Leah Conboy, DO

Figure – The green discoloration of this child’s teeth is the result of severe hyperbilirubinemia.
 The child’s bilirubin levels had been elevated above 20 mg/dL for 5 months.

A 26-month-old girl presented   to the general   nephrology clinic for   evaluation of chronic   renal insufficiency. During   the examination, the physician   noted green discoloration of the   teeth (

The child was born at 38 weeks’   gestation via emergency cesarean   delivery for placenta abruptio. Her   weight, length, and head circumference   were appropriate for gestational   age. APGAR scores were 1, 1, 2,   and 4 at 1, 5, 10, and 20 minutes,   respectively. She was intubated   and remained on a ventilator for 4   months. She had persistent hypotension   and oliguria that required inotropic   support with dopamine. At 2   weeks of age, she had meconium   ileus with perforation and disseminated   intravascular coagulation secondary   to peritonitis. 

 sepsis subsequently developed.   She underwent terminal ileal   resection of 15 cm with ileostomy.   At that time, conjugated hyperbilirubinemia   developed, with total and   direct bilirubin levels of 34.7 mg/dL   and 23.2 mg/dL, respectively. This   was probably secondary to sepsis   and total parenteral nutrition.

The bilirubin levels remained   elevated for 5 months, despite treatment   with phenobarbital. The mother   reported that her daughter’s   jaundice had resolved but that when   her primary teeth erupted they had   a greenish discoloration.

CAUSES OF DENTAL PIGMENTATION
 Staining of the teeth in children   has been well documented from various   causes-the most recognized   being tetracycline administration.   Green dental pigmentation (chlorodontia)   is relatively uncommon.

The causes of discolored teeth   can be divided into 2 categories:   intrinsic and extrinsic. Extrinsic   staining occurs when deposition is   outside of the enamel. Common   causes of extrinsic staining include   poor oral hygiene, iron preparations,   dental caries, and fluorosis. Intrinsic   staining is when the stain is incorporated   into the enamel and dentin.

 Intrinsic   staining is most commonly   caused by tetracycline administration   during gestation or during the   years of tooth development. It may   also present as a manifestation of   dentinogenesis imperfecta or amelogenesis   imperfecta, 2 genetic disorders   of tooth development.

 Systemic   illnesses (eg, congenital porphyria   and congenital hypothyroidism) and   metabolic diseases (eg, tyrosinemia   and alpha

-antitrypsin deficiency)   can also cause discoloration of teeth.   Intrinsic green staining of teeth from   hyperbilirubinemia is rare.

GREEN TEETH AS A COMPLICATION OF HYPERBILIRUBINEMIA
 Hyperbilirubinemia causes accumulation   of bilirubin pigment   within the skin and mucous membranes   that manifests as yellow discoloration.   In the newborn, jaundice   becomes apparent on the face at a   serum bilirubin level of about   5 mg/dL; it progresses caudally as   the level increases.

 When bilirubin   levels are elevated for several   months, bilirubin pigments deposit   throughout the body, including the   teeth. Histological evaluation of   green-stained deciduous teeth from   patients with hyperbilirubinemia has   shown bilirubin deposits.

 Intrinsic   staining of primary teeth may vary   in color from yellow to dark green.   In the soft tissues, the pigment is removed   over time. However, in the   hard dental tissues, the pigment becomes   trapped because of the lack   of metabolic activity and thus results   in permanent discoloration.

Neonatal hyperbilirubinemia   occurs in about 60% of newborns   during the first week of life.

 However,   the prevalence of green-stained   teeth associated with hyperbilirubinemia   is unknown. About 50 cases   of green dental discoloration have   been reported, mostly in the dental   literature.

 Most of these cases occurred   in children with hyperbilirubinemia   secondary to biliary atresia.   This raises the question of the role   of direct hyperbilirubinemia in the   pathogenesis of green-stained teeth.   Perhaps because conjugated bilirubin   is more water-soluble, it is able   to be incorporated into the developing   dentition.

Less common causes of green-stained   teeth associated with hyperbilirubinemia   include Rh incompatibility,   ABO incompatibility, hemolytic   disease, and sepsis. In a review   of 48 children with green-stained   teeth secondary to hyperbilirubinemia,   the mean duration of jaundice   was 24.6 weeks and the maximum   serum total bilirubin level was   20 to 90 mg/dL.

 The primary teeth   appear to be most affected, although   staining of permanent dentition   has been reported.

 Often, a sharp   dividing line separates the normal-colored   tooth from the green-stained   portion.

The eruption of the first tooth   is a much anticipated milestone in   the developing child. The advent of   a discolored tooth can be an unsettling   surprise for parents. Thus, it is   important to provide anticipatory   guidance to families of children with   severe hyperbilirubinemia.

MANAGEMENT OF STAINED TEETH
 Treatment of pigmented teeth   is mainly cosmetic. Stained primary   dentition will eventually be replaced   with normal permanent teeth. As   children age, treating the teeth can   help improve self-esteem, although   most experts do not recommend   treatment of primary teeth. Composite   veneers or crowns and bleaching   are 2 of the treatment options available   for stained primary or permanent   dentition.

 Rosenthal P, Ramos A, Mungo R. Managementof children with hyperbilirubinemia and greenteeth. 

 Naudi AB, Ammari AB, Fung DE. A report of2 cases of green pigmentation in the primary dentitionassociated with cholestasis caused by sepsis.

 GuimarÃ£es LP, Silva TA. Green teeth associatedwith cholestasis caused by sepsis: a case report andreview of the literature. 

Oral Surg Oral Med OralPathol Oral Radiol Endod.

 Plazza A, Stoll B. The fetus and the neonatal infant.Digestive system disorders. In: Kliegman R,Behrman R, Jenson H, Stanton B, eds. 

 18th ed. Philadelphia; SaundersElsevier; 2007:756-761.


 Watanabe K, Shibata T, Kurosawa T, et al. Bilirubinpigmentation of human teeth caused by hyperbilirubinemia.

 Herbert FL, Delcambre TJ. Unusual case ofgreen teeth resulting from neonatal hyperbilirubinemia.

Articles

A 26-month-old girl presented  to the general  nephrology clinic for  evaluation of chronic  renal insufficiency. During  the examination, the physician  noted green discoloration of the  teeth.

Leah Conboy, DO

Articles

Green Teeth in a Child With Hyperbilirubinemia