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The effect of at-home bleaching and

toothbrushing on removal of coffee
and cigarette smoke stains and color
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Evelise M Souza, J. Bazzi, Rui Mazur

Journal of the American Dental Association

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 The effect of at-home bleaching and
toothbrushing on removal of coffee and
cigarette smoke stains and color stability of
enamel
Juliana Zavala Bazzi, Marcio José Fraxino Bindo,
Rodrigo Nunes Rached, Rui Fernando Mazur,
Sergio Vieira and Evelise Machado de Souza
JADA 2012;143;e1-e7

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 RESEARCH

The effect of at-home bleaching

and toothbrushing on removal of coffee
and cigarette smoke stains and color
stability of enamel
Juliana Zavala Bazzi, DDS, MDS; Marcio José Fraxino Bindo, DDS, MDS, PhD;
Rodrigo Nunes Rached, DDS, MDS, PhD; Rui Fernando Mazur, DDS, MDS, PhD;
Sergio Vieira, DDS, MDS, PhD; Evelise Machado de Souza, DDS, MDS, PhD

Downloaded from jada.ada.org on May 31, 2012

I
n the last two
decades, the
appearance of
teeth has been of
great importance to
patients and dentists.
Patients’ desire for
whiter teeth has
prompted dentists to
try to meet their
expectations in terms
of dental esthetics. In
a review of the litera-
ture, Watts and Addy1
reported that tooth
discoloration has been
classified according to
the location of the
staining, which is
either intrinsic or
extrinsic.
Intrinsic stains are
a consequence of the
incorporation of pig-
mented materials into
dental tissues as a
result of localized or
generalized factors.
Localized discol-
oration can be caused
by pulpal necrosis and
bleeding, infection of
A B S T R A C T
Background. The authors conducted a study to evaluate the stain removal ability of
tooth bleaching and simulated toothbrushing after coffee and cigarette smoke staining
and to determine the enamel susceptibility to restaining.
Methods. The authors used a colorimeter to determine the baseline color of 40 bovine
labial enamel surfaces according to the Commission Internationale de l’Eclairage
L*a*b* coordinates. They immersed one-half of the specimens in coffee and exposed
one-half to cigarette smoke in a smoking machine. They took color measurements again
and determined the color change from baseline (∆E1) for each group. The authors
divided each group into two subgroups and subjected the specimens to at-home
bleaching (one hour per day for 21 days) or simulated toothbrushing (120 cycles per day
for 21 days), followed by another color measurement (∆E2). The authors repeated both
staining procedures (that is, cigarette smoke and coffee) and followed them with a third
color measurement (∆E3). They analyzed the data by using a two-way analysis of vari-
ance and the Tukey test (α = 5 percent).
Results. Both staining procedures resulted in similar values for ∆E1. The specimens
stained with coffee and cigarette smoke exhibited a significant reduction in color change
after bleaching (P < .05). However, toothbrushing resulted in a significantly reduced
color change only for cigarette smoke–stained specimens (P < .001). The discoloration
in coffee-stained specimens increased after restaining, irrespective of the stain removal
method (P < .05).
Conclusions. The study results show that at-home bleaching removed both coffee
and cigarette smoke staining. The restaining potential was greater for specimens
stained with coffee than for those stained with cigarette smoke, regardless of the
removal method used.
Clinical Implications. Six percent hydrogen peroxide at-home bleaching was
effective in removing stains caused by coffee or cigarette smoke. However, continued
frequent consumption of coffee can increase the staining susceptibility of enamel.
Key Words. Enamel staining; coffee; cigarette smoke; tooth bleaching; toothbrushing.
JADA 2012;143(5):e1-e7.

Dr. Bazzi is a student in a master of science program in dentistry, Pontifical Catholic University of Paraná, Curitiba, Paraná, Brazil.
Dr. Bindo is an adjunct professor, Department of Restorative Dentistry, School of Dentistry, Federal University of Paraná, Curitiba, Paraná, Brazil.
Dr. Rached is a professor, Graduate Program in Dentistry, Pontifical Catholic University of Paraná, Curitiba, Paraná, Brazil.
Dr. Mazur is a professor, Graduate Program in Dentistry, Pontifical Catholic University of Paraná, Curitiba, Paraná, Brazil.
Dr. Vieira is a professor and director, Graduate Program in Dentistry, Pontifical Catholic University of Paraná, Curitiba, Paraná, Brazil.
Dr. Souza is a professor, Graduate Program in Dentistry, Pontifical Catholic University of Paraná, R. Imaculada Conceição, 1155, Prado Velho, Curitiba,
Paraná, Brazil, 80215-901, e-mail evesouza@yahoo.com. Address reprint requests to Dr. Souza.

JADA 143(5) http://jada.ada.org May 2012 e1

Copyright © 2012 American Dental Association. All rights reserved.
RESEARCH
primary teeth, inadequate endodontic treatment
and amalgam staining.2 Generalized intrinsic
discolorations are the result of environmental or
genetic factors, such as dental fluorosis, tetracy-
cline treatment, diseases of childhood and
hereditary disorders—such as amelogenesis and
dentinogenesis imperfecta—that affect the
dental structures.2,3
Extrinsic stains have a multifactorial etiology
involving chromogens that are derived from
dietary sources or pigmented substances that
are used habitually in the mouth. Coffee, tea,
red wine, orange juice, some soft drinks and
food colorants are considered staining agents
that lead to extrinsic tooth discoloration when
consumed frequently.4 Investigators also have
reported occupational exposure to chemicals,
tobacco smoking and chewing, and frequent
use of mouthrinses and other medicaments as
being etiologic factors involved in tooth
discoloration.1,2,5
Before treatment, the practitioner must
assess the patient’s dental and medical history
and conduct a thorough oral examination to
identify the source of the discoloration. In addi-
tion, he or she should examine the teeth for the
position and distribution of staining; the pres-
ence of enamel defects, caries and restorations;
and the patient’s oral hygiene status.3
Some extrinsic stains can be removed par-
tially or totally by means of toothbrushing with
dentifrice, professional prophylaxis or enamel
polishing.2 When these treatments are unsuc-
cessful, clinicians can bleach the teeth. Bleach-
ing is a conservative therapy used widely to
remove persistent tooth discoloration.6 Night-
guard vital bleaching, which was introduced by
Haywood and Heymann,7 is considered an effi-
cient and safe method that has been in common
use for two decades.8 Investigators and clinicians
have modified and improved the original tech-
nique across time; changes include the develop-
ment of varying concentrations of carbamide
peroxide, the introduction of hydrogen peroxide
agents and the reduction in usage time.
The literature is limited with regard to data
pertaining to the best choice and efficacy of
stain removal techniques. This also is true for
studies of the susceptibility of discolored teeth
to restain after bleaching when the patient’s
exposure to the staining agent continues.
Therefore, we decided to conduct a study to
evaluate the ability of chemical (tooth
bleaching) and mechanical (toothbrushing)
treatments to remove coffee and cigarette smoke
stains and to determine the susceptibility of
teeth to restaining after completion of each
e2 JADA 143(5) http://jada.ada.org May 2012
Copyright © 2012 American Dental Association. All rights reserved.
stain removal technique. We tested the fol-
lowing hypotheses: tooth bleaching and tooth-
brushing would be equally effective in removing
cigarette smoke and coffee stains, and neither
stain removal treatment would influence the
susceptibility of teeth to restaining.
METHODS
Preparation of specimens and baseline
color measurements. We collected 40 bovine
maxillary incisors and stored them in 0.2 per-
cent thymol solution at 4°C for three months.
One of us (J.Z.B.) sectioned the roots by using a
double-sided diamond disk at low speed under
water cooling. She sectioned the crowns longitu-
dinally to separate their labial surfaces and to
produce 7 × 7-millimeter blocks. The thickness
of the specimens was the same as the combined
Downloaded from jada.ada.org on May 31, 2012
thickness of the enamel and dentin from the
labial surface to the pulpal chamber. Two of us
(J.Z.B., M.J.F.B.) embedded the sections in
epoxy resin by using 25-mm diameter polyvinyl
chloride rings and left 2 mm of tooth structure
exposed above the resin surface.
The researchers flattened the surfaces of the
specimens by using 600- and 800-grit silicon
carbide sandpaper and polished them with
1,200-grit silicon carbide sandpaper under run-
ning water in a rotary machine. They then
cleaned the specimens in an ultrasound bath
with distilled water for 10 minutes. One of us
(J.Z.B.) sealed the dentin adjacent to the
exposed enamel with a resin-based composite
(Filtek Supreme XT, 3M ESPE, St. Paul, Minn.),
which was used in association with 35 percent
phosphoric acid conditioning for 15 seconds and
an etch-and-rinse two-step bonding system
(Adper Single Bond, 3M ESPE), to prevent the
diffusion of staining agents into the exposed
dentin.
One of us (R.N.R.) measured baseline color by
using a portable colorimeter with a 6-mm diam-
eter tip (VITA Easyshade, VITA Zahnfabrik,
Bad Säckingen, Germany). He took color read-
ings in accordance with the Commission Inter-
nationale de l’Eclairage (CIE) L*a*b* system
(ISO 11664-4:20089) against a white back-
ABBREVIATION KEY. a*: Magenta/green (negative
values indicate green, positive values indicate
magenta). b*: Blue/yellow (negative values indicate
blue, positive values indicate yellow). CIE: Commis-
sion Internationale de l’Eclairage. ∆E: Total color
difference. ∆E1: Color change from baseline value to
value after staining. ∆E2: Color change from baseline
value to value after bleaching or toothbrushing.
∆E3: Color change from baseline value to value after
restaining. L*: Lightness.

ground. The investigator placed the tip of the
colorimeter perpendicularly to and in full con-
tact with the specimen surface. He carried out
readings in triplicate in a room with controlled
temperature. The investigator calculated the
average of the three readings, which resulted in
one value for each specimen in the group.
Staining procedures. One of us (J.Z.B.)
divided the prepared specimens into two groups
of 20 specimens each and subjected the first
group to coffee staining. The investigator pre-
pared a coffee solution with instant coffee by
dissolving 6 grams of powder in 300 milliliters
of boiling water and immersed the specimens in
this solution for 72 hours at 37°C. We changed
the coffee solution daily. Another investigator
(R.F.M.) subjected the second group to discol-
oration in a cigarette smoking machine. He
positioned the 20 specimens at the bottom of a
glass jar; two silicone tubes were placed into
the jar through holes in the lid. One tube was
connected to a vacuum machine and the other
to a five-port linear cigarette holder.10 Once he
assembled the device, the investigator applied
a negative pressure (approximately 20 millime-
ters of mercury [1 mm Hg = 133 pascals]), and
the cigarettes were smoked, which produced
smoke in the jar.11 All of the cigarettes were
smoked to a length of 10 mm beyond the tip-
ping paper that covers the filter. The tooth
specimens were exposed to the mainstream
smoke, and the jar was kept saturated for 10
minutes. We repeated this cycle three times
(that is, four times in all) for all 20 specimens.
One of us (R.N.R.) assessed color changes (∆E1)
by determining the color differences between
L*a*b* coordinates at baseline and those after
the staining procedures.
Stain removal procedures and color
measurements. Toothbrushing. We divided
the stained specimens (coffee and cigarette
smoke) into two subgroups each. One subgroup
from both the coffee- and cigarette smoke–
stained groups underwent toothbrushing in a
mechanical toothbrushing machine equipped
with two stainless steel boxes, both of which
contained five sample holders. The researcher
(J.Z.B.) positioned the toothbrush heads, which
had soft nylon bristles, in metallic devices that
kept the long axis of the toothbrush heads par-
allel to the enamel surfaces. After she posi-
tioned the specimens inside the holders, the
enamel surfaces underwent the action of the
toothbrushes (Sorriso, Kolynos Original,
Colgate-Palmolive, São Bernardo do Campo,
São Paulo, Brazil) at a load of 200 g.12 The
researcher performed the toothbrushing cycles
Copyright © 2012 American Dental Association. All rights reserved.
RESEARCH
with the use of a slurry prepared immediately
before testing; the slurry consisted of tap water
mixed with a fluoridated dentifrice (Colgate
MFP, Colgate-Palmolive) in a ratio of 2:1. The
toothbrushing machine performed 120 cycles
each day at a frequency of approximately 278
strokes per minute, simulating 25 seconds of
toothbrushing13 a day and resulting in a total
of 2,520 cycles in 21 days.
Simulated at-home bleaching. The other
one-half of specimens underwent simulated at-
home bleaching. We used a vacuum-forming
machine (Plastvac P7, Bio-Art, São Carlos, São
Paulo, Brazil) to produce two thin plastic trays
and seated the trays on 10 specimens. The
investigator (J.Z.B.) placed the at-home
bleaching agent (White Class 6%, batch 310810,
FGM Dental Products, Joinville, Santa Cata-
Downloaded from jada.ada.org on May 31, 2012
rina, Brazil) on the enamel surfaces in a 1-mm
thick layer. According to the manufacturer,14
this bleaching gel has a neutral pH and is com-
posed of 6 percent hydrogen peroxide, neutral-
ized carbopol, potassium nitrate, sodium fluo-
ride, aloe vera, calcium gluconate, stabilizers
and deionized water. The specimens underwent
bleaching at 37°C for one hour per day for 21
days according to the manufacturer’s instruc-
tions. After completion of the bleaching treat-
ment, the investigator removed the tray and
rinsed all of the specimens under tap water.
Between each of the experimental procedures,
we stored the 40 specimens in dark containers
containing artificial saliva at 37°C ± 1°C. We
performed color measurements (∆E2) after the
bleaching and simulated toothbrushing pro-
cedures, as described earlier.
Restaining procedures and color meas-
urements. We immediately restained all speci-
mens with the same agent (coffee or cigarette
smoke) used for the initial staining, according to
the procedures described earlier. We then car-
ried out new color readings (∆E3).
Color change analysis. At each treatment
stage, we calculated mean color change values
for each group of specimens. We characterized
color changes by comparing individual coordi-
nate parameters (∆L*, ∆a*, ∆b*) at baseline (0)
with parameters after each stage of the study
(1), as follows:
∆L* = L1* − L0*
∆a* = a1* − a0*
∆b* = b1* − b0*
where L* = lightness, a* = magenta/green (neg-
ative values indicate green, positive values indi-
cate magenta) and b* = blue/yellow (negative
values indicate blue, positive values indicate
yellow).9
JADA 143(5) http://jada.ada.org May 2012 e3
RESEARCH
TABLE
Color changes (∆E) in bovine enamel,
according to experimental conditions.
GROUP MEAN VALUES (STANDARD DEVIATION)*
∆E1† ∆E2‡
Cigarette 25.43 (3.36) A,a
7.81 (2.63) AB,b
Smoke/Bleaching
Cigarette 23.59 (1.95)A,a 3.20 (1.85)B,b
Smoke/Toothbrushing
Coffee/Bleaching 18.88 (6.11)A,a 4.31 (2.08)B,b
Coffee/Toothbrushing 18.74 (6.37)A,b 17.72 (7.11)A,b
* Groups connected by the same lowercase letters in rows and the same uppercase
letters in columns are not statistically significantly different (P > .05).
† ∆E1: Color change from baseline value to value after staining.
‡ ∆E2: Color change from baseline value to value after bleaching or toothbrushing.
§ ∆E3: Color change from baseline value to value after restaining.
We calculated color differences (∆E) by using
this formula9:
∆E = [(∆L*)2 + (∆a*)2 + (∆b*)2] × 1⁄2
Statistical analysis. We analyzed the ∆E*
data by using repeated-measures two-way
analysis of variance and the Tukey test for mul-
tiple comparisons. In all cases, we set statistical
significance at the .05 level (α = 5 percent). One
of us (S.V.) performed statistical analyses by
using statistical software (IBM SPSS 15.0, IBM,
Somers, N.Y., and Statistica 9.0, StatSoft, Tulsa,
Okla.).
RESULTS
We found significant differences in stain-
removing ability and susceptibility to restaining
between removal agents and staining agents,
respectively, as well as a significant interaction
between both factors (P < .05). The table shows
the mean values and standard deviations for all
color change measurements in each group. The
figure shows the specimens before and after
staining with coffee and cigarette smoke.
The first color measurement showed that cig-
arette smoke and coffee staining resulted in
similar discoloration (P > .05). At the second
color measurement, toothbrushing resulted in a
significant reduction in color change (∆E2) only
for specimens stained with cigarette smoke
(P < .001), whereas tooth bleaching resulted in
significantly reduced ∆E values for specimens
stained with cigarette smoke or coffee (P < .05).
Restaining with cigarette smoke did not
increase the color change significantly for speci-
mens that underwent bleaching or tooth-
brushing (P > .05). In contrast, restaining with
coffee resulted in significantly more discol-
oration for both groups of specimens, irrespec-
tive of the stain removal method (P < .05). At
e4 JADA 143(5) http://jada.ada.org May 2012
Copyright © 2012 American Dental Association. All rights reserved.
the last color measurement (∆E3),
the coffee-stained specimens that
underwent toothbrushing experi-
enced the highest mean discol-
oration, with statistically signifi-
cant differences between these
∆E3§ specimens and the specimens that
5.51 (2.01)B,b were stained with cigarette smoke
(P < .05).
8.24 (3.49)B,b
DISCUSSION
14.51 (7.44)A B,a The literature contains reports of
25.40 (10.90)A,a different thresholds for color
change above which the change is
clinically perceptible.15-21 Although
∆E values lower than 1.5 can be
measured by using a spectropho-
tometer, they typically cannot be
Downloaded from jada.ada.org on May 31, 2012
detected by the human eye.6 Under direct
viewing, a person trained in color recognition
may be able to detect a ∆E value of 1.5 to 2.5
units, whereas a person with average color
matching ability typically can recognize a shift
in ∆E of 2.5 to 3.5 units.16,20 Johnston and Kao17
evaluated color matching according to visual
observation and colorimetry and reported that
the mean color difference considered visually
perceptible—and clinically unacceptable—was
3.7. Researchers consider ∆E values below 3.3
clinically acceptable.18 In our study, ∆E values
ranged from 3.2 to 25.4. Thus, the color change
observed in the cigarette smoke/toothbrushing
group was the only discoloration that could be
considered clinically acceptable.
Researchers frequently use bovine teeth as
an alternative to human teeth in laboratory
studies of evaluation of color changes.22-27 Their
use avoids the ethical issues related to use of
human teeth, and bovine teeth also have larger
flat areas that can accommodate the tip of the
colorimeter handpiece. In addition, bovine teeth
do not differ significantly from human teeth in
terms of baseline color.26
Dietary factors. It is well known that dietary
factors lead to extrinsic tooth discoloration.4 Like
other drinks such as tea and red wine, coffee has
been reported to be one of the main staining
agents.6,27-29 The pH value of the solution plays an
important role in the degree of discoloration.22
According to Addy and colleagues,30 low-pH bev-
erages are responsible for an increase in tooth
staining. In addition, the inherent roughness, fis-
sures and porosities in tooth surfaces may con-
tribute to the increased staining caused by cer-
tain solutions.27 Although we used polishing
procedures in this study to ensure standardiza-
tion of the specimens, the enamel surfaces may

A B
Figure. A. Bovine tooth specimen before staining (baseline). B. Bovine tooth specimen stained with coffee. C. Bovine tooth specimen
stained with cigarette smoke.
have had some irregularities and cracks. This
might be a reason for the failure of toothbrushing
to remove stains caused by coffee; this staining
agent probably diffuses through these structural
defects more easily than does cigarette smoke
because it is in liquid form.
According to Guler and colleagues,28 the
average time to drink one cup of coffee is 15
minutes and the average amount of coffee con-
sumed per day by coffee drinkers is 3.2 cups.
Therefore, in our study, 72 hours of exposure to
coffee simulated consumption of the drink
across three months. We considered this suffi-
cient to produce discoloration similar to that
produced by cigarette smoke at the first color
measurement.
Cigarette smoke. Researchers have used
cigarette smoking machines widely in studies in
which they investigated cigarette smoke as a
staining agent for restorative materials.5,31-33 To
our knowledge, however, researchers have not
investigated the staining susceptibility of teeth
subjected to cigarette smoke. According to
Wasilewski and colleagues,5 cigarette smoke
consists of air, water, carbon monoxide, carbon
dioxide and tar. However, as cigarettes burn,
components such as tar, sugars (sucrose, invert
sugar, high-fructose corn syrup or any combina-
tion of the preceding) along with cocoa are
transferred to the smoke by heating. We believe
these components probably are responsible for
the discoloration because of their dark color and
ability to stick to the surface of teeth. Neverthe-
less, this type of staining appears to be superfi-
cial and is removed easily with toothbrushing
and tooth bleaching, as shown by the results of
this study. Furthermore, unlike coffee, cigarette
smoke failed to produce further staining after
toothbrushing and bleaching.
Tooth bleaching. Hydrogen peroxide acts as
Copyright © 2012 American Dental Association. All rights reserved.
RESEARCH
C
a strong oxidizing agent by forming free radi-
Downloaded from jada.ada.org on May 31, 2012
cals, reactive oxygen molecules and hydrogen
peroxide anions.34 These reactive molecules
attack long-chained dark-colored molecules and
split them into smaller, less-colored molecules
that diffuse out of the tooth.35 Changes in the
enamel surface, such as erosion and porosities,
that occur after bleaching procedures might be a
result of the extended contact time between the
bleaching agent and the tooth structure.8
Because the bleaching agent used in our study
was composed of 6 percent hydrogen peroxide
applied for one hour per day, we expected the
effect on the enamel surface to be insignificant.
Several authors conducted studies of the effect
of 6 percent hydrogen peroxide bleaching gel on
enamel microhardness and morphology, the
results of which showed no significant effect
with respect to either of these properties.36-38
Also, we must take into consideration the effect
of the artificial saliva used during the 21-day
bleaching treatment. Some researchers have
reported the remineralizing effect of saliva
during bleaching protocols, which could signifi-
cantly reduce the number of enamel surface
porosities and the susceptibility of enamel to
discoloration.8,27,39
Although researchers in previous studies have
investigated the staining susceptibility of
enamel after tooth bleaching,23,26,27 none, to our
knowledge, have compared tooth bleaching with
toothbrushing with regard to their ability to
remove tooth stains. Ghavamnasiri and col-
leagues23 examined the staining susceptibility of
enamel after bleaching with 16 percent car-
bamide peroxide, and they found greater color
changes in teeth that had undergone bleaching
and then been immersed in coffee for 30 minutes
than in teeth that had not been bleached but
only had been immersed in coffee. Liporoni and
JADA 143(5) http://jada.ada.org May 2012 e5
RESEARCH
colleagues27 reported that coffee, unlike red wine,
was unable to stain enamel surfaces after they
underwent bleaching with 35 percent hydrogen
peroxide. In our study, tooth bleaching with 6
percent hydrogen peroxide was effective in
reducing enamel staining caused by either of the
staining agents, and susceptibility to restaining
was more evident in specimens stained with
coffee than in those stained with cigarette smoke.
Toothbrushing. Toothbrushing produced a
significant reduction in color change, but only
for the specimens stained with cigarette smoke.
This result may be attributable to the superfi-
cial features of this type of staining, as well as
to the cleaning ability of the calcium carbonate–
containing dentifrice. The abrasiveness of a den-
tifrice, and hence its ability to remove staining,
is related directly to both the type and amount
of abrasive it contains.24 We chose a regular
fluoridated dentifrice for our study instead of a
whitening dentifrice to evaluate only the stain
removal ability of toothbrushing as an element
of daily oral hygiene without any added
bleaching effect.
Both toothbrushing and at-home tooth
bleaching removed staining caused by cigarette
smoke, which we considered to be severe at the
first measurement. In addition, the color was
stable, even after restaining. Coffee staining,
however, was resistant to removal by tooth-
brushing; therefore, the effect was cumulative.
In contrast, tooth bleaching removed the coffee
stains effectively, but after restaining, the color
values returned to their initial values. Conse-
quently, if a patient continues to consume coffee
frequently after undergoing tooth bleaching, the
treatment outcome can be compromised.
On the basis of our findings, we rejected the
first hypothesis because toothbrushing was less
able to remove coffee stains than was tooth
bleaching. We also rejected the second hypoth-
esis because the stain removal methods behaved
differently for both staining agents. Tooth-
brushing and bleaching increased the staining
susceptibility only of the enamel that had been
stained previously with coffee.
CONCLUSIONS
The results of this study show that at-home
tooth bleaching reduced discoloration after
staining with cigarette smoke or coffee. Tooth-
brushing had the same effect only for enamel
stained with cigarette smoke. Although ciga-
rette smoke and coffee staining resulted in sim-
ilar discoloration at the first color measure-
ment, enamel stained with coffee was more
susceptible to restaining than was enamel
e6 JADA 143(5) http://jada.ada.org May 2012
Copyright © 2012 American Dental Association. All rights reserved.
stained with cigarette smoke, irrespective of the
stain removal method. ■
Disclosure. None of the authors reported any disclosures.
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the literature. Br Dent J 2001;190(6):309-316.
2. Hattab FN, Qudeimat MA, al-Rimawi HS. Dental discoloration:
an overview. J Esthet Dent 1999;11(6):291-310.
3. Nathoo SA. The chemistry and mechanisms of extrinsic and
intrinsic discoloration. JADA 1997;128(suppl):6S-10S.
4. Addy M, Moran J. Extrinsic tooth discoloration by metals and
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5. Wasilewski Mde S, Takahashi MK, Kirsten GA, de Souza EM.
Effect of cigarette smoke and whiskey on the color stability of dental
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7. Haywood VB, Heymann HO. Nightguard vital bleaching. Quin-
tessence Int 1989;20(3):173-176.
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