The Journal of the American Dental Association
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J Am Dent Assoc, Vol 134, No 8, 1066-1071.
© 2003 American Dental Association
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RESEARCH

JADA Continuing Education

An evaluation of a technique to remove stains from teeth using microabrasion



RICHARD B.T. PRICE, B.D.S., D.D.S., M.S., F.D.S. R.C.S. (EDIN.), Ph.D., ROBERT W. LONEY, D.M.D., M.S., M. GORMAN DOYLE, D.D.S., M.S. and M. BRENT MOULDING, D.M.D., M.S.


   ABSTRACT
TOP
 ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. Microabrasion using a paste made of acid and pumice is a technique that has been used to remove white, yellow and brown stains from enamel. The authors evaluated the technique by studying the effectiveness of a proprietary microabrasion product.

Methods. One author used microabrasion to remove white, yellow and brown stains from within the outermost layer of the tooth enamel of 32 subjects. Standardized slides of the teeth were taken before and one week after treatment. Four prosthodontists evaluated the paired images, using a standardized questionnaire and visual analog scales ranging from 1 (no improvement in appearance or stain not removed at all) to 7 (exceptional improvement in appearance or stain totally removed). The evaluators were calibrated and blinded.

Results. The evaluators always identified a difference between the pretreatment slides and posttreatment slides; they found no difference between the control slides. In all cases but one (97 percent), the treated teeth had improved in appearance with more uniformity in color. Analysis of variance revealed no differences between evaluator ratings (P = .146). The intraclass correlation coefficient for ratings of individual cases by different evaluators was 0.72, representing a "good" level of correlation of the ratings for improvement of appearance and for stain removal. Mean (± standard deviation) ratings were 5.38 (± 1.26) for improvement of appearance and 5.06 (± 1.26) for stain removal.

Conclusions. This study showed that enamel microabrasion could remove stains from within the outermost layer of tooth enamel, thereby improving the appearance of the teeth.

Clinical Implications. This study supports recommendations that enamel microabrasion is an effective, atraumatic method of improving the appearance of teeth with stains in the outermost layer of enamel.

A number of microabrasion techniques to improve the appearance of fluorotic teeth have been described.1–23 McCloskey reported that Kane successfully removed fluorosis stains by applying acid and heat in 1916.11 In the 1960s, McInnes12 used a mixture of five parts of 36 percent hydrochloric acid, or HCl; five parts of 30 percent hydrogen peroxide; and one part ether as a topical treatment. This technique was modified slightly by Chandra and Chawla22 who applied the solution with cuttlebone and sandpaper disks in a rotary instrument in the 1970s. They observed a noticeable loss in mesiodistal curvature in some teeth after the procedure. In the 1980s, Myers and Lyon14 reported improvement when they used a calcium sucrose phosphate gel to remove tooth stains. Their procedure involved etching teeth for two to three minutes with 37 percent phosphoric acid, followed by a pumice abrasion with rotary instrumentation of the surface. They repeated these two steps followed by a four-minute application of a mixture of 2 percent sodium fluoride. Next, they applied a 40 percent calcium sucrose phosphate gel and left it on the tooth surface for 30 minutes. If there was no significant improvement after four weeks, they repeated the treatment. Murrin and Barkmeier13 applied 36 percent HCl mixed with pumice to the enamel surface with a slowly rotating rubber cup for up to five minutes to remove stains in the enamel. They then bleached the teeth with 30 percent hydrogen peroxide and heat, applied topical fluoride and polished the teeth.

Microabrasion using a paste containing hydrochloric acid and pumice is effective in removing stains from the outermost layer of enamel and improving the appearance of the teeth.

In 1986, Croll and Cavanaugh2 advocated a regimen to remove fluorosislike stains from the teeth that consisted of up to 15 separate five-second applications of a thick paste made of 18 percent HCl mixed with a fine pumice powder, followed by 10-second water rinses. They used the thick paste to stop the acid from spreading over the teeth and gingivae and to provide a vehicle for pressure-induced abrasion of the teeth. They isolated the teeth being treated with a rubber dam sealed cervically with cavity varnish and applied sodium bicarbonate paste around the isolated area to help neutralize any acid overflow. They applied an acid-pumice mixture to the facial surface of each affected tooth with a wooden stick using a gentle rubbing motion for five seconds and then rinsed the tooth with water for 10 to 15 seconds and dried it with compressed air. They repeated this procedure until the stains were removed and the desired color correction was achieved. In most cases, they reported that distinct color improvement occurred by the sixth or seventh application. If no change was apparent after 12 to 15 applications, they stopped microabrasion to avoid excessive enamel loss. After the final application of the HCl-pumice paste, they smoothed the tooth surface with a paste of pumice and water in a rubber cup and then polished the surface with sandpaper disks. A 1.1 percent neutral sodium fluoride gel was then applied for four minutes to aid remineralization of the enamel. This technique forms the basis of the PREMA compound (Premier Dental Products, Plymouth Meeting, Pa.), which was introduced in 1990.

Croll and colleagues3,4,24–33 have described extensively the microabrasion technique using PREMA, which is an abrasive paste containing HCl, silicon gel, silicon carbide and silica gel. The compound is polished onto the surface of the teeth using hand applicators and rotary mandrels using a 10:1 gear reduction contra-angle on a standard slow-speed handpiece.33 Croll and colleagues32 reported that 15 seconds of gingival exposure to the compound followed by 30 seconds of water rinsing was harmless. Some gingival soft-tissue ulceration occurred after 30 seconds of exposure, but it healed completely in seven days. Consequently, a rubber dam is recommended when using PREMA to protect the soft tissues.9,24

At the International Symposium on the Non-Restorative Treatment of Discolored Teeth in 1996, it was concluded that microabrasion was a safe and effective atraumatic method of removing superficial enamel defects.34 In 2001, the United Kingdom National Clinical Guidelines in Paediatric Dentistry recommended the use of micro-abrasion to treat fluorosis, postorthodontic demineralization, localized hypoplasia and idiopathic hypoplasia where the discoloration is limited to the outer enamel layer.35 Although there have been numerous case reports,2–5,7,8,11,12,16,19,23,24,26,36–38 there have been only a few trials conducted to study the effectiveness of enamel microabrasion to remove stains and most of these trials were limited in size.1,9,20,39 In 2000, Ashkenazi and Sarnat39 reported the successful outcome of a two-and-one-half to four-year follow-up of the microabrasion technique, but the sample was only five children.

We conducted a controlled, blinded study to evaluate the esthetic effectiveness of enamel microabrasion using PREMA in removing white, brown or yellow stains from secondary dentition enamel. We hypothesized that the compound would effectively remove the fluorosislike stains from tooth enamel and improve the appearance of the teeth.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
After the Dalhousie University Ethics Committee, Halifax, Nova Scotia, Canada, approved the research project, we placed an advertisement in a local dental newsletter, inviting dentists to refer patients who had mild-to-severe enamel stains in secondary dentition for a microabrasion study. Dentists referred 32 subjects to Dalhousie University Faculty of Dentistry. We explained the purpose of the study to the subjects and obtained their informed consent. The subjects received an oral examination at no charge, and we assessed the affected teeth. The exclusion criteria were the presence of defects in the enamel surface, visible stains on the lingual and facial surfaces or caries in teeth that required microabrasion.

One author (R.B.T.P.), who had more than six years’ experience with enamel microabrasion, treated all 32 subjects using PREMA as described by Croll.33 Before treatment, each subject received a rubber cup prophylaxis to remove any superficial stain on the teeth. Next, we took standardized pretreatment clinical slides under controlled lighting conditions on the same day that the treating practitioner treated the teeth with microabrasion. We re-evaluated the subjects at least one week after treatment to assess the results and to take posttreatment slides. We used the same background, camera, flash, ambient light, exposure and batch of slide film for all of the slides.

During an evaluation session, we projected the 32 paired pre- and posttreatment slides of the subjects side by side in a darkened room with the post-treatment view of the treated teeth projected randomly on either the right or left side. Four calibrated and blinded prosthodontists assessed the slides under standard viewing conditions using a standardized questionnaire and visual analog scales, or VAS, with ranges of 1 to 7 (Figure 1Go). We used five pairs of duplicate slides showing teeth at the same stage of treatment and five duplicate pairs of slides showing teeth before and after treatment as controls to test for intra- and interrater reliability. We calculated the intraclass correlation coefficient for ratings of individual cases by different raters using a two-way random-effects model.40



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  		Figure 1. Visual analog scales. A. Comparing the two views on a scale of 1 to 7 to rate the improvement in appearance. B. Comparing the two views on a scale of 1 to 7 to rate the degree of stain removal. SD: Standard deviation.

 
The evaluators always identified a difference between the pretreatment slides and the post-treatment slides.


   RESULTS
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
The evaluators always identified a difference between the pretreatment slides and the posttreatment slides; they found no difference between the control slides. In all but one subject (97 percent of subjects treated), the evaluators found that the treated teeth had improved appearance and more uniform color. Figure 2Go and Figure 3Go show representative pre-and posttreatment images of the anterior teeth. On a scale of 1 (no improvement in appearance or stain not removed at all) to 7 (exceptional improvement in appearance or stain totally removed), mean ratings (± SD) were 5.38 (± 1.26) for improvement of appearance and 5.06 (± 1.26) (Figure 1Go) for stain removal. Analysis of variance, or ANOVA, revealed no differences between evaluator ratings (P = .146). The intraclass correlation coefficient, or rI, for ratings of individual cases by different evaluators was 0.72.



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  		Figure 2. Typical example of pretreatment (A) and posttreatment (B) results showing that white stains were removed from the incisal third of both central incisors.

 


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  		Figure 3. A. Pretreatment view of intense white stains covering most of the central incisors. B. Posttreatment results, showing removal of most of the white stains from both central incisors.

 

   DISCUSSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
The 32 subjects in this study were all referred to the Dalhousie University Faculty of Dentistry for microabrasion by their dentists. The subjects had mild-to-severe enamel stains, and they all met the inclusion criteria. The mean ratings (± SD) of 5.38 (± 1.26) for improvement of appearance and 5.06 (± 1.26) for stain removal on a scale of 1 to 7 indicate that while not all of the stains had been removed, the evaluators thought there had been a significant improvement in appearance. We accepted the hypothesis that the microabrasion compound would be able to remove the stains from enamel and improve the appearance of the teeth. Similar results were reported in a 41-subject clinical trial by Train and colleagues,41 who showed that mildly stained teeth had the greatest esthetic improvement after microabrasion using PREMA.

In our study, the raters were blinded and calibrated. We assessed them for intrarater reliability by having them unknowingly rate five paired duplicate slides at the same treatment stage. All of the raters correctly identified that there were no differences in these paired identical images. We also tested intrarater reliability by having the evaluators rate five pairs of pre- and posttreatment images twice. Since an rI of 0.6 to 0.74 represents a "good" level of correlation of ratings,40 the rI of 0.72 for individual cases by different evaluators was good.

Not only does microabrasion mask and remove stained tooth structure, thus improving tooth coloration, but the surface layer created during treatment is a highly polished, densely compacted, mineralized structure.33 While the exact reason for the color change that occurs after microabrasion is not known, the microabraded surface reflects and refracts light from the tooth surface in such a way that mild imperfections in the underlying enamel are camouflaged.33 The acid also may penetrate and bleach the organic compounds within the enamel,42 which might explain the improvement in tooth color. Mild surface abrasion of the enamel prisms with simultaneous acid erosion compacts mineralized tissue within the organic region of the enamel, replacing the outer prism-free region.42 Light reflected off of and refracted through this new surface is thought to act differently than light from an untreated enamel surface.33,42 In addition, subsurface stains may be camouflaged by the optical properties of the newly microabraded surface.32 Croll33 has named this phenomenon the "abrasion effect." Hydration of the tooth by saliva augments the optical properties of this altered enamel surface,33 and the application of topical fluoride further improves these optical properties.

Using polarized light microscopy, Donly and colleagues42 examined longitudinal sections of human incisors after they had received 10 20-second applications of PREMA compound. They found that after microabrasion the tooth surface contained a dark area that demonstrated positive birefringence. After microabrasion paste compound was applied 20 times, this dark surface layer appeared even thicker. As might be expected after simultaneous abrasion and erosion with a compound containing HCl, this surface demonstrated an atypical enamel structure. Part of this "abroded" surface was washed away between applications of the microabrasion compound, but a large portion of the abrasive and mineral byproducts of treatment remained as a dense, polished surface layer that was more opaque than the untreated natural enamel.42 This highly polished enamel surface was not colonized as rapidly by Streptococcus mutans as were surfaces that had not been microabraded.43 There also is some evidence that the treated enamel may be more resistant to demineralization.44 Long-term follow-up studies, however, are required to see if teeth treated with microabrasion are more resistant to caries and to see if any relapse of the staining occurs.

During microabrasion, the teeth should be properly isolated with a rubber dam, and the patient should wear eye protection.33 If a microabrasion paste such as the PREMA compound leaks under the rubber dam, some gingival ulceration may occur, but the tissues should heal completely within one week.32 If the teeth are overtreated with the compound, which can occur if the enamel is very thin or if the stains are severe,41 the exposed dentin may become sensitive, and a direct resin-based composite restoration, a porcelain veneer or a crown may be required.31 The alternative to using enamel microabrasion to improve the esthetic appearance of teeth is to place a direct resin-based composite, a veneer or a crown. Therefore, we support practice guidelines that recommend microabrasion as a conservative first treatment of choice for removing superficial stains in the enamel before proceeding to a less-conservative treatment.34,35


   CONCLUSIONS
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
We evaluated the effectiveness of a microabrasion compound to remove white, yellow and brown stains from the tooth enamel of 32 subjects. Standardized slides were taken after oral prophylaxis but before microabrasion treatment and again at least one week after treatment. Four prosthodontists evaluated the paired images using a standardized questionnaire and VAS, with ranges from 1 (no improvement in appearance or stain not removed at all) to 7 (exceptional improvement in appearance or stain totally removed). The evaluators found that there was a difference between the pretreatment slides and the posttreatment slides; they found no difference between the control paired slides. In all but one subject (97 percent), the evaluators found that the treated teeth had an improved appearance and a more uniform color. ANOVA revealed no differences between evaluator ratings (P = .146). The rI of 0.72 for ratings of individual cases by different evaluators, represents a good level of correlation of the ratings for the level of improvement or degree of stain removal. Mean ratings (± SD) were 5.38 (± 1.26) for improvement of appearance and 5.06 (± 1.26) for stain removal.

We believe that the results of this study show that enamel microabrasion using the PREMA compound is effective in removing stains from the outermost layer of enamel and improving the appearance of the teeth.


   FOOTNOTES
 

Dr. Price is a professor, Department of Dental Clinical Sciences, Faculty of Dentistry, Dalhousie University, 5981 University Ave., Halifax, Nova Scotia, B3H 3J5, Canada, e-mail "rbprice{at}dal.ca". Address reprint requests to Dr. Price.


Dr. Loney is a professor and the director, Graduate Prosthodontics, Department of Dental Clinical Sciences, Faculty of Dentistry, Dalhousie University, Halifax, Nova Scotia, Canada.


Dr. Doyle is an assistant professor, Department of Dental Clinical Sciences, Faculty of Dentistry, Dalhousie University, Halifax, Nova Scotia, Canada.


Dr. Moulding is a professor, Department of Restorative and Prosthetic Dentistry, University of Saskatchewan, Saskatoon, Canada.


This study was funded by Premier Dental Products (Plymouth Meeting, Pa.) and the Dalhousie University Alumni Oral Health Research Fund.


The authors thank Dr. J. Murphy, B.Ed., M.Ed., Ed.D., associate professor, Faculty of Dentistry, Dalhousie University, for his assistance with the statistical analyses and Dr. J. Wilson, B.Sc., D.D.S., M.S., for participating as one of the evaluators.


   REFERENCES
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 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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