cons sheet # 12 - Karmel Qasem

Tooth Discoloration

* Classification:
1- Extrinsic Discoloration:
Located on the outer surface of the teeth, and have no Relation with the structure of dentine and Enamel.
II Intrinsic Discoloration:
Internal stains within the Enamel or Dentine structure.


I- Extrinsic Discolorations Causes:-
1- Dental plaque and calculus
2- Food and Beverage "Juice"
3- Tobacco
4- Chromogenic bacteria
5- Metallic compounds
6- Topical medication
7- Predisposing factors.

1) Dental plaque and calculus:
- Poor oral hygiene is the most common cause of extrinsic discoloration
- Accumulation of plaque and calculus cause Yellow, brown or even black stains (usually occurs on the cervical area of the tooth).
2) Food and beverage: - due to tannins deposition.
- Deposition of Tannins which is found in Tea, coffee, coke and other beverages causes brown stains on the outer and inner surfaces of the teeth.
- In the south East of Asia, some women die their teeth to match their hair and Eyes as a sign of beauty "It's a cultural habit"

3) Tobacco:-
- Stains from cigarettes, cigars, pipes and chewing tobacco can cause tenacious not easily to be Removed" dark brown and black stains.
- Covers the cervical one third to one half of the tooth , pan:- (as a chewing tobacco): It's a combination of (betel nut, betel leaf and lime), elects a copious production of Blood- Red saliva that causes a red- black stain on the teeth, gingival and oral mucosa.
4) Chromogenic bacteria:
- It's easy to recognize, that it appears as a black stain around the cervical line.
- Stains typically the gingival margin of the tooth.
- The most common is black stain caused by Action myces species.
- Green stains are attributed to fluorescent bacteria and fungi such as penicillin and Asperqillas species, but they are less common.
Note:- It also appears in good oral hygiene, and if you remove it, it will come back again because it's part of the "oral flora", so you don't need to treat it because it doesn’t cause any disease unless there is an esthetically problem .
5) Metallic compounds:
- Interaction of the metallic compounds with dental plaques produces surface stains.
* Industrial exposure to:
a- Iron, silver, manganese Brown- black stains:
b- Mercury, lead- copper, nickels Blue- green stains.
c- Chromic, Acid, fumes deep orange stains.
d- Iodine solution Brown stains.
Note: You can consider the fillings as Amalgam as intrinsic cause, because the corrosion products will integrate within the tooth structure.



6) Topical medication:-
As mouth washes that contain chlorohexidine should be used for short period of time (for 1 week) due to its antibiotic effect and its ability to cause tooth discoloration.
a- Chlorohexidine rinse causes a brown staining after several weeks of use, particularly on acyclic teeth
b- Iron- containing oral solution (treatment of iron deficiency anemia) causes black stains.
c- Silver nitrate Black stains.
d- Stannous fluoride Brown stains.
**Predisposing factors:
- Enamel defects stains deposit on them easier.
- Salivary dysfunction was in low saliva flow.
- Poor oral hygiene.
Pits and fissures Areas that are stained easily so it's not always caries.

II- Intrinsic Discoloration:-
- Internal in Enamel and dentine structures.
- caused by deep internal stains on Enamel and dentine.
- Internal stains are more complicated to treat.
- Stain distribution varies from localized to generalized involvement.
- An Understanding of the timing of tooth formation (Sequence formation) can help us explain the causes of intrinsic discoloration.
- Causes:-
1- Dental materials 2- Dental conditions and caries
3- Trauma 4- infections
5- Medications 6- Genetic defects and hereditary
Diseases.


1) Dental materials:
- Amalgam Restoration can generate corrosion products leaving a gray- black color, especially in large acuity preparation with undermined enamel.
- Pins, composite, glass inomer and acyclic restoration gradually leave a color in the tooth surface.
- Other dental materials cause intrinsic discoloration as Eugenol, formocrezole and root canal sealers.

2) Dental conditions and caries:-
A) Aging:-
- As a permanent teeth age, the dentition progressively becomes more gray and yellow, because:
1) Enamel becomes thinner (tooth wear) that allow the underlying dentine to show through the enamel, that’s why the teeth become yellowish in color " most common cause"
2) The permeability of teeth over a long period of time usually allows the infusion of significant pigments Chromogenic food and tobacco usually cause extrinsic discoloration, but sometimes, they can infuse inside the tooth structure and becomes an intrinsic discoloration, if they were used for a long period of time.
B) Non- carious lessens:-
- Tooth Abrasion: mechanical loss of tooth structure manifest as yellow area" as in tooth brushing" showing off the underlying dentine.
- Tooth Erosion: chemical loss of tooth structure frequently can cause yellowish discoloration. (As in frequent ingestion of acidic food, beverage.....).
C) Carious lesions:
- Incipient carious lesions manifest as "chalky white appearance"
- The carious process can self- arrest and remirieralized occurred, however, the brown discoloration usually remains.
- Extensive caries that involve destruction of both enamel and dentine produce a color ranging from light brown to dark brown or almost black.
- So, if there was on arrested caries and the surface was intact, you don't have to make restoration.

3) Trauma:

- Trauma to the developing urerupted permanent teeth can disturb enamel formation and may result in enamel Hyperplasia (turner tooth).
- Enamel Hyperplasia: (turner tooth):- Not normal enamel there is a problem in the ameloblast .it could be pitted or smooth, yellow/brown /black/ or even white in color, it depends on severity.
- Visualized as a localized opacity or brown lesions on the erupted tooth (turner tooth).
- Urerupted permanent incisors are commonly affected after inclusion injuries to primary incisors to young children, incisors are the most teeth affected by trauma.
- Trauma that occurs to the erupted teeth can cause discoloration dark to brown color due to death of pulp.
- Occurs in teeth with fully formed roots and have sustained irreversible pulpal injury non- vital with intrapulpal hemorrhage that integrates within the tooth structure producing brown- black teeth.
4) Infections:
- Periapical infections of primary teeth can disturb amelogenesis of underlying permanent teeth, resulting in localized enamel hyperplasia.
- Maternal rubella, Cytomegalovirus (CMV) infection and toxemia of pregnancy can cause also tooth discoloration.
- It manifest as a focal opaque band of enamel hyperplasia confined to primary teeth.
- Systemic postnatal infections. Eg: high fever, measles, chicken pox, streptococcal infections, scarlet fever can also cause enamel hyperplasia.
- The band like unesthetic hyperplasia defects are visualized on enamel.
* Some people ask if their children have caries lesion on their primary teeth , is it important to treat ? the answer will be YES , because if we leave them , they will affect the permanent teeth in bad way in the future!!
* To understand points above, read these notes:-
1- The primary teeth are formed in the intrauterine the life but the permanent teeth are formed after birth so if the mother was affected by this disease as fever the primary teeth will be affected. But if the baby was affected, the permanent teeth will be affected.
2- The position of bands are different due to the different morphology of the teeth, that for an example, the band appears in the middle 3rd of the centrals but it appears in the upper tip the canine and the 6th molar .

5) Medications:
A) Tetracycline:
- Induce different types of discoloration varying from yellow- orange to dark blue- gray in "which is difficult to treat"
- Severity of staining depends on the close duration, the type of tetracycline and the dose concentration.
- Staining of tetracycline frequently occurs at an early age, and is caused by ingestion of the drug concomitant with the development of the permanent teeth tetracycline does not lead to discoloration if teeth formation is completed, (as in enamel hyperplasia, if the teeth formation was completed, they will not be affected.
- However, studies show that permanent teeth in adult can. Experience a gray discoloration as a result of long exposure to it.
* The Erupted teeth have a bright yellow band like appearance, but upon exposure to sunlight, it gradually changes into dark - blue color.
- It affects both primary and permanent teeth after maternal or childhood ingestion.
- Diffuses into enamel, dentine and bone chelating Ca++ and incorporates into the hydroryapatite cryptal.
B) Fluoride: Affects (Bone+ teeth).
- Present in water.
- Dental fluorosis is characterized by enamel discoloration resulting from hypo mineralization due to excessive ingestion of Florida during the early maturation stage of enamel formation.
- Fluorosis affects primary and secondary dentition with Broad range
Of clinical findings.
Broad range: appears more than one form as being mild, severe......
* Mild form appears as white chalky apperance.
• Moderate to severe; extensive mottling, pitting and brown discoloration on enamel surface.
- Source: - Early overdose and ingestion of fluoridated water, or misuse of topical fluoride as in tooth pastes and mouth washes and Vitamins.
* It's affected by the dose and duration of fluoride exposure.
6- Genetic defects and Hereditary diseases:-
- They affect both primary and secondary dentitions.
a- Amelogenesis lmperfecta "problem in the enamel ".
- Affects primary and secondary dentitions, and shows numerous clinical manifestations as in Hypo plastic teeth demonstrated with Rough or pitted enamel surfaces that are at greater risk for extrinsic staining.
- Appearance is variable (mottled, opaque, while yellow) or brown stain) Here the dentine is not affected.
- It's of 2 types: one type is associated with disorders in the bone "osteogenesis imperfect" and the other affects only the teeth.
* In order to differentiate between fluorosis and Amelogenesis lmperfecta , you should ask the patient whether he had discoloration on his primary teeth or not , if yes then it will be Amelogenesis lmperfecta !
b- Dentinogenesis imperfecta
* Appearance: 1o and 2o teeth are affected
- Brown or blue appearance with distinctive translucency.
- Enamel chips off easily any that the DEJ is not strong so the enamel chips off and the dentine will be affected.
c- Dentinal dysplasia: problem in the dentine and it is less important.

* Treatment modalities of tooth discoloration:
- The treatment will depend on the severity of discoloration regardless, whether it was intrinsic or extrinsic). However, extrinsic discoloration is easier to treat because it occurs on the external surface of the tooth: sometimes cleaning, polishing or/and finishing are enough to remove stains, while intrinsic discoloration doesn't come out easily.
- Modalities: warp by which we remove the discoloration of teeth by:
1- Micro abrasion
2- Macro –abrasion
3- Bleaching
4- Veneers facing ;( porcelain/ composite).
- Micro+ macro abrasion: Conservative treatment for the reduction or elimination of superficial stains.
- Always start your treatment using the simplest most conservative way, if it doesn't work, use other which is less conservative.
- In macro+ micro abrasion, we remove very small amounts of the tooth structure.
- Bleaching is another approach.
- Veneers involve the Removable of considerable amounts of tooth structure "it's not conservative ".
- The technique of micro+ macro abrasion results in the physical + chemical removal of tooth structure. And they are indicator for stains that do not extent more than few tenth of mm into the enamel (external stains).
- If the stains remain after treatment, we use restorative techniques as an alternating eg: veneer, crown or composite restoration.
- Tooth discoloration due to tetracycline will result in bluish stains, and the patient usually believes that his/ her smile is unaesthetic. In this case bleaching may not work, so we put veneers.
* Now in more details:
1- Micro- Abrasion: The physical + chemical removal of tooth structure along with superficial stains:
- We use it in enamel hyperplasia or turner tooth in which the lesions are usually much localized (present on one of the centrals), brown or opaque in color, so if one tooth is involved and it's not affected that much, we use micro abrasions.
- We use pumice Hydrated paste + 11% Hcl
- Physical affect "the abrasiveness of the pumice".
Hcl: chemical Affect Dissolution of enamel by the acid
- So we put a basic paste containing Hcl on the tooth "Brushing the material on the teeth".
- After treatment, we should polish the tooth with a prophylactic past to restore the surface luster.
- Sometimes, topical fluoride is also used to enhance remineralization, because small amounts of enamel are removed during treatment.
2- Maroabrasicns:
- We use composite finishing burs or diamond finishing burs in high speed using a water coolant.
- It's more aggressive less conservative than micro abrasive.
- Mild furorosis can be treated by this technique.
- After treatment, final polishing is achieved by using an abrasive rubber point.
3- Bleaching: - Divided into
1) Vital 2) Non – vital bleaching (necrosis)
Depending a whether the tooth is vital or not.
- In general, bleaching is the application of a chemical agent to oxidize the organic pigment of the tooth.
- Bleaching does not remove the stain but rather oxidize the pigment, so that it loses its color.
- Hydrogen peroxide (H2O2) is used mainly.
* Vital bleaching is carried out: (1) At home or (2) In the office.
In the office:
- One or two visit – more extensive.
- We use higher concentration of (H2O2)
At home: The patient uses an occlusal splint in which (H2O2) is placed.
- The patient wears this occlusal splint "tray" at night for 7 days "the process takes place at night.
- We use lower concentration of (H2O2).
* In the office, the gum is protected by isolating material " (H2O2) is very irritant ", so what we do , we put the material on the tooth for 15 minutes, then we rinse it, and then we put the material again for 15 mines and so on....... This is repeated for several times to achieve the required outcome.
* In the office, the procedure is more intensive compared to carrying out the procedure at home, where it's more gradual.
- In office bleaching is better controlled with best Results.
* At home bleaching: the occlusal splint is fabricates to the patient, that places a get contain (H2O2) inside it and wars them at night for 7 days.
* Non- vital bleaching: used with non- vital teeth eg: In endodontically treated tooth "undergoes Root canal therapy"
- When the teeth are traumatized and are not properly endodontically treated, the color will become darker, so that we do endodontic treatment and at the level of orifice we seal it by glass inomer in order not to let the bleaching material to go through the root because it cause damaging effects.
* The treatment is carried out by:-
1) Proper endodontic treatment "Here we deal with the biological components as Bacteria.
2) Placing a gel inside the axis of the tooth after the Endo- treatment. "Here we deal with the discoloration"
- It's more effective than vital bleaching.
- In 1% of the cases, cervical erosion may occur.
4) * Veneers: a layer of tooth colored restorative material applied to the tooth, to restore a localized or generalized defect or intrinsic discoloration.
- Mainly applied on the labial surface.
- Veneers can be: - composite / porcelain
.
* Veneers can be:-
1) Complete veneers: the whole labial surface is covered.
2) Partial veneers: only a part of the labial surface is covered.
* The veneer will cover the labial surface and will extend slightly to the incisal surface and lingual surface too.


Last lecture cons for Dr.Suzan
Done by: Karmel Qasem