Abstract
Background
Tooth discoloration is an aesthetic problem that is linked to a variety of causes and it could be a source of embarrassment, leading to reduced self-esteem.
Aim
To determine the prevalence of self reported tooth discoloration and the distribution of the different intrinsic tooth discolorations.
Methodology
A retrospective study that reviewed the distribution of tooth discoloration reported by patients that presented for treatment of tooth discoloration at conservation clinic of the dental centre University College Hospital, Ibadan between December 2011 and December 2014. Data collected from patients’ case files included patients’ demographics, type of tooth discoloration as diagnosed by attending consultant and treatment offered. Data were analyzed using SPSS version 20. Frequencies and means were used for continuous variables while chi square was used to compare the categorical variables. P value was set at ≤ 0.05.
Results
One hundred and thirty six patients reported tooth discoloration as their major reason for presentation at the clinic. The patients were between age 16-75 years with mean age of 35.62±14.31 years and male to female ratio of 1:1.13. Prevalence of reported tooth discolouration during the study period was 9.8%. Pulpal necrosis was the most reported cause of (86.8%) tooth discolouration, while fluorosis was the least (0.7%) reported. Non vital tooth bleaching was the most common treatment (72.1%) offered for tooth discoloration. No significant comparison was observed between gender and type of tooth discoloration, p=0.088.
Conclusion
Pulpal necrosis is a major cause of discoloration which leads to reduced self esteem. There is need to improve on dental awareness on causes of tooth discoloration for prevention and early presentation for management.
Keywords: Tooth discoloration, Pulpal necrosis, Non-vital bleaching, Self reported discoloration, Pulp necrosis, Nigeria
Introduction
The perception of tooth appearance in modern society could influence the changes in patients’ needs, and recently in developed countries and modern world, focus in dentistry is shifting from function to more of aesthetics1. Apart from pain being a major reason for seeking dental treatment in our environment2,3, tooth discoloration can be said to be another reason which could be a precursor or sequel to pain. Discoloration of teeth is an aesthetic problem that is linked to a variety of causes and it could be a source of embarrassment, leading to reduced self-esteem4.
Tooth colour ranges from grayish white to yellowish colour, however, a lot of people desire white teeth which show that tooth colour is a very important factor determining patients’ satisfaction with dental appearance5,6.
Broadly, discoloration could be intrinsic or extrinsic. Intrinsic discoloration can be pre or post eruption of teeth into the oral cavity. Pre eruptive causes of tooth discolouration include tetracycline stains, hypoplasia, and fluorosis while post eruptive tooth discolouration include pulpal necrosis following trauma majorly and also yellowish discoloration due to aging.
Studies7,8 on self assessed dental appearance have reported satisfaction of 50% and above. However Alkhatib et al8, reported that only 6% of the studied population reported tooth discolouration. Studies on tooth discolouration in this environment include Sede et al9 who reported 2.2% prevalence of tetracycline stain amongst adult population in a retrospective study. Also Koleoso et al10and Ajayi et al11 reported prevalence of fluorosis and hyperplasia and some other intrinsic stains in a cross sectional field study Though there are many reports on tooth discoloration, studies on prevalence of self reported intrinsic tooth discoloration are scarce. The study thus set out to determine the prevalence of self reported tooth discoloration and the distribution of these different intrinsic tooth discolorations among the patients presenting at the Conservation Unit of the Department of Restorative Dentistry in a Nigerian University Hospital.
Patients & Method
This is a retrospective, clinic based study, conducted to know the distribution of tooth discoloration amongst patients that presented for treatment of tooth discoloration at conservation clinic of the dental centre University College Hospital, Ibadan, Nigeria between December 2011 and December 2014. The 3-year study made use of record from the case files of the patients. The data collected included demographics of the patients, type of tooth discoloration as diagnosed by the attending consultant restorative dentist and the recorded treatment offered.
Data analysis
The data were analyzed using SPSS Version 20; frequencies and means were used for continuous variables while chi square was used to compare the categorical variables. Level of significance was set at ≤ 0.05.
Results
Out of 1388 patients seen during the study period, 136 patients reported intrinsic tooth discoloration giving a 9.8% prevalence of self reported tooth discolouration. The 136 cases of discoloration were seen in patients between age 16-75 years with mean age of 35.62±14.31years and male to female ratio of 1:1.13. Figure1 shows the various types of intrinsic discoloration seen in the 136 patients at Dental Centre, University College Ibadan between 2011 and 2014. Pulpal necrosis formed the majority (86.8%) of tooth discoloration seen, while fluorosis was the least (0.7%) type reported.(Figure1)
Figure 1. Distribution of various tooth discolorations.
Figure2 shows non vital tooth bleaching being the most common treatment (72.1%) offered for tooth discoloration followed by fabrication of porcelain fused to metal crown (PFM). Table 1 shows tooth discolouration according to gender. There was no significant comparison between gender and type of tooth discoloration, p=0.88 while Figure4 shows comparison of treatment given against type of discoloration and showed a significant value p=0.000.
Figure 2. Treatments offered for tooth discolouration.
Table 1. Types of tooth discolouration according to gender.
| Type of Discoloration | Male | Female | Total |
| Pulpal Necrosis | 55 | 63 | 118 |
| Hypoplasia | 4 | 6 | 10 |
| Tetracycline | 2 | 1 | 3 |
| Fluorosis | 1 | 0 | 1 |
| Pulpal calcification | 1 | 1 | |
| Others | 1 | 1 | 2 |
| P =0.88 | |||
Discussion
This study showed a prevalence of 9.8% intrinsic tooth discoloration amongst all cases seen during the study period. This result is more than 2.2% reported by Sede et al9., comparable to the 6% reported by Alkhatib et al8 but quite low compared to the range of 37.7% to 87.2% reported by other researchers10,12.The difference in the result may be due to the differences in the study designs and study population. While Sede et al9., looked at only prevalence of tetracycline in the clinical record of patients, Koleoso et al10and Khozeimeh et al12studies were cross sectional field studies with differences in age group of study population. Thus, there is need for more research on prevalence of clinic based self reported intrinsic tooth discolouration.
Pulpal necrosis was the major (86.8%) type of tooth discoloration seen during the study period as seen in Figure1. Pulpal necrosis is one of the complications that follow traumatic dental injury and this is usually evident by grayish black discoloration of the crown of tooth. This is however dependent on the extent or severity of damage to the neurovascular supply of the tooth13. The high percentage of tooth discoloration from pulpal necrosis in this study may be supported by the prevalence of trauma to anterior teeth which is said to be higher in permanent teeth (58.6%)13 but ranges between 6.5 % and 19.5% in Nigeria14-17. The trauma is usually from road traffic accident, fall, home and other forms of accident to the tooth12,17. Also with a high percentage (57.3%17 and 93.1%18) of children leaving traumatized tooth untreated as reported by studies done in Nigeria, it is not surprising to see pulpal necrosis as the greatest cause of intrinsic tooth discoloration Pulpal necrosis with or without pain is a sequelae of untreated traumatized teeth whose neurovascular supply has been destroyed19. This result is however contrary to that of Koleoso et al10 who found a lower (0.8%) prevalence of pulpal necrosis amongst other intrinsic discolorations. This lower prevalence could be due to the fact that the study was done among school children translating to a younger age group in whom traumatized teeth may not have stayed long enough to result in discolouration.
Enamel hypoplasia is a defect in quantity of enamel laid down in the tooth and the defect can be a small pit or dent in the tooth or widespread, making the entire tooth small and/or mis-shaped. The prevalence of enamel hypoplasia in this study was 7.4% as shown in Figure1. This is in agreement with the range of 7.0-7.5% recorded by previous workers10,20,21, but higher than that recorded by Slayton et al22 who reported 6% prevalence. All these studies however were done in participants who were younger than 15 years in age unlike this study that involved older participants. Though there is difference in age of presentation, clinical presentation may be delayed in some cases and some people however do not seek treatment until they are aware of the social effect of the discoloration and unaesthetic appearance caused by the defect.
The 2.2% prevalence of tetracycline stain in this study is comparable with what was documented by Sede et al9 but more than 0.4% reported by a Norwegian study23 and lower than 3.1% seen in 910 school children studied in Madrid reported by Dominguez24.
Though tetracycline stains still pose aesthetic problem, the use of tetracycline in this environment for children less than 10 years may still be in practice mainly due to self medication and possibly low awareness of its effect on developing teeth.
Fluorosis prevalence in this study was 0.7% (Figure1). This is in agreement with Mahmoodian et al25 but close to 0.3% and 0.5% recorded by Khozeimeh12 and Ghalayani26 respectively. This result is however very low compared to the reported prevalence of 11.4%11 and 36.5%20 seen in children of 12-14years olds in this environment. The community where this study was conducted has been reported to have low fluoride concentration in their water (0.02ppm-0.03ppm)27. However, other sources of fluoride may be contributory to development of dental fluorosis and also the clinic serves more than the people in the environment it is situated. Though the community where this study was conducted has been reported to have low fluoride concentration in their water (0.02ppm-0.03ppm)27, other sources of fluoride may be contributory to development of dental fluorosis and also the clinic serves more than the people in the environment it is situated.
Other forms of tooth discoloration seen included pulpal calcification which is also a possible sequelae to trauma.
Treatment of tooth discoloration ranges from non invasive bleaching of vital or non vital teeth, to veneering of the labial surfaces of the anterior teeth and possibly to more invasive crowning of the affected tooth depending on the level of affectation of tooth structure. In this study, the majority (71.3%) of the treatment done was non vital bleaching following root canal therapy of the affected teeth. Almost all (98.9%) of the cases had pulpal necrosis while only one was done in a case of pulpal calcification. The comparison of treatment offered and type of tooth discoloration showed a statistical significance (p=0.00). This shows that clinically in planning for treatment, with intact crown in a case of discoloration by pulpal necrosis, root canal treatment followed by non vital bleaching will suffice and need for extensive treatment may be avoided.
This study has shown that the prevalence of tooth discoloration seen at the study centre is a possible reflection of incidence of trauma to the teeth. It shows that patients do not present for treatment immediately post trauma to teeth, which is supported by Adekoya-Sofowora et al 17who found that only 16% of patients that had trauma to their teeth presented to dentists for treatment while others did not present for treatment even though they were referred. Also, the average duration between trauma and patient presentation was found to be 4.6 years in this environment as documented by Ajayi et al19. Thus consequences of trauma to anterior teeth mainly and the whole mouth as a whole should be looked into by restorative dentists especially. Also more awareness should be created by dentists generally, towards early presentation for treatment of affected teeth to prevent discoloration and other possible complications.
The study has shown that self reported tooth discolorations are low in this environment and this may be due to lack of knowledge or awareness of treatment possibilities.
The limitations of the study include small sample size for such a common condition and the fact that the study was not multicentred.
Conclusions
Pulpal necrosis as a result of trauma is a major cause of discoloration which leads to reduced self esteem. There is need to improve on dental awareness on causes of tooth discoloration for prevention of occurrence and also for early presentation for management.
Figure 3. Tooth discoloration compared with treatment offered.
Footnotes
Competing Interests: The authors have declared that no competing interests exist.
Grant support: None
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