What is the Differential Diagnosis of Abnormally Colored Teeth?

A 15-month-old male came to clinic for his health supervision examination. His parents are concerned that his teeth are developing a gray-black hue for the past couple of months.
He has been well otherwise.
The past medical history reveals he was diagnosed with iron deficiency anemia and treated with supplemental iron drops for the past 2 months.
The review of systems is negative.
The pertinent physical exam shows a healthy toddler with normal growth parameters. His teeth have a gray to black color uniformly across the teeth, but slightly more prominent at the gingival line. No caries are noted.
The diagnosis of therapeutic iron ingestion was made. The parents were told that this is extrinic staining of the teeth that will improve after he stops taking the iron and proper oral hygiene is all that is needed. He had been previously referred for his first dental visit and the need for dental health supervision was reiterated.

Dental abnormalities are common in healthy children. These can include anomalies of tooth eruption, morphology, number, size, shape, tooth structure and caries. Dental caries are one of the most common chronic health problems in children.

The American Academy of Pediatric Dentistry and the American Academy of Pediatrics recommends an oral examination for all infants within 6 months of the eruption of the first tooth and no later than 12 months of age.

Learning Point
Intrinsic staining is foreign substance incorporation into the developing enamel or changes in the hardness or thickness of the dental hard tissues. Treatment requires professional bleaching or esthetic restoration such as veneers.
Extrinsic staining is superficial and caused by plaque or other discoloring substances sticking to the teeth. Treatment includes removal by proper oral hygiene and abrasive agents used in dental cleanings. Extrinsic staining is not a risk to dental decay.

The differential diagnosis of abnormal tooth color includes:

Intrinsic Staining

  • Blue-black
    • Neonatal hyperbilirubinemia
  • Gray
    • Hemorrhage
    • Necrosis
    • Tetracycline
  • Green
    • Biliary atresia
  • Pink
    • Blood resorption
  • Red-pink-brown (due to blood pigments)
    • Anemias
    • Congenital porphyria
    • Cholestatic disorders
    • Hemolysis
  • White (especially spotted)
    • Hypocalcified-hypoplastic disease states
  • Yellow-Brown
    • Calcification
    • Fluorosis
    • Tetracycline

Extrinic Staining

  • Gray-Black
    • Iron
  • Green
    • Chromogenic bacteria
  • Yellow-Brown
    • Foods and beverages
    • Smoking

Questions for Further Discussion
1. What is the normal age range for first primary tooth eruption?
2. What is the normal age range for secondary tooth eruption?
3. What should be done if a child has too few or too many teeth?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for these topics: Dental Care.

To view current news articles on this topic check Google News.

Avery ME, First LR. eds. Pediatric Medicine. 2nd Edit. Williams and Wilkins, Baltimore, MD. 1994:1382-1383.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1287.

Yang CW. Pediatric Dental Basics. Cased Based Pediatrics for Medical Students and Residents.
Available from the Internet at http://www.hawaii.edu/medicine/pediatrics/pedtext/s01c12.html (rev.3/2003, cited 5/5/05).

Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

June 29, 2005