark yellow or brown
pigmentation.

Brown patches (Fig. 7)


Fig. 6. Yellow or brown patches These patches can locate in any
part of the tooth. However, very
often they appear on the labial surfaces of the anterior teeth. If brown
macules are located near the incisal edge of the incisors, the teeth have
a “burned” look.

30
In the dark pigmented macules
sometimes can be noticed some
included small white patches.
In such cases, the teeth have a
monstrous look.

Fig. 7. Brown patches

Enamel erosion (“enamel


pinching”) (fig. 8)
A very high concentration
of fluoride in drinking water
causes damages characterized
by impaired integrity of the
Fig. 8. Enamel erosion enamel in the form of erosions
located chaotically, dispersed on
the surface of the crown and associated with pigmented chalky patches,
giving a “pinched” (“eaten”) look to the teeth.

Destructive form of fluorosis


(Fig. 9)
In the most severe cases, small
erosions confluence between them,
it can lead to the tooth crown
shape changes or even destruction.
Such forms of enamel maculation,
even in case of very high levels of
fluoride in drinking water, usually
appear in children weakened by Fig. 9. Destructive form of fluorosis
chronic illnesses and those living
31
in unfavorable conditions (inadequate and insufficient nutrition, poor
housing conditions, etc.).

Fluorosis degenerated chalky


teeth (fig. 10)
In a number of cases, it can be
noticed a form of enamel dystrophy
characterized by a lifeless look of
the teeth, chalky degenerated, with
a lack of luster, and their surface is
sometimes rough. A characteristic
feature is symmetric location
Fig. 10. Fluorosis degenerated of the macules on the surface of
chalky teeth dental crowns. Homonymous teeth
are affected by the same form of
enamel maculation or erosion, repeating the exact same macules design
in symmetrical teeth. Different groups of teeth at the same person
may be affected by various degrees and forms of fluorosis (enamel
maculation). In the literature there are reports proving that endemic
fluorosis determine functional deficiency of the teeth, especially – the
fragility and increased abrasion.

32
DIFFERENTIAL DIAGNOSIS

In making the differential diagnosis between fluorosis and hypoplasia


it should be taken into account the fact, that besides the differences, they
also have many things in common, both in clinical and in etiology.
In hypoplasia as in fluorosis usually are affected the permanent teeth.
Deciduous teeth are rarely affected by fluorosis and by hypoplasia – less
often.
The localization of the fluorosis macules, as in hypoplasia, is directly
dependent on the age, time and duration of event factors action that
disturb the normal mineralization of the enamel.
A. fluorosis:
• the consumption of water with high concentration of fluoride.
B. hypoplasia:
• Artificial feeding at an early age;
• rickets;
• toxic dyspepsia;
• scarlet;
• measles;
• other pediatric disorders.
Depending on the localization of hypoplasia enamel changes can be
judged by the duration of action of unfavorable factors or other factors
on the body.
Both fluorosis and hypoplasia affects symmetrical teeth. In both
conditions it can be altered the shape of the dental crown.

Clinical differences between fluorosis and hypoplasia


1. In hypoplasia, enamel is thinning or the defects, localized some in
a row in the form of dimples having a round or oval shape, surrounding
33
the tooth like a sulcular string. The sulcuses can be single or in group
– scalar (in the form of steps). In fluorosis, enamel defects are detected
only in severe cases and the erosions are singular. Rarely can be noticed
more than one erosion on the same tooth.
2. Hypoplasia is met in seemingly intact enamel. Fluorosis enamel
erosions are seen on the background color changes. Macules are detected
not only in the region of erosion, but also on dental surfaces without
erosions.
3. In fluorosis, the caries develops slowly, in hypoplasia the teeth
affected by the decay are destroyed quickly.
4. In hypoplasia, the dental crown shape is characterized by one
or more of strangulations, which causes the tooth contours change. In
fluorosis, the dental crown shape changes rarely.
5. The coloring of fluorosis affected areas is chalky-white, from
yellow to dark- brown, while in hypoplasia – white or yellowish.
6.In fluorosis, with age, the macules may change their colour or can
disappear at all, while in hypoplasia the macules are steady, without
changes.
7.In fluorosis the fluoride concentration in drinking water is elevated,
while in hypoplasia the fluoride concentration isn’t important.
The diagnosis of fluorosis is established on the basis of the clinical
signs and of the informations about the fluoride concentration in drinking
water from the locality where the investigated person lived during the
early infant period.

34
Table 1.
Macular fluorosis, caries and hypoplasia characteristics
Features Fluorosis Decay Hypoplasia
The Before After eruption Before
appearance eruption eruption
Teeth Mostly Both permanent and Mostly
impairment permanent teeth temporary teeth permanent teeth
permanenţi
The On all the On the vestibular On all the
localization surfaces and proximal surfaces surfaces
The number of A lot Singular Mostly
macules singular
The Reduced or Manifested Reduced or
permeability normal normal
Macule’s For the rest of Disappear rarely Don’t
evolution the life disappear
Fluoride High Reduced or normal Reduced or
concentration in normal
water

Table 2.
The differential diagnosis of erosive form of fluorosis
Features Fluorosis Superficial Hypoplasia Wedge-shaped Erosion
decay defect
Complaints Esthetic Enamel Esthetic None Esthetic de-
defect defect defect fect
The localiza- All the In the fis- All the sur- On the vestibu- On the vestib-
tion surfaces sures, on faces lar surfaces ular surfaces
the proxi-
mal sur-
faces
Clinical Enamel Enamel Pinching Wedge-shaped The erosion
signs defect defect enamel defect defect
Permeability Reduced Pronounced Reduced or Low pro- Low pro-
for dyes or normal normal nounced nounced

35
PSYCHO-EMOTIONAL IMPACT AND SOCIOLODICAL
ASPECTS OF DENTAL FLUOROSI IN YOUNG PEOPLE IN
MODERN SOCIETY ( STUDY ):

Topicality of the study:


In recent years the aesthetic orientation has become very popular
in modern dentistry, as an increasing number of patients want to have
not only functional restorations, but also a brilliant smile (“Hollywood
smile”). Tooth discolorations or defects, especially those in the front
teeth, make the patients uncertain, leading them to communicate and
smile less. Finally, this determines psycho-emotional problems and non-
integration in the social environment.
Researchers in the country and abroad have made ​​in recent years
a number of scientific studies which serve as the foundation for the
concept of the interrelation of the quality of life and dental-maxillary
system status. Healthy teeth, beautiful smile is associated with good
health, success in your personal life and career. One of the diseases that
affects the aesthetic and change color and relief is the dental fluorosis.
The issue of affected aesthetic by dental fluorosis gets a special
actuality in Moldova, because there are several outbreaks of endemic
fluorosis, in which many children and young people show changes color
and texture of the teeth.

Purpose of the study:


Most of the scientific researches on this issue are devoted to dental
fluorosis etiology, pathogenesis, diagnosis, treatment and prevention.
Until now, appeared a lot of different techniques and whitening
substances.
Many times were argued the problems regarding the safe methods
and substances used in the treatment of dental fluorosis. In this article,
36
our group of authors will not target any whitening method, but will
discuss only the psycho-emotional effects of fluorosis.
At present there are a few studies that report a possible negative
impact of dental fluorosis on psycho-emotional state of the patient, and
all of them are contradictory. Some authors argue that dental fluorosis is
not a problem for young people; others recognize that this is an important
aesthetic issue, and the third – they could not get a clear answer, univocally.
The purpose of this study: the identification and characterization of
psycho-emotional problems caused by fluorosis discoloration of teeth
within sociological methods in various categories of young people.

Research materials and methods:


The research was lead by the Department of Therapeutic Dentistry
of the Dentistry Faculty of USMF “Nicolae Testemiţanu” within Dental
University Clinic during practical classes, involving, during 2009-
2011, 136 students from 3, 4 and 5 years performing dental screening
examinations.
The study consisted of interviewing patients aged between 19 and 25
years – born in regions with high fluoride content in drinking water (up
to 4.0 mg/l).
Each student – examiner during all cycles reserved by the Therapeutic
Stomatology Department USMF “Nicolae Testemiţanu” examined
(under the supervision of the teacher – coordinators of this study) on an
average 4 patients, most of the patients being students from the Chisinau
universities and colleges.
344 patients were examined, of which 263 – boys and 281 – girls. To
evaluate the severity of dental fluorosis, we used to investigate the mass
population by the WHO recommended classification.
Sociological component of the study consisted of the investigation,
using a simplified questionnaire.
The questioning was performed during the examination of the
patient and only in patients that lived or live in an endemic outbreak of
fluorosis.
Overall there were selected 78 girls and 74 boys.
37
All respondents (originating from endemic regions) were
conventionally divided into 4 groups according to the severity of dental
fluorosis:
• Group 0 – 21 people without morbid signs;
• Group A – 19 people with suspect forms of fluorosis;
• Group B – 74 people with mild fluorosis (gr. II, III);
• Group C – 38 people with severe fluorosis (gr. IV, V).
The questionnaire contained six questions that were optimized during
the pilot study, in accordance with the objectives of this study. 3 of these
questions were related to patient’s ID, ​​age, sex, residence.

Results and discussions:


The dental fluorosis frequency was determined being quite high.
Standardized index was 73.55 ± 3.24 %, the prevailing forms of fluorosis
were questionable and mild (60.63 ± 3.86%), the severe form was rare
– 14.44 ± 4.26 % of cases. Numerically speaking, this means that 27 of
544 patients selected had brown pigmentations on the enamel, and in
many cases – defects.
Because in Moldova in fluorosis endemic outbreaks live about 600
000 people, the number of young people aged 19-25 years, suffering
of severe dental fluorosis, may reach 19 000 (!!!). It is unlikely that
they will feel comfortable in a modern society, due to the psychological
peculiarities of this age.
The number presented is only a mathematics deduction (speculation),
and for determining the de facto situation, we started questioning patients
regarding the matter.
We were interested in the following:
• the patient ‘s attitude to the color of his teeth ;
• if the patient wants to treat fluorosis ;
• if the patient feels the social repercussions of this disease with
dental manifestations.
The first question was intended to determine patient’s satisfaction
about the color of their teeth and required an answer – yes or no.
The information obtained was ambiguous and a little bit unexpected.
38
On average, 37.73 % of respondents answered yes to the question, and
62.27 % – negative. The detailed analysis of the results revealed that the
views of young people correlate with the intensity of dental fluorosis.
The highest percentage of positive responses was recorded in groups
A (42.73 %) and B (40.23 %), the lowest – in group C (41.44 %).
In accordance to the classification presented, the questionable and
the mild fluorosis are characterized by impaired translucency of normal
enamel, ranging from a few isolated chalky white spots or patches to
manifested small white patches that cover less than ¼ of the labial
surface.
Such tooth discolorations usually do not attract the attention not
only of others, but even of the patients – confirmed during the course
of trial.
The study revealed a significant difference of the gender indicators:
on average, 59.17 % of girls and 36.81 % of boys were unhappy with
the color of teeth. The boys were less worried by fluorosis discolorations
that can be noticed in the mathematic difference of the values of all
groups sampled that is up to 10-20%.
The second question “Do you consider teeth discoloration a problem?”
requested one of the proposed answers (listed below): • no problem in
itself; • mild discomfort; • bearable problem; • serious problem.
The purpose of the question was to identify the existence of psycho-
emotional problems associated with fluorosis discoloration of teeth. So
55.55% of respondents affirmed the existence of the problem itself. In
the research prevailed the mild discomfort (32.48%), which probably
does not exert a negative effect on the psycho-emotional state of
young people. However, 21.08% of respondents, that means every 5th
respondent with dental fluorosis, periodically or permanently faced with
significant anxiety and communication difficulties.
The study was attempted to determine the dependency of the severity
of the intensity manifestations of dental fluorosis and sex. The female
students have proved to be more demanding to tooth color, which often
has negative psychological consequences if they were found discolored
teeth. In the group of girls with severe dental fluorosis was observed an
39
increased severity of certain psycho-emotional tension from 52.21 % to
73.21 %.
The last question discussed was “ Do you want to treat fluorosis, and
if not – why?”.
From the answers to the last question we found out that the main
reason why some patients do not like the idea of whitening teeth is the
previous failed attempts of treatment.
For example, two patients in the studied group complained that, after
whitening, they become darker than before bleaching. In both cases
we found that bleaching was performed in the center of endemic areas,
which very likely was the reason for treatment failure.
Some patients think that the restoration of the natural color is not long
lasting and that this treatment is more harmful than useful. Of course,
there is the fear of cavity formation after completing treatment.
Taking in consideration that the patients live in a limited endemic
area, they usually tell the following: “One person that I know has made​​
teeth whitening and after more than a year appeared caries”. Intensity
of fluorosis damage was not reflected on the number of refusals of the
treatment.
Patients with severe forms of fluorosis were afraid of operative
treatment and the uncertainty of the outcome duration.
For the students it is characteristic the reversed situation – with the
worsening of the pathology decreases the manifestations of the psycho-
emotional disorders.
The patients with minor fluorosis very often after finishing the
treatment (bleaching), they desire to do additional whitening treatment
for whiter teeth. They often compare the color of their teeth with the
Hollywood stars or Negroid race or Arabs and stubbornly insisting on
the continuation of the cosmetic treatment.
From the point of view of a specialist, a young man with fluorosis
discoloration of teeth should suffer psycho-emotional problems, the
depth of which is due to the severity of the disease and age. Severe
forms of fluorosis, hypothetically, are accompanied by more serious
disorders of psychological and emotional status.
40
However, the results of this survey do not coincide with the above
assumptions.

Conclusions:
1.The study results have proved to be ambiguous.
2. Discolorations of teeth caused by dental fluorosis are undoubtedly
a risk factor for psychological difficulties forming a large part of young
people. In this case, a predominant importance has the severity of
pathology and sex of the patient.
3. At the presence of a brown pigmentation of the enamel young
people appreciate their teeth color as being in acceptable limits and the
problems created by this – as insignificant.
4. When deciding on the possibility and necessity of dental fluorosis
aesthetic treatment it must be taken into account the patient’s wishes.
5. In patients with minor fluorosis of the teeth very often after
finishing the treatment (bleaching), they desire to do an extra whitening
treatment, for “whiter teeth”.

41
DENTAL FLUOROSIS TREATMENT

Dental fluorosis treatment includes:


• the reduction of the excessive doses of fluoride in consumed
drinking water;
• the application of various methods to remove pigmentation and
dental defects;
• the raising of the body resistance of the child;
• the indication of a reasonable diet (rich in calcium, phosphorus,
vitamins) and medicinal preparations with beneficial effect on mineral
metabolism.
Early forms (grades I, II) do not require special treatment if patients’
aesthetic requirements are fulfilled.
S. K. Gupta and coauthors (1996) affirms that some forms of dental
fluorosis can be treated by administration of ascorbic acid, calcium and
vitamin D3.
There are many well-known and practiced methods of “whitening”
(of depigmentation) in the case of pigmented macules, and in particular
of the teeth located in the front.
Professional literature describes various teeth whitening methods
(Murrin JR, Barkmeier WW, 1982; Hanosh FN, Hanosh GS, 1992,
Cohen S., Burns, R., 1998, etc..):
• Vital or devitalized (vital techniques involve only drug vestibular
applications (the big majority) or all tooth surfaces, and the devitalized
method is achieved after endodontic treatment, through the pulp
chamber);
• Internal, external and combined;
• performed at home (by the patient) or in the dental office.
Many authors have proposed methods for dental depigmentation
action “whitening” drugs that release free oxygen (hydrogen peroxide).
42
As substances for the bleaching of teeth affected by dental fluorosis
G.D. Ovrutkii (1962) proposed acetic and lactic acid.
I.O. Novik applied for removal of fluorosis macules the solution
composed of 5 parts of 33 % H2O2 and 1 part of ether. The technique
of processing of the fluorosis macules consists of embrocating affected
area with cotton balls soaked in the mixture mentioned above. Then the
rays of a quartz lamp are directed to the teeth. When the cotton balls dry
they are replaced with wet ones. The session lasts about 30 minutes. The
first results of treatment are noticed after the third session. In some cases
it is necessary to do 15-20 sessions.
V.K. Patrikeev (1958 ) and G.P. Colon (1980 ) proposed for the
depigmentation of the dark–brown macules on the front teeth the
saturated solution of citric acid (or tartaric acid), which, after application,
was neutralized with a sodium bicarbonate paste. After this, it was
recommended the polishing with pumice and wood stone. The treatment
was continued until the disappearance of the coloration.
I.G. Lucomskii proposed for the removal of the pigmentations and
for whitening the fluorosis macules the embrocating with fluoride paste
of 75%, and enamel exposure to ultraviolet radiation for 3 minutes.
The expected number of procedures is 3-5, with an interval of 1-2 days
between sessions.
G.D. Ovrutkii removed pigmented fluorosis macules by grinding the
affected areas with carborundum stone, and then on the polished enamel
surface applied for 10 minutes a cotton ball soaked in hydrogen peroxide
33%. The tooth, thus processed was irradiated with a quartz lamp within
3-4 min. And then the tooth surface was grinded with a 75% fluorine
paste. Later, after depigmentation, the tooth surface was polished with
wooden stone. Respective mechanical and chemical treatments of the
enamel were performed in 2-3 sessions with intervals of 5-7 days and
were intended to remineralize the tooth surface.
At the Therapeutic Dentistry Department of the ММDI (Moscow
Medical Dental Institute N. А. Semashko), the fluorosis pigmentations
are removed by the following method: the tooth surface is processed
with a cotton swab dipped in a solution of 36% hydrochloric acid, with
43
subsequent application of a solution of calcium gluconate for a period
of 15-20 min.
А . К . Nikolishin (1977 ) performed the whitening of the teeth affected
with fluorosis, by applying on the vestibular surface of the anterior teeth
a cotton swab dipped into a hydrochloric acid solution 36 % and 33 %
H2O2 in a ratio of 1:2, for a period of 5-7 min. After that, he applied on
the tooth a cotton pad moistened with a 33 % solution of H2O2 for a
period of 10-15 minutes. The oral cavity was rinsed with water at the
room temperature. On the same day, for stimulating the mineralization of
dental hard tissues, teeth whitening session was completed by introducing
therein by electrophoresis of a solution of calcium chloride for over 20
minutes. In addition, he invented a device – a spoon which is adapted
to the jaws containing alginate impression material, in which through
two pins, the bleaching solution was introduced. For severe forms of
dental fluorosis, А. К. Nikolishin recommend a complex treatment
administering orally and by electrophoresis the calcium preparations.
The professional literature describes methods of bleaching using
the heat and light, which involve the release of oxygen from hydrogen
peroxide. On the teeth is applied hydrogen peroxide solution 30-35 %,
after which they are exposed to the temperature of 40-57 ° C up to 20
min. this method requires at least 3 meetings with subsequent periodic
checks ( JR Murrin and WW Barkmeir , 1982).
J.R. Murrin and W.W. Barkmeir (1982) also proposed for the treatment
of dental fluorosis the following materials: vaseline, pumice stone sand,
36 % hydrochloric acid, sodium hypochlorite 5.25 % , H2O2 30 % , tin
fluoride in solution, tin oxide .
A mixture of pumice stone sand and a few drops of hydrochloric acid
were applied to the affected tooth surfaces using a circular motion for
over 5 min. And then it was neutralized with sodium hypochlorite, and
the teeth were rinsed with water. Cotton rolls, previously flattened and
soaked with H2O2 and heated to a temperature of 48.8 ° C, were applied
on the teeth vestibular surfaces for 5-10 minutes. The oral cavity was
rinsed with water at the room temperature and then – dried. For the next
processing step, on the teeth was applied a solution of tin fluoride. After
44
this was done, followed the gradual grinding of the superficial enamel
with tin oxide in association with carborundum stones or paper discs.
N.B. When using aggressive substances in the stages described above
must be strictly respected the caution measures. Personnel must be
provided with protective glasses and rubber gloves and patients should
be provided with special bibs and towels applied on the eyes and nose.
For the treatment of incipient forms of dental fluorosis is indicated
the remineralization therapy with calcium preparations (calcium
gluconate, calcium glycerophosphate), administered by applications or
by electrophoresis ( Lebedeva G.K., Galcenco V. М., 1981; Gnatiuc P.
Ia. , Burlacu V.Z. , Elaşco M.L. , 1984; Gnatiuc P. Ia. , Sirbu S.V. ,
Burlacu V.Z. , 1989).
In Moldova, for the treatment of shaded, maculous and chalky-
granular forms of fluorosis is widely and successfully practiced the
teeth whitening method proposed by the Therapeutic Stomatology
Department of the State Medical University of Moldova (Gnatiuc P. Ia.
and the coauthors, 1984).
At the Dental Clinic of the State Medical University were treated
patients with all forms of fluorosis and all degrees of damage. Their
treatment was performed in complex volume (general, local and
physiotherapy). All the patients were recommended a diet rich in protein,
vitamins and microelements. Considering the fact that fluoride is calcium
antagonist, a particular importance was given to its content in foods.
Bleaching itself includes:
• the application of a labial plastic extensor for the isolation of the
oral mucosal surfaces;
• teeth isolation for saliva;
• the application of the Vaseline on the marginal, vestibular and oral
gingiva (or other neutral ointment – combustion chemical prophylaxis);
• the application on the vestibular surfaces of the affected teeth (5
min.) of a cotton swab soaked in 18% hydrochloric acid;
• rinsing of the mouth cavity with sodium bicarbonate 2% liquid;
• the application on the same surface of a roll of cotton soaked in 33%
H2O2 liquid for a period of 5-10 min.;
45
• rinsing the mouth with sodium bicarbonate 2% liquid;
• the application on the bleached surfaces of the Calmecin paste for
20 min., or the Calcium gluconate 10% liquid;
• the enamel polishing with Calmecin or Calcine glycerin based pastes.
N.B. The food containing pigments (coffee, grapes, etc.) is
contraindicated and the tooth brushing is recommended to be performed
with toothpastes that do not contain fluoride “Jemciug” “Arbat” etc..
After whitening was finished it was recommended to combine the
fluctophoresis action of the 5% of calcium gluconate liquid, and the
ultraviolet ray irradiation device of the nasopharynx. Irradiation began
conventionally, with 1 min. for each jaw, each day by adding 1 min. and
reached finally 4 minutes. Achieving the 4-minute irradiation it was kept
stable until the end of the treatment.
Fluctophoresis was carried out for a period of 10 minutes using ASB-
2 device, current type III, power – up to 3-4 mA. As anode served two
blades with dimensions 1x8 cm, which were placed on the surfaces of
the affected maxilla and mandible teeth. The cathode was applied to the
cervical area. The procedure was performed daily, for 10 to 12 sessions
during one course of treatment.
Patients who, for one reason or another, could not undergo
physiotherapy were indicated after brushing the teeth to apply Calcium
gluconate 10% liquid (at home). During one month they were given
a set of multi-vitamins + calcium and were recommended to avoid
consumption of foods containing pigments during that month.
The patients were consulted for oral hygiene – brushing the teeth
with toothpastes containing calcium preparations.
In severe forms of fluorosis, particularly those associated with the
abrasion of the teeth, are indicated:
• the preparation of the eroded surfaces of enamel with pathologically
pigmentations;
• subsequent restoration using a light-cured composite ;
• in the case of the tooth crown destruction – a prosthetic restoration
using various methods: indirect adhesive facets or coating with ceramic
crowns, metal ceramic, acrylic, etc. combined.
46
COMBINED CONSERVATIVE TREATMENT OF THE
SUPERFICIAL TEETH DISCOLORATIONS

Nowadays, with the increasing needs of the patients to dental


aesthetics appears the need to update the data on teeth discolorations
and revaluate the methods and resources used in correcting them.
A particular importance is given to the aspect of the maximum sparing
of the hard dental and periodontal tissues, with preferred orientation to a
minimally invasive therapeutic approach. In this article the authors have
proposed to specify exactly this problem, providing updated summary
and innovative proposals.
The data presented in this article, are passed through the professional
experience and the results of clinical cases resolved during the years
1980-2011 at the Department of Therapeutic Dentistry of the SMFU
“Nicolae Testemiţanu”.
Discoloration is called any color change in human permanent teeth.
Usually, noncarious lesions change the color of teeth.
Since the number of carious lesions increases steadily, within different
groups of the population, and lead to discolorations, it is necessary to
understand the causes of these color changes of the teeth.
The tooth discoloration may be due to fluorosis, enamel hypoplasia,
enamel erosion, cuneiform defects, abrasion, chemical necrosis etc.

Staining of permanent teeth can be external, internal, mixed .


1. Dental external discolorations (temporary): plaque, food
colors, smoking, rinsing with chlorhexidine and etacridile lactate, iron
preparations (liquid form), Lichen dentalis fungus development, the
development of oral Bacteroides melaninogenicus, industrial emissions
(copper, lead).

47
2. Dental internal discolorations (permanent)
2.1. Congenital Pathology of dental hard tissues: fluorosis,
hypoplasia, “tetracycline” teeth, imperfect amelogenesis, haemolytic
disease of the newborn (in history), biliary tract anomalies, congenital
erythropoietic porphyria.
2.2. Acquired pathology of dental hard tissues:
2.2.1. Vital staining: food pigments, smoking (constant), rinsing with
chlorhexidine and etacridile lactate (used more than one month), iron
preparations (liquid, sustainable consumption), focal demineralization
of the enamel, cuneiform defect, enamel erosion, age discoloration of
the teeth, amalgam fillings, dental hard tissue necrosis.
2.2.2. Devitalized staining: tooth devitalization, endodontic filling
paste with resorcin-formalin or endometazone, various metal pins,
instrument’s fracture in the root canal, dental trauma.
3. Mixed dental stains: a combination of a few cases in the same
group, a combination of several causes of the different groups.
Thus, an imperative necessity presents the improvement of diagnostic
methods of dental discolorations and the development of a complex
program with appropriate curative and preventive measures.

***
The term enamel microabrasion has been used for the first time by
Theodore P. Croll (1989), indicating a method of discolorations removal
of the dental defects for the aesthetic improvement of the teeth.
Enamel microabrasion is a treatment method of the teeth
discolorations, which includes the removal of a microscopic enamel
superficial layer, with simultaneous erosion and polishing using a special
composition that contains an abrasive and hydrochloric acid, at the end
of the procedure remains a completely intact enamel. Thus, the removal
of the pigmented macules is achieved (including fluorosis). However,
the method is acceptable only if the thickness of tissue color change
does not exceed a few tenths of a millimeter.
Enamel microabrasion is a technique used as an aesthetic alternative
in enamel color changes (white patches, yellow, ribbed, gray –brown
48
coloring or pigmentation by demineralization), when these stain defects
are limited to the superficial layer or when it is intended to remove these
defects quickly, efficiently and conservatively. The method has proved
to be particularly effective for white and yellowish macules; it can only
be used on smooth tooth surfaces. Using enamel microabrasion in the
natural tooth fissures is inadmissible.
The technique is based on the mechanical and chemical reduction of
the superficial enamel of the tooth using a composition “acid-sanding”.
Sometimes this technique improves the enamel superficial layer
structure. For this purpose, it is removed by grinding a layer of enamel
with microscopic thickness (12 to 26 microns in one application, and up
to 200 microns – for a meeting). For comparison, the teeth loose a layer
of 50 microns at the removal of the brackets and up to 10 microns at the
enamel etching.
Hyperaesthesia, which occurs after dental bleaching and microabrasion
and can be successfully solved by applying of some remineralizing gels.
In more severe forms (erosive) of dental fluorosis these methods
precede the applying veneers, crowns or dentures.

Hydrochloric acid microabrasion technique:


18 % Hydrochloric acid is a strong etching agent that decalcifies
the tooth structure and macules which may be present in it, so that if
hydrochloric acid is used in combination with an abrasive agent (pumice)
then the affected enamel is completely eliminated – with the macules.

Indications:
Enamel microabrasion is productive in:
• superficial the staining that partially compromises the enamel;
• enamel hypoplasia is without loosing of structure (enamel systemic
hypoplasia or local, mild form);
• mild dental fluorosis (shaded shapes, stained and chalky-granular
of fluorosis);
• incipient caries lesions;
• pigmented macules – from yellow to brown;
49
• local enamel demineralization, the enamel surface roughness (after
orthodontic treatment – bracket removal) .
Enamel microabrasion technique fails to solve all the pathologies
associated with pigmentations or discolorations of the tooth enamel.
Contraindications [6]:
• “tetracycline” teeth;
• during the orthodontic treatment;
• age staining of the teeth;
• deciduous teeth;
• moderate enamel hypoplasia;
• devitalized teeth;
• the presence of cuneiform defects;
• denuded dental neck;
• presence of enamel erosion;
• imperfect amelogenesis;
• imperfect dentinogenesis;
• the presence of cracks on the enamel surface;
• erosive and destructive forms of fluorosis.
Tetracycline specific macules, imperfect dentinogenesis, enamel
hypoplasia and associated with devitalized teeth previously
endodontically treated require other methods, because these problems
are associated with enamel defects or defects that are very large –
expansive and deep .
Real limits of enamel microabrasion technique are dictated by the
depth and thickness of the enamel pigmentation.
Deep enamel lesions can be corrected only with fillings if the desired
result can’t be achieved by microabrasion.

50
Nowadays in our country and abroad for enamel microabrasion can
be used the following substances:
• a mixture of 18 % hydrochloric acid and pumice;
• the Prema kit containing 10 % hydrochloric acid, silicon carbide
and silica gel (Premier Dental Products Co., USA).
• the Opalustre kit containing hydrochloric acid and microparticles of
silicon carbide (Ultradent Products Inc. , USA).

ENAMEL MICROABRASION HISTORY STAGES


in Republic of Moldova

Enamel microabrasion techniques used in treating the mild fluorosis


and enamel hypoplasia, combined with remineralizing therapy that have
been introduced and extensively tested at the Department of Therapeutic
Dentistry SMFU “Nicolae Testemiţanu” during the years 1980-2011
includes four stages.

First stage:
Tooth bleaching has been done since 1980, using standard
procedures – the applications with hydrochloric acid combined with
hydrogen peroxide (33% hydrogen peroxide), that required at the end
of the procedure a remineralizing therapy with 10% calcium gluconate.
Because the 33% hydrogen peroxide determined strong burns of the
periodontal tissues and had no significant effect, in the mid-80s, it was
decided to give up using it (!).

The second stage:


This method has been used since 1982 to 1992.
• Oral cavity was processed with Vaseline.
• To rinse the mouth was prepared a sodium bicarbonate solution.
• Pathologically modified enamel surface was embrocated with a
cotton ball soaked in 18% hydrochloric acid (balls are then squeezed

51
to a cotton swab to remove the acid, avoiding its accidental spillage on
the oral mucosa) until the discoloration of affected portion is achieved.
At the end of the procedure, the enamel gloss disappeared, the tooth
acquiring a chalky shade.
• The procedure was performed without applying cotton rolls as
isolation (to avoid their soaking and causing acid burns of the oral
mucosa), but obligatory with the use of the mouth opener.
• In case of appearance in the lining of the oral cavity of a burning,
the patient rinsed the mouth with sodium solution.
• The teeth surfaces were treated with a polishing compound
prepared ex tempore and consisting of glycerine or Vaseline, 2-3 drops
of hydrogen peroxide and zinc phosphate cement powder (the powder
was added until a pasty consistency) .
• At that time a cotton ball was wrapped on the mill and then operated
at low speeds (because at high rotations it was possible the unwanted
abrasive acid mixture splashing) and applied to the enamel surface to
polish it.
• The precise removal of the mixture by rinsing the mouth.
• The procedure was finished by the administration of a remineralizing
therapy with 10% calcium gluconate.

The third stage:


In the early ‘90s, Therapeutic Stomatology Department employees of
SMFU “Nicolae Testemiţanu “ decided that the first two steps should be
merged into one.
“Classical” changed technique was implemented in 1992 and is used
(with slight compositional variations) until now.
This method allowed the reduction of the duration and complexity
of the procedure. In the above-mentioned polishing paste began to be
added a 36% hydrochloric acid in a 1:1 ratio.
The treatment was performed in accordance to all precautions.
The doctor and the patient wore big glasses, and in the oral cavity
was introduced saliva vacuum, mucous membrane of the gums was
compulsory covered with a thick layer of Vaseline.
52
When the sensation of burning appeared in the mucous membrane
of the mouth, the patient rinsed the mouth with sodium bicarbonate
solution.
• Then, the tooth surface was treated with a polishing paste, ex
tempore prepared with glycerine oil (or Vaseline), 2-3 drops of hydrogen
peroxide and zinc phosphate cement powder (the powder was added to
obtain a pasty consistency).
• A cotton ball was wrapped on the mill and then operated at low
speeds polishing the enamel surface. Of course, with the arrival in our
stores of the rubber cups, used for professional polishing of the teeth, the
wrapped in cotton mill became part of the past.
• After the careful removal (by rinsing) of the abrasive paste, was
performed ​​acidic polishing of the teeth (without applying a fluorinated
paste!), for the discoloration of the yellow or brown macules, requiring
the application at the end of the procedure of the 10 % calcium gluconate.
Remineralizing therapy course was planned from 10 to 12 consecutive
meetings.

The fourth stage:


In 2006, due to objective factors (difficulties in acquiring hydrochloric
acid), the paste composition has undergone some changes. Specifically
– in place of hydrochloric acid was added to the polishing paste the
acidic liquid of zinc phosphate cement, and the zinc phosphate cement
powder was replaced with the dental dentifrices abrasive paste, available
in the pharmacies. The zinc phosphate cement liquid (+ 2-3 drops of 3%
hydrogen peroxide) was mixed with Vaseline, adding abrasive “tooth
powder” in a 1:1 ratio.
This modified technique of microabrasion with the use of acidic liquid
of the zinc phosphate cement and the abrasive dentifrice powder was
named “spare” (or “mild”), in contrast to the “classic” one (in which are
used more aggressive ingredients), and is applied from 2007 until now.
Practical advantages are due to the frequent use of this acid in dental
offices and that it is less aggressive in case of accidental contact with the
mucosa of the mouth, skin or eyes of the patient or the operator.
53
Indications to “mild” microabrasion
This technique with the use of the acid liquid of the zinc phosphate
cement is indicated, primarily, in the case of small lesions located on the
vestibular surfaces of the anterior permanent or temporary teeth, which
do not have a deep cavity.
• Incipient decay lesions or “white patches”.
• Hypoplastic and fluorosis patches, with defined and diffuse opacity.
• After orthodontic treatment.
• If the bleaching did not resolve the aesthetic defect and was resolved
in association with adhesive restorations based on composites.
• Defect depth less than 0.2 mm.

The “mild” enamel microabrasion technique


Usually 3-4 clinical sessions are performed with an interval of seven
days.
• The doctor and the patient put their protection glasses, saliva vacuum
is inserted in the oral cavity, mucous layer of the gums is (necessarily)
covered with a thick layer of Vaseline or isolated using cofferdam.
• The polishing paste is applied on the teeth surfaces, prepared ex
tempore, and then the teeth are polished with a rubber cup at low speed.
• If during the treating of the dental surfaces with acid – abrasive
mixture, occurs a burning sensation in the oral cavity mucosa, the patient
is asked to rinse the mouth with sodium solution.
• After polishing the teeth, the acid – abrasive toothpaste is thoroughly
removed by abundant rinsing.
• At the end of the procedure necessarily should be applied 10% calcium
gluconate and color changes of macules are recorded. Remineralizing
therapy course consists of 10 to 12 consecutive meetings.
In the first two sessions, the enamel is exposed to acid –abrasive
paste applied by rubbing with a rubber cup rotated at low speed, and the
proximal inaccessible portions using celluloid stripes (abrasive belts).
In the last 1-2 sessions only minor local retouching/finishing are
made by applying calculated and manually friction with the abrasive –
54
acid paste on the rebel stains with a stick or a wooden spatula.
The application of fluoride containing remedies at this procedural
stage, appropriate to remineralizing therapy, although it is widely
recommended in the professional literature, we consider it inadmissible.

***
The determining factor for recommending a suitable technique of
enamel microabrasion is to identify the etiology of the macules and the
diseases that affect the tooth enamel.
As stated in the study of processed surfaces the microabrasion effect
is not limited to the removal of pathological enamel, but also in masking
the sub – surface stains by assigning strong reflector properties to the
superficial layer, which becomes more smooth and irretentive.
We certainly can notice that, thanks to remineralizing subsequent
therapy the superficial cleaned layer becomes harder.
After 1.5-3 months from the treatment meetings, the chalky
looking enamel constantly regains healthy shiny tissue characteristics.
Performing correctly execution of the microabrasion method, there were
no recorded dental or periodontal complications.
Based on our practical experience, we can say that patients have
never repeated the series of treatment, demonstrating, even after long
periods, the stability of the cosmetic outcome achieved once.

Clinical case.
Patient X, 22. Diagnosis: fluorosis, chalky form. During the
examination were detected yellowish patches.
Taking in consideration the localization of the macules on the tooth
surfaces and patient’s smile, for treatment we selected only six upper
front teeth.
3 clinical sessions were performed with an interval of seven days,
using a paste prepared ex tempore of acid fluid form the zinc phosphate
cement and the abrasive dentifrice powder.
After completing the microabrasion, we performed (required) the
polishing and topical application of calcium gluconate 10%.
55
The patient was very satisfied with the results, obtaining a beautiful
smile without resorting to some invasive or restorative methods.
Recommendations:
• The patient was recommended the consumption for at least a few
months in the diet of dairy products (milk, cheese) and not to consume
coloring food (coffee, tea, soup, beet etc.) .
• In addition, he was suggested the use of toothpastes containing
calcium salts in the personal hygiene of the oral cavity, excluding those
containing fluorine (for example, “Jemciug”).

Conclusions
1. The results of the last three enamel microabrasion techniques
associated with remineralizing therapy, introduced and implemented at
the Department of Therapeutic Dentistry SMFU “Nicolae Testemiţanu”
during the years 1982-2011 were positive, showing a long lasting
cosmetic effect of the bleached macules localized in the surface layers
of the enamel (in some forms of dental fluorosis and hypoplasia).
2. The techniques mentioned above are quite simple to perform
and do not require additional equipment in the dental office and are
economically advantageous.
3. The microabrasion ensures the reduction of a fine microscopic
layer dental pathologic enamel and masks the sub- superficial stains by
creating a smooth enamel surface. Making enamel surface irretentive
reduces the likelihood of dental deposits, this being also an important
aspect of oral sanitation.
4. Thanks to subsequent remineralizing therapy, the superficial
cleaned layer becomes harder. In 1.5-3 months after the treatment
sessions, chalky looking enamel constantly regains healthy shiny tissue
characteristics.
5. No complications were recorded after a right and accurate execution
of the microabrasion method: a) the teeth treated by the methods above
(“classical” or “sparing” enamel microabrasion) usually are not attacked
by caries, b) the compliance of the security techniques, periodontal
tissues are not affected.
56
6. Enamel microabrasion technique fails to solve all the pathologies
associated with enamel pigmentations or discolorations.

57
MODERN BLEACHING SYSTEMS AND PROCEDURES
FOR FLUOROSIS TEETH

In the shaded, stained and granular–chalky forms the following


conservative treatment methods are implemented: different whitening
systems (eg Opalescence X-Boost , Opalescence PF, Extreme- White ,
Rembrandt , etc.) .
Lately has been observed a pronounced upsurge of the whitening
method that is due to the simplicity of use, low aggressiveness on
enamel with minimum demineralization , the possibility of abolishing
sensitivity, lasting effect etc. Thus, for the treatment of dental fluorosis
can be used many bleaching systems , for example:
I. Opalescence Xtra – Boost – the active
substance is 38% hydrogen peroxide. The
whitening is a clinical procedure, and
includes the following steps:
1. Professional cleaning of the mouth;
2. Applying lip retractor;
3. Drying enamel;
4. Isolation of the gums with a light-cured
system called Opaldam , which is applied
on the marginal and interdental gingiva and
making sure that the aspiration of saliva is
occurred;
5. Activating the whitening gel Fig. 11.
Opalescence Xtra Boost injecting the activator
into the syringe with inactive bleacher , realizing approximately 20 to
25 moves from one syringe to another to homogenize the contents;
6. Application of the gel over the entire surface or only on the stains
of the teeth for a period of about 15-20 minutes ;
58
The procedure can be repeated several times in the same session .
II. Opalescence PF is a gradually and slightly longer bleaching
system based on carbamide peroxide 10 , 15 and 20 % . It’s an easy
method that gives the patient the possibility to avoid multiple visits to
the dentist that are labeled as stressful. Also, it is a method of bleaching
at home, so the patient may repeat the
whitening procedure after some time without
the need for a specialist’s appointment; and
as individual trays are made, the patient may
use a desensitizing gel based on fluorine to
remove the sensitivity that may sometimes
occur and to perform a general caries
Fig. 12.
protection of all teeth. Thus , this method
of whitening bear and a prophylactic note.
Clinical and technical stages :
• Professional cleaning of the mouth;
• Obtaining the impressions of both
arches;
• Obtaining the models, the base of which
is made in the form of a horseshoe ;
• On the vestibular surface of the tooth
that is included in the smile line (usually up Fig. 13.
to the first molar including the other teeth as
a support ) is applied a layer of a photopolymerizable
wax – LC Block-Out Resin, with a thickness of about
1mm at a distance of 1 – 1,5 mm above the free
gingival margin;
• Making the trays of different thicknesses and
their adjustment ;
• The patient applies on each labial surface of the
teeth in the trey with Opalescence PF gel with the size
of a grain of rice, and after oral application surpluses
are removed with a wool mesh. Trays are worn at
night, when salivation and motor activity are minor. Fig. 14.
59
Fig. 15.
The duration – about 8 hours a night. Bleaching gel should be alternated
with the desensitizing gel ( UltraEz that contains 3% potassium nitrate
and fluoride (0.25% neutral NaF ), Fluoropal contains 1.1% sodium
fluoride, Ultradent ). Whitening treatment duration depends on the
patient’s aesthetic satisfaction .
III. Opalescence Tres –White, is a very convenient and simple home
bleaching method. The active sub stance is 10% hydrogen peroxide.
In one bleaching set are included 10 applicators, 5 for maxilla and 5
for mandible, in which is included the bleaching system in the form
of a film that adheres to the teeth after the applicator is be removed.
The duration of the procedure – from 60 min. Usually, this method
of bleaching is indicated in patients with intolerability to impression
process or materials or the inability of wearing the treys. The most
common reported disadvantage is the gingival impairment because the
film does not have a precise delimitation of dental surfaces.
N.B. During the whitening treatment and 2 weeks after finishing it the
patient should not consume colored drinks or food.
In the erosive and destructive forms are applied the methods of
microabrasion (Opalustre System “ Ultradent “ USA ), restorative
treatment with composite materials and veneering (composite or ceramic
veneers) or orthopedic treatment .

60
IV. Zoom teeth whitening system:
The Zoom system is an in-office tooth whitening procedure that
utilizes a 25 percent hydrogen peroxide gel combined with Zoom’s
small but not significant
amounts of UVB (ultra-
violet) light.

Once the gel is


applied to the teeth the
Zoom Advanced Power
Chairside Lamp, helps
accelerate the bleaching
process. As the hydrogen
Fig. 16. Fig. 17. peroxide is broken down,
oxygen enters the enamel
and dentin to bleach the stained substances, leaving the structure of the
tooth unchanged.

Typically, the hydrogen peroxide gel is applied three times, at intervals


of 15 minutes. Immediately after the applications, a sensitivity-reducing
fluoride paste-gel is applied to the teeth.

As with all tooth whitening options-there are considerations and


disadvantages of this tooth whitening method. Individuals with a
strong gag reflex, or anxiety may have difficulty undergoing the entire
procedure. In addition, some people experience sensitivity during
treatment due to the small amount of heat generated by the Zoom light.
And as with other tooth whitening products, Zoom is not recommended
for children under 13 years old, or for pregnant or lactating women.

This Zoom procedure usually takes no more than one hour, but a
regular teeth cleaning is recommended prior to the actual Zoom teeth
whitening session.

61
CLINICAL CASE 1:
The pacient B. T., 24 years old, place of birth – Făleşti, addressed
with accusation of brown spots on teeth, dark color of the teeth, aesthetic
defect. MEDICAL HISTORY of the disease: the teeth had color disorders
since eruption. The patient didn’t address to a doctor. Water source has
not been changed.

Physical examination:
Endooral examination: hard and soft dental deposits are missing,
the enamel has a matte shade on all surfaces; On the vestibular surfaces,
especially of the upper incisors, are some pigmentations with a brown or
yellow tinge; In the enamel can be observed patches, small defects with
punctiform enamel tissue loss;
Clinical diagnosis: Dental fluorosis - granular-chalky form.
Performed treatment:
* Professional cleaning.
* Realization of the home whitening system with Opalescence PF
10% 4 tubes and 4 tubes UltraEz.
* Whitening procedures with Opalescence Xtra Boost were performed
(mostly on the dark enamel stains); 8 sessions, each consisting of 1-2
each procedures.
* Oral administration of the multivitamin therapy in complex with
Calcium-Vitamin D3.
The result:

Fig.18. Pretreatment Fig.19. Procedural phase Fig.20. The final result


situation

62
CLINICAL CASE NR 2:
The pacient M. S. , 30 years old, place of birth: Floreşti, addressed
with addressed with accusation of brown spots on teeth, dark color of
the teeth, aesthetic defect. MEDICAL HISTORY of the disease: the teeth
had color disorders since eruption. The patient didn’t address to a doctor.
Water source has not been changed.

Physical examination:
Endooral examination: hard and soft dental deposits are missing,
the enamel has a matte shade on all surfaces; On the vestibular surfaces,
especially of the upper incisors, are some pigmentations with a brown or
yellow tinge; In the enamel can be observed patches, small defects with
punctiform enamel tissue loss;
Clinical diagnosis: Dental fluorosis - granular-chalky form.
Performed treatment:
* Professional cleaning.
* Realization of the home whitening system with Opalescence PF
10% 6 tubes and 6 tubes UltraEz.
* Whitening procedures with Opalescence Xtra Boost were performed
(mostly on the dark enamel stains); 8 sessions, each consisting of 1-2
each procedures.
* Oral administration of the multivitamin therapy in complex with
Calcium-Vitamin D3.
The result:

Fig.21. Pretreatment Fig.22. Treatment phase Fig.23. The final result


situation

63
VENEERS: Classification, directions to implement, tooth
preparation methods for veneer’s usage; modeling

The veneer (laminate, adhesive facet) is a thin ceramic plate, plastic


of heat polymerization, or from composite, which covers the entire
facial surface of the tooth, and it imitates its natural look, aiming the
color and size correction the it.
Facets classification :
By purpose: correcting color, shape, combined.
After producing material: acrylic, ceramic, composites (microfile,
macrofile, hybrid).
After the method of production: standard (garnish), individual, direct
(consolidated), indirect, combined.
After tooth preparation: with preparation, without preparation.
By size: total, partial.
After the period of use: temporary, permanent.
The last time in the clinic is very often applied restorative technology
- direct method of veneer production, the latter being more accessible
and convenient for dentists (especially private ones) out of economic and
technical reasons - is overlooked the laboratory link in dental technique
The direct method provides veneer modeling from photopolymerization
composite and its polymerization on the tooth surface directly in the
mouth cavity.
Initially the veneer were originally used for the correction of anterior
teeth, later applicability being extended till pM2.
Indications for veneer’s manufacture: the correction of form, size
and color of the tooth, pathological abrasion of hard tissues expanded in
size, minor and moderate dental „crowdings”, dental trauma, correction
of unsightly interdental space - diastems and trems, replacing of bulky
composite fillings.
64
Contraindications for veneer manufacturing: teeth, which present
active destructive dental or periodontal processes, or have had a loss of
a significant amount of tooth structure.
Stages of veneer manufacture:
1. Cleaning the tooth surface from deposits;
2. the record of the color shades of the tooth in gingival third, middle
and incisal. Noting all the specific tooth elements and determining the
composite color;
3. Anesthesia of the tooth / teeth to be prepared / processed;
4. Preparation:
a -The formation of the threshold and vestibular surface
b – creation of marginal bevelling
c – shortening of the incisal edge
It should be noted that the thickness of veneer made by the direct
method varies in thickness with the one prepared in the dental laboratory
(ie the indirect method). Enamel should be reduced so as to be enough
space (cervical - from 0.3 to 0.5 mm, Central - 0.8 to 1.0 mm, -1.5 to 2
mm incisal edge) for composite material. All angles are rounded, and
the entire preparation will be smoothed. Although the average thickness
of the vestibular enamel of upper central incisor is approximately 1.75
mm, its thickness on a tooth with color changes, which requires bonding
techniques may be much smaller.
On the other hand, the expression level of tooth discoloration,
influences the thickness of the veneer, made through direct method.
Applying these rules of minimum guidelines for the direct method is
individualised. Veneer thickness in the direct method is determined
largely by the degree of tooth discoloration event - as the tooth is darker,
the more thick the veneer must be.
a. Applying to a large cylindrical drill with rounded top, are formed
three vertical sulcus on the vestibular surface of the tooth, beginning
from the incisal edge and 1 / 2 of dental crown height (approximately
up to the equator).
65
b. Ditches (sulcus) achieved are sustained, maintaining their vertical
orientation, to the perigingival area. The bottom of these trenches must
meet a strict parallelism with the vestibular wall of the tooth as in the
incisal half and in the gingival , about Ѕ the length of the notch below
its path under a certain angle to the other half of it.
c. The grooves guide are prepared at about 0.5 mm, then these sulcus
are joined by using a long cylindrical drill .
d. On preparation is made a slight convexity of the vestibular
surface, which is largely determined by the size and thickness of the
tooth. Gingival and incisal half of the tooth is prepared by moving
the drill in meso-distal sense. After finishing of the vestibular surface
preparation it is thinned with 0.75 to 1.50 mm - depending on the
necessary restorations. At tooth color correction the tissues resection
can be deeper – properly to the thickness of veneer planed.
e. Gingival margin of the processing facilities will have to finish at
the free gingival margin. It is formed a threshold along the gingival
margin with a depth of at l east 2 mm.
f. Keeping the long cylindrical drill parallel to the vertical axis of
tooth, it is necessary to prepare the vestibular surface in the proximal end
so far as is possible to hide the veneer’s edges. Edges of the prepared
surface are bevelled at 130 degrees. The proximal edges are located
vestibularily to ward the interdental contact point. Interdental contacts
are preserved whenever possible.
It is created a groove in the gingival-proximal region resembling
a”dog leg” shape, which extends along the gingival crest and conceals
the passage from the front edge to the contact surface. The veneer
passes from vestibular surface into the recess (dog-leg), and provides an
aesthetically optimal function in the gingival-proximal region.
g. An important issue is the need to lengthen (or not) the tooth at the
incisal edge.
I. If it is not necessary to lengthen the tooth, we choose the method,
according to which we fix only the labial surface of tooth crown. Incisal
edge of the processing will stop even before the incisal extremity of the
tooth. We exceed this limit only when the clinical requirements impose
66
this goal. In such situation in the region of incisal edge are removed
dental hard tissues, incisal edge is shortened with at least 1.5 to 2 mm.
The choice of material, from which we want to make the veneer,
is an important step of work, and depends directly on the goals that
we propose, and the methodical preparation of dental hard tissues. This
method of preparation involves the selection of materials to be prepared
microfile composites - because of its excellent aesthetic qualities. They
practically will not suffer from such a preparation method. Therefore the
characteristic fragility of microfile composites will not manifest at all.
There can also be used compomers and hybrid composites.
II. If it is necessary to lengthen the tooth crown, or defect involving
the incisal edge, the method of hard tissue preparation consists in the
following: At first we ask the patient to gear the teeth in the central
occlusion position, using carbon paper between the pre-upper jaw and
the lower. Then, imaginary (or with the pen), we draw a horizontal line
between the contact points. This is done because after vestibular surface
preparation, when we prepare additional the palatal surface, the limit
line preparation on the palatal surface would not coincide with the line,
which joins the points of contact. If the thickness allows, at the incisal
edge is created a lower threshold retention. In this case we respect the
rule applied for class IV: it is necessary to avoid the central contact of
antagonists directly with this region. Preparation limit on palatal surface
must pass above the line connecting the contact points in the orthognatic
bite or below - in the deep incisive overocclusion. In this case the veneer
modeling should be started at palatal surface, and going to the incisal
edge and overcovering it with a composite.
h. Then the edges and the surfaceare are smoothed with a fine
granulation diamond drill. At this labour it is easily pushed and protected
from trauma the epithelial wall of the gingival groove.
i. The prepared lingual surface is smoothed with a paired drill, and
the proximal one-with an acircular fine drill.
j. The preparation is ended with the help of some discs, abrasive
stones, polishing paste, strips.
10. Repeated application of the matrix;
67
11. Applying adhesive system
12. Polymerization of adhesive system;
13. Application of the stratified composite, and its polymerization.
Composite layers begin to be applied from the first cervical region,
moving gradually to the incisal edge.
When it comes to restoring incisal edge and shaping it is better
starting from the veneer of palatal surface. Coming out to the incisal
edge and overcovering it with a composite the restorative material is
brought onto the labial surface.
N. B. Incisal edge is restored by a single portion of the composite!
14. Matrix removal and thread retraction;
15. Grinding, tooth shape modeling and correction of incisal
edge, if the latter was covered with composite. On polishing stage of
proximal surfaces is necessary to work with narrow strips. Anatomical
peculiarities of the teeth are reproduced while modeling, and during
finishing. If we want to keep a good contact point, we grind with strips
especially at package and the lower third of the crown, protecting the
point of contact. The contact point follows to be remade at the final stage
of the restoration
For this is recommended the usage of plastic matrices of contour for
premolars and molars
At women the incisal angles of the frontal teeth group are a bit
rounded, but in men the angles are kept somewhat straight
16. Centric occlusion checking and correcting, if the overcovering
with composite made at incisal edge;
17. Surface contact processing with polishing strips;
18. Surface polishing with shiny pastes
19. Final lightening
20. Processing the restored surfaces with sealants.
The patient must be informed about the necessity of the thorough daily
oral hygiene, which leads to the preserving of the veneer’s shine. We
recommend visiting the dentist every six months - to correct restoration
and polishing of the veneer surface for prophylactic goals.
68
CLINICAL CASE NR 3:
The pacient B. R., 30 years old, place of birth: Falesti, addressed with
accusation of brown spots on teeth, dark color of the teeth, aesthetic
defect. MEDICAL HISTORY of the disease: the teeth had color disorders
since eruption. The patient didn’t address to a doctor. Water source has
not been changed.
Physical examination:
Endooral examination: hard and soft dental deposits are missing;
Enamel has a yellowish brown color on all tooth surfaces with dark
brown spots; In some places small defects are observed with punctiform
enamel tissue loss; On the pigmented or injured enamel and dentin can
be noticed deep erosions or defects; on the background of the pigmented
enamel are non-pigmented extensive portions and defects of different
forms - erosions; Enamel destruction, dentin erosion, destruction of
tooth crown which causes disturbance of the tooth pattern.
Clinical diagnosis: Dental fluorosis, destructive form.
Performed treatment:
* Professional cleaning.
* Realization of the home whitening system with Opalescence PF
10% 4 tubes and 4 tubes UltraEz.
* Whitening procedures with Opalescence Xtra Boost were performed
(mostly on the dark enamel stains); 8 sessions, each consisting of 1-2
each procedures.
* Oral administration of the multivitamin therapy in complex with
Calcium-Vitamin D3.
*On all maxillary incisors and canines were realized photo polymeric
veneers;
The result:

Fig.24. Pretreatment Fig.25. A treatment phase Fig.26. The final result


situation + Opaldam 69
DENTAL FLUOROSIS PREVENTION

Preventive measures of dental fluorosis in children consist of


excluding or reducing the uptake of fluoride ions, primarily by reducing
the water consumption with high concentrations of fluoride. Prevention
of fluorosis can be achieved by social (collective) and individual
measures.
R.D. Gabovici considers that in order to prevent dental fluorosis, a
child of 5-7 years should not consume food and drinking water that
contains more than 2.0-2.5 mg fluoride/day.
In the human body, fluoride is achieved mainly from drinking water.
During 24 hours, at the presence in drinking water of 1.5 mg/l of fluoride,
children receive through water more than 3.0 mg of fluoride, which can
lead to a macula form of fluorosis.
The purpose of the collective preventive measures
is the reduction of the fluoride in drinking water:
1. The source of the drinking water should be
changed;
2. In order to improve the fluorine concentration
it is recommended to mix the waters with various
concentrations of fluorine.
3. In decentralized drinking water supply may
be recommended decanting or freezing water or the
excess removal of fluoride with bone filters.
4. Collective preventive measures consist of purification with
aluminum magnesium hydroxide or calcium phosphate of the drinking
water with an excess of fluoride salts in special installations. Taking into
consideration that for now, it is impossible to provide treated water to
the entire population of the endemic districts it should be paid a special
attention to children communities.
70
Dental fluorosis can also be prevented through individual
conversations with pregnant women, children’s parents.
Individual prevention of dental fluorosis can be achieved by:
1. The artificial feeding of the newborns and the early food
diversification should be avoided.
2. When the food diversification is started the water with high
concentration of fluoride should be banned and replaced with mineral
water, milk or juices, especially in children organized communities; also
should be consumed food with low fluoride concentration.
3. Supplying the towns with high content of fluoride in drinking
water with bottled water (for drinking and cooking) with low fluorine;
4. Unfluoridating - purifying drinking water for children in endemic
areas of fluorosis; bipolar electrocoagulation with aluminum electrodes,
water treatment through the following methods: electromagnetic,
based on ion exchange and adsorption; based on the use of separation
membranes; based on the use of special bone filters; individual filtration
of the drinking water with personal filters.
5. Early food diversification should be avoided;
6. Oral hygiene toothpastes, liquids, gels, tablets containing fluorine
should be excluded and the toothpastes containing calcium preparations
should be recommended instead;
7. Food consumption with increased content of fluoride should be
limited: sea fish, fatty meat, spinach, melted butter, some varieties of
tea and artificial milk, food supplements (salt, juice, mineral water etc.)
replacing them with edibles rich in proteins (especially dairy), minerals
(calcium gluconate, P), vitamins (they reduce the toxic action of fluorine
in the infant's body, in particular vitamins A, B1, B2, D, C, P6, PP); the
tea should be excluded from the diet of children, pregnant and breast
feeding women, replacing it with natural milk (up to 1 liter per day).
In winter it is recommended to increase food consumption of fruits and
vegetables;
8. Products rich in calcium should be used in alimentation, which is
the fluoride antagonist and contributes to the elimination of fluorine from
the body; calcium exerts a protective action in case of low concentrations
71
of fluoride in water (1.0-1.5 mg/l ); the addition of calcium in the
drinking water with higher concentration of fluoride only influences the
character of changes in dental hard tissues manifested with less fluorosis
manifestations;
9. The prescription of calcium preparations (calcium gluconate,
calcium glycerophosphate , etc.) and multivitamins 3 times per year
(autumn, winter, spring) during one month (dosage – depending on the
age);
10. Sodium nucleinate administration in order to increase the child’s
nonspecific resistance of the organism;
11. The compliance of oral hygiene; children should be trained to
comply the oral hygiene, using for this purpose toothpastes that contain
calcium, but no fluoride (e.g., “ Novy Jemciug - calcium”, “Jemciug”,
“Arbat”, “Ceburaşka” etc.).
12. Fluoride medication should be interdicted without the doctor’s
recommendation.
13. An optimal regimen to sun exposure should be provided for
children of all ages; the deficit of sun exposure significantly reduces the
body’s resistance to fluorine;
14. Children from endemic areas should be sent to camps located
in places with low fluoride concentration in drinking water during the
holidays;
15. Rational natural alimentation, which must include a sufficient
amount of quality proteins.

72
CONCLUSIONS:

Dental fluorosis is a very big problem of the modern aesthetic


dentistry, and due to this the attention of the modern doctor and the
resident of an endemic area is paid to the fluorosis various aspects:
• The population in the endemic areas is exposed to uncontrollable
fluoride doses with undeniable toxicity on human body;
• Dental fluorosis is the local manifestation of a general disease.
Apart from the child’s teeth, fluoride affects other growing tissues: the
bones, the brain, endocrine system, etc..
• The prevalence of fluorosis grows with each decade.
• The disease can be prevented by changing the source of drinking
water.
• Besides the local treatment it’s recommended the general treatment
with antioxidant vitamins and Vitamin D3 with Calcium.
• The fluoridation of water, food and personal oral hygiene products
is a scientific error ignoring fundamental principles of science.
• The administration of the fluoride medication should be under the
strict control of the physician.
• Children from 3 to 5 years are categorically contraindicated fluorine
rich toothpastes.
• In endemic areas must be used the non-fluorinated toothpastes with
a high calcium concentration, regardless of the age of the consumer.
• a lot of doctors and parents underestimate and do not know the risk
of the children’s intoxication even with the dental fluoride toothpastes.
• one of the most used and successful methods used in the treatment
of the dental fluorosis (mild forms) is the teeth whitening based on
peroxides.
• Teeth whitening is a noninvasive method, and even though it
includes several sessions, the results appear very soon and are most of
the times spectacular.
73
BIBLIOGRAPHY:

1. Almeida, G. R. C; Schmidt, C. S.; Gerlach, R. F. A10-Differential diagnosis


between severe fluorosis and enamelogenesis imperfecta; // http://www.
scielo.br/scielo.php?pid=S1678-7757-2006000700012&script=sci_arttext
2. Borovski E.V. Stomatologia terapeutică; – 1990, p.90–93.
3. Bowen W.H. Fluorosis: is it really a problem?; // Acta Odontol Scand
2003; 61: 2: 81—86.
4. Christopher Bryson The Fluoride Deception; // Seven Stories Press, NY,
2004
5. Ciobanu S., Florea R. Conţinutul de fluor în apă în unele localităţi ale
Republicii Moldova; // În: Probleme actuale de stomatologie. – Materialele
Congresului III Naţional al medicilor stomatologi consacrat jubileului de 40
ani ai Facultăţii Stomatologie a USMF «N.Testemiţanu”, 1999, p.35.
6. Ely H.C.; Paviani I.S.; Baratz D.V. A23-Endemic area of fluorosis in
Venвncio Aires/RS – a political and sociological issue; // http://www.scielo.
br/scielo.php?pid=S1678-77572006000700012&script=sci_arttext
7. Ene A., Burlacu V., Ciumac S. Tratarea fluorozei cu vagotil; // În:
Materialele conferinţei ştiinţifice anuale a colaboratorilor şi studenţilor USMF
“Nicolae Testemiţanu” din Republica Moldova, 1994, p.434.
8. Fantaye W., Anne A., Asgeir B. et al. Perception of dental fluorosis among
adolescents living in urban areas of Ethiopia; // Ethiop Med J 2003; 41: 1:
35—44.
9. Franzolin, S. O. B.; Gonзalves, A.; Padovani, C. R.; Oliveira, L. F.;
Marta, S. N. Distribution of dental fluorosis according to the degree
and affected teeth; // http://www.scielo.br/scielo.php?pid=S1678-
77572006000700012&script=sci_arttext
10. Gnatiuc P., Gnatiuc E., Năstase C. Concentraţia de fluor în diferite
organe ale organismului uman; // Ch.: Medicina Stomatologică, Nr.3, 2008.
11. Gnatiuc P., Gnatiuc E., Năstase C. Conţinutul de fluor în organismele
vegetale şi animale; // Ch.: Medicina Stomatologică, Nr.3, 2008.
74
12. Gnatiuc P., Năstase C., Terehov Al. Profilaxia cariei dentare şi a fluorozei;
// În: Analele ştiinţifice USMF «N.Testemiţanu»; Chişinău, RM 2011, edit XII,
vol 4, p. 473-475.
13. Gnatiuc P., Terehov Al., Năstase C. Fluoroza dentară – handicapul
stomatologiei estetice moderne; // Ch.: Medicina Stomatologică, Nr.3, 2011.
14. Gnatiuc P., Terehov Al., Năstase C. Impactul psiho-emoţional şi aspecte
sociologice ale fluorozei dentare la persoanele tinere în societatea modernă;
// În: Analele ştiinţifice USMF «N.Testemiţanu»; Chişinău, RM 2011, edit XII,
vol 4, p.468-473.
15. Gnatiuc P., Terehov Al., Năstase C. Toxicitatea fluorului în vizorul
medicinei moderne; // Ch.: Medicina Stomatologică, Nr.4, 2011.
16. Gnatiuc P.Ia. Fluoroza dentară; // indicaţii metodice. – 2010
17. Gnatiuc P.Ia., Sîrbu S.V. Клиника, диагностика и лечение флюороза
зубов; // методические рекомендации. – Кишинев, 1986. с. 12.
18. Gnatiuc P.Ia. Профилактика флюороза зубов;// În: Сборник тезисов
научной конференции ГМУ. – Кишинев, 1992. – с. 492.
19. Gnatiuc P.Ia. Результаты лечения больных с флюорозом зубов; //
În: Сборник тезисов научной конференций ГМУ Кишинев, 1993; с. 491.
20. Gnatiuc P.Ia., Burlacu V.Z., Elaşco M.L. Применение
реминерализирующей терапии при лечении флюороза; //
Здравоохранение. – Кишинев, 1984, т. 2, с. 35–36.
21. Gnatiuc P.Ia., Calmaţui V.V. Отбеливание при флюорозе; //
Здравоохранение, 1989, № 3, с.38–39
22. Gnatiuc P.Ia., Gnatiuc E.V. Лечение гиперестезии зубов; // În:
Probleme actuale de stomatologie. Materialele Congresului stomatologilor
consacrat jubileului de 40 ani ai Facultăţii de Stomatologie „N. Testemiţanu».
1999. p.41.
23. Gnatiuc P.Ia., Gnatiuc E.V. Лечение эрозивной формы флюороза
зубов; // În: Probleme actuale de stomatologie. Materialele Congresului
stomatologilor consacrat jubileului de 40 ani ai Facultăţii de Stomatologie „N.
Testemiţanu». 1999. p.43.
24. Gnatiuc P.Ia., Gnatiuc E.V. О классификации флюороза зубов; // În:
Probleme actuale de stomatologie. Materialele Congresului stomatologilor
consacrat jubileului de 40 ani ai Facultăţii de Stomatologie „N. Testemiţanu».
1999. p.41.
25. Gnatiuc P.Ia., Gnatiuc E.V. Одномоментный метод отбеливания
при пятнистой форме флюороза; // În: Probleme actuale de stomatologie.
75
Materialele Congresului stomatologilor consacrat jubileului de 40 ani ai
Facultăţii de Stomatologie „N. Testemiţanu». 1999. p.42.
26. Gnatiuc P.Ia., Gnatiuc E.V. Содержание флюороза в питьевой воде
на территории РМ; // În: Probleme actuale de stomatologie. Materialele
Congresului stomatologic consacrat jubileului de 40 ani ai Facultăţii de
Stomatologie «N. Testemiţanu» 2001 p.64.
27. Năstase C., Terehov Al. Unele aspecte ale hipersensibilităţii dentare; //
În: Analele ştiinţifice USMF «N.Testemiţanu»; Chişinău, RM 2009, edit X, vol
4, p. 457-460.
28. Godoroja P.; Spinei A.; Spinei Iu.. Stomatologie terapeutică pediatrică;
– Chişinău, 2003, p.87–101.
29. Grec V., Gavriliţă A., Penicov M. Probleme principale în resursele
acvatice, alimentarea cu apă potabilă şi ameliorarea complexă în Republica
Moldova; // În: Tezele primei conferinţe ştiinţifice «Apele Moldovei»,
Chişinău, 1994, p.1–5.
30. Jamie Oliver Fluoride in Drinking Water; // http://socyberty.com/issues/
fluoride-in-drinking-water/ April 13, 2011
31. Joe Eugene Lepo & Richard A. Snyder Impact of Fluoridation of the
Municipal Drinking Water Supply: Review of the Literature; // http://uwf.
edu/rsnyder/reports/fluoride.pdf - May 2000
32. Levy S.M., Warren J.J., Jakobsen J.R. Follow-up study of dental
students’ esthetic perceptions of mild dental fluorosis; // Community Dent
Oral Epidemiol 2002; 30: 1: 24—28.
33. Manamperi A. S. P. Lesson learnt on an endemic problem in the Dry
Zone Sri Lanka: With special focus on Monaragala District; // http://www.
slageconr.net/slsnet/9thicsls
34. Mark Diesendorf How science can illuminate ethical debates: a case
study on water fluoridation; // Fluoride, Vol. 28, No.2, 87-104, May,1995
35. Martins, C.; Pinheiro, N. R.; Paiva, S. M. A36-Parents’ aesthetic
perception of dental fluorosis; // PIBIC/CNPq/UFMG. // http://www.scielo.
br/scielo.php?pid=S1678-77572006000700012&script=sci_arttext
36. Mattos, T. H. E.I; Dell’Acqua, S. MI; Rui, A. A. O.II; Grillo, C. M.II;
Fernandes, G. N.I; Cypriano, S.I ; Sousa, M. L. R.III A37-Dental fluorosis
perception and teeth appearance pleasure in students living at fluoride
high levels area; // PIBIC/CNPq/UFMG. // http://www.scielo.br/scielo.
php?pid=S1678-77572006000700012&script=sci_arttext

76
37. McKnight C.B., Levy S.M., Cooper S.E., Jakobsen J.R. A pilot study of
esthetic perceptions of dental fluorosis vs. selected other dental conditions;
// ASDC J Dent Child 1998; 65: 4: 233—238, 229.
38. Năstase C., Terehov Al., Gnatiuc P. Tratamentul conservativ
combinat în discromii dentare superficiale; // În: Analele ştiinţifice USMF
«N.Testemiţanu»; Chişinău, RM 2011, edit XII, vol 4, p. 476-483.
39. Ng F., Manton D.J. Aesthetic management of severely fluorosed incisors
in an adolescent female; // Aust. Dent. J. – 2007, Sep.; 52 (3): 243–8.
40. Programul Naţional de Sănătate Orală la Copii în Republica Moldova;
– 1998, p.6.
41. Rubin P. The Fluoride Controversy: The Facts & The Fiction; // http://
www.dentalwellness4u.com/layperson/fluoridefacts1.html
42. Sarrett D.C. Tooth whitening today; // JADA. – 2002. – Vol. 133. – Р.
1536–8.
43. Spinei Iu. Asistenţa stomatologică a copiilor cu fluoroză dentară; //
Revista neonatologică 2000.
44. Spinei Iu. Aspecte contemporane în asistenţa stomatologică copiilor cu
fluoroză; // Teza de doctor in ştiinte medicale. – Chişinău, 2001, p.54–55,73–
74,125.
45. Spinei Iu. Tratamentul fluorozei dentare la copii; // În: Probleme actuale
de stomatologie (materialele congresului naţional al medicinii stomatologice
consacrat jubileului de 40 ani al Facultăţii Stomatologie a USMF «N.
Testemiţanu»), 1999; p.181.
46. Stepco E. Utilizarea metodelor terapeutice complexe de corecţie a
metabolismului la pacienţii cu fluoroză; // Autoreferat al tezei de doctor în
medicină Chişinău, 2009.
47. Stepco E., Lupan I. Materiale de tratament local al fluorozei dentare;
// În: Analele ştiinţifice USMF «N.Testemiţanu» Chişinău, RM 2008, edit IX,
vol 4, p.321–323.
48. Stepco E., Lupan I. Tratamentul complex al fluorozei dentare; // Ch.:
Medicina Stomatologică. Ediţia consacrată celui de al XIV congres Naţional al
AS RM Chişinău, 2008 p.59–61.
49. Terehov Al., Năstase C. Discromii dentare; // În: Odontologia practică
modernă; – Iaşi: Nasticor, 2010; p. 441–442.
50. Ultradent Materials & Procedures manual; – 2002, p.89–92.
51. Warren J., Levy Sm. Current and future role of fluoride in nutrition; //
Dental Clinics of North America, 2003, no. 47, p.225–243.
77
52. Wondwossen F., Astrom A.N., Bardsen A., Bjorvatn K. Perception of
dental fluorosis amongst Ethiopian children and their mothers; // J Am
Dent Assoc 2002; 133: 10: 1405—1407.
53. Авцын А.П., Жаворонков А.А. Патология флюороза; – Новосибирск:
Наука. 1981, с. 88–89.
54. Авцын А.П., Жаворонков А.А., Риш М.А, Строчкова Л.С.
Микроэлементы человека; – Москва, 1991, с. 496.
55. Алкалаев К.К. Содержание и поглощение фтора отдельными
группами зубов; // Стоматология, 1964, N3, с. 3–8.
56. Барер Г.М., Гуревич К.Г., Смирнягина В.В., Фабрикант Е.Г.
Использование стоматологических измерений качества жизни; //
Стоматология для всех 2006; 2: 4—7.
57. Боровский Е.В. Терапевтическая стоматология: Обезболивание.
Отбеливание. Пломбирование. Эндодонтия; // М. 2005; 51–53.
58. Боровский Е.В., Леус П.А., Лебедева Т.К. Некариозные поражения
зубов; // Методические рекомендации. – Москва, 1978. – с. 16.
59. Виноградова Т. Ф. Стоматология детского возраста; – Москва, 1987.
60. Габович Р.Д., Овруцкий Т.Д. Фтор в стоматологии и гигиене; –
Казань, 1969; 512.
61. Грошиков М.И. Некариозные поражения тканей зуба; – Москва:
Медицина, 1985; с. 171.
62. Давыдов Б.Н., Беляев В.В., Клюева Л.П., Рябов Д.В. Социологическое
исследование флюороза зубов; // Стоматология Nr.5, 2009
63. Касьяненко А.С., Синиговский Г.Н., Ковган Н.И. Медико–
географическое изучение распространения флюороза зубов в
Полтавской области и меры профилактики; // În: Актуальные вопросы
стоматологии. – Полтава, 1981. – с. 15.
64. Кириллова Е.В., Матело С. К., Купец Т. В. Флюороз зубов – статус
вопроса в современной эстетической стоматологии; // Современная
стоматология 5/2010; с. 14–16
65. Комнов Д.В. Отбеливание зубов: применение в практике; //
Вестник стоматологии. – 1996. – №11–12. – с. 2.
66. Крихели Н. И. Особенности коррекции цвета зубов при дисколоритах.
Восстановление зубов, измененных в цвете. Эффективность метода
микроабразии эмали зубов; // Dentoday, №6(86), 2009:
67. Крихели Н.И. Отбеливание зубов и микроабразия эмали в
эстетической стоматологии. Современные методы; // . М. 2008.
78
68. Курякина Н.В. Терапевтическая стоматология детского возраста;
– Москва: Медицина, 2001.
69. Леонтьев В.К. Здоровые зубы и качество жизни; // Стоматология
2000; 5: с. 10—13.
70. Леонтьев В.К. Кариес и процессы минерализации: //Дис. … д-ра
мед. наук. М.,1978. 541 с.
71. Леонтьев В.К., Макарова Р.П., Кузнецова Л.И., Блохина Ю.С.
Сравнительная характеристика оценки качества жизни пациентами
стоматологического профиля; // Стоматология 2001; 6: с. 63—64.
72. Максименко П.Т., Николишин А.К. Диагностика, лечение и
профилактика флюороза зубов у детей; // Методические рекомендации.
– Киев, 1976.
73. Матело С. К.; Купец Т. В. Флюороз зубов – нарастающая проблема
современой эстетической стоматологии; // Prophylaxis today /фирма
ROCS/, 2008.
74. Михальченко В.Ф., Алешина Н.Ф., Радышевская Т.Н., Петрухин А.Г.
Болезни зубов некариозного происхождения; // Учебно–методическое
пособие, часть 1 (некариозные поражения, развившиеся в период
формирования и минерализации зубов). – Волгоград, 1998. – с. 24.
75. Николаева Т.А., Белецкий А.С. К вопросу о профилактике флюороза
и кариеса (изучение влияния фтора питьевой воды на организм
человека); // Гигиена и санитария, 1951, Nr. 12, с.7–11.
76. Николишин А. К. Наше видение патогенеза флюороза зубов; //
DentArt, №2 1996;12.
77. Николишин А. К.; Николишин Э. В. Спектрум ТиПиЭйч в лечении
тяжёлых проявлений флюороза зy6oв; // Densplay 6/2001, с. 12–14
78. Николишин А.К. Диагностика и лечение флюороза; // Актуальные
вопросы стоматологии. – Полтава, 1981.
79. Новик И.О. Пятнистая эмаль; // Стоматология. – 1951. – №4. – с.
3–9.
80. Образцов Ю.Л. Стоматологическое здоровье: сущность, значение
для качества жизни, критерии оценки; // Стоматология 2006; 4: с. 41—43.
81. Овруцкий Г.Д. Флюороз зубов; // Пособие для врачей/ Казань 1962;
с. 118.
82. Патрикеев В.К., Грошиков М.И., Варенников С.И., Чупрынина Н.В.,
Ардабацкая Г.А. Некариозные поражения зубов; // Методические
рекомендации. – Москва, 1973. – с. 42.
79
83. Пахомов Г.Н. Принципы и особенности лечения и профилактики
начального кариеса зубов: //Автореф. дис. … д-ра мед. наук. Рига, 1974.
40 с.
84. Руснак Б.С., Бергер И.И. Флюороз зубов; – Кишинев: Картя
молдовеняскэ, 1968.
85. Стоматологические обследования. Основные методы; // 4-е
издание. Женева 1997.
86. Сунцов В.Г. Пути совершенствования первичной профилактики
и лечения начального кариеса зубов у детей: //дис. … д-ра мед. наук.
М., 1987. 549 с.
87. Улитовский С.Б. Причины некариозных поражений зубов; // Новое
в стоматологии. –2001(95). – №5. – с. 63–65.
88. Федоров Ю.А. Гиперестезия твердых тканей зубов: клиника и
диагностика; // Орбит Экспресс 2005; 19: с. 6—11.
89. Флюороз – локальный вопрос?;//http://www.medicus.ru/stomatology/
spec/?cont=article&art_id=14705
90. Хоменко Л.А. Терапевтическая стоматология детского возраста;
– Киев, 2007.
91. Чекмезова И.В. Распространенность, клиника очаговой
деминерализации эмали и механизмы реминерализующей терапии
начального кариеса: //Автореф. дис. ... канд. мед. наук. Омск, 1983. 17 с.
92. Янушевич О.О., Крихели Н.И. Коррекция цвета зубов при
дисколоритах; // Российская Стоматология, 2, 2009: с. 12—17.
93. “Dental Fluorosis - What Causes it and How to Prevent It” - http://
www.bracesreview.com/dental-fluorosis-what-causes-it-and-how-to-prevent-
it.html
94. “Fluoroza (intoxicatia cu fluor)” - http://www.scritube.com/medicina/
Fluoroza-intoxicatia-cu-fluor34312013.php.
95. “Opalescence TresWhite Supreme Reviews - Teeth Whitening
Reviews” – http://www.teethwhiteningreviews.com/item.php?id=22
96. “Opalescence Teeth Whitening Review” - http://www.whitening--
teeth.com/products/index.html
97. “Opalescence PF Teeth Whitening System10% 15% 20% 35%” -
http://www.whiteteethsolution.com/opalescence-teeth-whitening.html

80
ANNEX

Fig. 1. Fluorosis impairment of the Fig. 3. The severe form of dental


skeleton fluorosis (patient from Syria, state
after the teeth whitening without
the water source being changed);

Fig. 2 a) The map of endemic


regions from Republic of
Moldova; b) the severe form of
dental fluorosis (patient from
Republic of Moldova)

81
The variation of the fluorosis maculation’s character
according to the form and the degree of teeth impairment.

Fig. 4. Chalky solitary patches Fig. 5. Yellowish patches

Fig. 6. Yellow or brown patches Fig. 7. Brown patches

Fig. 8. Enamel erosion Fig. 9. Destructive form of fluorosis


82
CLINICAL CASE NR 1 CLINICAL CASE NR 2

Fig.18. Pretreatment situation Fig.21. Pretreatment situation

Fig.19.Treatment phase Fig.22. Treatment phase

Fig.20. The final result Fig.23. The final result


83
MODERN BLEACHING SYSTEMS AND PROCEDURES FOR FLUOROSIS TEETH

CLINICAL CASE NR 3

Fig.24. Pretreatment Fig.26. The final result


situation + Opaldam 84