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Original Article

Application of a tooth-surface coating material to teeth with


discolored crowns
Takashi Hashimura, Aya Yamada*, Tsutomu Iwamoto, Makiko Arakaki, Kan Saito,
Satoshi Fukumoto
Division of Pediatric Dentistry, Department of Oral Health and Development Sciences, Tohoku University Graduate School of Dentistry,
Sendai 980-8575, Japan
a r t i c l e i n f o
Article history:
Received 10 December 2012
Received in revised form
4 March 2013
Accepted 6 March 2013
Available online 6 May 2013
Keywords:
Discolored teeth
Tooth coating material
S-PRG ller
Caries prevention
a b s t r a c t
Crown discoloration of permanent teeth is caused by trauma, periapical lesions of the
deciduous teeth, pharmaceuticals, and systemic diseases. Crown discoloration has been
treated with bleaching or crown restoration. However, these methods are not appropriate
during the growth and development period of children.
In this study, we used BeautiCoat (Shofu Inc., Kyoto, Japan), a tooth-surface coating
material that contains high levels of controlled-release uoride, that temporarily im-
proves crown color. We evaluated the effect of the primer on tooth-surface characteristics
in addition to the coating agents shear bond strength, tooth-surface condition, and
duration of attachment. Additionally, we surveyed patients satisfaction with the color
improvement.
The results showed no adverse effects of the primer on the enamel surface. The coating
material itself showed a high degree of shear bond strength. Based on observations of
shedding and fracturing in clinical applications, we found that the coating material
maintained long-term attachment if applied under conditions of strict moisture prevention
and it avoided areas of occlusion. Treated children and their parents were highly satised
with the color improvement. These results suggest that this coating material is appropriate
for improving the color of discolored teeth during childhood.
2013 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.
1. Introduction
Esthetic problems due to discolored crowns are common in
pediatric clinical practice. Causes of crown discoloration
during the formation of permanent teeth include periapical
lesions due to severe cavities in deciduous teeth and enamel
formationdisorders due to tooth trauma. Discoloration ranges
from white spots in mild cases to substance loss with dark
reddish-brown coloring. Crowns can also be discolored by the
use of tetracycline antibiotics or systemic diseases during the
tooth formative period [1,2].
Such crown discoloration can be treated in adults with
crown restoration methods, such as resin, laminating ve-
neers, facing crowns, and bleaching treatments. However, it is
difcult to achieve esthetic improvement in young children
during their period of growthand development using methods
* Corresponding author. Tel.: 81 22 717 8382; fax: 81 22 717 8386.
E-mail address: yamada-a@dent.tohoku.ac.jp (A. Yamada).
Available online at www.sciencedirect.com
Pediatric Dental Journal
j ournal homepage: www. el sevi er. com/ l ocat e/ pdj
p e d i a t r i c d e nt a l j o ur na l 2 3 ( 2 0 1 3 ) 4 4 e5 0
0917-2394/$ e see front matter 2013 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.pdj.2013.03.011
intended for adults. For instance, almost all at-home and in-
ofce bleaching procedures are not intended for young chil-
dren. Further, the use of irreversible crown restoration treat-
ments that require tooth preparation is not appropriate in
young children, because the gingival margin height has not
stabilized while the teeth are erupting or while the alveolar
bone is still forming. Therefore, a temporary treatment for
young children with crown discoloration is needed.
One such method is the tooth manicure, which uses ma-
terials that improve the color of teeth in a single day. However,
the organic solvents used in nail manicures are difcult to use
insidetheoral cavity; therefore, theeffectslast for only1e2days,
and it is difcult to maintain long-term color improvement.
In 2004, White Coat (Kuraray Medical Co., Osaka, Japan)
was developed, which is a tooth-coating material for exclusive
use in dental clinics. This material uses a self-etching primer,
and its adhesion durability is about 1 month. This product has
better durability compared to over-the-counter tooth mani-
cures [3,4].
Progress has since been made in developing materials with
better durability and good physical properties that cause little
damage to the tooth. Surface reaction type pre-reacted glass
ionomer (S-PRG) ller has been developed, which possesses
physical strength and high levels of controlled-release uo-
ride [5]. The tooth-surface coating material BeautiCoat
(Shofu Inc., Kyoto, Japan) contains this ller and is currently
used to treat discolored crowns [6]. Dental materials using S-
PRG ller include sealant materials [7], composite resin, or-
thodontic resin bonding system [8], denture base resin [9,10],
and root canal sealer [11]. Through the release and recharge of
uoride and various other ions, cavities can be prevented in
the area of repair and neighboring teeth, and the adhesion of
plaque to the tooth surface can be suppressed [12,13].
This study investigated the shear-adhesion strength and
durability of BeautiCoatin the oral cavity as well as the effect
of its tooth-surface primer on enamel surface characteristics.
Finally, a survey of patient satisfaction with color improve-
ment was also conducted.
2. Materials and methods
2.1. Effect of the primer used in the tooth-surface
coating material on enamel surface characteristics
Bovine tooth enamel specimens were subjected to no treat-
ment, the BeautiCoat Primer treatment (3 s), or 37% phos-
phoric acid etching treatment (30 s). Enamel surface
characteristics were then observed and analyzed with a
scanning electron microscope (SEM; VE-7800, Keyence, Osaka,
Japan) under gold-evaporated conditions.
2.2. Evaluation of shear bond strength of the tooth-
surface coating material
Enamel, dentin, metal, and porcelain were prepared under the
following conditions before shear bonding strength (SBS) test.
A bovine tooth surface was placed in an acrylic ring, and the
ring was embedded in epoxy resin. The bovine tooth surface
was polished using #600 SiC paper to expose enamel or dentin.
Precious metal (a gold-silver-palladium alloy) was polished
using #600 SiC paper, and the sandblast was applied to the
surface of metal using alumina-sand of 50e100 mm. Porcelain
was polished using #600 SiC paper to expose at surface.
The surface of bonding specimen was treated according to
the bonding method recommended by the manufacturer. A
mold (4 mm diameter, 0.2 mm height) was tted onto the
treated surface, lled with the coating material paste (BW2)
and light-cured to obtain a test specimen for SBS testing. After
being stored in water at 37

C and 2000 thermal cycling
(4e60

C), the specimen was evaluated for its SBS before and
after thermal cycling using a universal testing machine.
2.3. Clinical evaluation of the tooth-surface coating
material
BeautiCoat was applied to the teeth of 30 subjects (38 teeth;
upper central incisors and upper lateral incisors) with crown
discoloration believed to be caused by trauma or periapical
lesions of the deciduous teeth under the informed consent
from all parents. The patients were treated at the pediatric
dentistry department of Tohoku University Hospital (Miyagi
Japan) and Hashimura Dental Clinic (Saga, Japan).
The surfaces of the affected teeth were cleaned with a low-
speedconebrush. Primer Aandprimer Bwereplacedinadish1
drop at a time and mixed with a disposable chip brush. The
mixed liquid was applied to the surface of the teeth. It was left
in place for 3 s or more and was then dried with low-pressure
air. Next, the previously selected color-tone paste (white
base, BW1e4; white opaque, WO/paint color; yellowish, A0.5,
A3) was applied uniformly to the surface of the tooth using a
special BCapplicator. This was irradiatedfor 20s usingavisible
light-curing unit (G-light, GC, Tokyo, Japan), and the non-
polymerized layers were removed with dry gauze. Finally,
Gloss Rene (Shofu Inc., Kyoto, Japan) was applied to the tooth
surface, which was then polished with a bufng disk and
washed.
For the clinical evaluation of the tooth-surface coating
material, shedding and partial fracturing of the tooth surface
were observed at 1 week, 1 month, and 3 months after coating
treatment. Photographs of the oral cavity were taken to eval-
uate fractures. Fractured areas covering less than 5% of the
surface area of the labial side of the tooth were classied as
small fractures, and those covering 5% or more of the surface
were classied as fractures.
During observation, affected teeth in which fractures
occurredwerere-coated; at thispoint, theseteethwereexcluded
from the study. Moreover, if a tooths color made it difcult to
determine the presence of fractures through photographs or
surveys, a replica was made from a silicone impression, which
was then observed with a stereomicroscope (SZX12, Olympus,
Tokyo, Japan).
2.4. Satisfaction survey regarding the tooth-surface
coating material
A questionnaire was administered to the 30 affected children
and their parents. The questionnaire contained questions
concerning the level of satisfaction with the tooth-surface
coating material treatment of discolored teeth. The subjects
p e d i a t r i c d e nt a l j our na l 2 3 ( 2 0 1 3 ) 4 4 e5 0 45
were surveyed immediately after the coating treatment, 1
month after treatment, and 3 months after treatment. The
possible responses were: a) very satised, b) satised, c)
neutral, and d) not satised.
3. Results
3.1. Effect of the primer used in the tooth-surface
coating material on enamel surface characteristics
We evaluated the effect of the primer that is used before
applying the tooth-surface coating material on enamel sur-
face characteristics. To examine the effect of primer on tooth,
the primer was applied to the enamel surface of bovine teeth.
After performing gold-evaporation treatment, the enamel was
observed under a SEM. The enamel surfaces treated with a
37% phosphoric acid solution displayed decalcication, and
the enamel rods were exposed as in previous reports (Fig. 1C).
However, in the group treated with the primer, there was no
marked decalcication of the enamel surface, and the surface
characteristics were similar to the control (untreated) group
(Fig. 1A and B). These results suggest that this primer has few
adverse effects on the enamel.
3.2. Evaluation of shear bond strength of the tooth-
surface coating material
In order to evaluate the SBS of the tooth-surface coating ma-
terial, the material was bonded to enamel, dentin, precious
metal, and porcelain using a brass ring, after which the SBS
was measured. SBS of 10 MPa or more was observed in enamel
and dentin 24 h after adhesion. Maintenance of high bond
strength was conrmed in the group that received thermal
cycle treatment as well. SBS in precious metal and porcelain
was inferior to that of enamel and dentin (Fig. 2), but the
tooth-surface coating material displayed sufcient SBS more
than 10 MPa after a thermal cycle.
3.3. Clinical evaluation of the tooth-surface coating
material
After applying the tooth-surface coating material, shedding
and fracturing of the tooth surface were investigated. The
coating material was applied to the teeth of 32 subjects (38
teeth). Of these, investigations were conducted in 30 subjects
(36 teeth) 1 week after application, in 26 subjects (31 teeth) 1
month after application, and in 21 subjects (25 teeth) 3 months
after application. Shedding and fracturing were observed in 5
of 36 teeth (13.9%) 1 week after applying the tooth-surface
Fig. 1 e Scanning electron microscope micrographs of the enamel surface. (A) is the non-treated enamel surface. (B) and (C)
are the enamel surfaces after treatment by BeautiCoat Primer (Shofu Inc., Kyoto, Japan) for 3 s and 37% phosphoric acid for
30 s respectively.
Fig. 2 e The shear bond strength of the tooth-surface
coating material to enamel, dentin, precious metal,
porcelain, and resin were evaluated.
p e d i a t r i c d e nt a l j o ur na l 2 3 ( 2 0 1 3 ) 4 4 e5 0 46
coating material, 10 of 31 teeth (32.2%) 1 month after, and 8 of
25 teeth (32.0%) 3 months after (Table 1). Most of the fracturing
was observed on the incisal margin and cervix of the incisors
(Fig. 3). In 1 case, there was complete shedding of the coating
material from the tooth surface, which occurred at 1 month
after application. In this case, the child was not satised with
the color of the application. The child attempted to remove
the coating material, which resulted in complete shedding of
the material. Thus, there were no cases of complete shedding
under normal conditions.
3.4. Satisfaction with the tooth-surface coating material
The affected teeth mainly involved white turbidness of the
labial surface of the upper incisors, tooth substantial defect in
the crown, or generalized crown discoloration caused by pulp
necrosis due to trauma. The subjects reported being very
satised and satised in 23 of 24 cases (95.8%) immediately
after the procedure, in 19 of 20 cases (95.0%) 1 month after,
and in 17 of 17 cases (100%) 3 months after (Fig. 4).
Although this is a preliminary study, color improvements
after treatment with the tooth-surface coating material were
examined in different cases. In one case involving white
turbidness of the labial surface of the tooth, there was a
marked difference in color on the borders of the turbid and
normal areas. Applying a highly transparent paint did not
sufciently improve the tooth color, and the parent was not
satised with the result. Therefore, a white base with a lower
level of transparency was applied to the border areas to
obscure their edges, and the paint color was then applied. This
improved the parents level of satisfaction.
In a case involving brown-colored enamel hypoplastic
defect accompanied by substance loss of the labial surface of
the tooth, the white base with the lowest transparency, BW3,
was applied. After this, paint color A3 was used, which
resulted in color improvement (Fig. 5).
Fig. 6 shows a case inwhichtrauma to the upper-left lateral
and central deciduous incisors at age 1 year 6 months led to
early loss of the tooth from pulp necrosis, which caused early
eruption of the permanent tooth (upper central incisor) at age
4 years 3 months. The prior trauma caused spots on areas of
low enamel formation. As there was a difference in color
Table 1 e Frequency of shedding and fracturing of the
tooth-surface coating material.
Patient
no.
Tooth
no.
None Fracture
(5%<)
Fracture
(5%>)
Fallout
1 week 30 36 31 (86.1%) 3 (8.3%) 2 (5.6%) 0 (0%)
1 month 26 31 21 (67.7%) 8 (25.8%) 1 (3.2%) 1 (3.2%)
3 months 21 25 17 (68.0%) 5 (20.0%) 3 (12.0%) 0 (0%)
Fig. 3 e Shedding and fracturing of the tooth-surface coating material from the tooth were observed using replica model. (A)
is frontal view of fractured materials, and (B) is another case. (B-a): frontal view and (B-b) is incisal view.
Fig. 4 e Satisfaction with the tooth-surface coating material
was investigated immediately after the procedure, and 1
month after, and 3 months after.
p e d i a t r i c d e nt a l j our na l 2 3 ( 2 0 1 3 ) 4 4 e5 0 47
between the crown of the permanent tooth and the deciduous
teeth, the subject desired color improvement of the anterior
teeth. Paint color A0.5, which was close to the crown color of
the deciduous teeth, was applied to the surface of the per-
manent tooth. Coating of the permanent tooth crown with A3
led to an even higher level of satisfaction. In this case, because
the tooth-surface coating was performed during eruption of
the tooth, a difference in level between the tooth-gingival
margin and the coating material was observed on the labial
side of the tooth cervix 10 months after application. Further, a
microscopic fracture was observed on the mesial periphery of
the coating material. This fractured area was re-coated, and
no fracturing was observed 4 months later. However, a new
fracture was observed in the incisal margin (Fig. 7).
Fig. 5 e Clinical cases before and after treatment by the tooth-surface coating material to the case with white-colored
enamel hypoplastic defect.
Fig. 6 e Clinical cases before and after treatment by the tooth-surface coating material to the case with discolored
permanent tooth caused by the trauma of deciduous tooth.
p e d i a t r i c d e nt a l j o ur na l 2 3 ( 2 0 1 3 ) 4 4 e5 0 48
4. Discussion
S-PRG ller was developed as an advanced material that can
recharge and release uoride and other ions. This PRG ller
possesses the excellent characteristics of bothresins and glass
ionomer cements through its incorporation of resin-type
materials [14]. These materials are generally termed giomer
products, which are currently sold as composite resin,
bonding material, resin cement, sealant material, tooth-
surface coating material, and bonding material for use in
teeth straightening [15]. Furthermore, recent developments in
tooth-surface treatment agents have ledto the development of
tooth-surface coating materials that use self-etching primers.
These have allowed for relatively long-term retention of the
coating materials onthe toothsurface. This study investigated
a tooth-surface coating material that uses a self-etching
primer containing this S-PRG ller to treat teeth with dis-
colored crowns, which are frequently observed in pediatric
clinical practice.
The primer for the tooth-surface coating material used in
this study uses a methacrylate monomer 6-methacryloxyhex-
ylphosphonoacetate with an acidic base and an adhesive
monomer that is resistant to moisture. Observation under a
SEM demonstrated that this primer did not cause marked sur-
face decalcication of the enamel, and there was little damage
to the enamel. Thus, this gentle tooth-surface treatment ma-
terial is appropriate for use inthe immature permanent teeth of
childhood. Further, the tooth-surface coating material had
sufciently high bonding strength in shear bond tests and even
possessed high bonding strength with metal and porcelain
surfaces. This material is applicable for the repair of porcelain
fractures or discoloration as well as the esthetic improvement
of metal repairs. However, as this material has less bonding
than resin-type materials, it is a temporary method.
In actual clinical applications, apart from a single case where
the child intentionally removed the coating, no cases of natural
shedding were observedduring 3 months of observation. Incases
where fracturing occurred, the fractures appeared mostly in the
incisal margins involved in occlusion. However, there were no
malocculusions, suchastheedge-to-edgeocclusionandcrossbite
in these subjects. This suggests that fracture of coating materials
could be prevented by avoiding the incisal margin during the
coating procedure. In fractures near the gingival margin, perme-
ation of liquid from the gingival sulcus likely inuenced bonding
strength; however, fractureswerepreventedinthisareawhenthe
procedure was conducted under complete moisture prevention.
Therefore, more stable, long-term tooth-surface coating can be
achieved by completely preventing moisture using a rubber dam
and adjusting the extent of coating in the incisal margin area.
Furthermore, this tooth-surface coating material contains
S-PRGller, whichcansuppress bacterial plaque adhesionand
canrecharge and control the release of uoride and other ions.
The cavity-preventing effect of uoride ions is well known, but
of other ions released by this ller, strontium ions are partic-
ular in their ability to resist acid release from dental plaque,
inhibit bone resorption, promote bone formation, induce
calcication in dentin, and seal dentinal tubules [7,16e19].
Based on these functions, coating tooth surfaces with this
material not only achieves esthetic improvement, but also can
increase acid resistance, remineralization, and suppress adhe-
sion of plaque and bacteria to the tooth surface [6]. Further, this
material showed higher uoride release compared with con-
ventional sealant, but not glass ionomer cement (data not
shown). Thus, this coating material not only covers the surface,
but can also contribute to cavity prevention in the surrounding
area, which makes it appropriate for use in childhood. Indeed,
discolored portions of teeth have low calcication, and the
cavity rate tends to be high. Nevertheless, there were nocavities
observed in the affected teeth treated with this tooth-surface
coating or in the neighboring teeth.
Moreover, tooth discoloration caused by tetracycline anti-
biotics darkens over time due to the effect of ultra-violet rays
[20]. Although no such cases were included in this study,
Fig. 7 e Clinical progress of the case treated by the tooth-surface coating material for the erupting tooth. This is the same
case as that shown in Fig. 6.
p e d i a t r i c d e nt a l j our na l 2 3 ( 2 0 1 3 ) 4 4 e5 0 49
application of this tooth-surface coating material could limit
the progression of discoloration by blocking ultra-violet rays
[21]. The degree of satisfaction with the tooth-surface coating
material among affected children and their parents was
extremely high in this study. Even in cases that involved frac-
tures, the fractures themselves did not inuence the degree of
satisfaction, since the subjects were informed beforehand that
the procedure is a temporary method. Rather, because the
coating could be removed from the tooth to return it to its
normal state with almost no damage, the coating could be used
without worry, and color improvement could be tested easily.
Further, in a case of partial fracture of coating material, since it
is easily removable, it may be re-coated after removal.
In addition to the subjective evaluation of patient satis-
faction, further research on chronological changes for prog-
nosis prediction, such as quantication of color changes,
abrasion by tooth brush, and effect of the thickness of coating
material and occlusion is important in the future.
5. Conclusion
The results from the present study suggest that this tooth-
surface coating material is extremely useful for improving
color in teeth with discolored crowns in pediatric dental
practice. It is a valuable dental material that can improve es-
thetics as well as prevent cavities and strengthen teeth.
Disclosure
None of the authors has any conicts of interest that should
be declared.
r e f e r e n c e s
[1] Conchie JM, Munroe JD, Anderson DO. The incidence of
staining of permanent teeth by the tetracyclines. Can Med
Assoc J 1970;103:251e5.
[2] Antonini LG, Luder HU. Discoloration of teeth from
tetracyclines e even today? Schweiz Monatsschr Zahnmed
2011;121:414e31.
[3] Fujita M, Kawakami S, Noda M, et al. Color change of newly
developed esthetic restorative material immersed in food-
simulating solutions. Dent Mater J 2006;25:352e9.
[4] Manabe A, Kanehira M, Finger WJ, et al. Effects of opacity and
oxygen inhibition of coating resin composites on bond
strength to enamel. Dent Mater J 2009;28:552e7.
[5] Ikemura K, Tay FR, Endo T, et al. A review of chemical-
approach and ultramorphological studies on the
development of uoride-releasing dental adhesives
comprising new pre-reacted glass ionomer (PRG) llers. Dent
Mater J 2008;27:315e39.
[6] Iwaya I, Mukai Y, Fukukawa H, et al. Evaluation of enamel
acid resistance acquired under a temporary esthetic coating
material. J Dent Health 2009;59:125e31 [in Japanese].
[7] Simazu K, Ogata K, Karibe H. Evaluation of the ion-releasing
and recharging abilities of a resin-based ssure sealant
containing S-PRG ller. Dent Mater J 2011;30:923e7.
[8] Tomiyama K, Mukai Y, Teranaka T. Acid resistance induced
by a new orthodontic bonding system in vitro. Dent Mater J
2008;27:590e7.
[9] Mukai Y, Kamijo K, Fujino F, et al. Effect of denture base-
resin with prereacted glass-ionomer ller on dentin
demineralization. Eur J Oral Sci 2009;117:750e4.
[10] Kamijo K, Mukai Y, Tominaga T, et al. Fluoride release and
recharge characteristics of denture base resins containing
surface pre-reacted glass-ionomer ller. Dent Mater J
2009;28:227e33.
[11] Han L, Okiji T. Evaluation of the ions release/incorporation of
the prototype S-PRG ller-containing endodontic sealer. Dent
Mater J 2011;30:898e903.
[12] Mukai Y, Tomiyama K, Shiiya T, et al. Formation of inhibition
layers with a newly developed uoride-releasing all-in-one
adhesive. Dent Mater J 2005;24:172e7.
[13] Han L, Okamoto A, Fukushima M, et al. Evaluation of a new
uoride-releasing one-step adhesive. Dent Mater J
2006;25:509e15.
[14] Mousavinasab SM, Meyers I. Fluoride release by glass
ionomer cements, compomer and giomer. Dent Res J
2009;6:75e81.
[15] Nakamura N, Yamada A, Iwamoto T, et al. Two-year clinical
evaluation of owable composite resin containing pre-
reacted glass-ionomer. Pediatr Dent J 2009;19:89e97.
[16] Thuy TT, Nakagaki H, Kato K, et al. Effect of strontium in
combination with uoride on enamel remineralisation
in vitro. Arch Oral Biol 2008;53:1017e22.
[17] Saku S, Kotake H, Scougall-Vilchis RJ, et al. Antibacterial
activity of composite resin with glass-ionomer ller
particles. Dent Mater J 2010;29:193e8.
[18] Fujimoto Y, Iwasa M, Murayama R, et al. Detection of ions
released from S-PRG llers and their modulation effect. Dent
Mater J 2010;29:392e7.
[19] Yoneda M, Suzuki N, Masuo Y, et al. Effect of S-PRG eluate on
biolm formation and enzyme activity of oral bacteria. Int J
Dent 2012;2012. 814913.
[20] Ohno K, Kawasaki K, Tanaka S, et al. An experimental study
on the mechanism of tooth pigmentation and discoloration.
Jpn J Ped Dent 1976;14:285e99 [in Japanese].
[21] Fukui M, Shiraishi M, Yamamoto K. Characteristics of
esthetics coating material and inuence on tooth substrate.
Jpn J Conserv Dent 2008;51:24e39 [in Japanese].
p e d i a t r i c d e nt a l j o ur na l 2 3 ( 2 0 1 3 ) 4 4 e5 0 50