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Bleaching Procedure
SHAWFEKAR BTE HJ ABDUL HAMID
1/29/2009
It is a well known fact, that a tooth loses its natural color after removal of the pulp. This is due to dehydration of the tooth substance with consequent loss of translucency. Bleaching of a discolored pulpless tooth is possible when the discoloration is due to products of pulp decomposition, or food debris producing organic products, which gain access to the dentinal tubules, or to chromogenic bacteria. When the discoloration is due to metallic salts, bleaching is more difficult or even impossible. Discoloration of the tooth can be noticed several month s after death of the pulp or treatment of the tooth, due to slow formation of color-producing compounds. Traumatic injury of a tooth may cause rupture of the blood vessels in the pulp with diffusion of blood into the dentinal tubules. Such teeth can be noticed a dark pinkish immediately after accident, turning to a pinkish-brown some days afterward or even after the pulp removed.
Pulpal necrosis
When bacteria contaminate a necrotic pulp, hydrogen sulfide (produced by the bacteria) combines with the iron released from hemoglobin, to form an iron sulfide compound. This produces a blackish-gray discoloration. Necrotic debris left in pulp chamber recesses during/after endodontic therapy If allowed to remain, necrotic pulp tissue decomposes and penetrates dentinal tubules. It important to create adequate access openings and thoroughly debride all chamber recesses, especially pulp horns and fins.
closure, obturating materials should not be allowed to remain coronal to the attachment apparatus. Also, these teeth should have their chambers thoroughly cleaned with a solvent such as isopropyl alcohol or halothane immediately following obturation.
Restorative materials
Amalgam should not be used to restore the lingual access of anterior teeth. The buccal-lingual dimension of these teeth is too thin, and eventually these teeth will discolor. Pins can also release metallic ions and cause staining.
Bleaching Prognosis o The immediate results are oftentimes excellent. A very slight overbleach is indicated, in anticipation of short-term relapse.
o Color stability Over the long term, partial relapse is expected. This compromise is acceptable to most patients. Some will require rebleaching.
o Resorption Incidence is ~2-7% when no protective base used; near 0% with a base.
o Recall Resorption is often not evident until one year or longer post-bleaching.
Informed Consent
It is important to discuss the bleaching process and its prognosis with your patient. Patients are usually excited about bleaching, because they know little and have high expectations. Dont promise too much! Discuss a realistic prognosis, based on the patients degree/duration of discoloration. Shade improvements may be minimal or may not occur at all. Several appointments may be required for a walking bleach. Thin temporary restorations are often lost. There is the strong likelihood that some relapse will occur over the long term. Existing root canal therapy may require retreatment, due to technical deficiencies. Cervical root resorption is a risk. RCT performed in support of bleaching only (e.g. calcific metamorphosis) may result in a significant misadventure (e.g. radicular perforation), a root-end surgical procedure, or loss of the tooth! Wellinformed patients are more satisfied at the conclusion of therapy than those less informed. Treatment alternatives to nonvital bleaching exist: no treatment, laminate veneer, or a full crown.
Bleaching
the-counter products, as they are sometimes too abrasive and can damage the teeth with extended use. The ADA describes "whitening" as any process that will make teeth appear whiter, using one of two approaches. A product can bleach the tooth, therefore changing the natural tooth color. A bleach contains peroxide that helps remove deep and surface stains. However, a non-bleaching whitening product contains substances that help remove surface stains only.
Bleaching of a Tooth: Some people experience a graying of a tooth that either has been injured or had a root canal. You can have the tooth bleached internally so it will match the color of your others. It would remove the filling material at the back of the tooth and over a series of approximately 3 appointments, then it will place a special bleaching material inside the tooth. Once the tooth color matches that of your other teeth, you can return to your general dentist for a permanent filling. What a wonderful way to keep your smile looking healthy!
Following trauma, tooth discoloration is very common. The discoloration comes from the bleeding inside the pulpal chamber. The dentin becomes stained as the blood gets into the dentinal tubules and trapped in the pulp horns. The first step in restoring the natural color to the tooth is good endodontic therapy with adequate removal of the stained facial dentin and complete removal of the pulp horns. If the natural tooth color is not restored with this procedure, then the additional treatment of non-vital internal bleaching is indicated. A common error is incomplete removal of the pulpal horns due to a small apically placed access. Care must be taken to remove stained dentin and pulpal horns while trying to preserve maximum tooth structure. The following case shows how to "get the stain out".
After opening the access, staining can be seen in #9. #10 looks normal.
A round bur is used to remove the stain from the facial surface of the pulp chamber. Careful examination with magnification reveals remaining stain in pulp horns. The access is carefully refined to remove stain from pulp horns while keeping access as conservative as possible.
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Following removal of rubber dam, the change in coloration is noted. Patient is informed that the tooth is dehydrated and will continue to change color until rehydration is complete. At that time, evaluation can be made if additional internal bleaching procedures will be needed.
Obturation completed. Adequate endodontic therapy alone will often resolve the patient's esthetic concerns. Non-vital bleaching is a good adjunct for teeth requiring additional whitening.
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