Visible discoloration of the teeth can be caused by extrinsic factors, which stain the outside of the tooth. Alternatively, discoloration can be caused by intrinsic changes in the tooth, which are triggered during or after tooth development. Because the inner dentin of a tooth is darker than the white enamel covering a tooth, pits caused by thinning of the enamel can appear as dark areas. Problems with dental health such as trauma, genetics, exposures to chemicals and antibiotics, systemic diseases, malnutrition, or poor dental care can all contribute to discoloration.

• The risk of developing dental caries depends on multiple overlapping factors. Caries risk is influenced by family history, diet and feeding style, dental hygiene, and fluoride use. The highest caries risk is seen in children with complex medical needs, those from disadvantaged families, and in babies who bottle feed through the night. Dental caries risk assessment and counseling should be part of early childhood care.

• Children’s vitamins, especially those containing iron, can lead to external tooth stains. External tooth staining can also be seen from cigarettes or other tobacco products, coffee, and red wine.

• Dental trauma can damage primary teeth and influence the development of preeruptive permanent teeth. Even mild trauma, depending on timing and location, can lead to significant changes in tooth appearance.

• Systemic fluoride given during tooth formation helps teeth develop strong enamel. Topical fluoride throughout life helps protect teeth by preventing and repairing damage to enamel. However, excessive fluoride exposure during tooth development can lead to fluorosis. Despite some cosmetic consequences, most degrees of fluorosis strengthen the teeth against caries. Common sources of fluoride exposure are from fluoridated municipal water, toothpastes and rinses (if swallowed), and from dental treatments. Fluoride exposure after tooth development, past age 8, will not cause fluorosis.

• Significant systemic illness can alter a tooth’s appearance. Children with cystic fibrosis or renal insufficiency, for example, may have mottled teeth or hypoplastic enamel.

• Stains occur from tetracycline antibiotics, including doxycycline, when they are incorporated into a tooth during development. These antibiotics will not stain fully formed permanent teeth. Pregnant women, and children younger than 8 years old, should avoid tetracyclines.

• Milk bottle caries causes the most damage to the upper teeth and is associated with staining, caries, and destruction of the primary teeth.

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