Bleaching Hydrogen peroxide Bleaching tray Discoloration

1. Treatments Of Tooth
Discoloration
Presented by: Neha Upreti
Roll number: 43
1

2. Table of contents
• Introduction to tooth discoloration
• Prevention and prophylaxis
• Microabrasion
• Macroabrasion
• Bleaching
Introduction
Bleaching agents
Intracoronal bleaching
Extracoronal bleaching 2

3. Introduction
• Tooth discoloration is defined as ‘‘any change in the hue, color, or
translucency of a tooth due to any cause; restorative filling materials,
drugs (both topical and systemic), pulpal necrosis, or hemorrhage
may be responsible.’’
Ingle’s 6th edition
3

4. Prevention And Prophylaxis
• Certain teeth discolorations can be prevented by following strict oral
hygiene practice.
• Tobacco, coffee and tea stains can be prevented by keeping a check on
habits.
• Any discoloration which is at initial stage can be avoided with a
regular dental visit.
• Most of the surface stains can be removed by routine prophylactic
procedures.
4

5. Microabrasion
• It is a procedure in which a
microscopic layer of enamel is
simultaneously eroded and
abraded with a special compound
(usually contains 10% of
hydrochloric acid) leaving a
perfectly intact enamel surface
behind.
5

6. How much enamel layer is removed?
• The amount of enamel removed by microabrasion depends on the
number of applications of the concentrated hydrochloric acid/ pumice.
• 1 and 10 applications of the mixture for 5 seconds each,12-46µm
respectively.(Kendell)
• 3 and 15 applications for 5 seconds ,25- 140µm,respectively.(Sundfeld
et al)
• 12 applications for 30 seconds, 22µm.(Alves et al)
6

7. Indications of microabrasion Contraindications of
microabrasion
Developmental intrinsic stains and
discoloration limited to superficial
enamel only.
Age-related staining
Enamel discoloration as a result of
hypo or hyper mineralisation
Deep enamel hypoplastic lesions
Decalcification lesions from stasis
of plaque and form orthodontic
bands.
Areas of deep enamel and dentin
stains
Areas of enamel fluorosis. Amelogenesis imperfecta and
dentinogenesis imperfecta
Multicolored superficial stains Carious lesions
7

8. Protocols
• Clinically evaluate the teeth.
• Clean teeth with rubber cup and prophylaxis paste.
• Apply petroleum jelly to the tissues and isolate the area with rubber
dam.
• Apply microabrasion compound to areas in 60 seconds intervals with
appropriate rinsing.
8

9. • Repeat if necessary. Check the
teeth when wet.
• Rinse teeth for 30 seconds and
dry.
• Apply topical fluoride to teeth
for four minutes.
• Re-evaluate the color of the
teeth. More than one visit may
be necessary sometimes
9

10. Macroabrasion
• Macroabrasion is defined as removal of superficial white spots and
other surface stains or defects is called macroabrasion.
• High speed turbine finishing diamond tip like 12fluted composite
finishing bur is used.
• Fast,safe,efficient and alternative to enamel microabrasion.
• Light and intermittent pressure is used carefully when removing the
dental structure to avoid cavity formation.
10

11. • Irrigation is recommended to keep the tooth in hydrated state to
facilitate the assessmentof stain and/defect removal.
• Teeth that have white stain are particularly susceptible to dehydration ,
resulting in other apparent white stain that are not visible when tooth is
hydrated.
• Dehydration exaggerates the appearance of white spots and makes it
difficult to remove the defects.
11

12. • : (a) A 16-year-old girl presenting with
hard white fluorotic enamel stains and
with some localized eroded areas. (b)
Application of a high-speed tapered fine
diamond bur for removing the superficial
layer of the stained enamel. (c)
Application of microabrasive product
under rubber dam to remove the
remaining fluorotic enamel stains and
superficial irregularities promoted by the
fine diamond bur. (d) Polishing with
fluoridated prophylaxis paste. (e)
Application of a 2% neutral sodium
fluoride gel for 4 min. (f) Frontal view 14
days after enamel microabrasion of the
upper and lower arches
12

13. Advantages of
microabrasion
Disadvantages of
microabrasion
Minimum discomfort to the
patient.
Not effective for deeper stains
Can be easily done in less time by
operator.
Removes enamel layer.
Useful in removing superficial
stains.
Yellowish discoloration of teeth
has been reported in some cases
after treatment.
The surface of treated tooth is
shiny and smooth in nature.
13

14. Bleaching
• Bleaching may be defined as the
lightening of the color of the
tooth through the application of a
chemical agent to the oxidize the
organic pigmentation in the
tooth.
14

15. Factors affecting bleaching
• Surface cleanliness
Clean surface is important to distinguish between intrinsic and extrinsic
stains. Debris on the surface minimizes the contact of bleaching agent
with tooth surface.
• Concentration of peroxide
The effect of bleaching is increased with the increase in the
concentration of peroxide. In office bleaching employs 35%H2O2
which is more caustic in nature and at home bleaching is 10%
carbamide peroxide which is of low concentration and require multiple
sessions.
15

16. • Shelf life
Carbamide peroxide is more stable than hydrogen peroxide and has shelf
life of 1-2 years, while hydrogen peroxide has a shelf life of few weeks.
• Temperature
It is of importance during in-office bleaching. Incase if temperature
accelerates the release of oxygen free radicals ,reaction gets doubled with
an increase of 10 degree celcius.
Increase in the temperature also causes tooth sensitivity and irreversible
pulpal damage.
L.A shouldn’t be administered during bleaching.
16

17. • pH
H2O2 is active in alkaline pH.
Optimum ph ranges from 9.5 to 10.8
• Time
Increased contact time increases bleaching efficacy ,but the prolonged
contact results in tooth sensitivity.
• Sealed environment
Relevant in non-vital bleaching.H2O2 sealed in access cavity maintains
required concentration for active bleaching.
17

18. Bleaching Agents
The most commonly used bleaching agents are
• Hydrogen peroxide
• Sodium perborate
• Carbamide peroxide
• Over the counter agents
18

19. Hydrogen peroxide
• Used in dentistry as a whitening
agent
• Ranges in concentration between 5-
35% , in-office bleaching material
has 25-35% whereas at home
bleaching material has 3-7.5%.
• Can be classified as organic and
inorganic
19

20. Mechanism of action
• H2O2 has low molecular weight
and hence can penetrate the
dentin and release oxygen that
breaks down the double bond of
inorganic and organic
compounds inside the tubule.
20

21. Properties
• Clear, colorless, odorless liquid ,stored in lightproof amber bottles.
• Unstable and should be kept away from heat, which could cause it to
explode.
• Should be stored in sealed refrigerated containers where it retains sufficient
potency for approximately 3-4 months, but decomposes readily in open
containers and in presence of organic debris.
• Has ischemic effect on skin and mucus membrane and cause chemical
burns, especially painful if comes in contact with nailbed or fingernails.
• Amount needed for bleaching procedure is about 1-2 ml,can be dispensed
into clean dappen dish.
21

22. Sodium perborate
• Stable, white powder, normally supplied in granular form that has to
be ground into a powder before using.
• Three types
a)sodium perborate monohydrate
b) sodium perborate trihydrate
c) sodium perborate tetrahydrate
22

23. Mechanism of action
• The powder is water soluble . When mixed into a paste with
superoxol, this paste decomposes into sodium metaborate, water and
oxygen.
• Sodium perborate sodium metaborate+H2O2+O2
• When sealed into the pulp chamber ,sodium perborate oxidises and
discolors the stain slowly, continuing its activity over a longer period
of time. This procedure is called a walking bleach technique.
23

24. Carbamide peroxide
• Also known as urea hydrogen
peroxide.
• Concentration varies from 3-
45%depending on at-home or in
office bleach.
• The popular commercial
preparations have a
concentration of 10% carbamide
peroxide.
24

25. Mechanism of action
• Carbamide peroxide urea+ammonia+CO2+3.5%H2O2
• Additives in gel preparation include glycerine or propylene glycol,
sodium stannate, phosphoric acid or citric acid, flavoring agents e.t.c
• Some preparation contain carbopol,a water soluble polyacrylic acid
polymer, which is added as a thickening agent and prolongs the
release of active peroxide and improves shelf life.
25

26. Classification of bleaching procedures
• Intracoronal bleaching
Also known as non-vital bleaching
Or bleaching of endodontically
treated tooth
1. Walking bleach technique
2. In-office thermocatalytic bleach
3. Modified walking bleach
technique
4. LASER assisted bleaching
technique
• Extracoronal bleaching
Also known as vital tooth
bleaching
1. In-office vital bleach
2. At-home vital bleach
26

27. INTRACORONAL BLEACHING
27

28. Walking bleach technique
• First coined by Nutting and Poe in 1961 referring to the bleaching
action occurring between patients’ visits.
• Since that time, the technique evolved and underwent modifications ,
mainly by eliminating the use of superoxol and making it safe.
• Involves use of chemical agents within the coronal portion of an
endodontically treated tooth discoloration.
28

29. Steps of walking bleach technique
• Familiarize the patient with the possible
causes of discoloration, the procedure to
be followed, the expected outcome, and
the possibility of future rediscoloration.
• Radiographic evaluation should be done
to assess the quality of obturation.
Endodontic failure should always be
prioritized before bleaching.
• Evaluate the quality and shade of
restoration ,if present.If restoration is
defective replace it.
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30. 30

31. • Evaluate the tooth color with shade guide and take pre-operative
radiograph.
• Isolate the tooth with rubber dam to prevent the leakage of bleaching
agent onto the gingival tissue.
• Remove the restorative material from access cavity, expose dentin and
refine the access.
• Remove all materials to a level just below the labial–gingival margin.
Orange solvent, chloroform, or xylene on a cotton pellet may be used
to dissolve sealer remnants. Etching the dentin with phosphoric acid is
unnecessary and may not improve the prognosis.
31

32. • Place the mechanical barriers of 2mm thickness preferably of glass
ionomer cement, zinc phosphate or MTA on root canal filling
materials. The coronal height of barrier should protect the dentinal
tubules and conforms to the epithelial attachment.
• Prepare the walking bleach paste by mixing sodium perborate and an
inert liquid, such as water, saline, or anesthetic solution, to a thick
consistency of wet sand. With a plastic instrument, pack the pulp
chamber with the paste. Remove excess liquid by tamping with a
cotton pellet. This also compresses and pushes the paste into all areas
of the pulp chamber.
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33. • After removing the excess bleaching paste , place a temporary
restoration over it. Apply pressure with the temporary restoration over
it. Apply pressure with the gloved finger against the teeth until the
filling has set because filling may get displaced because of release of
oxygen.
• Remove the rubber dam and inform the patient that bleaching agents
work slowly and it may take few days to observe significant
lightening.
• Recall the patient after 2 weeks and repeat if necessary. In most cases,
discoloration will improve after 1 to 2 treatments. If after three
attempts there is no significant improvement, reassess the case for
correct diagnosis of the etiology of discoloration and treatment plan.
33

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

35. Clinical case illustrating the walking bleach technique. A,
Situation prior to endodontic treatment and internal bleaching.
Discolored maxillary left canine due to pulp necrosis. B,
Postoperative situation after endodontic treatment and
internal bleaching using the walking bleach technique. C,
Preoperative situation. D, Control radiograph after application
of sodium perborate for the walking bleach technique. E,
Labeling of part D showing placement of barrier material at the
CEJ level, bleaching agent, and coronal seal with temporary
filling material. F, Postoperative situation after bleaching, 35

36. Thermocatalytic technique
• Isolate the tooth to be bleached using a rubber dam.
• Place the bleaching agent (superoxol and sodium perborate separately
or in combination)in the tooth chamber.
• Heat the bleaching solution using bleaching stick/light curing unit.
• Repeat the procedure till the desired tooth color is achieved.
• Wash the tooth with water and seal the chamber using dry cotton and
temporary restorations.
• Remove the rubber dam.
36

37. • Recall the patient after 1 to 3 weeks.
• Do the permanent restoration of tooth using suitable composite resin
afterwards.
• Care must be taken when using these heating devices to avoid
overheating of the teeth and the surrounding tissues.
• Intermittent treatment with cooling breaks is preferred over a
continuous session.
• In addition, the surrounding soft tissues should be protected with
Vaseline, Orabase, or cocoa butter during treatment to avoid heat
damage.
• Potential damage by the thermocatalytic approach is external cervical
root resorption caused by irritation to the cementum and the
periodontal ligament.
37

38. Modified walking bleach technique
• Also known as internal/external bleaching technique or inside/outside
bleaching technique.
• Involves intracoronal bleaching technique along with home bleaching
technique.
• This combination of bleaching technique is helpful in treating difficult
stains, for specific problems like single dark vital or nonvital tooth and
to treat stains of different origin present on the same tooth.
38

39. Procedures
• Assess the obturation by taking radiographs.
• Isolate the tooth and prepare assess cavity by removing gutta-percha to
2-3mm below the cementoenamel junction.
• Place the mechanical barrier, clean the access cavity and place the
cotton pellet in chamber to avoid food packing into it.
• Evaluate the shade of tooth.
• Check the fitting of bleaching tray and advise the patient to remove the
cotton pellet before bleaching .
39

40. Instructions for home bleaching
• Bleaching syringe can be directly placed into chamber before seating
the tray or extra bleaching material can be placed into the tray space
corresponding to tooth with open chamber.
• After bleaching, tooth is irrigated with water, cleaned and again a
cotton pellet is placed in the empty space.
• Reassessment of shade is done after 4-7 days.
• When the desired shade is achieved ,seal the access cavity initially
with temporary restoration and finally with composite restoration after
at least 2 weeks.
40

41. LASER-Assisted bleaching technique
• It achieves power bleaching process with the help of efficient energy
source with minimum side effects.
• Laser whitening gel contains thermally absorbed crystals,fumed silica
and 35% H202
• Gel is applied and is activated by light source which in further
activates the crystals present in gel ,allowing dissociation of oxygen
and therefore better penetration into enamel matrix.
• FDA approved lasers are Argon lasers, Carbon dioxide lasers, GaAIAs
lasers
41

42. Argon Laser
Emits the wavelength of
480nm in visible part of
spectrum.
Activates the bleaching gel
and makes the darker tooth
surface lighter.
Less thermal effects on pulp
as compared to other heat
lamp
Carbon Dioxide Laser
Emits a wavelength of
10,600nm.
Used to enhance the effect of
whitening produced by argon
laser.
Deeper penetration than argon
laser thus more efficient tooth
whitening.
More deleterious effect on
pulp than argon laser.
42

43. Indications of intracoronal
bleaching
Contraindications of
intracoronal bleaching
Discolorations of pulp
chamber origin
Superficial enamel
discolorations
Moderate to severe
tetracycline staining
Defective enamel formations
Dentin discoloration Presence of caries
Discolorations not agreeable to
extracoronal bleaching
Unpredictable prognosis of
tooth
43

44. Complications of intracoronal bleaching
• External root resorption.
• Chemical burns if using 30-
35%H2O2 so gingival should be
protected using petroleum jelly
or cocoa butter.
• Decrease bond strength of
composite because of presence
of residual oxygen following
bleaching procedure.
44

45. Precautions for safer intracoronal bleaching
• Isolate the teeth effectively.
• Protect the oral mucosa.
• Verify adequate endodontic obturation
• Use protective barriers
• Avoid acid etching
• Avoid strong oxidisers.
• Avoid heat
• Recall periodically
45

46. EXTRACORONAL BLEACHING
46

47. Over the counter bleaching agents
• Includes tray systems ,trayless,
chewing gums, tooth pastes,
bleaching strips and paint on
products.
• These products primarily work
by removing extrinsic surface
stain only.
• The scientific rationales behind
such systems aren’t justified
because the cause of tooth
discoloration is diverse.
47

48. Advantages Disadvantages
More surface area for bleach to
penetrate.
Noncompliant patients
Treatment time in days rather than
weeks.
Overbleaching by overzealous
application
Decreases the incidence of cervical
resorption.
Chances for cervical resorption is
reduced but still exists.
Uses lower concentration of
carbamide peroxide.
48

49. Night guard bleaching
• Factors that guard the prognosis for night guard bleaching
History of sensitive teeth
Extremely dark gingival third of tooth visible during smiling.
Excessive white spots
Translucent teeth
Excessive gingival recession and exposed root surfaces.
49

50. Indications for home bleaching Contraindications for home
bleaching
Mild generalized staining Teeth with insufficient enamel for
bleaching
Age related discolorations Fractured or malaligned teeth
Mild tetracycline staining Teeth with inadequate or defective
restorations
Mild fluorosis Severe fluorosis or pitting hypoplasia
Aquired superficial staining Teeth with opaque white spots
Tobacco stains Teeth exhibiting extreme sensitivity
to heat, cold or sweets
Color changes related to pulpal
trauma or necrosis
Suspected or diagnosed bulimia
nervosa 50

51. Steps of Tray Fabrication
• Take the impression and a stone
model.
• Trim the model.
• Place a stock out resin and cure it
• Apply separating media.
51

52. • Choose the tray sheet material.
• Nature of the material used for fabrication of bleaching tray is flexible
plastic. Most common material is ethyl vinyl acetate.
• Cast the plastic tray in vacuum tray forming machines.
• Trim and polish the tray
• Check for the fitting of the tray retention and over extension.
52

53. Thickness of tray
• Standard thickness of tray is 0.035 inch.
• Thicker tray i.e 0.05 inch is indicated in patient with breaking habit.
• Thinner tray i.e 0.02 inch thick is indicated in patients who gag.
53

54. Treatment regimen
• Patient is instructed to brush the teeth before tray application.
• Patient is instructed to place enough bleaching material into the tray to
cover the facial surfaces of tooth. After seating tray in mouth, extra
material is carefully wiped away.
• wearing the tray during day time allows the replenishment of the gel
after 1-2 hours for maximum concentration. Overnight use causes
decrease in loss of material due to decreased salivary flow at night.
• While removing the tray, patient is asked to remove the tray from the
second molar region in peeling action. This is done to avoid soft tissue
injuries.
54

55. • Patient is instructed to rinse off the bleaching agent and clean the tray.
• Duration of treatment depends upon the original discoloration,
duration of the bleaching , patient compliance and time of bleaching.
• Patient is recalled for periodic check ups for assessing bleaching
process.
Maintenance after tooth bleaching
Additional bleaching can be done every 3-4 years if necessary with
duration of 1 week.
55

56. 56

57. Side effects of home bleaching
• Gingival irritation:- painful gums
after a few days of wearing trays.
• Soft tissue irritation:-from
excessive wearing of the trays or
applying too much bleach to the
trays.
• Altered taste sensation:-metallic
taste immediately after removing
trays.
• Tooth sensitivity:- most common
side effects.
57

58. In office bleaching
58

59. Thermocatalytic vital bleaching
• Equipments needed for in-office vital bleaching are
 Power bleach material
 Tissue protector
Energizing /activating source
Protective clothing and eye wear
Mechanical timer
59

60. Procedure
• Pumice the teeth to clean off any
debris present on the tooth surface.
• Isolate the teeth with rubber dam and
protect the gingival tissues with
orabase or Vaseline. Protect the
patients eyes with sunglasses.
• Saturate the cotton or gauze piece with
bleaching solution (30-35% H2O2 )
and place it in the teeth.
• Depending upon light, expose the
teeth. The temperature of device
should be maintained between 52-60
degree celcius
60

61. • Change the solution in between after every 4-5 minutes. The treatment
time shouldn’t exceed 30 minutes.
• Remove the solution with the help of wet gauge.
• Remove the solution and irrigate thoroughly with warm water.
• Polish the tooth and apply neutral sodium fluoride gel.
• Instruct the patient to use fluoride rinse on daily basis.
• Second and third appointment is given after 3-6 weeks as this would
allow the pulp to settle.
61

62. Light sources used for In-office bleach
Conventional Bleaching
Light
• Uses heat and light to activate
bleaching material
• More heat is required during
bleaching.
• Slower in action.
• Uncomfortable for patient.
Tungsten Halogen Curing
Light
• Uses light and heat to activate
bleaching solution.
• Applications of light 40-60
seconds per application per
tooth.
• Time consuming
62

63. Xenon plasma
Arc Light
• High intensity
light,so more heat
is liberated
during bleaching.
• Application
requires 3 secs
per tooth.
• Thermal action
and greater
potential for
thermal trauma.
Argon and
carbon dioxide
laser
• True laser light
stimulates the
catalyst in
chemical so there
is no thermal
effect.
• Requires 10
seconds per
application per
tooth.
Diode Laser
Light
• True laser light
produced from a
solid state source.
• Ultrafast
• Requires 3-5
seconds to
activates the
bleaching agent.
• No heat is
generated.
63

64. Non - thermocatalytic bleaching
• In this technique, heat source is not required.
Steps:-
Isolate the teeth using rubber dam.
Apply bleaching agent on the teeth for five minutes.
Wash the teeth with warm water and reapply the bleaching agent until
the desired color is achieved.
Wash the teeth and polish them.
64

65. 65

66. Advantages of in-office
bleaching
Disadvantages of in-office
bleaching
Patient preference More chair time and more
expensive
Less time than overall time needed
for home bleaching.
Unpredictable and quicker
deterioration of color
Patient motivation More frequent and longer
appointment.
Protection of soft tissues. Discomfort of rubber dam
66

67. Effects of bleaching agent on tooth and it’s
supporting structures
67

68. Structures Effects
Enamel 10% carbamide peroxide decreased enamel
hardness but application of fluoride showed
improved remineralisation
Dentin Uniform change in color through dentine
Pulp 3% H2O2 can cause:-
Transient reduction in pulpal blood flow
Occlusion of pulpal blood vessels
Cementum Cervical and external root resorption has been
seen in teeth treated by intracoronal bleaching
using 30-35% H2O2 68

69. Cervical resorption
Hydroxyl ions may be generated during
thermocatalytic bleaching especially
where ethylenediaminetetraacetic acid is
used.
Hydroxyl ions may stimulate the cervical
periodontal ligament to differentiate into
odontoclasts which begin root resorption
in area of tooth below epithelial
attachments.
Painless until resorption exposes pulp.
Severe resorption requires extraction of
tooth whereas mild resorption can be
managed with orthodontic extrusion and
restoring with post retained crowns
69

70. Effects on restorative materials
• Composite
Minimal change in colour, surface roughness and physical properties.
May increase microleakage at CEJ with earlier generation of dentin
bonding system.
Delay of any composite procedure is recommended for atleast one week
following bleaching.
70

71. • Amalgam
It may be susceptible to strong oxidative action of bleaching agents.
• Ceramics
no effect on colour or physical properties.
71

72. Other effects
• Mucosal irritations
• Genotoxicity and carcinogenicity
• Toxicity
72

73. Contraindications for bleaching
• Poor case selection
Patient having emotional or psychological problems aren’t suitable for
bleaching.
• Dentin hypersensitivity
Hypersensitive tooth need to provide extra protection before going for
bleaching.
73

74. • Extensively restored tooth
These tooth are not good candidate for bleaching because:-
- Do not have enough enamel to respond properly to bleaching.
- Tooth heavily restored with composite do not lighten but become more
evident after bleaching.
• Teeth with hypoplastic marks and cracks
Application of bleaching agents increases the contrast between white
opaque spots and normal tooth structure. In these cases bleaching can be
done in conjunction with:-
-Microabrasion
-Selected ameloplasty
-Composite resin bonding 74

75. References
• Grossman’s textbook of endodontics-14th edition
• Ingle’s endodontics-6th edition
• Textbook of endodontics-3rd edition
75

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