intracoronal bleach

TOOTH BLEACHING

Drg. Wiena Widyastuti Sp KG

Reference : 1. Greenwall L. 2001. Bleaching Techniques in Restorative

Dentistry . Martin Dunitz Ltd. Hal 1-8, 31-2, 37-42, 159-163,166,171, 173-178,180, 244-247.

2. Goldstein E.Ronald, Garber A. David. 1995. Complete

Dental Bleaching. Quintessence. Penulis Steiner dan West. Hal 101- 135.

3. Rateitschak H.Klaus, Wolf F.Herbert. 2000. Color Atlas of

Dental Medicine. Thieme. Hal 35 - 54

What is Bleaching? It is a bleaching process that lightens the discoloration of enamel and

dentin

This is done utilizing a mild solution which is retained in custom made tray that is worn over your teeth.

Teeth made of many colours, with natural gradation from the darker cervical to the lighter incisal third

natural gradation from the darker

cervical to the lighter incisal third

Variation affected by thickness of enamel and dentine, and reflectance of different colours

Blue, green and pink tints in enamel, yellow through to brown shades of dentine beneath

Canine teeth darker than lateral incisors

Teeth become darker with age (secondary/tertiary dentine, tooth wear/dentine exposure)

Tooth colour affected by: Individual interpretation

Time of day

Patient positioning/angle tooth is viewed at

Hydration of tooth (always take shade at start of appointment)

Individual interpretation

Tooth colour affected by: Skin tone (make-up)

Tooth colour affected by:

Surrounding conditions (e.g. lighting in clinic)

GENERAL INDICATIONS for Bleaching Procedure

Generalised staining

Ageing

Extrinsic stain - Smoking and dietary stains (tea/coffee etc)

Fluorosis

Tetracycline staining (combination with restorative techniques) Traumatic pulpal changes White spots Brown spots (not as good response)

GENERAL INDICATIONS for Bleaching Procedure

GENERAL CONTRAINDICATIONS

for Bleaching Procedure

Patients with

high/unrealistic

expectations



Decay and active periapical pathology

(must be resolved first)



Pregnancy/Breastfeeding

Sensitivity/cracks/exposed

dentine

GENERAL CONTRAINDICATIONS for Bleaching Procedure

Existing crowns / large restorations

(anteriorly)

Elderly patients with visible recession

and yellow roots (roots dont bleach

as readily as crowns)

If patients cannot afford changing

existing restorations post-bleaching

visible recession and yellow roots

CLASSIFICATION OF TOOTH DISCOLOURATION

Extrinsic discolouration

Intrinsic discolouration

Etiology of Tooth Discoloration

Extrinsic Stain

superficial changes

secondary to colored food, drinks (tea, coffee, cola), tobacco products, smokeless tobacco

more of a problem if there are microcracks

Tobacco products

Microcracks

Tea, Coffee, Cola

Extrinsic Discolouration:

E.g.

Plaque, chromogenenic

bacteria

Mouthwashes (chlorhexidine)

Smoking / chewing tobacco

Beverages (tea, coffee, red wine,

cola)

Foods (curry, cooking oils and

fried foods, foods with colorings,

berries, beetroot)

Antibiotics (erythromycin,

amoxicillin-clavulanic acid)

Iron supplements

* Aged Related Color Change

- thinned enamel - darkened dentin due to deposition of - secondary dentin, more yellowish

Intrinsic Stain

Medication given systemically, e.g. tetracyclin, minocyclin

Fluorosis

Systemic conditions, e.g. jaundice, erythroblastosis fetalis, porphyria

Dental caries

Old restorations showing through, e.g. amalgam

Trauma

Heredity

Etiology of Tooth Discoloration

Tetrasiklin

Fluorosis

Old Restorations

Trauma

Pre-eruptive:

Disease:

Haematological diseases

Liver diseases

Diseases of enamel and dentine (e.g. Amelogenesis/ Dentinogenesis imperfecta)

Medication:

Tetracycline, other antibiotics

Fluorosis stains (excess F)

Enamel hypoplasia (trauma or

infection)

Post-eruptive:

Trauma (e.g. pulpal

haemorrhagic products)

Primary and secondary caries

Tooth wear

Dental restorative materials

Ageing

Chemicals

Antibiotics

Minocycline (used to treat

acne)

Intrinsic Discolouration:

Types of Discoloration Colour Produced

Extrinsic (Direct stains)

Tea, coffee and other foods

Cigarettes/cigars

Plaque/poor oral hygiene

Brown to black

Yellow/brown to black

Yellow/brown

Extrinsic (Indirect stains)

Polyvalent metal salts and cationic antiseptics

e.g. Chlorhexidine

Black and brown

Intrinsic

(Metabolic causes)

e.g. Congenital erythropoietic porphyria

(Inherited causes)

e.g. Amelogenesis Imperfecta

e.g. Dentinogenesis Imperfecta

(Iatrogenic causes)

Tetracycline

Minocycline

Fluorosis

(Traumatic causes)

Enamel hypoplasia

Pulpal haemorrhage products

Root resorption

(Ageing causes)

Purple/brown

Brown or black

Blue-brown (opalescent)

Banding appearance:

classically yellow, brown, blue, black or grey

Grey

White, yellow, grey or black

Brown

Grey black

Pink spot

Yellow

Internalized

Caries

Restorations

Orange to brown

Brown, grey, black

Dental Assistants Role in Tooth-Whitening Procedure

Aid in recording the medical and dental history.

Assist in making shade selection.

Take intraoral photographs before and after whitening.

Take and pour up preliminary impressions for the tray.

Fabricate and trim the tray.

Provide postoperative instructions.

Assist in weekly or biweekly clinical visits.

BLEACHING

* Non vital teeth Intracoronal Bleaching Termocatalytic Bleaching * Vital teeth In-office Bleaching Home Bleaching * Combination Tehnique Inside-Outside Bleaching

Intracoronal Bleaching/Walking Bleach of Nonvital Teeth

It involves use of chemical agents within the coronal portion of an endodontically treated tooth to remove tooth discoloration.

Indications of

Intracoronal Bleaching

Discoloration of pulp chamber origin

Moderate to severe tetracycline staining

Dentin discoloration

Discolorations not agreeable to extracoronal bleaching

Contraindications of

Intracoronal Bleaching

Superficial enamel discoloration

Defective enamel formation

Presence of caries

Unpredictable prognosis of tooth

Intracoronal Bleaching Technique

Take the radiographs to assess the quality of obturation If found unsatisfactory, retreatment should be done


Isolate the tooth with rubber dam

Prepare the access cavity, remove the

coronal gutta percha, expose the

dentin and refine the cavity


Place mechanical barriers of 2 mm thick, preferably of glass ionomer cement, zinc phosphate, IRM, polycarboxylate cement on root canal filling material

The coronal height of barrier should protect the

dentinal tubules and conform to the external epithelial attachment


Now mix 10% sodium perborate with an inert liquid (local anaesthetic, saline, water, hydrogen peroxide) and place this paste into pulp chamber


After removing the excess bleaching paste, place a temporary restoration over it


Recall the patient after 1 to 2 weeks, repeat the treatment until desired shade is achieved

Restore access cavity with composite after 2 weeks.

BEFORE

AFTER

THERMOCATALYTIC TECHNIQUE OF

BLEACHING FOR NONVITAL TEETH

Take the radiographs to assess the quality of obturation

If found unsatisfactory, retreatment should be done

Isolate the tooth to be bleached using

rubber dam

Place bleaching agent (superoxol and

sodium perborate separately or in combination) in the tooth chamber

THERMOCATALYTIC TECHNIQUE

OF BLEACHING

Heat the bleaching solution using bleaching stick/light curing unit/bleaching wand


OF BLEACHING

Repeat the procedure till the desired tooth

color is achieved

Wash the tooth with water and seal the

chamber using dry cotton and temporary

restorations


OF BLEACHING

Recall the patient after 1 to 3 weeks

Do the permanent restoration of tooth

using suitable

Composite resins afterwards

External (cervical) resorption,

especially when used with

thermocatalytic activation

(heated instrument within

pulp chamber)

Heithersay found incidence

increased when associated

with trauma (3.9-9.7%) and

orthodontic treatment (24%)

NON-VITAL BLEACHING- RISK

External root

resorption Chemical burns if using 30 to 35 % H2 O2

Decrease bond

strength of

composite

NON-VITAL BLEACHING- RISK

Pre-operative radiograph

ensure no pathology (external resorption) prior to

commencing procedure

medico-legal

Warn patient if previous orthodontic

treatment or trauma- higher risk

Sealing GP with a 2mm RMGIC (minimum

2mm to prevent ingress of bleach into

pulp chamber

CLINICAL RELEVANCE:

Warn patient:

May not improve shade

May reverse, and patient may need

to repeat procedure in future at own

cost

May require other treatment:

veneer/crown

WARNINGS

Tooth is hollow whilst carrying out

bleaching and patient must be careful,

do not bit into hard foods, tooth may

fracture!

Cervical resorption Previous

trauma/ortho

If temp filling lost must see dentist

urgently (walking bleach)

WARNINGS

Essentially same technique as Non vital bleaching

1. Pre-op radiograph (assess endo)

2. Re-open access cavity

3. Ensure chamber free of GP

4. Seal off the root filling with resin-modified GIC

5. Place the 10% gel (may be higher) into a single

tooth tray with labial and lingual reservoirs.

6. Insert tray into the mouth. Remove excess as

necessary. This should be kept in position for at

least 2 to 3 hours and preferably overnight.

7. Clean the access cavities out with a toothbrush

or interproximal brush.

8. No limit to how many times the material can be changed and changing the material every 2 to 3 hours will probably speed up the process.

9. The access cavity should ideally left open for no longer than necessary (suggested 3 days?)

10. The chamber should be cleaned out thoroughly and temporised.

11. A definitive resin composite restoration of a light colour should not be placed until 14 days after the bleaching process.

*

1.History taking & examination

2.Examine the radiograph to establish adequate RCF

3.Take shade and photograph

4.Rubber dam isolation- single tooth

5.Remove all filling material and gutta percha 2-3mm

apical to CEJ (Williams/PCP 2 probe used).

*

6. All restorative material must be removed to allow bleaching agent to contact the internal tooth structure.

7. Mix RMGIC and place 2 mm thickness to assure a seal. Light cure for 20s.

8. Express Carbamide Peroxide into the cavity (use a small tip, e.g. the tips used for acid etch).

*

9. Place tiny cotton pellet into gel. Leave 1.0 to 1.5 mm of space to accommodate the provisional restoration.

10. Place a GIC provisional restorative material

to seal the access opening, check occlusion.

11. Repeat the procedure every 3 to 7 days until

the desired color change is achieved.

*

12. Remove provisional restorative material and

bleaching material to level of GI sealing

material. Rinse and clean access opening.

Place a temp restoration.

13. A definitive resin composite restoration of a

light colour should not be placed before 14

days after the bleaching process.

EFFECTS OF BLEACHING

AGENTS ON TOOTH AND

ITS SUPPORTING STRUCTURES

Possible Complications to Tooth Whitening

Thermal hypersensitivity Patient may experience sensitivity to heat and

cold after removal of the tray and material. The use of toothpaste for sensitive teeth is recommended.

Tissue irritation

Gingival tissue exposed to excess gel as a result of improper tray fit may become irritated. Tell the patient not to overfill the tray with material and to remove any excess after seating the tray.

TOOTH HYPERSENSITIVITY

Common side effect of external tooth bleaching.

Higher incidences of tooth sensitivity (67% - 78%) are

seen after in office bleaching with hydrogen

peroxide in combination with heat.

The mechanism responsible for external tooth

bleaching though is not fully established, but it has

been shown that peroxide penetrated enamel, dentin

and pulp.

This penetration was more in restored teeth than that

of intact teeth.

EFFECTS ON ENAMEL

Studies have shown that 10 % carbamide

peroxide significantly decreased enamel

hardness.

But application of fluoride showed improved

remineralization after bleaching

EFFECTS ON PULP

Penetration of bleaching agent into pulp through

enamel and dentin occur resulting in tooth

sensitivity.

Studies have shown that 3% solution of

H2O2 can cause:

Transient reduction in pulpal blood flow

Occlusion of pulpal blood vessels.

EFFECTS ON RESTORATIVE

MATERIALS

Surface roughening and etching

Decrease in tensile strength

Increased microleakage

No significant color change of composite material

itself other than the removal of extrinsic stains

around existing restoration

TOXICITY

The acute effects of hydrogen peroxide ingestion

are dependent on the amount and the

concentration of hydrogen peroxide solution

ingested.

The effects are more severe, when higher

concentrations are used.

TOXICITY

Signs and symptoms usually seen are ulceration

of the buccal mucosa, esophagus and stomach,

nausea, vomiting, abdominal distention and

sore throat.

It is therefore important to keep syringes with

bleaching agents out of reach of children to

prevent any possible accident.

intracoronal bleach

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