Discoloration of teeth

The colour of teeth ranges from yellowish to greyish-white depending on enamel translucency. Discoloration f teeth  is defined as any change in colour or any departure from normal colour.

Types of discoloration of teeth

·         Extrinsic-it occurs due to stains, restorative material, nasmyth membrane, tea, tobacco & chromogonic   bacteria.

·         Intrinsic-it is due to stains with in enamel & dentin because of deposition of certain substances.

Classification of discoloration of teeth

A.      Changes that occur solely in structure & thickness of dental hard tissue

1.       Disturbances in dental hard tissue

·         Dentinogenesis  inferfecta

·         Dental fluorosis

·         Enamel opacities

2.       Physiologic colour change due to age

3.       Obliteration of pulp chamber

4.       Internal resorption

5.       Initial enamel caries

B.      Discoloration caused by coloring agents taken up by dental hard tissue

1.       During formation

§  Erythoblastic fetalis

§  Neonatal hepatitis

§  Congenital defects in the bile duct

§  Tetracycline administration

§  Congenital heart disease

2.       After eruption

§  Endogenous

Ø  Necrosis of pulp

Ø  Haemorrhage  of pulp

§  Exogenous

Ø  Amelogenesis imperfecta

Ø  Turner tooth

Ø  Dental caries

Ø  Denudation of  dentin

Ø  Attrition,abrasion & errosion

3.       Various discolouring agents

·         Food & drink like coffee , tea, wines

·         Tobacco

·         Betal nut

·         Restorative material

·         Medicaments like silver nitrate, tin, iron & iodine

·         Blood pigment like hemosiderin,bilurubin & bilveridin

·         Products from decomposition of materials

Dentinogenesis imperfecta

Dentinogenesis Imperfecta

• Dentinogenesis imperfecta (hereditary Opalescent Dentin) is usually a genetic disorder associated with teeth development. This problem leads to the teeth to be stained (most often a new blue-gray or even yellow-brown color) as well as translucent. The teeth are usually weakened than normal, causing them to be at risk of fast wear, breakage, as well as loss. These problems could affect equally primary (baby) teeth as well as permanent teeth. This disorder comes in an autosomal dominant pattern, which implies 1 copy in the changed gene within every cell is sufficient cause the condition.
•  Teeth appear bluish grey or amber in shade.

Dental fluorosis

Dental fluorosis

·          Normal fluoride level is 1 PPM in water.

·          Increased quantity leads to mottled or pitted enamel

·          In mild form tooth shows white flecks.

·          In moderate, it shows white spot

·          In severe form, it leads to yellow or brown discoloration of enamel with pitting

Enamel opacities

·         It is due to disturbance in deposition of enamel matrix.

·         Teeth appear chalky opaque with white spots.

Physiologic colour change due to age

Color of teeth becomes darker with age due to increased amount of dentin formation, loss of enamel & staining.

Obliteration of pulp chamber

·         It can be because of trauma

·         Teeth appear darker than normal

·         Maxillary incisors are commonly affected

Internal resorption

Internal resorption

• It may cause pink spot in the tooth due to visibility of vascular tissue from enamel.Also called pink tooth of mummery
• The internal resorption can be immobile by Pulp extirpation procedure. plasticized gutta-percha is used for obturating the open canals.After that crown can be given.

Initial enamel caries

It is manifested as white chalky area on the tooth surface.

Erythroblastic fetalis

·         It is haemolytic anemia of new born caused  due to transmission of antibody & excessive hemolysis of erythrocytes.

·         Erythoblastic fetalis is based on immunization of Rh-negative mother by Rh +blood cells of the fetus or perhapsby previous transfusion of Rh positive blood cells.The mother produces anti Rh agglutinin.The passage of this soluble substance in to the circulation of infant causes complete destruction of the fetal erythrocytes.

·         Blood pigments like bilirubin & biluverdin are formed which are deposited resulting in stain.

·         Color varies from mgreen, bluish green to yellow brown or gray.

·         The color pigment is gradually reduced which is noticed particularly in the anterior teeth.

·         It is transient situation & usually will correct itself with eruption of permanent teeth.

Neonatal hepatitis

Yellowishn brown color of primary teeth caused by incorporation of bile pigment during formation of enamel & dentin.

Porphyria

·         It is autosomal recessive condition.

·         An inborn error in metabolism in which hepatoporphyrin circulating in blood  is seen in urine,teeth & bone.

·         The deciduous & permanent teeth may show red or brown or pinkinsh discoloration which is called as erythodontia

·         Ultraviolet light, the teeth always exhibit red fluorescence. It occurs due to its physical affinity of calcium phosphate.

Congenital defect in bile duct

In children with this disease, the primary teeth may become discoloured by bile pigment, generally green discoloration is seen

Tetracycline administration

Tetracycline staining

·         Discoloration of either deciduous or permanent dentition may occur as a result of prophylactic or therapeutic regimen instituted for pregnant females or infants.

·         May cause discoloration during formation period, tetracycline react with calcium to form calcium orthophosphate complex.

·         The minimum amount required to produce discoloration is 21/mg/kg/body weight.

·         It also caused enamel hypoplasia which may be seen in primary as well as permanent teeth.

·         It is deposited during mineralisation & can be demonstrated as golden fluorescence in ultraviolet light, which is more intense in dentin than enamel. Bands are more intense towards DEJ

·         It shows yellow to brown discoloration of teeth. The location coincides with the part of youth developing at the time of administration of tetracycline.

·         Hypoplasia & brown discoloration of teeth can occur if given in third trimester.

·         It is usually seen with different colour in different form of tetracycline

§  Chlortetracycline-grey brown

§  Oxytetracycline-yellowish

§  Demeclocycline-Yellow

§  Doxytetracycline-there is no changes in teeth color.

Congenital heart diseases

·         Children with cyanotic heart disease may have maxillary incisors of milk color or bluish violet color.

·         It may be due to mouth breathing or poorly oxygenated blood.

Amelogenesis imperfecta

Amelogenesis Imperfecta

• Amelogenesis imperfecta presents with abnormal formation of enamel . Enamel is composed mostly mineral, that is formed and regulated by proteins from it. Amelogenesis imperfecta is caused by the malfunction in the proteins within the enamel: ameloblastin, enamelin, tuftelin and amelogenin.
• Teeth exhibit mottled, opaque white brown yellow discoloration

Turner's tooth

Turner's tooth

In some cases of enamel hypoplasia there may be mild discoloration of enamel & it is centered to single tooth & is called turners tooth.Cementum gets deposited in area of deficient enamel formation, which gets stained & appears as yellowish brown colour.

Dental caries

Arrested caries shows dark discoloration while in case of active caries, there is yellowish discoloration of teeth.Pit & fissue caries show bluish discoloration as they undermine the enamel.

Tobacco chewing or smoking causes yellowish brown to black discoloration of teeth.
Treatment

no smoking

The treatment of discoloration of teeth depends on the etiology of the discoloration of teeth.Medical treatment may also be needed:-

1.  Diet and habits: Extrinsic staining due to food items, beverages, habits (like, smoking, chewing tobacco) is treated with a good dental prophylaxis and cessation of dietary or any other habits to avoid further discoloration of teeth.
2. Toothbrushing: Efficient toothbrushing twice daily using a tooth paste aids you to prevent extrinsic discoloration of teeth. The majority of tooth paste incorporate an abrasive, a detergent, and an antitartar agent. Additionally, some tooth paste now contain tooth-whitening agents also.
3. Professional tooth cleaning: A few extrinsic stains could possibly be removed with ultrasonic cleaning, polishing with the abrasive prophylactic paste, or air jet polishing with an abrasive powder.
4. Enamel microabrasion: This method involves the rotary application of a mixture of weak hydrochloric acid and silicon carbide particles in the water-soluble paste. The resultant surface is smooth and possesses a glazed appearance. Enamel microabrasion is indicated for the removal of superficial intrinsic discoloration of teeth., which include ,fluorosis and decalcifications secondary to orthodontic brackets or bands. Enamel microabrasion can be employed in bleaching.
5. Bleaching (tooth whitening): Bleaching is a safe, easy, and inexpensive modality that is used to treat many types of discoloration of teeth. Usually, bleaching is not indicated for the treatment of discoloration of the primary teeth. Bleaching includes 2 types of techniques: vital and nonvital.

• Vital bleaching
• Bleaching of vital teeth is indicated primarily for patients with generalized yellow, orange, or light brown extrinsic discoloration of teeth  (including chlorhexidine staining), even though it may be useful in ameliorating mild cases of tetracycline-induced intrinsic discoloration of teeth  and fluorosis.
• the bleaching agents most often used are carbamide and hydrogen peroxide. When this is  applied in higher concentrations, the agents produce more significant bleaching than they do without these measures.
• In clinics "power" bleaching requires the use of a 15-40% hydrogen peroxide solution and should be done by a dental professional because careful isolation of the teeth is required to protect the soft tissues from the caustic effects of the bleaching agent.
• The use of home bleaching systems is currently becoming very popular, they could be used by itself or  in conjunction with in-office bleaching. The systems should be used under the careful supervision of dentists. Patients apply a 10-22% carbamide peroxide solution into a custom-made mouthguard. After repeated daily or nightly (often while patients sleep) applications for 2-6 weeks, the teeth are gradually bleached. Whitening strips, using a 5.3% hydrogen peroxide-impregnated polyethylene strip, offer an at-home alternative to the above methods and can be recommended for maintaining already whitened teeth.
• Whitening toothpastes, containing 1% or less peroxide, are minimally effective.
• With darker stains, the best results are achieved by using a blend of office and home bleaching systems. Most patients also require periodic re-treatment.
•  Approximately two thirds of patients have short-term, minor tooth sensitivity to cold and/or gingival irritation. Tooth surfaces, particularly exposed roots or enamel surfaces with defects secondary to incomplete amelogenesis, are porous to the bleaching agent and are prone to develop cold sensitivity. Gingival irritation usually relates to improper fitting of the custom-made mouthguard.
• Allergic attacks to the bleaching agent are exceedingly rare.
• No side effects are documented in pregnant or breastfeeding women or perhaps in patients who smoke however, bleaching is not advised in these patients.

Nonvital bleaching

• Nonvital bleaching is indicated for discoloration of teeth secondary to pulpal degeneration. This technique involves placing mix of 30% hydrogen peroxide and sodium perborate into the pulp chamber for as long as 1 week.

For nonvital bleaching, a tooth unrestored crown is good.

 6. Dental restorations

•  Discoloration of teeth by dental caries or dental materials require removing the caries or restorative materials, accompanied by proper restoration in the tooth. Partial (eg, laminate veneers) or full-coverage dental restorations enables you to treat generalized intrinsic discoloration of teeth bleaching isn't indicated or even in which the aesthetic results of bleaching don't meet the patient's expectations.

7. Patients with severe dental involvement could possibly be candidates for extractions, and after that either   partial or complete removable dentures implant-borne prostheses may be used