Management of the single discoloured tooth. Part 1: Aetiology, prevention and minimally invasive restorative options

The single discoloured tooth is commonly encountered in general practice. This is the first of two articles covering the broad range of management options for the single discoloured tooth. This first part outlines the common causes of discoloration and possible methods of prevention. Minimally invasive techniques are covered. Clinical procedures are outlined and clinical cases used to demonstrate outcomes that can be achieved.

CLINICAL RELEVANCE

The single discoloured tooth is a commonly encountered clinical problem in general dental practice. A wide variety of management options exist and any one in particular may be most appropriate given the clinical scenario. It is therefore essential that general dental practitioners are familiar with the range of options that exist, as well as their indications, and consider adopting minimally invasive techniques in the first instance before moving to more invasive therapies.

Crossover clinical investigation of a whitening chewing gum for inhibiting dental stain formation in conjunction with tooth brushing

OBJECTIVE

The purpose of this clinical investigation was to evaluate the effectiveness of a marketed whitening chewing gum compared to a no-gum control in preventing the formation of extrinsic stains on the teeth of stain-forming subjects when chewed over a 12-week period of regular unsupervised use in conjunction with daily tooth brushing.

METHODS

This was a single-center, examiner-blind, randomized, 12-week crossover clinical trial. Stain-forming (after smoking or drinking coffee or tea) adults, starting with a stain-free baseline, either chewed the test gum (Orbit White) unsupervised four times per day, 15 minutes/chew, or used no gum along with daily brushing with a commercially available toothbrush and dentifrice for 12 weeks. At the crossover, all procedures were repeated with subjects assigned the opposite treatment. Extrinsic stain was measured at six and 12 weeks by both the Lobene Stain Index (LSI) and the Modified Lobene Stain Index (MLSI) using separate experienced examiners.

RESULTS

After 12 weeks, LSI stain scores showed a significant 25% reduction (p = 0.0008) in new stain formation for subjects using the test chewing gum along with tooth brushing versus tooth brushing alone (no-gum control). The corresponding MLSI stain scores demonstrated a 36% reduction (p < 0.0001) in the formation of extrinsic stain on the teeth.

CONCLUSION

The overall findings of this clinical study demonstrated that regular use of Orbit White chewing gum, soon after smoking or drinking coffee or tea, will supplement daily tooth brushing in preventing unsightly stains from forming on the anterior teeth compared to brushing alone.

The timing and operational management of the variables of bleaching in cases of rehabilitation in the esthetic field

Managing esthetic restoration in the presence of discolored teeth is a challenge for both the clinical team and clinician, whose aim is to use methods that are as minimally invasive as possible, and materials that allow the preservation of dental tissue. Should one wish to act on the discoloration of teeth that are to be restored, or on adjacent ones, it becomes essential to take action on dental tissues. This is done through bleaching and dental restoration, using materials that allow various clinical situations to be managed, such as those with different tonalities between the teeth: prosthetic materials that offer adequate uniformity in their results in those areas where it is necessary to mask the discoloration. The use of technology such as bleaching, and ceramic materials simultaneously can achieve excellent cosmetic results. This article explains how to integrate bleaching compared to prosthetic treatment, in terms of time, in the various cases of discoloration, and what factors to consider when choosing the timing.

Minimally invasive rehabilitation of a patient with amelogenesis imperfecta

This case report describes a minimally invasive step-by-step approach to treat a patient with amelogenesis imperfecta. This is a genetic developmental disorder of the dental enamel, which clinically manifests as white and dark discolorations of the teeth. The clinical examination did not reveal the true depth of the staining. Therefore, a step-wise treatment approach was chosen. The first step consisted of a home bleaching procedure, which led to a slight improvement of the esthetic appearance, but the stains were still clearly visible. The next step was the application of a microabrasion technique. This led to further improvement, but not to a satisfactory result for this patient who had high esthetic expectations. Thus, the third step was undertaken: it was planned to restore the maxillary incisors and canines with ceramic veneers. The dental technician prepared a wax-up, which served as a basis for a clinical mock-up. After discussing the mock-up and the treatment plan with the patient, crown lengthening was performed on teeth 11 and 23 to improve the pink esthetics. Subsequently, the teeth were prepared in a minimally invasive way and a final impression was taken. Following try-in, the six veneers were inserted with resin cement.

Comparative performance of two whitening systems in a dental practice

OBJECTIVE

A randomized, controlled clinical trial was conducted to compare the safety and whitening efficacy of high-adhesion tooth-whitening strips with a marketed in-office professional tooth-whitening system.

METHODS AND MATERIALS

This open-label study was conducted in a private dental practice, and adult volunteers were assigned (2:1) to either 9.5 percent hydrogen-peroxide whitening strips (Strip group) or an in-office light plus 25 percent hydrogen-peroxide whitening gel treatment (In-office group). The Strip group was instructed to treat the maxillary arch once daily for 30 minutes over a 20-day period, while the In-office group underwent professional application of light plus whitening gel in a single office visit. Whitening response was measured as change in yellowness (b*) and lightness (L*) at Day 21 using standardized digital images of the maxillary anterior teeth, while safety was assessed as tooth sensitivity and oral irritation occurrence. A total of 45 subjects enrolled, were randomized, and received treatment; 44 completed the study.

RESULTS

At Day 21, significant improvement in b* and L* was noted in both groups (P≤0.001). The adjusted mean (SE) ΔL* in the Strip group (1.72 (0.104)) was significantly greater than that in the In-office group (1.17 (0.153)) (P = 0.005). Both test products were well tolerated. Overall, both the strip and in-office treatments resulted in significant tooth whitening.

An esthetic concern leads the way to improved oral health

In order to make appropriate treatment decisions, clinicians must consider a patient's needs in total. As such, a systematic risk assessment is essential for developing a treatment plan that will both satisfy the patient's esthetic concerns and lower his or her risk for future problems. In this case, the patient's immediate concern was his smile, but he was unaware of the need for additional treatment, which included addressing occlusal dysfunction, extracting hopeless teeth and replacing them with an implant-retained prosthesis, and placement of indirect porcelain restorations. A comprehensive interdisciplinary approach between the clinician, implant surgeon, and laboratory was crucial for a successful outcome.

Accomplishing esthetics using enamel microabrasion and bleaching-a case report

This case report describes the sequential steps that were used to treat unesthetic, white, hard-texture enamel stains of unknown etiology. A tapered fine diamond bur was used to remove superficial enamel followed by the use of an enamel microabrasion compound Opalustre (Ultradent Products Inc). This technique removed the stains and was followed by polishing with a fluoride paste to restore the enamel to a smooth finish. The teeth were subsequently bleached with carbamide peroxide (Opalescence 10%, Ultradent Products), which achieved the patient's desired esthetic results.

Use of high-magnification loupes or surgical operating microscope when performing prophylaxes, scaling or root planing procedures

The use of high-level magnification (6-8x loupes magnification, or higher degrees of magnification provided by the surgical operating microscope), combined with head-mounted, coaxial lighting, may improve the ability of a dentist or dental hygienist to perform prophylaxis or scaling and root planing procedures, compared to the performance of these tasks using unaided vision or entry-level (2.5x) magnification, combined with overhead operatory lighting. A magnified view of the supragingival contours of a tooth surface facilitates visualizing the dimensions and curvature of the unseen sub-gingival tooth surfaces, which facilitates detection and removal of calculus that is located on these subgingival surfaces. Improved calculus removal ability may lead to better periodontal disease outcomes.

Management of dentinogenesis imperfecta: a review of two case reports

Dentinogenesis imperfecta (DI) is an inherited disorder that affects dentin and often manifests as tooth discoloration; in addition, the dentition is also extremely susceptible to wear. Treatment of DI focuses primarily on protecting affected dentin, reducing sensitivity, and improving esthetics. Routine restorative materials, such as amalgams and composites, may be used. In more severe cases, the treatment of choice is full coverage crowns, while bonding of veneers may be used to improve the esthetics of the anterior teeth. This study presents two cases of Type II DI in the same family and the management of each case. Restorative management included amalgams, composite veneers, crowns, bridges, and overdentures.

A complete esthetic approach with multiple diastemata in anterior teeth: 1-year follow-up

Anterior diastemata and discolored teeth may interfere with the harmony of a person's smile. This article presents a case involving multidisciplinary intervention for esthetic treatment utilizing integrated microabrasion, dental bleaching, and restorative solutions. The relevant aspects of etiology and treatment planning are discussed.

Comparison of enamel microabrasion with a combined approach to the esthetic management of fluorosed teeth

OBJECTIVE

To compare in vivo the efficacy of enamel microabrasion alone or in combination with vital tooth bleaching for the management of tooth discoloration caused by fluorosis.

METHODS

A total of 118 maxillary and mandibular fluorosed incisors and canines in 10 patients, scored from 1 to 7 according to the Tooth Surface Index of Fluorosis, were included in this study. All of the teeth were initially treated with enamel microabrasion (Opalustre, Ultradent Products Inc, South Jordan, UT, USA), and after 24 hours, an in-office bleaching technique (Opalescence Boost, Ultradent) was utilized (n=118). Standardized images of the teeth were taken using a digital camera prior to treatment and 24 hours after the enamel microabrasion and after the in-office bleaching therapy. The study groups were assigned according to evaluation time: a) after enamel microabrasion (Group 1) and b) after the combined approach (enamel microabrasion and in-office bleaching) (Group 2). Two calibrated and blinded examiners scored Group 1 and Group 2 images by comparing each with baseline images for "improvement in appearance," "changes in brown stains," and "changes in white opaque areas" using the visual analogue scales (VAS) that range from 1 to 7. "Patient satisfaction," "tooth sensitivity," and "gingival problems" were also recorded. The data were analyzed using two sample paired Wilcoxon signed-rank, Kruskal-Wallis, and Mann-Whitney U-tests (α=0.05).

RESULTS

The combined therapy revealed significantly higher scores than the enamel microabrasion procedure in terms of all of the evaluated criteria (p<0.001). Enamel microabrasion provoked less tooth sensitivity but led to lower patient satisfaction scores than the combined therapy (p<0.001); however, in terms of gingival problems, no differences were found between both groups.

CONCLUSION

The combined therapy, including enamel microabrasion and in-office bleaching, was more effective than enamel microabrasion alone in the esthetic management of fluorosed teeth.

Infiltration, a new therapy for masking enamel white spots: a 19-month follow-up case series

Enamel white spot lesions are frequent and can impact patients' quality of life. The most conservative treatment in such cases is microabrasion, a technique that presents some drawbacks. The proposed strategy is not based on the elimination of dysplastic enamel, but on masking the lesion by infiltrating the porous subsurface enamel with a hydrophobic resin that has a refraction index closer to that of sound enamel, after permeating the non-porous surface enamel through hydrochloric acid erosion. Erosion-infiltration approaches have been proposed to treat initial caries, but this report suggests extending it to two novel indications: fluorosis and traumatic hypo-mineralization lesions. Four cases were treated by erosion infiltration following the original protocol. They were followed up clinically at several intervals during a period of 19 months of clinical service. The clinical results, although not perfect, satisfied the patients entirely. Erosion infiltration could be a promising alternative for minimally invasive treatment in similar situations.

Microabrasion using 18% hydrochloric acid and 37% phosphoric acid in various degrees of fluorosis - an in vivo comparision

AIMS AND OBJECTIVES

The aim of this study was to assess the efficacy of 18% hydrochloric acid and 37% phosphoric acid by an in vivo comparison.

METHODS

Sixty fluorotic permanent maxillary central incisors from 30 patients were divided into 3 categories. The teeth received 5 seconds (mild fluorosis), 20 seconds (moderate fluorosis) and 30 seconds (severe fluorosis) application of 18% hydrochloric acid on 11 and 37% phosphoric acid on 21. Standardized intraoral photographies were taken immediately before, after, and one month after treatment. Vinyl polysiloxane impression of the patient were made before and after the treatment. A scanning electron microscopic (SEM) evaluation was carried out on the models to judge the surface alterations. Wilcoxon and Mann-Whitney tests were used to verify the hypothesis.

RESULTS

A statistically significant result was obtained in the reduction of white spot opacities, intensity of stains and the total area occupied by the stains in mild and moderate fluorosis teeth. Results of severe fluorosis had an unpredictable outcome. An SEM evaluation revealed good improvement in the surface texture of mild and moderate fluorosis teeth. Teeth with severe fluorosis showed only a slight improvement.

CONCLUSION

A microabrasion procedure is effective for treating mild and moderate fluorosis cases.

Tooth bleaching and young adults in Nigeria: knowledge, experiences and intention

OBJECTIVE

To assess the knowledge, experiences and intention to have tooth bleaching among young adults studying in a Nigerian University.

MATERIALS AND METHODS

A cross-section of part-time undergraduate students of University of Benin, Benin City, Nigeria were studied in 2010 using a self-administered questionnaire.

RESULTS

About three-quarters 289 (72.4%) of the respondents reported awareness of at least one cause of tooth discoloration. A total of 143 (35.8%) of the respondents have heard of tooth bleaching with main sources of information being friends/relatives, dentists and the internet. One-third 132 (33.1%) of the respondents correctly identified that the aim of tooth bleaching was to make the teeth whiter. The respondents that had correct knowledge about mechanism, duration and complications of tooth bleaching were 51 (12.8%), 25 (6.3%) and 35 (8.8%) respectively. The major perceived benefits of tooth bleaching reported by the respondents were self confidence boost 152 (38.1%) and improvement of one's beauty 107 (26.8%). Out of the 68 (17.0%) respondents that have attempted tooth bleaching, 36 (52.9%) used tooth whitening toothpaste. Out of the 151 (37.8%) respondents that expressed intention of having tooth bleaching procedure, 32 (21.2%) would pursue the course, no matter the cost.

CONCLUSION

In the studied population, knowledge of tooth discoloration was high, awareness and experiences of tooth bleaching were low but significant number expressed intention of having tooth bleaching. It is important that dentists increase oral health information particularly tooth bleaching information accessibility to the young adult population to improve the knowledge and prevent adverse effects.