Case 27
of 16. Your notes record that she was given oral fluoride
Discoloured anterior
teeth
SUMMARY
A 22-year-old woman presents at your general
dental practice surgery complaining of the poor
appearance of her teeth. What is the cause and what
treatment is appropriate?
Fig. 27.1 The appearance of the teeth.
History
Complaint
She is unhappy with the colour of the teeth which she feels
are becoming darker. She is very conscious of them and
realizes that she is reluctant to smile because of their
appearance.
History of complaint
The teeth looked slightly grey on eruption but they have
slowly darkened.
Dental history
The patient has had very little dental treatment but received
regular preventive care from your practice until the age
supplementation as a child. This was provided as fluoride
drops at a dose of 0.25mg daily from birth to 2 years and
0.5mg daily as tablets from 2 to 4 years, rising to 1mg daily
from 4 to 12 years of age.
Medical history
The patient is fit and healthy with no relevant medical con-
ditions noted on her medical history questionnaire.
What are the possible causes of discolouration of
teeth? What features of each cause aid differential
diagnosis?
The possible causes and relevant features are presented in
Table 27.1.
What specific questions would you ask this patient?
Explain why.
Did she suffer any illness between birth and 6 years?
This might account directly for the discolouration or could
have been the reason for antibiotic treatment with
tetracyclines. Further information on chronological hypoplasia
will be found in Case 56.
What toothpaste was used during fluoride
supplementation? The fluoride supplementation regimen
provided for this patient was recommended during her
childhood, but the doses would now be considered too high.
On these doses, a small proportion of patients would be
expected to show mild fluorosis. More severe fluorosis would
be associated with a second source of fluoride. The most
probable additional source would be ingestion of adult-
formula fluoride toothpaste, though living in an area with
fluoridated water should also be excluded.
Is there a family history of tooth discolouration or tooth
loss? A positive family history aids diagnosis of inherited
defects and is essential for diagnosis of some types of
amelogenesis imperfecta.
In response to your questioning the patient tells you that
she remembers taking many courses of antibiotics as a child
for chest infections. She cannot remember what toothpaste
she used before the age of 6, but for as long as she can
remember she has used an adult paste. She has no family
history of similar defects.
Examination
Intraoral examination
On examination the oral mucosa is healthy and oral hygiene
is good. The dentition is unrestored.
The appearance of the anterior teeth is shown in Figure
27.1. What do you see? How do you interpret the
appearance?
The morphology of the tooth crowns is normal and the
incisors, canines and premolars are a grey-brown colour.
There are some areas which appear less affected and others
which appear opaque white. Small flecks of white are
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CASE 126
D i s co lo u r e d a n t e r i o r t e e t h
Table 27.1 Possible causes of discolouration
Causes Features
Extrinsic staining
Dietary stains such as tea, coffee, cigarette smoke, betel quid Usually worse around gingival margin and in less well cleaned areas because these agents stain pellicle and plaque rather than
Chlorhexidine mouthwash enamel.
Pigments produced by the normal oral flora, usually the
subgingival flora
Turner tooth Infection of the deciduous predecessor causes enamel hypoplasia in a permanent tooth and the porous enamel absorbs extrinsic
stains. Tooth shape abnormal.
Intrinsic staining
Dental caries Associated with softening. Characteristic distribution of lesions. Slowly progressing and dentine caries are the types most frequently
stained.
Blood pigments Seen most frequently in nonvital teeth (as a result of pulp necrosis). Rarely may affect all teeth in conditions including rhesus
incompatibility (in the deciduous teeth only), porphyria and hyperbilirubinaemia. Colour ranges from dull red through brown to
grey or black.
Tetracycline staining Caused by administration of tetracyclines during tooth formation. When severe, this is a generalized green, brown or yellow colour,
darkening with time. The teeth may fluoresce under ultraviolet light in the early stages but this reduces as the colour darkens. When
mild there may be a chronological banding pattern with horizontal lines of discoloured enamel corresponding to individual courses
of tetracycline. Tooth shape is normal.
Fluorosis Varies from mild flecks of opaque white enamel to severely hypoplastic patches which take up extrinsic stain. The latter is only seen
in areas where fluorosis is endemic. The mildest effects are impossible to tell from the opaque flecks seen when water fluoride
concentration is very low. Affects all teeth. Moderately affected cases of endemic fluorosis may have an apparent chronological
pattern of fine white lines associated with periods of exposure to higher doses. Tooth shape normal unless condition is severe.
Amelogenesis imperfecta Numerous types. Affects all teeth, though some forms are much milder in the deciduous dentition. Colour change varies and is
secondary to either hypoplasia (thin hard translucent enamel through which dentine is visible), hypocalcification (chalky white
opaque soft enamel) and hypomaturation (patchy distribution of white opacities). Affected areas may also take up extrinsic stain.
Tooth shape may be normal and some types have a vertical banding, pitting or ridging pattern. Family history will be positive in
many cases. Mild types are difficult to distinguish from fluorosis.
Dentinogenesis imperfecta All teeth are an even grey-brown colour with altered translucency. The shape of the tooth crowns is normal but the roots are thin
and taper sharply. There is gradual pulpal obliteration by dentine. There may be a family history and, in some cases, osteogenesis
imperfecta is associated. Enamel fractures from the dentine and severe wear follow shortly after eruption.
Regional odontodysplasia Affects a group of adjacent deciduous and permanent teeth on one side of midline. Enamel hypoplasia leads to uptake of extrinsic
stain and yellow cementum may be present over the crown. Characteristic defects on radiography include thin enamel and dentine,
large pulps. Affected teeth often fail to erupt.
Chronological hypoplasia Horizontal band(s) of enamel hypoplasia, each associated with a specific insult, usually a severe illness or metabolic upset including
severe attacks of the common viral diseases of childhood. Affected bands are abnormal enamel which may be pitted, hypoplastic,
rough, opaque or completely absent, and also take up extrinsic stain.
Age change Teeth become yellower and slightly darker with age. This is an even colour change and it is usually mild.

scattered on the labial enamel. There are several prominent

horizontal lines on the teeth, most clearly seen in the enamel
of the gingival third of the crowns of both upper central
incisors.
The teeth are evenly discoloured and this has the
appearance of an intrinsic stain. The distribution of the
affected enamel is in a chronological pattern and affects all
enamel formed from birth to approximately 6 years of age.
The even distribution suggests that the cause was present
throughout development or that there were frequent or
prolonged exposures. The fine lines in the central incisors
suggest that a series of repeated exposures is the more
likely cause. The grey-brown colour is typical of tetracycline
staining.
The small white flecks are more difficult to explain. They are
not consistent with tetracycline staining and could be either
mild fluorosis or a normal feature made more prominent by
the dark enamel.
Investigation
What further examinations would you carry out? Explain
why?
The teeth should be examined after drying. This makes
porous defects more opaque and more visible and aids the
detection of fine chronological bands and enamel flecks. The
teeth could also be examined under an ultraviolet (UV) light
or near UV light to see whether they fluoresce green/yellow
because this would indicate tetracycline staining. The
fluorescence is not bright and cannot be seen unless the
room is dark and the illuminating lamp has a very low visible
light output.
Though not necessary for diagnosis in this case, it is always
prudent to test the vitality of discoloured teeth in case loss of
vitality is the cause. The vitality of the affected teeth would
determine the treatment options available.

Radiography is not a useful investigation in the present case.
Periapical radiographs would be indicated if teeth were
nonvital or affected by periodontitis. They would also be
helpful in a younger patient to determine whether unerupted
teeth were normal or if dentinogenesis imperfecta were
considered a likely cause.
In this case no fluorescence could be detected in the surgery
and all teeth were vital.
Differential diagnosis
What is your diagnosis?
The dark colour of the teeth is typical of intrinsic staining
caused by tetracycline. The history of yellow teeth becoming
darker over a period of years is also characteristic.
An enquiry to the patients medical practitioner confirms
that as a child she received repeated and sometimes pro-
longed courses of tetracycline for chest infection, confirm-
ing the diagnosis.
Why is fluorosis not the cause?
Fluorosis cannot account for the generalized discolouration.
The appearances are quite different, with mottled brown and
white patches. The scattered white flecks could be caused by
mild fluorosis and the fact that the patient used a fluoride
toothpaste as well as a fluoride supplement for many years
makes this a possibility. However, no definitive diagnosis can
be reached because there is no accepted diagnostic test for
mild degrees of fluorosis. Small numbers of such small white
flecks are found in normal enamel.
Treatment
How would you decide which teeth should be treated?
The patients main concern is her appearance. Only those
teeth which are affected and visible need be treated. The
factors that should be taken into account are the following.
The smile line. Observe the patient relaxed, talking and
smiling naturally. Note the level of the lip line, which teeth
and how much of each crown is visible. This will dictate
which teeth need treatment and, if restorations are necessary,
where the cervical margin should be placed. In this case all
upper teeth from first molar to first molar are visible during
smiling but second premolars and molars lie in shadow and
the staining is not obvious. The upper lip line runs along the
gingival margin of all upper incisors and canines, exposing
the interdental papillae.
The occlusion. Indirect porcelain or composite veneers are
difficult to make where the teeth are imbricated because the
teeth on the die model cannot be separated in the laboratory.
Alternative methods of treatment must be used. If there is
wear on the incisal edge then porcelain veneers, which are
inherently brittle, may fracture and direct composite veneers
may be preferable.
Occupation. A patient whose occupation depends on their
appearance may require both a greater degree of correction
of the tooth shade and treatment of a larger number of
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127
CASE
D i s co lo u r e d a n t e r i o r t e e t h
tooth surfaces. Performers and others who work in bright,
even artificial, light may also require restorations to look
natural under demanding lighting conditions. Fortunately,
these more unusual constraints do not apply
to this patient.
What treatment options are available? What are their
advantages and disadvantages?
The treatment options are presented in Table 27.2.
Which treatment is appropriate for this patient? Explain
why.
The selection of appropriate treatment is outlined in the flow
chart (Figure 27.3 p.129).
A conservative approach using carbamide peroxide bleaching
agents would be appropriate, and was tried initially. However,
in this case the patients lip line leaves the cervical enamel of
the incisors and canines exposed and the effectiveness of the
result is not predictable. Dark stain remained cervically after
bleaching and the patient requested porcelain veneers to
mask the discolouration.
Prognosis
The completed porcelain veneers are shown in Figure 27.2.
The appearance is not ideal and the disadvantage of having
to use opaque veneers is well shown. However, the patient
was very happy with this result.
What is the long-term prognosis for these veneers?
The veneers on the upper right canine and lateral incisor are
in crossbite with the lower canine and almost edge to edge
on the lateral incisor. On the upper left the same teeth are
edge to edge. There is a risk of chipping the incisal edges and
debonding.
Prevention
Tetracycline should no longer be prescribed to those below
the age of 12. Presumably tetracycline staining should no
longer be seen?
This is true, but unfortunately courses of tetracycline are still
occasionally prescribed for children. There are some specific
indications, such as cystic fibrosis, for which prolonged
tetracycline treatment is still provided to children.
Tetracyclines are available as over-the-counter drugs in some
countries.
Tetracyclines such as minocycline, which are well absorbed
and reach high blood levels, are the drugs of choice to
prevent infection in acne. They are frequently prescribed to
adolescents and young adults and may stain dental tissues
forming at this time, such as the roots of third molars.
However, minocycline may also stain bone and fully formed
teeth. The drug becomes incorporated into the pulpal surface
of the dentine and staining is darkest in teeth where there is
active secondary dentine formation. Because this stain lies
deep in the tooth, it cannot be bleached by external
bleaching agents.
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CASE 128
D i s co lo u r e d a n t e r i o r t e e t h
Table 27.2 Treatment options
Option Advantages Disadvantages
Vital bleaching agents using carbamide Work best with extrinsic stains and quite well for many intrinsic stains. Unpredictable effectiveness with tetracycline staining, often leaving a dark
(or urea) peroxide Easily applied in custom trays, nondestructive and easily repeated if zone cervically where the stained root shows through the thin cervical
necessary. enamel. However, almost always some improvement and this may satisfy
Does not alter the underlying tooth shade or translucency. If sufficient and the patient.
even lightening of the shade is achieved, bleaching produces the best Only appropriate when there are minimal or no restorations in the teeth.
appearance of all options. Restorations are not bleached and there is a theoretical concern that
Can also be used to mask severe staining before a veneer is placed. This bleaching agents might track to the pulp along the margins of restorations.
prevents the dark enamel showing through and allows a more translucent Some over-the-counter formulations are acidic and others may cause local
veneer to be used, improving the final appearance. soft tissue irritation, and should not be encouraged. Licensing regulations
vary between countries.
Nonvital bleach Allows bleaching of deeper dentine than a vital bleach, producing greater Only possible in nonvital teeth and so usually inappropriate for multiple
effect. teeth. To bleach dentine below the cervical enamel the bleaching agent
must be applied to the cervical part of the root canal as well as the pulp
chamber.
Direct composite, indirect composite or Good appearance possible, can be as good as crowns but much less Some tooth preparation is required, the amount varying slightly between
porcelain veneers destructive. types. The emergence profile or contour at the gingival margin must be
maintained by removing cervical enamel, to avoid a plaque trap.
When placed over darkly stained teeth, veneer and cement must be
opaque. This reduces translucency and produces a flat artificial colour to
the finished restoration.
Crowns Strong and retentive, a variety of bonded or reinforced crowns are Destructive of tooth tissue.
available if the occlusion is a problem. Margins may compromise periodontal health.
Very darkly stained teeth are best crowned. Expensive.
The porcelain is thicker than veneers so that opaque materials are not
required. If necessary, metal-bonded crowns completely mask the
underlying colour.
Usually the best alternative if the teeth contain extensive restorations.
Appearance can be excellent.

Fig. 27.2 The completed porcelain veneers immediately after

cementation.
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129

CASE
D i s co lo u r e d a n t e r i o r t e e t h

Review for wear. Veneers, or full

Moderate or Wear is often the factor coverage crowns,
mild defects in which determines the possibly adhesive
hard enamel need for treatment. A depending on
conservative approach distribution of defects
Generalized may be possible
defects in
amelogenesis
imperfecta or
dentinogenesis
imperfecta Enamel fractures Full coverage metal
off or is very soft ceramic or porcelain
crowns
Extensive defects Temporary or adhesive
in hard enamel crowns may be required
shortly after eruption

Localized enamel pits Small, possibly

or depressed defects multiple composite
White opaque restorations
fluorotic defects or or composite
enamel hypoplasia or porcelain veneers

Localized
defects
Brown stained If little effect
fluorotic Try enamel
microabrasion consider veneers or
patches and flecks full coverage
technique or vital
Pits and mild enamel bleaching, often crowns depending
hypoplasia which have effective on distribution
taken up extrinsic stain of defects

Discoloured Little effect

anterior metal ceramic
teeth or porcelain
crowns required

Intrinsic Vital bleach

stain may be
effective alone
Partial bleaching
and no other
contraindication
try composite or
Vital porcelain veneer
teeth

Prophylaxis Vital bleach

Diffuse Extrinsic may be effective usually effective
staining stain alone if prophylaxis
alone is not

If little effect
metal ceramic
or porcelain
crowns required
Endodontic
treatment with
Non-vital non-vital bleaching
teeth
May be effective
alone Partial bleaching
and no other
contraindication
try composite
or porcelain veneer

Fig. 27.3 Selection of appropriate treatment.