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Teeth Discoloration

Discoloration of the tooth is one of the most frequent reasons why a patient seeks dental

care. Tooth discoloration 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 ofdiscoloration 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(1)

.

Classification

The causes for tooth discoloration can be classified according to the location of the stains,

either as extrinsic or intrinsic(2, 3, 4)

. Extrinsic discoloration lies on the tooth surface or in

the acquired pellicle. The intrinsic discoloration occurs when the chromogens are

deposited within the bulk of the tooth, which maybe of local or systemic origin (5).

Extrinsic discoloration

Extrinsic discoloration is defined as discoloration located on the outer surface of the tooth

structure and is caused by topical or extrinsic agents(6)

. This can be divided into two

groups; direct and indirect. Direct staining is caused by compounds incorporated into the

pellicle layer and the stain is a result of the basic color of the chromogen. Direct staining

has multi-factorial etiology with the chromogens derived either from the diet or

substances habitually placed in the mouth. Indirect staining on the other hand is caused

by a chemical interaction at the tooth surface. It is usually associated with cationicantiseptics and metal salts. These agents are without color or a different color from the

stain produced on the tooth surface(7)

. Traditionally, extrinsic tooth discoloration can also

been classified according to its origin, as metallic or non-metallic(8)

.

Diet: Brown stains on the surface of the teeth could be due to the deposition of tannins

found in tea, coffee and other beverages(2)

.

Oral hygiene: Accumulations of dental plaque, calculus and food particles cause brown

or black stains (Figure 1). Chromogenic bacteria have also been suggested as an

etiological factor in the production of stains typically at the gingival margin of the

tooth(9)

.

Habits: Tobacco from cigarettes, cigars, pipes, and chewing tobacco causes tenacious

dark brown and black stains that cover the cervical one third to midway on the tooth(10)

.

Chewing of pan results in the production of blood red saliva that results in a red-black

stain on the teeth, gingiva and oral mucosal surfaces(11,12)


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Medication factors: Cationic antiseptics such as chlorhexidine, cetylpyridinium chloride

and other mouth washes can cause staining after prolonged use(3, 13)

. Chlorhexidine, for

example, produces brown to black discoloration. Most evidence indicates that the likely

cause of staining is the precipitation of anionic dietary chromogens onto the adsorbed

cations(14,15)

.

Some systemic medications (e.g. minocycline(16-18)

, doxycycline(19, 20)

, co-amoxiclav(21)

,

linezolid(22)

) are also shown to cause extrinsic staining. Metallic compounds are also

implicated in dental discoloration (e.g. Iron containing oral solutions(23, 24)

, mouth rinses

containing metal salts(25, 26)

).

Occupation and environmental factors: Industrial exposure to iron, manganese, and

silver may stain the teeth black. Mercury and lead dust can cause a blue-green stain;

copper and nickel, green–to–blue-green stain and chromic acid fumes may cause deep

orange stain(4)

. There is a positive correlation between dental extrinsic stains and the

concentration of trace elements, especially iron in the water sources(27)

(Figure 3).

Intrinsic Discoloration:

There are several causes of intrinsic tooth discoloration which have either an endogenous

or exogenous origin. These changes may occur during or after odontogenesis.

During odontogenesis, teeth may become discolored from the changes in the quality or

quantity of enamel or dentin, or from the incorporation of discoloring agent into the hard

tissues. Post-eruption discoloration occur when the discoloring agent enters the hard

tissues. They may originate from the pulp or the tooth surface

(28)

Metabolic: The diseases that have the potential to cause neonatal hyperbilirubinemia

may cause the incorporation of bilirubin into developing teeth, producing jaundice like

yellow-green tint within the dental hard tissue known as chlorodontia(29-31)

. Congenital

erythropoietin porphyria (Günther's disease) is a rare, autosomal recessive disorder

of porphyrin metabolism, resulting in an increase in the formation and excretion of

porphyrins. The porphyrin pigments have an affinity for calcium phosphate and are

incorporated into teeth during dental formation and these cause a characteristic reddish-

brown discoloration of the teeth, called erythrodontia. The affected tooth shows a red

fluorescence under ultra-violet light(28, 32, 33). Alkaptonuria, also known as phenylketonuria

or ochronosis is an inborn error of metabolism of tyrosin and phenylalanine causing a

build-up of homogenistic acid. This results in a brown discoloration of the permanent

dentition(34)

.

Disturbance during development of a tooth: Enamel hypoplasia may result due to the

disturbance of the developing tooth germ following trauma, infection or nutritional


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deficiency giving rise to localized or generalized enamel defects(35, 36)

. Periapical

odontogenic infections of the primary teeth can disrupt normal amelogenesis of the

underlying permanent successors and can cause localized enamel hypoplasia. Trauma to

developing, yet unerupted, teeth can also disturb amelogenesis and may result in enamel

hypoplasia, which is visualized as a localized opacity on the erupted tooth. Such

hypoplastic lesions are referred to as Turner's hypoplasia(37).

Crown formation begins in utero; therefore, the potential for extensive intrinsic

discoloration of the primary dentition may be present throughout pregnancy. Although

rare, maternal rubella or cytomegalovirus infection, maternal vitamin D deficiency, drug

intake during pregnancy and toxemia of pregnancy can lead to tooth discoloration, which

generally manifests as a focal opaque band of enamel hypoplasia. Systemic postnatal

infections (e.g., measles, chicken pox, streptococcal infections, scarlet fever) can also

cause enamel hypoplasia. The band like discoloration on the tooth are visualized where

the enamel layer has variable thickness and becomes extrinsically stained after tooth

eruption. Vitamins C and D, calcium, and phosphate are required for healthy tooth

formation. Deficiencies can result in exposure-related or dose-related enamel

hypoplasia(38)

.

Molar-incisor hypomineralization is an idiopathic condition characterized by severe

hypomineralized enamel affecting incisors and permanent first molars. The enamel

defects can vary from white to yellow to brownish areas and they always show a sharp

demarcation between sound and affected enamel. The possible etiologies for this

condition include environmental changes, infections during the early childhood, dioxin in

breast milk and genetic factors(39, 40)

.

Genetic defects and hereditary diseases: Genetic defects in enamel or dentin formationinclude amelogenesis imperfecta

(41)(Figure 4), dentinogenesis imperfecta and dentinal

dysplasia(42, 43)

. These hereditary diseases can be associated with intrinsic tooth

discoloration. Defects in enamel formation may also occur in a number of systemically

involved clinical syndromes such as Vitamin D dependent rickets(44)

, Epidermolysis

bullosa(45)

, Ehlers- Danlos Syndrome(46)

and pseudohypoparathyroidism(47)

.

After understanding the classification of teeth discolouration, we can conclude that the

discoloration that caused by smoking is categorized in the extrinsic discolouration

category . Smoking is a major risk factor for general health. In the oral cavity it can lead

to oral mucosal lesions, oral cancer, periodontal disease and consequent tooth loss .

However, perhaps the most visible and immediate dental manifestation seen by the public

is tooth discolouration. Smokers' teeth tend to develop tobacco stains; these may be

yellow, brown, dark brown or even black stains. The severity depending partly on

duration and frequency of the habit. Tooth discolouration may therefore have a

deleterious effect on individual's appearance, which in turn may result in social


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disadvantage for smokers.

Gingiva Hyperpigmentation

GINGIVAL MELANIN PIGMENTATION

Melanin pigmentation of the gingiva is of endogenous origin caused by excessive

deposition of melanin. It is more frequently observed in some races such as

Asian, African, and Mediterranean populations and called racial or physiological

pigmentation. However, pigmentation may vary not only among the subjects of

the same race, but within different regions of the mouth. This kind ofpigmentation presents as a well-demarcated, bilateral, dark-brown, asymptomatic

lesions in the keratinized gingiva mostly in the anterior region. This phenomenon

is due to more melanocyte activity as both dark- and light-skinned subjects have

similar amounts of melanocytes in the gingiva.

As toxic agents in tobacco smoke can induce melanocytes to produce melanin,

smoking is also a cause of pigmentation in subjects with light skin and may

aggravate pigmentation in dark-skinned subjects (smoker’s melanosis). The

severity and extent of melanosis is usually correlated with the duration and

quantity of smoking and it decreases following the cessation of smoking.

The melanin pigmentation of oral mucosa usually occurs in the mandibular

anteriorly vestibule-attached gingiva. Its frequency is mostly related to some

systemic diseases and drug usage. Melanin pigmentation is mostly common in

dark- skinned races. Melanin pigmentation of the oral cavity among tobacco

smokers, "smoker's melanosis," was first described by Hedin in 1977. Smoker's

melanosis may be due to the effects of nicotine (a polycyclie compound) on

melanocytes located along the basal cells of the lining epithelium of the oral

mucosa. Nicotine appears to stimulate melanocytes directly to produce moremelanosomes, resulting in increased deposition of melanin pigment as basilar

melanosis with varying amounts of mel anin incontinence. (Kamile Marakoglu,

MD, 2007)

Gingival melanin pigmentation is an aesthetic problem, not a medical problem.

The color and display rate of the gingiva when smiling is an essential part of


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overall aesthetics for today’s high cosmetic expectations. Since brown-black

melanosis lesions mostly involve anterior vestibular gingiva, heavily pigmented

gingiva can cause an unaesthetic smile.

Source :

Radiosurgery for Gingival Melanin Depigmentation

Written by Jeffrey A. Sherman, DDS, et alWednesday, 31 December 2008 19:00

http://www.dentistrytoday.com/aesthetics/143http://www.dentistrytoday.com/aesthetics/143


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Oral Health and Hygiene

How Effects Of Smoking Interrupts The Oral Hygiene?

The Effect Of Smoking On Oral Health

Visiting a dentist for an overall tooth analysis might results in unwanted issues if you are a regular smoker.

For a smoker, he or she must be well prepared for this and even those who continue to smoke in big

numbers must be aware with all the health issues that are triggered by it! Listed below are the most often-

occurring tooth problems in smoking people.

Bad Teeth. Smoking can trigger damage to your dentures in numerous ways. Moreover, people who smoke

may be put up with yellow or fading teeth’s exactly where it had been stained by the use of tobacco.

Sometimes the attack of tobacco is so persistent that it might give a permanent yellow tooth and here

cosmetic surgeries might not really help you.

Bad Breath. Smoke can trigger bad breath and this is due to the production of bacteria, which is all through

the function of the saliva glands, and this further produces an unpleasant smoke. Chewing gums or nicotine-

based fresheners may help to a certain extent but might not give you the desired results.

Plaque. With smoking, there is a germ build-up in the mouth and hence it prevents much salivation. It then

produces plaque in the mouth and as much as germs. There is a bigger possibility of gamut problems

caused by plaque in the smoker.

Tooth Loss. With present gum disease, loss of tooth is very likely. The tooth loses its stiffness from the soft

tissue. The more you smoke, the more you have to deal with tooth issues. Decaying is the other thing that

occurs whereas the jawbone may result in a complete tooth loss.

Smoking and oral health

http://www.medstorerx.com/smoking/how-effects-of-smoking-interrupts-the-oral-hygiene.aspxhttp://www.medstorerx.com/smoking/how-effects-of-smoking-interrupts-the-oral-hygiene.aspx


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Although smoking and chewing tobacco does not increase the risk of having cavities, it can

do lots of damage to the gums and other parts of the mouth:

• The risk of tooth loss in smokers is twice more than in non-smokers.

• Smoking is the main cause of throat and oral cancers.

• Smoking increases periodontal disease (gum disease). n fact! according to

the "ournal of #eriodontology! smokers are a$out four times more likely than

people who have never smoked! to have advanced periodontal disease.

• Smoking can cause in%ammation of the salivary glands.

• Smoking delays healing after tooth e&traction and can lead to a temporary

and painful condition known as dry socket.

• Smokers have less success with periodontal treatments and dental

implants.

Besides the significant and dangerous hazards mentioned above, other factors that smokers

should consider include:

• Smoking is a ma'or source of halitosis ($ad $reath).

• The loss of taste and smell can $e caused $y smoking and chewing

to$acco.

• Smoking stains teeth reducing the aesthetics of a smile.

• To$acco use can cause $lack hairy tongue! which refers to growths on the

tongue! making it look hairy and turning it yellow! green! $rown or $lack.Smoking might produce constant plaue and tartar $uild up.
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