• 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
- Ingle 6th edition
• Discoloration of the tooth is one of the most frequent reasons why a patient
seeks dental care. Tooth discoloration is usually aesthetically displeasing and
• 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.
• The etiology of dental discoloration is multifactorial. The correct diagnosis for
the cause of discolouration is important and has a profound effect on treatment
Classification Of Tooth Discolouration
Discolouration of teeth can be classified on basis of several factors. For example
location, etiology, no. of teeth involved, etc.
• 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
• These are common and it may be result of
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
• These are caused by deeper internal stains or
• Teeth with vital or non-vital pulp or endo
treated can be affected.
i. Hereditary disorders
iii. Excess fluoride
iv. High fevers associated with early
childhood illness, and other types of
v. Staining may be located in enamel or
Based on cause; Tooth discoloration usually occurs owing to patient- or
dentist-related causes.- [INGLE]
Pulp tissue remnants
Pins & posts,
Tooth formation defects:
Based on surface area or num
of teeth involved.
• 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
• Tetracycline staining
• Tobacco stains
• Because of ageing, generalised yellowish
• Tea or coffee stains.
Amalgam blues Calculus
Tobacco stains Non-vital tooth
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
• 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.
Based on etiology
• Amelogenesis imperfecta
• Dentinogenesis imperfecta
• Endemic fluorosis
• Erythroblastosis Fetalis
• Sickle cell Anaemia
• Certain medications ex.
POST- ERUPTIVE CAUSES:
• Dental materials
• Food, beverages and
habits such as smoking
• Idiopathic pulpal
• Traumatic injuries.
• Internal resorption
The most recent classification
- A. Watt and M. Addy
A. Watts, and M. Addy: Tooth discolouration and staining: a review of the literature.
British Dental Journal Volume 190 No.6 March 24 2001
• 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
– 1. Developmental defects
– 2. Acquired defects
a) Tooth wear and gingival recession
b) Dental caries
c) Restorative materials
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.
• 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
• Trauma: this kind of discolouration is often limited to single tooth.
• 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.
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.
• Scaling: Most of the surface stains can be removed by routine prophylactic
• Direct veneers
• Indirect veneers
• Ceramic crowns
• Non-vital bleaching
• Vital tooth bleaching
White spot lesions and orthodontic treatment. Prevention and treatment
Orthod Fr. 2014 Sep;85(3):235-44
• Certain teeth discolorations can be prevented by following strict oral hygiene
• 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.)
• 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.
• 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.
• 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.
• 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
• An alternative for removal of localized superficial
white spots and other surface stains or defects is called
• 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.
• 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.
• 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:
b. Processed composite
d. Pressed ceramic materials
• Based on preparation design:
Based on design
Indicated for the restoration of
localized defects or areas of
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.
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.
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
• 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.
• 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.
• 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
• 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.
• 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
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
1992: Rembrandt introduced whitening tooth pastes & enzyme based
1994: Light activation of the bleaching agents was introduced which
further led to activation of bleaching agents by argon laser, CO2 laser and
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.
Desirable results can be obtained most of the time
Painless to adults
No tooth reduction required
No anesthesia necessary
Least expensive to treatment alternatives.
Normal tooth colour may or may not be restored
Bleaching can cause discomfort in children because of their large
Sometimes it might irritate the adjacent soft tissue.
Chances of increased sensitivity are there.
Extended treatment time may be necessary.
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 .
• 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
• 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.
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.
• It is a colourless, clear, odourless liquid which should be stored in light proof
• 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.
• 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.
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
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.
• 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
• 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.
CARBAMIDE PEROXIDE/ UREA HYDROGEN
• 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
• Commercially available preparation has 10% carbamide peroxide.
• Carbamide peroxide breaks down to liberate urea+ Ammonia+ carbon dioxide +
• 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.
• 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
• 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.
• 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.
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.
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:
8. Frequency of application:
9. Sealed environment
11. Other factors like age, initial colour of teeth also play a major role.
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
- Discoloration of pulp chamber
- Dentine discoloration
- Discoloration not amenable to extra-coronal
- Superficial enamel stains
- Defective enamel formation
- Severe dentine loss
- Presence of caries
- Discolored composites
• 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.
A)IN-OFFICE NON-VITAL BLEACHING TECHNIQUE:
In any of the non-vital bleaching techniques, there are certain steps which are
• 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
• 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.
• 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
• 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.
• 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
• After these basic steps, in-office technique or walking bleaching technique can
• 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.
• 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
• 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)
• 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
• Evaluate patient after 2 weeks.
• Sodium perborate should be changed weekly.
• 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.
• 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.
• 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
• Indication – severe
- intact teeth without
• Standard endodontic
therapy + Intra-coronal
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.
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
• 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.
• 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.
HYDROGEN PEROXIDE TOOTH-WHITENING (BLEACHING)
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
• 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
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.
Vital bleaching techniques:
There are various techniques for bleaching vital teeth depending on the
degree of staining.
Mouth guard or Night guard or At-home .
• 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
• 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.
• 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.
• Apply heat with a heating device or light source. The temperature should be
controlled that the patient does not feel any discomfort, usually between 125F
and 140F (52C to 60C). 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
• 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
Night guard vital bleaching:
• 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
• Numerous products are available, mostly containing
1.5 to 10% hydrogen peroxide or 10 to 15% carbamide
peroxide, that degrade slowly to release hydrogen
• Carbamide peroxide products are the more commonly
used at home bleaching agents.
• 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
• Make alginate impressions of both the arches and cast is poured with dental
• Then the night guard is formed using a heated vacuum forming machine from a
soft vinyl night-guard material.
• 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.
• 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
• It is recommended that only one arch be bleached at a time beginning
with the maxillary arch.
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).
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
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
• There is insufficient evidence about the use of NSAIDs to prevent tooth
sensitivity caused by in-office bleaching procedures.
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.
• 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
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.
Management of few particular stains
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
• 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.
• 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.
• One study found that high concentrations of enzymes – specifically peroxidase
and lactoperoxidase – increased the rate of whitening when used with
• 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.
• 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
• Alkaptonuria is an autosomal recessive disorder of tyrosine degradation
• 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.
• 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.
• 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
• 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
• 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
• 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
• 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.
• 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
• 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.
• An excess ingestion of fluoride that induces multiple changes in the developing
• The choice between different treatments depends on the severity of the
• The aesthetic of mild fluorosis can be improved successfully with bleaching.
• Moderate fluorosis can be corrected with bleaching or in combination with
• Severe fluorosis may require porcelain laminate veneers, restorations or crowns.
• 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
• Generalized yellowish colour can be seen.
• Staining can be successfully treated with in-office and/or at-home 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
• Veneers and laminates can also be considered.
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.
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.
• 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
Ultra-thin/ no preparation veneers
• 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.
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
• 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.
• 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.
• 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
• 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
• 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.
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