Dr. JEEVITHA K V - 52.172.27.147:8080

“COMPARATIVE EVALUATION OF ACTIVATED CHARCOAL WITH COMMERCIALLY AVAILABLE DENTAL

MICROABRASIVE PASTE ON ENAMEL SURFACE”

By,

Dr. JEEVITHA K V

A DISSERTATION SUBMITTED TO THE RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE.

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF DENTAL SURGERY (M.D.S.) IN

CONSERVATIVE DENTISTRY & ENDODONTICS

Under the guidance of

Dr. LEKHA S, M.D.S Professor

DEPARTMENT OF CONSERVATIVE DENTISTRY & ENDODONTICS, THE OXFORD DENTAL COLLEGE,

BOMMANAHALLI, BANGALORE-560068 2016 - 19

VIII

LIST OF ABBREVIATIONS

SL NO ABBREVIATION WORD

1 HCl Hydrochloric acid

2 H3PO4 Phosphoric acid

3 µm Micrometre

4 mg Milligram

5 ml Millilitre

6

Ra Roughness regression

analysis

7 ∆ Delta

8 L Lightness

9 C Chroma

10 H Hue

IX

LIST OF TABLES

Sl.

No.

Title

Page

no.

1 ∆E spectrophotometer value and the profilometer surface roughness value obtained for Group 1 samples in pre and post microabrasion period.

40


41


42

4 Comparison of mean values of colour parameters between Pre and Post application period in Group 1 using Wilcoxon Signed Rank Test

43

5 Comparison of mean values of colour parameters between Pre and Post Treatment period in Group 2 using Wilcoxon Signed Rank Test

44

6 Comparison of mean values of colour parameters between Pre and Post Treatment period in Group 3 using Wilcoxon Signed Rank Test

45

7 Comparison of mean differences of color parameters between 03 groups using Kruskal Wallis Test followed by Mann Whitney Post hoc Analysis

46

8 Comparison of mean Roughness values between Pre and Post Treatment period in each study group using Wilcoxon Signed Rank Test

47

9 Comparison of mean values of Roughness (in µm) between 03 study groups during Pre & Post Treatment Period using Kruskal Wallis Test

48

10 Particle size of Opalustre

49

11 Particle size of activated charcoal 49

X

LIST OF GRAPHS

Sl.no. Title Page no.


50


50


51

4 Comparison of mean values of colour parameters between Pre and Post application period in Group 1 using Wilcoxon Signed Rank Test

51

XI

LIST OF FIGURES

Sl.no. Title Page no.

1 Activated coconut shell charcoal 31

2 Spectrophotometer 31

3 Thymol (for storage) 31

4 Distilliser 31

5 Opalustre 32

6 Rubber cups 32

7 Dappen dish and scoop 32

8 NSK Micromotor handpiece 32

9 HCl and Activated charcoal 33

10 Group 1 teeth samples 33

11 Group 1 Microabrasion 33

12 Opalustre (Group 2) 34


14 Application of Opalustre 34

15 Microabrasion with opalustre 34


17 Activated charcoal 35

18 Activated charcoal mixed with Distilled Water 36

19 Application of Activated charcoal 36

20 Microabrasion for group 3 36

21 Spectrophotometer 37

22 Profilometer 38

XIII

ABSTRACT

TITLE: Comparative evaluation of activated charcoal with commercially available dental

microabrasive paste on enamel surface.

BACKGROUND: Charcoal has been used to clean teeth and it is highly abrasive. The aim

of this study is to evaluate the effect of activated coconut charcoal on the enamel

morphology, in conjunction with HCl as a microabrasive mixture by means of roughness

analysis and spectrophotometer.

OBJECTIVES: To evaluate the colour change and surface roughness when activated

charcoal is used as a microabrasive agent and to compare the colour change and surface

roughness between activated charcoal microabrasive mixture and commercially available

product (Opalustre).

METHODS: Sixty human maxillary anterior teeth were divided into 3 groups;

experimental group -activated charcoal+HCl (group 1); Ultradent Opalustre (group 2);

activated charcoal +distilled water (group 3). Microabrasion was performed using NSK

micromotor at low speed (13000rpm), 10 application for 10 seconds for each test sample

was done. Pre and post applications VITA Easyshade Advance Spectrophotometer

measurements were made. Profilometer was used to check the roughness for all the three

groups pre and post application. The data obtained was subjected to statistical analysis.

Wilcoxon Signed Rank Test and Kruskal Wallis Test was done to compare the values.

(p<0.05)

RESULTS: There was statistical difference in the ∆E values of all the groups (group 1

p<0.001 group 2 p<0.001; group 3 p<0.001) between the pre application values (mean ∆E

XIV

of group 1= 4.66 group 2=6.58 group 3=6.11) and post applications (mean ∆E of group 1

= 4.91 group 2 = 6.49 group 3 = 4.09) signifying an improved color there was no statistical

difference among three groups.

All the three groups showed reduced Ra value post application (mean Ra of group 1= 0.8

µm group 2=1.01µm and group 3=1.08 µm) application roughness values compared to per

application roughness (mean Ra of group 1 although group 11.89 µm group 2 1.59 µm and

group 3 1.34 µm) and were found to be statistically significant (group 1 p =0.003 group 2

p=0.002 and group 3 p=0.03). There was no statically difference among the groups

although group 1 showed least Ra value.

CONCLUSION: Experimental microabrasive (activated coconut shell charcoal) mixture

is effective and showed similar results to Opalustre Ultradent. There was improved colour

and the enamel surface was found to be show least roughness compared to the other two

groups.

KEYWORDS: Activated Charcoal, Microabrasion, Microabrasive, Opalustre,

Profilometer, Spectrophotometer.

INTRODUCTION

The face of modern dentistry is interpreted by general population as means to improve

facial appearance and dental aesthetics. People relate improved aesthetics to brighter and

whiter smile. A lighter dentition is related to youth and health. Several treatments have

been introduced to the dental market to satisfy what patients seek regarding dental

esthetics. These techniques are still being evaluated in order to ensure an efficient

treatment with minimal chair time and low cost. For the superficial enamel stains or

defects, enamel microabrasion is preferred, as it is considered as an esthetic and

conservative treatment.1 Microabrasion is a procedure in which the enamel surface is

softened with acids such as Hydrochloric acid (HCl) and Phosphoric acid (H3PO4) and

the surface discoloration is removed by polishing with an abrasive material.

Since its introduction by Croll et al 2 in 1986, there have been numerous reports

describing various approaches3, 4. The association of Hydrochloric acid to abrasive

particles resulted in the development of few commercially available products. Prema

Compound (Premier Dental Company, Philadelphia, PA, United States), which has been

introduced into the dental market, contains 10% hydrochloric acid. Currently, a lower

concentration of Hydrochloric acid is used, approximately 6.6%, under the commercial

product name of Opalustre (Ultradent Products Inc., South Jordan, UT, United States)

Both products use silicon carbide as an abrasive with different granulations dispersed in a

water-soluble gel for easy removal.

Newer compound like Aluminium Oxide has been experimented with as an abrasive

agent in the microabrasion mixture.5 Charcoal also, is a known abrasive agent6 and has

been used to clean teeth, being applied onto a forefinger or a melastroma brush, since

historical times. Many commercially available products such as toothpaste and

toothbrushes containing charcoal are now available in market. They claim to have an

added teeth-whitening property due to its adsorbent property. Adsorption is

the adhesion of atoms, ions or molecules from a gas, liquid or dissolved solid to

a surface. No literature to date is available evaluating charcoal as a microabrasive agent.

Coconut shell charcoal has higher adsorbent property compared to other forms of

charcoal. Activated charcoal has increased surface area available for adsorption7 and is

hence preferred to plain charcoal.

Colorimeter, Spectro colorimeters and Spectrophotometers are often used to measure

colour. Among these Spectrophotometer is known to be the most accurate among all the

instruments used in color measurements. 8

Microabrasion results in loss of enamel ranging from 25 µm to 250 µm.10 This results

in change in the surface morphology such as surface roughness. To assess the change in

the enamel surface roughness, Profilometers are often used.5,10,11

Taking into consideration the abrasive nature of charcoal, the aim of this study is to

evaluate the colour change and roughness of enamel after microabrasion with activated

coconut shell charcoal on extracted teeth. The null hypothesis states that there will be no

difference in enamel roughness and tooth color change of the experimental microabrasive

material when compared with the commercially available paste.

OBJECTIVES

1. To evaluate the colour change and surface roughness when activated charcoal is

used as a microabrasive agent.

2. To compare the colour change and surface roughness between activated charcoal

microabrasive mixture and commercially available product (Opalustre).

3. To determine whether activated charcoal used with distilled water only can enhance

tooth colour.

REVIEW OF LITERATURE

Dental fluorosis is a major problem in areas of endemic fluorosis (e.g. as a result of too

much fluoride in the drinking water), such as in India and China. The most conservative

way to treat fluorosis is with microabrasion.

Raper et al in an attempt to remove brown stain from fluorine mottled teeth suggested

the use of 18% hydrochloric acid applied and rubbed with a wooden spatula wrapped with

cotton for a maximum time of 10 mins back in 194112. Mechanical application with a low-

rotation micromotor was first indicated in the 1970s, using a mixture of 18% hydrochloric

acid, hydrogen peroxide and ether.13 Combination with an abrasive agent was later

indicated by Murrin et al14 in 1982, who added pumice to 36% hydrochloric acid, resulting

in a slurry that was applied using a rubber cup coupled to a micromotor14. Enamel

microabrasion first described by Dr. Walter Kane (Colorado Springs, 1916), by rubbing

six maxillary anterior teeth with hydrochloric acid (HCl) under the flame of an alcohol

torch, he found favourable results in the treatment of enamel fluorosis without any

destruction or damage of enamel. However, for more than 60 years, most clinicians avoided

applying this technique, because of fear of damage or destruction of the enamel.15,16 In

1984, Mc Closkey introduced the use of acid combined with pumice 15 which was named

“microabrasion” by Croll two years later 1,16.

Enamel microabrasion was initially performed for the removal of fluorotic white spots

using 36% hydrochloric acid, as recommended by Kane. Croll et al described that enamel

microabrasion is a method of removing certain enamel dysmineralization and

décalcification coloration17.The article explains that in many cases, with insignificant and

unrecognizable loss of enamel, superficial enamel discoloration defects can be permanently

eliminated, improving the appearance of treated teeth.17,18

A heated metallic instrument was used to apply the acid to the altered enamel to increase

its penetration16. The author again proposed the use of an extra-fine diamond bur prior to

the use of the microabrasive agents to reduce the clinical time needed to perform the

procedure 19and hasten the chemical reaction between the acid and the enamel20. Concerned

about the safety of the technique the authors drew attention to the thickness of the enamel,

particularly at the cervical third of the tooth, which is thinner compared to the medium and

incisal third. They also recommended the use of sodium bicarbonate to neutralize the

effects of the hydrochloric acid. Concerned about the acid concentration, Croll et al17

recommended the use of the same mixture but with 18% hydrochloric acid. Croll later

stated that an ideal microabrasive system should include a low acid concentration and

abrasive particles in a water-soluble mixture that are applied with a low-rotation handpiece

to avoid scattering the compounds, thus making the procedure safer17.

A study was conducted to investigate the effect of time, number of applications and the

pressure (individually and combination) on enamel loss, in microabrasion. Teeth were hand

rubbed with 18% HCl-pumice mixture at the time intervals of 5, 10 and 20 seconds and 5,

10, and 15 applications, under pressures of 10, 20 and 30. Enamel loss was measured from

the treated sections. Enamel loss significantly increased as each variable separately

increased and was more when two variables increased at the same time. The study

concluded that the combination of 10 ten-sec applications or 15 five-sec applications with

20 g pressure resulted in enamel loss of slightly less than 250µm.21

Hoeppner et al reported that the enamel surface was more resistant to demineralization

four months after microabrasion with 35% phosphoric acid.22 Enamel microabrasion was

soon considered effective in cases of white, yellow or brown stains located in the outer

enamel layer .23

The association of hydrochloric acid to abrasive particles resulted in the development

of commercially available products. Prema Compound (Premier Dental Company,

Philadelphia, PA, United States), which contains 10% hydrochloric acid, was the first to

be introduced to the market. Currently, a lower concentration of hydrochloric acid is used,

approximately 6.6%, under the commercial product name of Opalustre (Ultradent Products

Inc., South Jordan, UT, United States). Both products use silicon carbide as an abrasive

with different granulations dispersed in a water-soluble gel for easy removal24. Meireles

SS, Andre Dde A, Leida FL, Bocangel JS, Demarco FF compared the surface roughness

and enamel loss produced by the two microabrasive technique using 37% phosphoric acid

and 18% hydrochloric acid applied using a wooden spatula for a total of 5 seconds and 10

applications each. The study concluded that microabrasion with phosphoric acid produced

greater surface roughness but less demineralization than hydrochloric acid.25 The use of

35% phosphoric acid instead of hydrochloric acid was proposed by Kamp in 1989, and was

considered advantageous as it is commonly used in clinical practice for other procedures.20

Rodrigues et al mentioned in his in-vitro study, enamel micro-abrasion presented itself

as a conservative approach, regardless of the type of the paste compound utilized. These

products promoted minor roughness alterations and minimal wear. The use of phosphoric

acid and pumice stone showed similar results to commercial products (Opalustre) for the

micro-abrasion with regard to the surface roughness and wear. Baglar S, Colak H,Hamidi

MM compared the commercially available opalustre microabrasive paste with evaluate

Novel Microabrasions paste as a dental bleaching material and its effects on enamel

surface. Prototype Mircroabrasive paste comprised of 8% HCl + silicon dioxide particles

and carboxymethyl cellulose. Samples were examined by scanning electron microscopy

(SEM) for surface changes. Changes in tooth color were measured before and after

treatment by VITA Easyshade Advance Spectrophotometer. In SEM and the

spectrophotometer three color measuring coordinate evaluations, no statistically significant

differences were not observed between the 1st and 2nd groups. The study demonstrated

that the prototype paste is a viable treatment option for dental fluorosis.26

A study evaluated the enamel morphology after microabrasion with experimental

compounds. Microabrasion using 6.6% HCl or 35% H3PO4 associated with aluminum

oxide (AlO3) or pumice with active or passive application; acids in passive application,

and a group without treatment. Roughness analysis was performed using a profilometer

roughness tester and representative specimens were evaluated using scanning electron

microscopy. Results showed that there was no significant difference between the acids used

and the applications. Passive application of HCl + AlO3 resulted in higher roughness when

compared with HCl + pumice. The conclusion of this study was that AlO3 may be a suitable

particle for use in microabrasive systems.5

It was found that active application resulted in less enamel loss compared to passive

application. A study was conducted to evaluate the effects of acids used in the

microabrasion technique on enamel. The superficial and cross-sectional microhardness;

depths of 10, 25, 50, and 75 µm) of enamel were analyzed. Morphology was evaluated by

confocal laser-scanning microscopy. Results showed that cross-sectional microhardness

decreased as the depth increased and reduced compared to the control group. Higher mean

cross-sectional microhardness result was obtained with the active application of H3PO4

compared to HCl. Conclusion of this study was that, although the acids displayed an

erosive action, use of microabrasive mixture led to less damage to the enamel layers.27

Berg and Donly identified the enamel glaze layer with polarized light microscopy and

scanning electron microscopy using SEM, Donly et a described the enamel glaze as an

amorphous layer of compacted mineral, resulting from simultaneous abrasion and erosion

of the enamel with PREMA Comound. Segura and colleagues discovered that human

incisor surfaces treated with PREMA Compound/ a microabrasive compound and topical

fluoride solution resist dissolution better than untreated surfaces when challenged with that

PREMA-treated surfaces colonize fewer Streptococcus mutans than do untreated surfaces.

Observations of hundreds of patients since 1985 have revealed that the smooth texture and

surface luster of microabraded teeth endures and surface appearance is enhanced as years

go by after treatment.28 Enamel microabrasion does not render a tooth surface more prone

to dental caries. On the contrary, enamel surface quality of microabraded teeth predictably

improves as time passes after treatment.

Case reports

Two cases illustrate the technique of treating enamel discoloration and decalcification

by beginning with bur cutting and completing with microabrasion compound. This

eliminates texture defects caused by bur cutting and reduces treatment time.29

Croll et al reviewed the technique of enamel microabrasion using a commercially

available compound of hydrochloric acid and fine-grit silicon carbide particles in a water-

soluble paste. It also described a method of combining enamel microabrasion with

carbamide peroxide home bleaching. Finally, it presents the cases of representative patients

who underwent enamel microabrasion (alone or in combination with dental bleaching) and

showed stable results.30

The technique of enamel microabrasion was evaluated by a group of authors by studying

the effectiveness of a proprietary microabrasion product. 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. 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. Authors concluded that enamel

microabrasion could remove stains from within the outermost layer of tooth enamel,

thereby improving the appearance of the teeth. Clinical implications of 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.31

In a clinical study to evaluate if simple microabrasion technique is effective in

improving the esthetics of enamel flurosis patients with a variety of severities were treated

using a water-cooled fine diamond polishing bur at high speed to remove the surface

enamel layers. Photographs of the affected teeth before and after treatment were shown by

computer to a panel of three judges (two lay and one experienced), who rated the

appearance of the teeth using a newly developed visual analog scale. The severity of

enamel flurosis was rated randomly and blind for 52 individual teeth (26 before and 26

after treatment). All judges found a significant improvement after treatment. The study

indicates that enamel flurosis of an objectionable nature can be significantly improved with

a simple microabrasion technique, thus conserving tooth structure and minimizing the cost

of treating.32

A study reviewed the status of enamel microabrasion method and its results 18 years

after the development and application of this method. A technique performing enamel

microabrasion with hydrochloric acid mixed with pumice and other techniques employing

a commercially available compound of hydrochloric acid and fine-grit silicon carbide

particles in a water-soluble paste have been described. Much has been learned about the

application of this esthetic technique, long-term treatment results and microscopic changes

to the enamel surface that has significant clinical implications. Clinical observations made

over 18 years are discussed. According findings of this study, the dental enamel

microabrasion technique is a highly satisfactory, safe and effective procedure.33

A case report describes the sequential steps that were used to treat unesthetic, white,

hard texture enamel stains of unknown etiology. A tapered fine diamond bur was used to

remove superficial enamel followed by the use of an enamel microabrasion compound

Opalustre (Ultradent Products Inc). This technique removed the stains and was followed

by polishing with a fluoride paste to restore the enamel to a smooth finish. The teeth were

subsequently bleached with carbamide peroxide (Opalescence 10%, Ultradent Products),

which achieved the patient’s desired esthetic results.34

Recent advances

Recent studies with microabrasion outlines the method of combining enamel

microabrasion with carbamide peroxide patient administered home bleaching for esthetic

improvement of teeth with fluorosis and fluorosis-like discoloration and has shown to be

successful in many clinical situations35 reviewed the technique of enamel microabrasion

using a commercially available compound of hydrochloric acid and fine-grit silicon carbide

particles in a water-soluble paste. It also describes a method of combining enamel

microabrasion with carbamide peroxide home bleaching. Finally, it presented the cases of

representative patients who underwent enamel microabrasion (alone or in combination

with dental bleaching). The study concluded that a decade of clinical experience and

research has demonstrated the acceptability of enamel microabrasion as a method of

improving the appearance of teeth with superficial dysmineralization and decalcification

defects.35

A combination of the micro abrasion procedure and casein phosphopeptide amorphous

calcium phosphate application reduced the enamel surface roughness significantly, when

compared to micro abrasion done alone. conclusion of this study was that application of

casein phosphopeptide amorphous calcium phosphate after micro abrasion procedure

significantly reduces the enamel surface roughness thereby decreasing the risk of caries.36

A study reviewed the attempt for teeth color correction utilizing that conservative

technique in a young girl whose maxillary anterior teeth presented an opaque white/brown

stain. Along with microabrasion, an innovative approach of application of casein

phosphopeptide-amorphous calcium phosphate crème on the tooth, and remineralization

was carried out thereby reducing postoperative sensitivity of the treated tooth. Based on

the results of this case report, it can be concluded that this technique is efficient and can be

considered a minimally invasive procedure.37

A clinical report illustrates a conservative technique to mask enamel discolorations in

maxillary anterior teeth caused by hypomineralization associated with

enamel fluorosis and subsequent direct resin composite to improve the anterior esthetics.

The treatment consisted of at-home whitening with 10% carbamide peroxide gel with

potassium nitrate and sodium fluoride in a custom-fitted tray to mask the brown-stained

areas, followed by resin infiltration to mask the white spot areas. An existing resin

composite restoration in the maxillary right central incisor was subsequently replaced after

completion of the whitening and resin infiltration procedures, whereas the two misaligned

and rotated maxillary lateral incisors were built up with direct resin composite restorations

to provide the illusion of adequate arch alignment, as the patient was unable to use

orthodontic therapy.38

Another study assessed the correction of dental fluorosis with a more conservative

treatment options, including the combination of microabrasion and bleaching. This clinical

report describes the use of these treatment options to address a young patient's dental

fluorosis.39

Microabrasion can be combined with dental bleaching for extra enhancement. In an

age of pervading concern about appearance these treatments can provide patients with

satisfying results.

The effects of resin infiltration and microabrasion on incipient carious lesions by surface

microhardness, roughness and morphological assessments, and resistance to further acid

attack of treated lesions were evaluated.: Enamel lesions treated with resin infiltrant and

microabrasion demonstrated similar hardness values, with a nonsignificant difference

compared with sound enamel. Resin infiltration demonstrated lower roughness values than

those of microabrasion, and the values did not reach the values of sound enamel. Further

demineralization for 10 d did not affect the hardness but increased the roughness of

infiltrated and microabraded enamel surfaces. Polishing did not influence the roughness of

microabraded enamel surfaces. After resin infiltration, porosities on enamel were sealed

completely. The surface structure was similar to that of the enamel conditioning pattern for

microabraded enamel lesions. the icon infiltration and microabrasion technique appeared

to be effective for improving microhardness. Icon appeared to provide reduced roughness,

although not equal to sound enamel. Further research is needed to elucidate their clinical

relevance.40

Charcoal as an abrasive agent

A study was conducted to determine the dental abrasive patterns in a selected group of

Malaysians. 350 inhabitants of Kerilla and Kongsi villages who cleaned their teeth using

table salt and charcoal, applied to their forefinger or a melastroma brush where enquired.

Frequency and duration of their tooth cleaning habit was recorded. Detailed examination

of teeth, gingival and pattern of tooth wear was done. All these patients showed abrasion

cavities of varying degrees of severity ‘depending on the type of abrasive used, the

frequency and duration of practice. The study concluded that all the above three agents are

highly abrasive.6

A study was conducted to evaluate the tooth substance loss caused by different

dentifrices and to correlate it with chemical composition, size, and shape of abrasives used.

An indigenously made automated machine was used for brushing the specimens. Sixty-

four freshly extracted premolars were allocated to eight groups (n = 8). Colgate toothpaste

was used as the control group. Each specimen was brushed in a vertical motion for 2½ h at

200 strokes/min with a constant applied load of 200 g corresponding to 6-month brushing.

The difference in weight (pre- and post-brushing) was determined by an analytical

weighing machine. Chemical analysis was done to determine the presence of iron oxide by

Inductively Coupled Plasma Mass Spectrometry method. Shape and size of the abrasive

particles was evaluated under scanning electron microscopy (SEM). One-way analysis of

variance and Paired t-test were used to analyze the data. Tooth substance loss was

maximum in the group brushed with red tooth powder, which was shown to contain the

highest amount of iron oxide and also exhibited large, irregularly shaped abrasive particles

under SEM. Tooth substance loss was documented to be correlated with chemical

composition (iron oxide and charcoal) and the size and shape of abrasive particles used in

dentifrices41

An article reviewed the roles associated with activated charcoal. While Activated

charcoal is mainly associated with treatment of poisoning substances, it has other important

roles in the treatment of patients with chronic kidney disease which enhances the outcome

of renal dialysis. We also indicated to the use of Activated charcoal in providing protection

for workers against vapours in working atmosphere through the use of charcoal cartridge.

Activated charcoal has potential roles in removal of heavy metals from environment

particularly water. Activated charcoal has therapeutic and environmental applications due

to its large surface area.42

Activated-charcoal treatment is typically commenced within the accident and emergency

department despite the lack of evidence demonstrating its effectiveness and the lack of

consensus among doctors in their methods of gastric decontamination (Greaves et al.

1996).43

A study evaluated the intra-device repeatability and accuracy of dental shade-matching

device (VITA Easyshade® Advance 4.0) using both in vitro and in vivo models. For the

repeatability assessment, the in vivo model utilized shade-matching device to measure the

central region of the labial surface of right maxillary central incisors of 10 people twice.

The following tooth colors were measured: B1, A1, A2, A3, C1 and C3. The in vitro model

included the same six Vitapan Classical tabs. Two measurements were made of the central

region of each shade tab. For the accuracy assessment, each shade tab from 3 Vitapan

Classical shade guides was measured once. CIE L*a*b* values were determined. Intra

class correlation coefficients were used to analyze the in vitro and in vivo intra-device

repeatability of the shade-matching device. The mean color differences for in vivo and in

vitro models were 3.51 and 1.25 E units, respectively. The device repeatability Intra class

correlation coefficients for in vivo measurements ranged from 0.858 to 0.971 and for in

vitro from 0.992 to 0.994. Accuracy of the device tested was 93.75%. the study concluded

that within the limitations of the experiment, VITA Easyshade®Advance 4.0 dental shade-

matching device enabled reliable and accurate measurement. It can be a valuable tool for

the determination of tooth colours.9

This study evaluated the effectiveness of two microabrasion products for the removal

of enamel fluorosis stains. Using a split-mouth study design, two operators used PREMA

(PM) and Opalustre (OP) to remove fluorosis-like stains from 36 subjects (10-12 years

old). Both products were rubbed onto the surface of the affected teeth for 30 seconds. This

procedure was repeated five times during each clinical appointment. A maximum of three

clinical appointments were scheduled. The subjects and/or their parents were questioned

about their satisfaction with the treatment. Two blinded evaluators appraised both sides of

the mouth using a visual scale system. The data were analyzed by Friedman repeated

measures ANOVA and Wilcoxon test. The majority of the subjects (approximately 97%)

reported satisfaction at the end of the treatment (p=0.0001). A significant improvement in

appear ance was detected after the second clinical appointment when using PREMA and

Opalustre (p<0.002) After the first clinical appointment, OP showed a statistically higher

mean rating for improvement in appearance (3.4 ± 0.7) than PM (2.4 ± 0.5) (p=0.002).

PREMA and Opalustre are effective, conservative methods for improving the

appearance of fluorosis-affected teeth; however, faster results can be obtained with

Opalustre. The results of this study show that the majority of subjects reported being

satisfied after microabrasion treatment.44

Enamel surfaces have been found to acquire a glass-like luster and an exceptionally

smooth texture following enamel microabrasion procedures. A commercially

available enamel microabrasion compound containing abrasive particles and a mild

concentration of hydrochloric acid, when applied by rotary compression, simultaneously

abrades and erodes (abrosion) the enamel surface.

Human enamel surfaces were evaluated microscopically after routine enamel

microabrasion procedures. The results show distinct evidence of enamel surface changes

that have been described as the abrosion effect.45

Since stylus profilometry applies a force on the sample surface, it is logical to

hypothesize that the profilometer penetrates the surface of the enamel softened by acid

solutions. A study was therefore conducted to test the hypothesis that surface profilometry

measurements of eroded enamel alter the surface of the enamel, to quantify the potential

effect of the surface alteration (scratches) on the measured values of enamel erosion by

atomic force microscopy and to compare the values of enamel loss caused by erosion as

measured by profilometry and non-contact confocal laser scanning microscopy. Enamel

samples, cut from unerupted human third molars were treated with Volvic Mineral Water

and citric acid solutions of different pH values. The enamel material loss was measured by

two different contact profilometers and a reflection mode confocal laser scanning

microscopy. The scratches depth was analyzed by atomic force microscopy. Results

demonstrated that the tip of the profilometer penetrated the surface of eroded enamel during

the profilometry measurements, leading to clearly visible surface scratches on the enamel

samples. The profilometers created surface scratches of a depth ranging from 57.6 (47.1)

nm to 577.1 (157.6) nm on the surface of the eroded enamel and led, therefore, to a larger

measured value of erosion. It was shown that the depth of the scratches depends on the pH

value, the erosion time and the profilometer used. Significance of this study was, with few

exceptions profilometers deliver reliable values of erosive enamel material loss, although

they create surface scratches on eroded enamel. Reflection mode confocal laser scanning

microscopy is a non-tactile, fast and precise method for analyzing enamel erosion

quantitatively in vitro.46

A study was conducted to evaluate, using study models (epoxy resin material), a

procedure that permits the reliable and accurate monitoring of erosive substance loss within

acceptable observation periods. The method is the profilometric measurement of erosive

tissue loss using acid-resistant markers, which represent both a reference area and a

structure for the defined retracing of a given erosive lesion surface. The study model

magnified values slightly (2.8%; not significant), the precision was < 4 lm, and the

repeatability was good (95% limits of repeatability ranging from)4.7 to 5.2 lm). The

estimated detection threshold for erosive loss is 15 lm, which appears to be adequate for

monitoring. The method is indicated for special dental care in cases of severe dental erosion

(e.g. eating disorders) and for clinical studies.47

MATERIALS AND METHODS

• Source of data Department of Conservative Dentistry and Endodontics, and Department of Oral and Maxillofacial Surgery, The Oxford Dental College, Hospital and Research Centre, Bangalore • Type of study Prospective, Interventional • Sample size 60 Human Maxillary incisors

Sample Size Estimation:

Analysis: A priority: Compute required sample size

Input: Effect size f = 0.40

α err prob = 0.05

Power (1-β err prob) = 0.80

Number of groups = 3

Output: Noncentrality parameter λ = 12.1600000

Critical F = 2.7318070

Numerator df = 3

Denominator df = 55

Total sample size = 58

Actual power = 0.8234006

The sample size was estimated using the software G Power v. 3.1.9.2

Considering the effect size to be measured (d) at 40%, power of the study at 80% and the

margin of the error at 5%, the total sample size needed is 58.

The total was rounded off to 60.

Hence, the sample size comprised of 20 samples per group.

Materials and instruments used:

Material/Instrument Purpose of use Company name Lot No.

Activated coconut

charcoal

Microabrasion SOAPYTWIST 24/08/2016

6.6% HCl Microabrasion

acid

Sciencecompany 26001621601

Dapen dish Container diadent

Opalustre Microabrasion Ultradent products

Inc

BPWXX

Polishing Rubber cup Active application Ultradent BPWXX

Micromotor Mechanical

application

NSK contraangle

handpiece

Applicator tips Application Ultradent BPWXX

2ml Syringe Carrying the

microabrasive

mixture

Unilok

Profilometer

roughness tester

Roughness

analysis

Mitutoyo

Study Procedure:

Ethics Committee Clearance taken for conduct of the study. Informed consent taken from patient

SOURCE OF DATA

Exclusion Criteria: Teeth with

Restoration

Crack lines or fracture

Caries

Morphological defects

Teeth stored in hydrogen peroxide

Inclusion Criteria: Maxillary incisors with full length crown

After cleaning teeth from surface residue following extraction, teeth were stored in pure

water containing 0.1% thymol.

Sixty Maxillary Anterior teeth were obtained.

Group 1: HCl + Charcoal

20 Samples Microabrasion was

performed with each sample tooth treated with

10 applications for 10 seconds each

Group 2: Opalustre




Group 3: Charcoal + Distilled water




Post Application: Roughness tested & Spectrophotometer measurement made

Pre Application: Profilometer roughness analysis & spectrophotometer

measurements done

Data stored & statistically analysed

Present study was conducted in the Department of Conservative Dentistry and Endodontics

and Department of Oral and Maxillofacial Surgery. Sixty human maxillary incisors were

obtained from patients above 18 years of age. Teeth were extracted for periodontal and

orthodontic purpose, from the Department of Oral and Maxillofacial Surgery, The Oxford

Dental College, Bangalore after obtaining patient’s consent and Ethical clearance.

Profilometer roughness test was done at the Central Manufacturing Technological Institute,

Bangalore.

INCLUSION CRITERIA:

Maxillary anteriors with full length intact crown.

EXCLUSION CRITERIA:

Teeth with

Restoration

Crack lines or fracture

Caries

Morphological defects

Teeth stored in hydrogen peroxide

Sixty extracted human maxillary anterior teeth were selected for the study. After cleaning

tooth and surface residue from the teeth following extraction, teeth were stored in pure

water containing 0.1% thymol until the study.

All the teeth were numbered from 1 to 60, where 1-20 numbered samples belonged to

Group 1, 21-40 belonged to group 2 and 41-60 belonged to group three. Numbering of

samples was done in order to avoid confusion in the pre and post treatment evaluations of

teeth samples.

Pre evaluation of the shades of all the teeth was done in an attempt to distribute them

equally among the three groups with the use of VITA Easyshade Advance shade guide.

Pre application Color measurements:

To evaluate whether the experimental abrasive mixture is effective with regard to colour

change, measurements were taken of the teeth samples in groups 1, 2 and 3 with VITA

Easyshade Advance (Vita Zahnfabrik) spectrophotometer before the applications for all

the 3 groups. Colour measurements were made according to the manufacturer’s

instructions. The equipment was calibrated before the measurement of each sample. The

measurement was made on the mid-third of the vestibular surface of each tooth. The tip of

the instrument was placed 90° relative to the tooth. The results of the spectrophotometer

were recorded according to the Vitapan Classical scale. Three measurements were taken

and the most repeated value was finalized for each time of testing.

Pre application Enamel roughness analysis

The enamel roughness was analyzed using a profilometer roughness tester (Mitutoyo

Sufitest, sp brazil). A diamond stylus was used to measure the surface roughness using a

cut off of 0.25mm and a speed of 0.5mm/s under a constant load of 5N. The numeric values

representing the roughness profile were computed and represented as Ra. The roughness

regression analysis was made for all the samples of the three groups before application of

microabrasive mixtures. The Ra values were recorded.

Preparation of experimental microabrasive material:

Equal quantity (3mg) of activated coconut charcoal was measured with a dosage spoon

and was mixed with 1ml of 6.6% HCl for Group 1 3 mg of activated charcoal was mixed

with 1ml of distilled water for Group 3.

Mixing was done just before the application in a sterile dappen dish and the mixture was

loaded into two respective syringes connected to an applicator tip provided by Ultradent.

Microabrasion method:

For samples from Group1, equal quantity of freshly mixed activated charcoal with HCl

which was loaded into a 2ml syringe attached to an Ultradent applicator tip was applied

onto the labial surface of each sample tooth. Each application approximated to 0.24mg of

material. Following the application, microabrasion was performed with rubber cups

coupled with a low speed (13000rpm) rotation, using an electric NSK micromotor

handpiece. Each sample tooth was treated with 10 applications for 10 seconds each. After

each application the enamel surface was rinsed and dried for 10 s each with dental three-

way syringe and the application was repeated.

Group 2 samples received application of OpalusterTM- Ultradent Products Inc. the product

was directly applied onto the labial surface of the sample teeth following which

microabrasion was performed with rubber cup as in samples of Group 1

Group 3 samples received application of mixture of activated charcoal and distilled

water. Mixture that was loaded into a syringe was directly applied onto the labial surface

of the tooth. Each application received approximately 0.24mg of the product.

Microabrasion was performed as in Group1.

Post application Color measurements:

After the microabrasion procedure, all the samples of the three groups were again

subjected to spectrophotometer colour measurements. Three measurements were taken

and the most repeated value was finalized for each time of testing, as mentioned earlier.

The values were recorded and tabulated for comparison.

Post application surface roughness assessment:

All the samples of the three groups were evaluated for surface roughness post

microabrasive procedure. The values were recorded and tabulated for comparison.

ARMAMENTERIUM

FIGURE 1: ACTIVATED COCONUT SHELL CHARCOAL FIGURE 2: SPECTROPHOTOMETER

FIGURE 3: THYMOL (STORAGE OF TEETH) FIGURE 4: DISTILLISER

FIGURE 5: OPALUSTRE FIGURE 6: RUBBER CUPS

FIGURE 7: DAPPEN DISH AND SCOOP FIGURE 8: NSK MICROMOROR HANDPIECE

GROUP 1

; FIGURE 9: HCl, DOSAGE SCOOP AND CHARCOAL

FIGURE 10: GROUP1 SAMPLE TEETH

FIGURE 11: GROUP 1 MICROABRASION(CHARCOAL+HCL)

GROUP 2 (OPALUSTRE)

FIGURE 12: OPALUSTRE FIGURE 13: GROUP 2 SAMPLE TEETH

FIGURE 14: APPICATION OF OPALUSTRE

FIGURE 15: MICROABRASION WITH OPALUSTRE

GROUP 3 (ACTIVATED CHARCOAL + DISTILLED WATER)

FIGURE 16: GROUP 3 SAPMLE TEETH FIGURE 17: ACTIVATED CHARCOAL SCOOP

FIGURE 18: ACTIVATED CHARCOAL (3mg) FIGURE 19: ACTIVATED CHARCOAL MIXED WITH

DISTILLED WATER

FIGURE 20: APPLICATION OF ACTIVATED CHARCOAL+ DISTILLED WATER ON SAMPLE TEETH

FIGURE 21: MICROABRASION FOR GROUP 3

SPECTROPHOTOMETER

FIGURE 22: SPECROPHOTOMETER MEASUREMENT OF SAMPLES

FIGURE 23: SPECTROPHOTOMETER MEASUREMENTS

PROFILOMETER

FIGURE 23: PROFILOMETER

RESULTS

Results and statistical analysis

TABLE 1: ∆E spectrophotometer value and the profilometer surface roughness value

obtained for Group 1 samples in pre and post microabrasion period.

Group 1 Pre Post

Sr. No. ∆E Roughness

(in µm)

∆E Roughness

(in µm)

1 21.1 11.5 22.1 1.4

2 13.5 0.44 17.5 1.03

3 15.6 2.85 21.9 1.1

4 9.7 5.1 10.2 1.33

5 22.2 1.1023 22.4 0.98

6 16.1 1.1 17.6 1.41

7 13.6 1.45 15.8 1.3

8 9.7 0.1 10.2 0.02

9 17.9 0.12 19.3 0.03

10 13.5 0.44 17.5 0.23

11 9.7 0.11 10.2 0.1

12 13.5 1.2 17.5 1.1

13 13.6 1.6 15.8 1.1

14 16.3 0.89 17.4 0.23

15 26.3 1.7 28.3 0.5

16 19.3 1.23 20.3 1.16

17 15.6 1.32 21.9 0.23

18 9.7 1.5 10.2 1.26

19 22.2 1.67 22.4 1.32

20 14.5 1.24 15.6 0.98



Group 2 Pre Post


(in µm)

∆E Roughness

(in µm)

1 26.1 6.15 26.7 1.16

2 20.3 0.659 21 0.75

3 18.7 0.848 24 1.0655

4 27.6 1.196 32.7 0.8762

5 8.8 1.66 10.1 1.4

6 12.3 1.789 14.9 1.356

7 11.7 0.488 13 0.97

8 20.1 2.44 22.2 1.67

9 10.7 1.294 12.3 1.03

10 19 0.98 20.4 0.56

11 28.3 0.67 29.3 0.568

12 25.8 1.24 25.6 0.98

13 18.3 2.674 19.3 1.984

14 18.7 1.763 24 1.678

15 12.3 0.536 14.9 0.34

16 20.3 1.78 21 1.4

17 11.7 0.783 13 0.452

18 7.8 1.562 15.4 0.439

19 23.4 2.68 23.7 1.27

20 9.7 0.56 10.2 0.34



Group 3 Pre Post


(in µm)

∆E Roughness

(in µm)

1 10.7 2.64

14.5 1.786

2 19 1.038 19 1.04

3 19.5 0.9 21.8 1.06

4 20.7 0.796 23.4 0.46

5 19.2 1.59

20.9 0.81

6 7.8 1.47 15.4 1.57

7 25.8 0.72 25.8 0.55

8 10.7 2.64 14.5 1.786

9 19 1.038 19 1.04

10 10.7 0.9 14.5 1.06

11 19 0.796 19 0.46

12 19.5 1.59 21.8 0.81

13 20.7 1.47 23.4 1.57

14 7.8 0.72 15.4 0.55

15 25.8 2.64 25.8 1.786

16 19 1.038 19 1.04

17 10.7 0.9 14.5 1.06

18 19 0.796 19 0.46

19 7.8 1.59 15.4 0.81

20 25.8 1.47 25.8 1.57

STATISTICAL ANALYSIS:

Statistical Package for Social Sciences [SPSS] for Windows Version 22.0 Released 2013.

Armonk, NY: IBM Corp., was used to perform statistical analyses.

Kruskal Wallis Test followed by Mann Whitney Post hoc Analysis was used to compare

the mean values of color stability & Roughness between 03 study groups during Pre &

Post Treatment Period. Wilcoxon Signed Rank Test was used to compare the mean

values of color stability & Roughness between Pre and Post Treatment period in each

study group.

The level of significance was set at p<0.05

TABLE 4: Comparison of mean values of colour parameters between Pre and Post application period in Group 1 using Wilcoxon Signed Rank Test

Parameters Time N Mean SD Mean Diff Z P-Value

L Pre Rx 20 12.61 2.83 -1.56 -3.823 <0.001*

Post Rx 20 14.17 2.91 a Pre Rx 20 2.52 2.51

1.74 -3.489 <0.001* Post Rx 20 0.78 1.34

b Pre Rx 20 26.60 5.18 3.72 -3.033 0.002*

Post Rx 20 22.89 6.18 ∆E Pre Rx 20 15.68 4.66

-2.03 -3.92 <0.001* Post Rx 20 17.71 4.91

C Pre Rx 20 8.04 4.52 -0.84 -1.498 0.13

Post Rx 20 8.88 4.63 H Pre Rx 20 -0.70 2.74

-0.31 -0.299 0.77 Post Rx 20 -0.39 2.39

*statistically significant Comparison of mean values of stability between the pre and post application test values In group 1(charcoal with HCl) show a statistically significant increase in the ∆E and L value whereas there was decrease in the a and b values. There was no significant difference seen in the C (chroma) and H(hue) values.

TABLE 5: Comparison of mean values of colour parameters between Pre and Post Treatment period in Group 2 using Wilcoxon Signed Rank Test


L Pre Rx 20 13.42 4.59 -1.72 -3.782 <0.001*

Post Rx 20 15.14 4.80 a Pre Rx 20 2.00 2.76

0.40 -1.787 0.07 Post Rx 20 1.60 1.66

b Pre Rx 20 31.09 8.90 2.30 -3.928 <0.001*

Post Rx 20 28.80 7.47 ∆E Pre Rx 20 17.58 6.58

-2.11 -3.921 <0.001* Post Rx 20 19.69 6.49

C Pre Rx 20 10.56 6.33 -1.02 -2.244 0.03*

Post Rx 20 11.58 6.18 H Pre Rx 20 -2.23 2.83

-0.10 -0.725 0.47 Post Rx 20 -2.13 2.56

*Statistically significant Comparison of mean values of stability between the pre and post application test values Show a statistically significant increase in the ∆E L value and decrease in b value,

signifying a improved colour. A significant decrease in the chroma was also obtained.

TABLE 6: Comparison of mean values of colour parameters between Pre and Post Treatment period in Group 3 using Wilcoxon Signed Rank Test


L Pre Rx 20 12.90 4.37 -1.83 -2.023 0.04*

Post Rx 20 14.73 2.93 a Pre Rx 20 1.44 3.15

0.11 -1.261 0.21 Post Rx 20 1.33 2.73

b Pre Rx 20 29.43 8.96 0.98 -2.478 0.01*

Post Rx 20 28.46 9.25 ∆E Pre Rx 20 16.91 6.11

-2.49 -3.934 <0.001* Post Rx 20 19.40 4.06

C Pre Rx 20 9.73 6.30 -0.44 -0.527 0.60

Post Rx 20 10.16 5.56 H Pre Rx 20 -1.77 2.97

-0.08 -2.257 0.02* Post Rx 20 -1.69 2.75

*Statistically significant Comparison of mean values of colour stability between the pre and post application test values Show a statistically significant increase in the ∆E and L values and decrease in a and b value , signifying a improved colour. Significant difference was also seen in H indicating a change in colour.

*Statistically significant There was no statistically significant difference seen in the ∆E between the three Groups. However there was statistical difference in a and b values between Group 1 and Group 2; and Group 1 and Group 3.

TABLE 7: Comparison of mean differences of color parameters between 03 groups using Kruskal Wallis Test followed by Mann Whitney Post hoc Analysis

Differences

Group 1 Group 2 Group 3

P-Value

Mann Whitney Post hoc Analysis

Mean SD Mean SD Mean SD G1 Vs

G2 G1 Vs

G3

G2 Vs G3

L_diff -1.56 1.61 -1.72 1.73 -1.83 3.23 0.64 .. .. ..

a_diff 1.74 1.29 0.40 1.25 0.11 0.54 0.002* 0.01* <0.001* 0.65

b_diff 3.72 4.09 2.30 1.90 0.98 1.71 0.001* 0.009* 0.001* 0.17

∆E_diff -2.03 1.90 -2.11 2.08 -2.49 2.67 1.00 .. .. ..

C_diff -0.84 1.93 -1.02 1.85 -0.44 2.35 0.71 .. .. ..

H_diff -0.31 1.47 -0.10 1.86 -0.08 0.60 1.00 .. .. ..

Spectrophotometer results:

In all the groups the ∆E values increases, which express the change colour in each group

from pre-application to post-application. This was found to be statistically in all the

groups. In this study it was found that all the three groups showed an increase in the

L*(lightness) compared to the pre-application (group 1 p <0.001*; group 2 p <0.001*;

group 3 p 0.04*) procedure indicating an improved color. There was a decrease in a* and

b* values in all the groups which again indicates improved tooth colour.

TABLE 8: Comparison of mean Roughness values between Pre and Post Treatment period in each study group using Wilcoxon Signed Rank Test

Group Time N Mean SD Mean Diff Z P-Value

Group 1 Pre Rx 20 1.83 2.53 1.00 -2.987 0.003*

Post Rx 20 0.84 0.51 Group 2 Pre Rx 20 1.59 1.28

0.57 -3.099 0.002* Post Rx 20 1.01 0.48

Group 3 Pre Rx 20 1.34 0.64 0.27 -2.245 0.03*

Post Rx 20 1.06 0.47 *statistically significant Profilometer roughness assessment showed statistically significant decrease in the roughness values of all three groups.

TABLE 9: Comparison of mean values of Roughness (in m) between 03 study groups during Pre & Post Treatment Period using Kruskal Wallis Test

Time


H P-Value Mean SD Mean SD Mean SD

Pre Rx 1.83 2.53 1.59 1.28 1.34 0.64 0.186 0.91

Post Rx 0.84 0.51 1.01 0.48 1.06 0.47 1.106 0.58 *statistically significant Comparison of roughness values of the three groups in pre-application and post-application did not show any statistically significant difference.

Profilometer results


µm group 2 = 1.01µm and group 3= 1.08 µm) compared to pre application roughness

(mean Ra of group 1 = 11.89 µm group 2 =1.59 µm and group 3 =1.34 µm) and were

found to be statistically significant (group 1 p=0.003, group 2 p=0.002 and group 3

p=0.03). There was no statistical difference between the groups although group 1 showed

least Ra value.

TABLE 10: Particle size of Opalusture range from 76.71 µm to 186.9 µm. A 50 percentile particle size was 117.1 µm

TABLE 11: Particle size of activated coconut shell charcoal was in the range of 3.03µm to 48.54µm. At 50 percentile the particle size was found to be 10.89µm

GRAPH 1:

GRAPH 2:

-5.00

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

L a b ∆E C H

12.

61

2.5

2

26.

60

15.

68

8.0

4

-0.7

0

14.1

7

0.7

8

22

.89

17

.71

8.8

8

-0.3

9

Comparison of mean values of color stability between Pre and Post Treatment period in Group 1

Pre Rx Post Rx

-5.00

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

L a b ∆E C H

13

.42

2.0

0

31

.09

17

.58

10.

56

-2.2

3

15

.14

1.6

0

28

.80

19

.69

11

.58

-2.1

3Comparison of mean values of color stability between Pre and

Post Treatment period in Group 2

Pre Rx Post Rx

GRAPH 3:

GRAPH 4:

-5.00

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

L a b ∆E C H

12

.90

1.4

4

29

.43

16

.91

9.7

3

-1.7

7

14

.73

1.3

3

28.4

6

19

.40

10

.16

-1.6

9

Comparison of mean values of color stability between Pre and Post Treatment period in Group 3

Pre Rx Post Rx

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

Pre Rx Post Rx

1.83

0.84

1.59

1.01

1.34

1.06

Me

an R

ou

ghn

ess

Val

ue

s

Comparison of mean values of Roughness (in mm) between 03 study groups during Pre & Post Treatment Period


DISCUSSION

It has been reported that a large majority of the population would seek treatment for

increasingly esthetic concerns. A brighter whiter teeth is most appreciated by the patient

and is a gratifying service a dentist can render. This has a positive psychological effect on

patients and often contributes to improved self image and enhanced self-esteem in

patients.48 These advancements provide a new dimension of dental treatments for patients

as well as dentists. Microabrasion and Macroabrasion represent conservative alternatives

for the reduction or elimination of superficial discolorations. As the terms imply, the

stained areas or defects are abraded away. These techniques do result in the physical

removal of tooth structure and, therefore are indicated only for stains or enamel defects

that do not extend beyond a few tenths of a millimeter in depth. If the defect or discoloration

remains after treatment with microabrasion or macroabrasion, restorative alternatives are

performed.

Abrasion is a material-removal process that can occur whenever surfaces slide against

each other. Macroabrasion uses a 12-fluted composite finishing bur or a fine grit finishing

diamond in a high-speed handpiece to remove the defect. Two body abrasion occurs in

macroabrsion. In this mechanism the abrasive particles are tightly bound to the abrasive

instrument (bur) that is used in removing material from the substrate surface (enamel).

Microabrasion is a procedure in which the enamel surface is softened with acids such as

Hydrochloric acid ( HCl ) or Phosphoric acid ( H3PO4) and the surface discoloration is

removed by polishing with an abrasive material. Polishing is similar to microabrasion but

without the use of an acid. Polishing is a process of providing luster or gloss on a material

surface. It is believed that because of the rapid movement of the polishing agent, top layer

of the material gets heated up causing it to flow and fill the scratches. Three body abrasion

occurs when abrasive particles are free to translate and rotate between the two surfaces.

The free particles in a three-body wear mode may be intentionally added abrasives or

detached debris from the worn surface. Most dental finishing and polishing devices operate

in the two-body mode. Nevertheless, dentist, hygienists and laboratory technicians use the

three-body abrasive mode in the form of loose abrasives, such as prophy or polishing

pastes. Three-body abrasive wear occurs when loose particles move in the interface

between the specimen surface and the polishing application device. Hence a three-body

abrasion occurs in microabrasion.

The main indication for enamel microabrasion is intrinsic discoloration or texture

alteration due to enamel hypoplasia, amelogenesis imperfecta, or fluorosis. Enamel surface

“dysmineralization” can be defined as a disturbance in formation of the inorganic

component of enamel during amelogenesis. The most conservative way to treat fluorosis

also is with microabrasion. Mild-to-moderate fluorosis, is a disorder involving the

maturation-phase enamel, where mainly the enamel surface layers are affected.49,50 Several

techniques ranging from microabrasion using sandpaper disks,13 burs 51 to slurry abrasion

combined with strong acids to dissolve mineral and remove thin layers of enamel16,18 have

been devised to treat esthetically objectionable fluorosis.

The microabrasion technique removes the porous surface enamel layer as well as the

entrapped stains, by rubbing a gel that contains an acid and an abrasive compound in a

similar way that a dental prophylaxis with pumice and water is performed. The enamel

stain or defect is removed by a combination of the erosive and abrasive effects of the

recommended mixture containing low acid concentrations and an abrasive agent, applied

mechanically using a low-rotation micromotor. Some authors have coined this

simultaneous abrasion and erosion effect as “abrosion”. 45 It should be the first option for

the management of teeth with intrinsic stains because it removes opaque, brown stains and

smoothens surface irregularities by providing a more regular and lustrous surface. As the

technique is considered safe and minimally invasive, it can also be combined with tooth

bleaching when necessary. It is also found that there is no known risk to the dental pulp

from enamel microabrasion treatment.18

Enamel microabrasion was initially performed for the removal of fluorotic white spots

using 36% hydrochloric acid, as recommended by Kane in 1926. Raper et al suggested the

use of 18% hydrochloric acid applied and rubbed with a wooden spatula wrapped with

cotton for a maximum time of 10 min. Mechanical application with a low-rotation

micromotor was first indicated in the 1970s, using a mixture of 18% hydrochloric acid,

hydrogen peroxide and ether. Combination with an abrasive agent was later indicated by

Murrin et al in 1982, who added pumice to 36% hydrochloric acid, resulting in a slurry that

was applied using a rubber cup coupled to a micromotor. Newer compounds such as

pumice and aluminium oxide have been experimented with as an abrasive agent in the

microabrasion mixture. Charcoal being a known abrasive agent, has been used to clean

teeth, applied to forefinger or a melastroma brush since historical times. Many

commercially available products such as toothpaste and toothbrushes containing charcoal

are now available. They claim to have an added teeth whitening property although no

literature are available to support the claim. Taking into consideration the abrasive nature

of charcoal, this study used charcoal as a microabrasive agent.

Activated charcoal has an advantage of being extra porous and has an enhanced

adsorbent property. Hence activated charcoal was opted over plain charcoal. Activated

charcoal has been increasingly used in the medical field. It is considered as the first-line

agent in treating poisoning specially after passing several hours since ingestion. Its

adsorption property helps remove overdosed drugs and heavy metals from the body,

administrating multiple doses of activated charcoal work to decrease the absorption and

blood concentration of many drugs. Charcoal is also used in dental offices in removal of

mercury vapours.52

Any carboneous materials (animal, plant, or mineral origin) with high concentration of

carbon can be simply changed into activated carbon (using both chemical or gas activation

methods). The most common raw materials are wood, charcoal, nut shells, fruit pits, brown

and bituminous coals, lignite, peat, bone and paper mill waste (lignin) that are used for

manufacturing of activated carbon. It has been reported that the best grades of activated

carbon are obtained from the coconut shell and apricot pits53 hence activated coconut shell

charcoal was used in this study.

Concerned about the acid concentration, Croll et al recommended the use of the same

abrasive mixture with 18% hydrochloric acid. The association of hydrochloric acid to

abrasive particles resulted in the development of commercially available products.

PREMA Compound (Premier Dental Company, Philadelphia, PA, United States), which

contains 10% hydrochloric acid, was the first to be introduced to the market. Currently, a

lower concentration of hydrochloric acid is used, approximately 6.6%, under the

commercial product name of Opalustre (Ultradent Products Inc., South Jordan, UT, United

States). Both products use silicon carbide as an abrasive with different granulations

dispersed in a water-soluble gel for easy removal. Many studies and case reports have

showed a successful improvement in esthetics in teeth with mild fluorosis and

discolorations using Opalustre.44 A comparative study of PREMA and Opalustre showed

effective, conservative improvement in the appearance of fluorosis-affected teeth;

however, faster results was obtained with Opalustre.44 The manufacturers of the product

claim that it could be used to remove unsightly enamel decalcification defects which are

less than 0.2mm in depth. It has a distinct purple colour for accurate placement and control.

Hence Opalustre (Ultradent Products Inc., South Jordan, UT, United States) was chosen to

be the group for comparison.

The use of 35% phosphoric acid instead of hydrochloric acid was proposed by Kamp in

1989, and was considered advantageous as it is commonly used in clinical practice for other

procedures. 6.6% HCl was found to be more erosive than 35% phosphoric acid in a study

that compared the two acids.11 Since the product Opalustre used for comparison in the

present study contains 6.6% HCl as acid component, to standardize, for the experimental

group, 6.6% HCl was chosen over phosphoric acid for microabrasion.

A study showed that passive application resulted in increased roughness. In active

application, the use of mechanical means help in the scattering and renewing of the acid on

the enamel, without allowing the erosive substance to remain on the tooth surface for too

long.27 In the present study too active application using a rubber cup was done. The use of

a rubber cup coupled to the rotatory mandrel enables precise application of the compound

on the enamel surface, which eliminates splattering of the compound and makes the

procedure safer, easier, and quicker.54,55

Croll stated that an ideal microabrasive system should include a low acid concentration

and abrasive particles in a water-soluble mixture that are applied with a low-rotation

handpiece to avoid scattering the compounds, thus making the procedure safer. Hence

microabrasion was performed at 13000 rpm with a NSK micromotor handpiece for all the

samples in this study.

Enamel loss during microabrasive procedure increases as variables of time duration,

number of applications, and pressure applied during procedure increases. A greater amount

of enamel loss occurred when two or more variables increased at the same time. A 10 sec

application resulted in an enamel loss of less than 250 micrometer when performed with

18%HCl.21 Several studies have used a combination of 10 applications for 10 secs5 ,21 hence

the same was adapted in this study for all the groups.

Tooth substance lost as a result of an abrasive material was documented to be correlated

with chemical composition (iron oxide and charcoal), the size and shape of abrasive

particles used in dentifrices.41 The desirable properties of an abrasive material are: irregular

shape, size, distribution, concentration and hardness. Harder the particle (substrate), it

abrades and possesses high impact strength. The hardness of enamel ranks 5 on Mohs scale,

9-9.4 for silicon carbide. Charcoal ranges from 1 to 4 Mohs hardness. Abrasive point

should always fracture rather than dull out. Abrasive particle size determines the depth of

the scratch produced on the substrate. It has been shown that the abrasive wear rate

increases linearly as the particle size and concentration is increased to a critical size.56,57

Typically, this requires that particle size and shape of abrasive agents should be in a

desirable range (i.e., 1–20 µm or 5 –15 µm) and should not be sharp or angular.58 Hence

the particle size of the activated charcoal used and the particles of the Opalustre was

assessed in a wet –fluid (water )method. It was found that the particle size of the Opalustre

ranged from 76 µm to 186.9 µm where 50 percentile of them were of the size117.1 µm.

The particle size of activated charcoal ranged from 3.03 µm to 48.54 µm where 50

percentile of the particles were of size10.89 µm. Hence the particle size of the activated

charcoal used in this study was of desirable range. Each experimental sample teeth also

received equal amount of the microabrasive mixture per application i.e. 0.24mg (one level

scoop) mixed in 0.1 ml of HCl/ distilled water. Extracted human maxillary anterior teeth

were used in this study since microabrasion is an esthetic procedure normally done for

anterior teeth. It is also easier and cost effective to test for roughness on extracted teeth

than in vivo studies.

The purpose of Group 3 that comprised of application of charcoal in distilled water was

to check if charcoal alone (without acid) could affect the enamel tooth colour. This

procedure is more or less polishing of the tooth surface with an abrasive material in a liquid

media. The particle size of activated charcoal (3.03 µm to 42µm) used is in the range (i.e.,

1–20 µm or 5 –15 µm) of polishing pastes.

Photographs, Colorimeter, spectro colorimeters and spectrophotometers are often used

to measure colour. Spectrophotometer is known to be the most accurate among all the

instruments used in color measurements. 9 It was therefore used to assess the color change

caused by microabrasion. VITA Advance Easy 4.0 shade guide works on the principle of

spectrophotometer. It has been often used in clinical situations and in various studies to

measure colour.8,9

In Kim-Pusateri’s study the reliability of four different shade-matching devices compared

in controlled setting in the in vitro model ranged between 87.4% and 99.0%, with

ShadeScan having significantly lower reliability and VITA Easyshade with 96.4% .

Another in vitro study, conducted by Lagouvardos et al. reported significantly higher

measuring repeatability of VITA Easyshade® Advance 4.0 dental shade-matching device

in comparison to another shade-measuring device.9 Hence in present study the same device

was used.

VITA Advance Easy 4.0 spectrophotometer has a digital display which makes recording

of values of various colour parameters easier. Upto 30 readings can also be saved on the

device. It comes with a base line calibrator. In digital spectrophotometer the external

environmental lighting does not interfere with the reading, due to the LED technology that

is unaffected by ambient conditions. Hence can be used at any hour of the day and

standardized daylight or lamps 5500 - 6500 K will not be necessary. The measurement

results are shown as VITA classical and VITA SYSTEM 3D-MASTER shades.

The ∆E values of the VITA classical were recorded in this study.

A detailed information on the L, C, H, a, b and E values are obtained where

ΔE - The overall color deviation of the tooth.

ΔL +/- The tooth's lightness is higher (+)/ lower (-) than the VITA classical A1–D4

shade.

ΔC +/- The tooth's chroma is higher (+)/ lower (-) than the VITA classical A1–D4 shade.

Δh +/- The tooth's hue is yellower (+) / redder (-) than the VITA classical A1–D4 shade.

L represents lightness with 0 being a perfect black of 0% reflectance or transmission; 50 a

middle gray; 100 a perfect white of 100% reflectance or a perfect clear of 100%

transmission.

a represents redness-greenness of the color. Positive values of a* are red; negative values

of a* are green; 0 is neutral.

b represents yellowness-blueness of the color. Positive values of b* are yellow; negative

values of b* are blue; 0 is neutral.

VITA SYSTEM 3D-MASTER® shades

This screen displays the L*C*h* and a*b* coordinates in the

CIE L*a*b* color space for the measured tooth shade. This is an advantageous method as

it is possible to define the change between the colour parameters.

The formula to evaluate the colour difference between the samples is

∆E* = [(∆L*)2 + (∆a*) + (∆b*)2]1/2

∆E is defined as the difference between two colors in an L*a*b* color space. In VITA

Advance Easy 4.0 spectrophotometer, the ∆E values are automatically calculated by the

equipment itself by comparing the tooth shade with the built-in base line calibrator. The

difference between the pre and post application ∆E is represented as ∆E (difference in the

colour between the pre and post applications)

The following ∆E values are universally valid

The ∆E obtained in this study between the pre application and post application of all the

Groups was mostly in the range of 1-2 (very small difference, only obvious to a trained

eye).

Microabrasion reduces the enamel surface but also causes formation of a persisting

glasslike sheen. Croll at al coined the term "enamel glaze” 19 a smoother, compact, regular

and shiny polished surface obtained after microabrasion.26 The reasoning given by the

author was that this surface reflects light better and enable masking of surface

discoloration. In addition, loss of the prismatic structure obtained had more dense and

mineral rich resistant surface.

Berg and Donly identified the enamel glaze layer with polarized light microscope and

scanning electron microscope. Using SEM, Donly et al described the enamel glaze as an

amorphous layer of compacted mineral, resulting from simultaneous abrasion and erosion

of the enamel with PREMA Compound, another commercially available product similar to

Opalustre. Segura and colleagues studied that a microabrasive compound and topical

fluoride solution resist dissolution better than untreated surfaces. They found PREMA-

treated surfaces colonize fewer Streptococcus mutans than do untreated surfaces. A 18 year

follow up study observed hundreds of patients since 1985, revealed that the smooth texture

and surface luster of microabraded teeth endures a surface appearance that’s enhanced as

years go by after treatment.28 Enamel microabrasion does not render a tooth surface more

prone to dental caries. On the contrary, enamel surface quality of microabraded teeth

predictably improves as time passes after treatment. A shiny glass like surface texture is

formed on treated teeth within a few months after treatment. The exact mechanism of this

phenomenon is not known, but the author believes that the application of the acid /abrasive

compound gives enamel surfaces a superfine polishing, unlike other dental polishing

agents.18

The microabrasive procedure as by definition involves loss of surface enamel hence

was important to evaluate the surface roughness. Because the roughness value depends on

the measurement technique, the investigation protocol used to study surface roughness is

important. Surface roughness measurements are performed using Vickers diamond testing

machine, contact (or stylus) profilometer, non-contact optical profilometer, or scanning

electron microscopes (SEM).

To evaluate the enamel loss and the roughness produced by the experimental mixture,

profilometer has been used in several studies. Profilometer is a measuring instrument used

to measure a surface's profile, in order to quantify its roughness. Vertical resolution is

usually in the nanometre level, though lateral resolution is usually poorer. In Contact

profilometers a diamond stylus is moved vertically in contact with a sample and then

moved laterally across the sample for a specified distance and specified contact force. A

profilometer can measure small surface variations (from 10 nanometres to 1 millimetre) in

vertical stylus displacement as a function of position. The radius of diamond stylus ranges

from 20 nanometres to 25 μm, and the horizontal resolution is controlled by the scan speed

and data signal sampling rate. While in Non-contact profilometers is a non-contact method

optical profilometer using laser triangulation (triangulation sensor), confocal microscopy

and digital holography. However, stylus profilometer was opted as it was sufficient for our

requirement as per various studies 5,46,47 and also for feasibility

An even distribution of samples with respect to tooth shade and surface roughness into

three groups was done (p=0.65; p=0.91 respectively).

In all the groups the ∆E values increased, which express the change in colour in each group

from pre-application to post-application. It was found to be statistically significant in all

the groups (p<0.001 for all three groups). In this study it was found that all the three groups

showed an increase in the L*(lightness) compared to the pre-application (Group 1 p <0.001;

Group 2 p <0.001; Group 3 p= 0.04) procedure indicating an improved colour. There was

a decrease in a* and b* values in all the groups which again indicates improved tooth

colour. In other words, as a result of microabrasion procedure, there was an improvement

that occurred in the L* and ∆E values for all groups which was statistically significant.

Increase in ∆E in group 1 shows that the newer experimental microabrasive is effective in

improving the tooth colour. The results obtained from the inter group comparison of the

three groups showed no statistically significant difference in the ∆E values, although

Group1 showed maximum improvement in ∆E from pre to post application. The colour

change in the Group 2 from pre to post application of Opalustre was similar to study

conducted by Serdar et al (p<0.001).26 Since it’s the first study with activated charcoal as

a microabrasive agent, no comparison with other studies could be made.

The colour improvement in group 3 showed that the abrasive effect of activated charcoal

with mechanical action was effective in removing the superficial stains, even without an

acid (p<0.001).

The enamel roughness assessment for all the three groups showed a statistically

significant decrease in the roughness values between the pre-application and post-

application within the respective groups. This implies that the enamel surface was more

smoother following the microabrasion procedure. However, between the groups there was

no statistical difference, although group 1 showed more highly polished surface (mean Ra

0.84 µm) compared to Group 2(mean Ra 1.01µm) and Group 3(mean Ra 1.06 µm). This

could be because of the presence of acid that allowed uniform erosion followed by

abrasion with activated charcoal particles.

The particle size of activated charcoal (3.03 µm to 48.54 µm ) used in this study were

smaller in comparison to Opalustre (76 µm to 186.9 µm ) and thus provided a finer lustrous

surface than Group 2 though there was no statistically significant difference. It has been

shown that the abrasive wear rate increases linearly as the particle size and concentration

is increased to a critical size.56

Since there was no difference in the tooth colour and the enamel roughness of the

experimental microabrasive material when compared with the commercially available

paste, the null hypothesis was accepted.

The success of enamel microabrasion is directly related to the correct indication of

the clinical case and the proper execution of the technique. The newer experimental

microabrasive mixture is effective in improving the tooth colour. It is also safe since it uses

a low acid content and because of its paste like consistency, it does not flow uncontrollably.

In addition, the rotary application method takes less clinical time compared to non-powered

finger pressure application. Despite the low speed micraobrasion used in this

study(13000rpm), there was some amount of scattering of the abrasive material. Hence

microabrasion is better done under rubber dam in clinical situations.44, 59 This could also

prevent microabrasive material from getting lodged into gingival sulcus, especially with

charcoal which would be very unsightly.

Limitation of the study was that the teeth were stored in 100% humidity until the time

of experiment. However, despite the attempt of maintaining the teeth in humid atmosphere,

there was considerable amount of dehydration of the tooth during testing procedures which

could have resulted in variations in the spectrophotometer values.

Future studies are needed to assess the surface texture using SEM. Efficacy of charcoal

with various particle size and concentration of HCl have to be assessed. In a clinical

situation, teeth with fluorosis and hypoplastic defects will have a porous enamel surface

than non flourosed teeth (which has been used in this study) hence greater changes in the

lightness of the colour is expected. Hence further studies considering the above aspects

should be carried out.

CONCLUSION

The results of the study demonstrate that experimental microabrasion with activated

charcoal and HCl resulted in improved colour and spectrophotometer values similar to

commercially available product, Opalustre ultradent. The enamel surface was smoother as

the roughness was found to be least with the experimental group.

Hence activated charcoal can be considered for a microabrasive material over high cost

imported equivalent agents.

SUMMARY

Several treatments have been introduced to satisfy what patients seek regarding dental

esthetics. For superficial enamel stains or defects, enamel microabrasion is preferred, as it

is considered as an esthetic and conservative treatment. 1 Microabrasion is a procedure in

which the enamel surface is softened with acids (hydrochloric or phosphoric) and the

surface discoloration is removed by polishing with an abrasive material. Charcoal has been

used to clean teeth and that it is highly abrasive. Taking into consideration the abrasive

nature of charcoal, the aim of this study is to evaluate the effect of activated coconut

charcoal on the enamel morphology, in conjunction with HCl as a microabrasive mixture

by means of roughness analysis and spectrophotometer.

The null hypothesis states that there will be no difference in enamel roughness and

tooth color change of the experimental microabrasive material when compared with the

commercially available paste.

After ethical committee clearance and obtaining patents informed consent 60 maxillary

anterior teeth were selected for the study which were extracted due to periodontal reasons.

Teeth were cleaned under running water and stored in pure water with 0.1% thymol. Teeth

were then numbered, their enamel surface roughness (profilometer) and tooth colour

(spectrophotometer) measurements were recorded. Samples were divided into 3 groups as

following

Group 1(N=20): application of 6.6% HCl+ activated coconut charcoal.

Group2 (N=20): application of 6.6%HCl + silica (OpalusterTM- Ultradent Products Inc)

Group 3 (N=20): application of distilled water+ activated coconut charcoal.

Microabrasion was performed for 10 applications for 10 seconds each for all the samples

in each group with their respective microabrasive agent. Enamel roughness and colour

change was again evaluated post microabrasion procedure with profilometer and VITA

Easy Advance spectrophotometer (VITA Easy Advance) respectively. The results

obtained were tabulated and subjected to statistical analysis. Wilcoxon Signed Rank Test

and Kruskal Wallis Test was done to compare the values. The level of significance was set

at p<0.05 There was statistical difference in the ∆E values for all the groups (p<0.001)

between the pre application values (mean ∆E of group 1= 4.66 group 2 =6.58 group 3

=6.11) and post applications (mean ∆E of group 1 =4.91 group 2 =6.49 group 3 = 4.09)

signifying an improved color. There was no statistical difference between the groups with

respect to ∆E.


µm group 2 =1.01µm and group 3=1.08 µm) compared to pre application roughness (mean

Ra of group 1=1.89 µm group 2=1.59 µm and group 3= 1.34 µm) and were found to be

statistically significant (p=0.003, p=0.002 and p=0.03 for the 3 groups respectively). There

was no statically difference between the groups although group 1 showed least Ra value.

The results of the study demonstrate that experimental microabrasion with activated

charcoal and HCl resulted in improved colour and spectrophotometer values were similar

to commercially available product, Opalustre Ultradent. The enamel surface was smoother

as the roughness was found to be least with the experimental group. Hence activated

charcoal can be considered for a microabrasive material over high cost imported equivalent

agents.

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CERTIFICATE FORMAT OF INFORMED CONSENT FORM (ENGLISH)

CERTIFICATE FORMAT OF INFORMED CONSENT FORM (KANNADA)

COPY OF ETHICS COMMITTEE CLEARANCE

ANNEXURES

ROUGHNESS VALUES

ROUGHNESS VALUES

ROUGHNESS VALUES

ROUGHNESS VALUES

ROUGHNESS VALUES

ROUGHNESS VALUES

ROUGHNESS VALUES

ROUGHNESS VALUES

ROUGHNESS VALUES

SPECTROPHOTOMETER VALUES OF THE THREE GROUPS (∆E, L, C, H)

STATISTICAL ANALYSIS

GRAPHS: STATISTICAL ANALYSIS

GRAPHS: STATISTICAL ANALYSIS

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