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Bleaching discolored teeth

{Reference: endodontics principles and practice, ch:22}

Discolored teeth can be corrected by restorative procedures such as
crowns and veneers or by non- restorative procedures by bleaching.
Which option should we start with; restorative or non-restorative?
Non-restorative (bleaching), because its:
Less destructive (because in crown preparation and veneers it
involve removing sound tooth structure all around; 1.5mm for
ceramo-metal crown).
Less expensive
Less chair-side time consuming (restorative procedures involve
lab. Work)
Needs less visits
Simple to perform
So, for these reasons; we have to attempt bleaching first if there is a
possibility.
So, bleaching is more conservative, relatively simple to
perform, and less expensive.

Bleaching is mentioned 1400 years ago.

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Causes of discoloration:
A. natural or acquired causes:

1. Pulp necrosis:
The inflammation products of the pulp can permeate dentinal tubules
and this will color the crown, and we see a lot of brown incisors in
real life.
Pulpal products stain dentin, the longer the duration of the pulp
necrosis, the more severity the intensity of the stain.
These teeth can be bleached internally with short and long term
success , so if we have a discolored tooth with necrosis, we can
remove the necrotic tissue and we can change the color by internal
bleaching with reliable success results ; both in short and long term.

## Comments about pictures:
Sinus tract always indicate the loss of vitality {pus discharge},
the pus find its way through the sinus and get to the oral cavity.
Notch seed in upper incisor.

2. Calcific metamorphosis:
Which means extensive formation of tertiary dentin into the root canals
and pulp chamber and it's caused only by trauma.
It Caused by trauma that is not strong enough to lose the vitality, but it
can alter the odontoblasts' function; instead of laying a secondary dentin,
odontoblasts will form tertiary dentin and the rate of tertiary dentin
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formation is very quick and this will lead to obliteration of the root
canals and the pulp chamber.
when we have empty space with the translucency of enamel; there will
be certain color, if no space , there will be color change.
So, metamorphosis is caused by trauma that change the
odontoblasts into cells that make tertiary dentin or reparative
dentin in a quick rate rather than normal secondary dentin
formation leading to change in color.
External bleaching is attempted first, if not successful you have to
attempt internal bleaching; but in these cases because the pulp canal is
obliterated, RCT will be very difficult, because you have calcified
canals, and it's difficult to find the canals.

3. Age:
in elderly people , like in 70s or 80s their teeth color is darker than
younger people. Darkness of teeth increases with age, mainly due to:
1- formation of secondary dentin and
2- stains from food and tea and coffee
3- Thinning of enamel.
in this case you have to attempt the external bleaching , it's unwise to do
RCT and internal bleaching, so external bleaching can be use to correct
these discoloration.

4. Developmental defects:
Fluorosis:
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Excessive ingestion of fluoride during tooth formation results in
hypoplasia and porous enamel which is liable to staining.
Enamel hypoplasia: is a defective enamel formation, enamel will be
porous, chalky in color, upon eruption its whitish in color, absorbs
stains more , so usually these teeth are brownish in color.

Excessive ingestion of fluoride, which is more commonly from
drinking water, so for example here in Jordan, we have high level of
fluoride in Aqaba and Mafraq so we can see many people there with
Fluorosis, same thing in sudi Arabia because increased levels of
fluoride in drinking water.
Important thing to notice here; that the tooth should be affected
during development (childhood), when the teeth are actively
forming or in actively forming phase to get hypoplasia and then this
will later discolor having flourosis .
Systemic drugs:
You are familiar with tetracycline ingestion during tooth formation and
tetracycline will deposited in dentin, it has affinity to calcium, but its
mainly deposited in dentin.
The discoloration ranges from yellow to dark gray. The discoloration is
bilateral, it affects certain group of the teeth, so it depends on what age
the tetracycline was consumed, so if it's taken at the central incisors
development then the incisors will be colored; so it depends on what age
tetracycline was taken because teeth do form at different timing during
growth and childhood.
$$ External bleaching is of limited usefulness in this case; because
the tetracycline staining is within dentin. These tetracycline stained
teeth are vital teeth so to do an internal bleaching, if the patient is so
concerned we have to do Elective RCT and then internal bleaching
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(elective RCT: when the tooth is normal, NOT indicated for RCT, but
we do RCT, so we can place the bleaching agent inside the pulp
chamber and carry out internal bleaching process).

Defects in tooth formation: enamel hypoplasia: defective
enamel, bitting in enamel, hypocalcification: enamel intact but
porous.







Hypoplasia can be:
*inherited: amelogenesis imperfecta, dentinogenesis imperfecta;
both are inherited and affects primary and permanent dentition together
*environmental: high fever during childhood- during tooth
formation or even during pregnancy; if the mother got a sever fever
while the child intrauterine it will manifested as hypoplasia or if the
child develop fever in early childhood it will affect the development of
the teeth and showing as enamel hypoplasia in the later life.
It's common to see hypoplasia, enamel will be not as hard as normal
tooth , so it's more liable to stain and to get carious than normal surface
of enamel. Both centrals are affected, because both of them developed at
the same time.
Enamel hypoplasia is the defect of the teeth in which the tooth enamel is hard but thin
and deficient in amount. This is caused by defective enamel matrix formation with a
deficiency in the cementing substance.
Enamel Hypocalcification is a defect of tooth enamel in which normal amounts of
enamel are produced but are hypomineralized. In this defect the enamel is softer than
normal. Wiki.
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blood dyscrasias: massive lysis of RBCs can discolored forming
dentin, like in: erythroblastosis fetalis.
when we have a normal tooth and a trauma happen to it; a rupture of
blood vessels will happen and the pulpal by-products and the blood
can stain the tooth and cause erythroblastosis fetalis.
RH compatibility : if the mother is RH- and the father is RH+ then the
baby will be RH+ then during delivery the mothers body will form anti-
RH+ antibodies, because she is RH-, to fight RH-antigens from the
baby, in this case the mother will have anti-RH and those will NOT
affect the first baby because he had already born , but the problem
happen with the next baby and blood dyscrasias will happen to his
blood, now to overcome this we give the mother anti-RH antibodies to
prevent her body from forming antibodies.
The erythroblastosis fetalis result in lysis of red blood cells resulting in
discoloration of primary teeth.

B- Iatrogenic discoloration
(Iatro, is a latin word means physician, genic (genesis) means produced,
so it's something done by physician; mal practice of practitioner leads to
discoloration)
1) Obturating materials: most common, sever case, occurs when gutta
percha extending to pulp chamber.
As a general role:
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Anterior teeth: gutta percha should be 1mm apical to gingival
margin (1mm apical to CEJ , but because we cant see the CEJ
in the clinic we go 1mm apical to gingival margin).
Posterior teeth: gutta percha should be 1mm below the canal
orifice; to provide mechanical retention for amalgam.
Obturation materials extending to the pulp chamber by a careless dentist,
not bothering to cut it to the right level.

2) Remnants of pulpal tissues: if the dentist didnt extend the access to
eliminate the pulp horns. For example, the access of the upper
incisors should be triangular in shape, of the base of the triangle to the
insical edge and the apex toward the singulm to involve the pulp
horns.
To overcome this; extend the access to the right length and shape.
Pulp horns contain pulpal tissue that will stain the tooth
if remain untreated.

3) Metallic restorations: you have to use amalgam only for posterior
teeth; for class 1 or 2 cavities, some dentists use it to seal the lingual
access cavity of anterior teeth and the result is staining of the tooth;
because it will show through the tooth structure.

4) Composite restoration:

With time, there is a degree of microleakage of the oral cavity
fluids, like: saliva, coffee and tea it can stain the margin around the
restoration, the periphery will stain.
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the composite itself can discolor usually not sooner than 5-7 years
on less, if everything is done properly during preparation, the
edges might stain early (moisture control , acid etching and
bonding) composite is technique sensitive and any contamination
after acid etching procedures can be significant ,because composite
rely on micromechanical retention .


Bleaching agents:

1-Hydrogen peroxide:
- its very well known bleaching agent,
- its a liquid,
- powerful oxidizer,
- the concentration used is 30-35% is the most common, but they
found now to minimize this use as much as possible, we dont use
this concentration unless it's absolutely necessary , because it's very
strong concentration; it can burn the tissue(gingiva) if precautions
were not followed , it can cause external cervical root resorption
that will permeate the dentinal tubules and we will take about it
later.
So, this concentration is no longer used for safety concerns, although it
can give good results, it is not completely safe. Such concentrations
must be handled with care because it's unstable and may explode unless
kept in dark container and in the refrigerator, this concentration is
caustic and burn the tissues. (some dentist use hydrogen peroxide ( up to
3% )for irrigation in RCT instead of sodium hypochlorite).
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2- Sodium perborate:
- Used as internal chemical bleaching agent,
- It's used only for internal bleaching, placed inside the pulp chamber.
- Available in powder form
- It is stable when dry, but in the presence of acid or water, it will release
oxygen O2.
- Sodium perborate will decompose to hydrogen peroxide H2O2 and
oxygen O2.
So, it's in powder form used for internal bleaching

4- carbamide peroxide:
- very popular,
- over-the counter product ,
- It's in a gel form, it's used at home; put the gel at a tray or night
guard and the patient will wear it at home.
- The most popular concentration is 10% , but know , they introduce
20% concentration, but 10% is more popular and safer,
- 10% carbamide peroxide gives an effect like 3.5% hydrogen
peroxide, so hydrogen peroxide can produce a weaker bleaching but
the net result will be the same and it will take more time.(not sure!)
- Carbamide peroxide used for external bleaching,
- The adverse effects of carbamide peroxide: a little burn to the
gingiva and sensitivity to teeth, if these present we have to stop
bleaching for few days.

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Bleaching technique
Internal (nonvital) bleaching technique

Thermocatalytic technique,

- it become popular when hydrogen peroxide become popular,
- it's an internal technique it has to be done in root treated teeth
because we place the agent inside the pulp chamber; we soaked a
cotton pellet with hydrogen peroxide and we put it inside the pulp
chamber, then we put a hot instrument (like a plastic instrument)
over the cotton pellet to activate the hydrogen peroxide; this will
cause oxidization and some improvement in the color of the tooth.

Thermocatalytic: means facilitated by heat; heat applied to hydrogen
peroxide in the pulp chamber.


The walking bleach: the most popular internal agent is sodium
perborate
The steps:
[slide 22] This is a central incisor stained because the extended gutta
percha apical to the gingival margin, if we want to do internal bleaching
with sodium perborate we should do:
1- We have to explain to the patient that nothing guarantee that the
tooth will bake to normal exactly, this depend on the severity of
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staining if it too sever, it's unlikely that the bleaching alone will
result in color improvement, we should take photographs, to have a
reference for you and for your patient before starting the treatment
so you appreciate the difference at the end of the treatment.
2- Apply a rubber dam.
3- Remove all pulp horns, Cut the gutta percha 1mm apical to
gingival margin.
4- Apply a layer of GIC, or Zink phosphate apically to seal the gutta
percha , its like a base or lining , applying this layer is optional
with sodium perborate, because sodium perborate will not cause
external cervical root resorption , but if we put hydrogen peroxide
( the Thermocatalytic technique) inside the pulp chamber; it's a
must that you put this cement layer to seal the gutta percha. One
important thing when we place this cement layer is to make sure
that the cement layer doesnt block the pulp chamber, or fill the
pulp chamber ; it should be apical to the gingival margin, because
if it filling the pulp chamber the bleaching agent will not come into
contact with dentin and dentinal tubules. So again, with sodium
perborate you can place this layer of cement or you can avoid it.
5- Cover the sodium perborate with a temporary filling and send
patient home; it will permeate through the dentinal tubules and it
will act while the patient away from you, and
6- Patient reviewed after 2 weeks and you can evaluate the result and
repeat the procedures up to 3 or 4 times actually. in teeth with
necrotic pulp is very successful.

So, remove gutta percha 1mm apical to gingival margin and mix
sodium perborate with water to a consistency of wet sand, packed
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with a plastic instrument into pulp chamber, and remove excess water
by tamping with a cotton pellet.
Sodium perborate is a powder; we mix it with water or low
concentration hydrogen peroxide not more than 3.5% (to increase its
effect).
You should keep about 2mm of the temporary filling (not to fill the
whole cavity in tooth with bleaching agent.
**Pictures of a tooth with amalgam filling causing offensive staining,
we try to improve the color and after many visits we notice significant
change in color. But in sever discoloration it will not completely
remove the discoloration, so if the patient is so concerned, the other
option is to make a crown for this tooth.

If the first attempt doesnt give a satisfactory results; there are certain
measures that we can follow in order to improve the color, one of
them is:
1- removing a thin layer of dentin from inside the pulp chamber, this
will open the dentinal tubules, giving more chance for the oxygne
and hydreogen peroxide which is released by sodium perborate to
go into these dentinal tubules and to bleach the tooth.
2- If the result is not satisfactory; mix sodium perborate with
hydrogen peroxide rather than water, the book says that we can
mix it from 3-30%, but it's not recommended to mix it with
concentrations greater than 3% of concerns of cervical root
resorption.


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Final restoration:
Final restoration is really important; we should after we complete the
bleaching, you have to put seal or a liner or whatever, you should not
fill the whole cavity with composite, because this will lead to loss of
translucency and actual darkening of the tooth.
composite is opaque and it's not like the teeth, when you fill the pulp
chamber with opaque material and you have the overlying thin tooth
structure of enamel, this will cause actual darkening of the tooth, so
for completed RCT for example, and if you want to place final
restoration in the tooth, you must not fill the pulp chamber with
composite, so you have to put inside GI C , because it's like dentin in
color and the final layer will be composite so the whole cavity
shouldnt filled with composite otherwise the tooth will appear bluish.

Complications and safety:
Bleaching is getting popular nowadays, especially among females,
and you may face people that dont have discolored teeth but they
want whiter teeth, and that can be achieved; and we will mention that
now.
Safety of internal bleaching;
- If we use the hydrogen peroxide, it might produce cervical root
resorption enhanced by heat, but heat
- Chemical burns: its a caustic agent, if its contact the gingiva or the
lip, it can cause burning, so if you were to use hydrogen peroxide for
internal or external bleaching, you have to apply a protective cream
or Vaseline on the gingiva, and apply the rubber dam, so you will be
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sure that the agent will not leak to the gingiva and burning the
gingiva.

Internal bleaching: sodium perborate mixed with water or low
concentration of hydrogen peroxide.
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External (vital) bleaching technique:
- When the tooth is vital, in most of cases, much less predictable
results will be obtained
- If the stain was in dentin then the external bleaching is unlikely to
produce a color improvement, like, tetracycline staining, but if the
stain is in enamel or external stain then the external bleaching is
likely to be successful.
- Technique: 30% hydrogen peroxide applied as external bleaching
agent, as we said we dont recommend its use, but we need to know
that it's available as treatment option.


Enamel micro-abrasion its very effective and successful technique,
but we need to know that enamel micro-abrasion is not a true
bleaching , but its a selective decalcification and a selective a
removal of thin layer of stained enamel; we simply remove
decalcified and superficial stained enamel, we should not remove a
significant amount of enamel .
it's very successful for cases like, Fluorosis and hypoplasia .
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So its a sort of external improvement in color of the teeth, its
available in 36% and you have to dilute it in distilled water , dr.
wasnt sure if 18% concentration is available.
The following steps must be strictly followed , because 18%
hydrochloric acid can cause significant burn to your gingiva.

The technique:
1- The gingiva must be protective by a cream or Vaseline or cream
and the rubber dam needs to be applied and the free edge of the
rubber dam needed to be inverted.
2- 18% of HCL {hydrochloric acid} (if you have only 36%
concentration you have to dilute it) its mix with pumice to form a
thick paste,
3- the paste is applied on enamel by a wooden stick and its walked
against the enamel surface for about 5 seconds, followed by
rinsing with water for about 10 seconds,
4- Paste reapplied until the desired color is achieved .
5- And finally, because Hydrochloric acid is even stronger than the
phosphoric acid you have to apply sodium bicarbonate to
neutralize the acidity.

Then dr. showed an example about bleaching for Fluorosis, and there
are some notes about what he said:
We have to place wedges with rubber dam to ensure a perfect
seal and to prevent leakage of agent.
Sometimes its recommended to do normal etching; apply
phosphoric acid to do some decalcification, it's not always
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necessary to apply phosphoric acid for etching (which is used
for composite), you can use it or omit it, it's up to you.
We use pumice ( which is used for polishing ) to mix it with
hydrochloric acid and we use a wooden stick to rub the tooth
surface with this mixture, and after we finish , we wash it with
water and reapply the paste again until we get the desired color ,
it can be repeated up to 10 times , the result of enamel micro-
abrasion is stable for a long time , its relatively permanent if
initial lighting is achieved.


Safety:
Chemical burns because high concentration of hydrochloric acid
Decalcification is not very significant.


Mouth guard bleaching
Which is very popular but it should be used under the dentist
supervision, they put the bleaching agent in a mould and wear it for a
specific time,
- used for mild discoloration and for people who wants their teeth to
be brighter ,
- Most products have about 10% of hydrogen peroxide; it's actually
10-15% carbamide peroxide.

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The Procedure:
1- Make alginate impression for upper and lower arch and then you
make stone casts, and make on them like a tray to hold the
bleaching agent within it , on the cast you have to instruct the
technician to put spacer or Vaseline to place more room for the
bleaching agent ,
2- we ask the patient to put the bleaching agent in the guard and to
wear it at night while he is watching TV,
3- or any 3 hours at the day, and not to wear it more than 3 hours
because the bleaching agent will not be effective after 3 hours,
4- Treatment continues for about 4 weeks, the patient insert the
bleaching agent (10% carbamide peroxide gel) in the mould up to
1/3 of the incisal edge and place it.

this agent is expensive ( 120JD at DTC) so, we advice the patient to
put it in the most discolored tooth, it's not necessary to put it in
molars , because it's not important if molars get lighter or not, we
have to concentrate more in the teeth that we concern more and want
color improvement for them.


Prognosis

Short term; its effective
Long term results are still unknown
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It's usually gives a color improvement for 2 years , if the teeth were
not stained and you use it to make teeth whiter -only- then the long
term results will be optimum.

Safety:
Sometimes we have side effects:
1- Unpleasant taste
2- Burning sensation
3- Sensitivity of the teeth
4- Slight burn to the gingiva.
If that happen, ask the patient to stop using it, or using it every other
day, rather than every day.


So, for internal bleaching sodium perborate
External bleaching: carbamide peroxide

The end
Done by: Ala'a Al-Smadi.

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