34: Mottled teeth

34 Mottled teeth

Summary

Sophie is 8 years old. Her main concern is that all her permanent teeth have white patches, especially the upper central incisors. She is getting teased at school because the upper centrals also have brown patches. What are the causes of the white patches? How may they be treated?

History

Sophie noticed that the permanent teeth came through with the white and brown patches (Fig. 34.1). They have not changed in appearance since eruption.

image

Fig. 34.1 Disfiguring fluorotic mottling affecting upper permanent central incisors.

image What important questions would you now ask her mother?

Were the primary teeth normal?

If the answer to this is yes then it is unlikely to be an inherited defect and more likely to have a systemic origin.

image Is anyone else in the family affected?

Unless siblings are subjected to exactly the same systemic diseases and conditions it is likely that an affected sibling will indicate an inherited defect.

Sophie’s primary teeth were normal and she had no siblings, but neither her mother’s nor her father’s family had anyone with a similar problem.

image What childhood illnesses and infections did she have, and when?

A chronological hypomineralization or hypoplasia would suggest a systemic origin. There were no significant illnesses.

image What is Sophie’s fluoride history?

This must include where she has lived, any history of supplements, type of toothpaste used, amount of toothpaste used, any history of eating toothpaste.

It transpired that Sophie had never received any supplements, nor used toothpaste excessively. However, she lived on a farm with its own ‘well’ water supply. This was subsequently analysed and was found to be over 1 ppm fluoride. The diagnosis was one of fluorosis.

image What is the distribution of the mottling that you can see in Figure 34.1?

White and brown mottling of the incisal half of the labial surface of image and white mottling of the incisal third of the labial surface of image.

image Do you know why the labial surfaces of the upper permanent central incisors are often more affected by mottling?

Research has shown that these teeth are particularly susceptible to an excess ingestion of fluoride between 24 and 30 months of age.

Mild fluorosis gives a diffuse mottling that may manifest as diffuse lines or patches that merge into the background enamel. When the fluorosis becomes more severe the lines and patches coalesce to produce a confluent white surface. In very severe cases there is also pitting of the enamel. Well-defined or well-demarcated patches that do not follow a systemic or chronological distribution, or are localized, are not likely to be due to fluorosis.

image Which part of the enamel does mild fluorosis affect?

The outer 200–300 µm.

image How can you use this knowledge to your advantage during your clinical examination?

Look for areas of the dentition that are subject to erosion or attrition, e.g. the occlusal surfaces of the first permanent molars. If the mottled enamel has been removed on these surfaces then that confirms that the mottling is in the outer aspect of the enamel and the diagnosis is likely to be one of fluorosis.

Key point

History taking in suspected fluorosis:

• Fluoridated water in places of residence.
• Amount of paste and age brushing started.
• Supplements.
• ‘Eating’ toothpaste.

image In some cases of fluorosis there is, in addition to white mottling, some brown stain. What is the cause of the brown staining?

This is usually due to extrinsic agents becoming incorporated into the more porous white mottled areas of enamel. The brown mottling tends to get worse with time.

image What treatment options for Sophie would you consider for fluorotic mottling?

Microabrasion.
Composite veneers.

Microabrasion can be done in a variety of ways and is a controlled removal of the surface layer of enamel in order to improve discolorations that are limited to the outer enamel layer. It is not suitable for deep enamel or dentine discoloration. One of the most reliable methods that has been used extensively since 1986 is the hydrochloric acid (HCl)-pumice microabrasion technique. It is achieved by a combination of abrasion and erosion – the term ‘abrosion’ is sometimes used. In the clinical technique that will be described, no more than 100 µm of enamel is removed. Once completed the procedure should not be repeated again in the future. Too much enamel removal is potentially damaging to the pulp and cosmetically the underlying dentine colour will become more evident.

Indications:

• Fluorosis.
• Idiopathic speckling.
• Post-orthodontic treatment demineralization.
• Prior to ve/>

Related posts:

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  2. 39: Gingival bleeding and enlargement
  3. 3: Absent upper lateral incisors
  4. 12: Increased overbite
  5. 30: The fractured permanent incisor root
  6. 38: Dentinogenesis imperfecta

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Jan 2, 2015 | Posted by in Orthodontics | Comments Off on 34: Mottled teeth

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