endodontics

Lec. ‫ عالء مهدي الحداد‬.‫د‬

Teeth Discoloration and Bleaching

Tooth color varies according to race, gender and geographic region. The colour of teeth is
determined by:
1- The translucency and thickness of enamel at different levels.
Thickness of enamel which is greater at the occlusal/ incisal edge of
the tooth and thinner at the cervical third. That is why teeth are
darker on cervical third than at middle or incisal third.
2- Color and thickness of the underlying dentin. Dentin forms the bulk
of the tooth substance and contributes most to the overall tooth
color. Larger teeth such as the molars and the canine teeth have thick
layer of dentin, and therefore tend to be darker.
3- Colour of the pulp. The pulp is pink/red due to its vascularity, but is
rarely visible through the overlying enamel and dentin.
Any change in the hue, color, or translucency of a tooth due to any cause (restorative
materials, drugs, pulpal necrosis) is called discoloration.

CLASSIFICATION OF DISCOLORATION
Tooth discoloration may be classified as extrinsic or intrinsic discoloration or combination. Intrinsic
discolorations are incorporated into the tooth structure. Extrinsic discolorations are attached to the
tooth surface. Tooth discolorations may be hereditary, related to patient (behavior and age), or caused
by dental treatment (iatrogenic).
Classification of discoloration
• Intrinsic discoloration
• Extrinsic discoloration
• Combination of both.

Etiology of tooth discoloration

Intrinsic stains 4) Pulp tissue remnants

A. Systemic causes 5) Intracanal medicaments and root
1) Genetic filling materials
2) Disease 6) Restorative materials
3) Drug related 7) Dental caries
4) Metabolic 8) Aging
B. Local causes
Extrinsic stains
1) Pulpal hemorrhage
– Plaque and poor oral hygiene
2) Pulp necrosis
– Food and beverages
3) Calcific metamorphosis
– Tobacco use
– Chlorhexidine

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A. Intrinsic Discoloration
It is classified as systemic (generalized) or local as follows:

Systemic Intrinsic Causes

1) Genetic Causes
Amelogenesis imperfecta is a group of hereditary conditions affecting the structure and appearance
of enamel in the primary and secondary dentition. It may cause variable degrees of hypoplasia and
hypocalcification ranging from local pitting to generalized thinning of the enamel.
Clinical appearance of the enamel can be affected by discoloration as discoloring agents in the oral
cavity may gain easy access to the rough enamel surface.
Treatment depends on the severity and usually involves comprehensive restorative treatment.

Mild Moderate Severe

Dentinogenesis imperfecta and dentinal dysplasia are a group of hereditary disorders, characterized
by an abnormal dentine structure in the primary and secondary dentitions. Patient with
dentinogenesis imperfecta have teeth with yellow-brown, deep amber, or blue-gray discolorations
and higher translucency. Bleaching treatment will have minimal to no effect; comprehensive
restorative treatment is indicated.
Other diseases causing tooth discoloration are hematological diseases which include porphyria,
erythroblastosis fetalis or thalassemia, and sickle cell anemia which affect the RBC cells. And cause
pigmentation in the pulp that affect the teeth color.

2) Disease-Related Causes
High fevers during the age of tooth development may cause enamel hypoplasia leading to banding
type discolorations on the tooth surface. Vitamin and mineral deficiencies may induce hypoplasia.
Rickets, a vitamin D deficiency, Scurvy, vitamin C deficiency in conjunction with vitamin A deficiency,
and disturbances of phosphorus uptake can cause enamel hypoplasia.

3) Drug-Related Causes
Tetracycline is an antibiotic that was frequently used from the 1950s to the 1970s. Administration of
tetracyclines during tooth formation age make it bound to calcium and become incorporated into the
hydroxyapatite crystal of both enamel and dentin resulting in tooth discoloration. Discoloration can be
yellow, yellow-brown, brown, dark gray, or blue, depending on the type of tetracycline, dosage,
duration of intake, and patient’s age at time of administration. Because tooth development starts prior
to birth, women are advised to avoid taking tetracycline during pregnancy.

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Bleaching and veneers are the suggested treatments for tetracycline stains according to the severity
of the case, however, severe cases may require full coverage restorations.

4) Metabolic Causes
Enamel hypoplasia may also occur after excessive exposure to fluoride during tooth formation. This
exposure can lead to alterations in the mineralized tooth structure, especially in the enamel matrix,
and give the appearance of a mottled tooth with porous surface (fluorosis).
Shades of discoloration may vary greatly and can range from white spots with chalky appearances to
yellow or brown stains. In severe cases, a restorative approach may be indicated.

Local Intrinsic Causes

1) Pulpal Hemorrhage
Trauma may lead to the rupture of intrapulpal blood vessels with subsequent intrapulpal hemorrhage.
The hemolysis of erythrocytes will result in the degradation of hemoglobin into globin and the heme
protein, containing an iron atom. The iron, in the form of iron sulfides, may reach dentinal tubules,
causing discolorations in the surrounding dentin. Depending on whether the pulp recovers or
becomes necrotic, the discoloration may disappear or persist.

2) Pulp Necrosis
Inflammation of the dental pulp due to microbial,
mechanical, or chemical irritants can result in pulp
necrosis. Disintegration products from pulp
necrosis may become incorporated into dentinal
tubules and cause discoloration of the
surrounding dentin. The intensity of the
discoloration appears proportional to the time
period of pulp necrosis. These types of
discolorations tend to respond favorably to intracoronal bleaching.

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3) Calcific Metamorphosis/Dystrophic Calcification
Trauma, sometimes, can result in obliteration of the pulp with mineralized tissue. Odontoblasts can
become destroyed by the traumatic impact and replaced by cells from stem cell in the pulp. These
alternative odontoblasts may initiate rapid deposition of reparative dentin that may occupy the entire
pulp chamber, resulting in yellowish or yellow-brownish discolorations. Anterior teeth are mostly
affected.

4) Pulp Tissue Remnants

Remnant pulp tissue that was left behind after endodontic therapy will
eventually disintegrate and may discolor tooth structure. Therefore, pulp horns
and all other pulp tissues in the access chambers should be carefully removed
during treatment.

5) Intracanal Medicaments and Root Filling Materials

A variety of endodontic medications and root filling materials may be responsible for discolorations if
they are in direct contact with dentin allowing penetration into dentinal tubules.
Silver points, gutta-percha, epiphany, epoxy resin cement (e.g. AH26), resorcinol-formaldehyde resin
paste, CMCP, IKI, mineral trioxide aggregate (MTA), antibiotic pastes (e.g. triple antibiotic combination),
chlorhexidine and MTAD. These are some materials that may cause discoloration if left in pulp
chamber for long periods or if the material is incompletely removed from pulp chambers and access
cavities before final restoration. It is preferred to remove G.P about 2mm below the canal orifice
specially in anterior teeth.

6) Restorative Materials
Metallic filling materials, such as amalgam or gold, pins or posts mostly cause color changes, by adding
dark hues through the remaining tooth walls. Amalgam fillings, over time, will undergo corrosive
changes and degradation, with by-products causing color alterations in tooth structure.
The treatment for these conditions is removal of the filling and exchange with an aesthetic restorative
material such as composite. Composite resin restorations may cause discoloration through marginal
microleakage that allows for discoloring agents to penetrate into the tooth and dentinal tubules.
Additionally, rough and improperly finished and polished composite restorations are susceptible to
staining and discoloration.

7) Dental Caries
Progressing caries can cause tooth discoloration. Early stages of caries are characterized by white,
opaque enamel lesions. If caries arrests (arrested caries), the lesion may darken by taking up pigments
from exogenous sources (food, beverages and bacterial products), frequently rendering it a deep dark
brown or black color. When caries progresses and reaches dentin, it becomes dark and shows through
enamel walls.

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8) Aging
Teeth color tends to become progressively darker with age, which is a physiological change resulting
from dentin apposition and enamel wear and cracks in addition to the accumulative effects of
discoloring agents. Extracoronal bleaching can partially whiten age-related stains.

Extrinsic Causes
Extrinsic stains are food, beverage, or smoking-related superficial stains and discolorations. Peverages
such as coffee or tea or tar from smoking may cause dark, brownish discolorations. Extensive
consumption of oranges, carrots, licorice, or chocolate may lead to food-related stains. The effects of
staining may be accelerated by poor oral hygiene. Some mouthwashes like chlorhexidine can cause
staining. In general, extrinsic stains respond well to scaling, polishing, or bleaching.