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