Dental Traumatology 2013; 29: 2–7; doi: 10.1111/j.1600-9657.2012.01141.

Tooth discoloration induced by endodontic

materials: a literature review

Gabriel Krastl1,2,3, Nikola Abstract – It is common knowledge that materials used in endodontics may
Allgayer2, Patrik Lenherr4, Andreas cause discoloration and thus impair the aesthetic outcome of the treated tooth.
Filippi1,5, Pankaj Taneja6, Roland The purpose of this review is to summarise the existing knowledge on the
Weiger1,2 discoloration potential of materials used for endodontic procedures. A
1
Center of Dental Traumatology, University of comprehensive literature search covering the period from 1966 to 2011 was
Basel; 2Department of Periodontology, conducted on Pubmed and the Cochrane Library using different keyword
Endodontology and Cariology, University of combinations including ‘tooth’, ‘colour’, ‘discoloration’, ‘staining’, ‘endodontic’
Basel, Switzerland; 3Department of Oral
‘root canal’ ‘sealer’, ‘dressing’, ‘medicament’, ‘obturation’, ‘filling’, ‘treatment’,
Surgery, School of Dentistry, University of
Birmingham, UK; 4Clinic for Reconstructive
‘portland cement’, ‘MTA’ and ‘antibiotic paste’. Any relevant work published in
Dentistry and Temporomandibular Disorders, the English language in peer-reviewed journals and presenting pertinent
University of Basel; 5Department of Oral information related to the purpose of this overview was considered for inclusion.
Surgery, Oral Radiology and Oral Medicine, In addition, bibliographies of all relevant papers and previous review articles
University of Basel, Switzerland; 6Department of were hand searched and the reference lists from endodontic textbooks were also
Oral Surgery, Birmingham Dental Hospital, reviewed. Articles were excluded if an English abstract was unavailable, if only
Birmingham Community Healthcare NHS Trust, single clinical reports or conference reports were included, or if the topic was
Birmingham, UK unrelated to the subject. Ten in-vitro studies, one randomized controlled trial
Keywords: endodontic materials; and one multicenter randomized controlled trial met the inclusion criteria. There
endodontic medicaments; MTA; portland were not any recently used endodontic materials that would not induce at least
cement; sealer; tooth discoloration measurable colour changes. For a wide range of materials currently available on
Correspondence to: Dr. Gabriel Krastl, the market there is only scarce or no evidence available on their staining ability.
Center of Dental Traumatology and Endodontic therapy should not focus solely on biological and functional
Department of Periodontology, aspects, but take aesthetic considerations into account as well. To reduce the risk
Endodontology and Cariology, University of of material-induced tooth discoloration all materials should be applied carefully
Basel, Switzerland Hebelstrasse 3 in areas of aesthetic concern. The need for further research in this field and for
CH-4056 Basel, Switzerland
Tel.: 0041 61 2672622
the development of non-staining endodontic materials is evident.
Fax: 0041 61 2672659
e-mail: Gabriel.krastl@unibas.ch
Accepted 3 March, 2012

It is common knowledge that materials used in end- obtained via several searches on PubMed, and the
odontics may cause discoloration and thus impair the Cochrane library, using different keyword combinations
aesthetic outcome of the treated tooth. Among the teeth including ‘tooth’, ‘colour’, ‘discoloration’, ‘staining’,
requiring intracoronal bleaching having had previous ‘endodontic’ ‘root canal’ ‘sealer’, ‘dressing’, ‘medica-
dental treatment on a tooth was identified as one of the ment’, ‘obturation’, ‘filling’, ‘treatment’, ‘portland
main causes for discoloration (Fig. 1). Furthermore, cement’, ‘MTA’ and ‘antibiotic paste’.
internal bleaching of such teeth tends to be less effective Any relevant work published in the English language
compared to traumatically discoloured teeth because in peer-reviewed journals and presenting pertinent infor-
more applications of the bleach paste are necessary to mation related to the purpose of this overview was
obtain a satisfactory result (1). The long-term treatment considered for inclusion. In addition, bibliographies of
success of intracoronal bleaching is insecure as colour all relevant papers and previous review articles were
relapse is likely to occur (2). Thus, endodontic therapy hand-searched, and reference lists from endodontic
should not focus solely on biological and functional textbooks were also reviewed.
aspects, but take aesthetic considerations into account as Articles were excluded if no English abstract was
well. Material-induced tooth discoloration may be pre- available, if only single clinical reports or conference
vented to some extent by avoiding substances with a high reports were included or if the topic was not related to
risk of staining. The objective of this review is to the subject.
summarize the existing knowledge on the discoloration Ten in vitro studies, one randomized controlled trial
potential of materials used for endodontic procedures. and one multicentre randomized controlled trial were
A comprehensive literature search covering the period identified (Table 1). One of the in vitro studies was not
from 1966 to 2011 was conducted. The references were published in a peer-reviewed journal but appeared as a

2 Ó 2012 John Wiley & Sons A/S

 Tooth discoloration induced by endodontic materials 3

thesis. However, it was included as it was directly related

to the topic of this review. Overall, three studies were
published in the last millennium (all before 1989) testing
materials with low relevance in modern endodontics. The
remaining papers were published in the year 2000 or
later.

Publications from 1966 to 2000

As early as 1968, Gutierrez and Guzman investigated
whether various disinfectants, antibiotics or flushing
solutions were capable of producing tooth discoloration
in human teeth. Dentin discs were treated with the
different materials. The disinfectants camphorated
p-monochlorophenol and eugenol did not produce any
Fig. 1. Exposed roots during crown lengthening showing colour changes. Phenol, cresatin and solutions contain-
marked discoloration of the root canal treated right central ing penicillin, streptomycin or chloramphenicol caused a
and lateral incisor. slight discoloration of the dentin discs. Marked discol-
oration was observed when formocresol, the quaternary
ammonium compound Molca or tetracycline solutions

Table 1. Characteristics of the included studies. Substances or materials, which caused discoloration, are highlighted in italics
Title Author, Publishing Year Study Type Tested endodontic materials

Tooth discoloration in endodontic Gutierrez and Guzman (3) In-vitro Camphorated p-monochlorophenol, Eugenol, Phenol,
procedures. Oral Surg Oral Med Oral Formocresol, Cresatin, Zefirol, Molca
Pathol Sodium Penicillin, Streptomycin, Chloramphenicol,
Oxytetracycline, Chlortetracycline, Tetracycline,
Sigmamycin, Demethylchlortetracycline
Polyantibiotic Paste 1 (Penicillin Streptomycin)
Polyantibiotic Paste 2 (Penicillin, Terramycin,
Streptomycin)
Polyantibiotic Paste 3 (Penicillin, Declomycin,
Streptomycin)
N2, Walkhoff‘s Paste (iodoform + camphorated
p-monochlorophenol), Cresoform, Oxpara
Staining patterns in teeth discoloured by van der Burgt et al. (4) In-vitro Grossman’s cement, zinc oxide-eugenol, Diaket,
endodontic sealers Tubli-Seal, AH26, Endomethasone, N2, Riebler’s
paste
Tooth discoloration induced by van der Burgt et al. (5) In-vitro Grossman’s cement, zinc oxide-eugenol, Diaket,
endodontic sealers Tubli-Seal, AH26, Endomethasone, N2, Riebler’s
paste
The effects of Ledermix paste on Kim et al. (15) In-vitro Ledermix, Pulpdent paste
discoloration of immature teeth
The effects of Ledermix paste on Kim et al. (16) In-vitro Ledermix, Pulpdent paste
discoloration of mature teeth
In vitro longitudinal assessment of Parsons et al. (6) In-vitro AH26, Kerr Pulp Canal Sealer, Roths 801, Sealapex
coronal discoloration from endodontic
sealers
Sealer distribution in coronal dentin Davis et al. (7) In-vitro AH 26, Kerr Pulp Canal Sealer, Roth 801, Sealapex
Mineral trioxide aggregate as a Naik and Hegde (27) In-vivo Formocresol, MTA
pulpotomy agent in primary molars: (randomized
An in vivo study controlled trial)
In vitro computer analysis of crown Partovi et al. (8) In-vitro AH26, Endofill, Tubliseal, Zinc oxide eugenol, Apatite
discoloration from commonly used root canal sealer III, gutta-percha, Cavizol
endodontic sealers
Analysis of coronal discoloration from Elkhazin (9) In-vitro AH Plus, EndoRez, Sealapex, Kerr Pulp Canal Sealer
common obturation materials
Tooth discoloration of immature Kim et al. (38) In-vitro ciprofloxacin, metronidazole, minocycline, triple antibiotic
permanent incisor associated with triple paste
antibiotic therapy
Discoloration of teeth after avulsion and Day et al. (17) In-vivo Ledermix, Ultracal XS
replantation: results from a multicentre (multicenter
randomized controlled trial randomized
controlled trial)

Ó 2012 John Wiley & Sons A/S

4 Krastl et al.

were placed. The most severe discoloration was caused mental teeth revealed coronal discoloration, with signif-
by N2 pastes and polyantibiotic pastes containing icantly more severe values for AH 26 and Kerr Pulp Canal
tetracyclines, particularly those containing Declomycin. Sealer. This effect was attributed to the silver ions that
The discolouring effect of the tested chemicals was were part of the composition of both materials.
always stronger when used in the presence of human A follow-up study published by the same group
erythrocytes (3). assessed the penetration depth of the sealers into the
In 1986, van der Burgt (4) investigated the staining dentin (7). Because the described methodology was
patterns induced by eight endodontic sealers in human similar, it can be assumed that the same specimens were
premolars. The root was cut off and different sealers used. After a storage time of 2 years in individual vials in
were filled through the apical access into the pulp a humidor at 37°C, all teeth were split longitudinally in a
chamber. Two observers determined the colour changes facio-lingual direction for evaluation. Digital images
in the external tooth surfaces visually. were taken, and the depth of sealer penetration into
After 7 weeks, the teeth in all experimental groups dentin was evaluated using an image analysis software.
(excluding the teeth in the control group, which were The negative control groups (empty teeth) showed no
filled with distilled water) exhibited discoloration that dentin discoloration. The teeth in the positive control
was visible on the external surface. Grossman’s cement, group, which were filled with blood, showed complete
zinc oxide-eugenol, endomethasone and N2 induced a penetrations of the dentin up to the dentino-enamel
moderate orange-red stain. Diaket and Tubuliseal caused junction. Surprisingly, all four sealers showed only
a mild pink discoloration. AH 26 gave a distinct colour minimal sealer penetration and no evidence of discolor-
shift towards grey. Riebler’s paste caused a severe dark ation of the exposed dentinal surfaces. The findings were
red stain. In a second approach, the authors evaluated assumed to be a result of the smear layer not having been
the penetration depths of the discoloration into the removed, which obviously prevented the materials from
dentin. For this purpose, the premolars were hemi- diffusing into the dentin. However, the 2-year set sealers
sectioned in the buccolingual direction and the sectional in the endodontic cavity showed marked levels of
areas were examined by two observers. discoloration compared to fresh mixes. The most severe
Tubuliseal, Diaket and AH 26 produced discoloration colour change was observed for Kerr Pulp Canal Sealer
of the inner one-third of dentin. One-half of the inner and AH 26, whereas the least amount was observed with
dentin was stained by Grossman’s cement, zinc oxide- Sealapex and Roth 801. Thus, the authors concluded
eugenol, endomethasone and N2. The entire dentinal that the visible crown discoloration produced by these
depth was stained when Riebler’s paste was used. The sealers may not be necessarily associated with tubule
control group showed no discoloration. For each mate- penetration.
rial, the internal staining patterns were in agreement with A recent study assessed the degree of staining in tooth
the discolorations observed on the external surfaces. The crowns caused by commonly used endodontic sealers via
same eight sealers were examined in a subsequent study a computer analysis method (8). Discoloration induced
(5). Colour determination was carried out at regular by the root canal sealers AH 26, Endofill, Tubuliseal,
intervals for up to 6 months. zinc oxide-eugenol (ZnOE), Apatite root canal sealer III,
Similar colour changes as seen in the former test were gutta-percha and Cavizol (a filling material containing
obtained. Each material induced measurable tooth dis- ZnOE) was assessed on extracted human premolars.
coloration within 3 weeks. Diaket caused the least Teeth in the positive control group were filled with
discoloration, whereas Riebler’s paste produced the most amalgam, while distilled water was used in the negative
severe staining. Interestingly, the discoloration caused by control group.
Diaket appeared to be temporary. The teeth, which The roots were resected 3 mm below the cemento-
initially turned pink, returned to their original hues after enamel junction. The pulp chambers were cleaned using
6 months. Gates Glidden drills and K-files and were irrigated with
2.5% sodium hypochlorite through the apical access
opening. No attempt was made to remove the smear
Publications from 2000 to 2011
layer.
The negative controls showed the least levels of tooth
Endodontic Sealers
discoloration during all examination periods. The
A huge variety of sealers are available on the market. positive controls immediately showed severe discolor-
However, there are only four recent studies evaluating the ation, which was significantly different than seen in the
discoloration potential of some products. Parsons et al. experimental groups.
(6) assessed coronal discolorations produced by four After 3, 6 and 9 months, the order of severity of tooth
different sealers (Sealapex, Roth’s 801, AH 26 and Kerr discoloration (from highest to lowest values) was as
Pulp Canal Sealer). Two control groups were included, in follows: amalgam = Endofill > ZOE > Tubuliseal >
which one was filled with blood and the other was left AH 26 > gutta-percha > Apatite root sealer III >
empty. After 1, 3, 9 and 12 months, standardized pictures Cavizol > distilled water. For all groups, the discolor-
were taken of the teeth using a digital imaging system for ation was most evident in the cervical third of the crown
colour assessment. The teeth in the negative control group and on the cervical root surface, with minimal changes in
showed no evidence of discoloration for all time intervals. the occlusal third.
The specimens in the positive control group immediately Elkhazin investigated the discoloration effects of AH
showed severe coronal discoloration. All of the experi- Plus, EndoRez, Sealapex and Kerr Pulp Canal Sealer on

Ó 2012 John Wiley & Sons A/S

 Tooth discoloration induced by endodontic materials 5

extracted human teeth. The teeth were root-filled with with Ledermix paste became dark brown only when
gutta-percha and one of the four materials. The tooth exposed to sunlight. More severe staining was noted
colour was evaluated using a spectrophotometer. After 6 when Ledermix paste was filled in the pulp chambers
and 8 weeks, all four sealers showed significant coronal than when the paste was restricted to areas below the
discoloration, which increased with time. EndoRez CEJ. Compared to the findings of the first study,
produced the least discoloration, although not immature teeth seemed to be more severely stained than
statistically significant when compared to the other the mature teeth. The authors explain these findings with
experimental groups (9). the differences in the anatomy of dentinal tubules that
On the basis of the existing evidence, there is not any allow a higher diffusion rate of the material in immature
root canal sealer available that could guarantee colour teeth resulting in greater discoloration. In contrast to the
stability of the treated tooth. Because studies have not teeth with completed root formation, the immature
been conducted to evaluate the newer materials, a state- specimens produced statistically significant colour
ment cannot be given with regard to this. To minimize the changes even with the calcium hydroxide paste (16).
risk of discoloration, all obturation materials should be Recently, a multicentre randomized controlled trial was
strictly localized in the area of the root canal. published aiming to compare the effects of Ledermix and
the calcium hydroxide dressing Ultracal XS on the
discoloration of 27 replanted teeth. After 12 months, both
Endodontic Medicaments
medicaments caused measurable discoloration. However,
Ledermix, recommended for endodontic use owing to its in the Ledermix group, the discoloration was much more
antibacterial and anti-inflammatory properties, is used severe and warranted further treatment, compared with
since long time (10). In addition, during the last years, the Ultracal XS group. In the latter, only one patient was
Ledermix has gained much attention in dental trauma- concerned about the colour of the tooth (17).
tology as there is increasing evidence that it has the As non-staining alternative, Odontopaste (Australian
potential to inhibit inflammatory root resorption after Dental Manufacturing, Kenmore Hills, Australia) has
severe luxation injuries (11–13). recently been released onto the dental market (18).
Clinically, it has been noted that Ledermix paste may Compared to Ledermix, the tetracycline component was
cause discoloration, although studies have not proven replaced by clindamycin. Even though there is no
that claim before 2000 (14). The risk of tooth staining is publication in a peer-reviewed journal available support-
associated with the demethylchlortetracycline, a tetracy- ing that fact, the results of a recently published thesis
cline antibiotic. suggest that discoloration may be avoided with this
Kim investigated the discoloration effects of Ledermix medicament (19). Because the inhibiting effect of Leder-
in two studies, first in mature teeth and second in mix on external root resorption is primarily attributed to
immature teeth. Forty-five mature maxillary and man- the corticosteroid component (20, 21), intracanal corti-
dibular anterior teeth were prepared using the step-back costeroids may be a reasonable alternative in dental
technique. The smear layer was removed from all traumatology.
involved teeth with a 15% EDTA solution. Each tooth
was stored in a separate tube. The teeth were randomly
Portland Cement based materials
assigned to five experimental groups. In group 1,
Ledermix was inserted into the root canals below the Mineral trioxide aggregate (MTA) is based on portland
cemento-enamel junction (CEJ). In groups 2 and 3, cement and was introduced to the field of endodontics in
Ledermix was placed both into the canals and in the pulp 1993. Owing to its high level of biocompatibility and its
chambers, respectively. In group 4, the root canals and good sealing properties, it is regarded as the material of
the pulp chambers were filled with Pulpdent, a calcium choice in cases of vital pulp therapy (pulp capping,
hydroxide paste. The teeth in group 5 served as a control partial pulpotomy) or to seal pathways of communica-
group and were filled with saline. The specimens in group tion between the root canal system and the external root
3 were stored in the dark. Colour changes were measured surface (perforation, apexification or retrograde filling)
after 12 weeks with a spectrophotometer in a mounting (22–24). Especially in dental traumatology, MTA has
system, which was developed to consistently reproduce gained tremendous popularity during the last years,
the position of each tooth. aiming to replace calcium hydroxide in the treatment of a
In group 2, stronger grey brown colour changes were variety of pulpal and periodontal healing complications
noticed than seen in group 1. Both groups were (25).
significantly darker than the control group (5). No However, one of the main drawbacks of MTA is its
significant changes could be depicted in group 3 (Leder- discoloration potential (26). The grey-coloured formula,
mix) where the specimens have been kept in the dark. which was first introduced to the market, led to visible
Thus, exposure to sunlight was stated to be responsible colour changes on the outer surface. When it was used as
for the dark brown discoloration in group 2. a pulpotomy agent in primary molars, discoloration
Likewise, the specimens filled with calcium hydroxide occurred in 60% of all cases (27).
did not exhibit a significant staining compared to the To reduce the discoloration potential, the chemical
control group (15). composition of MTA was changed and an improved
In a second laboratory study with a similar experi- formulation was later introduced as white MTA. The
mental design, the effect of Ledermix paste on immature most significant difference between the two types of
teeth was investigated. Again the teeth that were filled MTA is the lack of iron ions in white MTA (28).

Ó 2012 John Wiley & Sons A/S

6 Krastl et al.

However, it has been reported that white MTA may GmbH). According to clinical observations of the first
cause discoloration as well (29, 30). Some authors state author, no visible coronal discoloration seems to
that the discoloration induced by MTA may be attrib- occur. However, there are no studies to support this
uted to bismuth oxide, which is added to improve the finding.
radiopacity in both grey and white formulations (31).
However, no scientific evidence is available to support
Conclusion
this statement.
Because MTA is based on industrial portland cement Almost all materials used in modern endodontics may
with bismuth oxide added as an radiopacifier, pure stain teeth. It is noteworthy that in the included studies
portland cement was suggested as an alternative (32). for this review, there were not any endodontic materials
Although manufacturers such as Medcem GmbH that could be identified that would not induce at least
(Weinfelden, Switzerland) claim that a better colour measurable colour changes. For a wide range of mate-
stability is achieved when using portland cement instead rials currently available on the market, there is only
of MTA, no studies were found that investigated colour scarce or no evidence available on their staining ability.
changes when using portland cement for endodontic Therefore, endodontic therapy should not focus solely
procedures. on biological and functional aspects, but take aesthetic
Keeping in mind that in cases of vital pulp therapy considerations into account also. To reduce the risk of
(such as partial pulpotomy after crown fracture with material-induced tooth discoloration, all materials
exposed pulp) the capping material is placed in the coronal should be applied carefully in areas of aesthetic concern.
part of the tooth, there is a considerable need for a non- The need for further research in this field and for the
staining biocompatible portland cement–based material. development of non-staining endodontic materials is
evident.
Antibiotic pastes
Conflict of interest
To disinfect the root canal system and set the
conditions for subsequent revascularization in the field The authors declare no conflict of interests.
of regenerative endodontic procedures, a triple antibi-
otic mixture (3Mix-MP) was suggested (33, 34). The
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