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discoloration of teeth and management

teeth discoloration and its managment

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discoloration of teeth and management

  1. 1. Dr. Alka Shukla MDS student Dept of Conservative dentistry & Endodontics
  2. 2. Contents: • Introduction. • Classification of tooth discoloration. Intrinsic Extrinsic Internalised. • Diagnosis and treatment planning. • Management/ treatment: Scaling Microabrasion Macroabrasion
  3. 3. • Veneers: • Direct veneers • Indirect veneers • Ceramic crowns • Bleaching: • Introduction • History • Indications and contraindication • Non-vital bleaching • Vital tooth bleaching • Various agents used.
  4. 4. • Instructions to patient • Over-the-counter products • Recent advances • Conclusion • References.
  5. 5. • 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.” - Ingle 6th edition Introduction :
  6. 6. • 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.
  7. 7. • 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. • The etiology of dental discoloration is multifactorial. The correct diagnosis for the cause of discolouration is important and has a profound effect on treatment outcome.
  8. 8. Classification Of Tooth Discolouration Discolouration of teeth can be classified on basis of several factors. For example location, etiology, no. of teeth involved, etc.
  9. 9. • Most commonly followed classification which was given by Dayan et al 1983, Hayes et al 1989 is based on location of discolouration. EXTRINSIC STAINS INTRINSIC STAINS • These are located on the outer surfaces of the teeth. • These are common and it may be result of various causes: i. Remnants of Nasmyth membrane ii. Poor oral hygiene iii. Existing restoration iv. Gingival bleeding v. Plaque and calculus accumulation. vi. Eating habits: tea, coffee stains,etc. vii. Tobacco chewing habit viii. Chromogenic bacteria ix. Mouthwashes- Chlorhexidine • These are located on internal surfaces of teeth. • These are caused by deeper internal stains or enamels defects. • Teeth with vital or non-vital pulp or endo treated can be affected. • Causes: i. Hereditary disorders ii. Medications iii. Excess fluoride iv. High fevers associated with early childhood illness, and other types of trauma. v. Staining may be located in enamel or in dentin.
  10. 10. Based on cause; Tooth discoloration usually occurs owing to patient- or dentist-related causes.- [INGLE] Dental stains Dentist-Related causes Endodontically related Pulp tissue remnants Intracanal medicaments Obturating materials Restoration related Amalgams, Pins & posts, Composites Patient-Related Causes Pulp necrosis, Intrapulpal haemorrhage, Dentin hypercalcification, Tooth formation defects: -Developmental defects -Drug-related defects
  11. 11. Based on surface area or num of teeth involved. LOCALISED GENERALISED • Non-vital tooth • Amalgam blues • Turner’s hypoplasia: Due to trauma, high fever during the stage of development • Localised area of dys-mineralization or the failure of the enamel to calcify properly can result in hypo-calcified white spot. • After eruption, poor oral hygiene during orthodontic treatment frequently results in decalcified defects. • Tetracycline staining • Fluorosis • Tobacco stains • Because of ageing, generalised yellowish discolouration • Tea or coffee stains.
  12. 12. Amalgam blues Calculus Tobacco stains Non-vital tooth
  13. 13. Tetracycline stains Decalcification Turner’s hypoplasia Fluorosis
  14. 14. Classification By Nathoo And Gaffar 1977 based on chemistry of discoloration: • N1-type dental stain (direct dental stain) - Chromogen binds to the tooth surface & interacts with the tooth surface via an ion exchange mechanism. Color of the chromogen is similar to the stain. • Eg- bacterial adhesion to pellicle, tea, coffee, metals and wine
  15. 15. • N2-type dental stain (direct dental stain) - The chromogen changes colour after binding to the tooth. Eg- food that has aged. • N3-type dental stain (indirect dental stain) – The colourless material or prechromogen binds to the tooth and undergoes a chemical reaction to cause a stain. Eg- browning of foods that are high in carbohydrate and sugar, cooking oils, baked products and fruit.
  16. 16. Based on etiology PRE-ERUPTIVE CAUSES: • Alkaptonuria • Amelogenesis imperfecta • Dentinogenesis imperfecta • Endemic fluorosis • Erythroblastosis Fetalis • Porphyria • Sickle cell Anaemia • Thalassemia • Certain medications ex. Tetracycline staining. POST- ERUPTIVE CAUSES: • Age • Dental materials • Food, beverages and habits such as smoking • Idiopathic pulpal recession • Traumatic injuries. • Internal resorption
  17. 17. The most recent classification - A. Watt and M. Addy DentalStains Intrinsic Extrinsic Internalised Metallic Non-Metallic A. Watts, and M. Addy: Tooth discolouration and staining: a review of the literature. British Dental Journal Volume 190 No.6 March 24 2001
  18. 18. Internalised discolouration • Internalised discolouration is the incorporation of extrinsic stain within the tooth substance following dental development. It occurs in enamel defects and in the porous surface of exposed dentine. The routes by which pigments may become internalised are: – 1. Developmental defects – 2. Acquired defects a) Tooth wear and gingival recession b) Dental caries c) Restorative materials
  19. 19. Diagnosis and treatment planning: • In the treatment of tooth discolorations, the accurate diagnosis of the patient’s problem must be the dentist’s first goal. Without a thorough understanding of the factors affecting the patient’s dentition, any treatment would merely be conjectural. For this reason following steps should be followed: 1. Complete medical history: Questions should be asked on: – Pregnancy: while there has been no indication that tooth whitening during pregnancy is contraindicated , conventional wisdom leads one to avoid any elective procedure until its absolute safe.
  20. 20. • Tetracycline exposure: it will be helpful for the dentist to know whether tetracycline has had any part in the discoloration of the teeth. This knowledge may change both the approach to, and prognosis of treatment. • Fluoridation: if concentration of fluoride in water is more than 1 ppm which is a recommended concentration, children are likely to develop significant discoloration. • Trauma: this kind of discolouration is often limited to single tooth.
  21. 21. • Habits: certain forms of repetitive behaviour may influence the present coloration of teeth. Ex certain beverages, smoking, etc. • Sensitivity: any known allergy or sensitivity to hydrogen peroxide, polyresin, or any of the other materials used for tooth whitening will certainly alter the course of treatment.
  22. 22. 2. Pre-treatment pictures: pictures should be taken before commencing any treatment. This picture is then called the baseline. Any improvement from this point onwards can be attributed to dental treatment. 3. Prophylaxis: routine scaling and prophylaxis will eliminate plaque, calculus and extrinsic staining.
  23. 23. Management/ treatment:
  24. 24. • Prevention: • Scaling: Most of the surface stains can be removed by routine prophylactic procedures. • Microabrasion • Macroabrasion • Veneers: • Direct veneers • Indirect veneers • Ceramic crowns • Bleaching: • Non-vital bleaching • Vital tooth bleaching
  25. 25. White spot lesions and orthodontic treatment. Prevention and treatment Orthod Fr. 2014 Sep;85(3):235-44 PREVENTION • Certain teeth discolorations can be prevented by following strict oral hygiene practice. • Tobacco stains, coffee stains can be prevented by keeping a check on habits. • 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, fluoride containing mouth rinse, gel, varnish, bonding materials, elastic ligature). • Regular visit to dentist. (Any discolouration which is at initial stage can be avoided.)
  26. 26. Microabrasion: • In 1984, 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 involves the surface dissolution of the enamel by acid along with abrasiveness of pumice to remove superficial stains or defects. • Since that time, 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.
  27. 27. • Microabrasion technique involves the physical removal of tooth structure and does not remove stains or defects through any bleaching phenomena. • Fluorosis stains can also be removed by microabrasion if the discoloration is within the 0.2-0.3 mm removal depth limit. • Treated area are polished with a fluoride containing paste to restore surface lustre and enhance re-mineralization.
  28. 28. McInne’s technique: • This technique uses a combination of 5 parts of 30% H2O2, 5 parts of 36% HCl and 1 part of diethyl ether. The solution is applied directly to the stained areas for 1 to 2 minutes with cotton applicators. While the surface is wet, a fine cuttle disc is run over the stained surfaces for 15 seconds. This process is repeated until the desirable results are achieved, during subsequent appointments. • Modified McInn soln: 18% HCl & 20% hydrogen peroxide.
  29. 29. • Jahanbin A et al in 2015 showed that pumice powder alone had similar effects as 18% HCl on removing the white spot lesions. Nevertheless, 18% HCl makes the enamel susceptible for subsequent colour staining more than the other microabrasion methods.
  30. 30. Macroabrasion: • An alternative for removal of localized superficial white spots and other surface stains or defects is called macroabrasion. • It uses a 12- fluted 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 hydrated state to facilitate assessment of defect removal.
  31. 31. • After removal of the defect or on termination of any further removal of tooth structure, a 30-fluted composite finishing bur is used to remove any facets or striations creation by the previous instruments. • Final polishing is accomplished by abrasive rubber point. • To accelerate the process, a combination of macroabrasion and microabrasion also may be considered. Gross removal of the defect is done by macroabrasion followed by final treatment with microabrasion.
  32. 32. Veneers: • It is a layer of tooth-coloured material that is applied to a tooth surface to restore localized or generalised defects and intrinsic discolorations. • Common indications for veneers are: facial surfaces that are malformed, discoloured, abraded, or eroded or have faulty restorations. • Several factors should be evaluated before pursuing full veneers as treatment option. For example, patient’s age, occlusion, tissue health, position & alignment of teeth and oral hygiene. • Based on material, it can be of four types: a. Composite b. Processed composite c. Porcelain d. Pressed ceramic materials
  33. 33. • Based on preparation design: Based on design Partial veneer: Indicated for the restoration of localized defects or areas of intrinsic discolouration Full veneer: Indicated for restoration of generalised defects or area s of intrinsic staining involving most of the facial surface of the tooth Full veneer can of two types: window preparation or incisal lapping.
  34. 34. Labial and proximal views:
  35. 35. 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.
  36. 36. • 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.
  37. 37. INDIRECT VENEER TECHNIQUE: • Many dentists find that the preparation, placement and finishing of several direct veneers at one time is too difficult, fatiguing and time-consuming • In addition, veneer shades and contours can be better controlled when made outside of the mouth on a cast. • Using intense light, heat, vacuum pressure or a combination of these cured composite can be produced that possess improved physical & mechanical properties compared with traditional chairside composite.
  38. 38. Bleaching Treatment:
  39. 39. • Definition: “ 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” - Sturdvent 5th edition • Bleaching is an treatment modality involving an oxidative chemical that alters the light absorbing and/or light reflecting nature of a material structure ,thereby increasing its perception of whiteness . -Ingle ,6th edition.
  40. 40. • Bleaching will lighten teeth and the degree of lightening varies with the individual. Teeth that tend to be yellow in colour are the easiest to lighten and give the best results. Darker teeth may need more time to lighten but virtually all cases involving bleaching can have positive results. • Whitening offers a conservative, simplified, and economical approach to changing the color of teeth. As a result, tooth whitening has become one of dentistry’s most popular esthetic treatments.
  41. 41. • The desire for whiter teeth is not completely a recent phenomenon. A professional response to the unrelenting quest for white teeth dates back at least 2000 years. • In 14th century Guy de chauliac a known surgeon, recommended a procedure for whitening of teeth i.e, cleaning of teeth gently with a mixture of honey and burnt salt to which some vinegar has been added.
  42. 42. Historical background of bleaching: • Unsuccessful bleaching: Middle ages. • Initial attempts at bleaching 1848: 1st attempt of non-vital bleaching 1868: 1st attempt of vital tooth bleaching 1877: Chapple introduced oxalic acid 1888: Taft recommended calcium hypochlorite 1884: Harlan- hydrogen dioxide 1895: Electrical currents concept
  43. 43. • Beginning of Modern bleaching techniques: 1918: Abbot- superoxol and heat • Successful non-vital bleaching: 1958: Pearson- intrapulpal bleach. Pearson reported the use of superoxol sealed within the pulp chamber. He found that within 3 days, the oxygen releasing capacity of the solution had whitened the experimental teeth to some extent. 1967: Nutting & Poe- Walking bleach. they packed a mixture of 30% H2O2 and sodium perborate in the pulp chamber for 1 week • Modern techniques: 1978: superoxol, heat and light 1989: Munro- out patient tooth whitening
  44. 44.  1992: Rembrandt introduced whitening tooth pastes & enzyme based dentifrices.  1994: Light activation of the bleaching agents was introduced which further led to activation of bleaching agents by argon laser, CO2 laser and plasma arc. 1999: Diode laser was introduced as a vector in tooth whitening. From 1995 till date a variety of concentrations of bleaching gels containing remineralizing agents and fluoride have been available.
  45. 45. Advantage  Desirable results can be obtained most of the time  Painless to adults  No tooth reduction required  No anesthesia necessary  Least expensive to treatment alternatives.
  46. 46. Disadvantage  Normal tooth colour may or may not be restored  Bleaching can cause discomfort in children because of their large pulps.  Sometimes it might irritate the adjacent soft tissue.  Chances of increased sensitivity are there.  Extended treatment time may be necessary.
  47. 47. Contra-indications to bleaching • Patient selection – Patients with emotional or psychological problem or those with unrealistic goals do not make good candidates for bleaching. • Dentinal hypersensitivity – These symptoms may be associated with severe cases of attrition, erosion, abrasion or abfraction .
  48. 48. • Generalized dental caries and leaking restoration – Use of bleaching agents for such patients who fall in this category may lead to severe, generalized hypersensitivity • Heavily restored teeth – Teeth with visible, tooth colored restorations respond poorly to bleaching because the composite restorations do not lighten and become more evident after bleaching. • Teeth with opaque white spots • Teeth slated for bonded restorations or orthodontic bracketing. – Oxygen produced during bleaching remains in the enamel or dentin oxygen interferes with the bonding agent and induces bonding failure.
  49. 49. Various Bleaching Agents: The active ingredient in tooth bleaching materials is peroxide compounds. While currently a variety of bleaching materials are available, the most commonly used peroxide compounds : 1. Hydrogen Peroxide 2. Sodium Perborate 3. Carbamide Peroxide • Hydrogen peroxide and carbamide peroxide extra-coronal bleaching. • Sodium perborate intra-coronal bleaching.
  50. 50. HYDROGEN PEROXIDE • It is a colourless, clear, odourless liquid which should be stored in light proof amber bottles. • It ranges from 5- 35 % • Peroxide can be classified as organic or inorganic. • They are strong oxidizers and can be considered as the product of hydrogen peroxides when hydrogen atoms are substituted with metals[ inorganic form] or with organic radicals. • Hydrogen peroxide has a lower molecular weight and hence can penetrate dentine and release oxygen that breaks down the double bond of inorganic and organic compounds inside the tubules.
  51. 51. • Care should be taken in handling it because it can cause chemical burns on the area of contact. • Concentration ranging from 25-38% is recommended for in-office bleaching. • Concentration ranging from 3- 7.5% is used for home bleach.
  52. 52. Mode of Supply of Hydrogen peroxide:- Solution: Various concentrations of hydrogen peroxides are available, but 30% to 35% stabilized solutions are the most commonly used. They can be used either alone or mixed with sodium perborate. Gel: Also available in the form of Silicon dioxide gels containing various concentrations of hydrogen peroxide (6 to 38%). Recently introduced is the Opalescence xtra boost which contains 38% hydrogen peroxide for quicker results and which does not even require light activation (Syringes).
  53. 53. Teeth whitening strips:- • These are flexible pieces of plastic or polyethylene that have been coated on one side with a thin film of hydrogen peroxide gel. • The idea of the teeth whitening strips was to reduce the thickness of the peroxide gel. • The thickness of the bleaching gels on the whitening strips is about 0.2mm while that of a paper is 0.1mm. It is ½ to 1/5th quantity compared to the tray bleaching.
  54. 54. SODIUM PERBORATE • It is a stable, white powder, normally supplied in a granular form that has to be ground into a powder before using. • They differ in oxygen content that determines their bleaching efficacy. • Their pH is alkaline, and it depends on the amount of H2O2 released and the residual sodium metaborate. 3 types are there Sodium perborate monohydrate Sodium perborate trihydrate Sodium perborate tetrahydrate
  55. 55. • These mixture reacts with water to give sodium perborate, hydrogen peroxide and oxygen is released. • When mixed into a paste with superoxol, this paste decomposes into sodium metaborate, water and oxygen. It oxidizes the stains slowly. • It is more easily controlled and is safer than concentrated H2O2. Therefore it is the material of choice in most intra-coronal bleaching procedures.
  56. 56. CARBAMIDE PEROXIDE/ UREA HYDROGEN PEROXIDE • It exists in the form of white crystals or as a crystallized powder containing approx 35% H2O2 . • Its concentration ranges from 10- 30% depending on at- home and in-office bleach. • Commercially available preparation has 10% carbamide peroxide. • Carbamide peroxide breaks down to liberate urea+ Ammonia+ carbon dioxide + hydrogen peroxide.
  57. 57. • Additive in gel preparation include glycerine or propylene glycol, sodium stannate, phosphoric or citric acid and flavouring agents. • Some preparations contain carbopol, a water soluble polyacrylic acid polymer, which is added as a thickening agents and it prolongs the release of active peroxide and improves shelf life.
  58. 58. • The mechanism of tooth bleaching in unclear at present; however it is generally believed that free radicals produced by H2O2 may be responsible for bleaching effects. • Principal mechanism is that the oxidizing agents reaches the sites within enamel and dentin to allow a chemical reaction to occur between discoloured segment and the active ingredient.
  59. 59. • H2O2 diffuse through enamel matrix and the free oxygen radical which are generated interact with organic molecules to attain stability. • Bleaching agents opens the more highly pigmented carbon ring [ yellow colour] and converts them to carbon chain and breaks double bonds which absorbs lesser amount of light and hence tooth appears lighter. • In addition to chemical reaction , other possible mechanisms include cleansing of tooth surface , temporary dehydration of enamel surface during the bleaching process , and change of enamel surface.
  60. 60. Hydrogen peroxide acts as a strong oxidizing agent through the formation of free radicals , reactive oxygen molecules, and hydrogen peroxide anions. These reactive molecules attack the long- chained, dark-colored chromophore molecules and split them into smaller, less colored, and more diffusible molecules.
  61. 61. FACTORS AFFECTING BLEACHING A number of factors, relating to both patient and material used may contribute to bleaching efficacy and subsequent stability of bleaching achieved. 1. Surface cleanliness: 2. Type of peroxide compound: 3. Concentration of peroxide: 4. Shelf life of material: 5. Temperature:
  62. 62. 6. pH: 7. Time: 8. Frequency of application: 9. Sealed environment 10. Additives: 11. Other factors like age, initial colour of teeth also play a major role.
  63. 63. Classification of bleaching techniques: • Based on teeth vitality: 1. Non-vital bleaching 2. Vital teeth bleaching • Based on whether the procedure is performed in clinic or out side: 1. In- office bleaching technique 2. Walking bleach/ dentist prescribed/ home applied bleaching
  64. 64. NON-VITAL BLEACHING PROCEDURE
  65. 65. • INDICATIONS: - Discoloration of pulp chamber - Dentine discoloration - Discoloration not amenable to extra-coronal Bleaching • CONTRAINDICATIONS: - Superficial enamel stains - Defective enamel formation - Severe dentine loss - Presence of caries - Discolored composites
  66. 66. • Most of the techniques use some of the derivative of hydrogen peroxide in different concentration and application techniques. • Bleaching effect generally has an appropriate life span of 1-3 years, but sometimes changes may be permanent. • With bleaching there is transitory decrease in the potential bond strength results from residual oxygen or peroxide in the tooth that inhibits the set of the bonding resin, precluding adequate resin tag formation in the etched enamel.
  67. 67. A)IN-OFFICE NON-VITAL BLEACHING TECHNIQUE: In any of the non-vital bleaching techniques, there are certain steps which are common. • Radiographic assessment of the status of the periapical tissues and the quality of endodontic obturation. If the obturation is inadequate, the tooth should be retreated prior to bleaching. • Evaluate the tooth colour with a shade tab by taking photographs at every appointment. • Vaseline should be applied to the gingival tissues, followed by isolation with rubber dam which should fit tightly at the cervical margin of the tooth to prevent possible leakage of the bleaching agent onto the gingival tissues.
  68. 68. • Remove all restorative material from the access cavity, expose the dentin and refine the access. Verify that the pulp horns and other areas containing pulp tissue are clean. • Remove the obturation material to just below labial gingival margin. Orange solvent, chloroform or xylene on a cotton pellet may be used to dissolve sealer remnants. • Next is the application of the barrier material. This is one of the most important step as the improper location, material and the shape of the barrier material could lead to external cervical resorption.
  69. 69. • It is important to seal exposed root filling material with a sealing cement (RMGIC is recommended) before placement of bleaching agents. • It is also advocated that the bleaching agent be applied in the coronal portion of the tooth, incisal to the level of periodontal ligament to prevent unwanted leakage of the bleaching agent through lateral canals or canaliculi to periodontal ligament. • After these basic steps, in-office technique or walking bleaching technique can be followed.
  70. 70. B)WALKING BLEACH: • In this technique, a mixture of sodium perborate and inert liquid such as water, saline or anesthetic solution or even H2O2 can be used but preferably lower concentrations are placed in the pulp chamber. Studies have shown more number of external cervical resorption cases with the combination of sodium perborate and 30% hydrogen peroxide. • Studies with different types of sodium perborate, water and H2O2 have shown that the combination of sodium tetra borate with water was quiet effective.
  71. 71. Steps: • Probe circumferentially to determine outline of CEJ. • Isolate the tooth with a rubber dam. • A protective cream, such as Orabase or Vaseline, must be applied to oral mucosa. • Remove all restorative material from the access cavity, expose the dentin and refine the access. Pulp horns and pulp tissue are cleaned. • Remove all material below the labial gingival margin. Chloroform, Orange solvent or xylene on a cotton pellet may be used to dissolve sealer remnants. • Cement barrier is placed (2mm)as protective barrier for protection. (polycarboxylate cement, zinc phosphate, or cavit)
  72. 72. • Prepare the walking bleach paste of wet sand consistency (water or saline). • With a plastic instrument, pack the pulp chamber with the paste. • Excess liquid from sodium perborate should be removed by tamping with a cotton pellet. Access cavity is sealed with temporary restoration, at least 3 mm in thickness. • Evaluate patient after 2 weeks. • Sodium perborate should be changed weekly.
  73. 73. • If after 3 attempts there is no significant improvement, reassess the case for correct diagnosis and treatment plan. • After obtaining desired results, pulp chamber is rinsed and calcium hydroxide is placed for two weeks. • Later calcium hydroxide is removed, chamber is dried, etched and composite is placed.
  74. 74. Thermocatalytic • It is done by placing 30 to 35% (Superoxol) in the pulp chamber followed by heat application either by electric heating devise or specially designed lamps. • External Cervical Root Resorption (damage) may be caused by irritation to the cementum and periodontal ligament. • This is possibly because of oxidizing agent combined with heating. Therefore, application of highly concentrated hydrogen peroxide and heat during intracoronal bleaching is questionable and should not be carried out routinely.
  75. 75. Ultraviolet photo-oxidation: • This technique applies ultraviolet light to the labial surface of the tooth to be bleached. A 30 to 35% hydrogen peroxide solution is placed in the pulp chamber on a cotton pellet followed by a 2 minute exposure to ultraviolet light. Supposedly, this causes oxygen release, like the thermocatalytic bleaching technique.
  76. 76. INTENTIONAL ENDODONTICS & INTRACORONAL BLEACHING • Indication – severe tetracycline stains. - intact teeth without coronal defects • Standard endodontic therapy + Intra-coronal Walking Bleach Technique.
  77. 77. Suggestions for safe intra-coronal bleaching  Isolate the tooth effectively.  Protect the oral mucosa  Verify adequate endodontic obturation  Use protective gingival barriers  Avoid acid etching-(irritation to PD)  Avoid strong oxidizers – Sodium Perborate should be use  Avoid heat with strong oxidizers  Recall periodically- 6 months after bleaching.
  78. 78. Restoration of intra-coronal bleached teeth: • The pulp chamber and access cavity should be carefully restored with a light cured acid etched composite resin, which is light in shade. • It should be placed at a depth that seals the cavity and provides some incisal support. • Curing is recommended from labial aspect to result the shrinkage of the composite towards the axial walls, and thus reducing the rate of microleakage. • Placing a white cement beneath the composite restoration is recommended.
  79. 79. • Residual H2O2 can affect bonding therefore, waiting for at least 7 days after bleaching is recommended. • Packing calcium hydroxide paste in the chamber for a few weeks prior to permanent restoration, to counteract acidity caused by bleaching agents and to prevent root resorption is also recommended.
  80. 80. HYDROGEN PEROXIDE TOOTH-WHITENING (BLEACHING) ADVERSE EFFECTS. Cervical root resorption is a possible consequence of internal bleaching and is more frequently observed in teeth treated with the thermo-catalytic procedure. It is asymptomatic and is generally noticed during routine examination. The exact cause of this response is not fully understood. • Irritating chemical diffuses through dentinal tubules and cementum defects and causes necrosis of the cementum. Inflammation of the periodontal ligament Root resorption.
  81. 81. After 2 years
  82. 82. • Direct contact with H2O2 induces cytotoxic effects 35% H2O2 is caustic and may cause chemical burns and sloughing of the gingiva. • Several carcinogenesis studies indicated H2O2 might act like a promoter. • High concentration of hydrogen peroxide damage enamel surface integrity. But few studies have also shown that bleaching with 35% hydrogen peroxide gel was more effective than with the 20% gel, without promoting significant adverse effects on enamel surface microhardness. Effect of hydrogen peroxide concentration on enamel colour and microhardness. Operative dentistry ,2015, 40-1,96-101 by Borge AB et al
  83. 83. Inhibition of resin polymerization. • Residual H2O2 in tooth structure after bleaching adversely affects the bonding strength of resin composites to enamel and dentin. • Scanning electron microscopy (SEM) examination has shown an increase in resin porosity . • Studies have reported that 3 mins of catalase treatment effectively removed all of residual H2O2 from the pulp chamber of human teeth.
  84. 84. Vital bleaching techniques: There are various techniques for bleaching vital teeth depending on the degree of staining.  In-office.  Mouth guard or Night guard or At-home .  Over-the counter.
  85. 85. In-office: Techniques:- • Familiarize the patient about causes of discoloration, procedure to be followed and the treatment outcome. • Make radiographs to detect the presence of caries, defective restorations and proximity to pulp horns. • Evaluate tooth colour with shade tabs by taking photographs at all the appointments. • Apply Vaseline or oraseal and then isolate with rubber dam by using waxed dental floss or wedges for additional sealing. Avoid using metal clamps, as they are subjected to heat.
  86. 86. • Do not inject a local anesthetic. • Position protective eyeglasses over the patient’s and operator’s eyes. • Clean the enamel surface with pumice and water. • For the darkest or most severely stained areas acid etch with 35% phosphoric acid for 5 to 10 seconds and rinse with water for 60 seconds. • Place a small amount of 30 to 35% H2O2 solution into a dappen dish. Apply the H2O2 liquid on the labial surface of the teeth using a small cotton pellet or a piece of gauze. Bleaching gel can also be used instead of solution which can be better controlled.
  87. 87. • Apply heat with a heating device or light source. The temperature should be controlled that the patient does not feel any discomfort, usually between 125F and 140F (52C to 60C). Re-wet the enamel surface with H2O2 as necessary. If the tooth becomes too sensitive, discontinue the bleaching procedure immediately. Do not exceed 30 min even if satisfactory results are not obtained. • Various heating devices: – Tungsten-Halogen curing light – Argon laser – Carbon dioxide laser – Xenon plasma arc light – Diode laser light
  88. 88. • Inform the patient that cold sensitivity is common, especially during the first 24 hrs and advise to use a fluoride rinse daily for 2 weeks. • Recall the patient after 2 weeks and evaluate the effectiveness of bleaching by using the same shade tab used pre-operative assessment. Repeat the procedure if necessary.
  89. 89. Night guard vital bleaching: Technique:- • This technique has been widely advocated as a home bleaching technique with a wide variety of materials. The process utilizes a custom fitted mouth matrix or tray, which holds and bathes the teeth in a whitening solution • Numerous products are available, mostly containing 1.5 to 10% hydrogen peroxide or 10 to 15% carbamide peroxide, that degrade slowly to release hydrogen peroxide. • Carbamide peroxide products are the more commonly used at home bleaching agents.
  90. 90. • Familiarize the patient with the probable causes of discoloration, procedure to be followed and the expected outcome. • Carry out thorough oral prophylaxis • Assess the colour of the teeth with a shade tab by taking photographs at all the appointments. • Make alginate impressions of both the arches and cast is poured with dental stone. • Then the night guard is formed using a heated vacuum forming machine from a soft vinyl night-guard material.
  91. 91. • Insert the mouth guard to ensure proper fit. Remove and apply the bleaching agent in the space of each tooth to be bleached. Reinsert the mouth guard over the teeth and remove excess bleaching agent. • A10-15% carbamide peroxide bleaching material is used. It degrades to 3% hydrogen peroxide and 7% urea.
  92. 92. • Familiarize the patient with the use of bleaching agent and wearing the mouth guard. • Total treatment time using an overnight approach is usually 1-2 weeks. • It is recommended that only one arch be bleached at a time beginning with the maxillary arch.
  93. 93. Complications of vital teeth bleaching: 1. Systemic effect-Accidental ingestion of large amount of these gels may be toxic and cause irritation to the gastric and respiratory mucosa. 2. Dental Hard Tissue Damage. 3. Tooth Sensitivity - mild to moderate. 4. Pulpal damage, gingival & Mucosal Damage. 5. Damage to Restorations -Composite resins (softening and cracking of the resin matrix) -Liberation of mercury and silver from amalgam restorations. (10% Carbamide peroxide and 10% H2O2).
  94. 94. FariaESilva AL et alEffect of preventive use of nonsteroidal antiinflammatory drugs on sensitivity after dental bleaching: a systematic review and metaanalysis. J Am Dent Assoc. 2015 Feb;146(2):8793 Tooth sensitivity [TS] is a typical side effect associated with tooth bleaching procedures. To overcome it certain steps were taken. • Potassium nitrate and sodium fluoride reduce tooth sensitivity. • The anti-inflammatory medication etoricoxib 60 mg was tried but it was unable to reduce the presence and intensity of TS. • The perioperative use of the anti-inflammatory ibuprofen 400 mg was also not able to avoid tooth sensitivity but reduced its intensity up to one hour after bleaching. • There is insufficient evidence about the use of NSAIDs to prevent tooth sensitivity caused by in-office bleaching procedures.
  95. 95. Instructions to patient: • Avoid staining your teeth with tea, coffee, red wine, cola and smoking for a couple of days after whitening . • Bleach won’t whiten caps, crowns or fillings, and these may need to be replaced if they no longer match the rest of your teeth. • Teeth may need re-whitening after a couple of years or so. • To have Realistic expectations.
  96. 96. Over-the-counter: • Many home bleaching products are available over the counter. This approach is not recommended as overuse and abuse are a concern. • These systems include 1. Tooth pastes – AP-24, Rembrandt 2. Mouth rinses – Crest 3. Tooth brushes – Spine brush pro whitening 4. Dental floss – Super smile
  97. 97. 5. Teeth whitening strips – Crest 6. Chewing gums – Brits smile, Happy dent, orbit white. 7. Paint on varnish – Vivastyle 8. Bleaching pens - Brite smile stick or pen • These products primarily work by removing extrinsic stains. • Although there are many whitening agents sold over the counter, the best results are obtained by dentist-supervised programs.
  98. 98. Management of few particular stains in detail:
  99. 99. Tetracycline dental discoloration • Tetracycline result in discolorations of the tooth substance when administered during tooth development . • Minocycline has the ability to affect permanent dentition even in adults usually seen with long term usage. • The staining varies, depending on the type of antibiotic used, from yellow or grey to brown with or without banding
  100. 100. • Classification (Jordan and Boksman 1984).  1. First Degree. Mild tetracycline staining. This staining is yellow to grey with no banding and is uniformly spread throughout the tooth.  2. Second Degree. Moderate tetracycline staining. This is yellow brown to dark grey staining. 3. Third degree. Severe tetracycline staining. This is blue grey or black and is accompanied by significant banding across the tooth. 4. Fourth degree. Intractable staining is that staining that is so severe that bleaching is ineffective.
  101. 101. • Tetracyclines chelates with calcium ions to form a stable tetracycline calcium ortophosphate complex. These complexes are deposited into bone and teeth. Dentine is more susceptible to staining than enamel. • Tetracycline stain is the most resistant to tooth whitening and typically requires the longest whitening treatment. • Effective treatment over a period of one to six months has been reported with use of 10%–20% concentrations of carbamide peroxide. • Ninety months post-treatment, whitening of tetracycline-stained teeth was found to be retained and stable.
  102. 102. • One study found that high concentrations of enzymes – specifically peroxidase and lactoperoxidase – increased the rate of whitening when used with carbamide peroxide. • Haywood has shown that tetracycline-stained teeth may respond to long bleaching treatments, some tetracycline discolorations can require from 1 to 12 months of treatment every night. • Leonard et al. (2003) stated in their study that tetracycline-stained teeth can be whitened successfully using a 6 month active treatment with 10% carbamide peroxide, and that shade stability may last at least 90 months post treatment.
  103. 103. • Prognosis is variable depending on the specific degree and intensity of staining. The prognosis of vital bleaching is good for degree I. • Sometimes in severely stained teeth, intentional root canal treatment followed by intra-coronal bleaching is more effective. • In cases where the teeth are severely stained in the gingival area and a bleaching treatment has no effect, porcelain veneers or placement of a crown will be options to restore esthetics and function
  104. 104. Alkaptonuria • Alkaptonuria is an autosomal recessive disorder of tyrosine degradation pathway. • Alkaptonuria is characterized by deficiency of a hepatic enzyme, homogentisate 1,2-dioxygenase (HGD), which helps break down homogentisic acid (HGA), a step on tyrosine degradation pathway. • Mutations in HGD gene impair this role of the enzyme, and resulting in accumulation of HGA and its oxidized product. Excess of these substances are deposited in the body.
  105. 105. • According to a case report this metabolic error may cause a bluish discoloration of the teeth • There is no reports describing how to treat the stained teeth caused by alkaptonuria.. Bleaching should be tried first, but the blue or grey stains are difficult to change. When the stains do not respond to bleaching, they have to be either removed by abrasion or masked by restorative treatment.
  106. 106. Porphyria • Porphyria is a rare condition resulting from errors in enzymes involved in haem metabolism which results in the accumulation of porphyrins in various parts of body. • The steps in the biosynthesis of heme require specific enzymes, and deficiencies of these enzymes result in porphyria. • It leads to a discoloration of the teeth, due to a deposition of porphyrin pigments.
  107. 107. • The deposition of red-brown porphyrin pigments in the tooth substance causes a characteristic red discoloration of the teeth, which is most marked in the cervical area and is reduced towards the occlusal surface. • To improve the aesthetics in teeth with red-brown porphyrin pigments deposited. The dental treatment options are crowns, facings and/or laminated veneers.
  108. 108. Hyperbilirubinemia • Hyperbilirubinemia results in elevated serum levels of bilirubin and it is chemically defined as a serum concentration of bilirubin larger than 1.5 mg/100 mL. • When hyperbilirubinemia occurs during the period of tooth development, serum bilirubin may be deposited in the dental hard tissues and cause a green stain. • The treatment for the condition is bleaching or placement of esthetic crowns.
  109. 109. Amelogenesis imperfecta. • Amelogenesis imperfecta [AI] is a group of hereditary disorders characterized by abnormal amelogenesis, affecting both primary and permanent dentitions. • AI is caused by mutations in the genes that control the enamel formation. • The treatment of different AI types depends on the AI type and the phenotype of the affected enamel. The treatment can range from preventive care using sealants, tooth whitening, microabrasion, and bonded technique for esthetic improvement to prosthetic reconstruction
  110. 110. Dentinogenesis imperfecta • Dentinogenesis imperfecta is a hereditary defect of the dentin affecting both the primary and permanent dentitions. • Bleaching and prosthetic crowns are recommended. • Croll et al (1995) reported a case with successful bleaching of teeth with dentinogenesis imperfecta discoloration. They used application of 10% carbamide peroxide in a custom-tray for home bleaching.
  111. 111. Fluorosis • An excess ingestion of fluoride that induces multiple changes in the developing enamel. • The choice between different treatments depends on the severity of the fluorosis. • The aesthetic of mild fluorosis can be improved successfully with bleaching. • Moderate fluorosis can be corrected with bleaching or in combination with microabrasion. • Severe fluorosis may require porcelain laminate veneers, restorations or crowns.
  112. 112. Aging • In geriatric patients, an increased yellowing or greying of the teeth can be observed. This is partially due to internal changes and partially due to surface morphology changes. As the patient ages, the incisal edges wear and become less translucent, the enamel thins, and the dentin thickens, also resulting in a more yellow and a more dense appearance. The severity of such intrinsic staining varies. • Generalized yellowish colour can be seen. • Staining can be successfully treated with in-office and/or at-home tooth whitening agents.
  113. 113. Turner’s tooth • Trauma/Infection of a Primary Tooth Infection in, or trauma to, a primary tooth, as well as childhood diseases such as measles, can result in the appearance of a white or mottled area on the permanent tooth. • Some success has been achieved with these using a microabrasion/etching technique. • Veneers and laminates can also be considered.
  114. 114. Traumatized Permanent Teeth or Teeth with a history of trauma • According to Plotino, trauma- or necrosis-induced discoloration can be successfully bleached in about 95% of the cases, compared with lower percentages for teeth discolored as a result of medicaments or restorations • One treatment option for darkened teeth is veneers (in mild cases) or crowns. But a less invasive option for teeth that have been endodontically treated is to bleach the tooth using external bleaching, an internal “walking bleach” method, or a combination of the two.
  115. 115. Recent techniques:
  116. 116. Jun-Ichiro Kinoshita et al.Vital Bleaching of Tetracycline-Stained Teeth by Using KTP Laser: A Case Report. European Journal of Dentistry. July 2009 - Vol.3 • KTP (Karium-Titanium-Phosphoric acid), which is a type of Nd:YAG laser, seems to be appropriate for bleaching of tetracycline-stained teeth. • KTP tends to penetrate into dentin with less damage. This laser does not increase temperature much. Its photons have high energy that facilitate the chemical and photodynamic reactions without damage to both hard and pulp tissues. It has been shown that KTP laser is capable of producing significantly more effect than LED or diode laser. • KTP is cooler in temperature and stronger in photon energy, which means KTP is suitable for vital teeth bleaching without damage to pulp tissue.
  117. 117. • The idea of not removing tooth structure and pain-free dentistry has helped to create the demand for no preparation veneers. • No-preparation or minimally invasive veneers are veneers that have ultra-thin or “Contact lens” thickness of 0.3-0.5 mm. • They are placed without the tooth being altered, so they do add to the overall structure of the tooth and might feel a little bulkier than the classic porcelain veneers. Ultra-thin/ no preparation veneers
  118. 118. • Example: Lumineers by Cerinate • Lumineers are an improved variant of the porcelain veneer. They have the same function as the porcelain veneers and provide the same benefits to the patient. • The placement of lumineers doesn’t involve the peeling of the enamel of the tooth and therefore might be a better long term solution than veneers. When placing lumineers, the structure of the tooth remains unchanged.
  119. 119. RESIN INFILTRATION TECHNIQUE • The loss of mineralized layer creates porosities that change the refractive index of usually translucent enamel. • A new minimally invasive technique for treating white spot lesions is by caries infiltration by resin, for example "Icon.“ • The resin completely fills the pores within the tooth, replacing the lost tooth structure and stopping caries progression. After conditioning of lesions using 15% hydrochloric acid gel, desiccating the tooth with ethanol is performed, which allows easy penetration of resin into the porous tooth The resin penetrates into the lesion by capillary forces. Novel treatment of white spot lesions: A report of two cases. Journal of conservative dentistry.
  120. 120. • This technique prevents further progression of initial enamel caries lesions and occludes the microporosities within the lesion by infiltration with low-viscosity light-curing resins that can rapidly penetrate into the porous enamel. • Borges AB et al in 2015; in a case series presented that the resin infiltration technique can be successfully used to mask fluorosis and hypomineralised areas of enamel.
  121. 121. CONCLUSION: • Unlike olden days, dentistry in this era has various option to treat discoloured teeth. Today dental markets are full of various teeth whitening products. • But which procedure or technique is suitable to treat which type of discolouration that is a big responsibility on dentist’s shoulder. Therefore proper evaluation of discoloured teeth and then selecting appropriate option to treat it plays a key role in success of treatment. • In addition, routine monitoring of bleaching by dentists allow early detection of any possible complications. • To conclude, for a desired and favourable outcome a through knowledge of etiology, treatment options, products and its properties is supreme demand.
  122. 122. References: • Art & Science of operative dentistry- sturdevent- 5th edition. • Grossman’s endodontics- 12th edition. • Color atlas of tooth whitening- Gerald McLaughlin • Fundamentals of operative dentistry- James Summit.- 2nd edition. • Bleaching techniques in restorative dentistry- Linda Greenwall. • Textbook of Endodontics- Ingle, 6th edition. • A. Watts, and M. Addy. Tooth discolouration and staining: a review of the literature. British dental journal volume 190 no.6 march 24 2001. • Colour masking of developmental enamel defects: A case series Operative dentistry ,2015, 40-1, 25-33 • Effect of hydrogen peroxide concentration on enamel colour and microhardness. Operative dentistry ,2015, 40-1,96-101 by Borge AB et al
  123. 123. • FariaESilva AL, Nahsan FP, Fernandes MT, MartinsFilho PR. Effect of preventive use of non-steroidal anti-inflammatory drugs on sensitivity after dental bleaching: a systematic review and meta-analysis. J Am Dent Assoc. 2015 Feb;146(2):8793. • Wang Y , Gao J , Jiang T , Liang S , Zhou Y , Matis BA. Evaluation of the efficacy of potassium nitrate and sodium fluoride as desensitizing agents during tooth bleaching treatment—A systematic review and metaanalysis. J Dent. 2015 Aug;43(8):91323. • De Paula EA , Loguercio AD, Fernandes D, Kossatz S, Reis A. Perioperative use of an anti- inflammatory drug on tooth sensitivity caused by in office bleaching: a randomized, tripleblind clinical trial. Clin Oral Investig. 2013 Dec;17(9):20917. • Paula E, Kossatz S, Fernandes D, Loguercio A, Reis A. The effect of perioperative ibuprofen use on tooth sensitivity caused by inoffice bleaching. Oper Dent. 2013 NovDec;38(6):6018 • Lagori G , Vescovi P , Merigo E , Meleti M , Fornaini C. The bleaching efficiency of KTP and diode 810 nm lasers on teeth stained with different substances: An in vitro study. Laser Ther. 2014 Mar 27;23(1):2130
  124. 124. • Muñoz MA, Arana-Gordillo LA, Gomes GM, Gomes OM, Bombarda NH, Reis A, Loguercio AD. Alternative esthetic management of fluorosis and hypoplasia stains: blending effect obtained with resin infiltration techniques. J Esthet Restor Dent. 2013 Feb;25(1):32-9. • Leonard, R.H., Jr., et al., Nightguard vital bleaching of tetracycline-stained teeth: 90 months post treatment. J Esthet Restor Dent, 2003. 15(3): p. 142-52. • Philip H Newsome, L.H.G., Management of tetracycline discoloured teeth. Aesthetic Dentistry Today, 2008. 2: p. 15-18. • Sanchez, A.R., R.S. Rogers, 3rd, and P.J. Sheridan, Tetracycline and other tetracyclinederivative staining of the teeth and oral cavity. Int J Dermatol, 2004. 43(10): p. 709-15

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