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 Table of Contents  
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 26-29

Conservative esthetic management with in-office bleaching of dental fluorosis

General Dentist, Gandhinagar, Gujarat, India

Date of Submission07-May-2022
Date of Acceptance27-May-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Dr. Krishna Shah
General Dentist, Gandhinagar, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmo.ijmo_7_22

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Tooth discoloration varies in etiology, appearance, localization, severity, and adherence to the tooth structure. It can be intrinsic, extrinsic, or a combination of both. Extrinsic stains are typically caused by tobacco use or by drinking coffee and tea, wine, and pigmented residue from food. This can be removed by regular dental cleaning and brushing the teeth with whitening toothpaste. Intrinsic teeth stains occur most commonly due to exposure of high levels of fluoride, tetracycline antibiotic administration and pulpitis, inherited developmental disorders, and trauma. This can be treated with professional bleaching or at-home chemical teeth-whitening products, porcelain, and composite veneering. Among these procedures, bleaching procedures are more conservative, simple to perform, and less expensive. This case report suggests that in-office bleaching is an effective and conservative method for esthetic correction of tooth discoloration in severe and mild dental fluorosis.

Keywords: Dental fluorosis, esthetics, in-office vital bleaching

How to cite this article:
Shah K. Conservative esthetic management with in-office bleaching of dental fluorosis. Int J Med Oral Res 2022;7:26-9

How to cite this URL:
Shah K. Conservative esthetic management with in-office bleaching of dental fluorosis. Int J Med Oral Res [serial online] 2022 [cited 2022 Dec 4];7:26-9. Available from: http://www.ijmorweb.com/text.asp?2022/7/1/26/349246

  Introduction Top

Dental fluorosis is a qualitative defect of enamel (hypomineralization), caused by excessive intake of fluoride during the formative period of dentition either by consuming in food, water, air or by excessive use of toothpaste. According to the World Health Organization guidelines, the optimum fluoride level of drinking water is 1 Part Per Million (PPM). Fluoride consumed in excess than the optimum value may lead to skeletal and dental fluorosis. A Centre for Disease Control and Prevention recommends at least 0.7 PPM and a maximum amount of 1.2 PPM of fluoride is present in drinking water to maintain caries prevention and reduce the risk of dental fluorosis.[1],[2],[3],[4]

Fluorosis is endemic in about 25 countries in the world. During the formative stage of tooth development, an increased fluoride level affects ameloblasts and interferes with the calcification process of the matrix. Change of matrix composition, diminish matrix production and change in ion transport mechanism occur if fluoride consumption is more excessive than the normal level during the Matrix formation stage. In the maturation phase, there is the retention of amelogenin proteins in the enamel structure, leading to the formation of hypomineralized enamel.

The resultant effect ranges from questionable changes (occasional white flecking or spotting of enamel) to mild changes (white opaque areas involving more of the tooth surface). Brownish staining, discrete or diffuse pitting, and tendency to wear or even fracture of enamel can be observed in moderate and severe changes due to dental fluorosis. This may compromise the individual appearance, social integration, and quality of life.

Hence, one of the most frequent reasons patients seek dental care is discolored anterior teeth. The treatment of discolored teeth has gained immense popularity in the practice of esthetic dentistry which includes bleaching, microabrasion, macroabrasion, veneering, and placement of porcelain crowns. Bleaching treatment can be performed on nonvital tooth which includes thermocatalytic bleaching and walking bleaching. Whereas, bleaching on vital teeth may be done by in-office bleaching, the dentist prescribed home applied either bleaching or self-bleaching using over-the-counter products.[5],[6],[7],[8]

The equipment needed for an in-office bleaching includes

  • Power bleach material
  • Activating source
  • Protective clothing and eyewear
  • Tissue protector
  • Mechanical timer.

Advantages of in-office bleaching

  • Less time than overall time needed for home bleaching
  • As the procedure is under professional, risk factor is eliminated
  • Protection of soft tissue.

Disadvantages of in-office bleaching

  • Expensive than other bleaching procedures
  • Unpredictable outcome and results depend on the factors such as age, type of stains, and so on
  • Discomfort of rubber dam.

  Case Reports Top

Case 1

A 42-year-old male patient reported to Shraddhadeep Dental Clinic, with a complaint of discolored teeth. The patient was unable to recollect the time since when the teeth were discolored. However, he reported that his teeth were discolored for many years. The family history revealed that the patient's two brothers also suffered from discoloration of teeth variably from white streaks to severe brown stains. On asking for further history, the patient affirmed that he came from the Aravalli Range of North Gujarat, where the available source of drinking water was a salt pit.

Intraoral examination revealed brownish discoloration of all enamel surfaces along with white streaks and discrete pitting present on maxillary and mandibular teeth. Discoloration was equally prominent on maxillary and mandibular teeth. Gingival recession was observed on mandibular central incisors with no tooth mobility. Pulp sensibility testing of discolored teeth was carried out using electric pulp testing. It indicated normal pulp with all these teeth. No history of any systemic disease or allergy was reported. Based on clinical features and history, a diagnosis of the severe form of dental fluorosis was made (According to the Dean's fluorosis index, score-4).

Before commencing treatment, suitable various treatment options, such as in-office power bleaching, microabrasion, home bleaching, and composite veneers, were discussed with patients along with potential risks, advantages, and disadvantages. Treatment options for the gingival recession of lower anterior teeth were discussed; however, the patient only opted for “in-office bleaching.” An informed consent was obtained from the patient. Tooth color shade was verified using Eventbrite shade guide. Oral prophylaxis and polishing were carried out before starting the bleaching procedure.

For this patient, we have used the Everbrite in-office tooth whitening kit. The kit contains hydrogen peroxide, photoactivator, light cure dental dam, fluoride gel and lip balm, protective mouth bib, cheek retractor, tooth shade guide, mixing, and application accessories.

Lip balm was applied to protect the lip area and placed protective mouth bib and cheek retractor in a way that patient will not feel any discomfort. Cotton rolls were placed on maxillary buccal, mandibular buccal, and lingual vestibule to gain dry field. The tip was inserted onto the Softdam syringe and applied evenly to the gingiva and light cured for 20 s.

The patient and dentist personnel in the operatory had worn eye protection glasses. The powder content in a photoactivator jar was thoroughly mixed by using the spatula and 35% hydrogen peroxide was added to the photoactivator jar and mixed thoroughly until we got homogeneous gel-like consistency. The material was filled into the syringe and applied onto the teeth evenly. Plasma arc curing light (LITEX wavelength 500–600 nm) was used and performed four whitening cycles for 10-min for each cycle (40 min). After that, the bleaching gel was removed using air-water syringe and suctioned away. The oral cavity was examined for any remaining material.

The patient was recalled after 10 days and was satisfied with the lightening shade of his teeth. As a precautionary measure desensitizing toothpaste and gel was prescribed for possible postoperative sensitivity and gingival irritation which usually goes away in 2–3 days posttreatment. The patient was recalled after 1, 3, and 6 months for follow-up. There was no pain, sensitivity, or rebound effect associated with bleached teeth [Figure 1] [Figure 2].
Figure 1: Pre-operative photograph

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Figure 2: Post-operative photograph

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Case 2

A 20-year-old male patient reported to Shraddhadeep Dental Clinic, Gandhinagar, with a chief complaint of having pearly white patches and yellowish discoloration on upper front teeth. On history taking, it was found that the patient live in Sabarkantha district (a fluoride endemic region) of Gujarat state since childhood. A review of past and present medical and dental history suggests no contraindications for dental treatment. On clinical examination, it has been observed that the patient has class 2 malocclusion, division 2. Due to which patient has marginal gingivitis, especially in mandibular anterior. Furthermore, it was evident that the merging of white lines and cloudy areas of opacity involving many parts of the tooth surface suggest of having mild dental fluorosis (according to Dean's Fluorosis Index). A radiographic examination revealed intact lamina dura and no periodontal ligament space widening, and no pulpal changes or caries.

All the suitable treatment options were discussed with patients including orthodontic treatment for malocclusion and veneers, microabrasion, bleaching, porcelain and composite crowns, bleaching for discolored teeth along with its procedure, treatment plan, and potential outcome. The patient was not willing for orthodontic treatment. He wanted the least invasive and most cost-effective treatment for his teeth. The patient was not willing for other treatment options where removal of tooth structure is necessary. Thus, the proposed treatment for this patient is in-office bleaching.

To protect soft tissue, and reduce the salivary flow and contamination, we put cotton rolls on buccal vestibule areas of both arches. All teeth were cleaned using pumice slurry and air-dried after the gingival barrier was applied and light cured for about 20 s. As per the manufacturer's instruction, equal amount of bleaching powder and 35% hydrogen peroxide was taken and mixed well until it reached to gel-like material and then, this gel-like material was applied over teeth using an applicator tip. Allowed mixture for 10 min and three cycles were performed in one session. The gel was removed using suction, and teeth were rinsed with water.

The patient was satisfied with the bleaching treatment and did not wish for any other treatment. Postoperative instructions were given to the patient. The patient was asked for follow-up at 1, 3, and 6 months. There was no pain or sensitivity associated with the given treatment [Figure 3].
Figure 3: Pre and post-opertive picture

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  Discussion Top

Discoloration or staining of teeth reduces the self-esteem of an individual. A beautiful white sparkling smile is a prime asset to patient's appearance as it contributes immensely to a positive self-image and boosts one's confidence. Hence, discoloration of teeth is the most common reason, for which patients seek treatment. Bleaching is the most conservative, cost-effective, noninvasive esthetic treatment option available in the field of dentistry. There are various types of bleaching material available in the market with light sourcing. This includes plasma arc, laser, and halogen lamp which act as an activator. The most used bleaching agent is hydrogen peroxide. In the at-home applied bleaching technique, a lower concentration of hydrogen peroxide (approximately 6%–7%) is used and for in-office bleaching, its concentration varies around 35%. Another type of bleaching agent used is carbamide peroxide.[9]

In the whitening process, various light sources are used, which act by activating the bleaching agent by increasing its temperature, may accelerate the oxidation reaction. These light sources are plasma arc, light-emitting diodes (LEDs), halogen lamps, and lasers which are being used to get faster results of the bleaching process and improve the effectiveness. However, the effectiveness of light sources in the bleaching procedure has generated controversy, as some studies have shown the light sources are inconclusive and does not alter the final result. Furthermore, some studies are showing greater levels of tooth dehydration and increase in pulpal temperature. Suleiman et al. reported that increase in the intra-pulpal temperature with the use of lights was below the critical threshold of 5.5 C. The resultant effect not only increases the tooth sensitivity but also causes difficulty in assessing the actual whitening result.[10],[11]

Tooth sensitivity is the most common side effect of the bleaching procedure. Higher concentration of hydrogen peroxide causes slight demineralization, alters enamel morphology, and makes it more porous. This, in turn, exposes dentinal tubules of teeth and these tiny channels run through the enamel surface of the tooth to its nerve supply. This may cause mild-to-severe dentinal hypersensitivity. However, it normally persists 4–7 days after the conclusion of treatment. As per recent studies by A Smidt et al., it is perceived that saliva has as protective effects as in it helps in dilutions, alteration of the pH value and increase in buffering capacity, supplying calcium, and phosphate ions – all these are contributing factors for tooth remineralization. Dentinal hypersensitivity can be reduced by adding desensitizing agent in bleaching material and prescribing desensitizing paste or gel. Tooth sensitivity even though is a common side effect; it did not overwhelm the advantages of bleaching.[12]

The side effects of in-office bleaching may be associated with the composition of bleaching agents, concentration, pH values, and time, usage of fluoride. Thus, some manufacturers have invented low concentrations of H2O2, fluoride gel, and desensitizing agents to minimize the side effects. Pandya M et al. Conducted in-depth clinical trial study on 30 patients about the effects of various light sources and resultant adverse effects, alteration in the patient's hard and soft tissues, and effectiveness of bleaching procedure with the end result. It showed that Everbrite along with plasma arc has no gingival irritation and mild dental sensitivity as compared to Pola office + along with LED, whiteness HP MAXX along with Quartz, Tungsten Halogen light, and Opalescence Boost with no light activation. Thus, we used the Everbrite whitening kit for the bleaching of both patients.[13]

  Conclusion Top

The findings of these case reports suggest that in-office bleaching is a simple, effective, and noninvasive method for esthetic correction of severely discolored teeth. It is less time-consuming than at-home bleaching and cost-effective than composite or porcelain veneers. Everbrite in the combination of plasma arc light showed better results. It showed significant results up till 6 months after treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Fluorides and oral Health First report of the Expert Committee on Water Fluoridation. WHO Technical Report Series No. 146. Geneva: WHO; 1958.  Back to cited text no. 1
Dean H, Arnold FJ, Elvove E. Domestic water and dental caries. V. Additional studies of the relation of fluoride domestic waters to dental caries experience in 4,425 white children, aged 12 to 14 years, of 13 cities in 4 states. Public Health Rep 1942;57:1155-79.  Back to cited text no. 2
Goyal A, Verma M, Toteja GS, Gauba K, Mohanty V, Mohanty U, et al. Validation of ICMR index for identification of dental fluorosis in epidemiological studies. Indian J Med Res 2016;144:52-7.  Back to cited text no. 3
[PUBMED]  [Full text]  
Angmar-Mansson B, Ericsson Y, Ekberg O. Plasma fluoride and enamel fluorosis. Calcif Tissue Res. 1976;22:77-84.  Back to cited text no. 4
Abanto Alvarez J, Rezende KM, Marocho SM, Alves FB, Celiberti P, Ciamponi AL. Dental fluorosis: Exposure, prevention and management. Med Oral Patol Oral Cir Bucal 2009;14:E103-7.  Back to cited text no. 5
Sulieman M, Addy M, Rees JS. Surface and intra-pulpal temperature rises during tooth bleaching: An in vitro study. Br Dent J 2005;199:37-40.  Back to cited text no. 6
Pandya M, Ponnappa KC, Kumarswami S, Desai A, Muchhadia R, Sheth N. Six months clinical evaluation of efficacy of four variable percentages of bleaching agents with different modes of activation in 30 individuals: An in vivo study. J Res Adv Dent 2015;4:150-62.  Back to cited text no. 7
Hein DK, Ploeger BJ, Hartup JK, Wagstaff RS, Palmer TM, Hansen LD. In-office vital tooth bleaching – What do lights add? Compend Contin Educ Dent 2003;24:340-52.  Back to cited text no. 8
Joiner A. The bleaching of teeth: A review of the literature. J Dent 2006;34:412-9.  Back to cited text no. 9
Buchalla W, Attin T. External bleaching therapy with activation by heat, light or laser – A systematic review. Dent Mater 2007;23:586-96.  Back to cited text no. 10
Martin J, Fernandez E, Bahamondes V, Werner A, Elphick K, Oliveira OB Jr., et al. Dentin hypersensitivity after teeth bleaching with in-office systems. Randomized clinical trial. Am J Dent 2013;26:10-4.  Back to cited text no. 11
de Arruda A, Santos PD, Sundfeld R, Berger S, Briso A. Effect of hydrogen peroxide at 35% on the morphology of enamel and interference in the de-remineralization process: An in situ study. Oper Dent 2012;37:518-25.  Back to cited text no. 12
Smidt A, Feuerstein O, Topel M. Mechanical, morphologic, and chemical effects of carbamide peroxide bleaching agents on human enamel in situ. Quintessence Int 2011;42:407-12.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3]


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