Tooth Discoloration Clinical Presentation

Updated: Sep 07, 2015
  • Author: Dharti N Patel, DMD, FDS, RCSEd, FICOI; Chief Editor: Dirk M Elston, MD  more...
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Presentation

History

The patient's history of tooth discoloration provides useful information regarding the etiology.

  • Chief complaint and history of chief complaint

    • In most patients, the chief complaint is related to aesthetics. The complaint is a result of mild-to-severe discoloration of any or all portions of the teeth, typically the anterior teeth. Stains associated with foods (eg, blueberries), beverages (eg, tea, coffee), tobacco products, medications (eg, tetracycline), and other causes (eg, anemia) are almost universally painless. Alternatively, the patient may present with a chief complaint of a poor or unaesthetic smile and discolored teeth.

    • Some patients may present initially with pain. Pain and discoloration can be a result of dental caries, a dentoalveolar infection, deep dental restorations, severe developmental or acquired defects in the enamel or dentin, or trauma that leads to pulpal necrosis. [24]

    • Enamel and/or dentin defects increase the potential for pulpal penetration by bacteria, which can lead to irreversible pulpal disease.

    • Patients with early pulpal disease (ie, reversible pulpitis) have fleeting sharp pain that is elicited by a stimulus such as exposure to cold or something sweet.

    • Chronic and untreated pulpal disease progresses to irreversible pulpitis, a condition resulting in pulpal death. Irreversible pulpitis produces poorly localized, lingering pain that is described as boring or gnawing and is aggravated by eating, exposure to a cold stimulus, or lying down (eg, many patients wake from sleep because of pulpitis pain). Analgesics (eg, acetaminophen, nonsteroidal anti-inflammatory drugs) often relieve irreversible pulpitis pain.

    • The progression of pulpitis causes more pain, which is frequently severe in nature, aggravated by heat, and often relieved by application of cold. Occasionally, chronic pulpitis results in the spontaneous development of pain.

    • Pulpal death and necrosis can lead to an acute apical periodontitis and an acute apical abscess, both of which can cause severe throbbing pain localized to the involved tooth, as well as regional lymphadenopathy.

    • Ultimately, the abscess can progress to cellulitis and facial-space infection, which causes facial swelling, pain in the regional lymph nodes, fever, malaise, difficulty in eating or opening the mouth, and dysphagia. In extreme cases, the infection and associated inflammatory products can become life threatening if vital structures are involved (eg, cases of dyspnea due to compromised airway, infection of mediastinum, cavernous sinus).

  • Medical history: A history of maternal or childhood diseases or the use of medications (see Causes) may explain tooth discoloration because the conditions can adversely influence normal tooth development. Knowledge of the onset and duration of maternal or childhood disease and the dosing of medications also helps.

  • Family history: Several genetic diseases are associated with tooth-associated disorders the most common include AI, DI, and DD. Patients may be unaware of the diseases but often confirm that a family member had similar tooth discoloration.

  • Social history: The use of tobacco and similar products, such as the chewing of areca (betel) nuts, commonly leads to staining of the teeth. Determining the type of tobacco habit (eg, smoking vs chewing) is important because the distribution of the stain may vary.

  • Dental history: The dental history can reveal useful information regarding the last dental cleaning, previous dental treatments, amount and scheduling of fluoride intake, oral hygiene practices, use of mouthwash, and traumatic events involving dentition.

  • Diet history: A history of nutritional deficiencies or ingestion of foods that can stain teeth is important. Querying patients about the quality of their diet, including the amount and frequency of fresh fruits and vegetables consumed and the use of sugared beverages between meals, is always useful.

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Physical

Physical characteristics of extrinsic discoloration

Usually, discoloration colors include brown, black, gray, green, orange, and yellow; on occasion, a metallic sheen is present. The scratch test is usually used to distinguish between extrinsic and intrinsic discoloration.

In terms of distribution patterns, primary or secondary teeth (or both, as in a child in the mixed dentition stage) may be involved. The distribution is either generalized to all teeth or localized to certain teeth or tooth surfaces. Extrinsic staining of 1 tooth is unusual. Extrinsic stains often are found on surfaces with poorer toothbrush accessibility (eg, at the tooth-gingival interface [cervical regions] and between the teeth [interproximal regions]).

Regarding other physical findings, teeth with extrinsic tooth discoloration usually demonstrate no signs of pulpal disease.

Physical characteristics of intrinsic discoloration

Usually, discoloration colors include brown, black, gray, green, orange, and yellow; also, a metallic sheen may be observed. Unlike extrinsic discoloration, teeth with intrinsic discoloration may be red or pink. Under ultraviolet light, teeth with tetracycline staining and congenital porphyria may fluoresce yellow or red, respectively. Intrinsic discoloration cannot be removed by using the scratch test.

In terms of distribution patterns, primary and secondary teeth may be involved. The distribution is either generalized to all teeth or localized to certain teeth or tooth surfaces. An intrinsic etiology usually exists when a single tooth is discolored. When multiple teeth are involved, patterns of banding are indicative of intrinsic staining.

Regarding other physical findings, teeth with intrinsic discoloration may demonstrate signs of pulpal disease.

  • Inspection

    • Visual inspection requires the use of a handheld dental mirror and a good light source, which permit examination of the varying shades and patterns of tooth color and the integrity and surface texture of all enamel surfaces.

    • Transillumination is the simple process of directing a light source (eg, fiberoptic probe) through an anterior tooth from the buccal surface to the lingual surface. This process can facilitate inspection of tooth discoloration, particularly when associated with dental caries.

    • Ultraviolet light exposure is not a common diagnostic tool, but it may offer further clues about the etiology of intrinsic discoloration because the tooth may emit a characteristic fluorescence.

  • Scratch testing

    • Discolored tooth surfaces are scratched with care by using a dental explorer, scaler, or similar sharp instrument to assess surface texture.

    • Noncarious discolorations are hard and nonpenetrable.

    • Light scratching with a dental instrument removes weakly adherent plaque that causes extrinsic discoloration.

    • If the discoloration requires removal with a sharp dental scaler, the discoloration is considered to be tenacious.

  • Exploration

    • Use a sharp dental instrument to explore soft and penetrable discolorations that probably are dental caries and/or faulty restorations. Incipient caries can undergo remineralization, and defects left following overzealous exploration may be less amenable to remineralization, warranting judicious use of an explorer.

    • These dental disorders require definitive therapy.

  • Percussion and palpation

    • Percussion of a discolored tooth with the handle of a dental mirror and palpation of the tooth over the covered root surface may reveal additional information regarding pulpal disease.

    • Discolored teeth associated with infections (eg, acute pulpitis, apical periodontitis, apical abscess) are sensitive to percussion and palpation.

  • Pulp testing

    • Pulp testing techniques are used to diagnose the pulpal status of teeth discolored as a result of dental caries, deep dental restorations, severe developmental or acquired enamel/dentin defects, or trauma leading to pulpal necrosis.

    • Thermal testing of teeth is conducted by using the application of cold (ice or vapocoolant) or heat (thermoconductive material such as dental compound or gutta percha). Surrounding teeth should be covered with cotton rolls or similar material and the cold or heat source applied directly to the tooth in question.

    • Electric pulp testing is used to assess pulp vitality and degree of pulpal disease.

  • Extraoral and intraoral soft tissue examination: Swelling, tender lymphadenopathy, trismus, and other signs associated with facial-space infection of odontogenic origin may accompany the physical presentation of a discolored tooth.

  • Comprehensive head, neck, and oral examination

    • Neck lymphadenopathy and tenderness upon palpation to neck lymph nodes may be indicative of infection.

    • An asymmetric mandible may be a sign of previous trauma.

    • Ecchymoses may be suggestive of a bleeding disorder.

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Causes

The causes of extrinsic and intrinsic dental discoloration are as follows (see also Pathophysiology):

Extrinsic causes

  • Brown stain

    • Tobacco products

    • Dental plaque

    • Tea, coffee, wine, and other beverages

    • Certain foods

    • Metals

    • Iodine

    • Chlorhexidine rinse

    • Cetylpyridinium chloride rinse

    • Stannous fluoride

    • Khat leaf

    • Doxycycline

  • Black stain

    • Tobacco products

    • Betel nut

    • Dental plaque

    • Chromogenic bacteria

    • Tea, coffee, wine, and other beverages

    • Certain foods

    • Metals

  • Green stain

    • Chromogenic bacteria

    • Tea

    • Metals

  • Orange stain

    • Chromogenic bacteria

    • Metals

    • Doxycycline

Intrinsic causes - Localized color changes (in 1 or 2 adjacent teeth)

  • White (opaque) stain

    • Mild trauma to teeth during enamel formation (secondary teeth), eg, Turner tooth

    • Periapical infection of primary tooth

    • Traumatic injury to primary tooth or teeth

    • Incipient caries (primary or secondary teeth)

  • Yellow stain

    • Moderate trauma to teeth during enamel formation (secondary teeth), eg, Turner tooth

    • Periapical infection of primary tooth

    • Traumatic injury to primary tooth or teeth

    • Trauma without hemorrhage

    • Composites or glass ionomer or acrylic restoration

    • Caries (active)

    • Focal tooth abrasion

  • Brown stain

    • Severe trauma to teeth during enamel formation (secondary teeth), eg, Turner tooth

    • Periapical infection of primary tooth

    • Traumatic injury to primary tooth or teeth

    • Composite, glass ionomer, or acrylic restoration

    • Caries (active or remineralized)

    • Pulpal trauma with hemorrhage

  • Blue, gray, or black stain

    • Amalgam restoration

    • Glass ionomer or acrylic restoration

    • Metal crown margin associated with porcelain fused to metal crown

    • Pulpal trauma with hemorrhage

Intrinsic causes - Regional color changes

  • White (opaque) stain

    • Infection (maternal or childhood) during enamel formation

    • Trauma to multiple teeth during enamel formation

    • Mild fluorosis (short-term exposure)

    • Nutritional deficiency

  • Yellow stain

    • Infection (maternal or childhood) during enamel formation

    • Moderate fluorosis (short-term exposure)

    • Trauma to multiple teeth during enamel formation

    • Nutritional deficiency

    • Epidermolysis bullosa

    • Regional tooth abrasion or erosion

    • Diseases causing hyperbilirubinemia

  • Brown stain

    • Infection (maternal or childhood) during enamel formation

    • Severe fluorosis (short-term exposure)

    • Trauma to multiple teeth during enamel formation

  • Blue, gray, or black stain - Tetracycline therapy (short-term exposure)

  • Green stain - Diseases causing hyperbilirubinemia (eg, HDN, biliary atresia)

Intrinsic causes - Generalized changes (involving primary and/or permanent dentitions)

  • White (opaque) stain

    • Mild fluorosis

    • Amelogenesis imperfecta

  • Yellow stain

    • Moderate fluorosis

    • Amelogenesis imperfecta

    • Dentinogenesis imperfecta

    • Dentinal dysplasia

    • Epidermolysis bullosa

    • Diseases causing hyperbilirubinemia

    • Hemolytic diseases

    • Generalized tooth attrition, abrasion, or erosion

  • Brown stain

    • Porphyria

    • Tetracycline therapy (long-term exposure)

  • Blue, gray, or black stain

    • Tetracycline therapy (long-term exposure)

    • Minocycline therapy

  • Green stain - Diseases causing hyperbilirubinemia (eg, HDN, biliary atresia)

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