Tooth discoloration in endodontic procedures

Tooth discoloration in endodontic procedures JuarL H. Gutie’rrez, D.D.S.,’ Concepcibn, Chile UNIVERSITY

OF COiSClWCI6X

and Mo’nica Guzmbn, D.D.S., SCHOOL OF DENTISTRY

D

entine discolo8ration often occurs, following pulpal infection or necrosis, as a consequence of hemoglobin combining with chemicals present in the saliva or in the root canal (for example, dressings, disinfectant pastes, or root canal cements). Numerous reports have appeared in the literature concerning the seriousness of the ever-increasing occurrence of enamel hypoplasia and tooth discoloration as a result of oral administration of antibiotics, especially the tetracycline drugs.]+ The studies to be reported here were undertaken to determine whether disinfectants, antibiotics, or flushing solutions are capable of producing tooth discoloration. MATERIALS

AND

METHODS

Human dentine disks prepared from upper anterior teeth immediately after extraction were employed. From each root five disks, 2 to 3 mm. thick, were prepared by removal of the cementum with Carborundum wheels. Four of these disks were treated with drugs, and the fifth one was left as a control. The disinfectant agents used included phenol, formocresol, eugenol, camphorated p-monochlorophenol, cresatin, and solutions prepared according to Stewart.9 and Grove’P formulas. Two quaternary ammonium componncls--Zefirol (Bayer) and Molca (Andromaco)-dilutetl 1 : 1,000 were used. Two drops of each drug wcw employed ; one was placed over a disk and the other was placed over another disk on which a drop of a 1 per cent solution of human red blood cells suspended in *Professor

706

and Chairman

of the l)epartment

of Operative

Ikntistry

ancl F;ntlodontics.

Volume 26 Pu’umber 5

Tooth discoloration

in endodontic

procedures

167

saline had been deposited previously. The same procedure was carried out with two ribbons of No. 1 Whatman paper (chromatography type) instead of dentine disks. Dentine disks and Whatman paper were also used to determine the discoloration produced by three decreasing concentrations in saline solution of the following antibiotics : sodium pencillin G, streptomycin, chloramphenicol, tetracyclines, Sigmamycin, and Declomycin (demethylchlortetracycline) . PBSC, Grossman’s polyantibiotic paste, and three other polyantibiotic pastes were used as dressings and also tested with Whatman paper. All of the pastes tested contained basically the same amount of penicillin (1 million units) and streptomycin (1 gram), suspended in 1 ml. of propylene glycol. Other antibiotics were also tested: PCSN = Penicillin-chloramphenicol (250 mg. ) -streptomycin-nystatin (125,000 units) PTS = Penicillin-Terramycin (250 mg.) -streptomycin PDS = Penicillin-Declomycin (100 mg.) -streptomycin These polyantibiotic combinations and a group of disinfectant pastes, such as N, (Apical and Medical types), Walkhoff’s paste (iodoform plus camphorated p-monochlorophenol) , Cresolform, and Oxpara (Caulk), were used as dressings. After mechanical preparation, the first dressing was allowed to remain for 24 hours at 20° C. in a humid atmosphere. After the first dressing was washed out with saline solutiont a second dressing was placed for another 24 hours under the same conditions. Then teeth were split open with a specially designed device. Hydrogen peroxide solutions of 30, 20, and 10 volumes, a commercial concentrated solution of sodium hypochlorite, and 10 per cent sodium hypochlorite were tested on Whatman paper and used as flushing agents. In addition, other different groups of teeth were flushed with 10 ml. of the different concentrations of hydrogen peroxide and sodium hypochlorite described above, one separate group of teeth for each concentration tested. After complete evaporation of the liquids at room temperature, the teeth were split open to determine whether discoloration had occurred. RESULTS The results of the study are presented in Tables I, II, and III. While camphorated p-monochlorophenol and eugenol did not produce any change, phenol and cresatin caused a slight discoloration (+) on dentine disks and Whatman paper, the same as penicillin, streptomycin, chloramphenicol, and PBSC and PCSN polyantibiotic pastes. Stewart’s and Grove’s solutions caused discoloration only in the presence of erythrocytes. Formocresol and Molca exhibited a marked discoloring ability (fst) . The same degree of discoloration (ttt) was observed when tetracycline drugs and Sigmamycin were used. Zefirol showed a rather moderate tendency toward discoloration (++) . The most intensive action was caused by N, pastes (+++ or +++) , demethylchlortetracycline (t+t) , PTS (-t-t+), and PDS polyantibiotic paste (M). When the specimens were observed under ultraviolet light, the teeth treated in vitro with polyantibiotic pastes containing Terramycin and Declomycin showed

O.S.,0.11.& 0.1’. SorPnlhcr, 1968 I. The discoloring

Table

I Xethod Dentine disk Dentine disk plus 1% erythrocytes Whatman paper Whatman paper plus 1% eryttmocytes Eey to symbols: - = No change;

effects of’ drags

_I_-Camwhornted I p-monodloroph,?nol -

Disinfectan,t I

1

slight

Ph en01 +

Cresatin +

-

++

++

++ =

discoloration;

moderate

discoloration;

ttt

II. The discoloring effects exhibited by decreasing concentrations biotics tested alone and in the presence of erythrocytes

Table

Antibiotic

1 Concentration

Sodium oenicillin

Streptomycin

Oxytetracycline, tetracycline,

Table

Ill.

Method D.D. D.D. + E. W.P. W.P. t E.

chlortetracycline, or sigmamycin

500 mg./ml. 250 mg./ml. 125 mg.Jml.

D.D. D.D. + E. W.P. W.P. t E.

Marked (+++)

150 mg.Jml. 75 me./ml. 37.5 mE.)ml.

D.D. D.D. t E. W.P. W.P. + E.

Severe ( +++t)

E. L

marked

Discoloration

500 mg./ml. 250 mg./ml. 125 mg./ml.

disk;

=

of anti-

or chloramphenicol

Key to symbols: D. D. = Dentine solution ; W.P. = Whatman paper.

infectant

)

500.000 U./ml. 25O:OOO U.>ml. 125,000 U./ml.

I

tested

Bugenol -

+

+ =

tested alonta and in the presence of

1 per cent erythrocytes

suspension

in saline

The discoloring effects exhibited by polyantibiotic pastes and dispastes tested alone and in the presence of erythrocytes Type of paste and rrsults

Method

used

W.P. W.P. + E. L.S. L.S. + E. Key

PBSC lPGSN 1 PTS / ++ ++ t ++ +++ + +++ + + t+t

PDS ++ +++ i-t++ tttt

1 N,A +t +++ +++ +it

1 N,&f +t t++t +++t ++++

j Wp ( CFp + t++ iit + +t t+

1 Ozp +++ ++

to symbols:

suspended in saline W.P. = Whatman paper; E. x 1 per cent erythroeytes L.S. = longitudinal section of tooth treated with paste and later split open. PASTES: PBSC = Grossman’s polyantibiotic paste; PCSN = polyantibiotic containing PTS = polyantibiotic containing penicilIinpenicillin-streptomycin-chloramphenicol-nystatin; terramycin-streptomycin; PDS = polyantibiotic containing penicillin-Declomycin-streptomycin; Na = N, Apical; N,M = N, Medical; Wp = Walkhoff’s paste; CFp = Cresolform CauIk paste; Oxp = Oxpara Caulk paste. - = No discoloring action; t = slight discoloration; ++ = moderate discolora RESULTS: tion; +++ = marked discoloration; +++t = severe discoloring action. METHODS:

solution;

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Tooth discolwath in esdodontic procedures 709

Number 5

erythrocytes

Stewart's

sol&ion

Control with

Grooe's

solzction

Zejtrol

Formocresol

Yolea

-

-

ttt

+tt

tt

tt

tt

+tt

ttt

+t

ttt

ttt

tt

tt

tt

ttt

ttt

saline

solution

discoloration.

a green fluorescence.This effect can be diagnostic of teeth colored by thesetwo drugs, whether they are administered topically or parenterally. The discoloring effect of the chemicalstested was always worse when the drugs were used in the presenceof human red blood cells, This phenomenonwas very significant when disinfectant pasteswere used. With regard to flushing solutions, none of the hydrogen peroxide solutions tested showedany discoloring abilit,y, either in dentine disks or on Whatman paper. Hypochlorite solutions had somediscoloring effect in contact with human erythrocytes. More important, sodium hypochlorite exhibited a great tendency to crystallize over dentine disks, Whatman paper, or root canal walls, an observation that we have made before.*l Sometimesthis crystallization cannot be removedby washing with water or with any type of flushing solutions. With respect to the methods employed, the use of dentine disks for discoloration tests is very difficult to evaluatebecauseof the variance in the natural color of the teeth, the small area exposedto the drugs, and the refraction of light on the polished surfaces of the disks. The use of recently extracted teeth treated with antibacterial agents or polyantibiotic pastesallowed us to evaluate closely what really happensin the topical application of drugs used in endodontics under clinical conditions. The split-open teeth showedroot dentine discoloration whenever the drugs had been applied. The most efficient and easiest method of evaluating these drugs was with ribbons of No. 1 Whatman paper which discolored rapidly when the tested drugs were deposited on them. This procedure can therefore serve as a rapid laboratory test to determine drug discoloration of teeth. DISCUSSION

A review of the literature has confirmed the occurrenceof profound histologic alterations and discoloration of deciduousand permanent teeth as a result of the administration of tetracyclines to pregnant women or to infants in the suckling period or during the first year of life.‘?, I3 Theseteeth, when viewed under ultraviolet light, showeda green fluorescence. Weymanl” has suggestedthe use of oxytetracycline to prevent the discoloring effectsof certain antibiotics. It is difficult to acceptthis conceptof preven-

tion, however, since tile SNrllC illltil)iotic*s tl!;r.t, ~)lwclu0~ cliS~0lOlXt ion Of’ teeth after general administration also cause tliscoloi~;rtiorr whert ust~tl tlrt&ngs on endodont~icall~ treated teeth. This is tranc oi’ all tt>tr;rcycline tirr~gs, atlministered alone or in combination with other antibiotics (Sigmamycin, for inst~ancc) Discoloration occurs following general adrninist~atiorr or topical applicat,ion oE 1 grwn HlLoreSwnCC SPell Terramycin or Declomycin on tocth, as c+tlcnred by 111~ when teeth thus treated WCI’Cobsrrved nncler* nltravioh~t light. In the light of our clinical irrrd csperimcntal findings, wc bclicvc that, tetracyclines or combinations of t,hesr drugs with other antibiotics should not bc is cqccial1.v contrarecommended. The use of l)rclom~cirr in root can;11 thc>rapy indicated, since in our experiments that antibiotic prodncctl the most severe type of discoloration (+t++) . ilS

CONCLUSIONS 1. Formocresol, Molca 1 :l,OOO solution, the three tetracyclines, and Sigrnamycin are capable of markedly discoloring human dentine disks and Whatman paper. 2. T\T, pastes and polyantibiotic pastes containing tetracyclines, particularly those containing Declomycin, produced a severe discoloration (-t+t+) when tested in vitro. When observed under ultraviolet light, teeth treated with Terramycin and Declomycin gave a green fluorescence. 3. Commercial undiluted and 10 per cent sodium hypochlorite used as flushing solutions produce dentine discoloration, especially in the presence of red blood cells. However, the main problcrn seems to be the tendency of sodium hypochlorite to crystallize on root, canal walls. 1. The discoloring effect always increased when the drugs were t&cd in the presence of human erythrocytcs. SUMMARY We have conducted an cxperimcntal study in which dentine disks and Whatrnan paper were used to test discoloring effects of disinfectants, antibiotics, and flushing solutions used in endodontics. Each of the chemicals was t,ested alone and in the presence of a 1 per cent suspension of human erythrocytes in saline solution. I’olpantibiotic and disinfectant pastes wcrc used as dressings on recently extracted teeth, which were t.hen split, open to show discoloration. The most severe discoloring action was exhibited by the t,wo N, pastes and b- polyantibiotic pastes containing Terramycin and Dcclomyein. REFERENCES

1. DeVeber, L. L.: Photosensitivity, Loosening of the Nails, ant1 Discolouration of the Nails and Teeth in Association with Demethylchlortetra~ydine (Declompcin), Canad. M. A. a. 86: 168-172, 1962. 2. Wallman, I. S., and Hilton, H. B.: Prematurity, Tetracyclint~, and Oxytetraqcline in Tooth Development, Lancet 1: i20-721, 1962. and Yc,llorr Teeth, Lancet, No. 7232, 3. Davies, P., Little, K., and Aherne, W. : Tetracyclines p. 743, 1962. 4. Miller, J’.: Tetracyelines in Teeth and Bones, Lane&, No. 7238, p. 1072, 1962.

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Tooth discolorationsin en~domdontic prowdures 711

5. Pindhorg, J. J.: Misfarvning af taender eftcr tetmcyklinl~ehandling (English summary), Tandlaegbladet 66: 775-880, 1962. 6. Weyman, *J., and Porteous, J. R.: Discoloration of Teeth Possibly Due to Administ,ration of Tetraeyelines: A Preliminary Report, Brit. D. J. 113: 51-54, 1962. 7. Porteous, .J. R., and Weyman, 3.: Tetracyclines and Yellow Teeth, Laucet, No. 7234, p. 861, 1962. 8. Gr@n, P., and aohannesseu, L. B.: Fluorescence of Tetracycline Autibiotics in Bone, J. Bone Surg. 40A: 897, 1958. 9. Stewart, G. G.: Medicamentos de redueido poder inflamatorio, somctidos a la prueba de1 tiempo, en terapeutica de conductos, Rev. Assoc. odont. argent. 50: 82-87, 1962. 10. Pucci, F.: Conductos radiculares, Part II, Montevideo, 1945, Barreiro y Ramos, p, 456. 11. GutiBrrez, 5. II., and Garcia, J.: Microscopic and Macroscopic Investigation on Results of Mechanical Preparation of Root Canals, ORAL SURG.,OFLALMEU. & ORAL PATH. 25: 108, 1968. Antibiotics and Tooth Discoloration, 12. Franckel, M. A., and Halves, R. R.: Tetracycliur J. D. Res. 43: 780, 1965. 13. Johnson, R. H.: The Effects of Tetracyclines on Teet,h and Bones, J. D. Res. 43: 780, 1965. Appearances of Tetracycline Staining of the Teeth, Brit. 14. Weyman, J.: The Clinical D. J. 118: 289-291, 1965.