34 Mottled teeth
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?
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.
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.
Do you know why the labial surfaces of the upper permanent central incisors are often more affected by mottling?
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.
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.
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.