Dental Stain

‫ ﺳﮭﺎ أﺳود دھش اﻟﻌزاوي‬.‫م‬

B.D.S, MSc. Periodontology
 Dental Stain
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• Pigmented deposits on the tooth surface.

• There has been a recent increase in interest in the treatment of tooth

staining and discolorations as shown by the large number of tooth
whitening agents appearing on the market.

• The correct diagnosis for the cause of discoloration is important as,

invariably, it has a profound effect on treatment outcomes.
 COLOUR AND COLOUR PERCEPTION
• Teeth are typically composed of a number of colours and a gradation of
colour occurs in an individual tooth from the gingival margin to the incisal
edge of the tooth. The gingival margin often has a darker appearance
because of the close approximation of the dentine below the enamel.
• In most people canine teeth are darker than central and lateral incisors and
younger people characteristically have lighter teeth, particularly in the
primary dentition. Teeth become darker as a physiological age change; this
may be partly caused by the laying down of secondary dentine, incorporation
of extrinsic stains and gradual wear of enamel allowing a greater influence on
colour of the underlying dentine.
 CLASSIFICATION OF TOOTH DISCOLOURATION
• INTRINSIC DISCOLORATION
• Intrinsic discoloration occurs following a change to the structural
composition or thickness of the dental hard tissues.
• 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 recognized:
• 1.Alkaptonuria
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• 2. Congenital erythropoietic porphyria

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• 3. Congenital hyperbilirubinaemia
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• 4. Amelogenesis imperfecta
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• 5. Dentinogenesis imperfecta
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6. Tetracycline staining
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7. Fluorosis
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8. Enamel hypoplasia
9. Pulpal haemorrhagic products (Trauma
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to tooth)

10. Root resorption

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11. Ageing
• EXTRINSIC DISCOLORATION After tooth eruption
• Extrinsic discoloration is outside the tooth substance and lies on the
tooth surface or in the acquired pellicle. The origin of the stain may
be:
adsorption (Deposition Pellicle)
• 1. Metallic (Mouth wash) (chemical reaction)
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• 2. Non-metallic
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• INTERNALIZED DISCOLORATION
• Internalized discoloration is the incorporation of extrinsic stain within the
tooth substance following dental development. It occurs in enamel defects
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and in the porous surface of exposed dentine. The routes by which
pigments may become internalized are:
1. Developmental defects
Flourosis/toxicity of flor
Flor
change hydroxyapetate to
2. Acquired defects
I florrapetite (make the tooth
a) Tooth wear and gingival recession resistance to acid)
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b) Dental caries
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c) Restorative materials
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 THE MECHANISMS OF TOOTH DISCOLORATION
• INTRINSIC TOOTH DISCOLORATION occurs during tooth development and
results in an alteration of the light transmitting properties of the tooth
structure.
• 1. Alkaptonuria: This inborn error of metabolism results in incomplete
metabolism of tyrosine and phenylalanine, which promotes the buildup of
homogentisic acid. This affects the permanent dentition by causing a brown
discolouration.
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Porphyrin Hemoglobin
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• 2. Congenital erythropoietic porphyria:
• Metabolic disorder in which there is an error in porphyrin metabolism leading
to the accumulation of porphyrins in bone marrow, red blood cells, urine,
faeces and teeth causes A red-brown discolouration of the teeth.
• 3. Congenital hyperbilirubinaemia: The breakdown products of haemolysis will
cause a yellow-green discolouration.
• 4. Amelogenesis imperfecta: In this hereditary condition, enamel formation is
disturbed with regard to mineralization or matrix formation and is classified
accordingly. The appearance depends upon the type of amelogenesis
imperfecta, varying from the relatively mild hypomature 'snow-capped' enamel
to the more severe hereditary hypoplasia with thin, hard enamel which has a
yellow to yellow-brown appearance.
• 5. Dentinogenesis imperfecta: Dentine defects may occur genetically or
through environmental influences.
• The teeth are usually bluish or brown in color, and demonstrate
opalescence on transillumination. The pulp chambers often become
obliterated and the dentine undergoes rapid wear, once the enamel has
chipped away, to expose the amelo-dentinal junction.
• 6. Tetracycline staining: Systemic administration of tetracyclines during
development is associated with deposition of tetracycline within bone and
the dental hard tissues. Tetracycline is able to cross the placental barrier and
should be avoided from 29 weeks in uterus until full term to prevent
incorporation into the dental tissues. Since the permanent teeth continue to
develop in the infant and young child until 12 years of age, tetracycline
administration should be avoided in children below this age and in breast-
feeding and expectant mothers. Teeth affected by tetracycline have a
yellowish or brown-grey appearance
• 7. Fluorosis:
• This may arise endemically from naturally occurring water supplies or from
fluoride delivered in mouth rinses, tablets or toothpastes as a supplement.
The severity is related to age and dose.
• The enamel is often affected and may vary from areas of flecking to diffuse
opacious mottling, whilst the color of the enamel ranges from chalky white
to a dark brown/black appearance. The brown/black discoloration is
posteruptive and probably caused by the internalization of extrinsic stain
into the porous enamel. Fluoride only causes fluorosis in concentrations of
greater than 1 ppm in drinking water.
I part per million

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systemic y
• 8. Enamel hypoplasia: This condition may be localized or generalized. The
most common localized cause of enamel hypoplasia is likely to occur
following trauma or infection in the primary dentition.Such localized
damage to the tooth-germ will often produce a hypoplastic enamel defect,
which can be related chronologically to the injury. Disturbance of the
developing tooth germ may occur in a large number of fetal or maternal
conditions eg maternal vitamin D deficiencies, rubella infection, drug
intake during pregnancy and in pediatric hypocalcaemic conditions. Such
defects will be chronologically laid down in the teeth depending on the
state of development at the time of interference. There may be pitting or
grooving which predisposes to extrinsic staining of the enamel.
• 9. Pulpal hemorrhagic products:
• The discoloration of teeth following severe trauma was considered to be
caused by pulpal hemorrhage.
• Haemolysis of the red blood cells would follow and release the hem group
to combine with the putrefying pulpal tissue to form black iron sulphide.
• The depth of dentinal penetration determines the degree of
discolouration.
• 10. Ageing: The natural laying down of secondary dentine affects the light-
transmitting properties of teeth resulting in a gradual darkening of teeth
with age.
 EXTRINSIC DISCOLORATION
• The causes of extrinsic staining can be divided into two categories; those
compounds which are incorporated into the pellicle and produce a stain as a
result of their basic colour, and those which lead to staining caused by
chemical interaction at the tooth surface.
• Direct staining has a multi-factorial aetiology with chromogens derived from
dietary sources or habitually placed in the mouth. Tobacco smoking and
chewing are known to cause staining, as are particular beverages such as tea
and coffee.
• Indirect extrinsic tooth staining is associated with cationic antiseptics and
metal salts. The agent is without colour or a different colour from the stain
produced on the tooth surface.
Extrinsic tooth discolouration has usually been classified according to its
origin, whether metallic or nonmetallic.
• Non-metallic stains: The non-metallic extrinsic stains are adsorbed onto tooth
surface deposits such as plaque or the acquired pellicle. The possible etiological
agents include dietary components, beverages, tobacco…etc.
• Metallic stains: Extrinsic staining of teeth may be associated with occupational
exposure to metallic salts and with a number of medicines containing metal salts,
e.g:
-The characteristic black staining of teeth in people using iron supplements and iron
foundry workers.
- potassium permangenate producing a violet to black colour when
used in mouth rinses;
- silver nitrate salt used in dentistry causes a grey colour, and
- stannous fluoride causes a golden brown discolouration.
 INTERNALIZED DISCOLORATION
• The stains taken up into the body of enamel or dentine are the same as that
causing extrinsic tooth discolouration, including in particular dietary
chromogens and the by-products of tobacco smoking. Dental defects
permitting the entry of chromogenic material can be classified under the
headings of 'developmental and acquired'.
• 1. Developmental defects: The most important defects are considered under
the 'intrinsic tooth discoloration' section. developmental defects may expose
dentine either directly or later caused by early loss of enamel as in
dentinogenesis imperfecta. Chromogens are then able to enter the dentine
directly or facilitated almost certainly by the tubule system.
• 2. Acquired defects:
• a) Tooth wear and gingival recession :Tooth wear is usually considered to be a
progressive loss of enamel and dentine due to erosion, abrasion and attrition. As
enamel thins the teeth become darker as the colour of dentine becomes more
apparent. Once dentine is exposed the potential of chromogens to enter the body
of the tooth is increased.
• b) Dental caries: The various stages of the carious process can be recognized by
changes in colour as the disease progresses. For instance, the initial lesion is
characterized by an opaque, white spot. The hard, arrested lesion is black having
picked up stain from exogenous sources.
• c) Restorative materials including amalgam: Some of the materials used in
restorative dental treatment may have an effect on the color of teeth.Eugenol and
phenolic compounds used during root canal therapy contain pigments which may
stain dentine. Some of the poly antibiotic pastes used as root canal medicaments
may cause a darkening of the root dentine. Clinicians are familiar with the dark grey
to black colour of dentine following the removal of a long-standing amalgam
restoration.
HOW CAN WE PREVENT TEETH DISCOLORATION?

• By making a few simple lifestyle changes, you may be able to prevent

teeth discoloration. For example, if you are a coffee drinker and/or
smoker, consider cutting back or quitting all together. Also, improve
your dental hygiene by brushing and flossing regularly and getting
your teeth cleaned by a dental hygienist every 6 months.
 WHAT TREATMENT OPTIONS ARE AVAILABLE TO
WHITEN TEETH?
• Dental treatment of tooth discoloration involves identifying the etiology and
implementing therapy.
• A- Diet and habits: Extrinsic staining caused by foods, beverages, or habits
(e.g., smoking, chewing tobacco) is treated with a thorough dental rophylaxis
and cessation of dietary or other contributory habits to prevent further
staining.
• B- 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.
• C- 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. However, these modalities can lead to enamel
removal; therefore, their repeated use is undesirable.
• D- Bleaching (tooth whitening): Bleaching includes 2 types of techniques: vital and
nonvital.
• Vital bleaching: Currently, the bleaching agents most commonly used are
carbamide and hydrogen peroxide.
• In office "power" bleaching involves the use of a 15-40% hydrogen peroxide
solution and must be performed 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.
• home bleaching systems may be used alone or in combination with in-office
bleaching. The systems must be used under the careful supervision of dentists or
dental hygienists. Patients apply a 10-22% carbamide peroxide solution into a
custom-made mouth guard. After repeated daily and/or nightly (often while
patients sleep) applications for 2-6 weeks, the teeth are gradually bleached.
• Non vital bleaching
• Non vital bleaching is indicated for the treatment of teeth with
discoloration secondary to pulpal degeneration. This technique involves
placing a mixture of 30% hydrogen peroxide and sodium perborate into the
pulp chamber for as long as 1 week.
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Thank you