TOOTH DISCOLOURATION

 Stains are external, on the surface

tissues.
 Discoloration is within the tooth itself
External stains include those caused by:
 Tea, soda, dark beverages, colored beverages, dyed foods,
even dark healthy foods like blueberries or strawberries
 Iron contact can cause external staining (such as metal salts)
 Iron supplements or anything with a high level of iron
 Improper brushing (excessive plaque left behind that
accumulates)
EXTRINSIC DISCOLOURATION

 Beverages/food
 Smoking
 Poor oral hygiene (chromogenic bacteria): green/orange stain
DRUGS
 Iron supplements: black stain
 Minocycline: black stain
 Chlorhexidine: brown/black stain
INTRINSIC DISCOLOURATION

ENAMEL
 LOCAL CAUSES CARIES
 Idiopathic
 Injury/infection of primary predecessor
 Internal resorption
 SYSTEMIC CAUSES
 Amelogenesis imperfecta
 Drugs (e.g. tetracyclines)
 Fluorosis
 Idiopathic
 Systemic illness during tooth formation
 INTRINSIC DISCOLOURATION
DENTINE
 Local causes Caries
 Internal resorption
 Metallic restorative materials
 Necrotic pulp tissue
 Root canal filling materials
 Systemic causes
 Bilirubin (haemolytic disease of newborn)
 Congenital porphyria
 Dentinogenesis imperfecta
 Drugs (e.g. tetracyclines)
 Teeth are grey – this is likely caused by tooth trauma
 Teeth are blue, purple or red – likely caused by food dye or tooth
trauma
 Teeth are brown – likely caused by a dark beverage or tooth trauma
 Teeth have orange stains – caused by improper brushing bacteria
accumulate
 Teeth have white spots – might be early tooth decay
Treatment options

 Vital bleaching—chairside and at home technique.

 Inside/outside bleaching.
 Hydrochloric acid–pumice micro-abrasion technique.
 Non-vital bleaching.
 Localized composite resin restorations.
 Composite veneers—direct and indirect.
 Porcelain veneers.
 Adhesive metal castings.
 Full crowns
Vital bleaching/whitening—out with
dental surgery/at home
INDICATIONS
•Mild fluorosis.
•Moderate fluorosis as an adjunct to hydrochloric acid–pumice micro-abrasion.
•Yellowing of ageing.
•Single teeth with sclerosed pulp chambers and canals.
•Selective bleaching for aesthetic purposes.
ARMAMENTARIUM
•Upper impression and working model.
•Soft mouthguard—avoiding the gingival tissues.
•10% carbamide peroxide gel.
 Technique
1. Take an alginate impression of the arch to be treated and cast a working model in stone.
2. Relieve the labial surfaces of the teeth by about 0.5mm and make an acrylic pull-down vacuum-
formed splint as a mouthguard with or without reservoirs for bleaching agent on the teeth
requiring lightening
3. The splint should be no more than 2mm thick and should not cover the gingival tissues. It is only a
vehicle for the bleaching gel and is not intended to protect the gingivae.
4. Instruct the patient on how to floss their teeth thoroughly.
5. Perform a full-mouth prophylaxis and instruct them how to apply the gel into the mouthguard.
6. Note that the length of time the guard should be worn depends on the product used.
7. Review about 2 weeks later to check that the patient is not experiencing any sensitivity, and then
at 6 weeks by which time 80% of any colour change should have occurred.
Vital bleaching/whitening—chairside

 INDICATIONS
 •Very mild tetracycline staining without obvious banding.
 •Mild fluorosis.
 •Yellowing due to ageing.
 •Single teeth with sclerosed pulp chambers and canals.
 ARMAMENTARIUM
 •Rubber dam with clamps and floss ligatures.
 •Orabase® paste.
 •Topical anaesthetic.
 •Gauze.
 •37% phosphoric acid.
 •Heating light with rheostat.
 •30–35% hydrogen peroxide.
 •Polishing stones.
 •Fluoride drops.
Technique
1. Take preoperative periapical radiographs and perform vitality tests.
Replace any leaking restorations.
2. Clean the teeth with pumice and water to remove extrinsic
staining. Take preoperative photographs with a tooth from a
Vita shade guide, registering the shade adjacent to the patient’s
teeth.
3. Apply topical anaesthetic to gingival margins.
4. Coat the buccal and palatal gingivae with Orabase®
paste as extra
protection from the bleaching solution.
5. Isolate each tooth to be bleached using individual ligatures. The
end teeth should be clamped (usually from second premolar to
second premolar).
6. Cover the metal rubber dam clamps with damp strips of gauze
to prevent them from getting hot under the influence of the heat
source.
7. Etch the labial and a third of the palatal surfaces of the teeth with phosphoric acid for 60
seconds, wash, and dry. Thoroughly soak a strip of gauze in the hydrogen peroxide and cover
the teeth to be bleached.
8. Position the heat lamp 13–15 inches (33–38cm) from the patient’s teeth. Set the rheostat to a
mid-temperature range and increase it until the patient can just feel the warmth in their teeth;
then reduce it slightly until no sensation is felt.
9. Keep the gauze damp by reapplying the hydrogen peroxide every 3–5 minutes using a
cotton bud. Make sure that the bottle is closed between applications as the hydrogen peroxide
deactivates on exposure to air.
10. After 30 minutes remove the rubber dam, clean off the Orabase® paste, and polish the
teeth. Apply the fluoride drops for 2–3 minutes.
11. Note that postoperative sensitivity may occur and should be relieved with paracetamol.
12. Assess the change—it may be necessary to repeat the process three to ten times per arch.
Treat one arch at a time. Keep the patient under review as rebleaching may be required after a
year or more.
13. Take postoperative photographs with the original Vita shade tooth included.
(a) A discolored upper right central incisor with

(b) a radiograph confirming sclerosis of the pulp chamber and

root canal.

(c) Appearance of upper right central incisor after four chairside

bleaching treatments.
Non-vital/inside–outside bleaching/
whitening
 Indications
• Discolored non-vital teeth.
• Well-condensed gutta percha root filling.
• No clinical or radiological signs of periapical disease.
 Contraindications
• Heavily restored teeth.
• Staining due to amalgam.
 Armamentarium
• Impression and working model.
• Soft mouthguard—avoiding the gingival tissues.
• 10% carbamide peroxide gel.
Technique

• VISIT 1
– Take preoperative periapical radiographs.
– Take preoperative photographs including shade tab.
– Take an alginate impression of the arch to be treated and cast a
working model in stone.
– Relieve the labial surfaces of the teeth by about 0.5mm and make
an acrylic pull-down vacuum-formed splint as a mouthguard with
or without reservoirs for bleaching agent on the tooth/teeth
requiring lightening.
The splint should be no more than 2mm thick and should not cover the gingival tissues.
Visit 2

– Instruct the patient on how to floss their teeth thoroughly. Perform a full-mouth prophylaxis.
– Remove access cavity restoration and pulp chamber restoration.
– Remove gutta percha filling to 1mm below the level of the dentogingival junction. You may
need to use adult burs in a miniature head.
– Instruct patient how to undertake localized cleaning of the access cavity as well as apply the
gel into the access cavity and mouthguard reservoir.
– Instruct the patient to wear the mouthguard each day/night until the follow-up appointment.
Further visits

– Review at two-week intervals to check the degree of colour change.

– Aim to over-bleach the affected tooth/teeth to allow a degree of relapse.
– Once the endpoint has been reached, restore the access cavity with composite ensuring that
the shade chosen compliments the new aesthetics
Model of upper arch with wax relief to the tooth
requiring treatment and acrylic relief to the
adjacent teeth together with
custom-made mouthguard for inside/outside
whitening to ‘upper left
central incisor
 The hydrochloric acid–pumice
micro-abrasion technique
 Indications
• Fluorosis.
• Idiopathic speckling.
• Post-orthodontic treatment demineralization.
• Prior to localized composite restorations or veneer placement for well-demarcated stains.
• White/brown surface staining, e.g. secondary to primary predecessor infection or trauma (Turner teeth).
 Armamentarium
• Bicarbonate of soda/water.
• Soft white paraffin.
• Fluoridated toothpaste.
• Pumice.
• Rubber dam.
• Rubber prophylaxis cup.
• Soflex discs (3M).
• 18% hydrochloric acid
 Technique
1. Perform preoperative vitality tests; take radiographs and photographs.
2. Clean the teeth with pumice and water, wash, and dry.
3. Isolate the teeth to be treated with rubber dam, including placement of soft white paraffin under the
dam.
4. Place a mixture of sodium bicarbonate and water on the dam behind the teeth as protection in case of
spillage.
5. Mix 18% hydrochloric acid with pumice into a slurry and apply a small amount to the labial surface
for 5 seconds using either a rubber cup rotating slowly or a wooden stick.Wash for 5 sec, repeat the
procedure for 5 times.
6. Remove the rubber dam.
7. Polish the teeth with the finest Soflex discs.
8. Polish the teeth with fluoridated toothpaste in a rubber cup for 1 minute.
9. Review in a month to assess the outcome, to undertake vitality tests, and to take clinical
photographs .
10. Review biannually, checking pulpal status.
(a) Characteristic appearance of fluorotic discoloration. (b) Rubber dam isolation with bicarbonate of
soda in position. (c) Application of hydrochloric acid–pumice slurry with a wooden stick. (d)
Appearance 2 years after treatment.
 Non-vital bleaching/whitening
 Indications
• Discolored non-vital teeth.
• Well-condensed gutta percha root filling.
• No clinical or radiological signs of periapical disease.
 Contraindications
• Heavily restored teeth.
• Staining due to amalgam.
 Armamentarium
• Rubber dam.
• Glass ionomer or IRM cement.
• 37% phosphoric acid.
• Bleaching agent (e.g. sodium perborate, hydrogen peroxide, or carbamide peroxide).
• Cotton wool.
• White gutta percha.
• Composite resin.
• Non-setting calcium hydroxide
 Technique
1. Take preoperative periapical radiographs. These are essential to check for an adequate root filling.
2. Clean the teeth with pumice and make a note of the shade of the discolored tooth.
3. Place rubber dam, isolating the single tooth. Ensure adequate eye and clothing protection for the patient, operator,
and dental nurse.
4. Remove palatal restoration and pulp chamber restoration.
5. Remove root filling to 1mm below the level of the dentogingival junction. You may need to use adult burs in a
miniature head.
6. Place 1mm of cement over the gutta percha.
7. Gently freshen the dentine with a round bur. Do not remove excessively.
8. Etch the pulp chamber with 37% phosphoric acid for 30–60 seconds, wash, and dry. This will facilitate the ingress of
the hydrogen peroxide.
9. Place the bleaching agent, either alone or on a cotton-wool pledget , into the pulp chamber.
10. Place a dry piece of cotton wool over the mixture.
11. Seal the cavity with glass ionomer cement.
12. Repeat the process at weekly intervals until the tooth is slightly over-bleached.
13. Place non-setting calcium hydroxide into the pulp chamber for 2 weeks. Seal with glass ionomer cement.
14. Finally, restore the tooth with white gutta percha (to facilitate reopening the pulp chamber again, if necessary, at a
later date) and composite resin
(a) Intensely darkened non-vital
upper left central incisor

(b) treated by four changes of

bleach.
Localized composite resin restorations

 Indications
• Well-demarcated white, yellow, or brown hypomineralized enamel such as those seen in
MIH
 Armamentarium
• Rubber dam/contoured matrix strips.
• Round and fissure diamond burs.
• Enamel–dentine bonding kit.
• New generation highly polishable hybrid composite resin.
• Soflex discs (3M) and interproximal polishing strips.
 Technique
1. Take preoperative photographs and select the shade (Fig. 11.7(a)).
2. Apply rubber dam and contoured matrix strips if required.
3. Remove full extent of demarcated lesion with a round diamond bur down to the amelodentinal
junction (ADJ).
4. Chamfer the enamel margins with a diamond fissure bur to increase the surface area available for
retention if required.
5. Etch the resultant cavity margins. Wash and dry.
6. Apply the prime and bonding agent as per the manufacturer’s instructions.
7. Apply the chosen shade of composite, use a brush lubricated with the bonding agent to smooth and
shape, and light-cure for the recommended time.
8. Remove the matrix strip/rubber dam.
9. Polish with graded Soflex discs (3M), finishing burs, and interproximal strips if required. Add
characterization to the surface of the composite.
10. Take postoperative photographs
(a) Well-demarcated white opacities on the
upper central
incisors;

(b) treated by localized composite

restorations.
Composite resin veneers
 Indications
• Discolouration.
• Enamel defects.
• Diastemata.
• Malpositioned teeth.
• Large restorations.
 Relative contraindications
• Insufficient tooth tissue available for bonding.
• Oral habits (e.g. woodwind musicians).
• Occlusal factors.
 Armamentarium
• Rubber dam/contoured matrix strips.
• Preparation and finishing burs.
• New generation highly polishable hybrid composite resin.
• Soflex discs (3M) and interproximal polishing strips.
 Technique
1. Use a tapered diamond bur to reduce labial enamel by 0.3–0.5mm if appropriate. Identify the finish
line at the gingival margin and also mesially and distally just labial to the contact points.
2. Clean the tooth with a slurry of pumice in water. Wash and dry, and select the shade.
3. Isolate the tooth with rubber dam and a contoured matrix strip. Hold this in place by applying
unfilled resin to its gingival side against the gingiva and curing for 10 seconds.
4. Etch the enamel as per the manufacturer’s instructions.
5. Apply a thin layer of priming and bonding resin to the labial surface with a brush as per the
manufacturer’s instructions. It may be necessary to use an opaquer at this stage if the discoloration is
intense.
6. Apply composite resin of the desired shade to the labial surface and roughly shape it into all areas
with a plastic instrument; then use a brush lubricated with unfilled resin to ‘paddle’ and smooth it into
the desired shape cure it.
7. Flick away the unfilled resin holding the contour strip and remove the strip.
8. Finish the margins with diamond finishing burs and interproximal strips
Characterization should be added to improve light reflection properties
(a) A young patient with amelogenesis imperfecta. (b) Contoured matrix strip in position. (c)
Incremental placement of dentine shade composite.
(d) Postoperative view showing final composite veneers.
Porcelain veneers

 Porcelain has several advantages over composite as a veneering material: its appearance is
superior, it has a better resistance to abrasion, and it is well tolerated by the gingival
tissues.
 However, a non-standard application that is being used more frequently at a younger age
is the restoration of the peg lateral incisor if placement of a direct composite resin
restoration is considered unsuitable.
Adhesive metal castings
 Indications
• Amelogenesis imperfecta.
• Dentinogenesis imperfecta.
• Dental erosion, attrition, or abrasion.
• Enamel hypoplasia.
 Armamentarium
• Gingival retraction cord.
• Elastomeric impression material.
• Facebow system.
• Semi-adjustable articulator.
• Rubber dam.
• Panavia-Ex (Kuraray
 Technique
1. Obtain study models (these are essential) and photographs ifpossible.
2. Perform a full-mouth prophylaxis.
3. Ensure good moisture isolation.
4. Place retraction cord into the gingival crevices of the teeth to be treated and remove immediately prior to
taking the impression.
5. Take an impression using an elastomeric impression material (a putty–wash system is best) and check that the
margins are easily distinguishable.
6. Take a facebow transfer and interocclusal record in the retruded axis position.
7. Mount the casts on a semi-adjustable articulator.
8. Construct cast onlays a maximum of 1.5mm thick occlusally in either nickel–chrome or gold.
9. Grit-blast the fitting surfaces of the occlusal onlays.
10. Return to the mouth and check the fit of the onlays, and sandblast before fitting.
11. Polish the teeth with pumice and isolate under rubber dam where possible.
12. Cement onlays using Panavia-Ex.
13. Check occlusion and record extent of discrepancies.
14. Review in a week to check occlusion and other problems, and regularly thereafter
(a) Marked occlusal enamel loss of lower first permanent
molars.

(b) Cast occlusal onlays in situ after replacement of amalgam

restorations with composite resin.
Indirect composite resin onlays

 Direct composite onlays, indirect composite onlays, and porcelain onlays are an alternative
to cast metal onlays.