Extrinsic stains and management: A new insight

Abstract

Tooth discoloration is a frequent dental finding associated with clinical and esthetic problems. It differs in
etiology, appearance, composition, location and severity. Knowledge of the etiology of tooth staining is of
importance to dental surgeons in order to enable a correct diagnosis. The practitioners should also have the
basic understanding of the mechanism of stain formation before carrying out any treatment procedures which will facilitate better treatment outcomes. Recently there have been advancements in the various treatment options in this field. This article is a comprehensive review on extrinsic stains and the treatment modalities.

Full text

J. Acad. Indus. Res. Vol. 1(8) January 2013 435
©Youth Education and Research Trust (YERT) Sruthy Prathap et al., 2013
ISSN: 2278-5213
Extrinsic stains and management: A new insight
Sruthy Prathap, H. Rajesh, Vinitha. A. Boloor and Anupama. S. Rao
Dept. of Periodontics, Yenepoya Dental College, Nithyananda Nagar Post, Deralakatte, Mangalore-575018, Karnataka, India
sruthysreekumar@yahoo.com; +91 9980433489
______________________________________________________________________________________________
Abstract
Tooth discoloration is a frequent dental finding associated with clinical and esthetic problems. It differs in
etiology, appearance, composition, location and severity. Knowledge of the etiology of tooth staining is of
importance to dental surgeons in order to enable a correct diagnosis. The practitioners should also have the
basic understanding of the mechanism of stain formation before carrying out any treatment procedures which
will facilitate better treatment outcomes. Recently there have been advancements in the various treatment
options in this field. This article is a comprehensive review on extrinsic stains and the treatment modalities.
Keywords: Tooth discoloration, esthetic problems, tooth staining, treatment outcomes, extrinsic stains.
Introduction
It is widely recognized that today’s youth and
appearance oriented culture prizes an attractive smile
and white teeth, with sales of whitening products rising
dramatically in the past decade. Some of these products
are sold as ‘over the counter products’ and have no
professional involvement in their application. The correct
diagnosis for the cause of color discoloration is important
as, invariably, it has profound effect on treatment
outcomes. It would seem reasonable, therefore that
dental practitioners have an understanding of the
etiology of tooth color discoloration in order to make a
diagnosis and enable the appropriate treatment to be
carried out (Aryan, 2005). Dental stains differ in etiology,
appearance, composition, location, severity and degree
of adherence. Attraction of material to the tooth surface
plays a critical role in the deposition of extrinsic dental
stains. However the mechanism that determines the
adhesion strength is not completely understood (Tirth et
al., 2009).
Normal variations in tooth color: A basic understanding of
the elements of tooth color is important for many aspects
in dentistry. Teeth are typically composed of various
colors and a gradation of color occurs in an individual
tooth from gingival margin to the incisal edge of the
tooth. Near the gingival margin, tooth often has a darker
appearance because of close approximation of the
dentine below the enamel. In most people canine teeth
are darker than central and lateral incisors and young
people characteristically have lighter teeth, particularly in
the primary dentition. Teeth become darker as a
physiological age change; this may be partly caused by
laying down of secondary dentin, incorporation of
extrinsic stains and gradual wear of enamel allowing a
greater influence on color of the underlying dentine. Also
and tooth wear and gingival recession can directly or
indirectly affect tooth color. The science of color is
important in dentistry with regard to color perception and
description, and can be improved with training.
The viewing conditions are extremely important and
variables such as the light source, time of day,
surrounding conditions and the angle of tooth viewed
affects the apparent tooth color. Light is composed of
differing wavelengths and the same tooth viewed under
different conditions will exhibit a different color, a
phenomenon known as metamerism (Watts and Addy,
2001).
Classification of tooth discoloration
Intrinsic discoloration: Intrinsic discoloration occurs
following a change to the structural composition or
thickness of the dental hard tissues. The normal color of
teeth is determined by the blue, green and pink tints of
the enamel and is reinforced by the yellow through the
brown shades of dentine beneath. A number of metabolic
diseases and systemic factors are known to affect the
developing dentition and cause discoloration as a
consequence. Local factors such as injury are also
recognised.
1. Alkaptonuria.
2. Congenital erythropoietic porphyria.
3. Congenital hyperbilirubinaemia.
4. Amelogenesis imperfect.
5. Dentinogenesis imperfect.
6. Tetracycline staining.
7. Fluorosis.
8. Enamel hypoplasia.
9. Pulpal haemorrhagic products.
10. Root resorption.
11. Ageing.
Extrinsic discoloration: Extrinsic color discoloration is
outside the tooth substance and lies on the tooth surface
or in the acquired pellicle.
The origin of the stain may be:
1. Metallic.
2. Non-metallic.
REVIEW ARTICLE

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©Youth Education and Research Trust (YERT) Sruthy Prathap et al., 2013
Table 1. Types of stains, source, appearance and common sites.
Types of stains Source and predisposing factors Appearance on the tooth surface Common sites
Brown stain
The color is due to tannin. Intake of coffee
and tea. Causes-insufficient brushing.
Inadequate cleansing action of dentifrice.
Chromogenic bacteria.
Thin, translucent, acquired
bacteria free pigment pellicle.
(1) Buccal surface of
maxillary molars.
(2) Lingual surface of
mandibular incisors.
Black stain
(1) Coal tar combustion products due to
smoking.
(2) Penetration of pits and fissures, enamel
and dentine by tobacco juices.
Iron containing oral solutions.
Exposure to iron, manganese, silver.
These are tenacious dark brown
or black with brown
discoloration.
(1)Involves all the teeth.
(2) Common on pits and
fissures.
Black stain
More common in woman, may occur in
excellent oral hygiene. High tendency for
recurrence:
(1) Associated with low incidence of caries
in children.
(2) Chromogenic bacteria-e.g. Gram
positive rods-Actimomyces species
Bacteriodes melaninogenicus.
Iron containing oral solutions.
This is a thin black line, firmly
attached on tooth surface.
(1) Near the gingival
margin of facial and
lingual surface of a tooth.
(2) Diffuse patch on the
proximal surface may be
seen.
Orange stain
Chromogenic bacteria Serratia marcescens,
Flavobactraium lutescens. Exposure to
chromic acid fumes in factory workers
(Manuel et al., 2010). Both facial and lingual
surface of anterior teeth.
Green stain
Children are frequently affected due to
inadequate daily plaque removal,
chromogenic bacterial deposits or
decomposed hemoglobin.
(i)Fluorescent bacteria- Penicillium.
(ii)Fungi-Aspergillus.
(iii) Associated with children with T. B. or
cervical lymph node.
3) Copper salts in mouth rinse (Manuel
et al., 2010).
4) Exposure to copper and nickel in the
environment in factory workers (Manuel
et al., 2010).
These are green or greenish
yellow stains of considerable
thickness. This type of stain is
considered as stained remnants
of enamel cuticles.
Facial surface of
maxillary anterior teeth.
Metallic stain
This type of stain is caused by metals and
metallic salts. Metals are penetrated into
tooth substances and produces permanent
decolonization or they bind with pellicle and
produce surface stain.
Source of metals:
(I) Introduction of metals into oral cavity.
(II) Metal containing dust inhalation by
worker.
(III)Oral administration of drugs.
Some metals that cause’s
stains:
Copper dust-Green stain
Iron dust-Brown stain
Magnesium-Black stain
Silver- Black stain Iodine- Black
stain Nickel- Green stain.
Metal penetrating into tooth
substance causes permanent
discoloration where as that bind
with pellicle causes surface stain
(Manuel et al., 2010).
Generalised appearance
on all the teeth.
Yellowish brown stains
Chlorhexidine has affinity for sulfate and
acidic groups such as those found in
pellicle, plaque constituents, carious lesion
and bacterial cell wall. So it is retained into
oral cavity and stained oral tissues
(Manuel et al., 2010).
Yellowish brown to brownish.
The stains are not permanent in
nature. It can be removed with
proper brushing with dentifrice.
(i)Cervical and
interproximal area of the
teeth.
(ii) Plaque and other
restorations.
(iii) Dorsum of tongue.
Yellow Essential oil and phenolic mouth rinse
(Manuel et al., 2010).
Golden brown stains Due to use of stannous fluoride (Mosby's
Dental Dictionary, 2008).
Violet to black Presence of potassium permanganate in
the mouth rinses (Manuel et al., 2010).
Red-black
Use of betel leaves and nuts commonly
seen in adults and children in the Eastern
Hemisphere, where betel leaves and nuts
are used as stimulants (Mosby's Dental
Dictionary, 2008).
Thick, hard, dark brown or black
extrinsic stain left on the teeth
after chewing the leaves of the
betel palm (Mosby's Dental
Dictionary, 2008).
Facial, lingual and
occlusal surfaces of both
anterior and posterior
teeth.

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Internalised discoloration: Internalised discoloration is the
incorporation of extrinsic stain within the tooth substance
following dental development. It occurs in enamel defects
and in the porous surface of exposed dentine. The routes
by which pigments may become internalised are:
1. Developmental defects.
2. Acquired defects.
a) Tooth wear and gingival recession.
b) Dental caries.
c) Restorative materials (Manuel et al., 2010).
Extrinsic tooth discoloration: The causes of extrinsic
staining can be divided into two categories;
a) Direct extrinsic tooth staining: Those compounds
which are incorporated into the pellicle and produce a
stain as a result of their basic color.
b) Indirect extrinsic tooth staining: Those which lead to
staining caused by chemical interaction at the tooth
surface.
Direct extrinsic tooth staining has a multi-factorial
aetiology with chromogens derived from dietary sources
or habitually placed in the mouth (Fig. 1). These organic
chromogens are taken up by the pellicle and the color
imparted is determined by the natural color of the
chromogen. Tobacco smoking and chewing are known to
cause staining, as are particular beverages such as tea
and coffee (Fig. 2 and 3). The color seen on the tooth is
thought to be derived from polyphenolic compounds
which provide the color in food (Pearson, 1976). Indirect
extrinsic tooth staining is associated with cationic
antiseptics and metal salts. The agent is without color or
a different color from the stain produced on the tooth
surface. Interest in the mechanisms of extrinsic tooth
staining was rekindled in 1971 with the observation by
Flotra et al. (1971) that tooth staining increases with the
use of chlorhexidine (Fig. 4).
Classification of extrinsic tooth staining
Extrinsic tooth discoloration has usually been classified
according to its origin, whether metallic or non-metallic
(Gorlin and Goldman, 1971).
Non-metallic stains: The non-metallic extrinsic stains are
adsorbed onto tooth surface deposits such as plaque or
the acquired pellicle. The possible aetiological agents
include dietary components, beverages, tobacco,
mouthrinses and other medicaments. Chromogenic
bacteria have been cited in children (Fig. 5 and 6).
Particular colors of staining are said to be associated
with certain mouths, for instance, green and orange in
children with poor oral hygiene and black/brown stains in
children with good oral hygiene and low caries
experience (Theilade et al., 1973). Conclusive evidence
for the chromogenic bacterial mechanism has not been
forthcoming. The most convincing evidence for the
extrinsic method of tooth staining comes from the
differing amount of stain found in a smokers and
non-smokers (Ness et al., 1977).
Fig. 1. Stains due to betel nut.
Fig. 2. Smoking stains.
Fig. 3. Tobacco stains.
Fig. 4. Chlorhexidine stains.

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Metallic stains: Extrinsic staining of teeth may be
associated with occupational exposure to metallic salts
and with a number of medicines containing metal salts
(Addy and Roberts 1981). The characteristic black
staining of teeth in people using iron supplements and
iron factory workers is well documented (Nordbo et al.,
1982). In a study conducted on school going students of
black stain scraping was taken from 5 students and it
was subjected to analysis for trace elements. Trace
elements analysis was done by (ICP) Inductively
Coupled Photo spectrometry. Out of 5 scrapings,
3 showed presence of ferrous ions of about 2.56%,
calcium ions 17.15% and magnesium ions 0.72%, while
the remaining 2 samples showed calcium 14.86%,
magnesium ions 0.82% and no presence of ferrous ions
(Tirth et al., 2009). Copper causes a green stain in
mouthrinses containing copper salts (Waerhag et al.,
1984) and in workers in contact with the metal in
industries (Dayan et al., 1983) (Table 1).
A number of other metals have associated colors such
as potassium permanganate producing a violet to black
color when used in mouth rinses; silver nitrate salt used
in dentistry causes a grey color, and stannous fluoride
causes a golden brown discoloration (Ellingsen et al.,
1982). It was previously thought that the mechanism of
stain production was related to the production of the
sulphide salt of the particular metal involved (Moran
et al., 1991). This is perhaps not surprising since the
extrinsic stain coincided with the color of the sulphide of
the metal concerned. However, those proposing the
hypothesis appeared not to consider the complexity of
the chemical process necessary to produce a metal
sulphide. As mentioned earlier the interest aroused by
the staining noted with use of chlorhexidine mouth rinse
has prompted renewed interest in the mechanism of
stain formation. For this reason most of the research into
stain formation has been carried out on chlorhexidine,
although there are other antiseptics which cause staining
to a lesser extent and the mechanism proposed could be
applicable to staining found with polyvalent metals. The
characteristic staining of the tongue and teeth noted by
Flotra and co-workers in 1971 is not peculiar to
chlorhexidine, it has been reported in other cationic
antiseptics, the essential oil/phenolic mouth rinse
‘Listerine’ and following prolonged use of delmopinol
mouthrinses (Claydon et al., 1996). There is great
individual variation in the degree of staining from person
to person, this makes explanation more difficult as it may
be caused by intrinsic factors, differences in extrinsic
factors or both. No longer accepted theories of stain
formation with chlorhexidine include breakdown of
chlorhexidine in the oral cavity to form parachloroaniline
(Gjermo et al., 1973) and also that chlorhexidine may
reduce bacterial activity such that partly metabolised
sugars were broken down and then degraded overtime to
produce brown-colored compounds (Davies et al., 1970).
Most recent debate has centered around three possible
mechanisms.
Fig. 5. Orange stains due to chromogenic bacteria.
Fig. 6. Black stains due to chromogenic bacteria.
Non-enzymatic browning reactions: Berk (1976)
suggested that the protein and carbohydrate in the
acquired pellicle could undergo a series of condensation
and polymerisation reactions leading to
colordiscoloration of the acquired pellicle. Chlorhexidine
may accelerate formation of the acquired pellicle and
also catalyze steps in the Maillard reaction (Yates et al.,
1993). Observation of furfurals, intermediate products in
Maillard reactions, in brown-discolored pellicle has lent
support to the theory (Nordbo, 1977), but the evidence is
inconclusive (Eriksen et al., 1985). Moreover, these
authors did not consider at all the same staining
phenomenon observed with the numerous other
antiseptics.
The formation of the pigmented sulphides of iron and tin:
this theory suggests that chlorhexidine denatures the
acquired pellicle to expose sulphur radicals. The
exposed radicals would then be able to react with the
metal ions to form the metal sulphide. Warner and
coworkers have shown increased levels of iron in
chlorhexidine treated individuals compared with water
controls, no evidence was shown for tin (Warner et al.,
1993). They then went on to conclude that the
chromophore was not a sulphide, but a sulphur
containing organic compound and metal ion complex and
that chlorhexidine promoted the deposition of sulphate
proteins. However, somewhat anomalously although the
amount of stain and iron levels were increased.

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Management of stains
Proper diet and habits: Extrinsic staining caused by
foods, beverages, or habits (eg, smoking, chewing
tobacco, coffee and tea) is treated with a thorough dental
prophylaxis and cessation of dietary or other contributory
habits to prevent further staining (Azer et al., 2011).
Tooth brushing: Effective tooth brushing twice a day with
a dentifrice helps to prevent extrinsic staining. Most
dentifrices contain an abrasive, a detergent, and an
anti-tartar agent. In addition, some dentifrices now
contain tooth-whitening agents.
Over-the-counter products: Three types of whitening
toothpastes are manufactured. The first type, based on
use of an abrasive to remove extrinsic stains, has been
available for many years (Haywood and Robinson, 1997;
Council on Scientific Affairs, 1997). All toothpastes,
however, contain some abrasives and are capable of
potentially removing stains whether they are labeled
"whitening" or not. Toothpastes with a high content of
abrasives should not be recommended for daily use.
Secondly, the newer whitening toothpastes contain a
bleaching agent, such as peroxide, but the Council on
Scientific Affairs of the American Dental Association
(ADA) does not recommend them for long term use
(Hosoya and Johnston, 1989). Lastly, cosmetic
toothpastes, containing titanium dioxide, cover extrinsic
stains like paint covers a wall and do not change the
internal tooth color (Haywood and Robinson, 1997).
Professional tooth cleaning: Some extrinsic stains may
be removed with ultrasonic cleaning, rotary polishing with
an abrasive prophylactic paste, or air-jet polishing with
an abrasive powder (Weaks et al., 1984). However,
these modalities can lead to enamel removal; therefore,
their repeated use is undesirable (Croll, 1977).
Ultrasonic and sonic scaling: Ultrasonic and sonic
scalers are referred to as power-driven scalers. The
small, quick vibrations in combination with a water flow
give us a whole new level of effectiveness in removal of
deposits on the tooth surface. The benefits of ultrasonic
scaling include increased efficiency of calculus removal
and less need for hand scaling. High vibrational energy
generated in the oscillation generator is conducted to the
scaler tip, causing vibrations with frequencies in the
range of 25,000–42,000 Hz. The amplitude ranges from
10 to 100 μm. Micro-vibration crushes and removes
calculus under cooling water. Ultrasonic and sonic
scalers vary in their efficiency in removing calculus from
the tooth surfaces. Sonic scalers are air-turbine units that
operate at low frequencies ranging between 3000 and
8000 cycles per sec (Cps). Tip movement and the effect
of root surfaces can vary significantly depending on the
shape of the tip and type of the sonic scaler. In general,
tip movement is orbital. Sonic scalers provide a simple
and inexpensive mechanism.
Sonic scalers have a high intensity noise level because
of the release of air pressure needed for movement of
the tip of the sonic hand-piece (American Academy of
Pediatric Dentistry, 2000).
Selective polishing: Selective polishing involves polishing
only the areas of stains. In this procedure, the dental
auxiliary can select specific teeth to be polished using a
prophylactic angle and rubber cup with a fine paste, and
can brush the remaining teeth with a toothbrush to
remove bacterial biofilm on tooth surfaces. According to
the American Academy of Periodontology (2000) and
other sources (Mellberg, 1979), polishing for
approximately 30 sec with a prophylactic paste
containing pumice can remove between 0.6 µm and 4
µm of the outer enamel. The outer surface of the enamel
contains a natural component of fluoride, with the highest
amount of fluoride concentrated on its surface. When
using a prophylactic angle with a prophylactic cup on this
enamel-rich surface, the dental assistant may not only
remove the fluoride layer, but also introduce a rough
surface and/or scratches on the tooth surface, which can
contribute to the further harboring of bacteria on these
surfaces.
Benefits: Minimises irreversible loss of enamel. Prevents
damage to the restorative surfaces requires less time.
More time can be spent for patient education.
Prophylactic paste: Prophylactic pastes contain abrasive,
water, humectants, binder, sweetener, flavoring and
coloring agents. Prophylaxis polishing agents are
available in two basic forms: dry powders, also referred
to as flours that must be mixed with a liquid (water,
fluoride, or mouth rinse) and commercially prepared
polishing pastes that are available in bulk or individual
unit doses. Dry powders or flours are not graded
according to grit, rather they are graded in order of
increasing fineness: F, FF, and FFF. Powders or flours
with no wetting agent represent the greatest quantity of
abrasives that can be applied per unit of time and they
create excessive heat. Therefore, the use of dry
abrasives or powder on a dry polishing cup is
contraindicated due to the potential for thermal injury to
natural teeth. The grit of commercially prepared polishing
pastes is graded from fine to coarse, based on a
standard sieve through which the particles pass (Wilkins,
2009). The types of abrasive particles used in polishing
pastes vary among the commercial varieties and from
one grit size to another, yet there is no industry standard
to define what these terms mean or what size the
abrasive particle must be. The types of abrasive particles
used in commercial prophylaxis polishing pastes include
flour of pumice, aluminum oxide, silicon carbide,
aluminum silicate, silicon dioxide, carbide compounds,
garnet, feldspar, zirconium silicate, zirconium oxide,
boron, and calcium carbonate (Wilkins, 2009).

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Others include emery, perlite, and silica. Commercially
prepared prophylaxis polishing pastes combine
abrasives with a binder, humectants, coloring agent,
preservatives, and flavoring agents. Manufacturers
generally do not disclose the amount of ingredients in
their polishing pastes because the information is
proprietary. However, it is general knowledge that
pumice and glycerin are the most commonly used
ingredients in commercially prepared polishing pastes.
Some commercially prepared polishing pastes contain
fluoride. Fluoride in prophylaxis polishing pastes is not a
replacement for a fluoride treatment (Wilkins, 2009).
Unfortunately, many dental hygienists use whatever type
of polishing paste is available on every patient,
regardless of the grit size. Even worse is the fact that
some dental hygienists subscribe to the "coarse grit
theory." The premise for this ill-advised idea is that the
use of the coarsest polishing paste available will remove
the heaviest amounts of stain as well as the lightest
amounts, thus saving time. Providers who polish in this
fashion ignore the professionally recommended method
of using the polishing grits in a progression of coarse,
medium, and fine applications, which is supported by
well-established science and is applied not only in health
care but in mechanical polishing procedures in a variety
of industries. In an ideal setting the progression from
coarse to fine paste is best. In clinical practice, if a dental
hygienist is using medium grit paste it is best to follow
with fine grit. Coarse grit polishing pastes can produce
hypersensitivity, rough tooth surfaces, pastes are only
needed in situations of heavy stain.
Proof of the widespread use of the "coarse pumice
theory" lies in the published sales of coarse grit as the
leading selling brand of polishing paste; 80% of polishing
paste sales are in coarse grit and 10% are in medium
grit. Coarse grit polishing pastes may remove and
accelerate staining and the retention of dental plaque
and calculus.
Port polisher: Port polisher consisting of orangewood
points is helpful in situations when aerosol should not be
produced, in abraded cervical areas, or when electricity
is not available. However slowness of the procedure and
amount of hand strength for instrumentation are its
drawback. Although highly abrasive in nature, polishing
or finishing strips present an option for
inter-proximal areas or line angles but should be
cautiously used to avoid cutting of soft tissues.
New options and available evidence
For many years, the most notable advancement in
traditional polishing was the introduction of prophy
pastes in unit-dose cups. Since then, new formulations of
commercial polishing pastes have been added to the
polishing armamentarium. For more than a decade,
commercial polishing pastes that contain perlite as an
abrasive ingredient have been available.
Prophy pastes containing perlite make claims that the
abrasive particles break down and become less abrasive
under pressure. Scientific evidence supports the fact that
the abrasive agents in these products do break down
under load (pressure). However, scientific evidence
supports the fact that most abrasives in polishing pastes
break down under pressure. Amorphous calcium
phosphate (ACP) products that include a polishing paste
claim to remineralize enamel subsurface carious lesions.
These products are missing a body of research in vivo.
The current research exists only in vitro. Three scientific
questions need to be addressed: Is it possible to burnish
an ingredient such as ACP into enamel with a polishing
product that is abrasive and meant to remove stain?
What are the true benefits of ACP or similar products
such as casein phosphopeptide-amorphous calcium
phosphate (CPP-ACP) over the known remineralization
properties of fluoride? Why has fluoride been added to
some of these ACP and CPP-ACP products? Polishing
paste with calcium sodium phosphosilicate is a new
development. Calcium sodium phosphosilicate is a
bioactive glass that releases calcium and phosphorus
ions rapidly and is currently being incorporated into other
dental products. Scientific clinical research is not
available to support the claim that this product
immediately relieves dentinal hypersensitivity. Some in
vitro studies of ACP, CPP-ACP, and calcium sodium
phosphosilicate-containing products do indicate clinical
promise; however, the lack of in vivo research to date is
the matter of concern. It will be a leap forward if the
additives to polishing pastes can remineralize carious
lesions and immediately relieve hypersensitivity on a
long-term basis.
There is no doubt that polishing pastes are going through
a period of renewal as manufacturers are looking for
ways to add remarkably active ingredients to such an
inexpensive and easy delivery system. It is challenging,
however, for manufacturers to add these novel
ingredients while retaining the expected performance of
polishing pastes. Hopefully, the future will bring about
this much-needed research and the introduction of new
products (Litkowski et al., 1997).
Air jet polishing: Air polishing was first introduced to the
dental community in the late 1970s as a mechanism to
quickly and easily remove extrinsic stain and soft
deposits. It also helps minimize hand, wrist, neck and
eye fatigue like a cavitron tip, by helping to remove stain
quicker than scaling and polishing the conventional way.
Air polishing uses a water soluble sodium bicarbonate
mixture to help in the removal of stain and plaque during
a routine hygiene appointment. Air polishing is great to
help in the removal of stain due to smoking, coffee, tea,
chlorhexidene and other extrinsic factors. Aluminum
trihydroxide is an alternative solution to the sodium
bicarbonate for patients, they are sodium restricted and
have heavily stained enamel. Avoid use on dentin,
cementum and restorative resins.

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Use of the air polisher for stain removal involves three
steps: patient selection and preparation, clinician
preparation, and the actual clinical technique.
Air polishing should follow a careful review of the
patient's medical and dental history, and a thorough
examination of the oral hard and soft tissues. Indications
and contraindications, effects on hard tissues,
restorations, safety, and alternative uses should be
reviewed prior to treatment planning the use of the air
polisher. Preparation of the patient should include an
explanation of the procedure, removal of contact lenses,
an anti-microbial rinse, application of a lubricant to the
lips, placement of safety glasses or a drape over the
nose and eyes, and placement of a plastic or disposable
drape over the patient's clothing. Operators should use
universal precautions, including protective apparel, a
face shield or safety glasses with side shields, gloves,
and a well-fitting mask with high-filtration capabilities.
The actual air polishing technique includes proper patient
and operator positioning for adequate access and direct
vision, use of high-speed suction if an assistant is
available, or use of the saliva ejector and
aerosol-reduction device when working alone. The
suction orifice of the saliva ejector should be as close as
possible to the tip. It also may enhance patient comfort if
moistened 2x2 gauze square is placed over the tongue
or lip in the area being polished. Rapid, sweeping strokes
are recommended, with the tip directed at a 60 angle to
the tooth for anterior teeth, 80 for posterior teeth, and a
90 for occlusals. Cupping the lip with the forefinger and
thumb allow the water to pool in the vestibule for easier
evacuation and minimal aerosol dispersion. Polishing two
to three teeth at a time by fully depressing the foot pedal,
then rinsing the teeth and tongue by pressing the foot
pedal half way increases efficiency and minimizes the
saline taste. A systematic approach to polishing all teeth
will increase efficiency. Polishing for five seconds or less
per tooth is usually adequate to remove most of the
stains.
Conclusion
Tooth discoloration is a frequent dental findings
associated with clinical and esthetic problems. It differs in
etiology, appearance, composition, location and severity.
Knowledge of the etiology of tooth staining is of
importance to dental surgeons in order to enable a
correct diagnosis to be made when examining a
discolored dentition and allows the dental practitioner to
explain to the patient the exact nature of the condition. In
some instances, the mechanism of staining may have an
effect on the outcome of treatment and influence the
treatment options the dentist will be able to offer to
patients. Dental auxiliaries must use good judgment
when considering coronal polishing and practice
preventive procedures as the standard of care, which
means that treatment must be individualized.
Patients may not be aware of the effects of rubber-cup
polishing on the enamel, so it is the job of the dental
assistant to educate patients on the philosophy of
polishing based solely on need.
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