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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
GENERAL CONTRAINDICATIONS
for Bleaching Procedure
Decay and active periapical pathology
(must be resolved first)
GENERAL CONTRAINDICATIONS
for Bleaching Procedure
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
Intracoronal Bleaching Technique
Isolate the tooth with rubber dam
Prepare the access cavity, remove the
coronal gutta percha, expose the
dentin and refine the cavity
Intracoronal Bleaching Technique
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
Intracoronal Bleaching Technique
Now mix 10% sodium perborate with an inert liquid (local anaesthetic, saline, water, hydrogen peroxide) and place this paste into pulp chamber
Intracoronal Bleaching Technique
After removing the excess bleaching paste, place a temporary restoration over it
Intracoronal Bleaching Technique
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
THERMOCATALYTIC TECHNIQUE
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
THERMOCATALYTIC TECHNIQUE
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.