Conservative approach to hypomineralization and fluorosis-related stains: a case report

Abordagem conservadora em manchas por hipomineralização e fluorose: relato de caso

ABSTRACT

White spot lesions on the dental surface, resulting from enamel hypomineralization and/or dental fluorosis, arise from disturbances in enamel development. When anterior teeth are affected, these lesions may compromise smile esthetics and negatively impact self-esteem. The treatment protocol is defined according to lesion severity, taking into account their extent, depth, and color, as well as the patient’s chief complaint. This clinical case report describes a minimally invasive approach for the management of white spot lesions in anterior teeth. A systemically healthy 21-year-old patient sought dental care reporting dissatisfaction with tooth color and the presence of white spots on the maxillary anterior teeth. Clinical examination identified mild fluorosis, areas of hypomineralization, and an existing restoration with inadequate shade and marginal adaptation. The esthetic impact of the condition was assessed using the Oral Health Impact Profile (OHIP-14), with an initial score of 16, indicating impaired oral health-related quality of life. Treatment included enamel microabrasion to remove or reduce superficial fluorosis-associated stains, in-office dental bleaching to harmonize tooth color, and direct composite resin restorations to correct hypomineralized areas and replace the pre-existing restoration. After one year of follow-up, clinical stability was observed and the OHIP-14 score decreased to 1, demonstrating a significant improvement in psychosocial impact. The proposed approach proved effective for esthetic rehabilitation, addressing the patient’s complaints and achieving satisfactory outcomes with maximal preservation of tooth structure.

Indexing terms
Dental esthetics; Dental enamel hypomineralization; Dental fluorosis

RESUMO

Manchas brancas na superfície dental, decorrentes de hipomineralização do esmalte e/ou fluorose, resultam de defeitos no desenvolvimento do esmalte. Quando acomete dentes anteriores, podem comprometer a estética do sorriso e afetar negativamente a autoestima. O protocolo de tratamento é definido conforme a severidade das manchas, considerando extensão, profundidade e coloração, bem como considerar a queixa do paciente. O presente relato clínico descreve uma abordagem minimamente invasiva para o tratamento de manchas brancas em dentes anteriores. Um paciente jovem, de 21 anos, normossistêmico, procurou atendimento odontológico relatando insatisfação com a coloração dos dentes e a presença de manchas brancas nos dentes anteriores superiores. No exame clínico foi possível identificar fluorose leve, áreas de hipomineralização e uma restauração com cor e adaptação insatisfatória. O impacto da condição estética foi avaliado por meio do OHIP-14, com escore inicial de 16, indicando comprometimento da qualidade de vida relacionada à saúde bucal. O tratamento incluiu microabrasão em esmalte para remoção ou diminuição das manchas superficiais associadas à fluorose, clareamento dental de consultório para uniformizar a cor, e restaurações com resina composta para correção das áreas hipomineralizadas e substituição da restauração pré-existente. Após um ano de acompanhamento, observou-se estabilidade clínica e redução do escore do OHIP-14 para 1, demonstrando melhora significativa do impacto psicossocial. A abordagem proposta mostrou-se eficaz na reabilitação estética, permitindo solucionar as queixas do paciente e alcançar resultados satisfatórios com máxima preservação da estrutura dental.

Termos de indexação
Estética dentária; Hipomineralização do esmalte dentário; Fluorose dentária

INTRODUCTION

White spot lesions on dental enamel may have different etiologies and, when located on anterior teeth, can significantly compromise smile aesthetics and negatively affect patients’ self-esteem. Among the main causes of these alterations, enamel hypomineralization and dental fluorosis stand out, both resulting from disturbances during enamel development [¹].

In addition to esthetic impairment, alterations in anterior enamel may negatively affect oral health-related quality of life. Validated instruments, such as the Oral Health Impact Profile-14 (OHIP-14), enable standardized assessment of the functional, psychological, and social impact of these conditions, thereby supporting a more comprehensive evaluation of therapeutic outcomes.

Enamel hypomineralization is classified by the World Dental Federation (FDI) as a qualitative defect in which the amount of enamel is normal, but its mineralization is insufficient. This deficiency results in well-demarcated opacities between sound and affected enamel and yellowish or brownish discolorations. The compromised areas tend to present increased fragility, structural loss, and greater susceptibility to dental caries. Systemic and genetic factors may also contribute to the development of these alterations [²-⁶].

Dental fluorosis, in turn, occurs during the enamel maturation phase and is associated with excessive fluoride exposure. Other factors, such as low body weight, alterations in renal function, and calcium homeostasis imbalance, may also influence its development. The severity of fluorosis depends on the dose, duration, and timing of fluoride exposure [⁷,⁸]. In milder forms, there is a loss of natural enamel luster and the appearance of opaque white spots, whereas in more severe cases, more intense color changes are observed, ranging from yellow to brown.

Given these conditions, it is essential to prioritize minimally invasive approaches, tailored to the specificities of each case, to maximize preservation of healthy tooth structure while mitigating the esthetic complaint. Techniques such as enamel microabrasion, dental bleaching, and direct composite resin restorations – used alone or in combination – have demonstrated effective outcomes in improving the esthetics of affected teeth [⁹-¹¹].

CASE REPORT

Ethical aspects

The case was conducted in accordance with the guidelines set forth in Brazilian National Health Council Resolutions No. 510/16 and No. 466/12, which regulate research involving human participants in Brazil. The research protocol was approved by the Research Ethics Committee (REC) of the Centro Universitário Católica de Quixadá – Unicatólica, under opinion No. 7,920,290. The patient signed an Informed Consent Form, authorizing the treatment and the use of their data and images for scientific purposes.

A systemically healthy 21-year-old male patient sought dental care reporting dissatisfaction with smile esthetics, particularly regarding the maxillary anterior teeth. The main complaints involved tooth color and the presence of white spots. During clinical examination, lesions compatible with mild fluorosis were observed, more evident on teeth 12, 13, 22, and 23, as well as a hypomineralized white spot located in the incisal third of tooth 21. An existing restoration with unsatisfactory shade was also identified at the incisal angle of tooth 11, along with mild shade asymmetry among the anterior teeth (figure 1).

Before therapeutic planning, the Oral Health Impact Profile-14 (OHIP-14) instrument was administered to assess the impact of the esthetic condition on oral health-related quality of life. The patient presented an initial score of 16, indicating impairment predominantly in the psychological and social domains.

Figure 1
Assessment of the depth of white spot lesions using the transillumination technique

For case planning, shade selection was performed using the VITA Classical shade guide, which revealed shade A2 for teeth 12, 11, 21, and 22, and shade A3 for teeth 15, 14, 13, 23, 24, and 25. In addition, the depth of the white spot lesions was evaluated using the transillumination technique, with a Radii-Cal light-curing unit (SDI Holdings Pty Ltd, Santa Catarina, Brazil) positioned on the palatal surface of the teeth. This procedure allowed light transmission and visualization of the affected areas, revealing greater extension and depth of the lesion in tooth 21 (figure 2).

Figure 2
Assessment of the depth of white spot lesions using the transillumination technique

A treatment plan was proposed comprising enamel microabrasion to remove superficial fluorosis-associated stains, in-office dental bleaching to harmonize tooth color and reduce the visibility of any residual lesions, and a composite resin restoration in the hypomineralized area, in addition to replacement of the pre-existing restoration.

Before the microabrasion procedure, prophylaxis was performed using a prophylactic paste (Herjos, Vigodent, Rio de Janeiro, Brazil), followed by application of a desensitizing gel containing 2% potassium nitrate (FGM, Joinville, Santa Catarina, Brazil) for 10 minutes. Under rubber dam isolation, Whiteness RM microabrasion paste (FGM, Joinville, Santa Catarina, Brazil) was applied to the lesions with localized, manual friction using a Robinson brush for 10 seconds (figure 3), according to the manufacturer’s instructions. This process was repeated, with rinsing and individual assessment of each lesion after every abrasion cycle. After the tenth application, no further clinically significant changes were observed, and the session was concluded. Finally, the surfaces were polished with a Diamond R felt disc and Diamond R polishing paste (FGM, Joinville, Santa Catarina, Brazil), followed by application of neutral fluoride gel (Maquira, Maringá, Paraná, Brazil).

Figure 3
Microabrasion procedure -manual friction of the paste over the lesion surface using a Robinson brush (hand-operated, without rotary activation).

After 14 days, the patient returned to initiate the in-office dental bleaching protocol. The initial smile appearance was recorded (figure 4A), and the treatment was subsequently performed in three clinical sessions, with a 7-day interval between sessions. Before application of the bleaching agent, prophylaxis was carried out with pumice (Maquira, Maringá, Paraná, Brazil), followed by shade assessment using the VITA Classical shade guide (Vita Zahnfabrik, Bad Säckingen, Germany) and application of a 2% potassium nitrate-based desensitizing gel (FGM, Joinville, Santa Catarina, Brazil) for 10 minutes (figure 4B). A gingival barrier (Top Dam Blue, FGM, Joinville, Santa Catarina, Brazil) was then applied to the cervical portion of the teeth to be bleached. The bleaching agent used was Whiteness HP Maxx, a 35% hydrogen peroxide-based gel (FGM, Joinville, Santa Catarina, Brazil), prepared according to the manufacturer’s instructions and maintained in contact with the tooth surface for 45 minutes in each session (figure 4C). As a result, shade harmony was achieved, with all teeth reaching shade A1 at the end of the three sessions (figure 4D). An increase in the value of the underlying tooth substrate was observed after bleaching, which rendered the white spot less noticeable due to greater contrast with the adjacent substrate.

Figure 4
Steps of the in-office dental bleaching protocol. A) Initial appearance of the smile prior to bleaching. B) Application of the desensitizing gel based on 2% potassium nitrate. C) Application of 35% hydrogen peroxide bleaching gel on the dental surfaces, with a gingival barrier in place. D) Final shade assessment after three bleaching sessions.

Due to the need to mask the localized hypomineralized opacity in tooth 21, restoration of this tooth was performed in conjunction with replacement of the unsatisfactory restoration in tooth 11. The procedures were carried out under rubber dam isolation, and in both cases Empress Direct composite resin (Ivoclar Vivadent, Barueri, São Paulo, Brazil) in shade A1 was used, with dentin and enamel composites.

On tooth 21, cavity preparation involved partial removal of the white spot lesion, extending to the margins of sound enamel, allowing the affected area to be subsequently masked with the restorative material. On tooth 11, after removal of the old restoration, a lesion compatible with hypomineralization was also observed; therefore, superficial removal of the lesion was performed, following the same approach to ensure that both preparations presented a similar aspect, thereby providing a more homogeneous restorative outcome. For preparation finishing, a bevel was created along the entire contour of the sound enamel margins, increasing the area of acid etching in order to mask the tooth-restoration interface and enhance adhesion to dental structures (figure 5A-D).

Figure 5
Steps of the preparation and restoration of teeth 21 and 11. A) Aspect of the preparation after partial removal of the white spot lesion on tooth 21. B) Application of the adhesive system on tooth 21. C) Aspect of the preparation after superficial removal of the white spot lesion on tooth 11. D) Application of the adhesive system on tooth 11.

Prior to composite resin placement, prophylaxis was performed with pumice stone (Maquira, Maringá, Paraná, Brazil) throughout the preparation, followed by selective enamel etching with 37% phosphoric acid (Angelus, Londrina, Paraná, Brazil) for 30 seconds. Subsequently, a two-step self-etch adhesive system (Clearfil SE Bond; Kuraray Noritake Dental, São Paulo, Brazil) was applied, with the primer restricted to dentin and the adhesive applied to both enamel and dentin, followed by light curing for 40 seconds using a Radii-cal light-curing unit (SDI Holdings Pty Ltd, Santa Catarina, Brazil). The dentin composite resin was applied in a thicker layer, whereas the enamel composite was placed as the final, thinner layer. Each layer was light cured for 40 seconds, according to the manufacturer’s instructions.

Initial finishing and polishing of the restorations were performed using multilaminated burs at low speed and a Diamond R felt disc (FGM, Joinville, Santa Catarina, Brazil), respectively. After 48 hours, the patient returned for a refined finishing and polishing session, using a sequence of Sof-Lex™ Pop-On abrasive discs, orange series (3M, Sumaré, São Paulo, Brazil), multilaminated burs with 12 and 30 blades at low speed (figure 6A-B), Jiffy polishing spirals in green and white (Ultradent, South Jordan, USA), and a Diamond R felt disc with Diamond R polishing paste (FGM, Joinville, Santa Catarina, Brazil). At the end of the treatment, a significant improvement in smile harmony was observed, with uniform tooth color and effective masking of the previously identified lesions. The final outcome met both aesthetic and functional expectations, providing a more natural appearance to the smile and ensuring patient satisfaction (figure 6C-D).

Figure 6
Steps of the final finishing and polishing procedures. A) Delineation of the anatomical structures of teeth 11 and 21 prior to the finishing protocol. B. Finishing performed with a 30-blade multilaminated bur at low speed on the buccal surfaces of teeth 11 and 21. C. Lateral view of the central incisors after the restorative, finishing, and polishing procedures. D. Immediate final appearance after polishing

At the 12-month follow-up, the OHIP-14 was re-administered, showing a reduction in the score to 1, indicating a significant improvement in oral health-related quality of life.

DISCUSSION

The present clinical case report described the management of white spot lesions resulting from mild fluorosis and hypomineralization affecting the enamel of the permanent maxillary central and lateral incisors and canines, causing esthetic discomfort to the patient. After clinical assessment and differential diagnosis, a conservative approach was selected [¹²], consisting of dental bleaching associated with microabrasion for the lesions related to mild fluorosis, as well as direct composite resin restorations for the hypomineralization lesion [¹³,¹⁴]. The treatment plan was grounded in the principles of minimally invasive dentistry, prioritizing maximal preservation of sound tooth structure [¹⁵].

Among the developmental enamel defects described in the literature are dental fluorosis, enamel hypoplasia, molar-incisor hypomineralization, and amelogenesis imperfecta [⁵]. Each of these conditions presents distinct etiology, clinical characteristics, diagnostic criteria and management strategies. Therefore, accurate diagnosis is a determining factor for therapeutic success in both the short and long term. To achieve this, clinicians must be adequately calibrated and able to recognize the clinical and histological differences among these conditions, enabling the selection of the most appropriate treatment plan for each situation [⁵,⁸,⁹,¹¹].

Among auxiliary diagnostic methods, the transillumination technique stands out as a non-invasive tool that allows estimation of enamel lesion depth based on optical properties. Directed illumination enables differentiation between superficial lesions, which present lighter shades, and deeper lesions, which appear darker, thus contributing to a more conservative clinical decision-making process. This approach has been widely described in the literature as an effective complementary resource for assessing the extent of enamel lesions [¹⁶,¹⁷].

Theoretical and practical knowledge regarding the particularities of each type of lesion is essential for accurate diagnosis. The use of intraoral photographs and calibrated algorithms for detecting molar-incisor hypomineralization can improve diagnostic accuracy and, consequently, support the selection of the most appropriate clinical approach. In this way, it is possible to establish an effective, minimally invasive, and resolutive treatment strategy, ensuring preservation of healthy structures and individualized care [⁵,¹⁸].

The association of different techniques, such as dental bleaching and enamel microabrasion, may enhance aesthetic outcomes in cases of white spot lesions by promoting better optical masking and tooth color uniformity [¹⁹]. Conversely, it was observed that in deeper lesions, bleaching alone may be insufficient, requiring combination with complementary techniques such as microabrasion to intensify the results [⁹]. This combined approach has been corroborated by several authors [²⁰-²³].

The literature also supports the effectiveness of enamel microabrasion in removing superficial white spot lesions, particularly in cases of mild fluorosis, promoting aesthetic improvement with minimal enamel wear [²⁴-²⁶]. As a conservative, low-cost technique with excellent prognosis, microabrasion is considered the first-line treatment for superficial lesions [⁹,¹⁹]. In the present case, the association of microabrasion and bleaching aimed to achieve greater aesthetic stability by preparing the substrate for the success of the restorative phase, as demonstrated in the literature [²⁷].

According to an international consensus published by the European Organization for Caries Research (ORCA) and the Cariology Research Group of the IADR, deeper white spot lesions may require direct restorative interventions, either with resin infiltration or composite resin restorations [¹⁴]. Direct restorative techniques are considered simple procedures with adequate predictability, low cost, and excellent aesthetic, functional, and clinical longevity outcomes, in addition to allowing repairs and preservation of the remaining dental structure.

In cases of more extensive lesions, aesthetic rehabilitation can be achieved through adhesive restorative protocols [²⁸,²⁹]. These authors recommend partial removal of the lesion up to a limit that allows adequate masking, preparation on sound enamel, and extended acid etching approximately 1 mm beyond the bevel, favoring optimal optical results and an imperceptible transition between tooth and restoration.

Beyond the objective esthetic improvement, the psychosocial impact of the treatment was evidenced by the application of the OHIP-14. The initial score of 16 indicated a relevant impairment in oral health-related quality of life, especially in the psychological domains, a finding frequently reported in patients with anterior esthetic alterations. After treatment and at the 12-month follow-up, the score decreased to 1, indicating a marked improvement in functional, psychological, and social impact. The OHIP-14 questionnaire has been widely used to assess oral health–related quality of life, demonstrating suitable clinical applicability and satisfactory psychometric properties in recent studies. Examples include its use in measuring the subjective perception of oral health in different clinical contexts.

Therefore, minimally invasive treatments should be prioritized as the first-line therapeutic approach when clinically indicated [³⁰]. The success of the present clinical case was achieved through accurate diagnosis, careful selection of techniques, and the association of procedures supported by the literature [²³], in addition to the use of high-quality restorative materials. This approach enabled the esthetic and functional rehabilitation of the affected teeth while preserving sound tooth structure, promoting patient satisfaction, and ensuring the clinical stability observed at the 12-month follow-up.

CONCLUSION

This case report underscores the importance of an accurate diagnosis and the combination of minimally invasive techniques for the conservative management of lesions associated with mild fluorosis and hypomineralization. The adopted approach proved effective and predictable, promoting esthetic and functional rehabilitation while preserving sound tooth structure, in addition to the clinical stability observed at the 12-month follow-up. Furthermore, a significant improvement in oral health-related quality of life was verified, as evidenced by the reduction in the OHIP-14 score, demonstrating a positive impact of the treatment on the patient’s perceived well-being.

• Article aligned with the Good Health and Well-Being and Quality Education goal of the Sustainable Development Goals (SDGs).
• How to cite this article
  Bandeira RS, Gonçalves LMS, Vieira LGD, Gonzalez AF, Rabelo CS, Ribeiro MM. Conservative approach to hypomineralization and fluorosis-related stains: a case report. RGO, Rev Gaúch Odontol. 2026;74:e20260035. http://dx.doi.org/10.1590/1981-86372026003520260014

Data Availability

The research data are available from the corresponding author upon reasonable request.

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Edited by

• Assistant editor
  Luciana Butini Oliveira

Publication Dates

• Publication in this collection
  24 Aug 2026
• Date of issue
  2026

History

• Received
  26 Mar 2026
• Accepted
  01 May 2026