ULTRACONSERVATIVE

TREATMENT OF
DISCOLORED TEETH

Presented by : Dr Sheetal C Kasargod

Guided by: Dr Annapoorna Kini
 Introduction
Definition
Classification
CONTENTS Diagnosis & Treatment plan
Treatment- Bleaching

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 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

INTRODUCTION discolouration of even a single tooth can negatively

influence the quality of life.

Esthetics is a primary concern amongst young patients

and represents a challenge to the dentist.

Therefore several techniques have been devised to

minimize or completely eliminate tooth discoloration.
 “ Any change in the hue, colour, or translucency of a
tooth due to any cause; restorative filling materials,

DEFINITION
drugs (both topical and systemic), pulpal necrosis, or
haemorrhage may also be responsible.”

- Ingle 6th edition

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CLASSIFICATION
Localised :
a) Trauma

b) Endo
treatment

c) Amalgam
stain

Generalised:
a) Environmental
b) Genetic
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 Direct

Indirect

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 Dental
stains

Dentist Patient
related related

Restoration Necrosis
Endodontically
related related Hypercalcification
Haemorrhage
Tooth formation
Developmental
Drug related
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• Nathoo type 1 (N1): Colored substance (chromogen) bonds to the tooth surface. Dental
stains formed by tea, coffee, wine, chromogenic bacteria, and metals have a similar hue to
the chromogen.

• Nathoo type 2 (N2): After attaching to the tooth, N2-type colored substance changes color.
The stains are really food stains of the N1 kind that deepen over time.

• Nathoo type 3 (N3): N3-type colorless substance or prechromogen adheres to the teeth and
causes a stain through a chemical reaction. Carbohydrate-rich meals (e.g., apples,
potatoes), stannous fluoride, and chlorhexidine all create N3- type stains.

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• Internalised discoloration :
It 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) Dental caries
b) Restorative materials
c) Tooth wear and gingival recession

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 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.

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• 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

• Habits: Certain forms of repetitive behaviour may influence the present coloration of teeth.
Eg: 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

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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.

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 TREATMENT
• Prevention
• Oral prophylaxis
• Bleaching
• Microabrasion
• Macroabrasion
• Lumineers
• Reattachment of tooth fragments

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 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.)
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 BLEACHING
• The lightening of colour of a tooth through the application of a chemical agent to oxidize the organic
pigmentation in the tooth is referred as bleaching- STURDEVANT.

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INDICATIONS

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 CONTRAINDICATIONS
1. Poor Case Selection-Patient having emotional or psychological problems is not right choice for
bleaching.

2. Dentin Hypersensitivity- Hypersensitive teeth need to provide extra protection before going for
bleaching.

3. Extensively Restored Teeth- These teeth are not good candidate for bleaching because:
• They do not have enough enamel to respond properly to bleaching.
• Teeth heavily restored with visible, tooth colored restorations are poor candidate as composite
restorations do not lighten, in fact they become more evident after bleaching.

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4. Teeth with Hypoplastic Marks and cracks.
Bleaching done in conjunction with

Selective
Composite
enameloplasty
Microabrasion resin
bonding

5.Defective and Leaky Restoration-

• Discoloration from metallic salts particularly silver amalgam: Dentinal tubules of the tooth become
virtually saturated with alloys and no amount of bleaching with available products will significantly
improve the shade.
• Defective obturation: If root canal is not well-obturated, then refilling must be done
 ADVANTAGES

Ultra conservative Desirable results Painless

No anesthesia Least expensive

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 DISADVANTAGES
• In a study, it was concluded that thirty percent H2O2 can cause severe irritation or burns on contact
with skin or eyes.

• In a histologic study in women about the effect of home bleaching, it was revealed that there are
changes observed in epithelial proliferation rate and morphological changes with epithelial
thickening
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• Reduces the micro-hardness of dentine and enamel, mechanically weakens the dentine.

• Higher incidences of tooth sensitivity (from 67 -78%) were reported after bleaching with H 2 O 2
combination with heat. Tooth sensitivity normally persists for up to four days after bleaching but
durations of up to 39 days have been reported.

• Cervical root resorption

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 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 are:

• Hydrogen Peroxide
• Sodium Perborate
• Carbamide Peroxide

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 Thickening agents (Carbopol)
• Inactive ingredients : Better retention
Prolonged Active oxygen release (4x)
Carrier Maintain moisture
Help to dissolve other ingredients.

Surfactant and pigment dispersant surface-wetting agent

Preservative prevent bacterial growth

accelerate breakdown of H2O2 by
releasing transitional metals such as
iron, copper, and magnesium.

improve the taste and acceptance

Flavoring
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 HYDROGEN PEROXIDE
• Colourless, clear, odourless liquid , stored in light proof amber bottles.

• Ranges from 5- 35 %

• Has low molecular weight so can penetrate dentin and release oxygen

• Bitter taste and is highly soluble in water to give an acidic solution.

• 25-38% in-office bleaching , 3- 7.5% home bleach.

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 MODE OF SUPPLY
• 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).
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.

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 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:

1. Sodium perborate monohydrate

2. Sodium perborate trihydrate
3. Sodium perborate tetrahydrate

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• Sodium perborate is stable when dry, but when combined with water, it decomposes to form
METABORATE HYDROGEN PEROXIDE, AND NASCENT OXYGEN ,
it is more easily controlled and safer than concentrated hydrogen peroxide solutions.

• This substance breaks up into a less concentrated hydrogen peroxide that, at a second
stage, releases active oxygen and initiates the bleaching process.

• Such a combination reduces the aggressive power of 30% to 35% hydrogen peroxide.

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 CARBAMIDE PEROXIDE
• It exists in the form of white crystals or as a crystallized powder containing approx 35% H2O2
• Used in concentrations ranging from 3 to 45%.
• For gel preparations, glycerine, propylene glycol, sodium stannate, citric acid and flavouring
agents are added.
• It is decomposed into hydrogen peroxide (10% carbamide peroxide produces 3.6% hydrogen
peroxide).
• 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.2 9
 MECHANISM OF ACTION
• 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 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.

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• Use of light sources during the bleaching process improves the efficiency of whitening.

High radiation energy (≈3.5 eV for the used wavelength).

The absorption of photons by peroxide

Formation of free radicals that cleaves the chromophore molecules.

In addition, the absorption of photons increases the reactivity of the chromophore molecules to the
peroxide because of the increase in the energy of its C=O bonds, C=C, and C=C–C=C.
For vital teeth:
In-office bleaching:
• Thermocatalytic vital tooth bleaching(Power bleaching)
• Non-thermocatalytic vital tooth bleaching
• Microabrasion assisted bleaching
Dentist prescribed home bleaching (Night guard vital bleaching)
Non-vital teeth:
• Thermocatalytic in office technique
• Walking bleach technique
• Modified walking bleach technique
• Combination technique
Intracoronal bleaching :
It involves use of chemical agents within coronal portion of an endodontically treated tooth to remove
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tooth discoloration
 VITAL BLEACHING
• Vital bleaching technique requires use of materials that do not endanger the tooth structure and the
soft tissue.
• Hydrogen peroxide (30-35%)

Indications:

• Superficial extrinsic colour discrepancies

• Extrinsic and intrinsic stains of moderately darkened and moderate intense colour
• General yellow to brown discolouration

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Contraindications :

• Severe discolouration from amalgam corrosion

• Tetracycline stains
• Extensive restorations or caries
• Inherent sensitivity of the patient to bleaching

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Advantages :
• Adverse effects of thermocatalytic temperature
rise on the pulp.
• Treatment is totally under dentist's control.
• Potential for early results.
• Resultant post-treatment sensitivity.

Disadvantages :
• If etching is performed with bleaching, polishing is
• Cost factor required after each visit resulting in small amount
• Unknown duration of the treatment of enamel loss.

• Discomfort of rubber dam

• Potential for soft tissue damage to patient and
operator.
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 PREPARATION OF PATIENT
• Shade of the patient's existing dentition is recorded with a standardized shade guide tab and
a photograph of patient's teeth is taken for records.

• Thorough prophylaxis is performed.

• The patient is draped with a protective cap and is made to wear protective eye glasses.
• No local anaesthesia is administered.
• Teeth are isolated with heavy gauge rubber dam.
• Before rubber dam application, oraseal (a light cured resin) or orabase paste is applied to
protect recommended.

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• Oraseal can also be applied to amalgam restorations reducing the risk of build up of heat from the light
source.
• Vaseline is applied to the patient's lips before mounting the rubber dam frame.
• Wet gauze is placed over the patient's lips to prevent thermal trauma.
• Hydrochloric acid (18-36%): The hydrochloric acid causes decalcification of tooth substance along
with removal of stain.

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 THERMOCATALYTIC
BLEACHING/POWER
BLEACHING
Use of heat alone or heat and light both:

1. Heat light unit: The bleaching light provides high intensity light and heat , needed to activate
bleaching agents.
A narrow beam of light is concentrated in one section of the mouth at a distance of approximately 13-15
inches. Calibrated rheostat controls the amount of light and heat simultaneously.

2. Heat unit: Heat unit with accurate temperature control and continuous read out is used to activate
the bleaching agent.
Two tips are available-one to fit the contour of labial surface of a non-vital tooth and one is inserted in
the coronal access opening. The recommended temperature is:

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• Vital teeth 46°C to 60°C
• Do not exceed 30 minutes of treatment in each appointment
• After removing the heat source, tooth is allowed to cool to avoid sudden temperature
change that can be deleterious to the pulp.
• After five minutes, tooth is washed with warm water for one minute
• Bleaching appointments are scheduled 2-4 weeks apart with minimum requirement of
three treatments
• However, not more than ten treatments are recommended.
• Colour is checked one week after the third treatment.
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 SOURCE OF HEAT
• Photoflood lamp
• Polymerization light
• Spirit lamp
• Commercial bleaching units
• Light-heat lamp
• Lasers such as argon and diode

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• Quartz tungsten halogen curing light : The standard curing light provides
heat to simulate the chemical reaction by activating light sensitive
chemicals in the bleaching agent.
• Each application is used for 40-60 seconds.

• Plasma arc: It provides intensity of light similar to or slightly higher than

halogen curing temperature. A four second application leads to an
intrapulpal temperature rise of 2.2°C. Maximum allowable time- 30s per
tooth.

• Rembrandt tooth whitening system: This system includes the use of a

plasma arc light (named Rembrandt Sapphire).
• This bleaching can be fitted with a Rembrandt Whitening Crystal so as to
enable the dentist to treat both the arches simultaneously.
• The wavelength of light -- range of 400-525 nm (blue-green colouration).

The Zoom! Teeth whitening system: Use of mercury metal halide light with a wavelength of
300-450nm (violet colouration).

• An infrared filter, which filters these radiations, thereby minimizing the amount of heat
generated at the surface of tooth during the whitening treatment

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 PROCEDURE
Using an eye dropper, a small amount of the bleaching solution (30-35% ) is placed into a dappen dish.

The teeth are properly isolated preferably with rubber dam

With a small plastic instrument, the cotton or gauze is pressed and shaped to cover the entire surface

Selected heating unit is positioned

Solution is applied after every heating cycle.

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After removing the gauze/cotton, the teeth and the entire rubber dam are washed

Teeth are neutralized by sodium bicarbonate.

Instruct the patient to avoid coffee. tea and cola drinks for two weeks.

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 NON-THERMOCATALYTIC
BLEACHING
• Superoxol (5 parts of H2O2 + 1 part of ether)

• Mclnnes solution: 5 parts of 36% HCI (increases the penetration of solution) + 5 parts 30%
H2O2, (bleaches the enamel by process of oxidation) + part of 0.2% anaesthetic ether
(removes the surface debris)

• Modified Mclnnes bleaching solution consisting of 30% H2O2, and 20% NaOH in 1:1 ratio
along with 0.2% ether has been introduced

• Self-activating bleaching agent for vital teeth.

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The bleaching agent as prepared by Matsuba (1996) contains:
• 35% H2O2 - 0.4ml
• CaO - 0.12gm
• Aerosil - 0.32, 0.48 or 0.64gm (to alter/ control the viscosity)

• After rubber dam application, paste is applied on the teeth for five minutes and reapplication is done as
required followed by copious irrigation of warm water

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 MICROABRASION-ASSISTED
BLEACHING
• Microabrasion is a procedure involving the surface dissolution of the stains of enamel by the acid
preferably 18% HCl) along with the abrasives preferably pumice powder

• Microabrasion is indicated for improvement of particular tooth colour.

• This is also used in cases where routine bleaching is not effective .

Advantages:
• lt helps to remove superficial stains and discolouration and polishing. The result is achieved with
minimal patient discomfort and operator difficulty. The treated teeth display a smooth texture and
shine.
Disadvantages:
• Microabrasion removes enamel layer. Since it removes enamel layer, teeth sometimes appear more
yellow after treatment.
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 NIGHT GUARD VITAL
BLEACHING
• 10% carbamide peroxide, delivered in a custom fitting mouth tray.

• The patient is asked to keep the tray along with the medicament over the teeth during night
time

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Indications:
• Persons dissatisfied with the original colour of their otherwise sound teeth.
• For brown fluorosis stains
• For discoloured teeth that have darkened from trauma but are still vital or have a poor endodontic
prognosis
• As retreatment of walking bleach after reversal of the treatment
• For discoloured teeth even though considered for the placement of porcelain or other esthetic veneer.
• For teeth affected with dentinogenesis imperfecta.
• To lighten natural teeth to match existing ceramic crowns, fixed partial dentures, etc

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 MODE OF ACTION
• As the solution is flown onto the tooth surface, carbamide peroxide being unstable dissociates into
water, urea and/or oxygen.

Carbamide peroxide dissociates into H2O2, and urea

Further dissociates into water and oxygen.

The oxygen radicals cause oxidation of pigmentation in the tooth.

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 COMMERCIAL PREPARATIONS
• 10% carbamide peroxide with carbopol e.g. Proxigel. Ultralite, ete.
• 10% carbamide peroxide without earbopol (fast oxygen releasing) e.g. Glyoxide, Dentalite, ete.
• 15% carbamide peroxide e.g. Nu smile.
• 1%-10% H,0, eg. Peroxyl, Brite smile etc.

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 TECHNIQUE
• Sleeping with the night guard tray filled with the bleaching solution , solution is changed each night.

• Wearing the loaded night guard tray during the day while changing the solution every 1-2 hours.

• Polyethylene strips impregnated with 5.25% of H2O2 is also used without tray

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 FIRST APPOINTMENT
Initial shade examination and evaluation of the adjacent structures

Cast is formed after taking impressions

Tray material is selected

Fabricating the tray: 0.040 inch or 0.035-inch ethyl vinyl acetate , 0.020 inch polypropylene has also
been used

Tray material is allowed to cool on the casts

Trimmed by scalloping the tray about 2.0 mm of tissue apical to gingival crest,covered facially and
lingually.
 SECOND APPOINTMENT
Two to three drops of bleaching material is placed into the area of each tooth to be bleached.

After inserting the night guard, the excess material is wiped out. Patient is instructed not to drink or rinse
during treatment.

The bleaching solution is replaced every one and half to two hours during daytime regimen.

A single application of bleaching material at bedtime is indicated, if worn at night.

The daytime regimen requires one to three weeks and four to six weeks are required for night time
bleaching
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P R E S E N TAT I O N T I T L E

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 ADVERSE EFFECTS
• Sensitivity: increases intrapulpal temperature, inflammatory changes get recovered within one month.

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• pH of the solution along with desiccation of the tooth surface are the factors aiding in sensitivity
• Measures to prevent : Introduction of potassium nitrate and sodium fluoride added to 10% carbamide
peroxide

• Minor ulceration of the gingival tissues leading to pharyngitis etc

• Hydrogen peroxide and hydrochloric acid can result in removal of the surface enamel; can affect
adhesion of composites and glass-ionomer cement to the tooth surface

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 NON VITAL BLEACHING
• Bleaching involves bleaching of non vital teeth, which are discoloured because of pulpal necrosis and
related complications.

• The commonly used solutions are:

• Hydrogen peroxide
-Superoxol (30%)
• Sodium perborate
• Sodium percarbonate

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 TOOTH PREPARATION
Approximately 2.0-3.0 mm of root canal restorative material is also removed in an apical direction beyond
CEJ

Tooth washed with 3% H202, solution, rinsed with water and dried

0.5-1.0 mm thick calcium hydroxide plug is sealed in direct contact with the root obturation material.

The rest of the root canal is filled with dual cure glass-ionomer cement

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 THERMOCATALYTIC
Either superoxol and sodium perborate separately or a combination of both is introduced

Heated with a bleaching wand at low to medium setting

The process is repeated as required with the total treatment time not more than 20-30 minutes along with
remoistening of the cotton pellets at regular intervals.

Tooth is rinsed with water. A fresh, dry cotton pellet is placed in the pulp chamber and sealed with
temporary sealing agent

The patient is recalled after one to three weeks

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P R E S E N TAT I O N T I T L E

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 WALKING BLEACH
• Involves placement of the bleaching agents in the pulp chamber
over an extended period of time ranging from 24-48 hours to 7-
10 days.

• The pulp chamber is sealed with temporary materials.

• The commonly employed agents are superoxol, sodium

perborate and their combinations.

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 Thick paste of sodium perborate and 35% H2O2 applied into the pulp chamber

Lingual access is sealed with a material capable of providing a good marginal seal

Fast setting zinc oxide eugenol, zinc phosphate cement, glass-ionomer cement, etc.

A case representing the walking bleach technique

(A) Initial photography of trauma induced discoloration and fracture

(B) 6-month follow-up photography of the case postbleaching with
10% carbamide peroxide

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 MODIFIED WALKING BLEACH
• Aldecoa and Mayordomo (1992)' described a modified technique for severe tetracycline
discolouration

• After a desired result is obtained by walking bleach technique, a mixture of 10%

carbamide peroxide and sodium perborate is placed in the pulp chamber for 4 to 6
weeks.

• Liebenberg (1997) introduced a modified technique that relies on patient's cooperation.

• Intracoronal 10% carbamide peroxide gel in a splint constructed from 0.020"
polypropylene coping material

• The splint is used to retain the bleaching agent and to prevent ingress of debris into
the access cavity. 66
 COMBINATION
• Technique involves the combined use - thermo- catalytic in office non-vital bleaching technique
followed by walking bleach regimen
• mixture of sodium perborate and superoxol. It provides synergistic effect and is effective in 90% of
cases.

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 INSIDE OUTSIDE BLEACHING
• Bleaching occurs simultaneously with in the tooth structure and on tooth external surface

• 10% carbamide peroxide gel applied internally and externally in root-filled, discolored teeth and
refreshed on a regular basis.

• A fast technique because the oxygen reactive species released from the hydrogen peroxide freely
diffuse inside and outside of the tooth structure to effect tooth whitening

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Advantages :
• Higher surface area available internally and externally for the bleaching agent, which might shorten
the treatment duration.

• Neutral pH value minimizes the risk of external cervical root resorption and gingival irritation

• Less chair time is required and there is no need to place a dressing in the access cavity.

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Indications :
• Cases in which simultaneous bleaching of non-vital and vital teeth in same arch is necessary

• young patients, successfully applied in immature teeth subsequent to apexification

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 ADVERSE EFFECTS
• Adversely affects the marginal seal leading to marginal leakage
• Cervical root resorption :ranges from 0 to 7%.
The features affecting the root resorption are:

 10% of anterior teeth have cervical areas in which enamel and cementum do not meet.
 Cervical resorption occurs coronal to the endodontic seal.

 Location, shape and material of a bleach barrier between endodontic filling material and the pulp
chamber can effectively curtail this problem

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