The terms you are using are those that would be used by academics and not so much by practicing cosmetic dentists. But they are a useful way to categorize teeth stains. Of the terms you mentioned, extrinsic and intrinsic would probably be heard more often clinically among practicing dentists than endogenous and exogenous.
Extrinsic stains would be those that exist on the surface of the teeth. Tobacco creates extrinsic stains. Here’s a picture of some teeth with extrinsic stains.
These are child’s teeth, and children, as their teeth are developing, tend to pick up some of these stains as different naturally-occuring bacteria come to populate their mouths. Peridex mouthwash causes this type of stain. The milder stains of this type can be removed by brushing (e.g. whitening toothpastes). The more stubborn ones will need to be removed by a dental cleaning, or by Supersmile toothpaste.
Intrinsic stains would be those that are absorbed into the actual structure of the teeth. They take a long time to develop. Years of drinking coffee or tea, smoking, or even eating highly pigmented fruits such as raspberries, will cause the teeth to darken. These stains tend to be brownish or yellowish. They cannot be removed by any toothpaste, but they can easily be removed by bleaching. Here are before-and-after photographs of teeth that had these accumulated stains which were treated with the Kör deep bleaching system.
Exogenous stains would be those that are caused by outside agents. All of the stains mentioned above would be exogenous. All can be removed by either a surface cleaning of the teeth or by bleaching.
Endogenous stains are those that were acquired during the development of a tooth. Tetracycline stains would be in this category. If the antibiotic tetracycline is taken during the development of permanent teeth (between birth and twelve years old) it binds to the dentin of the tooth and becomes a deeply embedded stain. Fluorosis stains are more superficial but they are also developmental—they are caused by the consumption of too much fluoride while teeth are forming. From the point of view of a cosmetic dentist, you could also call a dark natural pigmentation in the teeth to be an endogenous stain. Some people’s teeth are just naturally dark.
The treatment of these endogenous stains is different. Tetracycline stains respond somewhat to bleaching, but are best treated by porcelain veneers. Fluorosis stains should not be treated by bleaching because they occur in splotches. However, the natural pigmentation of teeth can be treated effectively by bleaching. With persistent bleaching treatments, people can get their teeth whiter than they were when they first erupted into their mouths.
I hope this is helpful. Good luck in your schooling.
– Dr. Hall
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I appreciate your help. Last year I began getting mysterious brown staining on my teeth that my dentist cannot remove. He did not tell me it could be fluoride. A natural health practitioner told me it is from excess fluoride. I am 63 years old. I have not used fluoride toothpaste in years, but my township has fluoride added to the water. I have been drinking Poland Spring water which also has fluoride. I do not drink wine or coffee. Last year I started drinking a cup or two of green tea daily which I just found out has plenty of fluoride, so this must be what pushed me to fluoride overload and brown staining. I only drink plain water now. Do you know which bottled water brands do not contain fluoride? Which type of whole house water filtration system removes fluoride?
Which cosmetic dentists in New York City would you recommend for bonding? I have had some previous bonding in NJ and was not happy with the color matching.
– Linda in New Jersey
Dental fluorosis is a mottling of the enamel caused by excessive intake of fluoride while teeth are forming. In its mild form it is manifest by white spots. When it is more severe the spotting or mottling can be brown.
Once your teeth are formed, they will not be stained by fluoride. So if this is a stain that is new, it has nothing to do with fluoride.
I’m a little puzzled by your statement that this is a stain that your dentist can’t remove. Once your teeth are fully formed, any stain that they pick up should be able to be removed. Let me explain the two different ways to do this, depending on the stain.
There are only two types of stain that you would be getting on your teeth at age 63. One type would be external staining – something that attaches itself to the surface of your teeth. Any stain of this character should be able to be polished off. Supersmile toothpaste also works very well for removing these types of stains. It enzymatically removes the protein pellicle on your teeth, and it is that pellicle to which the stains adhere.
The other type of stain would be internal staining. Your teeth can absorb pigments from food and drinks. Tea is an excellent source of this stain, and, from the clues you are giving me, that seems to be the top candidate for this stain. I would know better if I could see it myself. Internal stains get absorbed into the enamel of the teeth and can only be removed with bleaching. Internal staining would be manifested by a general darkening of the color of the teeth. External staining would probably concentrate around the gumline of the tooth and the spaces between the teeth and would be irregular in appearance. Internal staining would be evenly distributed throughout.
I would not recommend bonding for this type of staining, if that’s what you have. Bleaching works better, is much less expensive, and doesn’t require anything artificial to be attached to your teeth, so it will look nice perpetually. Bonding would also require an expert cosmetic dentist, which limits you to about 1-2% of dentists. Any of the expert cosmetic dentists we recommend on our site would do an excellent job with bonding. But you don’t need an expert cosmetic dentist for bleaching – many dentists can do that well.
If you do need bonding work, however, and you are in New Jersey, you shouldn’t need to go to New York. Dr. Allyson Hurley, in Bedminster, does a fine job with bonding. She is AACD accredited. Google her and you will find her website. Dr. Jeff Golub-Evans, in Manhattan, is internationally renowned for his bonding skills, and sees many fashion models and movie stars, if you need that level of care.
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I have four porcelain veneers on upper teeth, that have stayed color stable, etc However after a cleaning last year, I am seeing a small gray stain forming on top of one at margin I don’t know if it was damaged but find it interesting given correlation in time I do go to a highly respected cosmetic dentist and staff is trained to maintain veneers etc Is there a way to clean margin and remove the stain?
Joe from Dallas
I’m at a disadvantage in not being able to see this stain you’re talking about, so I’m going to take a guess at what it looks like. And I don’t know how old they are.
Porcelain veneers have the characteristic of being very stain resistant – even more stain-resistant than natural teeth. And, as you said, they are also very color stable. When they do stain, it is usually from one of two causes. Either the surface of the porcelain veneer has been damaged – the glaze has been broken possibly due to the use of power polishing equipment or acid fluorides. Or, there is something getting under the veneers.
For the sake of being able to say something, let’s assume that these are older veneers that have been on maybe ten or twenty years, and that the stain starts right at the edge of the porcelain veneer and involves the first millimeter or two of the veneer. This is the type of stain that would be the most likely to confine itself to the edge of the veneer.
If these assumptions are correct, then the stain probably comes from leakage – the margin of the porcelain veneer has broken down and microscopic particles are getting between the veneer and the tooth. It is called microleakage, and it starts being just a stain, but if not addressed and repaired, it can grow into decay.
If this is the case, you would not be able to have this stain polished out. The veneer would have to be removed and replaced. And it wouldn’t be related to any damage that could have been done during your cleaning.
Links: read more about stained teeth.
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Dear Dr. Hall,
I have two amalgam fillings I would like removed completely and replaced with composite for two back teeth. However, my dentist mentioned to me these fillings may have stained the teeth and they may not be as aesthetic after the work is done.
Is it true that amalgam fillings can stain teeth, and if so what does create the stain? And what option can exist to remove such stain? In addition, these two teeth have around 70% filling: Is white composite a good option for strength and durability vs amalgam?
– Stephan in Seattle
I have taken out a lot of old amalgam fillings and replaced them with composite and they always looked better. Yes, amalgam can discolor your tooth a little bit, but I never found that to be an issue that significantly detracted from the appearance of a back tooth.
It sounds to me like your dentist simply isn’t very comfortable with the composite fillings on back teeth. I would absolutely warn you about trying to press this matter. Placing composite fillings in back teeth is very different from placing amalgam fillings, and I have received e-mails of some horror stories of patients ending up needing root canal treatments because of the damage to their teeth from improper technique. If your dentist is indeed trying to tell you that he or she doesn’t want to do this, just drop the matter. If this is important to you, I would advise finding a different dentist who is trained to provide the kinds of services you want and whose values are more in line with yours.
And I have two additional points about these fillings, which you say cover about 70% of the teeth. If that’s true, the teeth really should have crowns, if the fillings are that large. So you’ve given me another reason to question your dentist. But if they do have fillings, the white composite fillings bond to the tooth and strengthen it where the amalgam fillings just sit in the tooth and make it easier for the tooth to fracture. The amalgam material itself is stronger than the composite, but the combination of the filling plus the tooth is much stronger if the filling is composite.
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My son has brown fluoride stains on his front teeth. We have had a local dentist bleach his teeth but the stains are still evident. She recommends veneers but I wonder what the difference in cost is between bonding and veneers? Also can you recommend a cosmetic dentist in Amarillo, TX. Amarillo is the closest city to our small hometown.
Doreen in Texas
Don’t have the dentist who did the bleaching do the veneers or the bonding. She doesn’t sound like she knows what she is doing. It sounds like you have figured that out.
Teeth bleaching doesn’t work for splotched teeth. I shake my head every time I hear one of these stories, that another dentist doesn’t know how to do this.
Depending on the extent of the stains (these fluoride stains are called fluorosis), yes, direct dental bonding may be the best thing – this would cover up the stains. And thank you for asking for our recommendation. But even Amarillo is a problem. I just looked there again and can’t find anyone I would recommend.
And, as I check a map, I see that you are clear out in a remote rural area of the Texas panhandle. I know it’s going to be a 4-5 hour trip, but if you want this done right, I would really suggest you go to Oklahoma City. Very few dentists are going to know how to do this right, and they tend to gravitate to larger cities. In Texas, they go to Dallas, Austin, San Antonio, Houston, and other parts of east and central texas. I have looked in West Texas and only last month did I finally find someone in Lubbock that I would refer patients to. And we can’t yet find anyone in Amarillo.
Dental bonding is an art. It has to be done freehand, and they simply don’t teach it in dental school. And dentists have to be passionate about appearance-related dentistry to know how to do it well and to stock the materials on hand to be able to do it right.
I would recommend Dr. Michael Forth in Edmond, OK. That’s a northern suburb of Oklahoma City. He does beautiful work.
Read more about stained teeth.
Dr. Hall, I’m writing about my 9 year old daughter. She has severe fluorosis stains on her teeth. Her bottom central and lateral incisors are extremely yellow (those are the only permanent bottom teeth she has so far). Her top central and lateral incisors are very blotchy, and one of them is jagged on the side. She currently has braces correcting the problems resulting from years of sucking her fingers. Her teeth have bothered her for some time. The only reason we put braces on now, instead of waiting for the 12 yr molars, is to give her more self-confidence with her smile. It also gives us a little more time to figure out how to correct the fluorosis.
Thanks, Carly from Arizona
You say your daughter has severe fluorosis. When fluorosis is severe, you need to cover the stained teeth with porcelain veneers – cover all of the teeth that are part of her smile.
Fluorosis is caused by consuming too much fluoride while the teeth are forming. Much natural drinking water has some fluoride in it. There is some natural water that doesn’t have enough fluoride, which makes teeth more susceptible to decay. Communities where this occurs generally add fluoride to the drinking water to bring it to the optimal level of about one part per million. But some communities naturally have water that has too much fluoride, and then some of it needs to be removed. If it isn’t, drinking that water for extended periods while the teeth are forming can cause fluorosis. Or, where people are drinking their own untreated well water, this can occur. Fluorosis can also be caused by mistakenly consuming fluoride supplements when it isn’t needed or by swallowing too much fluoridated toothpaste.
Mild fluorosis causes spotting of the teeth, and the spots can be white or brown, depending on the severity. Often direct bonding can be used in these cases, which just covers the affected spots.
If the fluorosis spotting is extensive, then the teeth need to be covered more extensively, and porcelain veneers would be the treatment of choice.
If there is just a general yellowish color, but that color is even – not mottled – then I would try teeth bleaching first. If that is the case, you’re probably not dealing with fluorosis but some other cause of the staining.
Just be sure you go to a highly experienced and capable cosmetic dentist. This is beyond the ability of your family dentist. Beyond the technical ability and beyond his or her artistic understanding.
You’ll want to wait until the braces come off. And the dentist will need to know how to time the work. I don’t know how long the braces will be on, but when they come off it may be possible that her very front teeth still haven’t fully erupted. In that case, it may be best to do some direct bonding temporarily, or something else. There will be a lot of different ways to tackle the problem, and a lot will depend on her attitude toward the problem. Dentists who aren’t artistically sensitive just aren’t equipped to handle these self-image issues very well, but experienced cosmetic dentists are quite used to them.
There is no minimum age for porcelain veneers, as long as the dentist knows what he or she is doing, and properly factors in the degree of present and future tooth eruption and other factors. Children can also have teeth bleaching.
– Dr. Hall
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