Dental non-caries disease

Discoloration of teeth Anomalous formation of teeth Chapter 5 Discoloration of teeth Anomalous formation of teeth

Discoloration of teeth Intrinsic discoloration Extrinsic discoloration

Intrinsic discoloration of teeth pigmentation of internal structure anomalous development of teeth Extrinsic discoloration of teeth drug、food、drinks、tobacco surface staining of teeth or denture

Extrinsic staining chlorhexidine staining tobacco and coffee stains

Intrinsic discoloration dental bleaching Treatment of dental discoloration Intrinsic discoloration dental bleaching resin repair crown repair Extrinsic discoloration ultrasonic scaling

Dental fluorosis tetracycline pigmentation teeth Dental bleaching technique

Dental Fluorosis Dental fluorosis occurs as a result of long-term intake of fluoride during the period of tooth formation Characterized by an increasing porosity of the surface and subsurface enamel causing the enamel to appear opaque

Etiological factors of dental fluorosis Fluorides in drinking water Fluorides in foods and drinks Fluoride ingestion period

The optimum level of fluoride in drinking water supplies 1ppm（1mg/L)：maximum caries protection while causing minimal dental fluorosis

The level depends on the mean annual maximum air temperature USA: 0.7~ 1.2 ppm China：0.5~1 ppm

Fluorides in foods and drinks Fish, tea, etc Fluoride solubility Calcium and magnesium

The period of risk of developing dental fluorosis For many years it was believed that only during certain stages of tooth formation can fluoride exert its toxic effect on enamel: the stage during which enamel is laid down by the ameloblasts

So long as a tooth has not yet erupted into the mouth,it may be sensitive to exposure to fluoride The later in the pre-eruptive life of a tooth that it is exposed to fluoride the less severe will be the resulting degree of dental fluorosis

The pathogenesis and pathology of dental fluorosis ALP (Alkaline phosphatase) inhibitor hypo-mineralization of interrod substance super-mineralization of enamel rod

Clinical features of dental fluorosis Permanent dentition: symmetrically distributed in the mouth, but not all teeth are equally affected The least affected teeth are the incisors and first permanent molars The premolars and other molars are most severely affected

Primary dentition Similar clinical features Less severely affected than their permanent successors

Changes from fine white opaque lines running across the tooth on all parts of the enamel, to features where parts of the chalky white and porous outer enamel become detached and discolored

The loss of surface enamel in the severest cases results in a loss of anatomical form of the teeth

Indices for measuring dental fluorosis (the Dean index) “Normal” (score: 0) The enamel represents the usual translucent semi-vitriform type of structure The surface is smooth, glossy, and usually of a pale, creamy white colour

Questionable (score: 0.5) The enamel discloses slight aberrations from the translucency of normal enamel, ranging from a few white flecks to occasional white spots This classification is utilized in those instance where a definite diagnosis of the mildest form of fluorosis is not warranted and a classification of “normal” not justified

Very mild (score: 1.0) Small, opaque, paper white areas scattered irregularly over the tooth but not involving as much as approximately 25% of the tooth surface Frequently included in the classification are teeth showing no more than about 1-2mm of white opacity at the tip of the summit of the cusps of the bicuspids of second molars

Very mild (score: 1.0)

Mild (score: 2.0) The white opaque areas in the enamel of the teeth are more extensive but not involve as much as 50% of the tooth

Moderate (score: 3.0) All enamel surfaces of the teeth are affected, and surfaces subject to attrition show marked wear Brown stain is frequently a disfiguring feature

Severe (score: 4.0) All enamel surfaces are affected and hypoplasia is so marked that the general form of the tooth may be affected

The major diagnosis sign of this classification is the discrete or confluent pitting Brown stains are widespread and teeth often present a corroded-like appearance

The TF index --originally proposed by Thylstrup and Fejerskov --score 0-9 --the TF index is a logical improvement and extension of Dean’s index --It is more precise and sensitive in its characterization of various degrees of severity of dental fluorosis, especially in its capacity to distinguish between the spectrum of changes associated with the early signs and with the more severe forms of dental fluorosis

The prevention of the dental fluorosis Defluoridation of drinking water Lime softening Alum, alum and lime Activated alumina Activated carbon Electrodialysis Reverse osmosis Natural bone, bone char and charcoal ……

The shortcomings of several the above-mentioned methods -high initial cost of defluoridation plant -high operation and maintenance costs -low fluoride removal capacities -undesirable effects on water quality -generation of sludge -complicated procedures

The treatment of dental fluorosis For very mild dental fluorosis: Physically grinding away the outer porous fluorotic enamel until the underlying almost sound and better mineralized enamel is exposed

Pronounced opacities and stains can be removed by alternatively applying phosphoric acid to enamel surface and polishing with an abrasive, finished by applying a mineralizing solution and topical fluorides to the treated enamel

In the cases of severe dental fluorosis: -Restoration with composite resins cosmetically unsatisfactory in the long run -Repair with crowns

Tetracycline Stained Teeth background pathogenesis classification clinical features prevention and treatment

Background 1940s, clinical initial usage of Tetracycline 1950s, Tetracycline Stained Teeth reported 1970s, brought to attention

Onset time of the illness Calcification stage of tooth formation 4 months afterwards during gestational period placenta Pigmentation of primary dentition children below 7-year-old tetracycline Stained teeth or enamel hypoplasia

Pathogenesis Discoloration of dentine and enamel tetracycline +Ca+ compound of tetracycline-Ca+ mineralization inhibition enamel hypoplasia

The classification of the illness mild：yellow or gray staining no enamel defect moderate：brown-gray staining severe：brown-gray or black band-like staining accompanying enamel hypoplasia

Prophylaxis and treatment Prevention of Tetracycline Stained Teeth No tetracycline for--- pregnant women breast-feeding women children below 8-year-old

Treatment of Tetracycline Stained Teeth Bleaching technique Composite resin repair Crown repair

Bleaching Technique Indication: discoloration teeth Mild to moderate mottled enamel Tetracycline Stained Teeth Non-vital discolored teeth

Bleaching Technique Non-vital bleaching technique In-office vital bleaching technique In-home vital bleaching technique

Non-vital bleaching technique Pulpectomy, root canal therapy removal 2~3mm root canal filling material 30%H2O2 in pulp chamber every 3 days 4~6 times in all coronal restoration

Non-vital bleaching technique Walking bleach technique Clinically effective Shortcomings: non-vital tooth external absorption of tooth cervix

In-office vital bleaching technique 30%H2O2 enamel demineralization enamel pellucidit enamel remineralization

In-home bleaching technique Matrix bleaching technique Nightguard vital bleaching technique 10%-15% carbamide peroxide

In-office bleaching technique

Bleaching technique

Dental structural anomalies Enamel Hypoplasia Hereditary dentinogenesis imperfecta Congenital syphilitic teeth

Enamel Hypoplasia Developmental disturbance of enamel, which appears as a surface defect, during the period of tooth formation enamel dysplasia enamel hypocalcification

Enamel Hypoplasia Etiology Clinical feature Prevention and cure

Etiology of Enamel Hypoplasia Nutrient: VitA、C、D，Ca、P Endocrine factor: parathyroid gland Mother and baby related disease: chickenpox, scarlatina, gravida rubella Local factor: periapical periodontitis of primary teeth (Turner teeth)

Clinical feature of Enamel Hypoplasia Systemic hypoplasia affect homologous teeth Several groups of teeth are involved frequently

The classic clinical features vary from a grooved line across the tooth surfaces to a wider band of faulty deformed enamel Always characterized by having smooth rounded and well-demarcated borders

Enamel hypoplasia

Mild : Hypomineralization No alteration in enamel integrity Color and pellucidit change Chalk-like enamel

Severe: Band- or groove-like enamel defect Pit or honeycomb appearance enamel Thinned Incisal edge defected cusp

Enamel hypoplasia associated with dental fluorosis

Symmetry lesion of Enamel hypoplasia 1yr after birth 1 to 2yr after birth 3yr after birth

Prophylaxis of enamel hypoplasia related disease prevention during the period of dental development

Treatment of enamel hypoplasia anti-caries treat cover with resin ceramic restoration

Differential diagnosis Enamel hypoplasia well-demarcated borders along incremental line one or one group tooth/teeth Dental fluorosis long-term lesion frog-like, no borders high fluoride region

Dental fluorosis Enamel hypoplasia

Hereditary dentinogenesis imperfecta Hereditary opalescent dentin Autosomal dominant inheritance disease Developmental disturbance of unknown origin of the pulpo-dentinal organ

The discoloration is due to the fact that the pathologically disturbed pulpo-dentinal organ can be seen through the translucent enamel Enamel loss and severe dental attrition

Less, enlarged irregular dentinal tubule Narrowed, blocked pulp chamber and root canal

Treatment Primary dentition: protection incisal edge and occlusal surface with plastic splint Permanent dentition：crown and overdenture

Congenital syphilitic teeth Hutchinson teeth Mulberry molars Pfluger teeth Moon teeth 61 16 621 126

Dental morphologic abnormality Microdontia、macrodontia, conic shaped teeth Fused teeth, geminated teeth, concrescence of teeth Abnormal central cusp Dens invaginatus Enamel pearl

Microdontia

Macrodontia and conic shaped teeth

Fused teeth two dental germ

Geminated teeth one tooth germ

Concrescence of teeth

Abnormal central cusp

Dens evaginates

The treatment of abnormal central cusp Pulp capping Grinding Apexification Root canal therapy

Dens invaginatus Dens–in-dente is the result of invagination of the coronal aspect of the enamel organ down into the dental papilla

Clinically, giving the appearance of a tooth within a tooth Maxillary lateral incisors are most commonly involved

Classification of Dens invaginatus Invaginated lingual fossa Invaginated root groove Talon cusp Dens-in-dente

Invaginated lingual fossa Invaginated root groove

Dens-in-dente

The treatment of Dens invaginatus Indirect pulp capping GIC restoration Endodontic treatment Periodontic treatment Tooth extraction

Enamel pearl

Abnormal number of teeth Supernumerary tooth Partial anodontia Congenital anodontia

Supernumerary teeth Teeth that develop from accessory tooth buds The mesiodens is most commonly, a small cone-shaped tooth located between the maxillary central incisors Also, distomolars and premolars Treatment: None, unless for esthetic or occlusal interference

Supernumerary teeth Supernumerary teeth in cleidocranial dysplasia

Anodontia Congenitally missing teeth Complete(anodontia ) or partial missing (oligodontia) Third molars, lateral incisors, second premolars

Anodontia Hereditary ectodermal dysplasia and head- and-neck radiation therapy are associated with anodontia or oligodontia

Partial anodontia

Congenital anodontia

Anodontia of ectodermal dysplasia

Dental eruptive disorder Early eruption of tooth deciduous or permanent teeth natal tooth and neonatal tooth Delayed eruption of tooth Ectopic eruption of tooth