Managing Discoloured Non-Vital Teeth: the Inside/Outside Bleaching Technique

RESTORATIVERESTORATIVE DENTISTRY DENTISTRY Managing Discoloured Non-Vital Teeth: The Inside/Outside Bleaching Technique NEIL J. POYSER, M ARTIN G.D. KELLEHER AND PETER F.A. BRIGGS Abstract: should be supported by appropriate The discoloured, non-vital anterior tooth is a common aesthetic concern for special investigations. A methodical many patients. It can have a profound effect on their self-esteem, interaction with approach will ensure that the chance of others and employability. Discoloured non-vital teeth are frequently compromised failure is reduced and that any owing to previous trauma, caries, endodontic therapy and failed restorations. Destructive invasive treatment options are likely to weaken the residual structure of consequence of possible failure is the tooth. This can reduce the prognosis and challenge the long-term viability of the minimal. Ideally, the treatment option tooth, thereby initiating further prosthetic predicaments. This paper discusses modern chosen should provide a predictable approaches to the treatment of discoloured teeth. The importance of preventing and result and be the most beneficial and eliminating the potential for discoloration will be highlighted. The paper will include a cost-effective one for the individual detailed technical account on the application of the inside/outside bleaching technique, patient. with several clinical examples. The most common cause of discoloration in non-vital teeth is the Dent Update 2004; 31: 204–214 presence of pulpal haemorrhagic Clinical Relevance: The inside/outside bleaching technique offers multiple products. The discoloration seen is benefits to patients and practitioners when considering the options for a discoloured thought to be due to the accumulation non-vital tooth. of the breakdown products of haemoglobin or other haematin molecules5 from the pulp, and commonly follows trauma. Discoloration can also be seen after he presence of an unsightly Noticeable discoloration of teeth can endodontic intervention. It has been T discoloured tooth may be of great be a physical handicap that impacts reported that 10% of patients are concern to some patients and lead them on a person’s self-image, self- unhappy with the appearance of their to seek professional dental advice and/or confidence, physical attractiveness tooth following root canal therapy.6 treatment. The aesthetic improvement of and employability.4 Patients frequently ask ‘Will my tooth a patient’s smile can have a profound go ‘black’ now that it has been root affect on the patient’s confidence and A number of techniques have been treated?’ Restorative materials may oral health,1,2 and an improvement in oral developed to manage the problem of a contribute to the discoloration. It is health can significantly contribute to single pulpless discoloured tooth. The known that a number of the materials total well-being.3 aim of this paper is to discuss inside/ used during endodontic therapy, such outside bleaching and to compare the as silver-containing sealants and merits and problems of different points, polyantibiotic pastes, eugenol Neil J. Poyser, BDS, MFDS RCS(Edin.), and phenolic compounds may cause Specialist Registrar in Restorative Dentistry, GKT techniques. Dental Institute of King’s College London, St darkening and staining of the root George’s and Mayday Hospitals, London, Martin dentine.7 The migration of tin ions from G.D. Kelleher,BDS, MSc, FDS RCPS(Glasg.), Diagnosis amalgam restorations may also Consultant in Restorative Dentistry, GKT Dental An accurate diagnosis allows the contribute to discoloration. In the Institute of King’s College London, Royal Surrey, majority of cases, it could be said that it Kent and Canterbury Hospitals and Peter F.A. formulation of the optimal treatment Briggs, BDS, MSc, MRD, FDS RCS(Eng.), plan. In order to establish the is inappropriate management, choice of Consultant in Restorative Dentistry, GKT Dental diagnosis, it is necessary to obtain a techniques, or the placement of Institute of King’s College London and St full history and perform a inappropriate materials that are George’s Hospitals, London. comprehensive clinical examination that responsible for the discoloration. 204 Dental Update – May 2004 RESTORATIVE DENTISTRY tray. Design the tray so that there are ab palatal and labial reservoirs for the target tooth, and so that the tray over the adjacent teeth is cut back to avoid the placement of the bleaching gel onto the unaffected teeth (Figure 3). l Check the bleaching tray for comfort and fit. Figure 1 (a). A non-vital root-filled central incisor tooth that has discoloured. (b) The tooth was whitened using the inside/outside bleaching. Endodontic Preparation l Remove the access cavity restoration to allow thorough cleaning of the whole pulp chamber THE INSIDE/OUTSIDE obturated with no evidence of (including the pulp horns) with BLEACHING TECHNIQUE periapical pathology. If in doubt, ultrasonic instrumentation. FOR MANAGING consider endodontic revision prior l Remove the coronal aspect of the DISCOLOURED ROOT- to commencing bleaching. gutta-percha root filling to 2–3 mm FILLED TEETH l Record the pre-operative shade. below the cemento-enamel junction. This technique was originally described l Assess patient compliance and This can be easily and safely carried in the American literature by Settembrini reliability in returning for closure of out with a heated plugger. This et al.8 and modification of the technique the access cavity. provides space for the placement of a was later described by Liebenberg.9 l Discuss the treatment options. protective barrier over the root filling. In essence, the bleaching gel is placed l Inform the patient that existing This barrier should prevent bacterial on the internal and external aspects of the restorations may not bleach and ingress around the root filling and discoloured root-filled tooth. The access post-bleaching they may appear prevent the percolation of hydrogen cavity is left open during treatment so different from the surrounding tooth peroxide into the periodontal tissues. that the 10% carbamide peroxide can be tissue. The patient should be warned Glass ionomer cement, zinc easily and regularly changed. A custom- of this and the fact that these phosphate or zinc polycarboxylate made bleaching tray keeps the bleaching restorations may require can be used for this seal (Figure 2h). agent in and around the tooth. replacement. A diagrammatical note l Ensure that the pulp chamber is free Discoloured root-filled teeth can be of those restorations should be of root-filling materials. successfully managed with the inside/ made and given to the patient. outside bleaching technique. The l Check whether the patient is allergic majority of cases can be successfully to peroxide or plastic. Patient Instructions managed using the technique described l Check whether the patient is l Insert the tip of the bleaching below and without the need for pre- pregnant or breast-feeding. syringe into the access cavity of bleaching endodontic revision (Figures l Provide the patient with verbal and each root-filled tooth and fill the 1a and b). If there is concern about the written instructions. cavity with the 10% carbamide endodontic status, revision of the root l Make contemporaneous notes peroxide. filling may be required prior to recording that the above has been l Load the appropriate reservoir within commencing the bleaching (Figures 2a-g). carried out the tray with a pea-sized amount of the 10% carbamide peroxide (Figure 2i). l Insert the tray over the teeth and Patient Selection and Pre- Accurate Diagnosis remove the excess gel as necessary operative Preparation l Know what you are attempting to with a finger, tissue or soft toothbrush. It should be noted that it is necessary to bleach as not all discoloured teeth Rinse gently and do not swallow. follow the standard 10% carbamide will be as amenable to the bleaching peroxide external night-guard bleaching technique as non-vital teeth (e.g. protocol: those with tetracycline staining or Bleaching Protocol amalgam migration). l The gel should be changed inside l Make and record the diagnosis. the tooth and within the tray every l Check the periapical status on two hours and the tray containing radiographs. Bleaching Tray the gel should be worn overnight. l Check that the root-filled tooth is l Take an alginate impression and l After the bleaching session the asymptomatic and satisfactorily construct an appropriate bleaching patient should clean the access Dental Update – May 2004 205 RESTORATIVE DENTISTRY Case Report This 18-year-old male was concerned about the appearance of his discoloured upper left central incisor. When the patient was 12 years of age the tooth suffered a subluxation injury, subsequently lost vitality and was root treated. This case report illustrates the management of this discoloured tooth utilizing the inside/outside bleaching technique. Prior to bleaching, endodontic revision was provided in this case as there was clinical and radiographic evidence of endodontic failure. Figure 2. (a) Pre-operative labial view of /1. Note the blue-grey discoloration concentrated Figure 2. (b) Pre-operative palatal view of in the cervical two-thirds of the crown. /1. Note the discoloration around the margins Figure 2. (c) Pre-operative radiograph of /1. of the leaking composite restoration. There is evidence of a sub-optimal root canal filling and a 6mm diameter periapical radiolucency. Clinical examination revealed the presence of a firm and tender apical swelling in the buccal sulcus. A decision was made to perform endodontic revision prior to commencing the bleaching. Figure 2. (d) Removal of the access cavity Figure 2. (f) The access cavity was modified restoration revealed a heavily contaminated Figure 2. (e) The contaminated gutta-percha in order to gain complete access to the pulp pulp chamber. Such an environment is not point was removed from the canal. Note the chamber, including the pulp horns. The conducive to the placement of well-bonded, acid- extent of contamination and debris.

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