pediatria polska 90 (2015) 155160

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Case report/Kazuistyka

Green teeth resulting from neonatal

hyperbilirubinemia: Report of a case

Norma Suely Falco de Oliveira Melo 1, Regina Paula Guimares

Vieira Cavalcante da Silva 2, Antonio Adilson Soares de Lima 1,*
1
Department of Stomatology, School of Dentistry, Universidade Federal do Paran UFPR, Curitiba-PR, Brazil
2
Department of Pediatrics, School of Medicine, Universidade Federal do Paran UFPR, Curitiba-PR, Brazil

article info abstract

Article history: In general, cosmetic changes or painful disorders often lead parents to seek dental care
Received: 05.11.2014 for their children. Several systemic disorders in pediatric patients can produce dental
Accepted: 11.12.2014 alterations. One of the manifestations of these disorders is the elevated serum level of
Available online: 23.12.2014 bilirubin (hyperbilirubinemia), a product of hemoglobin degradation, which is deposited
in mineralized and soft tissues. The aim of this article is to report a case of green teeth
Keywords: affecting all deciduous teeth in a 3-year-old girl. The patient was taken to see the dentist
 Hyperbilirubinemia by their parents due to the presence of green pigmentation in the teeth. During birth, the
 Dental enamel patient suffered a traumatic injury that resulted in hyperbilirubinemia. This kind of ena-
 Deciduous teeth mel pigmentation is permanent and occurred during the period of dental development.
 Tooth discoloration 2015 Published by Elsevier Sp. z o.o. on behalf of Polish Pediatric Society.

substances and bacteria, which represent deposits, adhered

Introduction
Changes in the normal color of deciduous and permanent
teeth may occur due to factors intrinsic or extrinsic. The
intrinsic stains are changes in the color of the tooth related
to systemic factors such as: genetic factors, birth defects,
metabolic defects, prenatal care, infectious diseases, neurolo-
gical disorders, endocrine, kidney, liver, nutritional decien-
cies and poisoning that usually occurred during odontogene-
sis [1]. Moreover, the formation of the extrinsic stains on
teeth occurs primarily from the remains of food, medicinal
to the enamel [2].
The intrinsic dental pigmentation is associated with
a chemical active change in the tooth structure and it
cannot be removed without changing the structure of the
tooth. It can be caused by erythropoietic porphyria, fetal
erythroblastosis, amelogenesis imperfecta, dental uorosis,
hyperbilirubinemia, decomposition of red blood cells and
medications (tetracycline) [3].
Bilirubin, a breakdown product of heme, is normally
excreted in the bile or further catabolized before excretion
in the urine. Approximately 80% of bilirubin is derived
from free hemoglobin resulting from hemocaterese. In this

* Corresponding author at: School of Dentistry Department of Stomatology, Universidade Federal do Paran UFPR, Rua Prefeito
Lothrio Meissner 632, Jardim Botnico, 80170-210 Curitiba-PR, Brazil. Tel.: +55 41 33604050; fax: +55 41 33604134.
E-mail address: aas.lima@ufpr.br (A.A.S. de Lima).
http://dx.doi.org/10.1016/j.pepo.2014.12.004
0031-3939/ 2015 Published by Elsevier Sp. z o.o. on behalf of Polish Pediatric Society.
156 pediatria polska 90 (2015) 155160

physiological process, senescent red cells with approxima-

tely 120 days are destroyed by macrophages in the spleen,
liver and bone marrow. Hyperbilirubinemia is a clinic condi-
tion characterized by an abnormal increase of bilirubin in
the blood, which may result in jaundice. The jaundice is the
clinical sign caused by the elevation of serum bilirubin
levels and its deposition in the skin, sclera, mucous mem-
branes and some organs (liver and kidneys). The deposition
of this pigment in these tissues and organs produces a color
ranging from yellow to black, passing through various
shades of green [4].
All healthy neonates develop unconjugated hyperbilirubi-
nemia during the rst week of life, but 50% of these patients
have jaundice, benign and transient in character [5]. Jaun-
dice occurs when the liver fails to eliminate bilirubin Fig. 2 Lateral incisor, canine, and first primary molar with
produced by the body [6]. Severe neonatal hyperbilirubine- enamel hypoplasia and green pigmentation
mia carries a potential for permanent neurological impair-
ment [7]. Furthermore, hyperbilirubinemia is associated with
the development of changes in color of the teeth, known as
green teeth [8]. These teeth do not show changes in their
morphology. However, the green coloration considerably Furthermore, the tip of the cusp canine was also pigmented.
affects the esthetics of the affected tooth. The appearance The clinical crown of all teeth showed hypoplasia areas
of the dentition is of concern to a large number of people between the middle and incisal thirds (Fig. 2). The teeth
seeking dental treatment and the color of the teeth is of of the lower arch also showed a green coloration on the
particular cosmetic importance [9]. The purpose of this crown (Fig. 3). At this time, the child has not had the eruption
report is to present a case of green teeth of the primary of the primary second molars. The upper and lower canines
dentition in a 3-year-old Brazilian girl. had green pigmentation in the incisal half of the crown. The
pigmentation of the rst primary molars reached of the
crown. According to the presence of this green pigmentation
Report of a case in the crown of teeth, a diagnosis of green teeth associated
with a systemic disorder has been established.
A patient of 2 years was brought for consultation by the The past medical history revealed that the child's mother
mother due to the presence of green teeth in the mouth. The was 28 years old and that she had consulted 4 times during
intraoral examination showed the presence of anterior pri- the prenatal period. During pregnancy, the mother had
mary teeth with a green aspect. All deciduous teeth were a urinary tract infection that was treated with cephalexin.
affected. No other changes involving the oral soft tissues The mother was admitted in premature labor and prema-
were observed. According to the story told by the mother, the ture rupture occurred an hour earlier. The child was born by
teeth were erupting in the mouth with a discoloration. The cesarean section with difcult extraction. The indication for
pigment involved about 5/6 of the crown of the incisor teeth this type of delivery was due to dystocia progression.
(Fig. 1). At 3 years of age, the child presented with the rst At birth, the child had been in gestation for 31 weeks
primary molars with half of the crown pigmented (Fig. 2). and was weighing 1660 g. The cause of preterm birth was

Fig. 1 Upper incisors showing discoloration and areas of

enamel hypoplasia Fig. 3 Clinical appearance of green teeth in the lower arch
 pediatria polska 90 (2015) 155160 157

premature rupture of membranes. After birth, the child

proved to be hypotonic, cyanotic and did not cry. A cycle of
positive-pressure ventilation and cardiac massage for reco-
very were made. In addition, she was intubated in the
delivery room. The newborn had neonatal asphyxia and
slow infusion. In addition, the child had tocotraumatism,
anemia, bloating, and early sepsis. The child was treated
with ampicillin, gentamicin, dopamine, furosemide, pipera-
cillin, tazobactam, dopamine, dobutamine, fentanyl and
metronidazole. A diagnosis of large lesion in subcapsular
hepatic lobe was established and it was classied as grade II
splenic laceration that was treated expectantly. Infection of
the child was treated for 52 days and the child remained
intubated (intubation) for 12 days due to apnea and surfac-
tant administration.
During her stay in the Intensive Care Unit, volume
globular and bilirubin levels were investigated (Table I).
Jaundice was diagnosed on the second day of life by
yellowish discoloration of the skin during routine physical
examination. The pathological jaundice was treated with
phototherapy. The child had the same blood type (A
positive) as the mother and received packed red blood cells.
The child presented with hyperbilirubinemia for about 2
months.
The mother was instructed on the importance of diet
and oral hygiene was reinforced. As the green pigmentation
affected the deciduous dentition and there was a possibility
it could also occur in the permanent dentition, the child's
mother was advised to return for follow-up dental. No
cosmetic treatment has been established in affected tooth.
As the child was premature, we observed a delayed eruption
of deciduous teeth and consequently also in the permanent
dentition.
Discussion
Bilirubin is produced mainly by degradation of the hemoglo-
bin of red blood cells, the nal product of the catabolism of
heme [6]. The clinical jaundice in newborns occurs when
bilirubin levels in blood plasma reaches values between
5 and 7 mg/dL. Severe neonatal hyperbilirubinemia, when
unmonitored or untreated, can progress to acute bilirubin
encephalopathy [10].
Neonatal jaundice is one of the most common problems
for newborn infants during the rst weeks of life, affecting
approximately 6070% of term babies and almost all prema-
ture babies [11]. According to Shrestha et al. [13], the risk
factors associated with preterm birth are: inadequate ante-
natal checkup (52%), maternal age <20 years (34.7%), ante-
partum hemorrhage (23.4%) and pregnancy induced hyper-
tension (13.1%). Morbidities more commonly observed in
preterm infants are: clinical sepsis (66.7%), hyperbilirubine-
mia (58.8%), birth asphyxia (26.8%) and hyaline membrane
disease (23.5%) [12]. The patient in this case report showed
the major health problems related to prematurity, especially
sepsis, neonatal jaundice, and apnea. In this case, bilirubin
was considered pathologic due to lesion in the subcapsular
lobe resulting from tocotrauma. The levels of total bilirubin
reached 30.58 mg/dL in the 18th day of life.
According to Watanabe et al. [12], total bilirubin levels
between 1.2 and 1.8 mg/dL are already capable of inducing
pigmentation tooth. These authors have identied levels of
bilirubin in deciduous teeth obtained from 2 patients with
a history of severe liver dysfunction and hyperbilirubinemia.
The teeth were histologically analyzed and bilirubin was
extracted and quantied by spectrophotometry. Histological

Table I Values of globular volume and levels of bilirubin of the patient

Date Globular volume Direct bilirubin Indirect bilirubin Total bilirubin
June 18 16% N N N
June 19 32.9% N N N
June 20 33.6% 3.27 mg/dL 9.29 mg/dL 12.56 mg/dL
June 21 37.5% 3.27 mg/dL 9.29 mg/dL 12.56 mg/dL
June 22 35.2% Absence of bilirubin in the
partial examination of urine
June 23 38.3% 11.97 mg/dL 8.11 mg/dL 20.08 mg/dL
June 25 32.2% Jaundice++/4+
June 28 30.1% 11.55 mg/dL 23.25 mg/dL 11.70 mg/dL
June 30 41.0% N N N
July 1 37.4% N N N
July 2 36.0% N N N
July 3 34.4% N N N
July 4 34.0% 20.25 mg/dL 8.08 mg/dL 28.33 mg/dL
July 5 46.0% 21.12 mg/dL 9.46 mg/dL 30.58 mg/dL
July 9 43.9% N N N
July 11 34.9% N N N
July 13 N 10.6 mg/dL 4.02 mg/dL 14.68 mg/dL
July 17 33.2% N N N
July 20 30.9% N N N
July 21 N 9.14 mg/dL 1.67 mg/dL 10.81 mg/dL
July 27 26.0% 10.46 mg/dL 5.35 mg/dL 15.18 mg/dL

N = sample not collected.

158 pediatria polska 90 (2015) 155160
analysis revealed a green line parallel to the incremental
lines of dentin. These authors analyzed the deciduous
canine of a child with a history of biliary atresia and
congenital hyperbilirubinemia at birth that showed that the
tooth were colored brown in the middle of the crown to half
of the root. The other case was a boy of 7 years of age with
a history of hemolytic anemia and hyperbilirubinemia at 18
months of life showed total bilirubin levels 2060 mg/dL.
The upper central incisors and lateral incisors had a change
of color of green. Furthermore, this color change reached
half incisal of the dental crown. These ndings were similar
to those observed in primary teeth of children of this report.
The normal color of teeth is determined by the shades of
blue, green and pink of the enamel and is reinforced by
shades of brown or yellow dentin below. Metabolic diseases
and systemic factors can affect the development of teeth
and cause tooth discoloration, such as: alkaptonuria, eryth-
ropoietic porphyria congenital, amelogenesis imperfecta,
dentinogenesis imperfecta, tetracycline stain, and congenital
hyperbilirubinemia. However, the teeth do not show morp-
hological changes [9]. The patient in this case report had
green teeth and areas of enamel hypoplasia. Despite these
changes, the teeth remained preserved in its form.
The areas of enamel hypoplasia observed in the crown of
the anterior teeth may be associated with systemic factors
and intubation, because the child remained intubated for 12
days. The literature reveals that tracheal intubation in the
neonatal period can cause enamel hypoplasia [14, 15].
The occurrence of hyperbilirubinemia in childhood is an
important fact because the consequences of this systemic
disorder can seriously compromise the color of teeth. The
rst report of case about green teeth associated with
jaundice was performed by Weyers [16] in 1956. Since then,
the dental literature shows some reports of patients who
developed green teeth associated to neonatal hyperbilirubi-
nemia [1728].
It is known that the location and extent of pigmentation
tooth corresponds to the period of tooth formation [28]. In
this case report, the patient presented dental pigmentation
in the crown of all deciduous teeth. These dental changes
corresponded to the period when she was admitted to the
Intensive Care Unit. Normally, deciduous tooth calcication
process begins in the 4th month of intrauterine life and
nishes 11 months after birth. The dental crown of incisors
is completely formed 1 month after birth and the canines
and molars after 6 months [29]. According to current
knowledge, enamel mineralization proceeds in 2 steps. At
rst, ameloblasts secrete a protein matrix in which hydro-
xyapatite crystals are deposited up to a concentration of
about 25%. In a second step, the enamel maturation, enamel
matrix proteins are degraded and resorbed almost comple-
tely, while hydroxyapatite crystals grow in thickness, until
the enamel attains a mineral content of about 95%. Conse-
quences of this formation in 2 stages are also evident in the
wisdom teeth showing crown pigmentation [30].
Enamel formation can be disrupted during the course of
a systemic disorder, and all the teeth that form in this
period may be marked by bands of enamel malformed.
After healing of illness, the formation of normal enamel
is restored again. Disorders induced by tetracycline or
bilirubin showed clinically the time of injury to the tooth
germ by the incorporation of these substances to the
enamel [12, 31].
In this case, the patient report presented different levels
of pigmentation of deciduous teeth. The crowns of the
central and lateral incisors were more affected as half of
their crowns were affected. The pigmentation was observed
involving only half of the crown of the molars. Moreover,
canine teeth were the least affected. As calcication of the
permanent dentition has its beginning from birth, the
possibility of dental pigmentation affecting the permanent
teeth, especially the rst molar, has not been ruled out.
High serum bilirubin levels favor the deposition of the
product of hemoglobin degradation in many tissues, inclu-
ding soft tissue and mineralized tissues. When hyperbiliru-
binemia occurs during dental development, the teeth can
develop a green color due to the bilirubin deposition. This
intrinsic pigment keeps teeth permanently pigmented. The
blood vessels of the dental follicle are the source of
nutrients for the ameloblasts to synthesize the tooth
enamel [32]. Thus, the pigmentation of the tooth is most
likely the result of the pigment passing through the
bloodstream to ameloblasts and, then, to the tooth enamel.
Bilirubin is a yellow pigment. However, when this pigment
undergoes oxidation it becomes a green pigment otherwise
called biliverdin. In the past, it was believed that the
accumulation of this pigment was responsible for the green
teeth associated with hyperbilirubinemia. However, a study
developed by Shibata et al. [33] proved that the green color
comes from the accumulation of bilirubin and not of
biliverdin.
The correct diagnosis for the cause of dental discolora-
tion is important as, invariably, it has a profound effect on
treatment outcomes. According to Shibata et al. [33], the
diagnosis of bilirubin pigmentation is usually based on
a clinical history of jaundice combined with the green
coloration. Therefore, it would seem reasonable that health
care providers have an understanding of the etiology of
tooth discoloration in order to diagnose and recommend
a more appropriate treatment.
Actually, cosmetic dentistry is presented as a source to
meet the esthetic and functional wishes of patients and
professionals. The tooth whitening is a technique used to
solve the esthetics of discolored teeth. It can be performed for
both vital and non-vital teeth. Various chemicals such as 35%
hydrogen peroxide, carbamide peroxide and sodium perbo-
rate and others are employed [34]. In general, the esthetic
result of whitening of natural teeth has a better result when
compared to the restoration or resin crowns. In this case, the
natural appearance of the enamel is more esthetic in relation
to restorative materials. The rst reports of tooth whitening
in primary teeth indicate the use of carbamide peroxide 10%
for treatment of dental uorosis. This technique requires
a high level of adherence of the patient and the esthetic
result does not always guarantee long treatment time due to
the limited life of these teeth [35].
Moreover, some adverse effects of the tooth whitening
may occur, such as: the external root resorption and dentin
sensitivity [36]. According to Lee et al. [37], the use in
children and adolescents of some dental bleaching agents
 pediatria polska 90 (2015) 155160
containing carbamide shows that: (1) 1 in every 23 patients
may experience tooth sensitivity and/or gingival irritation
after bleaching treatment, which may be more traumatic an
experience for children than adults; (2) depending on dose,
duration, frequency, and route, studies indicate excessive
exposure to peroxide can be potentially harmful; (3) degree
of potential toxicity and harmful outcomes increases in
those who overuse whiteners a concern in teenagers; (4)
careful case selection using stringent criteria is suggested
for primary teeth whitening; (5) whitening in healthy
adolescents is a case-by-case determination that must
include the weighing of risks (oral health and age) vs
benets (improved esthetic perception). However, there are
some options of treatment for green teeth in the permanent
dentition, such as: composite veneers, crowns, esthetic
facets and possibly bleaching [18, 19, 27].
Authors' contributions/Wkad autorw
According to order.
Conict of interest/Konikt interesu
None declared.
Financial support/Finansowanie
None declared.
Ethics/Etyka
The work described in this article has been carried out in
accordance with The Code of Ethics of the World Medical
Association (Declaration of Helsinki) for experiments invol-
ving humans; EU Directive 2010/63/EU for animal experi-
ments; Uniform Requirements for manuscripts submitted to
Biomedical journals.
r e f e r e n c e s / p i s m i e n n i c t w o
[1] Machado MAM, Telles PDS, Silva SMB. Diagnstico de
manchas no esmalte. Rev APCD 2001;55(3):206209.
[2] Costa SC, Imparato JCP, Franco AEA, Camargo MCF. Estudo
da ocorrncia de manchas extrnsecas negras em crianas e
sua relao ao baixo ndice de crie dental. Rev Odontol
Univ Santo Amaro 1997;5(4):3638.
[3] Igreja G, Miotto MHMB, Baptista G. Estudo dos fatores
responsveis por manchas dentrias extrnsecas. UFES Rev
Odontol 1999;1(2):3641.
[4] Brasileiro Filho G. Bogliolo Patologia Geral, 4th ed., Rio de
Janeiro: Guanabara Koogan; 2009.
[5] Furzn JA, Expsito M, Luchn C. Correlacin entre
bilirrubina srica y bilirrubinometra transcutnea en
neonatos estraticados por edad gestacional Correlation
between serum bilirubin and transcutaneus
159
bilirubinometry in newborns stratied by gestation age
Arch Venez Pueric Pediatr 2007;70(2):3946.
[6] McDonagh AF, Lightner DA. Like a shrivelled blood orange'
bilirubin, jaundice, and phototherapy. Pediatrics 1985;75
(3):443455.
[7] Cheng SW, Chiu YW, Weng YH. Etiological analyses of
marked neonatal hyperbilirubinemia in a single institution
in Taiwan. Chang Gung Med J 2012;35(2):148154.
[8] Sommer S, Magagnin K, Kramer PF, Tovo MF, Bervian J.
Green teeth associated with neonatal hyperbilirubinemia
caused by biliary atresia: review and case report. J Clin
Pediatr Dent 2010;35(2):199202.
[9] Watts A, Addy M. Tooth discolouration and staining:
a review of the literature. Br Dent J 2001;190(6):
309316.
[10] Hameed NN, Na' Ma AM, Vilms R, Bhutani VK. Severe
neonatal hyperbilirubinemia and adverse short-term
consequences in Baghdad, Iraq. Neonatology 2011;100
(1):5763.
[11] American Academy of Pediatrics Subcommittee on
Hyperbilirubinemia. Management of hyperbilirubinemia in
the newborn infant 35 or more weeks of gestation.
Pediatrics 2004;114(1):297316.
[12] Watanabe K, Shibata T, Kurosawa T, Morisaki I, Kinehara M,
Igarashi S, et al. Bilirubin pigmentation of human teeth
caused by hyperbilirubinemia. J Oral Pathol Med 1999;28
(3):128130.
[13] Shrestha S, Dangol SS, Shrestha M, Shrestha RP. Outcome of
preterm babies and associated risk factors in a hospital. J
Nepal Med Assoc 2010;50(180):286290.
[14] Seow WK, Brown JP, Tudehope DI, O'Callagan M.
Developmental defects in the primary dentition of low
birth-weight infants: adverse effects of laryngoscopy and
prolonged endotracheal intubation. Pediatric Dent 1984;6
(1):2831.
[15] Johnsen D, Krejci C, Hack M, Fanaroff A. Distribution of
enamel defects and the association with respiratory
distress in very low birthweight infants. J Dent Res
1984;63:5964.
[16] Weyers H. Development of green teeth (chlorodontia) in
children with icterus gravis. Kinderarztl Prax 1956;24
(7):289293.
[17] Zizlavsk V, Tich B. Green teeth as consequence
of hyperbilirubinemia. Cesk Pediatr 1974;29(2):
102103.
[18] Rosenthal P, Ramos A, Mungo R. Management of children
with hyperbilirubinemia and green teeth. J Pediatr 1986;108
(1):103105.
[19] Herbert FL, Delcambre TJ. Unusual case of green teeth
resulting from neonatal hyperbilirubinemia. ASDC J Dent
Child 1987;54(1):5456.
[20] Guimares LP, Silva TA. Green teeth associated with
cholestasis caused by sepsis: a case report and review of
the literature. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2003;95(4):446451.
[21] Alto LA, Pomarico L, Souza IP, Janini ME. Green
pigmentation of deciduous teeth: report of two cases. J Dent
Child (Chic) 2004;71(2):179182.
[22] Tjon A, Ten WE, Houwen RH. Green teeth. Arch Dis Child
2007;92(3):250.
[23] Amaral TH, Guerra CS, Bombonato-Prado KF, Silva FWGP,
Queiroz AM. Tooth pigmentation caused by bilirubin: a case
report and histological evaluation. Spec Care Dentist
2008;28(6):254257.
[24] Naudi AB, Ammari AB, Fung DE. A report of 2 cases of green
pigmentation in the primary dentition associated with
cholestasis caused by sepsis. J Dent Child (Chic) 2008;75
(1):9194.
160 pediatria polska 90 (2015) 155160
[25] Sommer S, Kramer PF, Magagnin K, Tovo MF. Unusual case
of green pigmentation in human teeth resulting from
neonatal hyperbilirubinemia. Gen Dent 2008;56(5):e21e23.
[26] Fernandes KS, Magalhes M, Ortega KL. Green Teeth. J
Pediatr 2011;158(3):510.
[27] Range H, Camy S, Cohen J, Colon P, Bouchard P. Dental
treatment of an adult patient with a history of biliary
atresia. Quintessence Int 2012;43(4):337341.
[28] Morisaki I, Abe K, Tong LS, Kato K, Sobue S. Dental ndings
of children with biliary atresia: report of seven cases. ASDC
J Dent Child 1990;57(3):220223.
[29] Lunt RC, Law DB. A review of the chronology of eruption of
deciduous teeth. J Am Dental Assoc 1974;89:872879.
[30] Schroeder HE. Orale Strukturbiologie.
Entwicklungsgeschichte, Struktur und Funktion normaler
Hart und Weichgewebe der Mundhhle und des
Kiefergelenks, 5th ed., Stuttgart: Thieme; 2000.
[31] Franco KMD, Line SRP, Moura-Ribeiro MVL. Prenatal and
neonatal variables associated with enamel hypoplasia in
deciduous teeth in low birth weight preterm infants. J Appl
Oral Sci 2007;15(6):518523.
[32] Nanci A. Ten Cate's oral histology: development, structure,
and function, 8th ed., St. Louis: Elsevier; 2008.
[33] Shibata T, Watanabe K, Oda H, Arisue M, Kurosawa T,
Tohma M, et al. Experimental bilirubin pigmentation of rat
dentine and its detection by a qualitative analytical
method. Arch Oral Biol 1996;41(5):509511.
[34] Campos SFF, Silva CRG, Cesar ICR, Rego MA. Technique of
evaluation of darkening deciduous teeth by reectance.
Cienc Odontol Bras 2005;8(4):4955.
[35] Brantley DH, Barnes KP, Haywood VB. Bleaching primary
teeth with 10% carbamide peroxide. Pediatr Dent 2001;23
(6):514516.
[36] Fugaro JO, Nordahl I, Fugaro OJ, Matis BA, Mjr IA. Pulp
reaction vital bleaching. Oper Dent 2004;29(4):363368.
[37] Lee SS, Zhang W, Lee DH, Li Y. Tooth whitening in children
and adolescents: a literature review. Pediatr Dent
2005;27:362368.