Tooth staining and discolouration

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Question:

I am having stains on my teeth from childhood. I have consulted several dentists and never found a permanent solution for this. Some of the doctors advised to do the clean-up every year and some did not. Now I have stopped going to the dentist for stain removal. Stains are still showing up and my teeth became so sensitive. Expecting a permanent solution to the problem that I am having.

Answer:

Teeth can be discoloured due to a variety of causes. In any individual such discolouration is usually due to a single cause. But very rarely more than one cause can be found. People often see staining of teeth as a single entity, although it is more complex.

Causes of teeth staining can be broadly divided into:

• Extrinsic causes (stains depositing on the teeth from the oral environment)
• Intrinsic causes (causes that arise from within the body)

Your history points towards a cause that is present from childhood probably from the time of eruption of teeth. In which case it is more likely to be due to an intrinsic cause. However, extrinsic causes are much more common. Therefore, extrinsic causes are explained first. Causes that affect only one or two teeth are not discussed in this article.

EXTRINSIC STAINING

These are the common reasons for staining;

• Inadequate or poor oral hygiene. Plaque and calculus deposits can give an unsightly yellow discolouration.
• Blackish pigment spots due to chromogenic bacteria which may occur in the oral flora (bacterial population) of some people especially in children
• Betel chewing and smoking
• Medications – particularly iron syrups
• Tea, coffee and other beverages
• Use of chlorhexidine mouthwash in the presence of bacterial plaque on the teeth

Generally, these conditions can be eliminated by instrumental removal of stains by dentist and maintaining high standard of oral hygiene thereafter. Sometimes a periodic stain removal will be needed. It is essential for betel chewers and smokers to give up their habit for the treatment to succeed.

INTRINSIC STAINING

These are the less commonly encountered reasons. They can be broadly classified into acquired type and inherited (runs in families) or congenital (present since birth) type.

Acquired type of intrinsic staining:

• Dental Fluorosis:
  This condition occurs due to excess accumulation of fluoride in the teeth. In Sri Lanka, dental fluorosis is endemic in some parts of Wayamba and Rajarata regions. This is due to high concentration of fluorides found in the ground water used for drinking. In fact, fluoride can prevent tooth decay (dental caries). But excess fluoride is bad for teeth. Dental fluorosis can be seen in other parts of the dry zone as well. It can cause staining of various degrees from mild to severe, depending on the concentration of fluorides in the water.
• Staining by tetracycline group of drugs:
  A young child’s milk teeth (baby/deciduous teeth) may develop a yellowish to brown stain if the mother used certain medications (tetracycline or doxycycline) during the second half of pregnancy or during breastfeeding. Similarly, a toddler or a child below the age of 14 may develop stained teeth if they took these medications.
• Erythroblastosis fetalis:
  This condition occurs due to (Rhesus) blood group incompatibility at child birth. If the mother has one of the negative blood groups (A, B, AB, O – negative) and the child has a positive blood group (A, B, AB, O – positive), the child can develop a condition called “Haemolytic Disease of the New-born.” This condition can lead to staining of the teeth. This will be seen when the deciduous teeth begin to erupt at the age of 6 months. The permanent teeth are only mildly affected.
• Changes associated with aging:
  With advancing age teeth tend to become yellowish due to thinning of the enamel resulting in translucency. The teeth appear yellow because of the colour of the underlying dentine.

Inherited/congenital types of intrinsic staining:

• Enamel defects:
  Enamel is the outermost hard layer of the tooth. An inherited condition known as Amelogenesis imperfecta causes poorly formed enamel There are 14 subtypes of this condition, depending on what aspect of enamel formation is affected.  Therefore, there is a huge variation in the pattern and degree of staining. When the poor quality enamel becomes worn off, pain may arise due to the exposure of the inner layer named ‘dentine’ which has nerve endings unlike the enamel.  Since this condition can run in families, there could be affected other members in the same family.  Both milk and adult teeth are affected. Additional staining from external causes may aggravate the discolouration.
• Dentine defects:
  An inherited condition named Dentinogenesis imperfecta can cause staining of teeth. Both milk teeth and permanent teeth are affected. The teeth appear greyish with an opal appearance.  Because of poorly developed interlocking between enamel and dentine, the enamel becomes sheared off leaving the soft dentine which becomes further stained. The dentine wears off rapidly leaving only the roots submerged in the gums and jawbone.
• Erythrodontia (Red teeth):
  Congenital erythropoietic porphyria is a rare genetic disorder. This condition results in anaemia due to broken red blood cells, reddish brown teeth, photosensitive skin rashes and blistering of the skin.

Because of such multiplicity of causes the management methods can vary extensively and treatment can vary from an affordably simple method to very expensive methods. Treatment methods may include veneering, fitting of ceramic crowns or intermediate restorations prior to fitting of crowns. As multiple teeth may be involved the cost can be considerable. Facilities for such treatment are not widely available in the government hospitals in Sri Lanka. Detailed discussion of different types of treatment is beyond the scope of this article. The specific treatment required for the questioner depends on the diagnosis of his/her condition. As this patient is having this problem for a long time and dentists appear not to have explained the issue, a brief explanation of the spectrum of tooth staining disorders has been presented which would enable him/her to appreciate the need for proper diagnosis of the problem. As the background information needed for diagnosis of some of the causes is only known to him/her, his/her readiness to provide such information would facilitate the correct diagnosis. Because the intrinsic staining cases present only rarely, most general dental practitioners are not fully conversant in the differential diagnosis. I would advise the questioner to consult a restorative dentistry consultant.

Authors: Prof. Siddique

References

1. Anvar, J. (2017, August 12). Tooth Staining and Discoloration. Retrieved October 23, 2019, from SlideShare: https://www.slideshare.net/iamjabrananwar/tooth-staining-and-discoloration
2. Barron, M. J., McDonnell, S. T., MacKie, I., & Dixon, M. J. (2008). Hereditary dentine disorders: dentinogenesis imperfecta and dentine dysplasia. Orphanet Journal of Rare Diseases, 31. doi:10.1186/1750-1172-3-31
3. Cafasso, J. (2017, August 29). Amelogenesis Imperfecta. Retrieved October 23, 2019, from Healthline: https://www.healthline.com/health/amelogenesis-imperfecta
4. SA, F., & MA, P. (1994). Congenital erythropoietic porphyria–oral manifestations and dental treatment in childhood: a case report. Quintessence International, 551-4.