Tooth discolouration is defined as “any change in the hue, colour, or translucency of a tooth due to any cause; restorative filling materials, drugs (both topical and systemic), pulpal necrosis, or haemorrhage may be responsible.” • Discoloration of the tooth is one of the most frequent reasons why a patient seeks dental care. Tooth discoloration is usually aesthetically displeasing and psychologically traumatizing. • Dental aesthetics, especially tooth colour, is of great importance to majority of the people; and discolouration of even a single tooth can negatively influence the quality of life. • An understanding of the etiology of tooth discoloration is important to a dentist in order to make the correct diagnosis. The knowledge of the cause of discoloration will also help the dental practitioner to explain the exact nature of the condition to the patient. Treatment options include vital and non-vital bleaching, microabrasion, composite and porcelain veneers, and porcelain crowns. Sometimes these treatments are combined for a more successful outcome. DIRECT PARTIAL VENEERS: • Small localized intrinsic discolouration or defects that are surrounded by healthy enamel are ideally treated with direct partial veneers. • The outline form is dictated solely by the extent of the defect and should include all discoloured areas. • Clinician should use coarse, elliptical or round diamond instrument with air water coolant to prepare the tooth to a depth of about 0.5 to 0.75 mm. • After preparation, etching and restoration followed by finishing is performed. • Use of an opaquing agent for masking dark stains can be employed. • DIRECT FULL VENEERS: • Cases where along with correction of discolouration, diastema closure or any other tooth form defect is also to be corrected, full veneer is an good option. • After teeth are cleaned and a shade is selected the area is isolated with cotton rolls and retraction cords. • The window preparation is made to a depth roughly equivalent to half the thickness of the facial enamel, ranging from approx 0.5-0.75 mm mid-facially and tapering down to a depth of about 0.2-0.5 mm along the gingival margins, depending on the thickness of enamel. • A heavy chamfer finish line at the level of the gingival margins, or crest provides a definite preparation margin for subsequent finishing procedures.

1. MANAGEMENT OF
DISCOLORED TOOTH
SUBMITTED BY
SUBHRAKANTI PANDIT
FINAL YEAR
Guided by
Dr. Chetna Dudeja

2. CONTENTS
 INTRODUCTION
 CLASSIFICATION OF DISCOLORATION
 MANAGEMENT OF DISCOLORED TEETH
 SCALING
 VENEER
 DIRECT VENEER
 INDIRECT VENEER
 CERAMIC CROWN
 BLEACHING TECHNIQUE
 IN-OFFICE BLEACHING
 WALKING BLEACHING
 POWER BLEACHING
 LASER
 COMPLICATION

3. INTRODUCTION
 Tooth discoloration is when the color of the tooth change. They don’t
look like as bright or while as they should. Tooth may be darken, turn
from white to different colors, develop white or dark spots in places.
 Tooth discoloration is defined as any change in hue, color or
translucency of a tooth due to any cause , restorative filling material,
drugs (both topical and systemic ), pulpal necrosis, or haemorrhage may
be responsible. …….. Ingle 6th edition

4. Acc. to Ingle
classification
DENTAL STAINS
DENTIST RELATED
CAUSES
ENDODONTICALLY
RELATED
PULP TISSUE REMNANTS
INTRACANAL
MEDICAMENT
OBTURATING MATERIAL
RESTORATION RELATED
AMALGAMS
PINS & POSTS
COMPOSITES
PATIENT RELATED
CAUSES
PULP NECROSIS
INTRACANAL
HEMORRHGAE,
DENTIN
HYPERCALCIFICATION
TOOTH FORMATION
DEFECTS

5. The most recent classification
A WATT M ADDY
DENTAL
STAINS
INTRINSIC
EXTRINSIC
INTERNALISED

8. MANAGEMENT/TREATMENT
 Prevention
 Scaling : most of the surface stain can be removed by routine prophylactic procedure
 Microabrasion
 Macroabrasion
 Veneer
 Direct veneer
 Indirect veneer
 Ceramic crowns
 Bleaching
 Non vital bleaching
 Vital bleaching

9. PREVENTION
 Certain teeth discoloration can be prevented by following strict oral hygiene practice.
 Tobacco stains, coffiee stains can be prevented by keeping a check on habit.
 Fixed appliances and the bonding materials increase the retention of biofilm and encourage the
formation of white spot lesions. Management of these lesions begins with a good oral hygiene regime
and needs to be associated with use of fluoride agents.
 Fluoridated toothpaste
 Fluorine containing mouth rinse
 Gel
 Varnish
 Bonding materials
 Elastic ligature
 Regular visit to dentist

10. MICROABRASION
 In1984, McCloskly reported the use of 18% HCL acid swabbed on teeth for removal of
superficial fluorosis stains.
 In 1986, Croll modified the technique to include the use of pumice with HCL acid to form a
paste applied with a tongue blade. This technique is called as microabrasion and it involve
the surface dissolution of the enamel by acid along with abrasiveness of pumice to remove
superficial stains or defects.
 Croll further modified the technique reducing the concentration of the acid to approx. 11% and
increasing the abrasiveness of the paste using silicon carbide particles, instead of pumice.
 Microabrasion technique involve the physical removal of tooth structure and does not remove
stains or defects through any bleaching phenomena.
 Fluorosis staings can be removed by microabrasion if the discoloration within -0.2-0.3.

12. Macroabrasion
 An alternative for removal of localized superficial white spots and other surface stains or
defects is called macroabrasion.
 It uses a 12 flited composite finishing bur or A fine grit finishing diamond in a high
speed handpiece to remove the defect.
 Air water spray is recommended as coolant and also to maintain the tooth in hybrid state
to facilitate assessment of defect removal .
 After removal of the defect or on termination of any further removal of tooth structure, a 30-
flited composite finishing bur is used to remove any facets or striation is creation by the
previous instruments.
 Final polishing is accomplished by abrasive rubber point.
 To accelerate the process, a combination of macroabrasion & microabrasion also may be
consider.
 Gross removal of the defect is done by macroabrasion followed by final treatment with
microabrasion.

13. veneers
 It is a layer of tooth coloured material that is applied to a tooth surface to restore
localized or generalized defects and intrinsic discoloration.
 Common indicators for veneer are
 Facial surfaces that are malformed,
 Discoloured
 Abraded
 Eroded
 Have faulty restoration

14. veneer
 Several factors should be evaluated before pursuing full veneer as treatment option.
e.g patient age , occlusion , tissue health, position & alignment of teeth and oral
hygiene
Based on material, it can be of four types…
composite
processed composite
porcelain

15. Based on preparation design
Based on design
Partial veneer:
Indicated for the restoration of
localized defects or areas of
intrinsic discoloration
Full veneer:
Indicated for restoration of
generalized defects or areas of
intrinsic staining involving most
of the facial surface of the tooth

16. VENEER PREPARATION

17. Direct partial veneer
 Small localized intrinsic discoloration or defects that are surrounded by
healthy enamel are ideally treated with direct partial veneers.
 The outline form is dictated solely by the extent of the defect and should
include all discounted areas.
 Clinician should use coarse, elliptical or round diamond instrument with air
water coolant to prepare the tooth to a depth of about 0.5 to 0.75mm
 After preparation, etching and restoration followed by finishing is performed
 Use of an opaquing agent for masking dark stains can be employed.

18. Direct partial veneer

19. Direct full veneers
 Cases where along with correction of discoloration , diastema closure or
any other tooth form defect is also be corrected, full veneer is an good option.
 After they are cleaned and a shade is selected the area is isolated with cotton
rolls and retraction cords.
 The window preparation is made to a depth roughly equivalent to half the
thickness of the facial enamel, ranging from approx. 0.5-0.75mm mid-facially
and tapering down to a depth of about 0.2-0.5mm along the gingival margins,
depending on the thickness of enamel.
 A heavy chamfer finish line at the level of the gingival margins or crest
provides a definite preparation margin for subsequent finishing procedures.

20. Direct full veneers

22. Indirect veneer
technique

23. Bleaching treatment
 Acc. to sturdvant 5th edition ,
The lightening of the colour of a tooth through the application of a
chemical agent to oxidize the organic pigmentation in the tooth is referred to as
bleaching.
Acc. to ingle 6th edition,
bleaching is an treatment modality involving an oxidative chemical that
alters the light absorbing and light reflecting nature of a material structure thereby
increasing its perception of whiteness.

24. Advantages of bleaching
 Desirable results can be obtained most of the time.
 Painless to adults
 No tooth reduction required
 No anaesthesia required
 least expensive to treatment alternatives
 Less time required

25. Various bleaching agents
 Commonly used peroxide compounds:
a. hydrogen peroxide
b. sodium perborate
c. carbonate peroxide
Hydrogen peroxide and carbamide extra-coronal bleaching
Sodium perborate intra-coronal bleaching

29. Mechanism of action of bleaching
agent
 HYDROGEN PEROXIDE H2O2
 An increase in temperature accelerates the speed of the bleaching reaction.
Hydrogen peroxide is more effective as a bleaching agent at pH values that are
close to the dissociation constant. Enzymes such as peroxidases can break
down hydrogen peroxide into oxygen and water. High concentrations of
hydrogen peroxide must be handled with great care. If accidentally brought into
contact with soft tissues, it is caustic and may cause chemical burns by free
oxygen radicals. For external bleaching procedures, the use of a rubber dam
with additional blockout isolation around the gingival margins is mandatory to
avoid iatrogenic complications.

30. Mechanism of action of bleaching
agent
 Carbamide peroxide (CH6N2O3)
 urea hydrogen peroxide, will break down into carbamide and hydrogen
peroxide in aqueous solution. It is an efficient bleaching agent. The
carbamide portion urea is well tolerated by the human body. Carbamide
peroxide is available as crystallized powder or white crystals that contain
H2O2 in a concentration of about 35%. Most common home bleaching
products contain carbamide peroxide at about 10% strength, but it can
reach up to 30% (equivalent to 3.5% to 8.6% hydrogen peroxide). Car-
bamide peroxide can be used for internal bleaching

32. Nonvital bleaching
in-office bleaching
walking bleaching
 In-office bleaching
 Rubber dam is placed.
 The pulp chamber is filled loosely with cotton fibres and the labial surface with a few strands of cotton fibre to form a matrix
for retaining the bleaching solution.
 35% H2O2 is used to saturate the cotton inside the pulp chamber for 5 min.
 Excess should be wiped immediately.
 A thin tapered instrument can be heated and inserted into the pulp chamber for 5 mins.
 An alternative to activate H2O2 is the use of light and heat from bleaching light.
 Light or heat speed up the breakdown of H2O2 and thus lighten the teeth more rapidly
 The heating instrument and cotton can be removed , process can be repeated for four to six times or 20-30 min each time
placing a new cotton fibre. On successful bleaching, the chamber is filled to within 2mm of the cavosurface margin with a
paste consisting of calcium hydroxide powder in sterile saline.
 Reseal the axis opening .

33. In-office bleaching
TECHNIQUE

34. clinical steps of the walking
bleach technique
A. Situation prior to endodontic treatment and
internal bleaching. Discoloured maxillary left central
incisor due to dental trauma.
B. Postoperative situation after endodontic treatment
and internal bleaching using the walking bleach
technique.
C. Access cavity after barrier placement
D. Application of sodium perborate.
E. Temporary coronal seal with adhesive restoration

35. walking bleach technique

36. walking bleach technique
A, Situation prior to endodontic treatment and internal bleaching. Discolored maxillary left canine due to
pulp necrosis.
B, Postoperative situation after endodontic treatment and internal bleaching using the walking bleach
technique.
C, Preoperative situation.
D, Control radiograph after application of sodium perborate for the walking bleach technique.
Labeling of part
E showing placement of barrier material at the CEJ level, bleaching agent, and coronal seal with temporary
filling material.
F, Postoperative situation after bleaching, permanent coronal seal with adhesive restoration.

38. POWER
BLEACHING
 TOOTH CLEANED WITH pumice
 Isolate the teeth with cheek retractor and cotton rolls
 Light cured resin dam is applied on gingival tissues.
 Powered bleach solution is mixed following manufacturer’s instructions.
 Thick gel (2-3mm) is applied over the labial surface of the teeth using disposable brush
 One tooth is exposed at a time for 10 sec
 Once one arch is completed, repeat twice for a total exposure of 30 sec each per tooth
 The gel is left over the teeth for additional 5 sec
 Remove the gel with wet gauze.
 Light cure resin dam is removed.
 Teeth are polished with pumice and diamond paste.
 Patient is instructed tea, coffiee and cola for 2 weeks.

39. laser
 The action is to stimulate the catalyst in the chemical. There is no thermal effect and less
dehydration of enamel
 Laser which are used…….
 Argon laser of 488 wavelength for 30 sec to evaluate the activity of bleaching gel
 Argon laser is in the form of blue light and is absorbed by dark colour.
 Another product is used is ion laser technology
 Co2 laser is employed with another peroxide solution to provide penetration of the bleaching
agent into the tooth to provide penetration of the bleaching agent into the tooth to provide
bleaching below the surface.
 They have more harmful effect on the deciduous teeth.

40. laser
 Photochemical laser whitening –smart bleach technique:
The pH of the bleaching gel is alkaline. Perhydroxyl radical is
produced which is more reactive than superoxide and due to
alkaline pH, enamel surface is not etched.
Diode laser light
a true laser light produced from a solid state source. It is
ultrafast, taking 3-5 sec to activate the bleaching of agent.
This type laser produces no heat.

41. Bleaching of teeth by laser
pre & post treatment

42. Complications of internal bleaching
 CERVICAL RESORPTION :
 H2O2 from the access cavity to the root surface through the acid treated patient dentinal tubules.
 This stimulates an inflammatory response leading to dentine resorption
 Calcium hydroxide paste is placed immediately after bleaching to reduce the possibility of resorption
 Spillage of bleaching agents
 FAILURE TO BLEACH :
 H2O2 improperly stored or expired.
 Incomplete complete removal of composite or gic which prevent bleaching agents to penetrate the dentinal
tubules
 Brittleness of crown
 Chemical burns

43. Conclusion
 Dentistry in this era has many option to treat the discoloured teeth. Various
products are available in the market, but which procedure or technique is
suitable to treat which type of teeth discoloration that is big responsibility of
dentist.
 Therefore proper evaluation of discoloured teeth and the select the appropriate
option to treat it paly a key role in the success of treatment.

44. references
 Art & science of operative dentistry- sturdevant 5th edition
 Grossman’s endodontics – 13th edition
 Textbook of endodontics – ingle 6th edition
 TOOTH BLEACHING—A CRITICAL REVIEW OF THE BIOLOGICALASPECTS j.E.
Dahl* U. Pallesen
 Nonvital Tooth Bleaching: A Review of the Literature and Clinical Procedures Gianluca Plotino, Laura
Buono, Nicola M. Grande, Cornelis H. Pameijer, Francesco Somma,