Enhanced CPD DO C & D O D RestorativeDentistry

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
beauty and perfection the demand for
an idealized appearance has never been
greater. This need for perfection has been
driven as much by societal expectations
as it has by the media. Age is no longer
a barrier to patients’ quests for improved
appearance, however, greater dissatisfaction
regarding dental appearance has been
reported in younger age groups.1 The dental
industry has considerable responsibility
and a versatile armamentarium to drive
Raj Dubal, BDS, MFDS RCS, MClin Dent
Pros, MRD RCS, FDS RCS, PG Cert Dent Ed,
Specialty Trainee in Restorative Dentistry
and Richard WJ Porter, BDS, BSc, MFDS
RCS, FDS(Rest Dent) RCS, Consultant in
Restorative Dentistry, St George’s Hospital,
Tooting, London, SW17 0QT, UK.
July/August 2018 DentalUpdate 601
improvements in appearance, and it is not
unusual for patients to approach dentists
and allied oral healthcare professionals
for advice regarding improving dental
appearance as well as facial aesthetics.
Visible caries has been reported to lead
to more negative judgements regarding
social competence, intellectual ability,
psychological adjustment and relationship
satisfaction.2 Tooth colour has been found
to exert an influence on social perceptions2
and, as such, can have an adverse influence
on individuals’ psychosocial health and
quality of life.3 Self-assessed perceptions of
tooth discoloration can be very critical. In
a self-assessment based national study of
3215 subjects, 50% of respondents reported
dissatisfaction with their tooth colour.4
With such high levels of dissatisfaction
with tooth colour it is unsurprising that
the demand for procedures to improve
tooth colour have increased significantly,
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and there is evidence that this can have
a considerable impact on patients’ self-
esteem.5
Dental aesthetic improvements
which a patient may desire can revolve
around a number of factors such as; shade,
morphology, size, alignment, symmetry and
the extent to which the teeth harmonize
with a patient’s face as a whole. Patients
can be very aware of the limitations of their
dental appearance, and tooth shade is a
commonly cited complaint. In a survey on
tooth whitening by the American Academy
of Cosmetic Dentistry (2012), the single
most common factor which respondents
reported that they would like to improve
about their smile is the ‘whiteness and
brightness’ of their teeth.6
Teeth may become discoloured
for a number of different reasons, and
a thorough history and examination
will give clues as to the aetiology of the
 RestorativeDentistry
Pre-Eruptive Causes of
Discoloration
Intrinsic − Fluorosis
− Tetracycline staining
− Developmental defects such as
amelogenesis imperfecta,
dentinogenesis imperfecta
− Trauma, eg Turner Teeth
− Infection − PA path of deciduous
teeth affecting permanent
teeth
− Maternal infection during
pregnancy, eg rubella or
cytomegalovirus
− Childhood infections until age 8
− Nutritional deficiencies
− Haematological dyscrasias, eg
Sickle Cell Anaemia or
thalassaemia
− Hereditary diseases, eg
erythropoietic porphyria
Extrinsic nil
Table 1. Pre- and post-eruptive causes of tooth discoloration.
discoloration, and thus the treatment which
is most likely to be effective. It is imperative
that the aetiology is ascertained prior to
proposing a particular treatment approach.
Aetiology and classification of
dental discoloration
Generally speaking, discoloration
of teeth may be either intrinsic or extrinsic,
and may present in isolation or affect the
dentition generally. Tooth discoloration may
also be classified as pre-eruptive or post-
eruptive in nature. Commonly cited causes
of extrinsic and intrinsic discoloration are
noted in Table 1.
602 DentalUpdate July/August 2018
Post-Eruptive Causes of
Discoloration
− Tooth surface loss
− Caries
– Trauma; iron sulphide
deposition in dentinal tubules
from intra pulpal haemorrhage
− Internal resorption
− Dental materials, eg amalgam,
Russian Red
− Ageing
− Plaque
− Calculus
− Chromogenic bacteria
− Tooth surface loss
− Food and drink stains such as
tea, coffee, red wine,
turmeric
− Tobacco; chewed or smoked
− Betel nut chewing
− Chlorhexidine-containing
agents
Extrinsic staining
Extrinsic stains tend to be as a
result of molecules bound to the surface
of a tooth by either weak chemical or
mechanical means (Figure 1). There is no
incorporation of the staining molecule into
the structure of the tooth. In light of this,
techniques which mechanically dislodge
or separate the stained molecules from the
tooth surface are effective, and these can
be minimally interventive. Such techniques
include the use of hand and ultrasonic
scalers, delivery of an abrasive slurry or
powder in jet form and polishing with
prophylaxis pastes. This is usually sufficient
to remove extrinsic stains. If such measures
are not effective, it may be necessary to
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Figure 1. Extra-oral view showing teeth with
external staining.
revisit the diagnosis as the stain may be
intrinsic in nature.
In mentioning abrasive and
mechanical means of stain removal, it is
worthy of note that some toothpastes
can be particularly abrasive, and can,
when regularly used, increase the surface
roughness of teeth. This can, in turn,
increase the propensity of the rougher
tooth surfaces to pick up stains at a greater
rate and magnitude. If such preparations
are used for long enough, thinning of the
translucent overlaying enamel can result
in more of the dentine shining through,
exacerbating the poor appearance of the
teeth. It is wise to advise patients against
the use of such preparations, as the
probability of surface enamel abrasion,
sensitivity and further deterioration in
shade is high. Some smokers’ toothpastes
and whitening dentifrices are renowned for
this.
Intrinsic staining
In contrast to extrinsic staining,
most intrinsic stains stem from one of three
causes:
1. Material in the pulp chamber:
such materials can include gutta percha
or stained restorative material left supra-
crestally within the pulp space of a tooth
following endodontic therapy.
2. Altered structure or
incorporations within the tooth: this can
include the incorporation of tetracycline or
fluoride metabolites into the structure of
the tooth.
3. Material in the dentinal tubules:
this can include breakdown products of
blood, dental materials or other agents.
In all cases, it is alterations in the
transmission and absorption of light
 RestorativeDentistry
through a tooth which results in an altered
appearance in tooth colour.
A good diagnosis for a good
outcome
A systematic approach and
accurate diagnosis of the aetiology of
discoloration is imperative in achieving a
more predictable and effective outcome.
Bleaching techniques should not be
employed without a thorough history,
appropriate examination and special
investigations, which may include
radiographs and sensibility testing. A
thorough history and focused exploration
of the nature of the staining will help to
identify the cause of the staining and thus
the most appropriate treatment.
Diagnostic criteria can include:7
1. Number and distribution of teeth
affected;
2. Duration of staining;
3. Progression of the intensity/darkness
of the stain;
4. Habits such as smoking, red wine,
chromogenic foods and drinks or use
of chlorhexidine-containing agents;
5. Colour;
6. History of trauma;
7. Previous treatment of affected teeth;
8. Familial considerations;
9. Associated syndromes and diseases.
Number and distribution of teeth affected
The number and distribution
of affected teeth can give an indication
of whether the discoloration is due to an
individual event, or a more generalized
aetiology. Individually stained teeth
may result from loss of vitality, previous
endodontic treatment, discoloured
restorations or a malaligned or in-standing
tooth which is more susceptible to staining.
If a small number of adjacent teeth are
affected, there may be some habit which
is predisposing the patient to the staining,
such as holding a cigarette adjacent to
a particular group of teeth repeatedly. If
symmetry is evident in the affected teeth,
and they may or may not be adjacent,
there may have been some factor such
as a childhood infection, pyrexia or a
metabolic disturbance which affected the
development of a particular group of teeth
at a particular time.
604 DentalUpdate July/August 2018
Generalized staining can be
indicative of either a habit or behaviour
which the patient partakes in which affects
all of the teeth. This can include the use
of mouthwashes with a tendency to stain
the teeth, drinking black coffee or tea or
similar causes. These stains are likely to
be extrinsic in nature. There may also be
factors which have affected the whole
dentition which are intrinsic in nature.
These would include developmental
defects such as amelogenesis imperfecta
and dentinogenesis imperfecta, or the
incorporation of other molecules into the
tooth structure at the time of development
such as tetracycline staining or fluorosis.
Duration of staining
Stains which have not been
present since eruption are likely to be
associated with some individual event,
action or behaviour. This may be following
trauma or treatment, or may be associated
with a causative factor such as tobacco use,
tea, coffee or a similarly staining agent.
Discoloration which has been evident
since eruption of the teeth is likely to be as
a result of a developmental aetiology, or
due to a systemic cause which has resulted
in an alteration or incorporation into the
crystalline structure of the teeth when they
were developing. Tetracycline staining or
fluorosis would be an example of this.
Progression in the intensity/darkness of the
stain
Discoloration of teeth which
is developmental in nature is likely to
be stable. Deterioration may occur if, in
the case of, for example, amelogenesis
imperfecta, the teeth begin to wear and
chip, and areas may stain faster due to
the rougher and more irregular remaining
tooth surfaces. In the case of progressive
staining, the history should explore the
presence of ongoing aetiological factors
such as tobacco use, tea, coffee, and other
chromogen heavy activities.
Habits such as smoking, red wine,
chromogenic foods and drinks or use of
chlorhexidine-containing agents
A thorough history of the
discoloration in conjunction with the clinical
examination should aid in highlighting any
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Figure 2. Extra-oral view of a discoloured
UR1 tooth which devitalized following crown
preparation and cementation of an all-ceramic
crown.
obvious aetiological factors, which should
lead to appropriate management, and
prevention as necessary.
Colour
An exploration of the colour of
the discoloured tooth or teeth can be of
considerable diagnostic value. While not
definitively diagnostic, in conjunction with a
thorough history, this can help to confirm a
suspected diagnosis.
Fluorotic teeth may be mottled,
speckled, smooth and, in severe cases,
can be brown and pitted. In contrast to
this, tetracycline-stained teeth can be
blue-grey to orange-brown in colour,
often with striated horizontal banding
present. Dentinogenesis imperfecta can
present with a bluish translucent hue, while
a traumatized tooth which is non-vital
may present with a grey discoloration. A
pink tooth may be indicative of internal
resorption or of a breakdown in tooth
structure, allowing proliferation of
periodontal soft tissue into the internal
tooth space, which shines through the shell
of the tooth.
History of trauma
Single anterior discoloured
teeth, particularly if grey or dark in nature,
should lead a clinician to enquire if any
previous dental trauma has occurred.
This discoloration may indicate that
the tooth has become non-vital, or has
previously been endodontically treated and
requires further intervention to improve
its appearance. Following trauma, pulp
necrosis may lead to blood breakdown
products, in particular iron sulphide, which

can pass down dentinal tubules and
cause a dark grey discoloration. Such
colour changes can take many months to
develop.
Following luxation injuries,
the coronal portion of a tooth may
become red in appearance. This can
occur due to the venous drainage of the
tooth being severed, while the arteriolar
supply is maintained. This red colour is
indicative of the coronal portion of the
tooth being engorged with blood. Over
time the discoloration can change to a
darker hue as iron sulphide again passes
into the dentinal tubules.
As previously mentioned, a
pink appearance to an individual tooth
may be indicative of internal resorption.
In such cases, resorption of the dentine
occurs and this is replaced by vascular
and hyperplastic soft tissue. As this tissue
approaches the surface of the tooth the
pink vascular tissue shines through the
tooth.
In the case of previously
traumatized teeth, a tooth may become
yellow and lack lustre. This may be
indicative of sclerosis of the root canal,
or the impact of a restorative material
within the coronal portion of the tooth.
The exact aetiology will be confirmed by
a thorough examination and appropriate
radiographs.
Previous treatment of affected teeth
An exploration of any
previous treatment of the affected tooth
or teeth is necessary. It is likely that teeth
in isolation will present in this manner,
and discoloration may be as a result of
an increased surface roughness, or due
to deterioration of a restorative material
over time. If a particular material has
been used in a number of teeth, and the
age of the material is comparable, more
affected teeth will be evident, although
the discoloured restoration should be
well demarcated and the stain may not
affect the tooth structure itself, indicating
polishing or refreshing of the restorative
material.
Commonly, previous
endodontic treatment or teeth which
have lost vitality can present with a
grey discoloration, and appropriate
investigation and management should
July/August 2018 DentalUpdate 605
RestorativeDentistry
Disorder Discoloration Cause
Alkaptonuria Brown Inborn error of metabolism which leads
discoloration to a build-up of homogentisic acid,
ultimately affecting the permanent
dentition.
Congenital Red or brown Congenital disorder, with likely
erythropoietic discoloured teeth metabolic impact of disorder at time of
porphyria (Gunther development.
disease)
Hyperbilirubinemia Yellow-green Incorporation of bilirubin into the dental
during the years of or blue-green hard tissues
tooth formation discoloration
Thalassaemia Blue, green or Metabolic impact of disorder at time of
brown tooth development
discoloration
Sickle Cell Anaemia Blue, green or Metabolic impact of disorder at time of
brown tooth development
discoloration
Cystic fibrosis A variety of May be due to common prescription of
discoloration tetracycline during tooth development,
or due to defective cystic fibrosis
transmembrane regulator, which
is known to be involved in enamel
formation
Table 2. Table showing different diseases and associated tooth discolorations.15,16,17
be instigated. In certain circumstances, discoloration to the patient is useful as
endodontic obturation materials which part of the history when generalized
have been used overseas may result in discoloration of the dentition is
alternative discolorations. An example of evident. This is particularly pertinent
this is the endodontic obturation material in cases of amelogenesis and
‘Resorcinol-formaldehyde resin’, more dentinogenesis imperfecta, as both
commonly known as ‘Russian Red’, and can run in families. Amelogenesis
is recognizable from the change towards imperfecta can have different
a red hue of the tooth. Mineral trixoxide inheritance patterns depending on
aggregate is also known to result in a which gene is affected and, as a result,
greying of tooth structure when used as it is difficult to predict if a person will
an obturation material (Figure 2). be affected or not. The most common
mutation affects the ENAM8 gene, and
Familial considerations these mutations are inherited in an
An exploration of any family autosomal dominant pattern, meaning
members being affected by similar that only one copy of the affected gene
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 RestorativeDentistry
Figure 3. Mindmap showing a diagnostic tree, which can aid in diagnosing causes of discoloration.
is sufficient to cause manifestation of the
disease. This disorder can also be caused
by mutations of the MMP20,9 KLK4,10
FAM83H,11 C4orf2612 or SLC24A413,14
genes.
It is worthy of note that
children who present with fluorosis
may also have siblings with similar
discoloration and, far from being
hereditary in nature, mindfulness and
adjustment in fluoride exposure can help
in preventing this in younger siblings.
Associated syndromes and diseases
A number of diseases and
syndromes have been reported which
can affect the colour of teeth. These tend
to have a metabolic underpinning which
results in changes in the appearance due
to developmental alterations. Examples
of these are listed in Table 2.
Summary
This article has aimed to
deliver an overview of the classification
606 DentalUpdate July/August 2018
and causes of dental discoloration.
Figure 3 presents a mindmap showing
a diagnostic tree which can aid in
diagnosing causes of discoloration. There
are a wide range of aetiological factors
and clinical manifestations which are
encompassed by the term discoloured
teeth. Accurate diagnosis is pivotal in
giving the clinician and thus patient an
indication of the appropriate treatment
modality and likely outcome.
A second part will review the
mechanism of action and various clinical
approaches using bleaching agents to
manage discoloured teeth.
References
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2. Kershaw S, Newton JT, Williams
DM. The influence of tooth colour
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Kingdom. J Dent 2004; 32: 561−566.
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Dentistry. Whitening Survey, Summer
2012.
 RestorativeDentistry

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