mikroabrasi hidrokolid dan fosforik asid

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CLINICAL RESEARCH

454THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY

VOLUME 8 NUMBER 3 AUTUMN 2013

Correspondence to:Dr Soumya Sinha

Assistant Professor, Department of Pediatric and Preventive Dentistry, M.A. Rangoonwala Dental College, Pune, Maharastra,

India, Pin: 411001; Tel: 09604208083; Email: [email protected]

Microabrasion using 18% hydro-

chloric acid and 37% phosphoric

acid in various degrees of uorosis

an in vivo comparision

Soumya Sinha,M.D.S.

Assistant Professor, Department of Pediatric and Preventive Dentistry,

M.A. Rangoonwala Dental College and Research Center, Pune, India

Kiran Kumar Sudulukunta Vorse,M.D.S.

Assistant Professor, Department of Pediatric and Preventive Dentistry,

M.A. Rangoonwala Dental College and Research Center, Pune, India

Hina Noorani,M.D.S.

Professor and Head, Department of Pediatric and Preventive Dentistry,

Parvategouda Mallanagouda Nadagouda Memorial Dental College and Hospital,

Bagalkot, India

Shivprakash Pujari Kumaraswamy,M.D.S.

Professor, Department of Pediatric and Preventive Dentistry,

Parvategouda Mallanagouda Nadagouda Memorial Dental College and Hospital,

Bagalkot, India

Siddhartha Varma

Assistant Professor, Department of Periodontics, School of Dental Sciences,

Krishna Institute of Medical Science Deemed Univeristy, Karad, India

Haragopal Surappaneni,M.D.S.

Assistant Professor, Department of Prosthodontics, St Joseph Dental College,

Eluru, Andhra Pradesh, India


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SINHA ET AL



Abstract

Aims and objectives: The aim of this

study was to assess the efficacy of 18%hydrochloric acid and 37% phosphoric

acid by an in vivocomparison.

Methods:Sixty fluorotic permanent max-

illary central incisors from 30 patients

were divided into 3 categories. The teeth

received 5 seconds (mild fluorosis), 20

seconds (moderate fluorosis) and 30

seconds (severe fluorosis) application

of 18% hydrochloric acid on 11 and 37%

phosphoric acid on 21. Standardized in-

traoral photographies were taken imme-

diately before, after, and one month after

treatment. Vinyl polysiloxane impression

of the patient were made before and after

the treatment. A scanning electron mi-

croscopic (SEM) evaluation was carried

out on the models to judge the surface

alterations. Wilcoxon and Mann-Whitney

tests were used to verify the hypothesis.Results:A statistically significant result

was obtained in the reduction of white

spot opacities, intensity of stains and the

total area occupied by the stains in mild

and moderate fluorosis teeth. Results of

severe fluorosis had an unpredictable

outcome. An SEM evaluation revealed

good improvement in the surface texture

of mild and moderate fluorosis teeth.

Teeth with severe fluorosis showed only

a slight improvement.

Conclusion:A microabrasion procedure

is effective for treating mild and moder-

ate fluorosis cases.

(Eur J Esthet Dent 2013;8:454465)




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Introduction

One of the most frequent reasons for

seeking dental care is discolored ante-rior teeth. In todays society, peer group

influences play a major role in a childs

mind. The appearance of a disfigured

smile negatively affects the psycho-

emotional development of children, in-

creasing their problems with social rela-

tions.1

Causes of tooth discoloration can be

extrinsic or intrinsic. Dental fluorosis is

one of the most common causes of intrin-

sic tooth discoloration. With the recent

stress on prevention of caries, the use

of fluoride has increased tremendously.

The increasing use of fluoride has lead

to a higher incidence of fluorosis, which

has become the impetus to search for

cosmetic solutions.

Various treatment regimens proposed

for the treatment of intrinsic tooth discol-

oration are:

Vital bleaching:

a) in office

b) home bleaching

Non-vital bleaching

Microabrasion

Composite resin restorations

Porcelain veneers

Each of the above mentioned techniques

come with their own set of limitations.

Porcelain veneers are recommended

only in the age group of 16 years andabove. Composite resin restorations are

not a conservative approach and also

tend to discolor over time. Many patients

report postoperative sensitivity follow-

ing vital tooth bleaching.2Hence a more

conservative and an interim protocol for

children is needed.

The treatment of dental fluorosis

through microabrasion, being a mini-

mally invasive technique in achieving

acceptable results in the removal ofenamel stains and surface defects was

taken up for the study.1 The primary aims

of carrying out the study were to com-

pare the efficacy of microabrasion by

using 18% hydrochloric acid and 37%

phosphoric acid in terms of:

Lightening of stains and reduction

in size of the opacities and stains by

both the acids.

Checking the surface alterations of

teeth with different degrees of fluoro-

sis following microabrasion using the

two acids through a scanning elec-

tron microscope analysis.

Checking for the permanency of treat-

ment outcome via a one-month follow-

up protocol.

Recording of any postoperative sen-

sitivity or soft tissue injury during the

treatment.

Materials and methods

A sample size of 60 teeth from 30 pa-

tients with varying degree of fluorosis

was included in this study.

The patients were divided into 3

groups following the Deans fluorosis

index:

Group 1: mild fluorosis

[1 and 2 score]: 10 patients Group 2: moderate fluorosis

[3 score]:10 patients

Group 3: severe fluorosis

[4 score]:10 patients3

Score 0 and 0.5 were not included for

the study.


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Criteria for the collection of data

Criteria for acceptability included the fol-

lowing: Children in the age group of 7 to 14

years, suffering from dental fluorosis

were included in the study.

Two permanent maxillary central inci-

sors at least two-third erupted.

Staining consistent with the appear-

ance of mild, moderate, or severe

dental fluorosis on both teeth. The

Deans Fluorosis index was used for

this classification.3

Presence of symmetrical distribution of

fluorosis within the dentition and a fluor-

ide history to verify systemic ingestion

as the etiology of enamel defects.

No contraindications to treatment.

The children were healthy and not suf-

fering from any systemic diseases or

nutritional deficiencies.

Consent for treatment was obtained.

Method of collection of data

The children for the study were selected

from those reporting to the department

of Pediatric and Preventive Dentistry

at Parvategouda Mallanagouda Nada-

gouda Memorial (PMNM) Dental Col-

lege. Parents of selected children were

informed regarding the nature and pur-

pose of the study and an informed con-

sent was obtained from them.

A full mouth supragingival scalingwas done for the patients using ultra-

sonic scaling tips. The maxillary anterior

region was isolated using a rubber dam.

18% hydrochloric acid + pumice ap-

plication was done on 11

37% phosphoric acid + pumice ap-

plication was done on 21

A slow rotating rubber cup in a contra-

angle micromotor hand piece was used

for the application.

Criteria for standardization

Group 1:

5 seconds application with 18%

hydrochloric acid on 11.


phosphoric acid on 21.

This is followed by 20 seconds

rinsing with copious water spray.

A total of 4 applications were per-

formed.

Group 2:








formed.

Group 3:








formed.

Following the microabrasion procedure

Casein-Phosphopeptide-Amorphous

Calcium Phosphate remineralizing solu-

tion [GC Tooth Mousse paste] was ap-

plied for 15 minutes. Photos were taken

before, immediately after and one month

post treatment. Photos were scanned


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CLINICAL RESEARCH

and analyzed in software Paint Shop Pro 7

for opacities and demarcations, followed

by an analysis in Image Pro Express 4.0

software used for the calculus of the totalopacity area.4Vinyl polysiloxane impres-

sions of the patient were made before and

after treatment. A scanning electron mi-

croscopic evaluation was carried out on

the models to judge the surface altera-

tions.3Four sets of criteria were used to

judge the photomicrographs:

Type of surface defect

Depth of surface defect

Shape/description of surface defects

Area affected by the defect as a

function of percentage of the tooth

surface

Criteria for scoring

Photographic analysis

Amount of white spot (WS) discoloration

as a function of percentage of surface of

tooth involved:

0 = none

1 = questionable

2 = less than 25%

3 = greater than 25% but less than

50%

4 = 50% or more

5 = entire surface involved or pitting

present

Intensity of yellow, orange, or brown

stain (SI):

0 = none 1 = light to medium

2 = dark

Amount of stain (SA) as a function of per-

centage of surface of tooth involved

0 = none

1 = less than 25%

2 = greater than 25% but less than

50%

3 = greater than 50%

Assessement of photomicrographs

(scanning electron microscopic

analysis)

Type of surface defect:

1 = smooth

2 = grooved

3 = pitted

4 = grooved and pitted

Depth of the surface defects:

1 = shallow

2 = medium

3 = deep

Shape/description of surface defects:

1 = discrete

2 = confluent

3 = discrete and confluent

Area affected by the defects as a func-

tion of percentage of surface of tooth:

1 = less than one-fourth

2 = greater than one-fourth but less

than half

3 = greater than half but less than

three-quarters

4 = greater than three-quarters.

Statistical analysis

Wilcoxon and Mann Whitney tests

were used to verify the hypothesis ofthe immediate and final equality of the

effect of the two pastes. Kappa statis-

tics were used to obtain the interrater

reliability.


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Results and observationsThe sample consisted of 30 subjects

ranging from 7 to 14 years. They were

divided into three equal groups of mild,moderate and severe fluorosis consist-

ing of 10 children each. Male and female

children were equally distributed in each

group. Results of the present study indi-

cate the following.

Photographic analysis

Amount of white spot (WS) discolora-

tion as a function of percentage of

surface of tooth involved

There was total of 43.8% of white spot

reduction during the treatment of Group

1 using 18% hydrochloric acid. This fur-

ther improved to 61.3% reduction fol-

lowing 1-month followup. A reduction

of 61% white opacities was seen after

treatment with 37% phosphoric acid.

This improved to 70.9% after a 1-month

followup period.

White spot opacities reduced by

30.5% in Group 2 after treatment with

18% hydrochloric acid. This improved

to 55.05% after 1-month follow- up. A

reduction of 38.5% after treatment and

an improvement to 67.6% in the white

opacities was observed with 37% phos-

phoric acid.

There was a total reduction of 17.3%

of white spot opacities in Group 3 after

treatment with 18% hydrochloric acid.

An improvement to 40.34% was ob-served after the 1-month follow- up. With

37% phosphoric acid, an improvement

of 25% was seen after treatment and an

improvement to 46.6% after a period of

1 month.

The efficacy of 37% phosphoric acid

in the removal of white spot opacities

appeared to be superior to 18% Hydro-

chloric acid. However the difference in

values was not statistically significant.

Intensity of yellow, orange,

or brown stain (SI)

A reduction of 52.65% in the intensity

of yellow stain with an improvement to

66.4% after 1 month was observed with

18% hydrochloric acid in Group 1. A

reduction of 58% with an improvement

to 62.7% after 1 month was seen after

treatment with 37% phosphoric acid.

There was a 44.9% reduction in the

intensity of yellow and brown stain fol-

lowing treatment with 18% hydrochloric

acid in Group 2. This further reduced

to 59% during the 1-month followup

period. A reduction of 47.5% stain inten-

sity was seen after treatment with phos-

phoric acid. This improved to 73.4% af-

ter 1 month.

In Group 3, the intensity of stain re-

duced by 33.5% initially and 49.7% af-

ter 1 month following treatment with 18%

hydrochloric acid. Forty-seven per cent

lightening of the intensity of yellow and

brown stain was seen postoperative af-

ter treatment with 37% phosphoric acid.

This further improved to 51.4% reduc-

tion after 1 month. The efficacy of 18%

hydrochloric acid and 37% phosphoric

acid in reduction of the intensity of yel-

low and brown stains was similar.

Amount of stain (SA) as a functionof percentage of surface of tooth

involved

In Group 1, there was a reduction of

52.7% in the total area affected by stain

following treatment with 18% hydrochlo-

ric acid and an improvement to 71.4%

after 1 month. In teeth treated with 37%


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phosphoric acid a reduction of 67.2%

and an improvement to 81.9% after 1

month was observed.

In Group 2, there was a 37.4% reduc-

tion in the total area affected by stain

immediately after treatment with 18% hy-

drochloric acid. This further decreased

to 62.8% during the 1-month follow-up

period. For the teeth treated with 37%

phosphoric acid there was a 44.8% re-

duction postoperatively and a total of72.6% reduction after 1 month.

For teeth treated with 18% hydrochlo-

ric acid in Group 3, a reduction of 24.2%

was observed postoperatively and an

improvement to 43.0% after 1 month. A

reduction of 35% in the total area of tooth

surface affected by stain was seen after

treatment with phosphoric acid. This fur-

ther improved to a 48.7% reduction after

a 1-month follow-up period.

The comparative difference in ef-

ficacy of 18% hydrochloric acid and

37% phosphoric acid in the reduction

of the total area of stain as a percentage

of tooth surface using Mann-Whitneys

U test was not statistically significant

(Figs 1 to 3).

Scanning electron microscopicevaluation: 10X magnification

Group 1: mild fluorosis

For the teeth in this category, the type of

surface defects changed from grooved

type to the smooth type in almost 50%

of the cases treated with 18% hydro-

chloric acid, and in 45% of the cases

treated with 37% phosphoric acid. The

rest of the cases remained unchanged.

There was a reduction in the depth ofthe surface defects by 37.5% for 18%

hydrochloric acid and 44.4% reduction

with 37% phosphoric acid. There was no

appreciable change in the shape of the

surface defects. The total area affected

by the surface defects reduced by 45%

in teeth treated by 18% hydrochloric ac-

Fig 1 Preoperative photography of 11 and 21

showing moderate fluorosis in a 9-year-old patient.

Fig 3 Photography after one-month follow-up.

Fig 2 Postoperative photography (after four cy-

cles of microabrasion).


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id and by 52% in teeth treated by 37%

phosphoric acid.

Group 2: moderate fluorosisThe type of surface defects improved

by 53.3% after treatment with 18% hy-

drochloric acid and an improvement of

55.5% was seen after treatment with 37%

phosphoric acid. The defects changed

from the grooved and pitted type to

the smooth type. The depth of the sur-

face defects reduced by 33.33% after

treatment with 18% hydrochloric acid

and by 50% after treatment with 37%

phosphoric acid. There was no statis-

tically significant change in the shape of

the surface defects. There was almost a

50% reduction in the total area occupied

by the surface defects in the postopera-

tive samples after treatment with 18%

hydrochloric acid and 37% phosphoric

acid. The remaining area occupied by

the defect was less than .

Group 3: severe fluorosis

An improvement of only 22.5% with 18%

hydrochloric acid and 27.27% after ap-

plication of 37% phosphoric acid was

seen in the type of surface defects. The

defects changed from grooved and pit-

ted type to either grooved or pitted

type. A slight reduction in the depth was

seen: 15% with 18% hydrochloric acid

and 23.8% with 37% phosphoric acid.

There was a significant improvement

in the shape of the surface defects withthe defects changing from discrete and

confluent and confluent to the dis-

crete type. A 34.6% change was seen

with 18% hydrochloric acid and 57.14%

change with 37% phosphoric acid.

The total area affected by the surface

defects reduced by 46% after treatment

with 18% hydrochloric acid and by 56%

after treatment with 37% phosphoric ac-

id. The final area affected by the defects

was between and of the total toothsurface. Though the teeth showed sub-

stantial loss of tooth structure, the initial

roughness was improved dramatically.

The performance of both 18% hydro-

chloric acid and 37% phosphoric acid

were comparable in all categories for

improvement of surface defects except

for type of surface defect in Group 2,

which 37% phosphoric acid gave super-

ior results (Figs 4 and 5)

Kappa statistics were run including all

possible combinations of comparisons

between raters. These statistics were

then averaged for inter-rater reliability,

to eliminate inter-operator bias. Kappa

values ranging from (0.24 0.00) were

obtained indicating good agreement

between the observers.

DiscussionDental fluorosis is a condition of enamel

hypomineralization due to the effects of

excessive fluoride on ameloblasts during

enamel formation. The main consequence

of dental fluorosis is compromised esthet-

ics, from white spots, striations or opaci-

ties on enamel in mild fluorosis, to post-

operative dark brown to black staining in

moderate and severe fluorosis.5

The use of chemical agents to re-move enamel stains is not recent. The

present study was done to compare

the efficacy of 18% hydrochloric acid

and 37% phosphoric acid in removing

fluorosis stains since phosphoric acid

is a well-known substance for the dental

practitioners.


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The results of our study showed that

there is a significant reduction of white

spot opacities, intensity of yellow, brown

and black stain and the total area affect-

ed by the stain in all the three groups.

All the three parameters seemed to im-

prove over the 1-month follow-up period.

This can be attributed to the fact that

enamel microabrasion abrades enamel

surface while compacting calcium and

phosphate into the interprismatic spac-

es. At the crystal surface level, crystal

growth occurs when two or more kink

sites (defined as two or more adjacent

surfaces) are available. A newly etched

enamel surface has proportionately

more kink sites. As the crystal growthcontinues, the number of available kink

sites, progressively decreases and the

remineralization process slows. A study

done by Peariasamy et al6demonstrat-

ed that etching and pumicing removed

34 4 m of surface enamel but no

mineral loss was observed in the sub-

surface layer. The treatment sequence

enhanced the formation of a new rem-

ineralized layer with a mean thickness

of 22 3 m.6 This polished surface

reflects light differently (abrosion effect)

and appears whiter than normal enam-

el.7 This is in accordance with various

studies done by Croll.8While the exact

reason for the color change that occurs

after microabrasion is not known, the mi-

croabraded surface reflects and refracts

light from the tooth surface in such a way

that mild imperfections in the underlying

enamel are camouflaged. The acid may

also penetrate and bleach the organic

compounds within the enamel, which

might explain the improvement in toothcolor. Hydration of the tooth by saliva

augments the optical properties of the

altered enamel surface and the applica-

tion of topical fluoride further improves

these optical properties.9

When success is defined as the

production of a normal, unfluorosed

Fig 4 Preoperative scanning electron microscop-

ic photography evaluation for teeth treated with mi-

croabrasion procedure in a patient with moderate

fluorosis.

Fig 5 Postoperative scanning electron micro-

scopic photography evaluation for teeth treated with

microabrasion procedure in a patient with moderate

fluorosis.


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SINHA ET AL



appearance or sufficient reduction in

fluorosis so that no further treatment is

needed, the results of this investigation

are most encouraging for patients withmild fluorosis. Moderately stained teeth

improved but continued to demonstrate

white spots and staining, and severely

fluorosed teeth showed only slight im-

provement. Similar results were found in

studies done by Loguercio et al10and

Train et al.11 This is because the mild

fluorotic lesions as demonstrated by

Thylstrup and Frejeskov11lie in the outer

80 -100m of enamel. The action of mi-

croabrasion is based upon the remov-

al of the first 100 to 200 m of surface

enamel. The moderate and severe fluo-

rosis lesions score greater than 4 on the

Thylstrup and Fejerskov index. These

have a pore volume of 10 to 25%, which

is considered too deep to be effectively

treated by microabrasion.11

Strampe et al12reported that pumice

alone removed enamel at the rate of 3m/

min, whereas pumice with 18% hydro-

chloric acid removed enamel at the rate of

88m/ min. Tong et al13reported that only

18% hydrochloric acid removed 100 m

of enamel, whereas 18% hydrochloric

acid + pumice removed up to 360 m of

enamel in the same duration. How much

enamel can be safely removed without the

subsequent need for restoring a tooth?

The rinsed tooth surface should be close-

ly inspected after each application to see

whether the site of the lesion has becomeconcave. If this has occurred and consid-

erable staining is still present, a bonded

resin composite restoration would be in-

dicated. Otherwise the treatment can be

considered complete once the wet tooth

surface shows no evidence of white spot

decalcification.14

The findings of the SEM evaluation

revealed that the degree of fluorosis is

a very important predictor for surface

alteration. In mild fluorosis, porosity isfound exclusively in the very outer lay-

er of enamel. As the severity of fluoro-

sis increases, the pores are present in

the deeper layers; in the most severe

cases, the pore volume of enamel be-

neath the surface can be 25% or more.

In the present study the mildly fluorosed

teeth were either unaffected or became

smoother. These findings are consistent

with the study done by Train et al.11In

moderately fluorosed teeth the surface

becomes smoother in terms of type of

defect. The defects changed from

the grooved and pitted type to the

smooth type. A decrease in the depth

of the surface defects and reduction of

the total area occupied by surface de-

fects was also observed. In the case of

severely fluorosed teeth not much im-

provement was observed in terms of

type and depth of defects. However, the

shape of the defects changed from con-

fluent to discrete and the total area af-

fected by the defects reduced by 50%.

The initial surface roughness was dra-

matically improved.

When comparing the two different ac-

ids used in the study, though clinically the

results of 37% phosphoric acid appear

to be superior, the difference in values

is not statistically significant. The effects

of phosphoric and hydrochloric acid aresimilar, suggesting that both can be ef-

ficaciously used for the microabrasion

procedure. These findings are consist-

ent with the study done by Cristina et

al.15Hydrochloric acid is a very strong

acid that demands careful techniques

for its use to avoid damage on the soft


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CLINICAL RESEARCH



tissues. On the other hand, phosphoric

acid could be considered as a safe and

efficient alternative; furthermore it is an

easily found substance in the dental of-fice.

Most patients in the study tolerated

the treatment well and were pleased

with the results. Though microabrasion

caused noteworthy enamel loss, pa-

tients expressed satisfaction with the

results even though the stain was not

entirely removed, often because the pro-

cedure rendered the stain less notice-

able by blending the boundaries into the

rest of the surfaces.

Conclusion

The major conclusions drawn from the

study are:

The microabrasion procedure is ef-

fective for treating mild and moderate

fluorosis cases. The best esthetic re-

sults were obtained in the mild fluoro-

sis category.

Treatment of severe fluorosis cases

with microabrasion gives an unpre-

dictable outcome and there is a need

for additional interventional treatment

procedures like resin restorations for

esthetic improvement.

Eight to 12 applications of the acid

and pumice mixture, for 5 seconds

application each for mild fluorosis and

20 seconds application for moderatefluorosis, split into 2 to 3 appointments

were sufficient to bring about an ap-

preciable esthetic improvement in the

teeth.

The enamel surfaces acquired a

glass-like luster and an exceptionally

smooth texture following the enamel

microabrasion procedure. The results

of the treatment following microabra-

sion are stable and show a continued

improvement over time. A good improvement in the surface

texture was seen in mild and mod-

erate fluorosis cases with the type

of surface defects changing from

grooved to the smooth type. There

was a sufficient reduction in the depth

and the total area occupied by the

surface defects.

In the severe fluorosis cases there

was slight improvement in the surface

topography with the type of surface

defects changing from grooved and

pitted to the pitted type. There was

also a reduction in the total area oc-

cupied by the defects. Though there

was a substantial loss of tooth struc-

ture, the initial roughness improved

dramatically.

Both hydrochloric acid and phos-

phoric acid can be effectively used

for microabrasion. Phosphoric acid

can emerge as a safe and easy alter-

native since it is easily available in the

dental office.

Patient satisfaction was extremely

high in the study. There was no report

of any gingival ulcerations, postoper-

ative sensitivity or loss of tooth vitality.

Researchs clinical

implications and relevenceto esthetic dentistry

One of the most frequent reasons for

seeking dental care is discolored an-

terior teeth. Microabrasion emerges as

a minimally invasive, economical and

quick in-office option for the treatment


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SINHA ET AL



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of intrinsic discoloration. Though 18%

hydrochloric acid has typically been ac-

cepted as the gold standard for micro-

abrasion procedures, through this studywe have been able to prove that 37%

phosphoric acid is equally efficacious.

This finding is very beneficial since 37%

phosphoric acid is easily available to the

general practitioner in the form of etch-ant used for composite restorations.


13/13

C o p y r i g h t o f E u r o p e a n J o u r n a l o f E s t h e t i c D e n t i s t r y i s t h e p r o p e r t y o f Q u i n t e s s e n c e

P u b l i s h i n g C o m p a n y I n c . a n d i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r

p o s t e d t o a l i s t s e r v w i t h o u t t h e c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s

m a y p r i n t , d o w n l o a d , o r e m a i l a r t i c l e s f o r i n d i v i d u a l u s e .

mikroabrasi hidrokolid dan fosforik asid

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