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Esthetic Dentistry ESTHETIC DENTISTRY A modified inside/outside bleaching technique for nonvital discolored teeth: a case report François Reitzer*, DMD/Claire Ehlinger*, DMD/Maryline Minoux, DMD, PhD Over the past decades, the walking bleach technique using so- that the access cavity is left open. To overcome this disadvan- dium perborate was considered a safe and effective method to tage, the present authors propose to seal the bleaching agent bleach nonvital discolored teeth. However, sodium perbor ate in the access cavity instead of leaving the latter open. Through has been classified as carcinogenic, mutagenic, and toxic for a clinical case, this paper presents and discusses several aspects reproduction by European Union legislation. Its use is therefore of this protocol, including the clinical steps, the design of the prohibited since April 2015. The initially described inside/out- bleaching tray, and the treatment of potential recurrences. The side bleaching technique, combining internal and external ap- present authors believe that the protocol proposed in this arti- plication of 10% carbamide peroxide, is an alternative to the cle is easier to use for the patient. Moreover, it prevents the walking bleach technique using sodium perborate. While good accumulation of food debris in the access cavity and avoids the esthetic results and low risks of external cervical resorptions colonization of coronary dentin by bacteria. (Quintessence Int have been associated with this technique, its main drawback is 2019;50: 802–807; doi: 10.3290/j.qi.a43248) Key words: carbamide peroxide, case report, inside/outside bleaching technique, sodium perborate, walking bleach technique Discoloration of anterior teeth is an esthetic concern for many study on 95 teeth, good or acceptable results were observed in patients.1 On pulpless teeth, intrinsic dyschromia often results 89% of the cases. After 3 years, 79.7% of these teeth maintained from post-traumatic hemorrhage or pulp necrosis. Inadequate good or acceptable results. No fracture or resorption occurred endodontic access cavity leaving persistent necrotic tissue in in the treated cases.10 the pulp horns is also a source of dyschromia.1-4 However, sodium perborate has been classified as carcino- Tooth whitening is a conservative alternative to more inva- genic, mutagenic, and toxic for reproduction (CMR substances) sive treatments such as veneers or crowns.5 Several techniques by European Union (EU) legislation. Its use is therefore prohib- have been described to bleach discolored nonvital teeth.3-7 The ited by Article 15 of Cosmetics Regulation 1223/2009, since principal active agent is, however, always hydrogen peroxide. April 2015.11 In response to this restriction, the search for an This can be directly applied to the tooth or be released from alternative technique is essential. carbamide peroxide or sodium perborate.3,6 The use of carbam- An inside/outside bleaching technique combining inter- ide peroxide or sodium perborate has the advantage of pro- nal and external application of 10% carbamide peroxide was moting a gradual release of hydrogen peroxide, thereby redu- initially described by Settembrini et al12 in 1997. In this tech- cing the risk of side effects associated with a massive release of nique, a protective barrier is placed on the gutta-percha in the bleaching molecules.5,6,8 The walking bleach technique using root canal to seal off the latter from the pulp chamber. A cus- sodium perborate in combination with distilled water was con- tom bleaching tray with a reservoir on the labial surface of the sidered a safe and effective method, associating good esthetic discolored tooth is then given to the patient, who is instructed results with absence of external cervical resorption.7,9,10 In a to inject 10% carbamide peroxide in the access cavity left 802 QUINTESSENCE INTERNATIONAL | volume 50 • number 10 • November/December 2019 Reitzer et al 1a 1b 1e 1f 1g 1c 1d 1h 1i 1j Figs 1a to 1k Modified inside/outside bleaching technique. (a and b) Initial clinical appearance. (a) Patient’s smile. (b) Intraoral view of the maxillary incisors. Note the grayish discoloration of the maxillary right central incisor. (c) Preoperative radiograph of the maxillary right central incisor. (d) Periapical radiograph taken after the endodontic treatment. (e) Intraoperative view of the access cavity after reducing the root filling 1.5 mm below the cementoenamel junction. (f) Intraoperative view of the zinc oxide–eugenol cement barrier. (g) Intraoperative view of 10% carbamide peroxide placed in the access cavity. (h) Design of the tray used for the nonvital tooth bleaching. (i) Bleaching tray applied to the teeth. (j and k) Post- operative appearance. (j) Intraoral view of the maxillary incisors. 1k (k) Patient’s smile. QUINTESSENCE INTERNATIONAL | volume 50 • number 10 • November/December 2019 803 ESTHETIC DENTISTRY 2a 2b 2c 2d 2e 2f Figs 2a to 2f Follow-up. (a to c) Clinical appearance 18 months after the treatment. (a) Intraoral view of the maxillary incisors. (b) Black and white picture showing the reduced value of the maxillary right central incisor compared to the contralateral tooth. (c) Patient’s smile showing a slight recurrence of dyschromia on the maxillary right central incisor. (d to f) Clinical appearance after 5 nights of external bleaching. (d) Intraoral view of the maxillary incisors. (e) Black and white picture showing that both maxillary central incisors have similar values. (f) Patient’s smile. open and in the tray reservoir, before inserting the tray into Case report the mouth.4,12-14 A clinical case is presented in which the patient was treated A 19-year-old woman presented to the endodontic depart- with a variant of the initially described inside/outside bleach- ment due to a grayish discoloration of her maxillary right cen- ing technique. The proposal is to seal 10% carbamide peroxide tral incisor. The patient had a history of trauma 5 years previ- into the access cavity instead of leaving the latter open. It is ously, which induced pulp necrosis associated with intrinsic suggested that this protocol is easier to use for the patient and discoloration of the tooth (Figs 1a to 1c). An endodontic prevents accumulation of food debris in the access cavity. treatment followed by an inside/outside bleaching technique 804 QUINTESSENCE INTERNATIONAL | volume 50 • number 10 • November/December 2019 Reitzer et al was proposed to the patient and written consent was of products with a concentration greater than 6% is prohib- obtained. ited.15 In addition, the use of sodium perborate has been for- The maxillary right central incisor was isolated with rubber bidden since April 2015.11 Together, these EU directives pose a dam and the access cavity was designed to include the mesial new challenge in the field of nonvital tooth bleaching. and distal horns. After performing the endodontic treatment, The inside/outside bleaching technique using a low concen- the access cavity was provisionally filled with Cavit (3M Espe) tration of carbamide peroxide (between 10% and 16%) is an and a periapical radiograph was taken (Fig 1d). interesting alternative to the walking bleach technique using The patient was seen 1 week later to begin the bleaching sodium perborate. This technique, initially described by Settem- procedure. The tooth was isolated with rubber dam before brini et al12 and then applied by other authors, has been re- removing the provisional restoration from the access cavity. ported to be associated with good esthetic results and no exter- The gutta-percha in the root canal was reduced 1.5 mm below nal cervical resorptions.13,16,17 Another advantage is the use of a the cementoenamel junction (CEJ) by a heated plugger (Fig 1e) single product for internal and external bleaching.4,14 and a 2-mm barrier of zinc oxide–eugenol cement (Dentsply) Nevertheless, this technique has the disadvantage of leav- was placed over the remaining gutta-percha to protect both ing the access cavity open. Accumulation of foodborne depos- the root canal and the CEJ from the diffusion of the bleaching its can then occur. To limit this, the patient is instructed to rinse agent (Fig 1f). The access cavity was then filled with 10% carba- the access cavity and to place a fresh cotton pellet after each mide peroxide (Fig 1g) and sealed with zinc oxide–eugenol meal.12,16 While useful, this procedure cannot completely pre- cement. vent the deposition of food debris, which may reduce the effec- In the previous session, an alginate impression of the maxil- tiveness of the bleaching. In addition, microorganisms can col- lary arch was taken and the dental laboratory technician was onize the exposed dentinal tubules which, due to the complex asked to create a bleaching tray with a specific design, including: histology of the dentin, cannot be entirely decontaminated.5,7,18 ■ a reservoir on the labial surface of the maxillary right cen- Furthermore, careful case selection is necessary since the tral incisor administration of the bleaching agent is based on the patient’s ■ holes in the labial surfaces of the adjacent incisors (Fig 1h). compliance and dexterity.13,14 To overcome these disadvantages, the proposal is to seal After testing the fitting of this tray (Fig 1i), it was given to the the bleaching agent in the access cavity. One critical step of this patient, who was instructed to inject the bleaching gel in the protocol is the placement of the provisional restoration over reservoir and to wear it overnight (5 to 6 hours). the bleaching agent, which can be difficult due to the texture The patient was reviewed for check-ups weekly, without of the latter. To facilitate this procedure, some cotton fibers can replacing the product in the tooth. After 3 weeks, the esthetic be placed between the bleaching agent and the provisional result was good (Figs 1j and 1k).
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