minimal treatment for severe fluorosis

minimal treatment for severe fluorosis

1. GOOD MORNING

2. Minimally Invasive Direct Approach for Severe Dental Fluorosis: Balancing Aesthetics and Quality of Life CASE REPORT Guyonvarch R, Estivals J, Kérourédan O. Minimally Invasive Direct Approach for Severe Dental Fluorosis: Balancing Aesthetics and Quality of Life. Clinical Case Reports. 2025 Feb;13(2):e70254. Presented by Y. Shenkari Indumathi ( Third year PG ) Department of Conservative Dentistry and Endodontics

3. INTRODUCTION Dental fluorosis is a disorder characterized by the hypomineralization of enamel due to excessive fluoride intake during tooth development. Depending on the degree of severity, fluorosis manifests as white and/or brown stains, and in severe cases, pitting of the enamel surface Management depends on the severity (Dean’s Index / TF Index), patient’s esthetic demand , and functional involvement .

4. Principles of Management Severity-based treatment – management depends on Dean’s index (mild, moderate, severe). Esthetic improvement – primary goal in anterior teeth. Conservation of tooth structure – preference for minimally invasive approaches first. Functional rehabilitation – in severe cases with structural loss.

5. MILD SEVERE MODERATE M A N A G E M E N T

6. Year Author(s) Title Journal Treatment Approach Conclusion 2015 Kumar S. et al. Microabrasion and CPP-ACP for severe fluorosis J Conserv Dent Microabrasion + CPP-ACP Improved esthetics, reduced discoloration, safe for young patients 2016 Wong HM et al. Effectiveness of resin infiltration in fluorotic teeth Int J Paediatr Dent Resin infiltration Masked white/brown spots, better esthetics minimally invasive 2017 Croll TP et al. Enamel microabrasion for fluorosis Oper Dent Microabrasion Effective for mild–moderate, limited effect in severe cases 2018 Alshahrani I. et al. Porcelain veneers in severe fluorosis J Prosthet Dent Porcelain veneers High esthetic success, durable, recommended for severe forms 2019 Gupta R. et al. Resin infiltration with bleaching for fluorosis J Esthet Restor Dent Infiltration + bleaching Combined approach improved masking of stains 2020 Akpata ES et al. Bleaching and microabrasion in fluorosis Community Dent Oral Epidemiol In-office bleaching + microabrasion Effective but relapse may occur, maintenance needed 2021 Peng Q. et al. Clinical performance of veneers in fluorosis Clin Oral Investig Veneers (ceramic/composite) High survival rate, stable esthetics over 3 years 2022 Chen X. et al. Minimally invasive esthetic management BMC Oral Health Combination of bleaching, infiltration, veneers Stepwise approach gives individualized results 2023 Alhassan A. et al. Esthetic management of severe fluorosis J Dent CAD/CAM veneers Excellent esthetics, conservative prep, good longevity 2024 Zhang Y. et al. Microabrasion + resin infiltration vs. veneers Int J Prosthodont Microabrasion + infiltration vs veneers Infiltration worked for moderate, veneers needed for severe 2025 Lee M. et al. Nanohybrid composite veneers for severe fluorosis J Esthet Restor Dent Direct composite veneers Cost-effective, esthetic, good short-term outcomes

7. Case report This case report underscores the relevance of minimally invasive techniques in managing severe dental fluorosis, offering a balance between aesthetic improvement and preservation of tooth structure. Composite Injection technique “Minimally Invasive Techniques”

8. Case History/Examination An 18- year- old female patient was referred to the Department of Dental Medicine at the University Hospital of Bordeaux (France) for aesthetic management of her brownish dyschromia, affecting her appearance and smile. Clinical ex amination revealed brownish- orange and chalky white lesions with associated enamel defects, particularly in the maxillary anterior region. The patient had good oral hygiene and a healthy periodontium. The patient had grown up in an endemic fluorosis area in Senegal.

9. Investigations Tooth Surface Index of Fluorosis (TSIF) score to assess the severity Oral Health Impact Profile- 14 (OHIP- 14) to assess the Oral- Health- Related Quality of Life ( OHRQoL ) OHIP-14 Scores range from 0 to 56 (0 to 8 per domain), with higher scores indicating greater discomfort. OHIP- 14 is recognized in the literature as good clinical practice for patients' follow- up. For this case, TSIF score is 7

10. Oral Health Impact Profile- 14 (OHIP- 14)

11. For this case, the initial OHIP- 14 score was 23.

12. STAGE 1 : MICROABRASION CLINICAL PROCEDURE “OPALUSTRE” A microabrasive compound (6.6% hydrochloric acid with silicon carbide particles)

13. STAGE 1 : MICROABRASION CLINICAL PROCEDURE followed by the application of a fluoride varnish ( Duraphat , Colgate). Polishing cups ( Opalcups ) were used for 1 min with gentle pressure, and repeated 3 times.

14. STAGE 2 : BLEACHING CLINICAL PROCEDURE

15. STAGE 2 : BLEACHING CLINICAL PROCEDURE Post- treatment, the dyschromias were more uniform, and brown lesions appeared lighter A remineralizing and desensitizing toothpaste ( Elmex Sensitive Professional) was prescribed to prevent sensitivity during bleaching.

16. Before Treatment After Treatment Microabsasion & Bleaching

17. STAGE 3 :macroabrasion CLINICAL PROCEDURE After a 1- month cessation to stabilize tooth color and ensure optimal bonding conditions, slight macroabrasion within the enamel was performed, followed by resin infiltration (Icon, DMG).

18. STAGE 3 :RESIN INFILTRATION CLINICAL PROCEDURE Step 1 : Etching with 15% hydrochloric acid (ICON etch, DMG) for 2 min with a scrubbing motion, rinsed for 30 s with water spray) Step 2 : Drying with 99% ethanol (ICON Dry, DMG) to simulate resin infiltration and remove water from the enamel microporosities

19. STAGE 3 :RESIN INFILTRATION CLINICAL PROCEDURE Step 3 : Applying the resin infiltrant (ICON infiltrant , DMG) for 3 min with a scrubbing motion In the maxilla, etching was repeated three times for stain reduction, followed by two applications, each polymerized for 40 s per manufacturer's instruction.

20. STAGE 4 : A) COMPOSITE INJECTION TECHNIQUE CLINICAL PROCEDURE For the maxillary teeth “canine to canine” An injected composite resin technique was applied, A wax- up model - used corrected minor malpositions of 11 and 21 and restored the distal angle fracture of 21. A trans parent silicone index ( Exaclear , GC) was fabricated from the same wax- up G- aenial Universal Injectable AO2 (GC) was injected through the index for every second tooth Polymerization was carried out through the transparent index, and excess resin was removed using a 15C blade and diamond burs To address enamel loss and residual dyschromia, further restorative treatments were considered.

21. STAGE 4 : A) COMPOSITE INJECTION TECHNIQUE CLINICAL PROCEDURE

22. STAGE 4 : B) COMPOSITE LAYERING TECHNIQUE CLINICAL PROCEDURE For mandibular teeth, a most conservative approach was taken, involving selective enameloplasty and composite layering using the Essentia system (Essentia, GC)

23. STAGE 5 : FINISHING AND POLISHING CLINICAL PROCEDURE Finishing and polishing on both arches were completed on the same day and renewed at the follow- up visit 2 weeks later DONE using the Enhance Pogo system and Prisma Gloss polishing paste (Dentsply Sirona),.

24. results At the 2- week follow- up (D14), clinical outcomes were satisfactory with the OHIP- 14 score markedly decreasing from 23 to 5. At the 6- month follow- up, aesthetic results remained stable, and the OHIP- 14 score further improved to 0. The domains most positively impacted by the treatment were psychological discomfort (ΔD0- M6 = 8), psychological disability (ΔD0- M6 = 6) and social disability (ΔD0- M6 = 4). Photographs taken before treatment at Day14 and at Month6 demonstrated significant improvement in the patient's smile aesthetics and overall OHRQoL .

25. treatment – Day 14 Before treatment treatment – Month 6

26. DISCUSSION This case report high lights that a minimally invasive approach can yield favourable aesthetic outcomes and improve quality of life, evidenced by the reduction of the OHIP- 14 score from 23 to 0 in 6 months. The treatment plan was carefully customized to align with the patient's age, the impact of the condition on their quality of life, and practical considerations such as cost and time constraints. In this case, Unlike more invasive options like veneers of crowns that require significant tooth preparation and may cause premature and irreversible damage, a stepwise, personalized approach was implemented.

27. discussion Regarding the clinical implications of minimally invasive approaches, the results of this case align with existing studies, since microabrasion was effective in reducing surface stains and defects with minimal enamel loss [ D. G. Pontes et al, 2012 ]. Bleaching was used to enhance the masking effect of resin infiltration on fluorotic opacities and to minimize enamel removal for direct restorations. This combination aligns with other studies suggesting bleaching as a relevant pretreatment for both direct and indirect aesthetic restorations in fluorosis cases  [ A. W. Raut et al, 2020 ]. Resin infiltration was used to increase enamel microhardness and improve the adhesion of overlying composites [ S. Paris et al2013, F. Crombie et al2014, A. M. Kielbassa et al2017 ].

28. discussion However, the long- term stability of direct restorations remains a concern, as maintenance may be required due to resin degradation. This report underscores the progressive and sustained psychosocial benefits of minimally invasive interventions. By adopting minimally invasive techniques, clinicians can provide cost- effective solutions that preserve tooth structure while significantly improving patients' daily interactions, self- esteem, and overall quality of life. Lack LONG - TERM evidence on the success of these MIIs is a concern.

29. Approach Success Rate Best Indication Longevity Supporting Authors Microabrasion 70–85% Mild–moderate 5+ yrs with maintenance Croll & Cavanaugh (1986); Sundfeld et al. (2014) Bleaching 60–80% Mild–moderate stains 1–3 yrs, relapse possible Torres et al. (2012); Sinha et al. (2016) Resin infiltration 75–90% Moderate fluorosis 3–5 yrs stable Paris & Meyer- Lueckel (2010); Ardu et al. (2016) CPP-ACP 50–65% (alone), 80% (with combo) Adjunct therapy Short-term Cochrane Review (Benson et al., 2013); Rao et al. (2020) Direct composite veneers 85–90% Severe fluorosis (cost-conscious pts) 3–5 yrs, repairable Waggoner & Johnston (2005); Hegde et al. (2018) Summary of Recent Studies (2015–2025) on Severe Dental Fluorosis Management

30. conclusion Despite the limited availability of long - term evidence, this case report highlights the significance of minimally invasive strategies as viable alternatives to indirect restorations for managing severe dental fluorosis.

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