Review Article

ALL ABOUT DENTAL STAINS: A REVIEW (PART II)

Suchetha A, 1 Khawar S, 2 Sapna N, 3 Vinaya S, 4 Mundinamane DB, 5 Jayachandran C 6
1. Professor & Head, Department of Periodontology, DAPMRV Dental College, Bangalore, Karnataka.
2. Post Graduate Student, Department of Periodontology, DAPMRV Dental College, Bangalore, Karnataka.
3. Reader, Department of Periodontology, DAPMRV Dental College, Bangalore, Karnataka.
4. Post Graduate Student, Department of Periodontology, DAPMRV Dental College, Bangalore, Karnataka.
5. Reader, Department of Periodontology, DAPMRV Dental College, Bangalore, Karnataka.
6. Post Graduate Student, Department of Periodontology, DAPMRV Dental College, Bangalore, Karnataka.

Abstract
Dental stains is a significant problems faced by people in the present showbiz society. There has been a rapid rise in
people demanding the treatment for tooth discoloration. Thus it becomes a duty for every clinician to possess the
knowledge and skill to manage dental stains according to the patient’s demands. In order to treat the stains, a correct
diagnosis is necessary to differentiate between an intrinsic stain and extrinsic stain that will dictate the management
procedure. Extrinsic stains are easier to remove from the tooth surface, can be managed by prophylaxis and polishing
whilst intrinsic stains are more difficult to manage. Usually bleaching is the most common method to manage intrinsic
stains. This article aims to discuss in detail, the methods to clinically diagnose and manage dental stains.
Key words – Bleaching, Discoloration, Esthetics, Whitening, Stains,

Introduction developed subsequently and become either more or less

severe with time. The extent of stains should be identified
Tooth staining is associated with many clinical and
with respect to the depth of affected enamel or dentine.6
esthetical challenges. They can have an impact on a
people’s image and self-confidence in this society, where Scratch Test: - This test differentiates between extrinsic
most people place tooth colour as a priority. As a dentist we and intrinsic stains. Armamentarium used is dental
must possess the ability to help these patients with a correct explorer, scalars, or any other sharp instruments. An
diagnosis and the choice of the most effective treatment extrinsic stain can be removed by use of these instruments
plan so that the aesthetic outcome is acceptable to the while intrinsic cannot be removed. Usually, if the removal
patient as well as the clinician.1 The previous part of this is difficult the stain is considered tenacious.3,5
article was a review about the different types of dental
The extrinsic stains is generalised in distribution on teeth
stains and their etiopathogenesis. This article is a review
surface while intrinsic can affect from a single tooth to
about the diagnosis and management of dental stains.
whole dentition. Tooth having extrinsic stains usually have
There are broadly two kinds of dental stains, intrinsic and no pulpal involvement.3
extrinsic stains that have different methods of management.
Radiographic Examination
To differentiate one from another a proper diagnosis and
clinical examination is required.2 A radiograph is used to determine the abnormalities in
structures and morphology of enamel and dentin, and the
Diagnosis of Stains
adequacy of root canal fillings in non-vital teeth. Vitality
In order to understand the type and etiopathogenesis of the test will suggest the presence or absence of a nerve supply
stain a through history should be taken from the patient that and vasculature.6
should include: - 3,4,5
Histological Examination
1) Dental history – History of previous restorations, root
Histological sectioning of extracted teeth may identify
canal treatment, trauma, use of mouthwashes including
hereditary and environmental abnormalities.6
supplementation, residence in natural water
fluoridation areas. Management of Stains
2) Medical history – Neo-natal or early childhood illness,
Extrinsic Stains
any drugs taken, maternal disease.
3) Family history – Presence of genetic disorder. The most commonly used procedure to treat extrinsic stains
4) Personal history – Quality of their diet, consumption is by a professional hygiene treatment and by polishing
of beverages between meals, history of malnutrition. tooth surfaces with polishing cups and more or less
5) Social history – A proper history of the nature of the aggressive abrasive pastes.
work and exposure to metal, history of tobacco or betel
Personal Management
leaf chewing habit, smoking.
a) Diet and habit: The patient should Control the amount
Clinical Examination
and type of beverages causing extrinsic stains, brush
It involves extra-oral and intra-oral examination, with their teeth immediately after consumption of stain
evaluation about the type of dentition present. The producing food. They must restrict their use of
distribution of the stains or hypoplasia should be clearly tobacco products that will significantly reduce the
established regarding type of dentitions affected, number of amount of extrinsic staining.7
teeth affected, and symmetry of staining present that have

Annals of Dental Specialty Vol. 4; Issue 2. Apr – Jun 2016 | 47

Suchetha A et al

b) Tooth brushing: - Patients must be advised on correct Micro Abrasion

tooth brushing technique with dentifrice containing
This technique is done by removal of a layer of enamel
sufficient cleaning and polishing power, or
surface. It involves ‘abrasion’ with dental instruments and
dentifrices, containing chelating agents, such as
‘erosion’ with acidic agents. This method is also sometimes
sodium citrate and citric acid, and proteolytic enzyme.
referred as ‘abrosion’.
Effective tooth brushing twice daily with a dentifrice
helps to remove and prevent the formation of extrinsic Mostly two main techniques for microabrasion are used.
staining. Most dentifrices contain an abrasive, a Either Hydrochloric acid or phosphoric acid with pumice
detergent, and an anti-tartar agent. Apart from that, can be used, which requires careful isolation of the teeth.
some dentifrices now contain tooth-whitening agents. Microabrasion is a simple, quick, and safe technique
Meswak (salvadora persica), a chewing stick used by indicated for fluorosis, post-orthodontic demineralisation,
some Afro-Asian and muslim communities, is an localised hypoplasia due to infection or trauma, and
efficient tool for the cleaning of teeth because it idiopathic hypoplasia when the stains is limited to the outer
contains a high amount of abrasive silica and calcium layer of enamel. The evaluation of effectiveness of
phosphate salts.4,7 microabrasion should be done after one month post-
treatment, as the teeth appearance will continue to improve
Professional Management
during this time.6
a) Oral Prophylaxis: Most of the extrinsic stains are
Bleaching
removed by professional scaling i.e.; hand, sonic or
ultrasonic scaling. Sonic and ultrasonic scalers are Bleaching refers to lightening and whitening of discoloured
more efficient in removal of stains and calculus from vital or nonvital teeth by using oxidizing materials like
the tooth surface.7 hydrogen peroxide, carbamide peroxide, and sodium
perborate. These materials have the ability to penetrate the
b) Polishing: It involves the use of hand piece with a
enamel and dentin, emitting reactive oxygen, which
rubber cup or disc insert and abrasive fine polishing
dissolves and release stain producing chromogens.
paste. Experiments indicate that application of pumice
Bleaching may be done for vital or non-vital teeth and it
and water slurry with a rotating rubber cup for 30
can be done in the dental office or at home.4,9
seconds removes about a 3-micron thick enamel
layer.8 For more tenacious stains, enamel The commonly used techniques of bleaching vital teeth are:
microabrasion (hydrochloric acid and pumice
1. Over the counter preparations (OTC)
abrasion) or home bleaching technique should be
2. Dentist prescribed home bleaching,
attempted.4,7
3. In-office bleaching,
c) Air jet Polishing: Air polishing was first introduced to
Over The Counter Preparation (OTC)
in the late 1970s that aids in easily removing extrinsic
stain and soft deposits. It also reduces the fatigue in There has been increase in popularity for over the counter
hand, wrist, neck and eye because of quicker action. It (OTC) bleaching products in recent years. They are
uses a water soluble sodium bicarbonate mixture to composed of a low concentration of whitening agent like 3–
help in the removal of stain and plaque. Air polishing 6% hydrogen peroxide and are applied to the teeth via gum
is effective in the removal of stain due to smoking, shields, strips or paint-on form.10 It is also available as
coffee, tea, chlorhexidine and other extrinsic factors. whitening toothpastes, pre-fabricated trays and whitening
Aluminum trihydroxide can be used instead of sodium strips.11 They should be applied twice per day for up to 2
bicarbonate for patients with sodium restrictio. Avoid weeks. The use of these bleaching agents has high safety
its use on dentin, cementum and restorative resins. concerns because they are not regulated by the Food and
Universal precautions including protective apparel, a Drug Administration.10
face shield or safety glasses must be used by the
Patients using over-the counter bleach should be educated
operator with side shields, gloves, and a well-fitting
that going for professionally applied bleach is safer. Using
mask with good filtration capacity.7
OTC bleaching products without the supervision of a
Intrinsic Staining dentist is a matter of concern in terms of safety and efficacy
and are not recommended, because it can be a potential for
Intrinsic stains are formed by incorporation of chromogenic
long-term over use and abuse by uninformed patients.12
materials into enamel and dentin. Staining could occur
before eruption (during odontogenesis) or after eruption. Dentist Prescribed Home Bleaching
They are more difficult to treat as compared to external
Klusmier in 1968 noticed whiter teeth after treatment of
stains, which occur on the tooth surface. Different kinds of
mouth injury using Gly-oxide, a hydrogen peroxide
intrinsic stains require different approach for treatment,
mouthwash in an orthodontic retainer. Haywood and
according to location and etiology of the stain. Generally
Heman published their first report of dentist prescribed
surface enamel stains can be treated using enamel
home bleaching in 1989. This technique is indicated in case
microabrasion whereas deeper internal stains can be
of staining due to aging, smoking, chromogenic materials,
managed by bleaching technique.4

Annals of Dental Specialty Vol. 4; Issue 2. Apr – Jun 2016 | 48

Suchetha A et al

tetracycline, or mild fluorosis. It is also called dentist-home non-vital tooth. In the middle of the 19th century bleaching
bleaching, Nightguard vital bleaching (NGVB), and matrix of non-vital teeth was introduced. Chemicals like oxalic
bleaching. 2,13 acid, Chlorinated lime, chlorine compounds, sodium
peroxide, sodium hypochlorite, or combination of 25%
This technique involves the use of a low concentration of
hydrogen peroxide in 75% ether (pyrozone) were often
bleaching agent (carbamide peroxide 10–20% which is
used. Harlan reportedly used hydrogen peroxide in 1884.
equal to 3.5–6.5% of hydrogen peroxide) that is almost one
Superoxol (30% hydrogen peroxide) was used by Abbot in
tenth of the concentration used by dentist in his clinics. If
1918. Prinz in 1924 recommended the use of heated
carbamide peroxide is being used as a whitening agent,
solutions of sodium perborate and superoxol to clean the
10% of it should be used for 8 hours per day, and if 15–
pulp cavity. The bleaching agents can be activated by using
20% concentration is used, it must be used for 3-4 hours by
Light heat or electric currents to accelerate the bleaching
the patients themselves and the procedure should be
reaction.4,18
supervised by dentists during recalls. The bleaching gel is
dispensed in a custom-fabricated mouth guard that is worn Some of the most commonly used methods of non-vital
over the teeth at night for 2 weeks at least. Dentist tooth bleaching is walking bleach and modified walking
prescribed home bleaching at present is probably the most bleach, thermocatalytic, and inside/outside bleaching.
widely used technique of tooth whitening.2,10,13
Walking Bleach: - This procedure was first introduced by
Dentist prescribed Home bleaching is simpler, less Salvas. It involves sealing a mixture of sodium perborate
expensive, less complicated, and requires less in-office time and water inside the pulp chamber of the discoloured tooth.
but active patient compliance is mandatory and the This process is repeated at intervals until the desired
technique suffers from high dropout rates and the excessive bleaching result is obtained. It is effective in managing
use by overzealous patients is also possible, which staining due to tetracycline.18
frequently causes thermal sensitivity.10,14,15
Modified Walking Bleach: - Nutting and Poe used 30%
In Office Vital Bleaching hydrogen peroxide instead of just water as in walking
bleach technique to improve the bleaching effectiveness of
In-office vital bleaching or power bleaching was the first
the mixture. Both walking and modified walking tooth
vital bleaching technique. In this technique, high
bleaching technique is commonly used for non-vital tooth
concentration of tooth-whitening agents (usually 25 to 40%
discoloration because of less destructive effect on dental
hydrogen peroxide) is used. The advantage of this
tissue and minimal chair side time.4,18
procedure is that the dentist has absolute control over the
procedure and he can stop it whenever the desired shade of Thermocatalytic Bleaching: - It is the best technique to
tooth is reached. The step involves the isolation of soft bleach non-vital teeth due to effective activation of
tissue with the help of rubber dam and application of hydrogen peroxide on heat application. It combines the
whitening gel on the teeth surface. The peroxide gel is then steps involved in walking bleach along with application of
activated by heat or light for around one hour. Various 30%–35% hydrogen peroxide in the pulp chamber followed
kinds of curing lights are available that can be used to by heat treatment with electric heating devices or specially
activate the bleaching gel or accelerate the whitening effect designed lamps. A heated metal instrument or other
such as halogen curing lights, Plasma arc lamp, Xe–halogen commercial heat applicators can also be used. In some
light, Diode lasers, or Metal halide light. Usually one studies hydrogen peroxide is shown to have caustic effect
appointment is enough to achieve significant result but if and often associated with a risk of external root
not, more sittings are considered to get the optimum resorption.4,18,19
whitening.2,10,16,17
Inside Outside Bleach: - It was first described by
Other techniques are also available like dual activated Settembrini et al in 1997. This is the technique of bleaching
system (Hi Lite) that is both chemically and light activated non-vital root canal treated teeth with carbamide peroxide
system that can reduce the bleaching time. Waiting room gels or hydrogen peroxide at high concentrations (15%–
bleaching technique involves heating 35% Carbamide 35%). The chemical in the form of gel is applied by means
peroxide under running hot water to activate it and then of a bleaching tray on both buccal surface and pulp
putting it in custom made trays and inserting it in patients chamber through the access opening and is placed directly
mouth and the patient is told to sit in the waiting room for on the tooth, which is isolated with rubber dam. Mainly
30 min. Apart from that ultrasonic technology is also being used in case of failure of walking bleach technique. In this
used in the belief that it will create more free oxygen technique, low concentration of bleaching gel is enough to
radicals from the bleaching agent to achieve improved get the optimum shade that adds up to its advantage. The
whitening effect.17 disadvantage of this technique is poor bacterial control that
can lead to failure of endodontic treatment.20
Non Vital Tooth Bleaching
Restorative techniques
It is also called intracoronal bleaching. The tooth must be
endodontically treated prior to starting non-vital bleaching. Composite Resin Restorations: - This technique mainly
There are numerous methods used by a dentist to bleach a masks the staining of the tooth using resin composites. It is

Annals of Dental Specialty Vol. 4; Issue 2. Apr – Jun 2016 | 49

mostly used in children and adolescents. It can cover either 10. Alqahtani MQ. Tooth-bleaching procedures and their
a localised area on the tooth or full veneering can be done controversial effects: A literature review. Saudi Dent J
that can either be placed directly in clinics or fabricated in 2014;26(2):33-46.
labs. It is indicated for localised hypoplasia, fluorosis, 11. Zantner C, Beheim-Schwarzbach, N, Neumann K,
tetracycline staining, Amelogenesis imperfecta, Kielbassa AM. Surface microhardness of enamel after
Dentinogenesis imperfecta etc.6 different home bleaching procedures. Dent Mater
2007;23(2):243–250.
Porcelain Veneers: This technique is useful in case of
12. Heymann HO. Non-restorative treatment of
severe tooth staining or failure of other techniques. An
discoloured teeth: Reports from the international
important requirement of this technique is that, the tooth in
symposium. J Am Dent Assoc 1997;128(Suppl):710-
question should have a good amount of enamel thickness
711.
present to provide good bond strength. Porcelain is
contraindicated in tooth with large immature pulp chamber 13. Haywood VB, Drake M. Research on whitening teeth
makes news. NC Dent Rev 1990;7(2): 9.
and pulp horns, and presence of immature gingival contour
as in case of adolescent patient. In case of severe 14. Leonard RH Jr, Van Haywood B, Caplan DJ, Tart ND.
discoloration of the tooth the clinician must evaluate the Nightguard Vital Bleaching of Tetracycline‐Stained
masking ability of the veneer that depends upon the Teeth: 90 Months Post Treatment. J Esthet Restor Dent
thickness and opacity of the material. Various types of 2003;15(3):142-53.
porcelains are available like feldspathic porcelain, leucite- 15. Haywood VB. History, safety, and effectiveness of
reinforced ceramics and high density alumina ceramic core current bleaching techniques and applications of the
veneer with feldspathic porcelain.6,21 Nightguard vital bleaching technique. Quintessence Int
1992;23(7):471-88.
Conclusion 16. Powell LV, Bales DJ. Tooth bleaching: its effect on
Staining can effectively be managed by the above oral tissues. J Am Dent Assoc 1991;122(11):50-4.
mentioned methods but knowledge about the type of stain 17. Sulieman M. An overview of bleaching techniques: 3.
will help the clinician to select the method to be used. The In-surgery or power bleaching. Dent Update.
use of bleaching products has increased considerably in the 2005;32(2):101-4.
past decade. The increasing demand for tooth bleaching 18. Plotino G, Buono L, Grande NM, Pameijer CH,
has driven many manufacturers and researchers to develop Somma F. Non-vital tooth bleaching: a review of the
bleaching products to be used either in the dental office or literature and clinical procedures. J Endod
at home. But the risk of its abuse by the patients is a matter 2008;34(4):394-407.
of concern and must be regulated. 19. Friedman S, Rotstein I, Libfeld H, Stabholz A, Heling
I. Incidence of external root resorption and esthetic
References results in 58 bleached pulpless teeth. Endod Dent
1. Goldstein RE. Esthetics in dentistry. PMPH-USA; Traumatol 1988;4(1):23-6.
2014 Dec 30. 20. Zimmerli B, Jeger F, Lussi A. Bleaching of nonvital
2. Sulieman M. An overview of bleaching techniques: I. teeth. Schweiz Monatsschr Zahnmed.
History, chemistry, safety and legal aspects. Dent 2010;120(4):306-20.
Update 2004;31(10):608-10. 21. Chu FC. Clinical considerations in managing severe
3. Manuel ST, Abhishek P, Kundabala M. Etiology of tooth discoloration with porcelain veneers. J Am Dent
tooth discoloration-a review. Nigerian Dent J Assoc 2009;140(4):442-6.
2010;18(2):56-63. Corresponding Author
4. Hattab FN, Qudeimat MA, al‐Rimawi HS. Dental
discoloration: an overview. J Esthet Dent Dr. Salman Khawar
1999;11(6):291-310. Post Graduate Student,
5. Kerr AR (2008). Retrieved online Jan 9, 2009 from Department of Periodontology,
http://emedicine.medscape.com/article/1076389- DAPMRV Dental College & Hospital,
overview. Bangalore, Karnataka, INDIA.
6. Wray A, Welbury R. Treatment of intrinsic E mail Id: - drsalmankhawar@gmail.com
discoloration in permanent anterior teeth in children
and adolescents. Int J Paediat Dent 2001;11(4):309-15.
7. Prathap S, Rajesh H, Boloor VA, Rao AS. Extrinsic
stains and management: a new insight. J Acad Indus
Res 2013;1(8):435-442.
8. Mellberg JR. The relative abrasivity of dental
prophylactic pastes and abrasives on enamel and
dentin. Clin Prev Dent 1979;1(1):13-8.
9. Feinman RA, Goldstein R, and Garber Da. Bleaching
Teeth, Chicago: Quintessence Pub,1987.

Annals of Dental Specialty Vol. 4; Issue 2. Apr – Jun 2016 | 50