Fluorosis marks on your teeth, and whether whitening, bonding or veneers will fix them

First, is it actually fluorosis?

Fluorosis is a change in the enamel caused by too much fluoride while the teeth were forming, roughly from birth to eight years old. The teeth develop under the gums with the marks already in them and come through that way. Adults cannot develop it, and children over about eight cannot develop it in the teeth already formed.

It has a recognisable pattern. The marks appear on matching teeth on both sides of the mouth, usually the front teeth and premolars, as fine white lines across the tooth, white flecks, or cloudy, paper-white patches. In stronger cases there are yellow or brown areas, and in the strongest the enamel surface is pitted.

Three things look similar and are not fluorosis:

• A chalky white band along the gum line, or around where braces used to be, is usually early decay. That needs treating for a different reason, and soon.
• A single marked tooth with normal teeth either side is more often the result of an injury or an infected baby tooth sitting above it while it formed.
• Creamy yellow or brown patches mainly on the first molars and front teeth, sometimes with enamel that crumbles, point to a different developmental condition that behaves differently under treatment.

So the first job of any appointment about white or brown marks is working out which of these it is. Everything below assumes the answer is fluorosis.

Why so many people in Bengaluru have it

The city’s piped water is not the cause. Fluorosis in India comes overwhelmingly from groundwater, borewells and handpumps drawing on rock that is naturally high in fluoride, and the people who have it mostly grew up on that water somewhere else.

Several districts of Karnataka are known for it, Kolar and Chikkaballapur among the best documented, and so are large parts of Andhra Pradesh, Telangana, Rajasthan and Gujarat. A great many adults living in Koramangala today spent their first eight years in one of those places. If you have fluorosis, you have probably had it since your adult teeth came through, and your parents may have it too.

That is worth knowing for one practical reason. If you have young children and your household uses borewell water, which is still common on the edges of Bengaluru, have it tested for fluoride. That is the one thing that prevents the next generation having the same marks.

The level decides the treatment

Dentists grade fluorosis by how much of the tooth is affected, and the grade maps closely onto what works. You can usually place yourself in one of these groups in a mirror, in daylight.

Very mild and mild. Faint white lines or flecks, or opaque white patches covering up to about half of the tooth. The surface is smooth. This is by far the most common, and most people with it never need anything more than the first two options below.

Moderate. The whole surface of the tooth is affected, with white mottling and noticeable yellow or brown staining, but the enamel is still smooth and intact.

Severe. Brown staining with pits, or areas where enamel has broken away, and the teeth sometimes look worn or uneven at the edges.

The four options, from least to most

Whitening. Whitening does not remove white fluorosis marks. What it does is lighten the tooth around them, and as the background moves closer to the colour of the flecks, they stop standing out. For faint marks that is often the whole answer. For brown fluorosis it does more, because that brown is stain absorbed into porous enamel and peroxide lifts a good deal of it. Expect the white flecks to look brighter for a day or two after a session before they settle back. The teeth whitening page explains in-clinic and take-home courses and how sensitivity is managed.

Treating the surface. The marks in mild fluorosis usually sit in the outer layer of enamel. Two techniques work on that layer without drilling. Microabrasion gently removes a very thin outer skin of enamel with a mild acid paste and a polishing cup, taking surface marks and brown stain with it. Resin infiltration works the other way round: the porous patch is filled with a thin resin, so it reflects light like the healthy enamel around it and the white patch fades. Neither needs an injection, and both are often combined with whitening. Which one suits a given tooth depends on how deep the marks run, which is something the examination tells you.

Composite bonding. When marks go deeper than the surface, or the enamel is pitted, tooth-coloured composite is bonded over the affected areas and shaped by hand. It takes one appointment, removes little or no tooth, and can be refined or redone later. Fluorosed enamel is harder to bond to than normal enamel, so the surface is prepared carefully, and a good result depends on that preparation more than on the composite itself.

Veneers. Porcelain veneers cover the whole front surface and give the most uniform, stain resistant result. They are the right answer for severe fluorosis with pitting, broken edges or wear, and sometimes for moderate cases where the person also wants to change the shape of the teeth. They are rarely the right answer for mild fluorosis, because they mean removing healthy enamel to hide marks that whitening or a surface treatment would have dealt with.

	Whitening	Surface treatment	Composite bonding	Veneers
Best for	Faint flecks, brown stain	Mild, surface marks	Deeper marks, small pits	Severe, pitted or worn
Drilling	None	None	Little or none	Some enamel removed
Appointments	1 to 2	1 to 2	1	2
Reversible	Yes	Largely	Yes	No

Where people go wrong

The common mistake is going straight to the most dramatic option. A smile with mild white flecks treated with eight porcelain veneers will look very even. It has also had healthy enamel removed from eight teeth, permanently, and those veneers will need replacing every ten to fifteen years for the rest of that person’s life. For mild fluorosis the honest sequence is the gentle options first, and only then, if the result is not enough, bonding or veneers on the teeth that still bother you.

The second mistake is the opposite: assuming nothing can be done. People with moderate brown fluorosis often hide their smile in photographs for decades because somebody once told them it was permanent. The marks in the enamel are permanent. How they look is very often not.

If it is your child

If you have noticed white marks on a child’s new front teeth, the first question is not treatment. It is where the fluoride is coming from, because the teeth further back are still forming.

Check whether the drinking water is borewell water, and have it tested if it is. Check how much toothpaste goes on the brush: a smear the size of a grain of rice until age three, and a pea sized amount after that, is the standard advice, and children who swallow larger amounts every day are the commonest source in cities. Fluoride toothpaste itself is not the enemy and stopping it causes decay. The amount is what matters.

Cosmetic treatment can wait. Faint marks often look less obvious as the child grows, and anything done later should start with the options that remove the least enamel.

What the appointment in Koramangala looks like

At Tooth District in S.T Bed Layout, Koramangala 4th Block, an appointment about fluorosis starts with an examination, not a shade guide.

Dr. Chaitanya K, whose postgraduate speciality is conservative dentistry, the branch concerned with restoring and improving natural teeth rather than replacing them, looks at the marks in daylight, checks whether any of them is decay, and works out how deep they run. Teeth carrying tartar or old stain are cleaned first, because a fair number of brown marks turn out to be ordinary stain sitting on top of the fluorosis.

You are then told which of the options above genuinely suits your teeth, which is very often the first or second rather than the last, priced in writing and in the order they would be done. Nothing is started at that visit. If the marks are faint enough that the honest advice is to leave them, that is what you will be told. If they are severe, the veneers and smile design page explains how a case like that is planned, tried in and only then bonded.