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Journal of Clinical Periodontology: 1978: 5: 229-236

Review Article
Key words: Tooth discoloration.
Accepted for publication: January 9, 1978.

Extrinsic discoloration of teeth


HARALD M. ERIKSEN AND HAKON NORDB0
Department of Operative Dentistry, Dental Faculty, University of Oslo,
Oslo, Norway

Abstract. The majority of tooth discolorations are extrinsic in nature and appear as brown
integuments. Various clinical indices and photometric techniques have been used for the
evaluation of extrinsic discolorations. Smoking, tea or coffee consumption and increasing
age are promoting factors and such discolorations are frequently seen in connection with
oral use of antibacterial plaque-inhibiting mouthrinses. Chemical alteration of the acquired
pellicle appears to be the major reason for these hrown integuments.

Discoloration of teeth may interfere with oral hygiene (Sutcliffe 1967). These dis-
the esthetic appearance and is therefore of colorations are most frequently found in
primary concern to most people (Fig. 1). children, primarily on the buccai surfaces
Based on localization and etiological fac- of the maxillary teeth (Leung 1950). Highly
tors, such discolorations are classified as retentive black or dark hrown integuments
extrinsic or intrinsic; a majority seem to he located along the gingival margins are also
of extrinsic origin (Voge! 1975). Extrinsic most frequently observed in the primary
discolorations may he caused by retention dentition. These dark deposits are of bac-
of colored substances in hacterial plaque terial origin and are usually seen in mouths
and/or the acquired pellicle or hy chemical with low caries activity and good oral hy-
alterations of these organic integuments. giene (Theilade et al. 1973). Brown dis-
The latter are frequently ohserved as un- colorations hound to the pellicle layer ap-
wanted side effects with many of the pro- pear most frequently on surfaces which
mising antibacterial agents used for chemi- favor the development of a thick pellicle,
cal plaque control. Furthermore, chromo- mainly along the gingival margins and in
genic plaque bacteria may cause extrinsic interproximal areas. Irregularities in the
discolorations. Knowledge about the etiolo- tooth surfaces such as hypomineralized
gy and composition of the extrinsic discolo- areas, abrasion and attrition lesions, arrested
rations should therefore be of interest and caries and exposed roots increase the possi-
importance. bilities for retention of discolored integu-
ments.
Color and Localization
Yellow, green and orange discolorations are Prevalence
caused by chromogenic bacteria in bacterial Generally the prevalence of extrinsic dis-
plaque deposits in connection with poor colorations increases with increasing age
230 ERIKSEN AND NORDB0

These discrepancies among investigators


may be caused by different prevalences of
extrinsic discoiorations in various popula-
tion groups or it may reflect the lack of
standardized and reproducible criteria for
the evaluation of stained integuments.
From a cross-sectional investigation in
England, Ness et al. (1977) found that 31 %
of the men and 21 % of the women had
moderate or severe extrinsic discoiorations,
evaluated according to a clinical index using
^i^. 1. Esthetically disturbing extrinsic discolo-
the grades no - slight - moderate - severe
ration due to a chiorhexidine mouthrinse.
Asihelisch storende Verfarbung durch Spuliing staining. This finding is in good agreement
mil chlorhexidinhaltigem Mundwasser. with the prevalence reported from experi-
Coloration externe, getiante dn point de vue mental investigations by Horowitz & Cham-
esthetique et due a des ringages de boiiche a la berlin (1971). Kitchin & Robinson (1948)
chiorhexidine. also reported that 18 % of a group of stu-
dents could be classified as heavy stainers.
These published frequencies are in good
and is higher among men (Ness et al. 1977). agreement with clinical experience and indi-
However, when differentiating between the cate that the tendency to develop extrinsic
various types of pigmented integuments, the discoiorations shows marked individual va-
yellow, green and orange plaque discolora- riations.
tions and the particular black pigmentation
mentioned previously decrease in frequency, Etiology
whereas the brown pellicle discolorations At least three main mechanisms involved in
show a marked increase with increasing age. the development of extrinsic discoiorations
Evaluation of the prevalence of various may be considered.
qualities of pigmented integuments is there-
fore most relevant in groups of children, 1. Production of colored components in
whereas a majority of investigations on ex- plaque by chromogenic bacteria. These
trinsic discoiorations among adults merely stains, mainly in the yellow, green and
evaluates the frequency of "staining" in orange shades, are based on specific ecolo-
general. gical conditions in the oral microflora and
The frequency of discoiorations among have a tendency to recur after removal. The
children shows wide variations. Leung same is found for the black stain described
(1950) found that 85 % of a group of chil- by Theilade et al (1973).
dren had some kind of" discoiorations, with
green deposits heing the most predominant. 2. Retention of colored substances from
Sutcliffe (1967) found only 25 % with dis- substrates passing through the oral cavity.
coiorations and he reported brown as the This mechanism causes mainly temporary
predominating stain. Gerdin (1970) con- staining of plaque and pellicle and is well
cluded ftom an investigation among Swe- illustrated by the use of disclosing solutions
dish schoolchildren that only 15 % showed for the demonstration of bacterial plaque.
discoiorations on their teeth and yellow/ Foodstuffs with strong color components
green deposits were most frequently found. (e.g. blueberries, coffee) may produce such
EXTRINSIC DISCOLORATION OF TEETH 231

discolorations. The importance of this


mechanism as a cause of extrinsic dicolo- Possible Mechanisms for the Formation of
ration is probably overestimated. Brown Pellicle Discolorations
There are at least three possible mecha-
3. Formation of colored products from nisms responsihle for developing a brown
chemical transformation of pellicle compo- discolored pellicle, either of them acting
nents. This group of discolorations appears alone or, most probably, in combination.
mainly as brown deposits and they are the
most frequently observed discolorations Denaturation of pellicle proteins
among adults. Clinically they are also the Denaturation of a protein will increase its
most interesting ones and they will there- stainability (Hjeljord et al. 1973). The pel-
fore be given special attention. The etiology hcle may he exposed to a variety of dena-
is obscure but a variety of etiological possi- turating agents under normal conditions.
bilities have been suggested based on the Tannic acid has a strong denaturating effect
present knowledge of the acquired pellicle. on proteins. It occurs as a natural constitu-
ent of various fruit, wines, tea and coffee.
In vivo rinsing experiments have demon-
The Acquired Peliicle strated that tannic acid promotes the for-
Research indicates that the acquired pellicle mation of a brown, stained pellicle (Nordb0
is formed by a selective adsorption of glyco- 1977). Ness et al. (1977) observed little di-
proteins from saliva (S0nju 1975). In the rect retention of colored substances from
mouth this process starts immediately after the use of tea and coffee. The denaturating
cleansing of a tooth surface and slows down effect of these beverages due to their tannic
after 60-90 min. This adsorbed organic acid content may therefore be the stain
coating is described as the pellicle in the promoting factor of importance. Further-
present review and no further effort is spent more, combination of tannins and copper,
on differentiating between the possible sub- iron and magnesium gives dark brown pre-
structures described by Listgarten (1976) cipitates in vitro (Meyer 1960).
and Meckel (1965). Various organic acids possess protein
The established pellicle is composed of denaturating activities. The same is also ob-
about 80 % proteins and 20 % carbohydra- served from many detergents and it has
tes, mainly glucose (S0nju 1975). The car- been speculated that the strong discoloring
hohydrate content in the pellicle is higher tendency observed in connection with oral
than what can be explained from a direct use of cblorhexidine (Fl0tra et al, 1971)
adsorption of salivary glycoproteins. Extra- may be caused by the detergent properties
cellular dextrans produced by oral micro- of this chemical. The reduction of extrinsic
organisms might be a possible additional discolorations in association with the use of
carbohydrate source. Bacteria are not found proteolytic enzymes'in a toothpaste further
adsorbed to the pellicle surface until 2 h indicates that protein deposits are of im-
after start of formation. An established bac- portance in the development of these dis-
terial plaque seems to reduce the thickness colorations (Harrison et al. 1963).
of the pellicle (Leach & Saxton 1966)
whereas the absence of bacteria may lead Chemical interactions between pellicle com-
to a continuous adsorption and the final ponents and reactants introduced to the oral
formation of a very thick pellicle structure cavity
(Tinanoff et al. 1976). A variety of substances introduced to the
232 ERIKSEN AND NORDB0

oral cavity under normal conditions may and may be a reaction similar to the dis-
react with components of the pellicle to coloration of the pellicle.
form colored products. Some of the most
important ones will be mentioned here. Conditions which favor the continuous for-
Various aldehydes and ketones occur in mation of a thick pellicle
the oral cavity as normal metabolites. The Undisturbed adsorption and apposition of
aldehydes in particular are known to react glycoproteins forming an extraordinary
with amino groups to form brown organic thick "consolidated" pellicle may increase
complexes (Berk 1976). Furfural, an alde- the possibilities for extrinsic discoloration.
hyde, occurs in a variety of baked products Many of the most successful antibacterial
and fruit and may also be formed in the agents tested in chemical plaque control
oral cavity by normal digestion of pentoses studies show a marked discoloring tendency.
(normal constituents of the pelhcle) and In the absence of plaque mediated by chior-
certain polysaccharides. This process is ca- hexidine (FJ0tra et al. 1971, L0e et al.
talyzed by malic- and other organic acids 1976), alexidine (Weatherford et al. 1977),
and phosphates (Meyer 1960, Braverman vantocil (Pluss 1975), staiuious fluoride
1963). Dark brown reaction products result (Svantun et al. 1911), brown pelhcle dis-
from interaction between furfural and pro- coiorations are reported to occur and extra-
teins (Berk 1976). It may be of interest that ordinary thick pellicle coatings may be one
furfural has been demonstrated in chlor- of the reasons (Tinanoff et al. 1976). In the
hexidine-discolored pellicle (Nordb0 et al. same way oral use of antibiotics should be
1977). expected to cause extrinsic discoiorations
Many investigations have pointed out the but surprisingly httle is reported in the lit-
connection between smoking and discolora- erature. Black hairy tongue is, however, a
tion of teeth (Ness et al. 1977). Retention well-known phenomenon in connection with
of stained tar components on the tooth sur- orally administered antibiotics (Zander
faces is mentioned as a possible cause but 1950).
the presence of furfural (Pohto 1967) and
acetaldehyde (Vogel 1975) in tobacco smoke
may indicate other mechanisms as well. Evaluation of Discoiorations
Organic complex binding is mediated by Extrinsic discoiorations may be evaluated
many divalent cations like iron, tin, stronti- according to color, intensity and distribu-
um, etc. (Mortimer 1971). These substances tion. In studies of intensity of discoiora-
are frequently mentioned in connection with tions, various clinical index systems have
discoloration of teeth whereas fluoride, been frequently used (Ness et al. 1977, L0e
being anionic, has been reported to reduce et al. 1976, Pluss 1975, Fanning et al. 1968,
discoiorations from chiorhexidine in a re- Snyder 1964, Kitchin & Robinson 1948).
cent clinical trial (Dolles & Gjermo 1977). Weatherford et al. (1977), Voipe (1974) and
Tin may also react with sulfuric compo- Davis & Rees (1975) based their investiga-
nents to form dark brown precipitates tions on an index system combining distri-
(Bmdevold et al. 1956). Breakdown pro- bution and intensity of the observed dis-
ducts from liexoses and pentoses form dark coiorations.
stained products by reacting with decalci- Planimetric methods have also been
fied dentin (Dreizen 1976). This may ex- applied (Shaw & Murray 1977), and plani-
plain the discoloration of arrested caries metric reading on photographs as used in
and poorly mineralized areas of the tooth the evaluation of plaque visualized by dis-
EXTRINSIC DISCOLORATION OF TEETH 233

This observation indicates that more re-


fined techniques for the detection of early
discolorations may be appropriate under
certain conditions.
Photometric evaluation of extrinsic dis-
colorations has been applied either directly
(Wilkinson & McPugh 1970) or from black
and white negative photographs of selected
teeth (Eriksen & Gjermo 1973) (Fig. 2). A
good correlation with the clinical estimation
was obtained by using these techniques. In
Fig. 2. Polished (41) versus unpolished (31) principle the reading of black and white
mandibular central incisor on a black and negatives is identical to a photometric
white negative fiim. The extrinsic discoloration
appears as a bright area and gives higher trans- reading of X-ray films (Hedin et al. 1974,
mission values than the polished control in the Isenherg et al. J968). A transmission elec-
microphotometer. The black areas accentuating tron beam in the scanning electron micro-
the striae of Retzius in the incisai part of the scope may act as a microphotometer. With
incisors are due to reflections from the flash-
light.
the use of computerized programs defining
the area to be read hy the microscope,
Vergleich zwischen einem polierten (41) und
nicht polierten (31) unteren Schneidezahn auf possibilities exist for developing a highly
einem schwarz-yveiss Negativ. Die ausaerliche sensitive system for examining the distribu-
Verfurhung erschelnt a!s helles Feld und er- tion and intensity of extrinsic discolorations
reicht im Mikrofotometer hohere Transmis- from photographs.
sionswerte als der polierte Kontrollzahn. Durch
Blitzlichtreflexe hervorgcrufene schwarze Fel- It is however appropriate to remember
der lassen die Retzius'schen Strcifen im inzi- tbe general requirements of a clinical index
salen Abschnitt hervortreten. system stated by Davis (1968) (here abbrevi-
Incisives centrales inferieures, I'une polie (41), ated). A clinical index system should be:
I'autre non polle (31) sur film negatif noir et
blanc. La coloration externe apparait conime
un endroit plus clair et donne, au microphoto- 1. Simple, and permit the investigation of
metre, des valeurs de transmission plus elevees large samples at a minimum of cost and
que la dent temoin polie.. Les endroits noirs time consumption
accentuant les stries de Retzius de la partie iu~ 2. Clear, easily defined and reproducible
cisale des incisives sent dus a la reflexion du
flash. 3. Suited for statistical analysis
4. Equally sensitive at all levels and clini-
cally meaningful.

The more sophisticated photometric me-


thods mentioned here should therefore he
closing solutions (Arnim 1963, Rekola & limited to certain experimental investiga-
Scheinin 1977) may offer new possibilities tions, while many of the clinical index sys-
in discoloration studies. tems are preferable in more extensive clini-
By using a binocular stereomicroscope in cal investigations. This statement is sup-
their experimental clinical discoloration ported hy the good correlation found be-
studies, Kitchin & Robinson (1948) oh- tween photometric and clinical evaluation
served that many of the participants had of pellicle discolorations (Wilkinson & Me
subclinical brown pellicle discolorations. Pugh 1970, Eriksen & Gjermo 1973, 1977).
234 ERIKSEN AND NORDB0

compatible with oral health than the un-


Prevention and Removal of Extrinsic
restricted pursuit of "clean white teeth".
Discoiorations
The plaque diseolorations produced by Zusammenfassung
chromogenic bacteria are easily removed by Zahnverfarbung. Ein Vbersichtsartikel
regular oral prophylaxis, and good oral hy- Die weitaus haufigsten Zafanverfarbungen sind
giene prevents their recurrence. The black ausserlich und erscheinen als brauner Belag.
stain primarily seen in the temporary den- Diese ausserlichen Verfarbungen sind mit ver-
schiedenen kiinischen und fotometrischen Ver-
tition is more firmly attached to the tooth fahren untersucht worden. Ranchen, Tee- und
surfaces and professional scaling and pohsh- Kaffetrinken sowie zunehmendes Alter tragen
ing may be required. Brown pellicle discoio- 2U den Verfarbungen bei. Sie treten haufig bei
rations are also quite firmly attached to the Anwendung von Plaque auflosenden Mund-
teeth and a professional cleaning may be wassem auf. Veranderungen des erworbenen
Pellikels scheinen hauptsachiich fur die braun-
necessary. When certain habits (smoking, lichen Verfarbungen verantwortlich zu sein.
heavy tea consumption, etc.) play an etiolo-
gical role, suspension of these habits is of
obvious benefit but at the same time diffi-
Coloration externe des dents. Mise au point
cult to accomplish. La plupart des colorations dentaires sont de
Most investigations indicate that the abra- nature exteme et apparaissent sous forme d'en-
siveness of the dentifrice is directly related duit de couleur bnine. Differents indices clini-
to its ability of removing brown peUicle dis- ques et des techniques photometriques ont ete
utilises pour evaluer les caracteristiques de ces
coiorations (Shaw & Murray 1977, Wilkin- coloratioas. L'usage du tabac, la consommation
son & McPugh 1970, McCauley et al. 1946). de the ou de cafe et I'age sont des facteurs pro-
By the use of nonabrasive dentifrices, a moteurs de la coloration, et celle-ci apparait
discolored pellicle may develop even on the souvent a I'occasion de rincages de bouche au
moyen de produits antimicrobiens inhibiteurs
facial surfaces of the front teeth. However, de- la plaque. L'alteration chimique de la pelli-
abrasive dentifrices may cause hard tissue cule acqiiise semble etre la cause majeure de
abrasion lesions in some individuals. As the ces enduits bruns.
discoloration tendency shows substantial va-
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The effect of NaF and SnFa mouthrinses on Norway

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