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“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
2 ∆E spectrophotometer value and the profilometer surface roughness value obtained for Group 2 samples in pre and post microabrasion period.
41
3 ∆E spectrophotometer value and the profilometer surface roughness value obtained for Group 3 samples in pre and post microabrasion period.
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.
1 ∆E spectrophotometer value and the profilometer surface roughness value obtained for Group 1 samples in pre and post microabrasion period.
50
2 ∆E spectrophotometer value and the profilometer surface roughness value obtained for Group 2 samples in pre and post microabrasion period.
50
3 ∆E spectrophotometer value and the profilometer surface roughness value obtained for Group 3 samples in pre and post microabrasion period.
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
13 Group 2 teeth samples 34
14 Application of Opalustre 34
15 Microabrasion with opalustre 34
16 Group 3 teeth samples 35
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
20 Samples Microabrasion was
performed with each sample tooth treated with
10 applications for 10 seconds each
Group 3: Charcoal + Distilled water
20 Samples Microabrasion was
performed with each sample tooth treated with
10 applications for 10 seconds each
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
TABLE 2: ∆E spectrophotometer value and the profilometer surface roughness value
obtained for Group 2 samples in pre and post microabrasion period.
Group 2 Pre Post
Sr. No. ∆E Roughness
(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
TABLE 3: ∆E spectrophotometer value and the profilometer surface roughness value
obtained for Group 3 samples in pre and post microabrasion period.
Group 3 Pre Post
Sr. No. ∆E Roughness
(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
Parameters Time N Mean SD Mean Diff Z P-Value
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
Parameters Time N Mean SD Mean Diff Z P-Value
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
Group 1 Group 2 Group 3
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
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) 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
Group 1 Group 2 Group 3
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.
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) 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
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ROUGHNESS VALUES
ROUGHNESS VALUES
SPECTROPHOTOMETER VALUES OF THE THREE GROUPS (∆E, L, C, H)
STATISTICAL ANALYSIS
GRAPHS: STATISTICAL ANALYSIS
GRAPHS: STATISTICAL ANALYSIS