Bleaching the Single Dark Tooth Learning Objectives Changing the Color of Just One Anterior Tooth Presents Unique Challenges

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Bleaching the Single Dark Tooth Learning Objectives Changing the color of just one anterior tooth presents unique challenges. • identify the causes of tooth discoloration in the initial examination. By Van B. Haywood, DMD | Anthony J. DiAngelis, DMD, MPH • discuss how tooth trauma impacts the approach to tooth bleaching. • discuss how endodontic treatment impacts there is no reason to initiate endodontic the approach to tooth bleaching. Abstrt ac therapy based on vitality testing alone. • describe each possible bleaching approach, Single dark teeth represent a major challenge to obtain best esthetic outcome in a Often single dark teeth are the result of the indications for each, and its benefits. patient’s smile. Treatment options may include single crowns, veneers, bonding, or trauma, which should be determined in bleaching. Bleaching is the most conservative option to consider, but the potential the dental history. It can take anywhere Logno o t www.insidedentistryCE.com for a successful outcome varies based on the cause and extent of the discoloration. from 1 to 20 years after the trauma be- to take the FREE CE quiz. fore any pulpal problems develop. Additional considerations for the occurring injury in permanent teeth.10,11 single dark tooth are the color of the Also, studies have reported that 71% to hen a patient must be aware of the basic principles of gingival tissues around the tooth, as well 92% of TDIs occur by age 19.12 presents with changing the color of one or more teeth as whether there is any root structure T he etiology of dental injuries varies either intrin- in order to implement a successful treat- visible due to recession. A smile analysis by age. In the 0 to 6 age group, falls pre- sic or extrin- ment plan. is used to determine these conditions as dominate.13 As children enter school, sic staining or well as the movement of the lip during falls, collisions with other children discoloration The Initial Examination smiling and whether a “gummy smile” and objects, as well as participation in and seems to T he first and most important con- exists. The dentin in the root is differ- organized physical activities and sports be a candidate for tooth bleaching, there sideration is to determine the cause ent from the dentin in the anatomic contribute to dental injuries.9,14-16 Tdis Wis a variety of factors and options for the of the tooth discoloration. A clinical crown, and does not bleach well if at in the teen and young-adult age group clinician to consider. What is the cause examination is conducted, which in- all, regardless of whether internal or are more the result of sports and motor for the discoloration? Is there tooth cludes evaluation of the color of the external bleaching is attempted. Also, vehicle accidents.14 Several studies have trauma involved, or has the affected teeth and the adjacent gingiva (Figure discolorations of the gingiva may cause documented that approximately one tooth been endodontically treated? 1). Additionally, transillumination, ra- a tooth that may be a perfect color match third of dental injuries are sports-re- What is the best delivery method for diographs, and pulp testing may be ap- to not be harmonious. Either of these lated.15-23 Other causes of TDIs include the patient’s lifestyle, financial situation, propriate. Radiographs should always conditions is magnified if the lip exposes physical abuse, fights, and assaults—of- and commitment level to home care? be taken of a single dark tooth, as teeth much of the root or gingiva because of a ten involving alcohol as an aggravating Single dark teeth present a unique chal- can undergo pulpal necrosis without hyperactive lip or gummy smile. factor.24-26 lenge for color change and the clinician any other symptom than becoming dark T he pulp can respond to trauma in (Figure 2). From this examination, the Trauma and Calcific a limited number of ways. Primarily it Van B. determination is made of whether the Metamorphosis can survive, die, or undergo pulp canal Haywood, DMD tooth is vital or not. A vital tooth may Many studies suggest that the preva- obliteration (PCO), often referred to Professor be darker due to trauma and resultant lence of traumatic dental injuries (TDI) as calcific metamorphosis.27 The latter Director of Dental bleeding into the dental tubules with- is high, although significant variation represents a common finding subse- Continuing Education Department of Oral out loss of vitality. Vital teeth may also occurs between countries, populations, quent to luxation injuries, 3.8% to 24%, 1-4 2,28-30 Rehabilitation discolor from internal or external re- age, and gender. Epidemiological and root fractures, 69% to 73%. School of Dentistry sorption, calcific metamorphosis, as well studies, while not always comparable, The precise mechanism of PCO is not Medical College of Georgia as decay or leaking restorations on the support the growing body of evidence known but disruption of the neurovas- Augusta, Georgia proximal or lingual surfaces. A non-vital that Tdis represent a significant chal- cular bundle appears to stimulate the tooth may have become darker from the lenge for clinicians.5 A study by Koste rapid formation of hard tissue (dentin Anthony J. same reasons as a vital tooth, but also and colleagues reported that 25% of or osseous) beginning within the pulp DiAngelis, DMD, MPH have experienced pulpal death. A tooth 6- to 50-year-olds in the United States chamber and progressing along the Chief Department 6 31 of Dentistry that has received endodontic treatment had experienced a TDI. Approximately pulp canal walls. It may present as Hennepin County may also later darken, especially if there 30% of children have sustained a TDI to partial or total obliteration of the pulp Medical Center is a poor seal of the endodontic access their primary dentition, and 25% of all canal space. Although radiographs may Minneapolis, Minnesota opening (Figure 3). school-aged children have experienced reveal what appears to be total oblitera- E ven if a tooth tests as non-vital, it a Tdi.7-9 Other reports document that tion of the pulp canal, generally there Professor University of Minnesota may not require endodontic therapy. If luxations represent the majority of remains clinical evidence of a pulp 32,33 Minneapolis, Minnesota there is no radiographic evidence of pa- primary teeth injuries, whereas crown canal and pulpal tissue. Clinically, thology and no clinical symptoms, then fractures constitute the most commonly the tooth will appear dark yellow due

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to the increased deposition of under- restorative procedure. A recent article the form of a discolored incisor presents bleaching efficacy.44 It is not possible lying dentin. Additionally, there may by daCunha and colleagues suggests a long-term esthetic challenge. The most to “spot bleach” a tooth either, because be a gradual diminution in response implementing endodontic therapy prior conservative approach to managing the bleaching material goes through to electrical and thermal pulp testing. to development of a periapical radiolu- PCO-induced discoloration is bleach- the enamel and dentin to the pulp in 5 PCO occurs more frequently in teeth cency in a tooth with PCO, based on two ing without endodontic therapy. to 15 minutes, and bleaches under res- with open apices and in more severe major considerations: (1) the technical torations and from one surface to the luxation injuries involving displace- difficulty and complications that may Tray Bleaching other (facial to lingual). It has also been ment.2,34 Extrusive and lateral luxation occur in treating these teeth; and (2) T here are a number of types of bleach- shown to bleach beyond the borders injuries in immature permanent teeth their review of a study that demonstrat- ing techniques to consider for both vital of the tray, generally to the cementoe- have demonstrated high rates of PCO.35 ed a 97.9% success rate for teeth treated and non-vital teeth, but these types may namel junction (CEJ), even if the tooth A recent study by Netto and colleagues without periapical radiolucencies vs a be divided mainly into those performed is only partially erupted. reported the chances of PCO in in- 62.5% success rate for teeth treated with in-office or those continued at home. T he ideal bleaching tray is fabricated truded permanent teeth to be six times periapical radiolucencies.42 Specific With the advent of nightguard vital on a horseshoe-shaped cast with no greater than in mature teeth, open vs clinical situations will dictate clinical bleaching involving tray application vestibule to provide good adaptation closed apex, and that PCO occurred in decisions; however, given the relatively of 10% carbamide peroxide, a method of the bleaching tray material. Also, the 26.7% of such injuries.36 PCO can oc- low incidence of pulp necrosis in teeth for bleaching single dark teeth became cast should be trimmed such that the cur in subluxated and crown-fractured with PCO, endodontic treatment usually more readily available, and did not in- central incisors are vertical to avoid teeth, although with less frequency.37 is not recommended in the absence of volve the use of highly caustic chemi- folds on the facial. One challenge in As mentioned previously, PCO is a a periapical radiolucency or symptoms. cals.43 The original recommendation fabrication of the single-tooth or regu- common occurrence after root frac- N onetheless, if a periapical lesion de- for a single dark tooth was to make a lar bleaching tray is trimming the cast tures. The location of PCO is thought velops, endodontic therapy can be both non-scalloped, no-reservoir tray, and without abrading either the teeth or the to be indicative of the type of healing. challenging and fraught with complica- bleach all the teeth. The tooth that was gingiva. This outcome is accomplished PCO in the apical segment only is sug- tions (Figure 4). The use of operatory darker generally took longer, so an “X” by trimming the cast from the base gestive of hard-tissue callus formation, microscopes in the hands of a skilled was made on that tooth mold of the tray rather than the sides (Figure 5). whereas PCO in the coronal segment or clinician is warranted and improves the so the patient could continue to bleach in both coronal and apical fracture seg- chances of a successful outcome. that tooth longer than the other teeth. Single-Tooth Bleaching Tray ments is indicative of connective tissue Most traumas to primary teeth are T he use of the “X” on the teeth to be An improvement on this concept is repair of the fracture.2,38 luxation injuries that frequently result in bleached was also helpful when the pa- the use of the “single-tooth” bleaching Pulp necrosis as evidenced by periapi- radiographic evidence of PCO. Although tient already had crowns on some teeth, tray when one tooth is darker, but the cal radiolucency is an infrequent sequela this may or may not result in crown dis- and placing bleaching material on them other teeth are reasonably acceptable to PCO occurring in approxi­mately 7% coloration, it ceases to be a concern for was a waste of material. While this tray (Figure 6). In this tray design, a conven- to 16% of cases; consequently, prophy- the patient, parent, or clinician as the system was simple and effective, it did tional non-scalloped, no-reservoir tray lactic endodontic therapy is not recom- tooth is eventually exfoliated. The only not always result in a perfect match of is fabricated. Then the teeth molds on mended by most authors.28,39-41 T eeth indication for bleaching primary teeth, the teeth. All the teeth would lighten, either side of the dark tooth are removed with PCO likely have diminished heal- which are generally very light, is trauma but often the darker tooth was not able (Figure 7 and Figure 8). The patient is ing capacity, and it is not well established that caused the tooth to become dark and to lighten as much as the normal teeth, given one syringe of bleaching mate- whether a secondary trauma or addi- the patient is being affected psychologi- and the resultant outcome was lighter rial and applies it only to the single dark tional dental treatment causes necro- cally by the darker teeth. There is no in- teeth, but still with one tooth slightly tooth mold and sleeps in the appliance. sis. In some instances, such as prepar- dication for endodontic therapy. darker than the others. Some authors T eeth will bleach at different rates and ing a tooth with PCO for an abutment, it I n contrast, younger patients who have recommended using a reservoir to different color levels.T he goal is to de- may be prudent to perform prophylactic sustain Tdis where development of the on the darker tooth, but the use of res- termine how light the single dark tooth endodontic therapy before the definitive permanent tooth is incomplete, PCO in ervoirs has not been shown to increase will bleach first.I f the color of the single

fig. 1 fig. 2 fig. 3 fig. 4

CLINICAL EXAMPLES (1.) A clinical examination demonstrates a single, very dark lateral incisor CLINICAL EXAMPLES (3.) A radiograph will indicate wheth- and a moderately dark central incisor with a crown on the adjacent central incisor and several er the dark color is related to materials remaining in the pulp dark gingival areas. (2.) A radiograph finds no pulp chamber in the slightly dark central incisor chamber, leaking restorations, caries, internal resorption, and a silver point on the darkest lateral incisor. A titrated approach to bleaching was needed us- or failed endodontic therapy. (4.) Endodontic therapy was ing individual tooth treatments. attempted on a tooth with calcific metamorphosis, with subsequent perforation and file fracture in the PDL.

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dark tooth does not get as light as the sur- been subsequently restored with an ac- rounding teeth, then the other teeth are ceptable lingual composite that matched not bleached (Figure 9) and the closest the tooth color. However, in subsequent match has been achieved. If the single years, the tooth may have discolored dark tooth matches the other teeth then, (Figure 10). In this situation, the deci- again, the other teeth are not bleached. sion for bleaching favors external bleach- Only if the single dark tooth gets lighter ing, because going inside the tooth to than the adjacent teeth should they remove the composite will weaken the be bleached, and in that case, daytime tooth (Figure 11). However, the choice fig. 5 fig. 6 bleaching in short intervals should be not to go inside the endodontic tooth used to avoid getting the adjacent teeth depends on whether the treating dentist lighter than the single dark bleached is aware of the extent to which the pulp tooth. Generally, the patient should be chamber was debrided during endodon- informed that the bleaching time for tic therapy, as well as the height in the the single dark tooth is about 8 weeks, chamber of the cement and filler. although it is highly variable. In-Office Bleaching fig. 7 fig. 8 “One challenge in I n-office bleaching is the oldest form of bleaching. Attempts to bleach single fabrication of the dark teeth date back to the 1800s, and single-tooth or regular bleaching a single dark tooth was one of the first bleaching research areas.45 bleaching tray is A number of materials have been used, trimming the cast but hydrogen peroxide has been the historic favorite. The high concentra- without abrading tion of hydrogen peroxide could be either the teeth or the applied externally or internally, and often involved heat and light. The gingiva. This outcome classic non-vital in-office bleaching is accomplished technique involved the placement of 35% hydrogen peroxide into the pulp by trimming the cast chamber, and increasing the chemi- from the base rather cal reaction by the use of heat or light. fig. 9 However, this technique lacks precise than the sides.” control as to the amount of lightening. More critically, when cases of external Endodontically Treated or internal resorption were evaluated, Anterior Teeth there were four common concerns list- I f the dark tooth has already received ed: 1) teeth had received trauma; 2) high endodontic therapy, then additional concentrations of peroxide were used; considerations for the discoloration 3) high heat was used to enhance the fig. 10 fig. 11 include remaining pulp materials in bleaching, and 4) there was no seal over the pulp chamber, endodontic sealer the gutta-percha. Although the dentist CASE EXAMPLE ONE (5.) Trimming the cast only from the base (with the or filler in the pulp chamber, and dark or cannot control the trauma, elimination central incisors horizontal) until the vestibule is removed and a hole oc- leaking restorations in the endodontic of the other three areas under dental curs in the palate will avoid the danger of damaging teeth from traditional trimming as well as create the best cast for use in a vacuum-former. (6.) A access opening, as well as endodontic control should be done to lessen the single dark tooth from trauma needs to be examined carefully and evalu- failure. The type of filler is also impor- chances of resorption and loss of the ated with a radiograph. The safest approach is to bleach this tooth alone tant, as silver points require different tooth. Other possibilities for resorp- until the tooth’s response and maximum lightening can be determined. (7.) The “single-tooth” bleaching tray has no reservoir or spacers and extends considerations from gutta-percha fill- tion include the fact that 10% of teeth onto the gingiva 1 mm to 2-mm, but avoids frenum movements. The teeth ers. Treatment considerations also do not have a connection between the not to be bleached have the tooth molds removed from the tray while may depend on when in the endodontic enamel and cementum, with possible maintaining the intact tray. (8.) The single-tooth bleaching tray extended further onto the palate than the traditional tray to preserve the tray treatment and subsequent follow-up percolation of hydrogen peroxide into integrity when the adjacent teeth molds were removed from the tray. The the tooth was noticed to be dark. the surrounding areas, lowering the pH. tray edges are hidden behind rugae and go onto the tissue in all areas. Endodontically treated teeth may be Using a bleaching product with a higher (9.) A reasonable match was obtained from about 8 weeks of single-tooth bleaching. Often patients discontinue treatment when the single tooth is treated from the inside, the outside, or pH or a salivary catalase are attempts no longer a mismatch, even if the outcome is not ideal. CASE EXAMPLE both. The decision for inside or outside to reduce resorption issues. TWO (10.) This root canal has been successful for 30 years, but the tooth depends on a knowledge of what has has become slightly discolored. There is no reason from the radiograph to re-enter the pulp chamber, as this will further weaken the tooth. External occurred inside the tooth during the Walking Bleach Technique bleaching by a single-tooth bleaching tray is indicated (11.) The 10% carb- endodontic therapy, as well as the type T he change in in-office bleaching led amide peroxide bleaching material was applied externally with the single- of restoration used to seal the access to the next step of “walking bleaching.” tooth bleaching tray nightly until the shade of the endodontically treated tooth returned to match the adjacent teeth. Should the tooth re-darken opening. The tooth may have received a I n this technique, the gutta-percha was again, the process can be repeated without danger to the tooth. Figure 10 satisfactory endodontic treatment and removed 2 mm below the CEJ and a and Figure 11 courtesy of Meigan Johnson.

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base was applied to seal the endodontic Inside Bleaching filling material from the pulp chamber. When performing internal bleaching Then, initially, a high concentration of on a non-vital tooth that has received hydrogen peroxide was applied, sealed, endodontic therapy, it is important to and the patient “walked out of the office” clean out the inside of the pulp cham- while the hydrogen peroxide oxidized ber (Figure 12). Often, when endodon- the discoloration. This treatment took tic therapy is performed because of anywhere from 1 to 6 weekly applica- trauma, the pulp chamber is large, with fig. 12 fig. 13 tions. The challenge was that the high high pulp horns. The access opening concentration of hy­drogen peroxide to the apex may not include debride- could be caustic to either the dentist ment of the chamber (Figure 13). The or the patient. Later, this technique restorative dentist should open the evolved into mixing the hydrogen per- access opening enough to access both oxide with sodium perborate to form the incisal extent as well as the lateral a mixture that was easier to handle. extent of the pulp chamber. Often, re- Sodium perborate breaks down into moval of the remaining pulp chamber fig. 14 fig. 15 about a 3% solution of hydrogen per- will significantly alter the color of the oxide. Finally, the high concentration tooth, even before the bleaching has of hydrogen peroxide was eliminated begun (Figure 14). and sodium perborate alone was used. I nternal bleaching treatment was fol- Inside-Outside lowed by the use of a catalase to neu- Closed Bleaching tralize the hydrogen peroxide and el- One of the best options for an endodon- evate the pH around the tooth. With tically treated tooth is to use both the any bleaching treatment, time should inside and outside techniques in combi- fig. 16 fig. 17 be allowed for the shade to stabilize and nation. Entering the inside of the tooth the oxygen to dissipate from the tooth. will allow removal of any pulp tissue, If bonding is initiated immediately af- filler, or cement sealer, as well as discol- ter bleaching, there is a 25% reduction ored restorations in the chamber. The in bond strengths due to the inhibition classic walking-bleaching treatment is of the composite set from the oxygen in performed as described above (Figure the tooth, resulting in shorter enamel 15 and Figure 16), then the tooth is tags. It generally takes about 2 weeks temporarily sealed while a single-tooth or longer for the shade to stabilize and bleaching tray is fabricated. Bleaching the bond strength to return to normal. continues at home externally using the Later, 10% carbamide peroxide was single-tooth tray approach until the sin- found to be equally as effective as so- gle dark tooth has reached its maximum dium perborate for internal bleaching, lightness (Figure 17). Then the patient at the same concentration, with the waits 2 weeks for the shade to stabilize additional benefit of causing a rise in and the bond strengths to return to f ig. 18 pH, which may be beneficial to avoid normal. Upon return to the dentist, a resorption. A 10% solution of carb- comparison of the single tooth is made CASE EXAMPLE THREE (12.) The initial examination and radiograph determined that the dark lateral incisor was abscessed. After endodon- amide peroxide is equivalent to 3.5% to the adjacent teeth. If the endodon- tic therapy, the tooth was then ready for bleaching. Had bleaching been hydrogen peroxide and 6.5% urea. It tically treated tooth remains slightly performed without the radiograph, the abscess would have remained is the urea that causes the increase in darker than the remaining teeth, an untreated and further damaged the tooth. (13.) The endodontic access opening should be enlarged until it can be certain that all the remaining pH within 5 minutes after application opaque stark-white composite is used brown pulp tissue has been removed from the lateral walls of the pulp to a level above 8, which cannot be ac- internally to fill the pulp chamber and chamber as well as the incisal extent. Pulps that became necrotic when complished with hydrogen peroxide provide an additional slight lightening the tooth was young often have pulp chambers much larger than the endodontic access opening. (14.) Even before bleaching the tooth, the re- alone. Also, the carbamide peroxide of the tooth (Figure 18). The final ori- moval of the brown necrotic pulp remnants and dental materials makes the has a slower peroxide release and is fice is closed with the appropriate color- tooth much lighter. This occurrence demonstrates how the materials inside active longer than hydrogen peroxide. matched composite to the external por- the tooth affect the color of the outside. (15.) For internal bleaching, the gutta-percha should be removed 2 mm below the CEJ. (16.) Once the gut- T his slower application of peroxide tion of the tooth. Some clinicians prefer ta-percha has been removed to the appropriate depth and from the walls seems to favor the rate of color change. to use a resin-modified glass ionomer of the pulp chamber, the endodontic filler is sealed from the pulp chamber Because trauma is one of the initia- internally to improve the bond to dentin, with a resin-modified glass ionomer. Etching is not required for bleaching. (17.)The patient may bleach externally (as well as internally) with a full tray tors of resorption, that event cannot followed by the traditional composite rather than a "single-tooth tray" to lighten all the teeth or because there be totally eliminated. Even teeth that restoration to close the opening. This are crowns that will not change color. To identify the dark tooth for ad- have not been bleached can begin to approach of both inside and outside ditional treatment, an “X” is placed on the tooth mold for the placement of the bleaching material. If the tray is to be worn during the day rather have resorption, so there is always that bleaching with a closed pulp chamber than at night, the “X” should be placed on the lingual. (18.) After the tooth possibility. Traumatized teeth should gives the benefits of both techniques. being bleached has reached its maximum lightening, the bleaching process have recall radiographs taken every T he inside bleaching segment allows should be stopped for 2 weeks to allow the shade to stabilize and the bond strengths to return to normal. Then an opaque whiter composite can 1 to 2 years, whether they have been the tooth to be cleaned as well as tem- be placed in the chamber if needed to further harmonize the tooth color. bleached or not. pers the final color with a composite

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restoration, while the outside bleaching single-tooth tray, then the standard re- adjacent tooth colors. A “single-tooth” 10. Hedegård B, Stalhane I. A study of trauma- segment allows the patient to bleach as placement of the internal carbamide bleaching tray is the tray of choice for tized permanent teeth in children aged 7-15 long as necessary to obtain the maxi- peroxide is performed weekly, taking 1 external bleaching. Single dark teeth years. Part 1. Swed Dent J. 1973;66:431-450. mum whitening of the tooth without to 6 office visits for completion. A pro- with calcific metamorphosis should not 11. Gelbier S. Injured anterior teeth in chil- returning to the office (Figure 19 and visional restoration maintains the seal, be treated endodontically unless there dren. A preliminary discussion. Br Dent J. Figure 20). Because a cast already ex- and the patient is instructed to call the are clinical symptoms of pain or radio- 1967;123:331-335. ists for the single-tooth tray, should the office immediately if occlusion or food graphic evidence of an abscess. 12. Davis GT, Knott SC. Dental trauma in single tooth get lighter than adjacent disrupts the provisional seal. For internal bleaching of an end- Australia. Aust Dent J. 1984;29:217-221. teeth, a new bleaching tray can be fab- odontically treated tooth, a “walking 13. Kramer PF, Zembruski C, Ferreira SH, ricated and the patient can use it for Bleaching or Crown Decisions bleach” approach using 10% carbamide Feldens CA. Traumatic dental injuries in day wear to titrate the color to a final T he question is often asked why the an- peroxide internally seems to afford Brazilian preschool children. Dent Traumatol. match. The average treatment time for terior endodontically treated tooth is the safest approach over previous tra- 2003;19:299-303. single dark teeth seems to be 8 weeks, not crowned today as it once was in the ditional methods. The combination of 14. Skaare AB, Jacobsen I. Dental injuries in although there is a wide range of treat- past. One reason for the resurgence of one internal bleaching appointment to N orwegians aged 7-18 years. Dent Traumatol. ment times. While 10% carbamide per- bleaching single anterior teeth is that debride the pulp chamber, followed by 2003;19:67-71. oxide is generally used for traditional the research has shown that while pos- tray bleaching with a single-tooth tray or 15. Hosnik A. Emergency treatment of dentoal- overnight treatment, higher concentra- terior teeth that have received a root ca- full non-scalloped, no reservoir tray pro- veolar trauma. Phys Sports Med. 2004;32(9):1-10. tions may be used once it is determined nal should be crowned, anterior teeth vides the flexibility of unlimited time of 16. Onetto JE, Flores MT, Garbarino ML. that sensitivity is not a problem. should only be crowned if they needed treatment without incurring significant D ental trauma in children and adolescents a crown regardless of the endodontic in-office charges. Additionally, waiting in Valparaiso, Chile. Endo Dent Traumatol. Inside-Outside therapy. The reason is because the single 2 weeks after bleaching for the shade to 1999;10:223-227. Open Bleaching greatest predictor of survival of an end- stabilize and the bond strengths to re- 17. Cornwell H. Dental trauma due to sport in I n special patients and situations, the odontically treated tooth is the amount turn to normal and then using internal the pediatric patient. Calif Dent Assoc J. 2005; dentist may chose to perform inside and of remaining dentin. If an intact anterior composite bonding can harmonize final 33(6)457-461. outside bleaching while leaving the ac- tooth has a root canal, the external enam- shade discrepancies. Regardless of the 18. Zerman N, Caralleri G. Traumatic injuries cess opening unrestored. In this situa- el and dentin is still intact. Preparing the technique used for bleaching, a relapse to permanent incisors. Endod Dent Traumatol. tion, the patient injects carbamide per- tooth for a crown after the endodontic is possible in 1 to 3 years, and is generally 1993;9:61-64. oxide into the pulp chamber and the tray, treatment removes the remaining den- best addressed by outside bleaching in 19. Skaare AB, Jacabsen I. Etiological factors then seats the tray in the mouth to pro- tin and results in a premature loss of the a single-tooth tray with 10% carbamide related to dental injuries in Norwegians aged tect the opening. While this may shorten tooth. Research has also shown that the peroxide to re-bleach the tooth until it 7-18 years. Dent Traumatol. 2003;19:304-8. treatment time due to the continued ap- post does not strengthen the tooth, and matches the surrounding teeth. 20. Gassner R, Bösch R, Tulit, Emskoff R. plication of fresh bleaching material, it cannot compensate for the loss of dentin. Prevalence of dental trauma in 6000 patients is essential that the patient be able to Hence, the tooth has a better prognosis to References with facial injuries: Implications for treatment. perform their part, and also return to be bleached and restored with composite 1. Glendor U, Halling A, Andersson L, Eilert- Oral Surg Oral Med Oral Path Oral Radiol the office to have the opening closed. than to receive a post, core, and crown. Petersson E. Incidence of traumatic tooth Endod. 1999;87:27-33. While the tooth will not get any tooth injuries in the county of Västmauland, Sweden. 21. Brunner F, Krasti G, Filippi A. Dental trauma decay during the bleaching process due Conclusion Swed Dent J. 1996;20:15-28. in adults in Switzerland. Dent Traumatol. to the increase in pH afforded by the T he single dark tooth is an esthetic 2. Andreasen JO, Andreasen FM, Andersson L. 2009;25:181-184. carbamide peroxide,46 there is the dan- challenge regardless of the treatment Textbook and Color Atlas of Traumatic Injuries 22. Promoting oral health: interventions for ger that the patient may cease bleach- approach. Bleaching the single tooth to the Teeth. 4th ed. Oxford, England: Blackwell preventing dental caries, oral and pharyngeal ing but not return in a timely fashion alone is the safest, most conservative Munskgaard; 2007. cancers and sports related craniofacial injuries: to have the orifice sealed.I f the office is approach to determining the response 3. Davis GT, Knott SC. Dental trauma in a report on recommendations of the Task Force not equipped to fabricate the additional of the single tooth before changing the Australia. Aust Dent J. 1984;29:217-221. on Community Preventive services. MMWR. 4. Brunner F, Krasti G, Filippi A. Dental trauma 2001;50(R R 21):1-13. in adults in Switzerland. Dental Traumatol. 23. Tuli T, Hachl O, Hohlrieder M, et al. 2009;25:181-184. D entofacial trauma in sports accidents. Gen 5. Glendor U. Epidemiology of traumatic dental Dent. 2002;50(3):274-279. injuries—a 12 year review of the literature. Dent 24. Needleman HL. Orofacial trauma in child Traumatol. 2008;24:603-609. abuse: types, prevalence, management and the 6. Kaste LM, Gift HC, Bhat M, Swango PA. dental profession. Pediatr Dent. 1986;8:71-80. Prevalence of incisor trauma in persons 6-50 25. Dimitroulis G, Eyre J. A 7-year review of years of age: United States, 1988-1991. J Dent maxillofacial trauma in a central London hos- Res. 1996;75:696-705. pital. Br Dent J. 1991;170:300-302. 7. Petti S, Tarsitani G, Arcadi P, et al. The preva- 26. Perkeentupa U, Laukkanen P, Veijola J, et al. lence of anterior tooth trauma in children 6 to 11 I ncreased lifetime prevalence of dental trauma f ig. 19 f ig. 20 years old. Minerva Stomatol. 1996;45:213-218. is associated with previous non-dental injuries, 8. Rocha MJ, Cardoso M. Traumatized perma- mental distress and high alcohol consumption. CASE EXAMPLE FOUR ((19.) The endodontically treated canine is much darker than the adjacent teeth, but in this less-esthetic area, a full tray was nent teeth in Brazilian children at the Federal Dent Traumatol. 2001;17:10-16. used to lighten all the teeth. The canine was bleached internally with one University of Santa Catarina, Brazil. Dent 27. Feiglin B. Dental pulp response to traumatic treatment and externally to completion. (20.) After 3 weeks of external Traumatol. 2001;17:245-249. injuries—a retrospective analysis with case bleaching with 10% carbamide peroxide at night, the adjacent teeth reached their maximum lightness. While the other teeth are slightly lighter than the 9. Flores MT. Traumatic injuries in the primary reports. Endod Dent Traumatol. 1996;12:1-8. canine, the color match was much closer and pleasing to the patient. dentition. Dent Traumatol. 2002;18:287-298. 28. Amir FA, Gutmann JL, Witherspoon DE.

50 inside dentistry | S eptember 2010 | insidedentistry.net Calcific metamorphosis: a challenge in end- odontic diagnosis and treatment. Quintessence co ntinuing education Int. 2001;32:447-455. 29. Andreasen J. Luxation of permanent teeth due to trauma. Scand J Dent Res. 1970;78:273-286. 30. Andreasen FM, Yu Z, Thomsen BL, Andersen quiz PK. The occurrence of pulp canal obliteration af- Log on to www.insidedentistryCE.com to take this FREE CE quiz. ter luxation injuries in the permanent dentition. Endod Dent Traumatol. 1987;3:103-15. 31. Robertson A, Andreasen FM, Bergenholtz G, et al. Incidence of pulp necrosis subsequent to pulp canal obliteration from trauma to Bleaching the Single Dark Tooth permanent incisors. J Endod. 1996;22:557-606. By Van B. Haywood, DMD; and Anthony J. DiAngelis, DMD, MPH 32. Kuyk JK, Walton RE. Comparison of the AS EGI Publications, LLC, provides 2 hours of FREE Continuing Education credit for this article for those who wish to document their continuing education radiographic appearance of root canal size to its efforts. To participate in this CE lesson, please log on to www.insidedentistryCE.com, where you may further review this lesson and test online. Log on now, actual diameter. J Endod. 1990;16(11):528-533. take the CE quiz and, upon successful completion, print your certificate immediately! For more information, please call 877-4-AEGIS-1. 33. Piatteli A. Generalized “complete” calcific degeneration or pulp obliteration. Endod Dent How long can it take after the trauma before any What percent solution of carbamide peroxide Traumatol. 1992;8:259-263. 1 7 pulpal problems develop? is equivalent to 3.5% hydrogen peroxide and 34. Jacobsen I, Kerekes K. Long term prognosis 6.5% urea? of traumatized permanent anterior teeth show- . A 1 to 20 days ing calcifying processes in the pulp cavity. Scand . B 1 to 20 weeks . A 3.5% J Dent Res. 1977;85(7):588-598. . C 1 to 20 months . B % 5 . C 10% 35. Holcomb JB, Gregory WB Jr. Calcific . D 1 to 20 years . D 17% metamorphosis of the pulp; its incidence and Approximately what percentage of children has treatment. Oral Surg Oral Med Oral Pathol. 2 sustained a TDI to their primary dentition? 8 If an endodontically treated tooth remains slightly 1967;24(6):825-830. darker than the remaining teeth after inside- . A 10% 36. Netto JJ, Gondim JO, deCarralho FM, Giro outside closed bleaching, which of the following . B 30% E M. Longitudinal clinical and radiographic is used internally to fill the pulp chamber? evaluations of severely intruded permanent in- . C 50% . D 70% . A an opaque stark-white composite cisors in a pediatric population. Dent Traumatol. . B a clear, transparent resin 2009;25(5):510-514. 3 In the 0 to 6 age group, which category of injuries . C a glass ionomer with carbamide peroxide 37. Robertson A. A retrospective evaluation of predominates? incorporated patients with uncomplicated crown fractures . D a glass ionomer with hydrogen peroxide . A motor vehicle accidents and luxation injuries. Endod Dent Traumatol. incorporated 1998;14:245-256. . B sports activities . C falls 38. Andreasen FM, Andreasen JO, Bayer T. 9 To perform inside and outside bleaching . D collisions with other children Prognosis of root fractured permanent incisors: while leaving the access opening unrestored, who prediction of healing modalities. Endod Dent injects carbamide peroxide into the pulp chamber Although radiographs may reveal what appears to 4 and the tray, then seats the tray in the mouth to Traumatol. 1989;5:11-22. be total obliteration of the pulp canal, generally protect the opening? 39. Schindler WG, Gullickson DC. Rationale there remains: for the management of calcific metamorpho- . A the dentist . A gram-positive bacteria in the pulp horn. sis secondary to traumatic injuries. J Endod. . B the assistant . B gram-negative bacteria in the pulp horn. 1988;14(8):408-412. . C the patient . C at least one patent furcation. 40. Smith JW. Calcific metamorphosis: a treat- . D it works by diffusion of a high concentra‑ . D clinical evidence of a pulp canal and pulpal tion from the outside ment dilemma. Oral Surg Oral Med Oral Pathol. tissue. 1982;54(4):441-444. 10 Anterior teeth should only be crowned instead of 41. Akertblon A, Hasselgren G. The prognosis Bleaching material goes through the enamel 5 bleaching if: for endodontic treatment of obliterated root and dentin to the pulp in: canals. J Endod. 1988;14(11)565-567. A. there is a high lip line. . A 5 to 15 seconds. 42. daCunho FM, deSouza IM, Monnerat J. B. there is a low lip line. . B 5 to 15 minutes. C. they needed a crown regardless of the Pulp canal obliteration subsequent to trauma: . C 5 to 15 hours. endodotic therapy. perforation management with M.T.A. followed . D 5 to 15 days. D. posterior teeth are missing. by canal localization and obturation. Brazilian J Dent Traumatol. 2009;1(2):64-68. 6 Endodontically treated teeth may be treated from the: 43. Haywood VB. Tooth Whitening: Indications . A inside only. and Outcomes of Nightguard Vital Bleaching. . B outside only. Hanover Park, Ill: Quintessence; 2007. . C both inside and outside. 44. Haywood VB. The “bottom line” on bleach- . D neither inside or outside. ing 2008. Inside Dentistry. 2008;4(2):82-89. 45. Haywood VB. History, safety, and effec- AEGIS Publications, LLC, is an ADA CERP Recognized Provider. ADA tiveness of current bleaching techniques and CERP is a service of the American Dental Association to assist dental applications of the nightguard vital bleaching professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses technique. Quintessence Int. 1992;23:471-488. or instructors, nor does it imply acceptance of credit hours by boards Tufts University School of Dental Approved PACE Program Provider FAGD/MAGD Credit Approval of dentistry. Concerns or complaints about a CE provider may be Medicine peer-reviews all CE does not imply acceptance by a state or provincial board of Program Approval for dentistry or AGD endorsement. 7/18/1990 to 12/31/2012 46. Haywood VB. Orthodontic caries control directed to the provider or to ADA CERP at www.ada.org/goto/cerp. lessons for Inside Dentistry. Continuing Education and bleaching. Inside Dentistry. 2010;6(4):36-50.

52 inside dentistry | S eptember 2010 | insidedentistry.net

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of Program Approval for Continuing Education dentistry or AGD endorsement. 7/18/1990 to 12/31/2012 co ntinuing education M ail in answer form

Inside Dentistry is committed to your Continuing Education efforts.We are pleased to offer you another avenue for obtaining credits for your Continuing Education lessons. In addition to our FREE CE on our Web site, www.insidedentistryce.com, we are IN OFFICE TREATMENT now offering a mail-in option to our readers who prefer to send in their tests for scoring. For a nominal fee of $28 ($14 per credit) to cover administrative and handling costs, your test will be graded and your certificate will be sent to you in the mail.S imply use The Prescribing Information covers the following this page for your answers, fill it out completely, and send it along with your check or credit card information product sizes: 0.07 OZ (2.0 g) unit dose cups and 3.0 OZ (85 g) tubes PRESCRIBING INFORMATION Description: Colgate® Sensitive Pro-Relief™ SEPTEMBER 2010 is a desensitizing paste that provides instant Bleaching the Single Dark Tooth sensitivity relief after 1 application. The Pro- Argin™ Technology effectively plugs and seals open dentin tubules when polished into teeth with a rotary cup. 1 A B C D 6 A B C D Composition: Colgate® Sensitive Pro-Relief™ Desensitizing Paste contains hydrated silica, calcium carbonate, glycerin, arginine, water, 2 A B C D 7 A B C D bicarbonate, flavor, cellulose gum, sodium saccharin, FD&C blue no.1. Indications and Usage: Colgate® Sensitive 3 A B C D 8 A B C D Pro-Relief™ is to be used for the management of sensitive teeth, post scaling and root planing. It is a tubule occluding agent designed for 4 A B C D 9 A B C D professional application with a rotary cup during standard dental practice hygiene procedures. 5 A B C D 10 A B C D Dosage: To be determined by the dental professional for the treatment of dentin hypersensitivity.

Directions for use: check (payable to AEGIS Communications) 1. Place enough paste for one procedure in a credit card Please complete information and sign below: clean dappen dish or other suitable container Card Number Expiration Date: Month/Year (when dispensing from tube). 2. Fill a rotary cup with paste and run rotary cup / at low to moderate speed. 3. Polish product into each tooth, on sensitive Visa Mastercard American Express Total amount ($28 per test) areas or areas that can become sensitive (can be applied to entire dentition). Apply product to sensitive areas for 3 seconds, then repeat. Signature date NOTE: Throughout procedure, sufficient paste should be maintained on the cup to avoid overheating of the tooth surface. Saliva (Please Print Clearly) ADA Number evacuation is recommended to avoid excess Last 4 digits or SSN AGD Number dilution and swallowing of the paste. Contraindications: Colgate® Sensitive Pro- The Month and Day (not year) of Birth. Example, January 23 is 01/23 Month/Date of Birth Relief™ is contraindicated in patients with a known allergy to any of the components. Name ® ™ Warnings: Colgate Sensitive Pro-Relief may Address cause eye irritation upon contact. If contact with eyes occurs, immediately flush eyes with plenty City of water for 15 minutes. Seek medical attention state zip daytime phone if irritation or discomfort persists. Please mail completed forms with your payment to: AEGIS Communications Precautions: Colgate® Sensitive Pro-Relief™ CE Department, 104 Pheasant Run, Suite 105, Newtown, PA 18940 should be used only by individuals professionally trained to perform dental prophylaxis. During SCORING SERVICES: By Mail | Fax: 215-504-1502 | Phone-in: 877-423-4471 (9 am - 5 pm ET, Monday - Friday) use, wear protective glasses, mask and gloves. Customer Service Questions? Please Call 877-423-4471 Storage: Store at room temperature. Do not store pastes above 77°F (25°C). Keep out of Program evaluation direct sunlight. Close cap immediately after use Please circle your level of agreement with the following statements. to avoid moisture loss. (4 = Strongly Agree; 0 = Strongly Disagree) Lot number and Expiration date: The lot 1. Clarity of Objects 4 3 2 1 0 8. Relevance of review questions 4 3 2 1 0 number should be quoted in all correspondences which requires identification of the product. Do 2. Usefulness of the content 4 3 2 1 0 9. Did this lesson achieve its yes no not use after the expiration date. 3. Benefit to your clinical practice 4 3 2 1 0 educational objectives? Rev. 04/09 4. Usefulness of the references 4 3 2 1 0 10. Did this article present new yes no 5. Quality of the written presentation 4 3 2 1 0 information? Colgate Oral Pharmaceuticals, Quality of the illustrations: 4 3 2 1 0 How much time did it take you min a subsidiary of Colgate-Palmolive Company. New 6. 11. York, NY 10022 U.S.A. 7. Clarity of review questions 4 3 2 1 0 to complete this lesson? For full prescribing information please visit www.colgateprofessional.com Questions? Comments? Please Call: 1-800-962-2345