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Bleaching Part 1
Bleaching Part 1
Bleaching Part 1
Raj Dubal
Richard WJ Porter
An Update on Discoloured
Teeth and Bleaching Part 1:
The Aetiology and Diagnosis of
Discoloured Teeth
Abstract: A variety of bleaching materials and techniques are available across the dental market, and these are being used by
the profession as a conservative approach to improving the appearance of discoloured teeth. The array of materials available and
misunderstandings around the legality of their use has complicated the practitioner’s approach to making an informed choice regarding
dental bleaching. This article aims to provide an overview of the common causes of dental discoloration and presents a simple approach
to diagnosing potential causes of discoloured teeth.
CPD/Clinical Relevance: A sound and systematic approach to understanding and diagnosing causes of dental discoloration are
fundamental in ensuring the correct management approach and treatment outcome. This is key to ensuring that patients are not over-
treated and receive appropriate, safe and effective treatment.
Dent Update 2018; 45: 601–608
In a modern society which celebrates improvements in appearance, and it is not and there is evidence that this can have
beauty and perfection the demand for unusual for patients to approach dentists a considerable impact on patients’ self-
an idealized appearance has never been and allied oral healthcare professionals esteem.5
greater. This need for perfection has been for advice regarding improving dental Dental aesthetic improvements
driven as much by societal expectations appearance as well as facial aesthetics. which a patient may desire can revolve
as it has by the media. Age is no longer Visible caries has been reported to lead around a number of factors such as; shade,
a barrier to patients’ quests for improved to more negative judgements regarding morphology, size, alignment, symmetry and
appearance, however, greater dissatisfaction social competence, intellectual ability, the extent to which the teeth harmonize
regarding dental appearance has been psychological adjustment and relationship with a patient’s face as a whole. Patients
satisfaction.2 Tooth colour has been found can be very aware of the limitations of their
reported in younger age groups.1 The dental
to exert an influence on social perceptions2 dental appearance, and tooth shade is a
industry has considerable responsibility
and, as such, can have an adverse influence commonly cited complaint. In a survey on
and a versatile armamentarium to drive
on individuals’ psychosocial health and tooth whitening by the American Academy
quality of life.3 Self-assessed perceptions of of Cosmetic Dentistry (2012), the single
tooth discoloration can be very critical. In most common factor which respondents
Raj Dubal, BDS, MFDS RCS, MClin Dent
a self-assessment based national study of reported that they would like to improve
Pros, MRD RCS, FDS RCS, PG Cert Dent Ed,
3215 subjects, 50% of respondents reported about their smile is the ‘whiteness and
Specialty Trainee in Restorative Dentistry
dissatisfaction with their tooth colour.4 brightness’ of their teeth.6
and Richard WJ Porter, BDS, BSc, MFDS
With such high levels of dissatisfaction Teeth may become discoloured
RCS, FDS(Rest Dent) RCS, Consultant in
with tooth colour it is unsurprising that for a number of different reasons, and
Restorative Dentistry, St George’s Hospital,
the demand for procedures to improve a thorough history and examination
Tooting, London, SW17 0QT, UK.
tooth colour have increased significantly, will give clues as to the aetiology of the
July/August 2018 DentalUpdate 601
RestorativeDentistry
Figure 3. Mindmap showing a diagnostic tree, which can aid in diagnosing causes of discoloration.
is sufficient to cause manifestation of the and causes of dental discoloration. on the perceptions of personal
disease. This disorder can also be caused Figure 3 presents a mindmap showing characteristics among female dental
by mutations of the MMP20,9 KLK4,10 a diagnostic tree which can aid in
patients: comparisons of unmodified,
FAM83H,11 C4orf2612 or SLC24A413,14 diagnosing causes of discoloration. There
genes. decayed and ‘whitened’ teeth.
are a wide range of aetiological factors
It is worthy of note that and clinical manifestations which are Br Dent J 2008; 204: E9.
children who present with fluorosis encompassed by the term discoloured 3. Klages U, Bruckner A, Zentner A.
may also have siblings with similar teeth. Accurate diagnosis is pivotal in Dental aesthetics, self-awareness,
discoloration and, far from being giving the clinician and thus patient an and oral health-related quality of life
hereditary in nature, mindfulness and indication of the appropriate treatment
adjustment in fluoride exposure can help in young adults. Eur J Orthod 2004;
modality and likely outcome.
in preventing this in younger siblings. A second part will review the 26: 507−514.
mechanism of action and various clinical 4. Alkhatib MN, Holt R, Bedi R.
Associated syndromes and diseases approaches using bleaching agents to Prevalence of self-assessed tooth
A number of diseases and manage discoloured teeth.
syndromes have been reported which discolouration in the United
can affect the colour of teeth. These tend Kingdom. J Dent 2004; 32: 561−566.
to have a metabolic underpinning which References 5. Davis LG, Ashworth PD, Spriggs LS.
results in changes in the appearance due 1. Alkhatib MN, Holt R, Bedi R. Age and Psychological effects of aesthetic
to developmental alterations. Examples
perception of dental appearance and dental treatment. J Dent 1998; 26:
of these are listed in Table 2.
tooth colour. Gerodontology 2005; 22: 547−554.
Summary 32−36. 6. American Academy of Cosmetic
This article has aimed to 2. Kershaw S, Newton JT, Williams Dentistry. Whitening Survey, Summer
deliver an overview of the classification DM. The influence of tooth colour 2012.
606 DentalUpdate July/August 2018
RestorativeDentistry
http://www.aacd.com/proxy/ 10. Hart PS, Hart TC, Michalec MD, Brookes SJ, Jafri H, Ferguson CH et al.
files/Publications%20and%20 Ryu OH, Simmons D, Hong S. Identification of mutations in SLC24A4,
Resources/Whitening%20Survey_ Mutation in kallikrein 4 causes encoding a potassium-dependent
Aug12(1).pdf autosomal recessive hypomaturation sodium/calcium exchanger, as a cause
7. Walsh LJ, Liu JY, Verheyen P. Tooth amelogenesis imperfecta. of amelogenesis imperfecta. Am J Hum
discolouration and its treatment J Med Genet 2004; 41: 545−549. Genet 2013; 92: 307−312.
using KTP laser-assisted tooth 11. Kim JW, Lee SK, Lee ZH, Park JC, Lee 14. Herzog CR, Reid BM, Seymen F,
whitening. J Oral Laser Applications KE, Lee MH, Park JT, Seo BM, Hu JC, Koruyucu M, Tuna EB, Simmer JP, Hu
2004; 4: 7−21. Simmer JP. FAM83H mutations in JCC. Hypomaturation amelogenesis
8. Rajpar MH, Harley K, Laing C, Davies families with autosomal-dominant imperfecta caused by a novel SLC24A4
RM, Dixon MJ. Mutation of the hypocalcified amelogenesis mutation. Oral Surg Oral Med Oral
gene encoding the enamel-specific imperfecta. Am J Hum Genet 2008; Pathol Oral Radiol 2015; 119: e77−81.
protein, enamelin, causes autosomal- 82: 489−494. 15. Watts A, Addy M. Tooth discolouration
dominant amelogenesis imperfecta. 12. Parry DA, Brookes SJ, Logan CV, and staining: a review of the literature.
Hum Mol Genet 2001; 10: 1673−1677. Poulter JA, El-Sayed W, Al-Bahlani S et Br Dent J 2001; 190: 309−316.
9. Kim JW, Simmer JP, Hart TC, Hart al. Mutations in C4orf26, encoding a 16. Hargreaves KM, Berman LH. Cohen’s
PS, Ramaswami MD, Bartlett peptide with in vitro hydroxyapatite Pathways of the Pulp Expert Consult.
JD, Hu JC. MMP-20 mutation in crystal nucleation and growth Oxford: Elsevier Health Sciences, 2015:
autosomal recessive pigmented activity, cause amelogenesis p212.
hypomaturation amelogenesis imperfecta. Am J Hum Genet 2012; 17. Rao A. Principles and Practice of
imperfecta. J Med Genet 2005; 42: 91: 565−571. Pedodontics. London: JP Medical Ltd,
271−275. 13. Parry DA, Poulter JA, Logan CV, 2012: p436.
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