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Colors in tooth discoloration: A new classification and literature review

Authors:

Abstract

Purpose: There has been a recent increasing interest in the management of dental staining as shown by the large number of tooth whitening materials appearing in the market. The aim of this review is to search the literature regarding tooth discoloration in order to introduce a new classification in terms of different clinical colors. Methods: The PubMed database was searched for articles pertaining to the topic between the year 1932 and 2012. The search strategy for PubMed based on MeSH terms was: “tooth discoloration”, OR “tooth discolorations”, OR “tooth diseases”, OR “tooth bleaching”. Results: Based on the relevant evidence, it was shown that tooth discoloration can be found in nine different color spectrums: black, brown, blue, green, grey, orange, pink, red, and yellow. Each color may represent various origins, which needs further investigations to be revealed. Clinical significance: Our new classification based on clinical features of discolored teeth helps clinicians achieve timely diagnosis and avoid inappropriate therapeutic measures.
International Journal of Clinical Dentistry ISSN: 1939-5833
Volume 7, Number 1 © Nova Science Publishers, Inc.
COLORS IN TOOTH DISCOLORATION:
A NEW CLASSIFICATION AND LITERATURE REVIEW
Hamed Mortazavi1, Maryam Baharvand1
,
and Amin Khodadoustan2
1Associate Professor, Department of Oral Medicine,
Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2Periodontologist, DDS, MS, private practice, Tehran, Iran
ABSTRACT
Purpose: There has been a recent increasing interest in the management of dental
staining as shown by the large number of tooth whitening materials appearing in the
market. The aim of this review is to search the literature regarding tooth discoloration in
order to introduce a new classification in terms of different clinical colors.
Methods: The PubMed database was searched for articles pertaining to the topic
between the year 1932 and 2012. The search strategy for PubMed based on MeSH terms
was: “tooth discoloration”, OR “tooth discolorations”, OR “tooth diseases”, OR “tooth
bleaching”.
Results: Based on the relevant evidence, it was shown that tooth discoloration can be
found in nine different color spectrums: black, brown, blue, green, grey, orange, pink,
red, and yellow. Each color may represent various origins, which needs further
investigations to be revealed.
Clinical significance: Our new classification based on clinical features of discolored
teeth helps clinicians achieve timely diagnosis and avoid inappropriate therapeutic
measures.
INTRODUCTION
The aesthetic appearance of teeth has an important role in physical attractiveness of each
person. Discoloration of teeth is a more critical factor for many individuals to achieve an
aesthetic smile than restoring normal alignment of teeth within their arch [1-3]. According to
a recent study by Samorodnizky-Naveh, 37.3% of subjects were dissatisfied with their dental
appearance, and tooth color was the main reason for about 90% of them [4]. Therefore, it is
crucial for dental practitioners to have an understanding of the etiology and clinical
Tel: +98-21-29902311, Fax: +98-21-22403194, Email: marbahar@gmail.com
Hamed Mortazavi, Maryam Baharvand, and Amin Khodadoustan 18
presentation of tooth discoloration in order to make a diagnosis and select the most
appropriate treatment for each case [5].
Normally, teeth composed of many colors and a gradation of colors occurs in a single
tooth from gingival to the incisal edge. Because of the close contact of the dentin below the
enamel and thinning of the enamel the gingival third of teeth is darker than incisal third.
These differences in color may also be related to the thickness and translucency of enamel
and dentine. In most cases canine teeth are usually darker than central and lateral incisors.
Meanwhile, teeth become darker with age, so younger people have lighter teeth especially in
the primary dentition. This discoloration may be caused by the deposition of secondary and
tertiary dentine and pulp stones as a physiological senile change. Historically, tooth
discoloration has been classified as intrinsic or extrinsic in nature. Furthermore, a third
category of "Internalized discoloration" has recently been described (Box 1).
Intrinsic discoloration (ID) occurs following a change to the structural composition or
thickness of the dental hard tissues during tooth development (Box2). On the other hand, ID
occurs when the chromogen agents are deposited within the bulk of the tooth, especially in
the dentine, and are often of systemic or pulpal origin. This classification is divided into six
subgroups: 1) metabolic, 2) hereditary 3) iatrogenic 4) traumatic 5) idiopathic and 6) ageing
causes.
Extrinsic discoloration (ED) occurs when chromogen agents are deposited on tooth
surface or in the acquired pellicle. This classification can be divided into two subtypes: 1) non
metallic (direct staining), and 2) metallic (indirect staining).
Internalized discoloration describes the changes in normal tooth color because of dental
caries, tooth wearing and gingival recession, cracks and restorative materials. [2,5,6].
In contrast to all previous papers, in this review article we listed tooth discoloration based
on their color, which may help understand tooth discoloration and their causes more
practically.
LITERATURE SEARCH
The aim of this review was to search the literature regarding tooth discoloration in order
to introduce a new classification in terms of different clinical colors. The PubMed data base
was searched for relevant articles between the year 1932 and 2012.The following inclusion
criteria were used: extrinsic and intrinsic factors in tooth discoloration, chromogenic bacteria
and tooth staining, foods and tooth staining, medications and tooth discoloration, salivary
parameters and tooth staining, various dental materials and tooth discoloration, systemic
disease and tooth discoloration, habits and tooth staining. Exclusion criteria were articles
published in languages other than English and those without full texts.
The search concept based on MeSH terms was: “tooth discoloration, OR “tooth
discolorations”, OR “tooth diseases”, OR “tooth bleaching”. Totally 4371 articles were
initially found in PubMed, which their title and abstract were read to find the evidence met
our inclusion criteria mostly. Out of the relevant papers, 253 were review articles, 528 were
case reports, and the remainders 784 were clinical studies. Different color changes may be
found in discolored teeth as follows:
Colors in Tooth Discoloration 19
Box 1. Different types of tooth discoloration [5-9]
Type of discoloration Color produced
Intrinsic Metabolic causes
Congenital erythropoietic porphyria Red/brown or purple/brown
Alkaptonuria Brown
Inherited causes
Amelogenesis imperfecta Yellow-brown or dark yellow
Dentinogenesis imperfect Blue-brown [opalescent]
Dentin dysplasia Brown
Iatrogenic causes
Tetracycline staining Yellow, brown, blue, black or grey
Minocycline staining Brown
Ciprofloxacin staining Green
Fluorosis White, yellow, grey, or black
Traumatic causes
Enamel hypoplasia Yellow-brown or white subsurface
Dentin hypercalcification Yellow, yellow-brown
Pulpal hemorrhage products Grey-brown, black-pink
Internal resorption Pink
Idiopathic causes
Molar incisor hypomineralization White- yellow, brown
Extrinsic causes
Non metallic [direct staining]
Tea, coffee, and other foods Brown to black
Cigarettes Yellow
Cigars Brown to black
Plaques/ poor oral hygiene/ chromogenic bacteria Yellow, brown, green
Metallic [indirect staining]
Iron salts[polyvalent metal salts] Black
Copper salts Green
Silver nitrate Grey
Potassium permanganate Violet to black
Stannous Black
Nickel Green
Cadmium Yellow to brown
Iodine Black
Internalized causes
Developmental defects
Enamel hypoplasia
Enamel hypocalcification
Fluorosis
Acquired defects
Tooth wear and gingival recession Yellow
Dental caries White spots, orange, brown to black
Restorations Brown, grey, black
Hamed Mortazavi, Maryam Baharvand, and Amin Khodadoustan 20
Box 2. Environmental and hereditary causes of generalized intrinsic discoloration
of teeth [5,6,8,9,16,21,26,27,37,39]
Environmental Hereditary
Prenatal Post natal Only teeth involved Accompanied by
systemic disorders
Maternal
drug therapy
[Tetracycline]
Maternal
infection
Pregnancy
toxemia
Drug therapy
[tetracycline, fluoride]
Hematopoietic disorders
Erythroblastosis fetalis,
Icterus gravis
neonatorum,
Sickle cell anemia,
thalassemia
Infection
Measles, Chicken pox,
Scarlet fever
Nutritional deficiencies
-Amelogenesis
imperfecta
-Dentinogenesis
imperfecta
-Dentin dysplasia
-Epidemolysis
bullosa
-Erythropoietic
porphyria
-Osteogenesis
imperfecta
Box 3. Drugs related to tooth discoloration [5-9, 11, 13, 16, 21, 23, 26]
Ciprofloxacin Pentamidine
Clarithromycin Perindopril
Co-amoxiclave Propafenone
Enalapril Quinapril
Essential oil Ramipril
Etidronate Terbinafine
Fosinopril Tetracycline
Metronidazole Trandolpril
Minocycline Zopiclone
Penicilline
Colors in Tooth Discoloration
Black:
Primary and permanent teeth with black-stains are frequently encountered in
schoolchildren with good oral hygiene and low caries rate. As this type of staining
contains an insoluble iron salt, ferric sulphide, and high levels of calcium and
inorganic phosphor, it has been considered to be a special form of dental plaque.
Actinomyces, porphyromonas gingivalis, and prevotella melaninogenicus have been
found as the predominant microorganisms involved in black staining [10,11].
However, Saba according to a PCR microbiological study, established the leading
role of actinomyces in formation of black staining compared to other microorganisms
[12]. The underlying mechanism of bacterial chromogenicity has to be elucidated.
Colors in Tooth Discoloration 21
Black discoloration has also been found in people using iron supplements, containing
high amounts of iodine, and in iron foundry workers as well. Furthermore, the same
clinical manifestations were reported after use of 8% stannous fluoride that was
secondary to the combination of stannous (tin) ion with bacterial sulfides. This
pigmentation usually occurs in people with poor oral hygiene. The labial surface of
anterior teeth and the occlusal surface of the posterior teeth are the most common
affected sites [6,9].
A large number of medications may result in dental surface staining (Box 3). Like
other tetracycline derivatives, minocycline hydrochloride causes discoloration of
dental crowns and roots. Although the real mechanism is unknown, minocycline has
been shown to be incorporated into mineralizing dental tissues during tooth
formation [7]. In addition to teeth, it induces pigmentation in other tissues such as
oral mucosa, nails, skin, and bone. However, only 3% to 8% of long-term users
become affected. Several patterns of staining have been noted in the dentition. For
example, the root of developing teeth is stained dark black [9]. Other patterns will be
described in next parts of this paper .
Various materials used for root canal therapy may induce tooth discoloration,
because of un-reacted agents, or corrosion of some components owing to moisture
and/or chemical interaction with dentine. As an example, AH26, epoxy resin cement
containing bismuth trioxide as a filler and radiopaque material, can lead to black
discoloration in teeth after years [13].The same results were also reported by Davis
[14].
Blue, Blue- Brown, Blue-Grey, Dark Blue
This rare type of pigmentation is usually caused by chromogenic bacteria. Bussell
reported blue teeth discoloration in a 4- year -old boy with Wast syndrome. Further
investigations, revealed a moderate growth of pseudomonas aeruginousa, known as a
blue stain-producing bacterium usually implicated in chronic respiratory diseases, in
swab samples [15].
A blue-brown (opalescent) discoloration of teeth was also seen in patients with
dentinogenesis imperfecta (DI). It is a hereditary disorder of dentine in the absence of
any systemic problems characterized by abnormal dentinogenesis in primary and
permanent dentition. Severity of dental involvement depends on the stage of tooth
development, so that Primary teeth are affected more severely, followed by
permanent incisors and first molars. The second and third molars are less affected.
Three types of DI have been described: type I, is associated with osteogenesis
imperfecta (mixed connective tissue disorder of type I collagen), which may cause
opalescent primary teeth. Type II or hereditary opalescent dentine affects primary
dentition more severely than permanent teeth. A third type of disease is associated
with the radiographic feature of shell teeth having enamel of normal thickness,
extremely thin dentine, and an enlarged pulp. This type of disease is more common
in deciduous teeth [5, 9, 16].
A blue discoloration of dentition, on rare occasions, may be seen in patients with
Parkinson's disease [9].
Hamed Mortazavi, Maryam Baharvand, and Amin Khodadoustan 22
Another pattern of mynocycline staining is presented as a blue-grey discoloration of
the incisal three-fourths of crowns in fully erupted teeth. Dark blue dental
pigmentation has been reported in tetracycline users as well.
Intra-canal medicaments are used in management of traumatized teeth, inflammatory
root resorption, large periapical radiolucencies, and apexification [7]. Despite their
therapeutic advantages, some of these agents can discolor teeth if not completely
removed from the access cavity. In agreement with this point, Kim reported a blue
greyish tooth discoloration associated with triple antibiotic paste containing
ciprofloxacine, metronidazole and minocycline [18]
Brown, Dark Brown, Brown to Black, Brown-Grey, Golden Brown
Brown stain as a thin, bacteria-free pigmented pellicle usually is observed on the
buccal surface of maxillary molars and lingual surface of mandibular incisors in
people who use a dentifrice with inadequate clinging and polishing action [16].
Extensive use of tea, coffee and tobacco products often results in significant brown
pigmentation of the enamel. The main mechanism of extrinsic staining of teeth from
foods is not fully understood. Some researchers have demonstrated that anionic
polyphenols, found in pigmented foods and beverages (e.g. red wine and black tea),
interact with cationic salivary pellicles to form thick layers of stained materials on
tooth surface [19,20]. On the other hand, it was noted that physical and chemical
forces allow pigments to come in contact with and adhere to the tooth surface [21].
The tobacco staining results from penetration of coal tar products on the tooth
surface. Smokers usually exhibit involvement of the lingual surface of the
mandibular incisors. The degree of staining is not necessarily related to the amount
of tobacco consumed, but rather depends on enamel defects the tobacco products
adhere to [22]. Staining is also common in smokeless tobacco users.
Brown, brown –black and golden brown pigmentation has been reported, as an
extrinsic metallic stain, in individuals who use products containing iron, iodine and
stannous fluoride, respectively [6,16,23].
Chromogenic bacteria have also been reported in brown and black tooth
discoloration, especially in pediatric patients with good oral hygiene [5,6,24].
Chlorhexidine, one of the most current antiseptic mouthwashes, is associated with
brown or brown to black staining of teeth. The side effects of chlorhexidine were
first described by Flora in 1971 [25]. The pigmentation may be seen only one week
to ten days after using and most frequently involves the interproximal surfaces near
the gingival margin. An intensive discoloration has been associated with the use of
tea and wine simultaneously [9]. Chlorhexidine is adsorbed on the tooth via binding
of its positively charged molecules to negatively charged dental surface. Then some
cations such as calcium in plaque and saliva promote its slowly release in an active
form [16].
Tetracycline can cause brown or brown –grey tooth pigmentation. Tetracycline
staining was first described in the mid-1950s. After a decade in 1963, United States
Food and Drug Administration issued a warning about the use of this antibiotic for
pregnant women and young children [16,26]. Urist and Ibsen demonstrated the
ability of tetracycline to form complexes with calcium ions on the surface of
Colors in Tooth Discoloration 23
hydroxyapatite crystals [27]. Since it can cross the placental barrier, it must be
avoided from 29 weeks of pregnancy till delivery to prevent incorporation into the
dental tissue. The most critical time to avoid tetracycline for the prevention of tooth
discoloration in primary dentition is 4 months of uterus to 5 months post-partum. In
the permanent dentition, this period is from 4 months of infancy to approximately 7
years of age [5]. It is noteworthy that there is no association between tetracycline
staining and dental caries [16].
Dental fluorosis is the most common cause of intrinsic tooth pigmentation. The
negative effects of fluoride on the enamel were first described by Dean in 1932 [28].
Dental fluorosis may arise endemically from natural water supplies, or fluoride
containing products. Fluorosis occurs when concentrations of fluoride exceeds 1ppm
in drinking water. The severity of pigmentation is age and dose dependent. Both
primary and permanent dentitions can be affected [6,16].
Alkaptonuria is an autosomal recessive metabolic disorder. Incomplete metabolism
of phenylalanine and tyrosine promotes aggregation of homogentisic acid with a
brown discoloration of permanent teeth has been reported in patients with
alkaptonuria [29].
Dentine dysplasia type II is an autosomal dominant hereditary disorder that exhibits
some features of dentinigenesis imperfecta. Clinically, the teeth have a brown
discoloration similar to DI [9].
Molar incisor hypomineralization (MIH) is associated with a brown enamel
discoloration. Enamel in incisors and first permanent molars are severely
hypomineralized. Hypomineralization is not symmetrical and the appearance of
enamel is porous and brittle. The possible causes are: infections during early
childhood, dioxin in breast milk and genetic factors [30].
Sodium hypochloride is a bleaching agent without potential for dental discoloration.
However, Souza observed a brown pigmentation when NaOCl was combined with
chlorhexidine [31].
Green, Green to Blue-Green
Chromogenic bacteria have been implicated in green staining, especially on the labial
surface of the maxillary anterior teeth at the gingival third. It is common in children
with poor oral hygiene and is more frequent in boys than girls [6,32].
Green staining of the maxillary anterior teeth has also been induced by penicilllium
and aspergillus. These microorganisms grow only in alight areas; therefore, anterior
teeth are usually affected [16].
Green discoloration of exposed roots of erupted teeth is another pattern of
mynocycline staining [9]. Furthermore, a green to blue-green pigmentation has been
found in patients using products containing copper and nickel [16].
Green pigmentation in teeth (chlorodontia) may be associated with
hyperbilirubinemia. In this condition, bilirubin is deposited in mineralized tissues
such as bone and dentine. The primary teeth affected more frequently than permanent
dentition. The most common causes of hyperbilirubinemia leading to this type of
discoloration are as follows: 1) erythroblastosis fetalis, 2) biliary atresia, 3) biliary
hypoplasia, 4) premature birth, 5) ABO incompatibility, 6) neonatal respiratory
Hamed Mortazavi, Maryam Baharvand, and Amin Khodadoustan 24
distress, 7) significant internal hemorrhage, 8) congenital hypothyroidism, 9)
tyrosinemia, 10) α1-antitrypsin deficiency, 11) hemolytic anemia, 12) viral infection,
and neonatal hepatitis [9,33-35]. In addition, Swann and Guimaraes reported two
cases of green teeth associated with cholestasis caused by sepsis [36,37]. The
presence of green discoloration in teeth is an indicator of hyperbilirubinemia, and
determine when in life it was occurred [33]. Clinically, the teeth demonstrate a sharp
dividing line, separating discolored (formed during hyperbilirubinemia) and normal
colored portions (formed after normal concentrations of bilirubin were restored) [9].
Grey, Dark Grey, Grey to Black
Grey pigmentation is common in teeth with amalgam restorations. Corrosive
amalgam discolors the dentine by formation of silver sulfide. This type of
discoloration is difficult to remove by bleaching, and tends to recur during the time
[16,38].
Mercury, lead, and silver nitrate salts used in dentistry can cause a grey staining in
teeth [16,39].
Dental discoloration can occur as a result of materials used for endodontic
treatments. For example, Day showed that Ledermix, an intra-canal medicament
containing demeclocycline-HCl, can induce grey pigmentation if not removed
completely from access cavity at coronal level to gingival margin [40]. Davis and
Parsons have reported the same discoloration after use of sealer and sealapex,
respectively [14,41].
Dental traumatic injuries may create a dark grey discoloration when the blood
degradation products are diffused into the dental tubules. In such cases endodontic
treatment before or shortly after total pulp necrosis often prevents progression of
discoloration [9].
Orange, Orange-Red
The orange discoloration is less common than brown or green and was reported in
3% of the population. It usually occurs on the labial surface of mandibular and
maxillary anterior teeth at the gingival third [16].
Chromogenic bacteria such as serratia marcescens and flavobacterium have
important roles in this type of staining, especially in children with poor oral hygiene
[5,16].
Some root canal cements may also have potential to cause tooth discoloration. van
der Bungt reported orange-red tooth discoloration after use of Grossman's, zinc
oxide/eugenol, and endometasone cements [42].
Pink
Trauma-related stains may create a pink to grey discoloration in the teeth. The real
mechanism of color change is not fully understood. Apparently, different colors
represent different entities, some of which are related to pulpal damage with
subsequent healing, whereas others result from pulpal necrosis [43]. Pink
discoloration is usually seen one to three weeks after traumatic injuries because of
localized vascular damage [9].
Colors in Tooth Discoloration 25
Pink discoloration is a common clinical finding in teeth with internal resorption. This
condition is asymptomatic and usually detected through routine radiographic
examinations. The pink staining results from accumulation of granulation tissue in
the coronal dentine, undermining the crown. Infection and traumatic injuries to the
pulp tissue are the main causes of internal resorption as well as orthodontic
treatment. Radiographically, there is a punched out radiolucency, which disturb the
pulp chamber or root canal space [44,45]. In these cases endodontic treatments
should be done promptly, because extension of the defect can lead to a periodontal
involvement.
Color change in the teeth can also occur as a result of materials used for endodontic
treatments. van der Burgt and davis demonstrated a pink discoloration after use of
some root canal cements such as Tubli-seal, Diaket anf Roth’801 in the teeth [14,42].
A similar pink or red discoloration has been reported in the maxillary incisors of
lepromatous leprosy patients. Since the causative microorganism prefers low
temperatures, teeth are involved in selected areas [9,46].
Red, Red-Purple, Red-Brown
This type of discoloration has been reported in congenital erythropoietic porphyria
(CEP). CEP is a rare autosomal recessive metabolic disease, with mutation in the
gene that codifies uroporphyrinogen-III synthtetase, leading to porphyrin
accumulation in urine, skin, bone and dentine [5,47]. CEP is also known as Günther's
disease and was first described in 1911 by Günther [47]. In these cases, intraoral
examination revealed a red-purple or red-brown discoloration (Erythrodontia) in the
primary and permanent teeth. Furthermore, under Wood's lamp there was a bright red
fluorescence in the teeth [47].
Reddening of the upper central incisors in patients with lepromatous leprosy has been
reported by Rundall. This type of discoloration seems to be secondary to infection-
related necrosis and the rupture of small blood vessels within the pulp, with
deposition of hemoglobin into adjacent dental tubules [46].
A red-purple staining was also found by Tay when root canals were rinsed with 1.3%
NaOCl as an initial rinse followed by MTAD as the final rinse [48].
Yellow, Yellow- Green, Yellow-Brown
Yellow to yellow-brown discoloration has been observed in amelogenesis imperfecta
(AI), a hereditary condition characterized by various enamel defects such as
inadequate deposition of enamel matrix, insufficient mineralization of the matrix and
incomplete maturation of the enamel. The estimated frequency of this entity in
population varied between 1:718 and 1:14000. There are at least 14 different
subgroups, with numerous patterns of inheritance and a wide variety of clinical
presentations [5,6,9].
Traumatic injuries to teeth can induce either a resorptive or calcific response. In
calcific phase, after an excessive irregular dentine deposition in the pulp chamber,
the clinical crown becomes yellow or yellow-brown whereas, the tooth is still vital
[49]. This process is called dentin hypercalcification or calcific metamorphosis [6,9].
Several medications can lead to a yellow discoloration in teeth. For example, teeth
affected by tetracycline have a yellowish or yellow-brown discoloration, which is
Hamed Mortazavi, Maryam Baharvand, and Amin Khodadoustan 26
darker in eruption period, but the color diminishes with time [5]. The same
appearances were also reported after use of oxytetracycline and ciprofloxacine [8,9].
Yellow-green discoloration was found in patients with erythroblastosis fetalis
(because of incorporation of bilirubin in the developing dentitions), sickle cell
anemia and thalassemia [due to deposition of blood pigments within the dentinal
tubules] [16].
Remaining of intra-canal medicaments such as Iodine-potassium iodide( Iodoform-
based medicaments) and UltraCal XS during the endodontic treatments can result to
a yellow to yellowish brown staining in the teeth [18,40].
Some habits such as smoking [cigars or cigarettes] or chewing of Khat (Catha edulis)
leaves for its stimulant properties may produce yellow-brown dental staining [16].
CONCLUSION
Many color changes can be encountered when dealing with tooth discoloration. Approach
to the patient with discolored teeth might be more efficiently accomplished using our new
classification based on clinical findings rather than previously etiology- oriented
categorizations.
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... The gingival margin is usually darker in appearance because of the closeness of the dentin below the enamel. In most cases, canine teeth are usually darker than central and lateral incisors [38,39]. These color variations may also be related to the thickness and translucency of enamel and dentin [40]. ...
... These color variations may also be related to the thickness and translucency of enamel and dentin [40]. Teeth become darker as individual ages, probably due to the laying down of secondary and tertiary dentin, incorporation of extrinsic stains, and gradual enamel wear allowing a greater infl uence on the color of the underlying dentin [38,39]. In humans, dental staining is classifi ed as being intrinsic, extrinsic, or "internalized discoloration", depending on its depth of penetration within the tooth [34,38]. ...
... Teeth become darker as individual ages, probably due to the laying down of secondary and tertiary dentin, incorporation of extrinsic stains, and gradual enamel wear allowing a greater infl uence on the color of the underlying dentin [38,39]. In humans, dental staining is classifi ed as being intrinsic, extrinsic, or "internalized discoloration", depending on its depth of penetration within the tooth [34,38]. Intrinsic discoloration involves the deposition of chromogenic or hematological agents into the enamel or dentin matrix during development, illness, or trauma, while extrinsic stains develop when chromogenic agents, metal salts, or cationic antiseptics accumulate within the dental pellicle or the dental plaque. ...
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Background: Dental pathologies are noticeable alterations or deviations from normal dental architecture and can be influenced by genetic or environmental factors. This present study aimed to identify and report the dental pathologies in the Nigerian local pig. Materials and methods: The cleaned skulls of 47 local pigs, aged between 3-51 months were assessed for observable dental abnormalities such as missing teeth, fractured teeth, persistent deciduous teeth, dental caries, dental calculus, and tooth rotation. Results: The study revealed that 98% of the skulls had dental attrition while 96% had stained teeth. About 66% had a least a missing tooth while 78% of adult skulls had at least one persistent deciduous tooth. Fractured tooth, dental calculus, dental caries, and tooth rotation were observed in 46.8%, 74.4%, 34% and 21.3%, respectively. The most common persistent deciduous tooth was the second maxillary incisor, whereas the most commonly missed tooth was the first mandibular premolar, which was bilateral in 75% of affected skulls. Dental calculus was not observed on skulls below 6 months, while the incisor tooth was the most affected tooth by dental attrition. Conclusions: The Nigerian local pig, like other breeds, is susceptible to and has dental pathologies. The data obtained from this study will be beneficial to farmers, as early detection of dental abnormalities will promote productivity and reduces economic losses in pig husbandry. It will also be useful to researchers, especially those using pigs in Nigeria as a model for translation research and comparative dental studies.
... Understanding the basic principles of color and its practical application is also challenging [8]. Dental practitioners should have a good understanding of the etiology and clinical presentation of tooth discoloration to make the right diagnosis and select the most appropriate treatment for each case [9]. ...
... Another new classification is given based on the type of color [9] Black: Black discoloration has also been found in people using iron supplements, containing high amounts of iodine, and iron foundry workers as well. This pigmentation usually occurs in people with poor oral hygiene. ...
Article
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In the present modern society, There is a growing consciousness about the appearance among both men and women. The importance towards the esthetics has tremendously increased. Due to the recent advancements and growing awareness about esthetics, people are eager to know how dentistry would help in enhancing their smiles.The overall feeling of appearance is influenced by their appearance of the dentition. The appearance of the dentition is of concern to a large number of people seeking dental treatment and the colour of the teeth is of particular cosmetic importance. Tooth discoloration presents two major challenges to a dentist. The first challenge is to ascertain the cause of the stain and the second is its management. Discoloration may be limited to a single tooth or several teeth in a single arch or it may be generalized and evident on all of the teeth. Main key for the treatment lies in recognition of actual cause for the discoloration. In some cases, scaling and polishing the teeth will improve the situation; however, more extensive treatment often is needed to achieve a satisfying result.
... [4] Peck CC, Goulet J-P, Lobbezoo F, et al. Introduction: Tooth discolouration is a common subject of aesthetic dissatisfaction for which patients seek dental care [1,2]. Discolouration can be extrinsic (chromogenic agents deposited on the tooth surfaceenamel), intrinsic (chromogens deposited within the bulk of the toothdentin), and internalised discolouration, a combination of both [1,2]. ...
... Introduction: Tooth discolouration is a common subject of aesthetic dissatisfaction for which patients seek dental care [1,2]. Discolouration can be extrinsic (chromogenic agents deposited on the tooth surfaceenamel), intrinsic (chromogens deposited within the bulk of the toothdentin), and internalised discolouration, a combination of both [1,2]. Different factors can be accountable for dental staining, such as certain medicines, smoking, some foods/beverages (e.g. ...
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Introduction Tooth discolouration is a common subject of aesthetic dissatisfaction for which patients seek dental care [1 Mortazavi H, Baharvand M, Khodadoustan A. Colors in tooth discoloration: a new classification and literature review. Int J Clin Dent. 2014;7(1):17–27. [Google Scholar],2 Thomas MS, Denny C. Medication-related tooth discoloration: a review. Dent Update. 2014;41(5):440–447.[Crossref], [PubMed] , [Google Scholar]]. Discolouration can be extrinsic (chromogenic agents deposited on the tooth surface – enamel), intrinsic (chromogens deposited within the bulk of the tooth – dentin), and internalised discolouration, a combination of both [1 Mortazavi H, Baharvand M, Khodadoustan A. Colors in tooth discoloration: a new classification and literature review. Int J Clin Dent. 2014;7(1):17–27. [Google Scholar],2 Thomas MS, Denny C. Medication-related tooth discoloration: a review. Dent Update. 2014;41(5):440–447.[Crossref], [PubMed] , [Google Scholar]]. Different factors can be accountable for dental staining, such as certain medicines, smoking, some foods/beverages (e.g. coffee, tea, wine), poor oral hygiene (e.g. chromogenic bacteria), advancing age, trauma or disease [3 Kumar A, Kumar V, Singh J, et al. Drug-induced discoloration of teeth: an updated review. Clin Pediatr. 2012;51(2):181–185.[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]]. Medicines known to discolour teeth, especially during tooth development, include antibiotics, antihistamines, antihypertensives, antipsychotics and fluoride [2 Thomas MS, Denny C. Medication-related tooth discoloration: a review. Dent Update. 2014;41(5):440–447.[Crossref], [PubMed] , [Google Scholar],3 Kumar A, Kumar V, Singh J, et al. Drug-induced discoloration of teeth: an updated review. Clin Pediatr. 2012;51(2):181–185.[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]]. Yet, there are numerous drugs with scarce information in literature about its potential for tooth discolouration. To the best of our knowledge this is the first report of a patient´s tooth discolouration by staining, suspected to result from a prescribed magistral formula (MF) for weight loss. Materials and methods This study details a case of a non-smoking 51-year-old Caucasian woman presenting severely stained teeth and a clinical history of depression and pre-obesity, medicated with escitalopram (20 mg; antidepressant) and loflazepate (2 mg in SOS; anxiolytic). The patient referred taking hard gelatine capsules for weight loss (once daily for 3 weeks), prescribed as a MF; each unit was composed of chlordiazepoxide (8 mg; anxiolytic), phenolphthalein (PhP; 65 mg; laxative), furosemide (20 mg; diuretic), metformine (280 mg; antidiabetic), bupropion (120 mg; antidepressant), artichoke extract (110 mg; allegedly choleretic and diuretic), Citrus aurantium extract (150 mg; claimed stimulant and thermogenic). Written consent for data use was obtained from the patient. Results Several teeth presented discolouration by staining as dark brown spots, which together with the clinical history, allowed the establishment of aetiology and selection of treatment. The dental cleaning procedure (with ultrasound and final polishing with a zirconium silicate particles-based prophylaxis paste, without fluoride) was effective. Slimming MF was discontinued and staining did not reappear (up to 3 months), even though the patient maintained her other habits. Neither drugs, nor botanicals, in the patient’s MF were identified in literature as tooth stain-causing molecules. Discussion and conclusions The colour and type of staining is consistent with deposition of chromogens in tooth crests. Xerostomia, a common side-effect of the antidepressants, may have potentiated the chromogens' deposition, although the medicine did not enter in close contact with teeth. A systemic manifestation of the drug, as a result of a combination of intrinsic and extrinsic factors, is also possible. Stains may have originated from tainted plant extracts (containing tannins or uncontrolled/unlabeled heavy metals − Fe, Cu, Cd, Sn − due to phytogeography; contaminants) or PhP (an acid–base titration reagent, changing colour according to pH), here used as a stimulant laxative, withdrawn from medicines in many European countries due to its carcinogenic potential. The hypotheses raised warrant further investigation and clarification of the role of drugs/botanicals and contaminants in tooth staining.
... According to the research of Alp et al., after one week, all of the specimens had significant colour changes, with a steady increase for the other immersion periods [49]. The discolouration effect of the artificial saliva was investigated by a number of authors, and the results showed that there was a slight decrease in the delta E values with the progress of time [50]. This rate shows only a light degree of discolouration, which indicates a negligible change in the optical stability of the tested specimens. ...
Article
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Three-dimensional printed denture base resins are relatively new materials, and their properties need to be thoroughly investigated to assess whether they can be used clinically. The aim of the current study was to evaluate the colour stability of 3D printed and conventional denture base resins after immersion in different staining solutions. A total of 200 specimens were manufactured from two types of materials: 3D printed dental resin NextDent Denture 3D+ (NextDent, 3D Systems, the Netherlands) and heat-polymerized PMMA Vertex (3D Systems, the Netherlands), which were immersed in four types of colourants—artificial saliva, coffee, red wine and coke (n = 25). For measuring the colour changes (CIE-L*a*b* system), a SpectroShade Micro spectrophotometer (SpectroShade, Oxnard, CA, USA) was used. After seven days (T1), 14 days (T2) and 21 days (T3), the mean ∆E values were calculated and compared by the Bonferonni post hoc test. The data were processed using the statistical software SPSS 26. The level of significance for rejecting the null hypothesis was fixed at p < 0.05. The highest mean values for ∆E were found for both types of dental resin in red wine, and the lowest mean values for ∆E were found for 3D printed specimens in artificial saliva. The 3D printed denture base resin demonstrated better colour stability than the conventional acrylic materials. The staining effect correlated with the immersion time, with the red wine and coke having the strongest chromogenic impact and the period with the highest colour changes being 21 days.
... Better results were evaluated for the type of porcelain teeth. These studies showed that the denture teeth's composition and fabrication affect the colour stability [50]. The main reasons for the differences could be related to the type of polymerization, the level of residual monomer, or initiators such as dibenzoyl peroxide [51]. ...
Article
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This study investigated the colour stability of three dimensional (3D)-printed and conventional denture teeth after immersion in different colourants. A total of 60 artificial maxillary central incisors were selected from three types of materials: 3D-printed dental resin (NextDent, 3D Systems, Soesterberg, The Netherlands), prefabricated acrylic teeth in Ivostar Shade (Ivoclar Vivadent, Schaan, Liechtenstein), and SpofaDent Plus in shade A2 (SpofaDental, Jičín, Czechia). These were immersed in four types of colourants at room temperature (23 °C ± 1 °C), including artificial saliva (pH = 6.8) as a control group, coffee, red wine, and Coca-Cola (n = 5). The temperature and the pH of the colouring agents were maintained throughout all immersion periods. After 7 days (T1), 14 days (T2), and 21 days (T3), the ∆E values were measured with a SpectroShade Micro (SpectroShade, Oxnard, CA, USA) spectrophotometer. Their means were then calculated and compared by two-way ANOVA. The independent factors, immersion time and different staining solutions, as well as the interaction between these factors, significantly influenced ΔE. The highest and the lowest mean ∆Es were recorded for prefabricated teeth in red wine, and 3D-printed teeth in artificial saliva, respectively. All the specimens demonstrated an increased colour change at T1 compared to T3, and the difference in mean ∆E was statistically significant.
... Spectrophotometers can be defined as the most accurate, useful and applicable in everyday practice devices. They measure the amount of light energy reflected from an object at intervals of 1 to 2.5 mm for the entire visible spectrum [31]. These devices consist of a light source, a light scattering device, an optical measuring system, a detector and a device for converting the received light into a signal that can be subsequently analyzed. ...
Article
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The aim of this paper is to review the available literature on the different methods for color stability determination of CAD/CAM milled and 3D printed resins for denture bases. The methodology included applying a search strategy, defining inclusion and exclusion criteria and selecting studies to summarize the results. Searches of PubMed, Scopus, and Embase databases were performed independently by three reviewers to gather the literature published between 1998 and 2022. A total of 186 titles were obtained from the electronic database, and the application of exclusion criteria resulted in the identification of 66 articles pertaining to the different methods for color stability determination of CAD/CAM acrylic resins for denture bases. Color change in dental materials is clinically very important for the dental operator, as it determines the clinical serviceability of the material. Discoloration of the denture bases can be evaluated with various instruments and methods. Dental resins may undergo color changes over time due to intrinsic and/or extrinsic factors. The extrinsic factors are considered the more frequent causes of color changes. According to a number of studies, CAD/CAM fabricated acrylics have achieved better color stability than the conventional PMMA (polymethyl methacrylate) resins.
... Nowadays, dental bleaching is one of the important reasons for referring to dentists. [1] Parents, on the other hand, pay more attention to the color of their children's teeth, and children are more alert to their appearance than before and tend to look like people with white teeth. Dental discoloration reduces self-confidence and causes embarrassment and social problems and is psychologically harmful. ...
Article
Background: Charcoal toothpastes can whiten teeth through abrasion. The purpose of this study was to determine the level of whitening and abrasiveness of charcoal toothpastes in permanent teeth. Materials and Methods: In this in vitro study, 30 premolars were polished, sectioned, mounted, and stored for 5 days in a coffee solution at 37°C. The color and surface profile of the teeth were measured by spectrophotometry and a profilometric device, respectively. The specimens were divided into 3 groups of 10 and were brushed 2000 times (equivalent to 3 times a day for 1.5 months) in a brushing machine using 20 g of each toothpaste (Bencer, Beverly, and Colgate) mixed with 40 ml of distilled water. The color and surface profile were remeasured. Bonferroni test and repeated measures analysis of variance (ANOVA) were used to examine the abrasion. One-way ANOVA was used to assess the whitening. Results: The three toothpastes caused changes in the surface profile (P = 0.0001). ΔE was equal to 3.3 (within the acceptable range) in all groups (95% confidence interval). There was no significant difference in abrasion (P > 0.05) and color change (P = 0.884) among toothpastes. Conclusion: The results of this study showed that all the three used toothpastes have the abrasive and whitening effect on the samples significantly. The differences between the toothpastes were not significant.
... Discoloration of the teeth is frequently seen in the general population (1) . Young individuals are obsessed with their physical appearance and many attractive smiles are troubled by some type of simple defect that can be corrected easily, either on an individual tooth or on all teeth (2) .There has been an increase in the number of people seeking treatment for dental stains. ...
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Aims: was to evaluate the effect of microabrasion on teeth, to determine the effect of using 2 types of composite resins and influence of storage time on microleakage of composite restorations after microabrasion before making a restoration. Materials and Methods: Fourty premolar teeth extracted were used, the teeth were microabrased and composite restorations were made at certain times after microabrasion according to the different groups of the study, a standard cavity was prepared on the two surfaces of the teeth that were restored with either a microhybrid or nanoceramic composite restoration, the teeth were subjected to thermocycling, and sectioned buccolingually longitudinally . Marginal leakage was evaluated using a dye penetration method. Results: Least microleakage scores were observed when the teeth were restored with out microabrasion, microleakage increased after microabrasion with no signicant difference for the occlusal site for both materials, while a significant difference was seen in favor of Tetric N ceram at the cervical sites. No difference in microleakage scores were observed regardless of the time of restoration after microabrasion, there was no significant difference in microleakage scores depending on the type of the material. Conclusion: given the limitations of this study, there was an increase in levels of micro-leakage after microabrasion of teeth, regardless of the time of application of the restoration, microleakage was higher in gingival margins in all the groups, and no significant difference in microleakage scores depending on the type of material
Article
Background: The color of teeth in each individual varies greatly in which it is influenced by the color of dentin and enamel. The most frequent tooth discoloration that happened is caused by extrinsic stains like coffee. Coffee consumption habits are increasing along with the level of creativity in serving coffee. Nowadays, coffee with conventional methods like black/Turkish coffee and manual brewing methods such as drip brewing and espresso become popular coffee that are fancied by Indonesian people. Exposure to chromogenic substances and the acidic nature of coffee can cause the formation of pores in enamel and facilitate the deposition of dyes, which cause the color changes. Aim: The aim of this research was to analyze the effect of brewing methods on tooth discoloration. Method: This research was a true experimental study with a pre-post test control group design. Twenty eight post-extracted first premolar teeth samples divided into 4 groups for drip, espresso, black coffee and control by implementing random allocation. All samples were immersed in each coffee brewing group for 3 hours, 6 hours, and 9 hours. The teeth color was measured using a Chromameter based on the CIE L*a*b system. Statistical tests used Kruskal Wallis and Mann-Whitney test. Result: The Kruskal Wallis test showed differences in the color change ∆a * between the four groups (p < 0.05). Mann-Whitney test indicated a significant difference between the treatment group (drip, espresso, and black coffee group) and the control group (p < 0.05). Conclusion: Drip coffee, espresso and black coffee brewing methods can affect tooth discoloration, especially affects the red discoloration. But there is no difference in the effect of the drip, espresso, and black coffee brewing methods on tooth discoloration.
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Introduction Bruxism is defined as a repetitive jaw-muscle activity characterised by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible [1 Lobbezoo F, Ahlberg J, Raphael KG, et al. International consensus on the assessment of bruxism: report of a work in progress. J Oral Rehabil. 2018;45(11):837–844.[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]]. Its effects can be deleterious to the oral tissues and restorations, which highlights the importance of insight towards the fundamental aspects of occlusion in each patient. Dentists should therefore study and examine the individual occlusal schemes in order to plan and treat these patients [2 Lobbezoo F, Zaag JVD, Selms MKAV, et al. Principles for the management of bruxism. J Oral Rehabil. 2008;35(7):509–523.[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]]. Materials and methods Patient, male, 22 years old, with tooth wear compatible with bruxism. The diagnosis was made based on a multiple level of sensibility determined by the 2018 Bruxism Consensus of possible, probable or definitive diagnosis of bruxism. We applied a specific sleep bruxism questionnaire [3 Winocur E, Uziel N, Lisha T, et al. Self-reported bruxism – associations with perceived stress, motivation for control, dental anxiety and gagging. J Oral Rehabil. 2011;38(1):3–11.[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]] plus a clinical examination and questionnaire about clinical signs and symptoms based on the Diagnostic Criteria for Temporomandibular Disorders [4 Peck CC, Goulet J-P, Lobbezoo F, et al. Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. J Oral Rehabil. 2014;41(1):2–23.[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]]. After we applied an intra oral red coloured device for evaluation of bruxism during sleep for two, Bruxchecker®, and at the same time the patient slept with an electromyography device in the temporal muscle called Grindcare® with recording of audio and video during sleep. All the assumptions of the Helsinki Declaration have been fulfilled and an informed consent for clinical case of Clinica Dentária Egas Moniz approved by the ethic commission of Instituto Universitário Egas Moniz. Results We have a positive diagnose for definitive bruxism confirmed with 15.6 grindings/clenching bursts per hour on the first night and 4.7 grindings/clenching bursts per hour on the second night, with audio and video we could have the perception of sounds compatible with problems of the respiratory system but absence of sounds and images compatible with tooth grinding. Clinically signs of tooth attrition were observed as well as tongue and cheek indentations, our patient also answered positively to the specific sleep bruxism questionnaire. The Bruxchecker® was helpful to see the dental wear movements. Discussion and conclusions Polysomnography is the gold standard for the diagnosis of sleep bruxism. However, electromyography supplemented with audio and video recordings is increasingly advocated as an equally valid method. The existence of a device like Grindcare® which measures the number of muscles bursts per hour associated with clinical examination allows to give a definitive bruxism diagnosis if used for a determined number of nights. Bruxchecker® and Grindcare® results were somewhat confusing on both nights but this is due to extrinsic factors. The result was a definitive sleep bruxism diagnose according to the last bruxism consensus of 2018.
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Eruption of green, discolored teeth affecting the primary dentition has been described in association with congenital viral infection, sepsis, hemolytic jaundice, and cholestasis. The purpose of this paper was to present the cases of 3 extremely low birth weight preterm infants who were noted to have green teeth at the corrected ages of 10 to 12 months. All had a history of prolonged conjugated hyperbilirubinemia during their time in neonatal intensive care. For infants with prolonged conjugated hyperbilirubinemia, extreme preterm birth and/or extremely low birth weight may be additional risk factors predisposing to the eruption of green teeth in later infancy.
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The new edition of this highly successful volume continues to offer readers with a systemized and objective approach to the practice of oral and maxillofacial medicine. Winner of the Royal Society of Medicine and Society of Authors Book Award in the category of New Authored Book (2004), and Highly Commended in the British Medical Association Book Awards (2009), this volume is ideal for senior dental students, dental practitioners and for trainees and practitioners in oral medicine, surery, and pathology in particular.
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The endemic hypoplasia of the permanent teeth known as chronic endemic dental fluorosis, or mottled enamel, is a water borne disease associated with the ingestion of toxic amounts of fluorides in the water used for cooking and drinking during the period of calcification of the affected teeth. The permanent teeth in particular are affected, although in areas of medium to marked severity the signs of mottled enamel are at times observable on certain of the deciduous teeth.The causative factor of mottled enamel is operative during the period of tooth development. Hence the affected teeth erupt, showing the characteristic markings of the hypoplasia. Normally calcified teeth erupt showing a smooth, glossy, translucent structure, usually of a pale creamy white color. Teeth affected with mottled enamel, on the contrary, erupt showing a dull, chalky white appearance which in many instances later take on a characteristic brown stain, the frequency of brown
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Ahmed HMA, Abbott PV. Discolouration potential of endodontic procedures and materials: a review. International Endodontic Journal, 45, 883–897, 2012. Advances in endodontic materials and techniques are at the forefront of endodontic research. Despite continuous improvements, tooth discolouration, especially in anterior teeth, is considered an undesirable consequence following endodontic treatment as it creates a range of aesthetic problems. This article aims to discuss the intrinsic and internalized tooth discolouration caused by endodontic procedures, and to address the discolouration potential of materials used during root canal treatment, including root canal irrigants, intra-canal medicaments, endodontic and post-endodontic filling materials. In addition, the discolouration patterns caused by combined endodontic and nonendodontic aetiological factors are discussed. The recommended guidelines that should be followed by dental practitioners to prevent and manage tooth discolouration are also outlined.
Article
Black tooth stain in children has been associated commonly with a low caries experience. The present study aimed to to compare salivary factors and caries indices in children with and without black tooth stain and to investigate the relationship between caries and caries associated salivary factors in these children. Salivary flow rate, pH, buffering capacity, total calcium and phosphorus were determined. Calcium and phosphorus levels were assayed by Inductive Coupled Plasma with Atomic Emission Spectrometry. DMFT and dft indices were evaluated according to WHO criteria. Significantly higher levels of salivary buffering capacity and calcium, and lower flow rate were found in children with black tooth stain compared with those of without black tooth stain (p < 0.01, p = 0.044 and p = 0.037, respectively). The differences in phosphorus and pH were not significant between the groups. The dft index was found to be significantly lower in children with black tooth stain than children without black tooth stain (p = 0.030). However, DMFT did not change between the groups. There is no relationship between salivary parameters and caries indices in children with black tooth stain. It is suggested that low caries tendency seen in children with black tooth stain may be associated with high salivary calcium and buffering capacity.