Seminar on

Tooth discoloration
and its management

By:
Aditi Chandra
MDS-12
Department of Conservative Dentistry
and Endodontics
Subharti Dental College

TOOTH DISCOLOURATION AND ITS MANAGEMENT

INTRODUCTION
Discoloration of the tooth is one of the most frequent reasons
why a patient seeks dental care. Tooth is usually esthetically
displeasing and psychologically traumatizing. An understanding of
the etiology of tooth discoloration is important to a dentist in
order to make the correct diagnosis. The knowledge of the cause
of discoloration will also help the dental practitioner to explain the
exact nature of the condition to the patient. In some instances,
the mechanism of staining may have an effect on the outcome of
treatment and influence the treatment options offered by the
dentist to the patients.

DEFINITION
Tooth discolouration is defined as any change in the hue, colour,
or translucency of a tooth due to any cause; restorative filling
material, drugs(both topical and systemic), pulpal necrosis, or
hemorrhage may be responsible. (Ingle)

ETIOLOGY
According to Ingle

Patient related
causes

Dentist related
causes

EXTRINSIC STAINS
Feinman et al. in 1987, described extrinsic discolouration as that
occuring when an agent or stain damages the enamel surface of
teeth. Extrinsic staining can easily be removed by a normal
prophylactic cleaning.

Intrinsic stains
Intrinsic staining is defined as endogenous staining that has been
incorporated into the tooth matrix and thus cannot be removed
by prophylaxis.

Pulp Tissue Remnants

Tissue remaining in the pulp chamber disintegrates and cause

discoloration. Pulp horns must always be included in the access
cavity to ensure removal of pulpal remnants. Intracoronal
bleaching in these cases is usually successful.
Age
In elderly patients, color changes in the crown occur
physiologically, a result of excessive dentin apposition,thinning
of the enamel and optical changes. Food and beverages also
have a cumulative discoloration effect. These become more
pronounced in the elderly, owing to the inevitable cracking,
crazing, and incisal wear of enamel and underlying dentin.
Bleaching can be successfully done for many types of
discolorations in elderly patients.
Dentin Hypercalcification
Most frequently seen in anterior teeth. It is a pulpal response to
trauma, characterised by rapid deposition of hard tissue within
the root canal space. Traumatic injuries lead to temporary
disruption of blood supply
Destruction of odontoblasts
which are replaced by undifferentiated mesenchymal cells
which rapidly form irregular dentin. The translucency of the
crowns of such teeth gradually decreases, giving rise to a
yellowish or yellow brown discoloration. Extracoronal bleaching
may be attempted first. If unsuccessful, alternative approaches
like laminates ,veneers etc can be given.
Tooth formation defects
Discoloration may result from developmental defects during
enamel and dentin formation.

Hypocalcific

Hypoplastic

Enamel hypocalcification:
Distinct brownish or whitish area, commonly found on the
facial aspect of affected crowns.
The enamel is well formed with an intact surface.
Enamel hypoplasia :
Condition may be hereditary, as in amelogenesis imperfecta,
or a result of environmental factors such as infections,
tumors, or trauma.
Disturbance of the developing tooth germ may also occur in
a large number of fetal or maternal conditions eg; maternal
vitamin D deficiency, rubella infection, drug intake during
pregnancy and in paediatric hypocalcaemic conditions.
Enamel formation, the matrix is altered and does not
mineralize.
There may be pitting or grooving which predisposes to
extrinsic staining of the enamel in the region of tooth
disturbed, often then becoming internalised.
Bleaching effect may not be permanent depending on the
severity and extent of hypoplasia and the nature of the
discoloration.

Systemic conditions
1. Erythroblastosis fetalis

 Massive systemic lysis of erythrocyte releases large amounts

of hemosiderin pigment which penetrate and discolor the
forming dentin.
Stain does not involve teeth developing after cessation of
hemolysis .
Stain is usually green, brown or bluish in colour.
Such discoloration is now uncommon and is not amenable to
bleaching.
2. Congenital erythropoietic porphyria
Rare, recessive, autosomal, metabolic disorder.
There is an error in porphyrin metabolism leading to the
accumulation of porphyrins in bone marrow, red blood cells,
urine, faeces and teeth.
A red-brown discolouration of the teeth
The affected teeth show a red fluorescence under ultra-violet
light.
3. Sickle cell anemia
Inherited blood dyscrasia.
Increased hemolysis of red blood cells
Involves both dentitions.

Cause intrinsic blue, brown, or green discolorations.

Does not resolve with time.

4. Alkaptonuria
This inborn error of metabolism.

 Incomplete metabolism of tyrosine and phenylalanine, which

promotes the build up of homogentisic acid.
This affects the permanent dentition by causing a brown
discolouration
5. Congenital hyperbilirubinaemia
Massive haemolysis will lead to deposition of bile pigments
in the calcifying dental hard tissues, particularly at the
neonatal line.
The breakdown products of haemolysis will cause a yellowgreen discolouration
6. Amelogenesis imperfecta

In this hereditary condition.

Enamel formation is disturbed with regard to mineralization

or matrix formation.
The appearance depends upon the type of amelogenesis
imperfecta, varying from the relatively mild hypomature
snow-capped enamel to the more severe hereditary
hypoplasia with thin, hard enamel which has a yellow to
yellow-brown appearance
7. Dentinogenesis imperfecta

This is an autosomal dominant condition affecting both

deciduous and permanent dentition.

Dentinogenesis imperfecta I: Teeth are blue gray or amber

brown and opalescent.
Dentinogenesis imperfecta II: Teeth are usually bluish or
brown in colour, and demonstrate opalescence on
transillumination.

 Dentinogenesis imperfecta III: Teeth may be outwardly

similar to both types I and II of Dentinogenesis imperfecta.

Endemic Fluorosis
Ingestion of excessive amounts of fluoride during tooth
formation may produce a defect in mineralized structures,
particularly in the enamel matrix, causing hypoplasia.
Fluoride intake may arise from naturally occurring water
supplies or from fluoride delivered in mouthrinses, tablets or
toothpastes as a supplement. The severity is related to age
and dose, with the primary and secondary dentitions both
being affected in endemic fluorosis. The teeth are not
discolored on eruption, but their surface is porous and will
gradually absorb colored chemicals present in the oral cavity.
Discoloration is usually bilateral, affecting multiple teeth in
both arches. It presents as various degrees of intermittent
white spotting, chalky or opaque areas, yellow or brown
discoloration, and, in severe cases, surface pitting of the
enamel. Fluoride only causes fluorosis in concentrations of
greater than 1 ppm in drinking water and is not
distinguishable, clinically or histologically, from any other
type of hypoplastic or hypomineralised enamel. Since the
discoloration is in the porous enamel, such teeth can be
bleached externally.

Drug-Related Defects
Administration or ingestion of certain drugs during tooth
formation may cause severe discoloration both in enamel
and dentin.
Tetracycline

Tooth shades can be yellow, yellow-brown, brown, dark gray,

or blue, depending on the type of tetracycline, dosage,
duration of intake, and patients age at the time of
administration. Discoloration is usually bilateral, affecting
multiple teeth in both arches. Deposition of the tetracycline
may be continuous or laid down in stripes depending on
whether the ingestion was continuous or interrupted.
Mechanism of tetracycline discoloration: Tetracycline bound
to calcium is thought to be incorporated into the
hydroxyapatite crystal of both enamel and dentin. However,
most of the tetracycline is found in dentin.
Repeated exposure of tetracycline-discolored tooth to
ultraviolet radiation can lead to formation of a reddishpurple oxidation by-product that permanently discolors the
teeth. In children, the anterior teeth often discolor first,
whereas the less exposed posterior teeth are discolored
more slowly. In adults, natural photobleaching of the anterior
teeth is observed, particularly in individuals whose teeth are
excessively exposed to sunlight.

Tetracycline discoloration has been classified into three

groups according to severity:

First-degree discoloration is light yellow, light brown, or light gray

and occurs uniformly throughout the crown, without banding.

Second-degree discoloration is more intense and also without

banding.
Third-degree discoloration is very intense, and the clinical crown
exhibits horizontal color banding. This type of discoloration usually
predominates in the cervical regions.

Two approaches have been used to treat tetracycline

discoloration:
(1)

Bleaching the external enamel.

(2)
Intracoronal bleaching following intentional root canal
therapy.

Minocycline
Staining is common in adoloscents and adults whose teeth
have already formed.
Unlike tetracycline, which can be used in adults without the
risk of discolouration, minocycline is absorbed from the
gastrointestinal tract Chelates with iron and forms Insoluble
calcium-minocycline complexes.
Some minocycline stains may be responsive to bleaching.
Others with severe banding may require porcelain laminate
veneers
Plaque

Pellicle and plaque on tooth surface give rise to yellowish

appearance of tooth.
Food and beverages
Tea, coffee, red wine, curry and colas if taken in excess
causes brown stains on the outer (buccal, labial) and inner
(lingual, palatal) surfaces of the teeth.
Tobacco
Results in brown to black appearance of teeth that cover
the cervical one third to one half of the tooth.
A.

Poor oral hygiene

Green stains / Orange stains:
Occur due to Poor oral hygiene and Chromogenic bacteria .
Usually in cervical & gingival areas of tooth.
More common in mouth breathers & young persons .
Occur more readily on the labial surface of the maxillary
anterior teeth.

B. Brown stains:
Due to caries and Chromogenic bacteria.
Discolouration is due to surface decalcification.
Swimmers calculus
Swimmers calculus is defined as being a hard, brown tartar
deposit that usually appears on the front teeth.
It normally occurs in swimmers who spend more than 6
hours a week submerged in chlorinated or chemically treated
water in swimming pools.
The pool water contains chemicals which give the water a
higher pH than saliva, that cause salivary proteins to break
down quickly and form organic deposits on teeth.

Chemicals
1. Chlorhexidine stains:
Chlorhexidine rinse (0.12%) causes brown staining after
several weeks of use, particularly on acrylic and porcelain
restorations.

2. Metallic stains:
These are caused by metals and metallic salts introduced
into the oral cavity in metal containing dust inhaled by
industry workers or through orally administered drugs.
Mechanism of stain production is related to the production
of the sulphide salt of the particular metal involved.
Stains caused by different metals:
Copper dust: green stains
Iron dust: brown stains
Mercury: greenish-brown stains
Nickel: green stains
Silver: black stains
Potassium permanganate: violet-black stain
Stannous fluoride: golden-brown stain
Intracanal Medicaments
Several intracanal medicaments are liable to cause internal
staining of the dentin.
Phenolics or iodoform-based medicaments sealed in the root
canal and chamber are in direct contact with dentin, allowing
penetration and oxidization.
These compounds have a tendency to discolor the dentin
gradually.
Phenolic compounds- brown black stain
Iodoform- white silver stain
Intracoronal bleaching may be used to correct the problem.
Obturating Materials

 This is a frequent and severe cause of single tooth

discoloration.
Incomplete removal of obturating materials and sealer
remnants in the pulp chamber, mainly those containing
metallic components, often results in dark discoloration.
This is easily prevented by removing all materials to a level
just below the gingival margin
Intracoronal bleaching is the treatment of choice.
Prognosis depends on the type of sealer and duration of
discoloration.

Amalgams
Sometimes the dark appearance of the crown is caused by
the amalgam restoration that can be seen through the tooth
structure.
Silver alloys have severe effects on dentin owing to darkcolored metallic components that can turn the dentin dark
gray.
Amalgam blues:
Dark discolouration seen in the tooth structure adjacent to
amalgam restoration.
They mimick secondary caries.
It is caused by the gradual diffusion of metallic ions from
amalgam restoration into the dentin or by light passing
through the transluscent, thin enamel that is reflected from
the underlying amalgam.

Pins and Posts

Metal pins and prefabricated posts are sometimes used to
reinforce a composite restoration in the anterior dentition.
Discoloration from inappropriately placed pins and posts is
caused by the metal seen through the composite or tooth
structure.
In such cases, coverage of the pins with a white cement or
removal of the metal and replacement of the composite
restoration is indicated.

Composites
Microleakage around composite restorations causes staining.
Open margins may allow chemicals to enter between the
restoration and the tooth structure and discolor the
underlying dentin.
In addition, composites may become discolored with time,
affecting the shade of the crown.
These conditions are generally corrected by replacing the old
composite restoration with a new, well-sealed one.
Management of tooth discolouration

Diet and habits

Extrinsic staining caused by foods, beverages, or habits (eg,
smoking, chewing tobacco; see Causes and Pathophysiology) is
treated with a thorough dental prophylaxis (Dental pumice to
remove the stain, and then prophylaxis paste to smoothen the
tooth surfaces)
Prophyjet utilizing air to spray a mixture of fine baking soda
powder and water onto the surfaces of teeth.
Cessation of dietary or other contributory habits.
Toothbrushing:
Effective toothbrushing twice a day with a dentifrice helps to
prevent extrinsic staining.
Most dentifrices contain an abrasive, a detergent, and an
antitartar agent.
In addition, some dentifrices now contain tooth-whitening agents.
Professional tooth cleaning:

Some extrinsic stains may be removed with ultrasonic cleaning,

rotary polishing with an abrasive prophylactic paste, or air-jet
polishing with an abrasive powder.
However, these modalities can lead to enamel removal; therefore,
their repeated use is undesirable.
Enamel microabrasion
Indicated for the removal of superficial intrinsic tooth
discoloration, including that caused by fluorosis and
decalcifications secondary to orthodontic brackets or bands.
2 main technique :
Hydrochloric acid/pumice technique
Phosphoric acid/pumice technique
Simple to perform and the depth of enamel removed in 10
applications is approximately 100 m . (0.1 mm ).
The resultant surface is smooth and has a glazed appearance.
Enamel microabrasion may be used in conjunction with bleaching.
Enamel macroabrasion
ADVANTAGES:
Faster.
Does not require the use of a rubber dam or special
instrumentation.
Gross removal of the defect can be easily accomplished.
DISADVANTAGES:
High-speed instrumentation is technique sensitive.

 Makes way for the active reagents of bleaching system to

penetrate.
Bleaching (Tooth whitening)
The lightening of the color of a tooth through the application of a
chemical agent to oxidize the organic pigmentation in the tooth
BLEACHING MATERIALS:
1st generation liquid form, did not remain in tray for long,
required frequent replishment.
2nd generation viscous & gel form , prevents leaching out and
soft tissue irritation
3rd generation different vehicle & color, more patient friendly.
DIFFERENT BLEACHING AGENTS:
Hydrogen Peroxide
Cabarmide peroxide
Sodium perborate
McInnes solution (five parts 30% hydrogen peroxide, five parts
36% hydrochloric acid, and one part ethyl ether)
Hydrogen Peroxide
Various concentrations of this agent are available, but 30 to
35% stabilized aqueous solutions are the most common.
Silicone dioxide gel forms containing 35% hydrogen peroxide
are also available, some of them activated by a composite
curing light.
Hydrogen peroxide is caustic and burns tissues on contact,
releasing toxic free radicals, perhydroxyl anions, or both.

 High-concentration solutions of hydrogen peroxide must be

handled with care as they are thermodynamically unstable
and may explode unless refrigerated and kept in a dark
container.
Sodium Perborate
Available in a powdered form or as various commercial
preparations.
When fresh, it contains about 95% perborate, corresponding
to 9.9% of the available oxygen.
Stable when dry.
In the presence of acid, warm air, or water, it decomposes to
form sodium metaborate, hydrogen peroxide, and nascent
oxygen.
Three types of sodium perborate preparations are available:
monohydrate, trihydrate, and tetrahydrate.
Commonly used sodium perborate preparations are alkaline,
and their pH depends on the amount of hydrogen peroxide
released and the residual sodium metaborate.
More easily controlled and safer than concentrated hydrogen
peroxide solutions.
Material of choice in most intracoronal bleaching procedures.
Carbamide Peroxide
Also known as urea hydrogen peroxide.
Available in the concentration range of 3 to 45%.
Commercial preparations contain about 10% carbamide
peroxide, with pH of 5 to 6.5.

 Solutions of 10% carbamide peroxide break down into urea,

ammonia, carbon dioxide, and approximately 3.5% hydrogen
peroxide.
Bleaching preparations containing carbamide peroxide
usually also include glycerine or propylene glycol, sodium
stannate, phosphoric or citric acid, and flavor additives.
In some preparations, carbopol, a water-soluble polyacrylic
acid polymer, is added as a thickening agent.
Carbopol also prolongs the release of active peroxide and
improves shelf life.
Mechanism of bleaching
According to Kihn :

Hydrogen peroxide (oxidizing agent)

Diffuses into the tooth
Breaks down to produce unstable free radicals
Attack organic pigmented molecules
Smaller, less heavily pigmented constituents
Smaller molecules reflect less light, thus creating whitening
effect.

The mechanisms of Non-hydrogen peroxide containing materials

are that the moist tooth structure and the gel interact and
activate the gel. The oxygen complex interacts with the tooth
structure and saturates and changes the amino acids and double
bonds of oxygen which are responsible for tooth discoloration.

Factors affecting success

1. Age - younger patients experience a greater reduction in

yellowness immediately.
2. Type of bleaching - carbamide peroxide-based products stay
active for a lot longer than hydrogen peroxide-based
products.
3. Concentration of bleaching agent used - higher the
concentration of the agent, the more likely there will be side
effects.
4. Amount of discolouration and the cause of the
discolouration.
5. How much you decide to whiten you teeth at home; if you
only whiten your teeth once a twice a month, there will be
minimal improvement.
6. The design of the tray .
7. The number of bleaching treatments done and the time
bleached for.
Types of bleaching
Vital bleaching
In-office vital bleaching/Power bleaching
Power bleaching of vital teeth generally uses a high
concentration of peroxide solution (35- 50% hydrogen
peroxide) placed directly on the teeth, often supplemented
by a heat or light source to activate or enhance peroxide
release (Feinman et al 1987).
Indications:
Treatment of generalised gross staining such as tetracycline
staining

 Dentine sclerosis
Patients who may have difficulty in compliance with the
nightguard vital bleaching technique.
Lights that are typically within the blue light spectrum have been
found to contain the most effective wavelengths for initiating the
hydrogen peroxide reaction.
DN Dederich et al. (2004) reported that the best wavelength of
light used to facilitate power bleaching was in the 457 to 502 nm
visible blue light spectrum because of its significant aid in
bleaching the teeth while it did not produce the internal tooth
heating that other wavelengths of light might cause.
They definitely also were against the use of infrared wavelengths
that tend to heat the tooth, such as those employed by a CO2
laser.
Treatment sequence is as follow:
1. Gingivae are protected with Vaseline or Orobase .
2. Rubber dam is applied to isolate the teeth and to provide
maximum retraction of tissue.
3. The teeth are cleaned with a slurry of pumice and water,
then rinsed and dried.
4. The operator and the assistant should wear rubber gloves.
The eyes of the patient, assistant, and dentist must be
protected with safety glasses.
5. 30 to 35% hydrogen peroxide solution or a gel form is placed
on the teeth using a cotton-tipped applicator.
6. The bleaching light is positioned 25 to 30 cm from the teeth
for up to 30 minutes. The light produces heat, which hastens the
decomposition and penetration of hydrogen peroxide.

7.

The area is rinsed with water and rubber dam is removed

8. Mild analgesics are prescribed to relieve possible

postoperative sensitivity and the patient is instructed to avoid
taking hot and cold foods or drinks during the first few hours
following bleaching.
9.
The procedure may be repeated at 2- to 4-week intervals or
more as in the case of severe tetracycline staining,
Disadvantages:
1. Neither the patient nor the dentist can exactly control the
amount of lightening. The technique runs the risk of both
over- and under-bleaching.
2. The fee is usually higher as a greater amount of chair time is
required.
3. There is a possibility of soft tissue damage due to the caustic
nature of the high concentrations of peroxide.
4. There is a greater risk of post-operative sensitivity.
A higher incidence of tooth sensitivity (67-78%) was reported
after power bleaching (Heywood and Berry 2001, Cohen and
Chase 1979) compared with the nightguard vital bleaching,
using 10% carbamine peroxide (15-65%) (Nathanson and
Parra 1987, Heywood 1996, Leonard 1998, Schulte et al
1994).
Clinical comparison between the bleaching efficacy of lightemitting diode and diode laser with sodium perborate
Aim: To test the efficacy of a light-emitting diode (LED) light and a
diode laser, when bleaching with sodium perborate.

In group A, sodium perborate and distilled water were mixed

and placed into the pulp chamber, and the LED light was source
applied.
In group B, the same mixture was used, and the 810nm diode
laser was applied.
Conclusion: Both devices successfully whitened the
teeth. No
statistical difference was found between the efficacy of the LED
light and the diode laser.
Efficacy of intracoronal bleaching techniques with different light
activation sources
Aim: To evaluate ex vivo the efficacy of 35% hydrogen peroxide
for intracoronal bleaching when activated by LEDs, halogen lamp
or by the walking bleach technique.
Methodology: Forty extracted human maxillary central incisors
were selected. Samples were divided randomly into five groups:
group I received 35% hydrogen peroxide gel activated by
LEDs. Group II received 35% hydrogen peroxide gel activated by a
halogen lamp-based light curing unit. Group III received 35%
hydrogen peroxide gel followed by the walking bleach technique.
Group IV was neither artificially stained nor bleached (positive
control) and group V was stained, but not bleached (negative
control).
The shade of the teeth was assessed visually before and after
bleaching.
Results: No statistical differences regarding sample shades were
found amongst groups for the tested internal bleaching
techniques (P > 0.05).

Conclusions: Hydrogen peroxide for intracoronal bleaching when

activated either by LEDs, halogen lamp or by the walking bleach
technique presented similar efficacy.
Mouth guard bleaching
This technique has been widely advocated as a home
bleaching technique, with a wide variety of materials,
bleaching agents, frequency, and duration of treatment.
Numerous products are available, mostly containing either
1.5 to 10% hydrogen peroxide or 10 to 15% carbamide
peroxide, that degrade slowly to release hydrogen peroxide.
The carbamide peroxide products are more commonly used.
Higher concentrations of the active ingredient are also
available and may reach up to 50%.
Technique
1. An alginate impression of the arch to be treated is obtained
and cast in dental stone.
2. A spacer (reservoir) is provided over the teeth to be
bleached using suitable material (such as light-cured resin or
three layers of die relief or nail varnish applied in an even
coat 0.5- to 1 .O-mm thick).
3. A bleaching tray is fabricated on the cast, using a heat- and
vacuum-forming machine and a plastic sheet 0.6- to 0.9-mm
thick.
4. The edges of the tray are trimmed, using curved scissors, to
fit about 0.5 mm short of the gingivae.
5. Close fitting at the gingival margin in the patients mouth is
ensured.

6. The patient is supplied with a 10% carbamide peroxide

bleaching gel, such as Opalescence (Ultradent Products Inc.,
South Jordan, Utah).
7. The patient is instructed to brush his or her teeth before
bleaching.
8. The gel is dispensed evenly into the deepest portion of the
tray and toward the facial sides of each tooth to be bleached.
9.
After the tray is seated completely and firmly over the teeth,
excess material should be wiped off with a toothbrush and then
the mouth is rinsed.
10. The time interval between changing the bleach depends upon
the product used: usually it is replaced every 2 to 3 hours during
the day or a single application of bleaching gel is used at
bedtime for night bleaching.
11. It is recommended to bleach every second or third night.
12. Total treatment time usually is 2 to 6 weeks with 80% of the
success being achieved after 2 weeks.
Comparison of short term effectiveness of four different tooth
whitening systems
Aim: To compare the short term effectiveness and major side
effects of 4 popular bleaching systems.
Materials and Methods: A sample of 300 subjects were divided
equally into 4 groups and treated with ( home bleaching Opalescence 20%, in office Bright Smile, in office - Zoom, and in
office - Zoom plus home bleaching - Day White 9.5%).
Results: The four whitening systems were significantly effective at
3 days (T1) and 3 months (T2) after the whitening treatment. At
T2, there was no significant difference in whitening effectiveness

among the four whitening systems. Tooth sensitivity and gingival

irritation were associated with the 4 whitening systems.
Conclusion: The bleaching procedures tested in this study are
equally effective with high satisfaction level and with self-limiting
tooth and gingival sensitivity.
Whitening strips
The whitening strip is a novel bleaching system which uses a
flexible 5.3% hydrogen peroxideimpregnated polyethylene strip,
offer an at-home alternative to the above methods and can be
recommended for maintaining already whitened teeth.
In 2003, an improved bleaching strip was introduced which
contains 14% hydrogen peroxide (Crest Whitestrips Supreme).
The main advantage of the 14% hydrogen peroxide strip is more
effective whitening.
The peroxide molecules diffuse through the enamel down to the
dentinoenamel junction, where stains are oxidized, resulting in
whiter teeth.
These strips can be applied twice daily, for 30 minutes, for 14
days
Adverse effects
Approximately two thirds of patients have short-term, minor tooth
sensitivity to cold and/or gingival irritation.
Tooth surfaces, particularly exposed roots or enamel surfaces with
defects secondary to incomplete amelogenesis, are porous to the
bleaching agent and are more likely to develop cold sensitivity.
Mucosal irritation and ulceration: A high concentration of
hydrogen peroxide (from 30 to 35%) is caustic to mucous
membranes and may cause burns and bleaching of the gingiva.

Alteration of enamel surface.

Nonvital bleaching
Nonvital (intracoronal) bleaching refers to lightening
endodontically treated teeth
The two techniques used to bleach pulpless tooth are in-office
thermocatalytic and out-of office walking bleach .
The thermocatalytic technique involves placing 30 to 35%
hydrogen peroxide into the debrided pulp chamber and
heating it with a controlled rheostat, photoflood lamp, or
heated metal instrument, such as a ball burnisher.
The walking bleach is called so because the bleaching
takes place between appointments, which are 3 to 7 days
apart.
Walking Bleach Technique
The walking bleach technique that was introduced in 1961.
Involves the use of a mixture of hydrogen peroxide and sodium
perborate or sodium perborate mixed with water.
Sodium perborate is a stable white powder, when dissolved in
water, it decomposes into sodium metaborate and hydrogen
peroxide, releasing nascent oxygen.
In vitro studies have shown that three applications of sodium
perborate mixed with water are equally as effective as application
of sodium perborate and 30% hydrogen peroxide solution .
Sodium perborate mixed with water is potentially safer than when
mixed with hydrogen peroxide.
Technique

1. The discolored tooth is isolated using a rubber dam and the

gingiva are protected with Vaseline.
2. Any coronal filling materials are removed to a depth of 2 mrn
below the cementoenamel junction and 1-mrn layer of dental
cement such as glass ionomer or polycarboxylate, is placed over
exposed root canal filling and allowed to harden.
3. The pulp chamber is cleaned of any organic debris with a
cotton pledget soaked in chloroform or xylene, then rinsed and
dried.
4. The coronal internal dentin is etched with a 37% phosphoric
acid solution or gel for 30 seconds, then rinsed thoroughly and
dried. This removes the smear layer and allows better penetration
of the bleaching agent within the dentinal tubules.
5. One drop of 30 to 35% hydrogen peroxide is mixed with sodium
perborate in a dappen dish to a consistency of a thick paste.
Alternatively, sodium perborate may be mixed with distilled water.
The paste is placed into the pulp chamber with a large spoon
excavator or a plastic instrument, avoiding contact with the
enamel margins.
6. Excess mixture is excavated 2 mm into the access opening. A
small pledget of cotton wool is placed over the paste, then the
area is sealed with a temporary filling (e.g., IRM). Materials that
may result in a leaking seal must not be used.
7. The rubber dam is removed and the occlusion is examined. The
patient is required to return in 3 to 7 days for assessment of the
degree of whitening. The patient is instructed to return to the
clinic immediately should the temporary filling become dislodged.
8. The bleaching mixture is active for 24 hours and in most
instances, a single application will suffice. T he procedure may be
repeated if necessary, usually every 3 to 5 days for a mixture of

hydrogen peroxide and sodium perborate and biweekly for sodium

perborate alone.
9. When satisfactory result is attained, a rubber dam is placed,
the temporary dressing and the bleaching paste are removed, and
the area is washed and dried.
10. A thin layer of lightactivated glass ionomer is placed against
the axial dentin wall and the access cavity is restored with
composite resin.
Thermo-catalytic bleaching
This technique involves placement of 30%35% hydrogen
peroxide in the pulp chamber followed by heat application by
electric heating devices or specially designed lamps.
It has been observed that heat application causes a reaction that
increases bleaching properties of the hydrogen peroxide.
When heat is applied, a reaction produces foam and releases the
oxygen present in the preparation.
Technique
1. The discolored tooth is isolated using a rubber dam and the
gingiva are protected with Vaseline.
2. Any coronal filling materials are removed to a depth of 2 mrn
below the cementoenamel junction. such as glass ionomer or
polycarboxylate, is placed over the
3. A 1-mrn layer of dental cement, exposed root canal filling and
allowed to harden.
4. The pulp chamber is cleaned of any organic debris with a
cotton pledget soaked in chloroform or xylene, then rinsed and
dried.

5. The coronal internal dentin is etched with a 37% phosphoric

acid solution or gel for 30 seconds, then rinsed thoroughly and
dried. This removes the smear layer and allows better penetration
of the bleaching agent within the dentinal tubules.
6. A loose cotton pledget saturated with 30 to 35% hydrogen
peroxide is placed in the pulp chamber.
7. Heat is applied, using a commercial heat applicator or metal
instrument, alternately for 15 to 30 minutes while the hydrogen
peroxide-saturated pellet is changed frequently. If the patient
feels discomfort, the heat source is removed. The endodontically
treated tooth is believed to be able to withstand heating to 71C
without patient discomfort.
8. The area is rinsed then dried, using a water-clearing solution,
such as acetone or ethanol, to remove traces of bleaching
material, which adversely affects the bond strength of both
composite and glass ionorner to enamel and dentin.
9. The tooth is restored by placing a thin layer of glass ionomer
cement.
10. The glass ionomer and the enamel walls are etched, then
rinsed and dried. The cavity is filled with composite resin, and
polymerized.
Adverse effects
1. Cervical root resorption: The underlying mechanism for this
effect is unclear, but it has been suggested that the
bleaching agent reaches the periodontal tissue through the
dentinal tubules and initiates an inflammatory reaction (Cvek
and Lindvall, 1985).
It has also been speculated that the peroxide, by diffusing
through the dentinal tubules, denatures the dentin, which then

becomes an immunologically different tissue and is attacked as a

foreign body (Lado et al., 1983).
2.
Tooth crown fracture has also been observed after
intracoronal bleaching (Grevstad, 1981), most probably due to
extensive removal of the intracoronal dentin.
3.
In addition, intracoronal bleaching with 30% hydrogen
peroxide has been found to reduce the micro-hardness of dentin
and enamel (Lewinstein et al., 1994) and weaken the mechanical
properties of the dentin (Chng et al., 2002).
Dental restorations
Teeth discolored by dental caries or dental materials require the
removal of the caries or restorative materials, followed by proper
restoration of the tooth.
Partial or full-coverage dental restorations may be used to treat
generalized intrinsic tooth discoloration in which bleaching is not
indicated or in which the aesthetic results of bleaching fail to
meet the patient's expectations.
Porcelain laminate veneers for the treatment of tetracycline
staining.
Composite Resin Restorations
The large size of the immature pulp chamber and pulp horns, and
the immature gingival contour of the adolescent patient contraindicates the use of porcelain veneers.
Composite resin offers a satisfactory alternative and should be
used in child and adolescent patients.
Resin can be used by either to camouflage/replace discrete
localised areas of abnormal enamel ( localised composites ) or to
cover the entire enamel surface (veneer ).

Composite Veneers
Technique
(i) Use a tapered diamond bur to reduce labial enamel thickness.
Identify a finish line at the gingival margin and also mesially and
distally just labial to the contact points.
(ii) Clean tooth with a slurry of pumice in water. Wash and dry the
tooth. Select the shade.
(iii) Isolate the tooth either with rubber dam or contoured matrix
strip.
(iv) Etch the enamel for 60 secs, wash and dry.
(v) Apply a thin layer of bonding resin to the labial surface with a
brush and cure for 15 secs.
(vi) Apply composite resin of the desired shade to the labial
surface and smooth it into the desired shape. Cure 60 secs
gingivally, mesio-incisally, and disto-incisally, In addition cure 60
secs inciso-palatally if there has been extension to the palatal
surface. Different shades of composite can be combined to
achieve a transition from darker gingival areas to lighter more
translucent incisal region.
(vii) Finish the margins with diamond finishing burs and
interproximal strips and the labial surfaces with finishing discs.
Porcelain Veneers

Porcelain veneers are indicated for hypoplastic and discoloured

teeth in patients aged 16 years and over, when techniques such
as microabrasion, non-vital bleaching and composite resins have
failed to produce a satisfactory clinical result.
Summary
Treatment options for different kind of discoloration
Alkaptonuria:
Bleaching should be tried first, but the blue or grey stains are
difficult to change.
When the stains do not respond to bleaching, they have to be
either removed by abrasion or masked by restorative treatment.
Congenital erythropoietic porphyria:
To improve the aesthetics in teeth with red-brown porphyrin
pigments deposited, treatment options are crowns and/or
laminated veneers.
Congenital hyperbilirubinaemia:
Treatment for the condition is bleaching or placement of esthetic
crowns.
Amelogenesis imperfecta:
Management in affected children and adolescents have to be
focused on improving esthetics, reducing sensitivity, correcting or
maintaining vertical dimension and restoring the masticatory
function .
Early diagnosis is important in order to offer proper preventive
and restorative treatments over several phases.
The temporay phase starts soon after diagnosis in the primary
or mixed dentition and is continued with a transitional phase,

providing the patient with a functional and esthetic permanent

teeth before the permanent treatment phase in adulthood.
The treatment depends on the AI type and the phenotype of the
affected enamel and can range from preventive care using
sealants, tooth whitening, microabrasion , and bonded technique
for esthetic improvement to prosthetic reconstruction.
Dentinogenesis imperfecta:
Bleaching and prosthetic crowns.

Tetracycline:
Haywood has shown that tetracycline-stained teeth may respond
to long bleaching treatments, some tetracycline discolorations
can require from 1 to 12 months of treatment every night.
Leonard et al. (2003) stated in their study that nightguard vital
bleaching indicates that tetracycline-stained teeth can be
whitened successfully using a 6 month active treatment with 10%
carbamide peroxide, and that shade stability may last at least 90
months post treatment
Prognosis of vital bleaching : Degree I - Good Degree II Variable
Degree III & IV poor. In cases where the teeth are severely
stained in the gingival area and a bleaching treatment has no
effect, porcelain veneers or placement of a crown will be options
to restore esthetics and function.
Fluorosis:
The choice between different treatments depends on the severity
of the fluorosis. Mild fluorosis - bleaching . Moderate fluorosis bleaching or in combination with microabrasion . Severe fluorosis
- porcelain laminate veneers, restorations or crowns.

 Pulpal haemorrhagic product:

Pinkish hue seen initially after trauma might disappear in 2-3
months if the tooth becomes revascularized .
It is therefore wise to wait for 3 months before a bleaching
treatment.
Pulp necrosis:
Intracoronally bleaching is the treatment of choice.
According to Plotino trauma- or necrosis-induced discoloration can
be successfully bleached in about 95% of the cases, compared
with lower percentages for teeth discolored as a result of
medicaments or restorations .
Tooth wear and gingival recession:
To improve appearance of discolored roots of teeth, the exposure
to bleaching materials requires usually treatments of long periods,
longer than what is common for the bleaching of the enamel.

Conclusion
The correct diagnosis for the cause of discolouration is important
as, invariably, it has a profound effect on treatment outcomes.
Brown and yellow stainings are easier to change, while gray and
blue stains are mostly resistant to bleaching and the
discolorations located in the gingival area have a poor prognosis .
There are no guidelines telling the dental practitioner when it is
correct to carry out operative treatment. Therefore, in cases with
esthetic problems a grasp of the pathological processes involved

in tooth staining along with prevention of avoidable causes of

tooth staining is important.
Refrences
Ingles Endodontics 6 : Ingle, Bakland, Baumgartner.
Textbook of Endodontics (2nd edition): Nisha Garg, Amit Garg.
Tooth discolouration and staining: a review of the literature:
A. Watts and M. Addy- British dental journal volume 190 no.6
march 24 2001.
Complete dental bleaching: Ronald E. Goldstein
Sturdevants Art and Science of Operative Dentistry 5 th
Edition
Sruthy Prathap et al. Extrinsic stains and management: A
new insight. J. Acad. Indus. Res. Vol. 1(8)J anuary 2013.
Manuel ST, Abhishek P, Kundabala M. Etiology of tooth
discoloration- a review. Nig Dent J, Vol 18 (2), July - Dec
2010.
Faiez n. hattab et al. Dental Discoloration: An Overview.
Esthet Dent 11:291-310, 1999.