p e d i a t r i c d e n t a l j o u r n a l 2 3 ( 2 0 1 3 ) 4 4 e5 0

Available online at www.sciencedirect.com

Pediatric Dental Journal

journal homepage: www.elsevier.com/locate/pdj

Original Article

Application of a tooth-surface coating material to teeth with

discolored crowns

Takashi Hashimura, Aya Yamada*, Tsutomu Iwamoto, Makiko Arakaki, Kan Saito,
Satoshi Fukumoto
Division of Pediatric Dentistry, Department of Oral Health and Development Sciences, Tohoku University Graduate School of Dentistry,
Sendai 980-8575, Japan

article info abstract

Article history: Crown discoloration of permanent teeth is caused by trauma, periapical lesions of the
Received 10 December 2012 deciduous teeth, pharmaceuticals, and systemic diseases. Crown discoloration has been
Received in revised form treated with bleaching or crown restoration. However, these methods are not appropriate
4 March 2013 during the growth and development period of children.
Accepted 6 March 2013 In this study, we used BeautiCoat! (Shofu Inc., Kyoto, Japan), a tooth-surface coating
Available online 6 May 2013 material that contains high levels of controlled-release fluoride, that temporarily im-
proves crown color. We evaluated the effect of the primer on tooth-surface characteristics
Keywords: in addition to the coating agent’s shear bond strength, tooth-surface condition, and
Discolored teeth duration of attachment. Additionally, we surveyed patients’ satisfaction with the color
Tooth coating material improvement.
S-PRG filler The results showed no adverse effects of the primer on the enamel surface. The coating
Caries prevention material itself showed a high degree of shear bond strength. Based on observations of
shedding and fracturing in clinical applications, we found that the coating material
maintained long-term attachment if applied under conditions of strict moisture prevention
and it avoided areas of occlusion. Treated children and their parents were highly satisfied
with the color improvement. These results suggest that this coating material is appropriate
for improving the color of discolored teeth during childhood.
ª 2013 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.

1. Introduction reddish-brown coloring. Crowns can also be discolored by the

Esthetic problems due to discolored crowns are common in
pediatric clinical practice. Causes of crown discoloration
during the formation of permanent teeth include periapical
lesions due to severe cavities in deciduous teeth and enamel
formation disorders due to tooth trauma. Discoloration ranges
from white spots in mild cases to substance loss with dark
use of tetracycline antibiotics or systemic diseases during the
tooth formative period [1,2].
Such crown discoloration can be treated in adults with
crown restoration methods, such as resin, laminating ve-
neers, facing crowns, and bleaching treatments. However, it is
difficult to achieve esthetic improvement in young children
during their period of growth and development using methods

* Corresponding author. Tel.: þ81 22 717 8382; fax: þ81 22 717 8386.
E-mail address: yamada-a@dent.tohoku.ac.jp (A. Yamada).
0917-2394/$ e see front matter ª 2013 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.pdj.2013.03.011
 p e d i a t r i c d e n t a l j o u r n a l 2 3 ( 2 0 1 3 ) 4 4 e5 0
intended for adults. For instance, almost all at-home and in-
office bleaching procedures are not intended for young chil-
dren. Further, the use of irreversible crown restoration treat-
ments that require tooth preparation is not appropriate in
young children, because the gingival margin height has not
stabilized while the teeth are erupting or while the alveolar
bone is still forming. Therefore, a temporary treatment for
young children with crown discoloration is needed.
One such method is the “tooth manicure,” which uses ma-
terials that improve the color of teeth in a single day. However,
the organic solvents used in nail manicures are difficult to use
inside the oral cavity; therefore, the effects last for only 1e2 days,
and it is difficult to maintain long-term color improvement.
In 2004, White Coat! (Kuraray Medical Co., Osaka, Japan)
was developed, which is a tooth-coating material for exclusive
use in dental clinics. This material uses a self-etching primer,
and its adhesion durability is about 1 month. This product has
better durability compared to over-the-counter tooth mani-
cures [3,4].
Progress has since been made in developing materials with
better durability and good physical properties that cause little
damage to the tooth. Surface reaction type pre-reacted glass
ionomer (S-PRG) filler has been developed, which possesses
physical strength and high levels of controlled-release fluo-
ride [5]. The tooth-surface coating material BeautiCoat!
(Shofu Inc., Kyoto, Japan) contains this filler and is currently
used to treat discolored crowns [6]. Dental materials using S-
PRG filler include sealant materials [7], composite resin, or-
thodontic resin bonding system [8], denture base resin [9,10],
and root canal sealer [11]. Through the release and recharge of
fluoride and various other ions, cavities can be prevented in
the area of repair and neighboring teeth, and the adhesion of
plaque to the tooth surface can be suppressed [12,13].
This study investigated the shear-adhesion strength and
durability of BeautiCoat! in the oral cavity as well as the effect
of its tooth-surface primer on enamel surface characteristics.
Finally, a survey of patient satisfaction with color improve-
ment was also conducted.
2. Materials and methods
2.1. Effect of the primer used in the tooth-surface
coating material on enamel surface characteristics
Bovine tooth enamel specimens were subjected to no treat-
ment, the BeautiCoat! Primer treatment (3 s), or 37% phos-
phoric acid etching treatment (30 s). Enamel surface
characteristics were then observed and analyzed with a
scanning electron microscope (SEM; VE-7800, Keyence, Osaka,
Japan) under gold-evaporated conditions.
2.2. Evaluation of shear bond strength of the tooth-
surface coating material
Enamel, dentin, metal, and porcelain were prepared under the
following conditions before shear bonding strength (SBS) test.
A bovine tooth surface was placed in an acrylic ring, and the
ring was embedded in epoxy resin. The bovine tooth surface
was polished using #600 SiC paper to expose enamel or dentin.
45
Precious metal (a gold-silver-palladium alloy) was polished
using #600 SiC paper, and the sandblast was applied to the
surface of metal using alumina-sand of 50e100 mm. Porcelain
was polished using #600 SiC paper to expose flat surface.
The surface of bonding specimen was treated according to
the bonding method recommended by the manufacturer. A
mold (4 mm diameter, 0.2 mm height) was fitted onto the
treated surface, filled with the coating material paste (BW2)
and light-cured to obtain a test specimen for SBS testing. After
being stored in water at 37 " C and 2000 thermal cycling
(4e60 " C), the specimen was evaluated for its SBS before and
after thermal cycling using a universal testing machine.
2.3. Clinical evaluation of the tooth-surface coating
material
BeautiCoat! was applied to the teeth of 30 subjects (38 teeth;
upper central incisors and upper lateral incisors) with crown
discoloration believed to be caused by trauma or periapical
lesions of the deciduous teeth under the informed consent
from all parents. The patients were treated at the pediatric
dentistry department of Tohoku University Hospital (Miyagi
Japan) and Hashimura Dental Clinic (Saga, Japan).
The surfaces of the affected teeth were cleaned with a low-
speed cone brush. Primer A and primer B were placed in a dish 1
drop at a time and mixed with a disposable chip brush. The
mixed liquid was applied to the surface of the teeth. It was left
in place for 3 s or more and was then dried with low-pressure
air. Next, the previously selected color-tone paste (white
base, BW1e4; white opaque, WO/paint color; yellowish, A0.5,
A3) was applied uniformly to the surface of the tooth using a
special BC applicator. This was irradiated for 20 s using a visible
light-curing unit (G-light, GC, Tokyo, Japan), and the non-
polymerized layers were removed with dry gauze. Finally,
Gloss Refine (Shofu Inc., Kyoto, Japan) was applied to the tooth
surface, which was then polished with a buffing disk and
washed.
For the clinical evaluation of the tooth-surface coating
material, shedding and partial fracturing of the tooth surface
were observed at 1 week, 1 month, and 3 months after coating
treatment. Photographs of the oral cavity were taken to eval-
uate fractures. Fractured areas covering less than 5% of the
surface area of the labial side of the tooth were classified as
small fractures, and those covering 5% or more of the surface
were classified as fractures.
During observation, affected teeth in which fractures
occurred were re-coated; at this point, these teeth were excluded
from the study. Moreover, if a tooth’s color made it difficult to
determine the presence of fractures through photographs or
surveys, a replica was made from a silicone impression, which
was then observed with a stereomicroscope (SZX12, Olympus,
Tokyo, Japan).
2.4. Satisfaction survey regarding the tooth-surface
coating material
A questionnaire was administered to the 30 affected children
and their parents. The questionnaire contained questions
concerning the level of satisfaction with the tooth-surface
coating material treatment of discolored teeth. The subjects
46 p e d i a t r i c d e n t a l j o u r n a l 2 3 ( 2 0 1 3 ) 4 4 e5 0

were surveyed immediately after the coating treatment, 1

month after treatment, and 3 months after treatment. The
possible responses were: a) very satisfied, b) satisfied, c)
neutral, and d) not satisfied.

3. Results

3.1. Effect of the primer used in the tooth-surface

coating material on enamel surface characteristics

We evaluated the effect of the primer that is used before

applying the tooth-surface coating material on enamel sur-
face characteristics. To examine the effect of primer on tooth,
the primer was applied to the enamel surface of bovine teeth.
After performing gold-evaporation treatment, the enamel was
observed under a SEM. The enamel surfaces treated with a
37% phosphoric acid solution displayed decalcification, and
the enamel rods were exposed as in previous reports (Fig. 1C).
However, in the group treated with the primer, there was no
marked decalcification of the enamel surface, and the surface
characteristics were similar to the control (untreated) group
(Fig. 1A and B). These results suggest that this primer has few
adverse effects on the enamel.
3.2. Evaluation of shear bond strength of the tooth-
surface coating material
In order to evaluate the SBS of the tooth-surface coating ma-
terial, the material was bonded to enamel, dentin, precious
metal, and porcelain using a brass ring, after which the SBS
was measured. SBS of 10 MPa or more was observed in enamel
and dentin 24 h after adhesion. Maintenance of high bond
strength was confirmed in the group that received thermal
Fig. 2 e The shear bond strength of the tooth-surface
coating material to enamel, dentin, precious metal,
porcelain, and resin were evaluated.
cycle treatment as well. SBS in precious metal and porcelain
was inferior to that of enamel and dentin (Fig. 2), but the
tooth-surface coating material displayed sufficient SBS more
than 10 MPa after a thermal cycle.
3.3. Clinical evaluation of the tooth-surface coating
material
After applying the tooth-surface coating material, shedding
and fracturing of the tooth surface were investigated. The
coating material was applied to the teeth of 32 subjects (38
teeth). Of these, investigations were conducted in 30 subjects
(36 teeth) 1 week after application, in 26 subjects (31 teeth) 1
month after application, and in 21 subjects (25 teeth) 3 months
after application. Shedding and fracturing were observed in 5
of 36 teeth (13.9%) 1 week after applying the tooth-surface

Fig. 1 e Scanning electron microscope micrographs of the enamel surface. (A) is the non-treated enamel surface. (B) and (C)
are the enamel surfaces after treatment by BeautiCoat! Primer (Shofu Inc., Kyoto, Japan) for 3 s and 37% phosphoric acid for
30 s respectively.
 p e d i a t r i c d e n t a l j o u r n a l 2 3 ( 2 0 1 3 ) 4 4 e5 0 47

Table 1 e Frequency of shedding and fracturing of the

tooth-surface coating material.
Patient Tooth None Fracture Fracture Fallout
no. no. (5%<) (5%>)

1 week 30 36 31 (86.1%) 3 (8.3%) 2 (5.6%) 0 (0%)

1 month 26 31 21 (67.7%) 8 (25.8%) 1 (3.2%) 1 (3.2%)
3 months 21 25 17 (68.0%) 5 (20.0%) 3 (12.0%) 0 (0%)

coating material, 10 of 31 teeth (32.2%) 1 month after, and 8 of

25 teeth (32.0%) 3 months after (Table 1). Most of the fracturing
was observed on the incisal margin and cervix of the incisors
(Fig. 3). In 1 case, there was complete shedding of the coating
material from the tooth surface, which occurred at 1 month
after application. In this case, the child was not satisfied with
the color of the application. The child attempted to remove
the coating material, which resulted in complete shedding of
the material. Thus, there were no cases of complete shedding
under normal conditions.
3.4. Satisfaction with the tooth-surface coating material
The affected teeth mainly involved white turbidness of the
labial surface of the upper incisors, tooth substantial defect in
the crown, or generalized crown discoloration caused by pulp
necrosis due to trauma. The subjects reported being “very
satisfied” and “satisfied” in 23 of 24 cases (95.8%) immediately
after the procedure, in 19 of 20 cases (95.0%) 1 month after,
and in 17 of 17 cases (100%) 3 months after (Fig. 4).
Although this is a preliminary study, color improvements
after treatment with the tooth-surface coating material were
examined in different cases. In one case involving white
turbidness of the labial surface of the tooth, there was a
marked difference in color on the borders of the turbid and
normal areas. Applying a highly transparent paint did not
Fig. 4 e Satisfaction with the tooth-surface coating material
was investigated immediately after the procedure, and 1
month after, and 3 months after.
sufficiently improve the tooth color, and the parent was not
satisfied with the result. Therefore, a white base with a lower
level of transparency was applied to the border areas to
obscure their edges, and the paint color was then applied. This
improved the parents’ level of satisfaction.
In a case involving brown-colored enamel hypoplastic
defect accompanied by substance loss of the labial surface of
the tooth, the white base with the lowest transparency, BW3,
was applied. After this, paint color A3 was used, which
resulted in color improvement (Fig. 5).
Fig. 6 shows a case in which trauma to the upper-left lateral
and central deciduous incisors at age 1 year 6 months led to
early loss of the tooth from pulp necrosis, which caused early
eruption of the permanent tooth (upper central incisor) at age
4 years 3 months. The prior trauma caused spots on areas of
low enamel formation. As there was a difference in color

Fig. 3 e Shedding and fracturing of the tooth-surface coating material from the tooth were observed using replica model. (A)
is frontal view of fractured materials, and (B) is another case. (B-a): frontal view and (B-b) is incisal view.
48 p e d i a t r i c d e n t a l j o u r n a l 2 3 ( 2 0 1 3 ) 4 4 e5 0

Fig. 5 e Clinical cases before and after treatment by the tooth-surface coating material to the case with white-colored
enamel hypoplastic defect.

between the crown of the permanent tooth and the deciduous
teeth, the subject desired color improvement of the anterior
teeth. Paint color A0.5, which was close to the crown color of
the deciduous teeth, was applied to the surface of the per-
manent tooth. Coating of the permanent tooth crown with A3
led to an even higher level of satisfaction. In this case, because
the tooth-surface coating was performed during eruption of
the tooth, a difference in level between the tooth-gingival
margin and the coating material was observed on the labial
side of the tooth cervix 10 months after application. Further, a
microscopic fracture was observed on the mesial periphery of
the coating material. This fractured area was re-coated, and
no fracturing was observed 4 months later. However, a new
fracture was observed in the incisal margin (Fig. 7).

Fig. 6 e Clinical cases before and after treatment by the tooth-surface coating material to the case with discolored
permanent tooth caused by the trauma of deciduous tooth.
 p e d i a t r i c d e n t a l j o u r n a l 2 3 ( 2 0 1 3 ) 4 4 e5 0
Fig. 7 e Clinical progress of the case treated by the tooth-surface coating material for the erupting tooth. This is the same
case as that shown in Fig. 6.
4. Discussion
S-PRG filler was developed as an advanced material that can
recharge and release fluoride and other ions. This PRG filler
possesses the excellent characteristics of both resins and glass
ionomer cements through its incorporation of resin-type
materials [14]. These materials are generally termed “giomer
products,” which are currently sold as composite resin,
bonding material, resin cement, sealant material, tooth-
surface coating material, and bonding material for use in
teeth straightening [15]. Furthermore, recent developments in
tooth-surface treatment agents have led to the development of
tooth-surface coating materials that use self-etching primers.
These have allowed for relatively long-term retention of the
coating materials on the tooth surface. This study investigated
a tooth-surface coating material that uses a self-etching
primer containing this S-PRG filler to treat teeth with dis-
colored crowns, which are frequently observed in pediatric
clinical practice.
The primer for the tooth-surface coating material used in
this study uses a methacrylate monomer 6-methacryloxyhex-
ylphosphonoacetate with an acidic base and an adhesive
monomer that is resistant to moisture. Observation under a
SEM demonstrated that this primer did not cause marked sur-
face decalcification of the enamel, and there was little damage
to the enamel. Thus, this gentle tooth-surface treatment ma-
terial is appropriate for use in the immature permanent teeth of
childhood. Further, the tooth-surface coating material had
sufficiently high bonding strength in shear bond tests and even
possessed high bonding strength with metal and porcelain
surfaces. This material is applicable for the repair of porcelain
fractures or discoloration as well as the esthetic improvement
of metal repairs. However, as this material has less bonding
than resin-type materials, it is a temporary method.
In actual clinical applications, apart from a single case where
the child intentionally removed the coating, no cases of natural
49
shedding were observed during 3 months of observation. In cases
where fracturing occurred, the fractures appeared mostly in the
incisal margins involved in occlusion. However, there were no
malocculusions, such as the edge-to-edge occlusion and cross bite
in these subjects. This suggests that fracture of coating materials
could be prevented by avoiding the incisal margin during the
coating procedure. In fractures near the gingival margin, perme-
ation of liquid from the gingival sulcus likely influenced bonding
strength; however, fractures were prevented in this area when the
procedure was conducted under complete moisture prevention.
Therefore, more stable, long-term tooth-surface coating can be
achieved by completely preventing moisture using a rubber dam
and adjusting the extent of coating in the incisal margin area.
Furthermore, this tooth-surface coating material contains
S-PRG filler, which can suppress bacterial plaque adhesion and
can recharge and control the release of fluoride and other ions.
The cavity-preventing effect of fluoride ions is well known, but
of other ions released by this filler, strontium ions are partic-
ular in their ability to resist acid release from dental plaque,
inhibit bone resorption, promote bone formation, induce
calcification in dentin, and seal dentinal tubules [7,16e19].
Based on these functions, coating tooth surfaces with this
material not only achieves esthetic improvement, but also can
increase acid resistance, remineralization, and suppress adhe-
sion of plaque and bacteria to the tooth surface [6]. Further, this
material showed higher fluoride release compared with con-
ventional sealant, but not glass ionomer cement (data not
shown). Thus, this coating material not only covers the surface,
but can also contribute to cavity prevention in the surrounding
area, which makes it appropriate for use in childhood. Indeed,
discolored portions of teeth have low calcification, and the
cavity rate tends to be high. Nevertheless, there were no cavities
observed in the affected teeth treated with this tooth-surface
coating or in the neighboring teeth.
Moreover, tooth discoloration caused by tetracycline anti-
biotics darkens over time due to the effect of ultra-violet rays
[20]. Although no such cases were included in this study,
50 p e d i a t r i c d e n t a l j o u r n a l 2 3 ( 2 0 1 3 ) 4 4 e5 0
application of this tooth-surface coating material could limit
the progression of discoloration by blocking ultra-violet rays
[21]. The degree of satisfaction with the tooth-surface coating
material among affected children and their parents was
extremely high in this study. Even in cases that involved frac-
tures, the fractures themselves did not influence the degree of
satisfaction, since the subjects were informed beforehand that
the procedure is a temporary method. Rather, because the
coating could be removed from the tooth to return it to its
normal state with almost no damage, the coating could be used
without worry, and color improvement could be tested easily.
Further, in a case of partial fracture of coating material, since it
is easily removable, it may be re-coated after removal.
In addition to the subjective evaluation of patient satis-
faction, further research on chronological changes for prog-
nosis prediction, such as quantification of color changes,
abrasion by tooth brush, and effect of the thickness of coating
material and occlusion is important in the future.
5. Conclusion
The results from the present study suggest that this tooth-
surface coating material is extremely useful for improving
color in teeth with discolored crowns in pediatric dental
practice. It is a valuable dental material that can improve es-
thetics as well as prevent cavities and strengthen teeth.
Disclosure
None of the authors has any conflicts of interest that should
be declared.
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