INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA KULLIYYAH OF DENTISTRY

BLEACHING OF ENDODONTICALLY TREATED TEETH

Bleaching Procedure
SHAWFEKAR BTE HJ ABDUL HAMID
1/29/2009

It is a well known fact, that a tooth loses its natural color after removal of the pulp. This is due to dehydration of the tooth substance with consequent loss of translucency. Bleaching of a discolored pulpless tooth is possible when the discoloration is due to products of pulp decomposition, or food debris producing organic products, which gain access to the dentinal tubules, or to chromogenic bacteria. When the discoloration is due to metallic salts, bleaching is more difficult or even impossible. Discoloration of the tooth can be noticed several month s after death of the pulp or treatment of the tooth, due to slow formation of color-producing compounds. Traumatic injury of a tooth may cause rupture of the blood vessels in the pulp with diffusion of blood into the dentinal tubules. Such teeth can be noticed a dark pinkish immediately after accident, turning to a pinkish-brown some days afterward or even after the pulp removed.

BLEACHING OF ENDODONTICALLY TREATED TEETH

It is a well known fact, that a tooth loses its natural color after removal of the pulp. This is due to dehydration of the tooth substance with consequent loss of translucency. Bleaching of a discolored pulpless tooth is possible when the discoloration is due to products of pulp decomposition, or food debris producing organic products, which gain access to the dentinal tubules, or to chromogenic bacteria. When the discoloration is due to metallic salts, bleaching is more difficult or even impossible. Discoloration of the tooth can be noticed several month s after death of the pulp or treatment of the tooth, due to slow formation of color-producing compounds. Traumatic injury of a tooth may cause rupture of the blood vessels in the pulp with diffusion of blood into the dentinal tubules. Such teeth can be noticed a dark pinkish immediately after accident, turning to a pinkish-brown some days afterward or even after the pulp removed. The principal causes of discoloration are: 1. Decomposition of pulp tissue 2. Excessive hemorrhage following pulp removal 3. Trauma 4. Medicaments 5. Filling materials 6. Tetracycline group of antibiotics

STUDY QUESTIONS FOR 2006 ORAL EXAMINATION:

Discuss the various types of bleaching, rationale for each, indications/contraindications. Discuss nonvital bleaching technique steps/specifics (duration leave in, etc), and materials used. 3. Discuss the possible complications associated with nonvital bleaching.
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Indications for Nonvital Bleaching

o Intrinsic (intracoronal) discoloration of pulp chamber origin Endodontically treated teeth Teeth with necrotic pulps Teeth with vital pulps

Contraindications for Nonvital Bleaching

o o o o o Superficial (extrinsic) stains Extensively restored or broken down teeth Severe dentin loss Stains associated with hypoplastic enamel defects Inadequate endodontic therapy
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 Retreat prior to nonvital bleaching! o Previous bleaching without success

Etiology/Prevention of Single-Tooth, Intrinsic Discoloration Defects Calcific metamorphosis

The yellow discoloration of calcific metamorphosis is usually correctable with nonvital bleaching. The endodontic therapy performed after canal system obliteration can be difficult however, and prone to procedural mishaps, especially radicular gouging and perforation, or non-discovery of the canal. Advise the patient with severe calcific metamorphosis that efforts to endodontically treat and bleach an asymptomatic, pulpally vital tooth could result in a root-end surgery or loss of the tooth!

Pulpal hemorrhage due to trauma

Even following pulpal vascular disruption and hemorrhage, the pulp may remain vital. Extravasated red blood cells undergo hemolysis and release hemoglobin. The released hemoglobin breaks down to form several compounds (e.g. hemosiderin), which have the capacity to stain dentin a brownish-red color.

Hemorrhage following pulp extirpation

When canal hemorrhage is not adequately arrested following pulpectomy, blood can fill the canal space and remain in contact with dentin for a prolonged time. It is very important to arrest all hemorrhage prior to access closure! Internal (chamber) and external (cervical extracanal invasive) r esorption may result in a pink coronal hue.

Pulpal necrosis
When bacteria contaminate a necrotic pulp, hydrogen sulfide (produced by the bacteria) combines with the iron released from hemoglobin, to form an iron sulfide compound. This produces a blackish-gray discoloration. Necrotic debris left in pulp chamber recesses during/after endodontic therapy If allowed to remain, necrotic pulp tissue decomposes and penetrates dentinal tubules. It important to create adequate access openings and thoroughly debride all chamber recesses, especially pulp horns and fins.

Medications and sealing agents

Some endodontic sealers still contain silver (e.g. Kerrs P ulp Canal Sealer (EWT) and Tubliseal); however, almost all ZOE sealers (including our Roth) can cause discoloration, if left in contact with the dentin. For this reason, in endodontically treated teeth to be definitively restored by a composite access
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closure, obturating materials should not be allowed to remain coronal to the attachment apparatus. Also, these teeth should have their chambers thoroughly cleaned with a solvent such as isopropyl alcohol or halothane immediately following obturation.

Restorative materials
Amalgam should not be used to restore the lingual access of anterior teeth. The buccal-lingual dimension of these teeth is too thin, and eventually these teeth will discolor. Pins can also release metallic ions and cause staining.

Prerequisites for Nonvital Bleaching

Adequate endodontic treatment Be sure to thoroughly evaluate the adequacy of the existing endodontic treatment and the periradicular health of each tooth you plan to bleach. Adequate protective barrier Walking Bleach Technique 1. Isolate tooth with rubber dam. 2. Remove all restorative materials from pulp chamber. It can be difficult to discern composite restorative materials from tooth structure. If all composite is not removed from the dentin, bleaching results will be suboptimal. 3. Remove small amount of the highly discolored dentin from chamber. Let the chemicals do the bulk of the work. 4. Clean chamber with halothane or chloroform; wash out with sterile water. 5. Place a protective base (at least 2 mm thick) over GP to the level of the proximal CEJs. 6. Place thick paste of sodium perborate and water into chamber (wet sand consistency). 7. Clean margins of access opening. Cotton is unnecessary. 8. Place temporary restoration. Use Cavit, IRM or a GIC. TERM leaks and should not be used. If occlusion permits, bulk the temporary material into a slight convex form. 9. Advise patient to avoid function on temporary restoration. 10. Examine tooth in 3-5 days. Assess shade change and discuss progress with patient. Repeat procedure if bleaching result is partially successful, yet not adequate. Restore if adequate. Remember, a slight overbleach is recommended by many clinicians, because there may be a partial shade relapse over the first few weeks.

Restoration of Lingual Access

Retain translucency of crown Place protective base only to CEJ and not into chamber space Use solvent to dissolve/remove unset sealer immediately postobturation Use the lightest shade of composite resin Ensure optimal marginal adaptation of material Seal is critical to prevent re-discoloration

Postbleaching Cervical Resorption

This type of inflammatory external root resorption was first reported in 1979. It is very destructive and occurs primarily in the proximal CEJ regions. There is clearly a relationship between internal bleaching of teeth and the stimulation of periodontal ligament cells to resorb tooth structure. The exact etiology is unknown, although diffusion of hydrogen peroxide through patent dentinal tubules is believed to be the major factor. Other precipitating factors are theorized to be heating of the hydrogen peroxide and the original trauma. In approximately 10% of teeth, the enamel and cementum do not meet, thus allowing patent dentinal tubules to be exposed to the periodontal ligament. Also, traumatized teeth sustain cemental tears. It is possible that these teeth allow diffusion of chemicals through dentinal tubules to the PDL. To be safe, the best prescription for prevention is: 1. Avoid acid etching of chamber. 2. Avoid use of heat, if possible. 3. Avoid use of 30-35% hydrogen peroxide, if possible (use water or anesthetic). 4. Ensure a good quality obturation exists and place a protective base. 5. Recall (with radiograph) at 1 and 2 years post-bleaching. Treatment of this problem is complicated. Placement of calcium hydroxide to arrest the process, surgical repair and orthodontic extrusion/restoration have been described as efforts to retain these teeth affected by postbleaching cervical resorption. Alterations of bleaching techniques (eliminating 30% hydrogen peroxide, placing a protective base over GP) have been proposed to minimize resorption occurrence. Postbleaching resorption should be discussed as a part of the informed consent.

Bleaching Prognosis o The immediate results are oftentimes excellent. A very slight overbleach is indicated, in anticipation of short-term relapse.

o Color stability Over the long term, partial relapse is expected. This compromise is acceptable to most patients. Some will require rebleaching.

o Resorption Incidence is ~2-7% when no protective base used; near 0% with a base.

o Recall Resorption is often not evident until one year or longer post-bleaching.

Informed Consent
It is important to discuss the bleaching process and its prognosis with your patient. Patients are usually excited about bleaching, because they know little and have high expectations. Dont promise too much! Discuss a realistic prognosis, based on the patients degree/duration of discoloration. Shade improvements may be minimal or may not occur at all. Several appointments may be required for a walking bleach. Thin temporary restorations are often lost. There is the strong likelihood that some relapse will occur over the long term. Existing root canal therapy may require retreatment, due to technical deficiencies. Cervical root resorption is a risk. RCT performed in support of bleaching only (e.g. calcific metamorphosis) may result in a significant misadventure (e.g. radicular perforation), a root-end surgical procedure, or loss of the tooth! Wellinformed patients are more satisfied at the conclusion of therapy than those less informed. Treatment alternatives to nonvital bleaching exist: no treatment, laminate veneer, or a full crown.

Bleaching

Teeth bleaching to whiten teeth:

There are many products currently on the market that promise whiter, brighter teeth. The American Dental Association (ADA) states that if you are a candidate for a procedure, your dentist may suggest a procedure that can be done in a dental office. Other options include athome products, which may be dispensed by your dentist or purchased over-the-counter. But, dental professionals, and the ADA, issue a word of caution about the improper use of such over-

the-counter products, as they are sometimes too abrasive and can damage the teeth with extended use. The ADA describes "whitening" as any process that will make teeth appear whiter, using one of two approaches. A product can bleach the tooth, therefore changing the natural tooth color. A bleach contains peroxide that helps remove deep and surface stains. However, a non-bleaching whitening product contains substances that help remove surface stains only.

Who may benefit from teeth bleaching?

Most beneficial age spots yellow or orange spotting on teeth caused by coffees, teas, berries and other foods, or smoking Moderately beneficial gray or brown stains caused by fluorosis (excessive intake of fluoridated water) gray stains caused by smoking and/or the use of certain medications Not recommended overly-sensitive teeth persons with a gum or mouth disease (periodontal disease or oral cancer) persons with worn tooth enamel

What are some different teeth-whitening methods?

The dentist will use either an in-office bleaching system or laser bleaching while you are in the dental chair. Some patients, however, choose dentist-supervised at-home bleaching, which is more economical and, in many cases, provides the same results. One option for at-home bleaching involves using a custom-made mouthguard that can be worn comfortably while you are awake or sleeping. The mouthguard is so thin that you should even be able to talk and work while wearing it. Some bleaching systems recommend bleaching your teeth from two to four hours a day - these usually take three to six weeks to complete and work best on patients with sensitive teeth. Other systems recommend bleaching your teeth at night, while you sleep, which may only take 10 to 14 days to complete. Recently, more over-the-counter products are available that offer simple whitening solutions. However, they may not provide the dramatic improvement that a professional treatment option offers.

Teeth bleaching side effects and health risks:

The American Dental Association has granted its seal of approval on some teeth whitening products. Consult your dentist regarding which products are most effective and safe to use. Gum irritation and increased tooth sensitivity are the most common side effects of teeth bleaching. However, each individual may experience side effects differently.

Bleaching of a Tooth: Some people experience a graying of a tooth that either has been injured or had a root canal. You can have the tooth bleached internally so it will match the color of your others. It would remove the filling material at the back of the tooth and over a series of approximately 3 appointments, then it will place a special bleaching material inside the tooth. Once the tooth color matches that of your other teeth, you can return to your general dentist for a permanent filling. What a wonderful way to keep your smile looking healthy!

Following trauma, tooth discoloration is very common. The discoloration comes from the bleeding inside the pulpal chamber. The dentin becomes stained as the blood gets into the dentinal tubules and trapped in the pulp horns. The first step in restoring the natural color to the tooth is good endodontic therapy with adequate removal of the stained facial dentin and complete removal of the pulp horns. If the natural tooth color is not restored with this procedure, then the additional treatment of non-vital internal bleaching is indicated. A common error is incomplete removal of the pulpal horns due to a small apically placed access. Care must be taken to remove stained dentin and pulpal horns while trying to preserve maximum tooth structure. The following case shows how to "get the stain out".

Tooth #9 & #10 sustained traumatic injury.

Note the discoloration on #9.

After opening the access, staining can be seen in #9. #10 looks normal.

A round bur is used to remove the stain from the facial surface of the pulp chamber. Careful examination with magnification reveals remaining stain in pulp horns. The access is carefully refined to remove stain from pulp horns while keeping access as conservative as possible.

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Following removal of rubber dam, the change in coloration is noted. Patient is informed that the tooth is dehydrated and will continue to change color until rehydration is complete. At that time, evaluation can be made if additional internal bleaching procedures will be needed.

Obturation completed. Adequate endodontic therapy alone will often resolve the patient's esthetic concerns. Non-vital bleaching is a good adjunct for teeth requiring additional whitening.

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