- Email: [email protected]
Esthetic Restoration of Tetracycline-Stained Teeth
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Figures 6 and 7 show a patient before and after receiving dental laminates with ac ceptable results. The patient drank a great deal of tea daily, a habit that was to be greatly reduced or eliminated after the ve neers were placed. However, the excessive intake of tea was not curtailed and a photo graph of the same patient one year later (Fig 8) shows that the laminates are uniformly stained a pale yellow. History and evalua tion of the patient cannot be overem phasized when the long-range results of any dental restorative procedure are con sidered.
S u m m a ry Several com plications associated with the use of dental laminates have been
described. Most of the problems in volve marginal discoloration, bond ing, and retention. These difficulties can be addressed by proper construc tion of the laminates, prevention of salivary contamination, and m eticul ous attention to bonding procedures. Additional parameters involving oc clusion, orthodontic appliances, and dietary habits can also contribute to the clinical complications with dental laminates. T a]
Dr. Ronk is assistant professor, department of pediatric dentistry, Box J-426, J. H. M iller Health Center, University of Florida, Gainesville, Fla 32610. Address requests for reprints to Dr. Ronk.
1. C h a lk le y , Y . C lin ic a l u se o f a n te r io r lam inates— construction and placement. JADA 101(3):485-487, 1980. 2. R akow , B.; Light, E.; and C on d ello, P. Enam el bonded m echanically retained laminate veneer. Gen Dent 26(2):47-48, 1978. 3. Barkley, R.L.; Gaw, A.F.; and Faunce, F.R. Esthetic tooth restoration. Dent Surv 53(l):22-27, 1979. 4. Carr, A.B.; Robertson, M.R.; and Fleming, J.E. Custom contour laminate veneers. Dent Stud 58(6):42-44, 1980. 5. Carr, A .B.; Robertson, M.R.; and Flem ing, J.E. Color characterization of laminate veneers. Dent Surv 46-53, 1980. 6. Ronk, S.L. Dental laminates: which tech nique? JADA 102(2):186-188, 1981. 7. Perez, N.M.; Bassiouny, M.A.; and Carrel, R. In vitro m icroleakage of the laminate veneer sys tem. Acta de Odontol Pediatr l(2):77-82, 1980. 8. Hormati, A.A.; Fuller, F.L.; andDenehy, G.E. Effects of contam ination and m echanical distur bance on the quality of acid-etched enamel. JADA 10 0(l):34-38, 1980.
Esthetic restoration of tetracycline-stained teeth Jerry B. Black, DMD, MS
Teeth discolored by tetracycline can be improved by bonding composite resin veneers.
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’ hlorotetracycline was first iso lated in 1947. Since that time, four homologues have been discovered, and all have been used under various trade names for the treatment of a wide variety of infections. It was not until 1956 that Shwachman and Shuster’ reported discoloration of teeth when tetracyclines were used to treat infec tions in children. Subsequently, the permanent discoloration of develop ing teeth in people and animals by tet r a c y c l i n e h a s b e e n w e ll d o c u mented.210 This undesirable side ef fect has been frequently reported in the teeth of children with cystic fibrosis when tetracyclines are used during prolonged periods for the control of secondary infections of the respiratory system.11' 14 According to M ello,15 the most feas ible mechanism of discoloration ap pears to be the binding of tetracyclines to calcium in the crystal surfaces to form a complex. He also states that the tim e when tooth discoloration can occur ranges from the fourth month in utero to approximately the seventh 846 ■ JADA, Vol. 104, June 1982
year of life. The report of Lambrou and associates16 supports the concept that te tra c y c lin e is in co rp o ra ted into enam el during the m ineralization phase. T h e p s y c h o lo g ic a l im p a c t o f tetracycline-discolored teeth is well known. When self-awareness and peer pressure reach critical levels, patients and their parents become frustrated when they fail to find an immediate so lution to this problem. Significant psychological trauma can result while the patient waits until the pulps recede s u ffic ie n tly for the p lacem en t of crowns. Improvement or restoration of the patient’s self-esteem is the major consideration in the early treatment of stained teeth. Anterior teeth in pa tients I have treated have an extremely high degree of caries resistance. This observation is supported by results of research citing the effectiveness of tet racycline in significantly reducing caries activity in rats,17 ham sters,18 and people.19
T re a tm e n t p ro c e d u re s B lea ch in g vital teeth The technique of bleaching vital teeth was first used for treating enamel fluorosis.20'25 In 1970, Cohen and Par
kins26 published a method for bleach ing discolored dentin of patients with cystic fibrosis. Since then, the tech n ique for b lea ch in g te tra cy clin ed isco lo red teeth has changed lit tle.27"30 The most recent technique in volves a mixture of one part ethylether to five parts 30% hydrogen peroxide, w hich is applied to the labial surfaces of affected teeth and is followed by controlled application of heat. The prognosis is directly related to the severity and distribution of the stain and, to some extent, to the age of the patient. In general, only the uni form light gray or brown stains re spond satisfactorily. Several appoint ments may be required for the treat ment of more resistant stains. Acid etching of the labial enamel before the bleaching procedure may facilitate the lightening of the more resistant darker stains. Vital bleaching is not indicated for the dark gray or blue stains or for teeth showing stained zones contigu ous to normal-colored zones. In addition to the caustic effect of 30% hydrogen peroxide on soft tissue, it may also have a deleterious effect on pulp tissue. In a study of pulp reaction to bleaching, Seale and associates31 found that the greatest damage to pulps of dogs’ teeth was caused by hy drogen peroxide. On the basis of their
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findings, they recommended that bleaching periods be limited to the shortest effective time. The applica tion of heat must be closely monitored to avoid irreversible pulpal damage. Patients must be advised that the bleached teeth may be sensitive to cold for several days.
Laminate veneers Two types of laminate veneers are cur rently being used for the restoration of tetracycline-stained teeth. They are manufactured preformed lam i nates32'33 and hollow-ground denture teeth.34-36 One laminate veneer system (Mas tique Laminate Veneers) uses precon toured thin plastic veneers in a wide variety of sizes compatible with the la bial surfaces of the six maxillary an terior teeth. Although this technique has been refined, it still requires con siderable time because laboratory and patient appointment phases are re quired. This technique also creates significant bulk to which thé patient must accommodate. Retention of the veneer is dependent on the integrity of the bond between the veneer and the underlying composite resin. Because there is no provision for a finish line, the material must be feathered to the tooth surface, making it difficult to ac curately relate the margin of the resto ration to the free gingival margin and to the embrasure spaces. The hollow-ground technique re quires meticulous adaptation of the denture teeth to a stone model; how ever, it does not require the use of a masking agent between tooth and ve neer. The chemically cured bonding resin, which is used to attach the ven eer to the etched labial enamel, im poses a time limitation on the place ment of the veneer. The hollow ground technique makes no provision for a definite finish line for the restoration, and it also results in significant in crease in bulk of the restored teeth.
Composite resin veneers Preexisting gingival inflammation must be eliminated before veneers are placed, and the patient must accept the responsibility for maintaining strict oral hygiene after treatment. Current shade guides are nearly useless be cause they do not accurately represent the true colors of the restorative mate
rial. Uncured restorative material placed directly over the labial surface will best illustrate the overall effect. A water-cooled tapered diamond bur is used at high speed to reduce the labial enamel by approximately 0.5 mm and to create a shallow chamfer finish line. Because enamel reduction is minimal, anesthesia is usually not required. The gingival margin should be about 5.0 mm below the free margin of the gingiva. The proximal margins are located well beyond the external line angles but labial to the contact areas to ensure the most pleasing re sults and easy access for cleaning. The incisal margin ends at the labial incisal line angle but usually does not extend beyond the incisal edge. Crowns can be easily lengthened by the addition of composite resin; however, they are more subject to fracture from protru sive movements and incisive forces. Some patients may want to accept this added risk for the sake of improved esthetic appearance. The teeth are restored one at a time, usually starting with a central incisor. Short segments of mylar strip are placed interproximally, and the pre pared enamel is etched for one minute with the etching agent (Esticid). The surfaces must be kept wet with the etchant during this time. The mylar strips are removed and the etched enamel is thoroughly rinsed with water for at least 20 seconds. The tooth is reisolated and thoroughly dried to show the characteristic frosty appear ance of etched enamel. Fresh mylar strips are placed interproximally, and the entire etched enamel surface and margin areas are coated with a thin layer of bonding resin (Estilux-Durafill bond). Compressed air is used to blow off the excess bonding resin from a gingival to an incisal direction. The re sulting uniform thin layer of bonding resin is cured for 20 seconds with a vis ible light unit (Translux). The undesirable discoloration is now masked by coating the labial sur face (except for the margins) with a thin layer of color modifier (Estilux Color). More than one layer may be necessary for darker stains. Each sepa rate layer of color modifier is polymer ized for 40 seconds. Fresh mylar strips are placed interproximally and are ex tended into the gingival sulci. Selected wooden wedges may be used to ensure adaptation of the mylar strips
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to the tooth surfaces and to occlude the embrasure spaces which may other wise be filled with resin. Wedges must be placed and removed with care to prevent gingival bleeding. The appro priate shade of microfilled composite restorative material (Durafill) is ex truded from a threaded syringe onto a disposable pad. A clean 8A plastic in strument is used to pick up a segment of. material slightly shorter than the existing crown. The segment is placed in the center of the labial surface and is pressure-adapted toward the margins to form a layer approximately 2 mm thick. Initial adaptation is best accom plished with finger pressure. An 8A plastic instrument is used to contour and sculpt the material and to adapt it to the margins. The material is then po lymerized by exposure to visible light for 20 seconds. If an opaque shade is used, the exposure time is extended to 40 seconds. Fine finishing diamond burs and 12-bladed carbide burs are used to trim the margins and to contour the restora tion. An 8A plastic instrument is used to retract the free margin of the gingiva when the gingival margin of the resto ration is finished and polished. Labial contour, embrasure form, and resin thickness should be monitored care fully by viewing the restoration from an incisal direction with a mouth mir ror. Twelve-bladed carbide burs, white finishing stones, and rubber wheels are used to create anatomical detail. Medium /fine dental finishing and polishing strips followed by Sof-Lex polishing strips are used for finishing and polishing the proximal surfaces. The labial surfaces of the veneers are then polished to a high luster using Sof-Lex disks. The occlusion is checked to make sure there are no in terferences.
Report of cases Composite resin veneers have been used by the author to restore teeth that have a wide variety of staining patterns and intensities. The maxillary anterior teeth of patient 1 , an 18-year-old woman, before treatment are show n in F ig u re 1. The v en eers im mediately after completion are shown in Figure 2. Right and left three-quarter views of the completed veneers are shown in Fig ures 3 and 4. A n ato m ical d etail and enamel-like luster are demonstrated. Right and left profile views of the completed ve neers are shown in Figures 5 and 6. The contours are normal and there is no notice Black : RESTORATION OF STAINED TEETH ■ 847
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Patient 1.
Fig 1 ■ Patient 1. M axillary anterior teeth o f 18-year-old woman before
Fig 2 ■ Veneers immediately after completion of treatment,
treatm ent.
Fig 3 ■ R ight three-quarter view of completed veneers.
Fig 4 ■ Left three-quarter view of completed veneers.
Fig 5 ■ Right profile of completed veneers.
Fig 6 ■ Left profile o f completed veneers.
able additional bulk. The severely stained teeth of patient 2, a 19-year-old woman, before treatment are shown in Figure 7, left. Figure 7, right, shows the veneers immediately after com pletion. The maxillary anterior teeth of patient 3, 848 ■ JADA, Vol. 104, June 1982
a 17-year-old woman, before treatment are shown in Figure 8, left. Fig u re'8, right, shows the veneers immediately after com pletion. The patient requested that the spaces between the teeth be closed. The severely stained maxillary anterior teeth of patient 4, an 18-year-old woman,
before treatment are shown in Figure 9, left. Figure 9, right, shows the veneers im mediately after treatment.
Discussion Labial enamel reduction offers major
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Fig 7 ■ Patient 2. Left, m axillary anterior teeth of 19-year-old woman before treatm ent. Right, veneers immediately after completion of treatment.
Fig 8 ■ Patient 3. Left, m axillary anterior teeth of a 17-year-old woman before treatment. Right, veneers immediately after completion o f treatm ent.
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advantages for composite resin veneer restorations. It reduces or eliminates overcontouring.lt provides a definite margin for the restorative material. It results in a higher shear bond strength between the composite resin and tooth enamel.37 The labial surface of a maxillary cen tral incisor after pumicing and a oneminute acid etch is shown in Figure 10, top. The effect of etching is not al
ways uniform, as illustrated in this scanning electron m icrograph. Iso lated areas revealing a definitive etch ing pattern are separated by areas hav ing no pattern. After debonding the veneer, the tooth aspect of the bond site still shows the characteristic etch in g p a tte r n , w h ic h is p a r t ia lly obscured by resin remnants (Fig 10, middle). The resin aspect of the bond site shown in Figure 10, bottom, re
veals knob-like resin remnants that mirror the corresponding etched con figurations shown in Figure 10, mid dle. In an earlier study, Retief38 re ported similar findings; he concluded that failure between a resin and etched enamel should not be classified as a true interfacial failure, but rather as failure occurring partly w ithin the resin and partly within the enamel. The labial surface of a maxillary cenBlack : RESTORATION OF STAINED TEETH ■ 849
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Fig 10 ■ Scanning electron micrographs. Top, labial surface of m axillary
Fig 11 ■ Scanning electron m icrographs. Top, labial surface of m axillary
central incisor after pumicing and one-minute acid etch (orig mag x 250).
central incisor after 0.5 mm surface enamel reduction followed by one-
Middle, tooth aspect of debonded veneer revealing p artially obscured etch
minute acid etch (orig mag x 250). Middle, tooth aspect of fractured speci
ing pattern (left, orig mag x 250; right, orig mag x 2,500). Bottom, resin as
men shows no evidence o f etching pattern (orig mag x 250). Bottom, frac
pect o f debonded veneer revealing tag remnants (left, orig mag x 250; right,
tured surface of resin fragment shows no evidence o f etching pattern (orig mag x 250).
orig mag x 2,500).
850 ■ JADA, Vol. 104, June 1982
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tral incisor after 0.5 mm surface enamel reduction and a one-minute acid etch is shown in.Figure 11, top. A characteristic etching pattern is uni form over the entire reduced labial sur face. Attempts to debond this veneer result in fracture primarily through the restorative material, not in the area of the resin I tooth interface. The tooth aspect of the fracture side shown in Figure 11, middle, shows no evidence of an etching pattern. The resin frag ment shown in Figure 11, bottom, also shows no evidence of an etching pat tern. These findings support the observa tions of Schneider and associates37 that samples with mechanical surface reduction had more residual compos ite resin on the bond site after fracture than did samples with no surface re duction. They concluded that the strength of the enamel /resin bond after enamel reduction was closer to the cohesive strength of the composite resin than the bond strengths on unre duced enamel. Surface enamel reduction followed by acid etching results in a surface that is more favorable for the formation of resin extensions responsible for bond ing. This procedure would effectively eliminate any organic integument, aprismatic enamel, and fluoridecontaining enamel. The presence of any one of these entities or combina tions could ultimately affect the shear bond strength of a composite resin veneer. Previous attempts to restore tetracycline-stained teeth by bonding conventional composite resins to acid-etched surfaces have failed primarily because of shortcomings of the restorative material. The develop ment of photocurable, one component, microfilled composite resins made possible the creation of veneers having lifelike colors and excellent surface smoothness. In addition to a wide range of colors in the Durafill restorative material, several shades of color modifiers are available, which expand the potential for color matching and characterizing. Estilux color modifiers have the ability to mask discoloration and at the same time impart a natural enamel-like ap pearance to the tooth. Variations in the shades within individual teeth are ac complished by spreading or overlay ing one shade over another. Blending
shades by spatulation should be avoided because this introduces bub bles that result in surface porosity. The Translux visible light unit will cure the material up to a maximum thick ness of 4.5 mm. To create a more pleasing and a more uniform effect, it may be necessary to treat the maxillary first premolars of some patients. In these cases, care must be taken not to involve the cusp ridges so that excursive movements occur on enamel surfaces. Although the lower anterior teeth are also affected by tetracycline, they usually do not present a particular esthetic problem. When esthetics do influence a decision to treat lower an terior teeth, the technique described is equally applicable. Because this technique creates little if any additional bulk, patients do not have to go through a period of postop erative adjustment. Postoperative sen sitivity has not been reported by any patient treated by the technique de scribed here. The highly polished ve neer surfaces are extremely stain resis tant. At appropriate intervals, the orig inal luster of the veneers can be quickly restored by using superfine Sof-Lex polishing disks, and, if neces sary, the veneers can be easily re paired. Other applications of this technique include the restoration of teeth having any other form of intrin sic stain, fluorosed or hypoplastic enamel, or abrasion /erosion lesions, and the recontouring of teeth and clos ing of diastemas.
Conclusion The availability of new restorative ma terials and the development of a new technique have made possible a con servative alternative to the restoration of stained and malformed teeth. The direct bonding of composite resin ve neers is a viable alternative to veneer crowns. In addition to conservation of tooth structure, this method of treat ment allows the dentist to express a greater degree of creativity. Because the entire procedure is carried out in the dental operatory, the dentist can control the ultimate esthetic result. Of the various forms of conservative treatment for tetracycline-stained teeth, the technique described here is the most predictable, effective, and esthetic.
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This project was funded by Kulzer, Inc, Irvine, Calif. Dr. Black is associate professor, department of o p erative d e n tistry , U n iv ersity o f A labam a School of Dentistry, Birmingham , Ala 35294. Ad dress requests for reprints to Dr. Black. 1. Schwachman, H., and Shuster, A. The tetra cyclin es: applied pharm acology. Pediatr Clin North Am 3:295, 1956. 2. M ilch, R.A.; Ball, D.P.; and Tobie, J.E. Bone localization of the tetracyclines. J Natl Cancer Inst 19:8 7 ,1 9 5 7 . 3. Hilton, H.B. Skeletal pigmentation due to tetracycline. J Clin Path 1 5:112,1962. 4. Weyman, J., and Porteous, J.R. Discoloration of teeth possibly due to administration of tetracy cline. Br Dent J 113:51-54,1962. 5. Bevelander, G.; Cohlan, S.Q.; and Rolle, G.K. The effect of the administration of tetracycline on the development of teeth. J Dent Res 40:10201 0 2 4 ,1 9 6 1 . 6. Harcourt, J.K., and Johnson, N.W. In vivo in corporation of tetracycline in the teeth of, man. Arch Oral Biol 7 :4 31-437,1960. 7. Harcourt, J.K. Tetracyclines and tooth struc ture in man. J Dent Res 4 2:5, abstract, 1963. 8. Bechelm an, J.H., and Gingold, N.L. Devel opmental dental defects associated with systemic tetracycline therapy— review of literature and case report. NY J Dent 34:377-380,1964. 9. Johnson, R.H. Effects of tetracycline on teeth and bones. J Dent Res 43:847, abstract, 1964. 10. Weyman, J., and Porteous, J.R. Tetracycline staining o f teeth: a report of clinical material. J Dent Res 42:1111, abstract, 1963. 11. Shwachman, H., and others. The effect of long-term antibiotic therapy in patients with cys tic fibrosis of the pancreas. Antibiot Ann 692-699, 1958-59. 12. Zegarelli, E.V., and others. Discoloration of the teeth in patients w ith cystic fibrosis of the pancreas. NY State Dent J 27:237-238,1961. 13. Zegarelli^ E.V., and others. D iscoloration of the teeth in patients with cystic fibrosis: role of tetracycline therapy. Clin Pediatr 2 :3 2 9 ,1 9 6 3 . 14. Sullivan, R.E. Discoloration of the teeth in patients with cystic fibrosis. Indianap Dist Dent Soc 1 8:10-12,1964. 15. M ello, H.S. The m echanism o f tetracycline staining in primary and permanent teeth. J Dent Child 34:478-487,1967. 16. Lambrou, D.B.; Tahos, B.S.; and Lambrou, K.D. In vitro studies of the phenomenon of tetra cycline incorporation into enamel. J Dent Res 56(12):1527-1532, 1977. 17. Zipkin, I.; Larson, R.; and Rail, D.P. Re duced caries in offspring of rats receiving tetracy cline during various prenatal and post-partum periods. Proc Soc Exp Biol 104:158-160, 1960. 18. Harndt, R. Incidence of caries in the teeth of Syrian hamsters observed after administration of tetracycline during tooth development. Caries Res 4:316-317,1975* . 19. Nonomura, E.; Sofue, S.; and Moriwaki, Y. Characteristics of carious lesions in teeth discol ored by tetracycline. Jpn J Pedo 16:377-384,1978. 20. Younger, H.B. Bleaching mottled enamel. Tex Dent J 60:469, 1942. i 21. Merwe, P.K. The removal of the stain from mottled teeth. S Afr Dent S 1 8:31,1944. 22. Bailey, R.W ., and Christen, A.G. Bleaching o f v ita l te eth stain ed w ith en d em ic dental fluorosis. Oral Surg 2 6 :8 7 1 ,1 9 6 8 . 23. Chandra, S., and Charvla, T.N. Bleaching of
B lack : RESTORATION OF STAINED TEETH ■ 851
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brown patches on mottled teeth. J Indian Dent Assoc 4 3 :5 4 -5 9 ,1 9 7 1 . 24. Bouschor, C.F., and Dorman, H.L. Bleach ing fluoride stained teeth. Tex Dent J 91(6):6-8, 1973. 25. Colon, P.G. Improving the appearance of severely fluorosed teeth. JADA 86:1329-1331, 1973. 26. Cohen, S., and Parkins, F.M. Bleaching te tr a c y c lin e -s ta in e d v ita l te eth . O ral Surg 29(3):465-471, 1970. 27. Arens, D.E.; Rich, J.J.; and Healey, H.J. A p ra c tic a l m ethod o f b leach in g tetra cy clin estained teeth. Oral Surg 34:812-817, 1972. 28. Corcoran, J.F., and Z illich, R.M. Bleaching of vital tetracycline-stained teeth. J M ich Dent
Assoc 56:3 4 0 -343,1974. 29. Falkensten, R.J. Effective bleaching tech nique for removing tetracycline stains. Dent Surv 53:46-54, 1977. 30. Christensen, G.J. Bleaching vital tetracy cline stained teeth. Quintessence Int 6:13-19, 1978. 31. Seale, N .S.; McIntosh, J.E.; and Taylor, A.N. Pulpal reaction to bleaching of teeth in dogs. J Dent Res 6 0 {5 ):9 4 8 -9 5 3 ,1981. 32. Faunce, F.R., and Myers, D.R. Laminate veneer restoration of permanent incisors. JADA 93:790-792, 1976. 3 3 . P a t e r s o n , J . R . , a n d A n s o n , R .A . Lam inates— a practical approach to restoring tetracycline-stained teeth. Pediatr Dent 2(4):3003 0 3 ,1 9 8 0 .
34. C h alk ley , Y . C lin ic a l u se of an terior laminates— construction and placement. JADA 101:485-487,1980. 35. Faunce, F.R. Tooth restoration with pre formed laminate veneers. Dent Surv 53:3 0 ,1 9 7 7 . 36. Barkley, R.L.; Gaw, A.F.; and Faunce, F.R. Esthetic tooth restoration. Dent Surv 55:22-27, 1979. 37. Schneider, P.M.; Messer, L.B.; and Doug las, W.H. The effect of enamel surface reduction in vitro on the bonding of composite resin to per manent human enamel. J Dent Res 60(5):895-900, 1981. 38. Retief, D.H. Failure at the dental adhesiveetched enamel interface. J Oral Rehab 1:265-284, 1974.
Atypical odontalgia: differential diagnosis and treatment Michael K. Kreisberg, DDS Failure to properly diagnose atypical odontalgia may lead to unnecessary dental treatment that does not permanently relieve pain.
A
condition described as atypical odontalgia has recently been docu mented in the literature. The dental symptom is pain arising from the teeth and their supporting structures for which no organic cause is evident. The pain is described as severe, throbbing, and continuous. It usually begins in one quadrant, but often crosses the midline to the opposite side.1The pain may occur spontaneously or it may be exacerbated by thermal or tactile stim uli. Rees and Harris1 reported on 44 pa tients ranging in age from 20 to 70 years. Thirty-six (82%) of the patients were female. Symptom duration ranged from two months to 20 years. Brooke2 reported on 22 patients (all female) ranging from 32 to 74 years of age. The average duration of symptoms in this study was 5.6 years. Patients generally give a complex history of extensive dental treatment with no relief of pain. Although spon taneous remission may occur, it is usually short-lived. Root canal therapy or extractions may provide transient relief; however, the pain usually re curs with equal or greater intensity within days or weeks. This subsequent pain may persist at the site of the ex traction, or it may occur in another
J.
852 ■ JADA, Vol. 104, June 1982
tooth or quadrant. Brooke describes a sequence of events in which a tooth may initially be restored, later treated endodontically, then subjected to an apicoectomy, and finally extracted, each stage being a prelude to the next. Treatment is frequently provided be cause of the patient’s insistence that “something be done” rather than be cause of objective clinical evidence. Entire quadrants may eventually be treated endodontically or rendered edentulous, without cure. The effect of local anesthetic on the pain is variable. Although some individuals experi ence relief, the majority do not.
Etiology Atypical odontalgia is considered a lo calized form of a more generalized classification of facial pain known as atypical facial neuralgia. Rees and Harris suggest that the mechanism is vascular, involving persistent dilata tion of the blood vessels of the pulp and periodontal ligaments. This con dition is not considered a local disease entity. It is instead a symptom of an underlying disorder of affect as sociated with a temporary or perma nent deficiency of catecholamines, in particular norepinephrine, at func tionally important adrenergic receptor sites in the brain. The natural history of the pain is de scribed by Rees and Harris as one of exacerbations and remissions, which are often correlated to the patient’s psychological health and social cir
cumstances. In Rees and Harris’s study,1 66% of the patients had a pre vious history of depression; 30% suf fered migraines. In Brooke’s study,2 41% of the patients had a history of de pression; 33% had a history of mig raines.
Report of cases Case 1 A39-year-old white womanhad aconstant, severe dull ache in the right zygomatic and facial region. The patient had recently undergone full mouth reconstruction to correct a “temporomandibular joint dys function.” The symptoms appeared to lo calize in the maxillary right quadrant, and the patient was referred to an endodontist for evaluation. Root canal therapy was se quentially performed on all maxillary right teeth fromcentral incisor to second premo lar with no relief (Fig 1). The patient was next referred to an ear, nose, and throat physician who ruled out pathologic sinus conditions. Results of a neurologic consultation proved negative, and the patient was told that she would have to learn to live with the pain. Symptoms subsequently localized in the maxillary right central incisor, which had previously been endodontically treated. The patient was referred to a second en dodontist who advised apical surgery. Local injection of the maxillary right cen tral incisor as well as bilateral infraorbital injections failed to relieve the pain and the apicoectomy was postponed. The patient was then referred for further consultation. Results of a temporomandibular joint ex amination were normal, and there was no indication of an internal joint derangement.
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Figures 6 and 7 show a patient before and after receiving dental laminates with ac ceptable results. The patient drank a great deal of tea daily, a habit that was to be greatly reduced or eliminated after the ve neers were placed. However, the excessive intake of tea was not curtailed and a photo graph of the same patient one year later (Fig 8) shows that the laminates are uniformly stained a pale yellow. History and evalua tion of the patient cannot be overem phasized when the long-range results of any dental restorative procedure are con sidered.
S u m m a ry Several com plications associated with the use of dental laminates have been
described. Most of the problems in volve marginal discoloration, bond ing, and retention. These difficulties can be addressed by proper construc tion of the laminates, prevention of salivary contamination, and m eticul ous attention to bonding procedures. Additional parameters involving oc clusion, orthodontic appliances, and dietary habits can also contribute to the clinical complications with dental laminates. T a]
Dr. Ronk is assistant professor, department of pediatric dentistry, Box J-426, J. H. M iller Health Center, University of Florida, Gainesville, Fla 32610. Address requests for reprints to Dr. Ronk.
1. C h a lk le y , Y . C lin ic a l u se o f a n te r io r lam inates— construction and placement. JADA 101(3):485-487, 1980. 2. R akow , B.; Light, E.; and C on d ello, P. Enam el bonded m echanically retained laminate veneer. Gen Dent 26(2):47-48, 1978. 3. Barkley, R.L.; Gaw, A.F.; and Faunce, F.R. Esthetic tooth restoration. Dent Surv 53(l):22-27, 1979. 4. Carr, A.B.; Robertson, M.R.; and Fleming, J.E. Custom contour laminate veneers. Dent Stud 58(6):42-44, 1980. 5. Carr, A .B.; Robertson, M.R.; and Flem ing, J.E. Color characterization of laminate veneers. Dent Surv 46-53, 1980. 6. Ronk, S.L. Dental laminates: which tech nique? JADA 102(2):186-188, 1981. 7. Perez, N.M.; Bassiouny, M.A.; and Carrel, R. In vitro m icroleakage of the laminate veneer sys tem. Acta de Odontol Pediatr l(2):77-82, 1980. 8. Hormati, A.A.; Fuller, F.L.; andDenehy, G.E. Effects of contam ination and m echanical distur bance on the quality of acid-etched enamel. JADA 10 0(l):34-38, 1980.
Esthetic restoration of tetracycline-stained teeth Jerry B. Black, DMD, MS
Teeth discolored by tetracycline can be improved by bonding composite resin veneers.
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’ hlorotetracycline was first iso lated in 1947. Since that time, four homologues have been discovered, and all have been used under various trade names for the treatment of a wide variety of infections. It was not until 1956 that Shwachman and Shuster’ reported discoloration of teeth when tetracyclines were used to treat infec tions in children. Subsequently, the permanent discoloration of develop ing teeth in people and animals by tet r a c y c l i n e h a s b e e n w e ll d o c u mented.210 This undesirable side ef fect has been frequently reported in the teeth of children with cystic fibrosis when tetracyclines are used during prolonged periods for the control of secondary infections of the respiratory system.11' 14 According to M ello,15 the most feas ible mechanism of discoloration ap pears to be the binding of tetracyclines to calcium in the crystal surfaces to form a complex. He also states that the tim e when tooth discoloration can occur ranges from the fourth month in utero to approximately the seventh 846 ■ JADA, Vol. 104, June 1982
year of life. The report of Lambrou and associates16 supports the concept that te tra c y c lin e is in co rp o ra ted into enam el during the m ineralization phase. T h e p s y c h o lo g ic a l im p a c t o f tetracycline-discolored teeth is well known. When self-awareness and peer pressure reach critical levels, patients and their parents become frustrated when they fail to find an immediate so lution to this problem. Significant psychological trauma can result while the patient waits until the pulps recede s u ffic ie n tly for the p lacem en t of crowns. Improvement or restoration of the patient’s self-esteem is the major consideration in the early treatment of stained teeth. Anterior teeth in pa tients I have treated have an extremely high degree of caries resistance. This observation is supported by results of research citing the effectiveness of tet racycline in significantly reducing caries activity in rats,17 ham sters,18 and people.19
T re a tm e n t p ro c e d u re s B lea ch in g vital teeth The technique of bleaching vital teeth was first used for treating enamel fluorosis.20'25 In 1970, Cohen and Par
kins26 published a method for bleach ing discolored dentin of patients with cystic fibrosis. Since then, the tech n ique for b lea ch in g te tra cy clin ed isco lo red teeth has changed lit tle.27"30 The most recent technique in volves a mixture of one part ethylether to five parts 30% hydrogen peroxide, w hich is applied to the labial surfaces of affected teeth and is followed by controlled application of heat. The prognosis is directly related to the severity and distribution of the stain and, to some extent, to the age of the patient. In general, only the uni form light gray or brown stains re spond satisfactorily. Several appoint ments may be required for the treat ment of more resistant stains. Acid etching of the labial enamel before the bleaching procedure may facilitate the lightening of the more resistant darker stains. Vital bleaching is not indicated for the dark gray or blue stains or for teeth showing stained zones contigu ous to normal-colored zones. In addition to the caustic effect of 30% hydrogen peroxide on soft tissue, it may also have a deleterious effect on pulp tissue. In a study of pulp reaction to bleaching, Seale and associates31 found that the greatest damage to pulps of dogs’ teeth was caused by hy drogen peroxide. On the basis of their
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findings, they recommended that bleaching periods be limited to the shortest effective time. The applica tion of heat must be closely monitored to avoid irreversible pulpal damage. Patients must be advised that the bleached teeth may be sensitive to cold for several days.
Laminate veneers Two types of laminate veneers are cur rently being used for the restoration of tetracycline-stained teeth. They are manufactured preformed lam i nates32'33 and hollow-ground denture teeth.34-36 One laminate veneer system (Mas tique Laminate Veneers) uses precon toured thin plastic veneers in a wide variety of sizes compatible with the la bial surfaces of the six maxillary an terior teeth. Although this technique has been refined, it still requires con siderable time because laboratory and patient appointment phases are re quired. This technique also creates significant bulk to which thé patient must accommodate. Retention of the veneer is dependent on the integrity of the bond between the veneer and the underlying composite resin. Because there is no provision for a finish line, the material must be feathered to the tooth surface, making it difficult to ac curately relate the margin of the resto ration to the free gingival margin and to the embrasure spaces. The hollow-ground technique re quires meticulous adaptation of the denture teeth to a stone model; how ever, it does not require the use of a masking agent between tooth and ve neer. The chemically cured bonding resin, which is used to attach the ven eer to the etched labial enamel, im poses a time limitation on the place ment of the veneer. The hollow ground technique makes no provision for a definite finish line for the restoration, and it also results in significant in crease in bulk of the restored teeth.
Composite resin veneers Preexisting gingival inflammation must be eliminated before veneers are placed, and the patient must accept the responsibility for maintaining strict oral hygiene after treatment. Current shade guides are nearly useless be cause they do not accurately represent the true colors of the restorative mate
rial. Uncured restorative material placed directly over the labial surface will best illustrate the overall effect. A water-cooled tapered diamond bur is used at high speed to reduce the labial enamel by approximately 0.5 mm and to create a shallow chamfer finish line. Because enamel reduction is minimal, anesthesia is usually not required. The gingival margin should be about 5.0 mm below the free margin of the gingiva. The proximal margins are located well beyond the external line angles but labial to the contact areas to ensure the most pleasing re sults and easy access for cleaning. The incisal margin ends at the labial incisal line angle but usually does not extend beyond the incisal edge. Crowns can be easily lengthened by the addition of composite resin; however, they are more subject to fracture from protru sive movements and incisive forces. Some patients may want to accept this added risk for the sake of improved esthetic appearance. The teeth are restored one at a time, usually starting with a central incisor. Short segments of mylar strip are placed interproximally, and the pre pared enamel is etched for one minute with the etching agent (Esticid). The surfaces must be kept wet with the etchant during this time. The mylar strips are removed and the etched enamel is thoroughly rinsed with water for at least 20 seconds. The tooth is reisolated and thoroughly dried to show the characteristic frosty appear ance of etched enamel. Fresh mylar strips are placed interproximally, and the entire etched enamel surface and margin areas are coated with a thin layer of bonding resin (Estilux-Durafill bond). Compressed air is used to blow off the excess bonding resin from a gingival to an incisal direction. The re sulting uniform thin layer of bonding resin is cured for 20 seconds with a vis ible light unit (Translux). The undesirable discoloration is now masked by coating the labial sur face (except for the margins) with a thin layer of color modifier (Estilux Color). More than one layer may be necessary for darker stains. Each sepa rate layer of color modifier is polymer ized for 40 seconds. Fresh mylar strips are placed interproximally and are ex tended into the gingival sulci. Selected wooden wedges may be used to ensure adaptation of the mylar strips
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to the tooth surfaces and to occlude the embrasure spaces which may other wise be filled with resin. Wedges must be placed and removed with care to prevent gingival bleeding. The appro priate shade of microfilled composite restorative material (Durafill) is ex truded from a threaded syringe onto a disposable pad. A clean 8A plastic in strument is used to pick up a segment of. material slightly shorter than the existing crown. The segment is placed in the center of the labial surface and is pressure-adapted toward the margins to form a layer approximately 2 mm thick. Initial adaptation is best accom plished with finger pressure. An 8A plastic instrument is used to contour and sculpt the material and to adapt it to the margins. The material is then po lymerized by exposure to visible light for 20 seconds. If an opaque shade is used, the exposure time is extended to 40 seconds. Fine finishing diamond burs and 12-bladed carbide burs are used to trim the margins and to contour the restora tion. An 8A plastic instrument is used to retract the free margin of the gingiva when the gingival margin of the resto ration is finished and polished. Labial contour, embrasure form, and resin thickness should be monitored care fully by viewing the restoration from an incisal direction with a mouth mir ror. Twelve-bladed carbide burs, white finishing stones, and rubber wheels are used to create anatomical detail. Medium /fine dental finishing and polishing strips followed by Sof-Lex polishing strips are used for finishing and polishing the proximal surfaces. The labial surfaces of the veneers are then polished to a high luster using Sof-Lex disks. The occlusion is checked to make sure there are no in terferences.
Report of cases Composite resin veneers have been used by the author to restore teeth that have a wide variety of staining patterns and intensities. The maxillary anterior teeth of patient 1 , an 18-year-old woman, before treatment are show n in F ig u re 1. The v en eers im mediately after completion are shown in Figure 2. Right and left three-quarter views of the completed veneers are shown in Fig ures 3 and 4. A n ato m ical d etail and enamel-like luster are demonstrated. Right and left profile views of the completed ve neers are shown in Figures 5 and 6. The contours are normal and there is no notice Black : RESTORATION OF STAINED TEETH ■ 847
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Patient 1.
Fig 1 ■ Patient 1. M axillary anterior teeth o f 18-year-old woman before
Fig 2 ■ Veneers immediately after completion of treatment,
treatm ent.
Fig 3 ■ R ight three-quarter view of completed veneers.
Fig 4 ■ Left three-quarter view of completed veneers.
Fig 5 ■ Right profile of completed veneers.
Fig 6 ■ Left profile o f completed veneers.
able additional bulk. The severely stained teeth of patient 2, a 19-year-old woman, before treatment are shown in Figure 7, left. Figure 7, right, shows the veneers immediately after com pletion. The maxillary anterior teeth of patient 3, 848 ■ JADA, Vol. 104, June 1982
a 17-year-old woman, before treatment are shown in Figure 8, left. Fig u re'8, right, shows the veneers immediately after com pletion. The patient requested that the spaces between the teeth be closed. The severely stained maxillary anterior teeth of patient 4, an 18-year-old woman,
before treatment are shown in Figure 9, left. Figure 9, right, shows the veneers im mediately after treatment.
Discussion Labial enamel reduction offers major
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Fig 7 ■ Patient 2. Left, m axillary anterior teeth of 19-year-old woman before treatm ent. Right, veneers immediately after completion of treatment.
Fig 8 ■ Patient 3. Left, m axillary anterior teeth of a 17-year-old woman before treatment. Right, veneers immediately after completion o f treatm ent.
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advantages for composite resin veneer restorations. It reduces or eliminates overcontouring.lt provides a definite margin for the restorative material. It results in a higher shear bond strength between the composite resin and tooth enamel.37 The labial surface of a maxillary cen tral incisor after pumicing and a oneminute acid etch is shown in Figure 10, top. The effect of etching is not al
ways uniform, as illustrated in this scanning electron m icrograph. Iso lated areas revealing a definitive etch ing pattern are separated by areas hav ing no pattern. After debonding the veneer, the tooth aspect of the bond site still shows the characteristic etch in g p a tte r n , w h ic h is p a r t ia lly obscured by resin remnants (Fig 10, middle). The resin aspect of the bond site shown in Figure 10, bottom, re
veals knob-like resin remnants that mirror the corresponding etched con figurations shown in Figure 10, mid dle. In an earlier study, Retief38 re ported similar findings; he concluded that failure between a resin and etched enamel should not be classified as a true interfacial failure, but rather as failure occurring partly w ithin the resin and partly within the enamel. The labial surface of a maxillary cenBlack : RESTORATION OF STAINED TEETH ■ 849
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Fig 10 ■ Scanning electron micrographs. Top, labial surface of m axillary
Fig 11 ■ Scanning electron m icrographs. Top, labial surface of m axillary
central incisor after pumicing and one-minute acid etch (orig mag x 250).
central incisor after 0.5 mm surface enamel reduction followed by one-
Middle, tooth aspect of debonded veneer revealing p artially obscured etch
minute acid etch (orig mag x 250). Middle, tooth aspect of fractured speci
ing pattern (left, orig mag x 250; right, orig mag x 2,500). Bottom, resin as
men shows no evidence o f etching pattern (orig mag x 250). Bottom, frac
pect o f debonded veneer revealing tag remnants (left, orig mag x 250; right,
tured surface of resin fragment shows no evidence o f etching pattern (orig mag x 250).
orig mag x 2,500).
850 ■ JADA, Vol. 104, June 1982
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tral incisor after 0.5 mm surface enamel reduction and a one-minute acid etch is shown in.Figure 11, top. A characteristic etching pattern is uni form over the entire reduced labial sur face. Attempts to debond this veneer result in fracture primarily through the restorative material, not in the area of the resin I tooth interface. The tooth aspect of the fracture side shown in Figure 11, middle, shows no evidence of an etching pattern. The resin frag ment shown in Figure 11, bottom, also shows no evidence of an etching pat tern. These findings support the observa tions of Schneider and associates37 that samples with mechanical surface reduction had more residual compos ite resin on the bond site after fracture than did samples with no surface re duction. They concluded that the strength of the enamel /resin bond after enamel reduction was closer to the cohesive strength of the composite resin than the bond strengths on unre duced enamel. Surface enamel reduction followed by acid etching results in a surface that is more favorable for the formation of resin extensions responsible for bond ing. This procedure would effectively eliminate any organic integument, aprismatic enamel, and fluoridecontaining enamel. The presence of any one of these entities or combina tions could ultimately affect the shear bond strength of a composite resin veneer. Previous attempts to restore tetracycline-stained teeth by bonding conventional composite resins to acid-etched surfaces have failed primarily because of shortcomings of the restorative material. The develop ment of photocurable, one component, microfilled composite resins made possible the creation of veneers having lifelike colors and excellent surface smoothness. In addition to a wide range of colors in the Durafill restorative material, several shades of color modifiers are available, which expand the potential for color matching and characterizing. Estilux color modifiers have the ability to mask discoloration and at the same time impart a natural enamel-like ap pearance to the tooth. Variations in the shades within individual teeth are ac complished by spreading or overlay ing one shade over another. Blending
shades by spatulation should be avoided because this introduces bub bles that result in surface porosity. The Translux visible light unit will cure the material up to a maximum thick ness of 4.5 mm. To create a more pleasing and a more uniform effect, it may be necessary to treat the maxillary first premolars of some patients. In these cases, care must be taken not to involve the cusp ridges so that excursive movements occur on enamel surfaces. Although the lower anterior teeth are also affected by tetracycline, they usually do not present a particular esthetic problem. When esthetics do influence a decision to treat lower an terior teeth, the technique described is equally applicable. Because this technique creates little if any additional bulk, patients do not have to go through a period of postop erative adjustment. Postoperative sen sitivity has not been reported by any patient treated by the technique de scribed here. The highly polished ve neer surfaces are extremely stain resis tant. At appropriate intervals, the orig inal luster of the veneers can be quickly restored by using superfine Sof-Lex polishing disks, and, if neces sary, the veneers can be easily re paired. Other applications of this technique include the restoration of teeth having any other form of intrin sic stain, fluorosed or hypoplastic enamel, or abrasion /erosion lesions, and the recontouring of teeth and clos ing of diastemas.
Conclusion The availability of new restorative ma terials and the development of a new technique have made possible a con servative alternative to the restoration of stained and malformed teeth. The direct bonding of composite resin ve neers is a viable alternative to veneer crowns. In addition to conservation of tooth structure, this method of treat ment allows the dentist to express a greater degree of creativity. Because the entire procedure is carried out in the dental operatory, the dentist can control the ultimate esthetic result. Of the various forms of conservative treatment for tetracycline-stained teeth, the technique described here is the most predictable, effective, and esthetic.
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This project was funded by Kulzer, Inc, Irvine, Calif. Dr. Black is associate professor, department of o p erative d e n tistry , U n iv ersity o f A labam a School of Dentistry, Birmingham , Ala 35294. Ad dress requests for reprints to Dr. Black. 1. Schwachman, H., and Shuster, A. The tetra cyclin es: applied pharm acology. Pediatr Clin North Am 3:295, 1956. 2. M ilch, R.A.; Ball, D.P.; and Tobie, J.E. Bone localization of the tetracyclines. J Natl Cancer Inst 19:8 7 ,1 9 5 7 . 3. Hilton, H.B. Skeletal pigmentation due to tetracycline. J Clin Path 1 5:112,1962. 4. Weyman, J., and Porteous, J.R. Discoloration of teeth possibly due to administration of tetracy cline. Br Dent J 113:51-54,1962. 5. Bevelander, G.; Cohlan, S.Q.; and Rolle, G.K. The effect of the administration of tetracycline on the development of teeth. J Dent Res 40:10201 0 2 4 ,1 9 6 1 . 6. Harcourt, J.K., and Johnson, N.W. In vivo in corporation of tetracycline in the teeth of, man. Arch Oral Biol 7 :4 31-437,1960. 7. Harcourt, J.K. Tetracyclines and tooth struc ture in man. J Dent Res 4 2:5, abstract, 1963. 8. Bechelm an, J.H., and Gingold, N.L. Devel opmental dental defects associated with systemic tetracycline therapy— review of literature and case report. NY J Dent 34:377-380,1964. 9. Johnson, R.H. Effects of tetracycline on teeth and bones. J Dent Res 43:847, abstract, 1964. 10. Weyman, J., and Porteous, J.R. Tetracycline staining o f teeth: a report of clinical material. J Dent Res 42:1111, abstract, 1963. 11. Shwachman, H., and others. The effect of long-term antibiotic therapy in patients with cys tic fibrosis of the pancreas. Antibiot Ann 692-699, 1958-59. 12. Zegarelli, E.V., and others. Discoloration of the teeth in patients w ith cystic fibrosis of the pancreas. NY State Dent J 27:237-238,1961. 13. Zegarelli^ E.V., and others. D iscoloration of the teeth in patients with cystic fibrosis: role of tetracycline therapy. Clin Pediatr 2 :3 2 9 ,1 9 6 3 . 14. Sullivan, R.E. Discoloration of the teeth in patients with cystic fibrosis. Indianap Dist Dent Soc 1 8:10-12,1964. 15. M ello, H.S. The m echanism o f tetracycline staining in primary and permanent teeth. J Dent Child 34:478-487,1967. 16. Lambrou, D.B.; Tahos, B.S.; and Lambrou, K.D. In vitro studies of the phenomenon of tetra cycline incorporation into enamel. J Dent Res 56(12):1527-1532, 1977. 17. Zipkin, I.; Larson, R.; and Rail, D.P. Re duced caries in offspring of rats receiving tetracy cline during various prenatal and post-partum periods. Proc Soc Exp Biol 104:158-160, 1960. 18. Harndt, R. Incidence of caries in the teeth of Syrian hamsters observed after administration of tetracycline during tooth development. Caries Res 4:316-317,1975* . 19. Nonomura, E.; Sofue, S.; and Moriwaki, Y. Characteristics of carious lesions in teeth discol ored by tetracycline. Jpn J Pedo 16:377-384,1978. 20. Younger, H.B. Bleaching mottled enamel. Tex Dent J 60:469, 1942. i 21. Merwe, P.K. The removal of the stain from mottled teeth. S Afr Dent S 1 8:31,1944. 22. Bailey, R.W ., and Christen, A.G. Bleaching o f v ita l te eth stain ed w ith en d em ic dental fluorosis. Oral Surg 2 6 :8 7 1 ,1 9 6 8 . 23. Chandra, S., and Charvla, T.N. Bleaching of
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brown patches on mottled teeth. J Indian Dent Assoc 4 3 :5 4 -5 9 ,1 9 7 1 . 24. Bouschor, C.F., and Dorman, H.L. Bleach ing fluoride stained teeth. Tex Dent J 91(6):6-8, 1973. 25. Colon, P.G. Improving the appearance of severely fluorosed teeth. JADA 86:1329-1331, 1973. 26. Cohen, S., and Parkins, F.M. Bleaching te tr a c y c lin e -s ta in e d v ita l te eth . O ral Surg 29(3):465-471, 1970. 27. Arens, D.E.; Rich, J.J.; and Healey, H.J. A p ra c tic a l m ethod o f b leach in g tetra cy clin estained teeth. Oral Surg 34:812-817, 1972. 28. Corcoran, J.F., and Z illich, R.M. Bleaching of vital tetracycline-stained teeth. J M ich Dent
Assoc 56:3 4 0 -343,1974. 29. Falkensten, R.J. Effective bleaching tech nique for removing tetracycline stains. Dent Surv 53:46-54, 1977. 30. Christensen, G.J. Bleaching vital tetracy cline stained teeth. Quintessence Int 6:13-19, 1978. 31. Seale, N .S.; McIntosh, J.E.; and Taylor, A.N. Pulpal reaction to bleaching of teeth in dogs. J Dent Res 6 0 {5 ):9 4 8 -9 5 3 ,1981. 32. Faunce, F.R., and Myers, D.R. Laminate veneer restoration of permanent incisors. JADA 93:790-792, 1976. 3 3 . P a t e r s o n , J . R . , a n d A n s o n , R .A . Lam inates— a practical approach to restoring tetracycline-stained teeth. Pediatr Dent 2(4):3003 0 3 ,1 9 8 0 .
34. C h alk ley , Y . C lin ic a l u se of an terior laminates— construction and placement. JADA 101:485-487,1980. 35. Faunce, F.R. Tooth restoration with pre formed laminate veneers. Dent Surv 53:3 0 ,1 9 7 7 . 36. Barkley, R.L.; Gaw, A.F.; and Faunce, F.R. Esthetic tooth restoration. Dent Surv 55:22-27, 1979. 37. Schneider, P.M.; Messer, L.B.; and Doug las, W.H. The effect of enamel surface reduction in vitro on the bonding of composite resin to per manent human enamel. J Dent Res 60(5):895-900, 1981. 38. Retief, D.H. Failure at the dental adhesiveetched enamel interface. J Oral Rehab 1:265-284, 1974.
Atypical odontalgia: differential diagnosis and treatment Michael K. Kreisberg, DDS Failure to properly diagnose atypical odontalgia may lead to unnecessary dental treatment that does not permanently relieve pain.
A
condition described as atypical odontalgia has recently been docu mented in the literature. The dental symptom is pain arising from the teeth and their supporting structures for which no organic cause is evident. The pain is described as severe, throbbing, and continuous. It usually begins in one quadrant, but often crosses the midline to the opposite side.1The pain may occur spontaneously or it may be exacerbated by thermal or tactile stim uli. Rees and Harris1 reported on 44 pa tients ranging in age from 20 to 70 years. Thirty-six (82%) of the patients were female. Symptom duration ranged from two months to 20 years. Brooke2 reported on 22 patients (all female) ranging from 32 to 74 years of age. The average duration of symptoms in this study was 5.6 years. Patients generally give a complex history of extensive dental treatment with no relief of pain. Although spon taneous remission may occur, it is usually short-lived. Root canal therapy or extractions may provide transient relief; however, the pain usually re curs with equal or greater intensity within days or weeks. This subsequent pain may persist at the site of the ex traction, or it may occur in another
J.
852 ■ JADA, Vol. 104, June 1982
tooth or quadrant. Brooke describes a sequence of events in which a tooth may initially be restored, later treated endodontically, then subjected to an apicoectomy, and finally extracted, each stage being a prelude to the next. Treatment is frequently provided be cause of the patient’s insistence that “something be done” rather than be cause of objective clinical evidence. Entire quadrants may eventually be treated endodontically or rendered edentulous, without cure. The effect of local anesthetic on the pain is variable. Although some individuals experi ence relief, the majority do not.
Etiology Atypical odontalgia is considered a lo calized form of a more generalized classification of facial pain known as atypical facial neuralgia. Rees and Harris suggest that the mechanism is vascular, involving persistent dilata tion of the blood vessels of the pulp and periodontal ligaments. This con dition is not considered a local disease entity. It is instead a symptom of an underlying disorder of affect as sociated with a temporary or perma nent deficiency of catecholamines, in particular norepinephrine, at func tionally important adrenergic receptor sites in the brain. The natural history of the pain is de scribed by Rees and Harris as one of exacerbations and remissions, which are often correlated to the patient’s psychological health and social cir
cumstances. In Rees and Harris’s study,1 66% of the patients had a pre vious history of depression; 30% suf fered migraines. In Brooke’s study,2 41% of the patients had a history of de pression; 33% had a history of mig raines.
Report of cases Case 1 A39-year-old white womanhad aconstant, severe dull ache in the right zygomatic and facial region. The patient had recently undergone full mouth reconstruction to correct a “temporomandibular joint dys function.” The symptoms appeared to lo calize in the maxillary right quadrant, and the patient was referred to an endodontist for evaluation. Root canal therapy was se quentially performed on all maxillary right teeth fromcentral incisor to second premo lar with no relief (Fig 1). The patient was next referred to an ear, nose, and throat physician who ruled out pathologic sinus conditions. Results of a neurologic consultation proved negative, and the patient was told that she would have to learn to live with the pain. Symptoms subsequently localized in the maxillary right central incisor, which had previously been endodontically treated. The patient was referred to a second en dodontist who advised apical surgery. Local injection of the maxillary right cen tral incisor as well as bilateral infraorbital injections failed to relieve the pain and the apicoectomy was postponed. The patient was then referred for further consultation. Results of a temporomandibular joint ex amination were normal, and there was no indication of an internal joint derangement.