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Bleaching of severely darkened nonvital tooth case report—48 months

clinical control

Article in Journal of Esthetic and Restorative Dentistry · June 2020

DOI: 10.1111/jerd.12609

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Received: 17 April 2020 Revised: 13 May 2020 Accepted: 16 May 2020
DOI: 10.1111/jerd.12609

CLINICAL ARTICLE

Bleaching of severely darkened nonvital tooth case

report—48 months clinical control

Alana C. Machado MS1 | Sheila R. M. Braga MS1 | Daniele Ferreira MS1 |

Felipe F. Jacintho DDS2 | Tais Scaramucci PhD1 | Maria Angela P. Sobral PhD1

1
Department of Restorative Dentistry,
University of S~ao Paulo, S~ao Paulo, Brazil
2
Department of Pharmacology, School of
Medical Science, University of Campinas,
Campinas, Brazil
Correspondence
Maria Angela P. Sobral, Department of
Restorative Dentistry, School of Dentistry,
University of S~ao Paulo, Prof. Lineu Prestes
Avenue, 2227, S~ao Paulo, SP, 05508-000.
Email: mapsobra@usp.br
Abstract
Objective: To record in detail, the long-term success of a bleaching treatment
employing hydrogen peroxide in a severely darkened tooth.
Clinical considerations: Tooth discoloration is an important aesthetic complain of
patients. Because it is a relatively common condition, different materials and tech-
niques capable of restoring the tooth color in a minimally invasive, conservative, and
longstanding manner were developed. In this case, it was used the association
between mediate (walking bleach) and immediate (internal/external) bleaching tech-
niques using hydrogen peroxide as the main agent.
Conclusion: The association of techniques was a conservative therapeutic solution to
restore the natural color of the right upper central incisor, which was darkened after
an endodontic treatment performed more than twenty years ago. The bleaching pro-
tocol used presented no risk to the patient, such as cervical resorption and the color
was stable over a 48 months period, showing the success of the protocol proposed
for this case.
Clinical significance: There is a possibility to severely darkened teeth receive an ade-
quate bleaching treatment protocol, which can successfully restore the aesthetics
and natural color in a conservative and long lasting way.

KEYWORDS

bleaching, operative dentistry

1 | I N T RO DU CT I O N time.6,15 Concerns about it adverse effects were also reported, as the

The darkening of anterior teeth is a reason of aesthetic complains of
the patients, as it can negatively affect their appearance, resulting in
psychosocial impacts.1,2 The darkening of nonvitalized teeth may
occur as a result of pulp necrosis,3 pulp hemorrhage from trauma,4,5
6,7
remaining pulp tissue from the endodontic technique, restorative
8
materials present at the pulp chamber, treatment, or sealing materials
of the remaining root canals,9-13 aging and/or root resorption.14
Internal bleaching is a conservative technique indicated for the
treatment of nonvitalized and darkened teeth, and it presents aesthet-
ically acceptable results.1 However, there are some limitations of the
technique when darkening is severe and has been present for a long
possible recurrence of a darkened color.6,15,16 In addition, external
cervical root resorption, which according to Bersezio et al is a quite
rare side effect with a deficit in randomized clinical trials of patient
follow-up,17 however, this condition is consider as a potential nega-
tive effect that can cause significant biological risk thru periodontal
changes, compromising the dental element.17-22
Nevertheless, when the correct diagnosis of the color alteration is
made, and the appropriate treatment protocol is defined, the clinician
should consider dental bleaching as one of the first treatment alterna-
tives, since it is more conservative than restorative or prosthetic pro-
cedures.18 Among the existing techniques for bleaching nonvitalized
teeth, the walking bleach is an option and it consists of the association

J Esthet Restor Dent. 2020;1–8. wileyonlinelibrary.com/journal/jerd © 2020 Wiley Periodicals, Inc. 1

2 MACHADO ET AL.

of bleaching agents—sodium perborate (powder) and 20% hydrogen to record in detail the immediate and 48 months success of the asso-
peroxide (liquid)—that are inserted into the pulp chamber and held for ciation between walking bleach and internal/external bleaching tech-
3,23-27
a few days. The cavity is sealed provisionally. Another technique niques in a tooth that had been severely darkened for a long time.
used is the internal and external bleaching, in which the bleaching
agent (hydrogen peroxide 35%) is only applied during the clinic time,
concomitantly on the external and internal surface (pulp chamber) of 2 | CLINICAL CASE
28-32
the tooth to be bleached.
Variations in techniques and protocols can be applied for the A 41-year-old female patient presented the right upper central incisor
treatment of nonvitalized teeth,33 but there are no much long term severely darkened (Figure 1) after endodontic treatment and had
monitoring and records of nonvitalized teeth bleaching in the current
literature.5,21,25,31,32,34,35 Thus, the objective of this clinical case was

F I G U R E 1 Initial appearance of the smile. Evidence of

discoloration/staining of the right upper central incisor tooth

F I G U R E 3 A, Pulp chamber accessed, gutta percha inside

chamber. B, The millimeter probe with the premarked measurement
F I G U R E 2 Initial radiograph. Absence of periapical lesion and of the crown, which has not yet been reached. C, Root after
satisfactory endodontic treatment desobturation
MACHADO ET AL.
requested a treatment that would result in a harmonious smile. The
patient reported that the endodontic treatment was performed when
she was very young, for more than 20 years. And, that there was no
dental trauma, only the presence of fistula and painful symptomatol-
ogy, with the absence of caries lesion. At the initial anamnesis, patient
presented good general health. Although, at the oral evaluation was
diagnosed medium severity of periodontitis committing the posterior
tooth and gingivitis with high amount of calculus on the anterior
F I G U R E 4 A, Bleaching agent inserted internally into the pulp
chamber. B, Bleaching agent applied externally on the vestibular
surface. C, Bleaching agent mixed with microbrush
3
tooth. Pretreatment and control of this condition were done before
beginning the bleaching treatment.
To begin the bleaching treatment an initial radiographic was per-
formed to evaluate the conditions of endodontic treatment and of the
periodontal tissues. There was no periapical lesion, the endodontic
treatment was satisfactory and there was only soft bone resorption in
the cervical region of the anterior teeth, compatible with the patient's
age (Figure 2). The initial color of the tooth was recorded with
F I G U R E 5 A, Insertion of the bleaching agent into the pulp
chamber. B, Accommodation of the whitening agent with a cotton
ball. C, Bleaching agent in the pulp chamber
4 MACHADO ET AL.

photographs, which showed a severe darkening when compared to walking bleach technique. Temporary restoration and sealing was per-
the other teeth and a possible discoloration at the restoration inter- formed with glass ionomer cement, in order to keep the bleaching
face on the palatal surface. At this first clinic time, the patient was agent internally in the pulp chamber (Maxion-R—FGM Dental Prod-
informed that the bleaching treatment might not achieve the desired ucts; Figure 6).
effect. After 1 week of the procedure, the tooth appeared slightly lighter
For the bleaching protocol, the association of techniques (inter- (Figure 7A). The bleaching agent was then removed from the pulp
nal/external bleaching and walking bleach) was selected. For the inter- chamber and the previous procedures (internal/external technique
nal/external bleaching technique, 35% hydrogen peroxide bleaching and walking bleach technique) were repeated. Totally, there were two
agent (Whiteness HP Blue Calcium—by FGM Dental Products, Join- sessions for the walking bleach and three sessions for the internal/
ville, SC, Brazil) was used, and for the walking bleach technique,
sodium perborate (powder) associated with hydrogen peroxide 20%
(liquid; Whiteness perborate—FGM Dental Products).
To be bleached, the tooth received the adequate isolation. The
cervical-incisal length (by vestibular) of the crown was taken with the aid
of a probe, with the purpose of serving as reference for the installation
of the cervical cap to be performed at the entrance of the root canal.
The pre-existing restoration was removed to access the pulp
chamber. The presence of remaining gutta percha in the pulp chamber
was identified and promptly removed. Next, the filling in the entrance
of the root canal was removed, 2 mm beyond the cement-enamel
junction (Figure 3A-C) to enable the root canal to be sealed for the
application of the bleaching agent in whole coronary portion of the
tooth. The cervical cap was made using calcium hydroxide paste
(ASFER lt—S~ao Caetano do Sul, Brazil), followed by glass ionomer
cement (Vitrebond; 3MTM—Campinas, SP, Brazil).
The 35% hydrogen peroxide whitening agent (Whiteness HP Blue
Calcium—FGM Dental Products) was inserted internally into the pulp
chamber and externally throughout the vestibular face (Figure 4A,B)
for 45 minutes, according to the manufacturer's instruction. During
this period, it was agitated with a micro brush (Figure 4C). After the
full removal of the bleaching agent from the pulp chamber, the vestib-
ular surface was washed abundantly. The hydrogen peroxide (20%;
Whiteness perborate—FGM Dental Products) was internally inserted
into the pulp chamber associated with sodium perborate (Whiteness
perborate—FGM Dental Products Figure 5A-C) to perform the

F I G U R E 6 Sealing and maintenance of the bleaching agent F I G U R E 7 A, Slight whitening notable after 1 week. B, After
internally the pulp chamber made with temporary material, inserted second session, there is a whitening in the cervical region. C, After
with the help of the centrix syringe third session, the darkened tooth reached the color of the other tooth
MACHADO ET AL. 5

FIGURE 8 Final appearance of the teeth, postbleaching

external procedures. After the second session, the cervical region

appeared lighter (Figure 7B). After the third session, the darkened
tooth reached the color of the surrounding teeth (Figure 7C).
After reaching the desired bleaching effect, a suspension was
obtained using calcium hydroxide (ASFER lt, S~ao Caetano do Sul,
Brazil) and distilled water, which was left in the pulp chamber for
7 days. The cavity was again sealed with a temporary material, the
glass ionomer cement (Maxxion-R—FGM Produtos Odontológicos). In
the next session, the pulp chamber was washed abundantly, the cervi-
cal cap was maintained, and a palatal restoration was performed with
composite resin (Filtek z350 XT—3MTM, Campinas, SP, Brazil),
finishing the bleaching treatment for the dental element.
In order to optimize the aesthetic result and to meet the expecta-
tions of patient, external bleaching of the upper and lower arches was
performed, using the home whitening technique, with carbamate perox-
ide at 16% (Clariant home—Angelus, Londrina, PR, Brazil), applied in sili-
cone trays and used during sleep every day, for 2 weeks. After removal
of the product, the patient used a desensitizing agent (ClariantD-Sense—
Angelus, Londrina, PR, Brazil) containing 2% sodium fluoride and 5%
potassium nitrate applied to the tray for 30 minutes, every day through-
out the home treatment. After this treatment, the pre-existing restora-
tions were replaced in the upper anterior elements and the tooth color
became harmonious and with a natural whitening, attended the patient's
expectations (Figure 8).The case was followed up clinically by photo-
graphs of tooth color and radiographs comparison for 6 months, 1, 2,
and 4 years after treatment (Figure 9A-C). The results of the bleaching
F I G U R E 9 A, Follow-up after 6 months. B, Follow-up after 1 year,
were stable for 48 months, and no color regression was found or evi- plaque is observed in the lower teeth. B, Follow-up after 1 year, plaque
dence of external cervical resorption (Figure 10A,B). is observed in the lower teeth. C, Follow-up after 4 years, plaque and
dental calculus pronounced on the lower teeth

3 | DISCUSSION
Tooth discoloration may vary in etiology, aesthetics, location, and
severity.36 Determination of the etiology of the discoloration is
extremely important to a correct diagnosis of the case, and the imple-
mentation of the best bleaching protocol to follow. In the present
case, the etiology of the discoloration was from intrinsic origin, more
specifically, related to the presence of remnants of pulp and/or mate-
rial tissues in the pulp chamber after the endodontic therapy, in addi-
tion to a possible association with extrinsic pigments37,38 which also
affect the other teeth present in the oral cavity of the patient. Consid-
ering the high severity of the discoloration and the long period that
the teeth had received endodontic treatment (more than 20 years), an
6 MACHADO ET AL.
unfavorable prognosis of the tooth bleaching treatment was expected
for this case.39 In faced with such prognosis, controlling the patient's
expectation at the beginning of the treatment is an important step.
For cases of discoloration from intrinsic origin, the most indicated
4,9
treatment is the bleaching using intra-canal techniques. The walking
bleach technique associated with the internal/external technique was
used to achieve a satisfactory result in less time, in accordance with
other studies.34,40,41 The 35% hydrogen peroxide and a combination
of 35% hydrogen peroxide and sodium perborate were chosen
because of the high severity of the tooth discoloration and the need
25
for products with high concentrations to obtain better results.
Sodium perborate can be associated with water, although despite
being less aggressive, may not present results as satisfactory as when
associated with hydrogen peroxide, in addition to take longer to
obtain results.25,42 However, it should be mentioned that some
authors have seen no difference with the use of this association.3,43,44
The results of tooth bleaching are not often predictable and the
achievement of complete natural tooth coloration is not guaranteed.39
Some authors have suggested that tooth discolored for a long time do
not respond satisfactory to the internal bleaching treatment as teeth
6,15,39
discolored for a short period of time. It probably may be related
to the lack number of cases reported, the difference in bleaching tech-
niques and/or the quality of the final restorations from tooth dis-
colored for a long time. However, in this clinical case, the results were
satisfactory and long lasting, despite the discoloration being present
for more than 20 years. The success of the technique employed in this
clinical case described points that need further studies and clinical
case records that also describe the successful treatment of long-term
devitalized teeth.
It was reported that the clinical and radiographic follow-up of
teeth that received internal bleaching should be performed for at least
7 years, in order to evaluate not only the stability of the color
obtained, but also, the presence of possible alterations, such as cervi-
cal resorption.39 In the present case, the follow up was performed
periodically, for 4 years, until the present moment, and did not
F I G U R E 1 0 A, Radiograph after the
end of bleaching treatment. B, Four-year
control radiograph, with no evidence of
external cervical resorption
present recurrence of discoloration or cervical resorption. The real
mechanism responsible for cervical resorption is not yet well under-
stood. It was observed that, from 257 cases of cervical sorption,
24.1% was caused by orthodontic treatment, 15.1% was due to dental
trauma, 5.1% due to surgery, and 3.1% due to internal bleaching.45
Attin et al, show that patients who had bleaching therapy at a young
age often have external resorption and a possible explanation is that
because of wide dentinal tubules in young teeth, hydrogen peroxide
can more easily penetrate into the periodontium.3
A recent study from Bersezio et al17 correlated internal bleaching
with the presence of inflammatory markers (RANK-L and IL-1β) lead-
ing to root resorption regulation and bone destruction in the peri-
odontal tissues. They found an increase level of this markers when
walking bleach technique with hydrogen peroxide (35%) or carbamide
peroxide (37%) was done with persistence of 3 months post
bleaching.17 Although, this study does not respond to the clinical fact
that root resorption could be produced by internal bleaching, it warns
of possible harmful effects of this technique. Suggesting that individ-
uals that had periodontal disease could be more susceptible to cervical
resorption, mentioning that these bleaching treatments may not be
recommended among them, because of their deficiency of inflamma-
tory biomarkers balance.17 In the present clinical case despite the ini-
tial periodontal condition presented by the patient, which was
controlled before start the bleaching treatment no cervical resorption
was clinically found after internal bleaching or after 4-year post-
bleaching. We can speculate that the level of inflammatory markers
could have increased, as in the study mentioned above,17 however,
perhaps our results demonstrate that this increase is not enough to
promote cervical resorption. Nerveless, the presence of inflammatory
markers were not evaluated in the present, study not allowing us to
properly discuss this kind of influence.
As attempt to avoid cervical resorption preventive measures were
performed, such as the cervical cap that prevents diffusion of the
bleaching agent into the dentinal tubules close to the enamel-cement
junction and consequently, inhibited the inflammatory action of the
MACHADO ET AL.
agents on the gingival tissues and a possible bone resorption.20 The
preparation of the suspension with calcium hydroxide and distilled
water for 7 days done after the conclusion of the bleaching, is rec-
ommended to allow the alkalization of the medium avoiding possi-
ble damages to the periodontal ligament, thus also preventing
reabsorption cervical.39 Another fact that might have contributed to
the nonappearance of cervical resorption is the favorable teeth
anatomy according to Bersezio et al the anatomic variability must
be considered, once anatomical defects could contribute to a supe-
rior dissemination of bleaching outside the root, what could conduct
to a chronic inflammatory process resulting in cervical resorption.17
The literature reports of color regression after long time follow-
up in nonvital teeth are relatively high. Some studies observed after
2 years, color recurrence of 10%, after 5 years 25% and after 8 years
49%.5,46-48 In another study, the success rate of bleaching in nonvital
teeth without color regression after 6 years was 45%, which con-
cluded that bleaching of nonvital teeth cannot be considered totally
effective in the long term.21
In the clinical case presented here, there was no recurrence of
the discoloration during the 4-year follow-up, which may be explained
by the control of bacteria done during the treatment, and also, by the
absence of infiltration of pigments and bacteria after the final restora-
tion, which could be the probable causes of color regression in
nonvital teeth.3 Nowadays, the appropriate and satisfactory cavity
seal provided by the adhesive systems associated with the composite
resins prevent the migration of pigments and bacteria into the pulp
chamber and may help to justify the color stability found. This is in
agreement with Abbott, 200935 who stated that all teeth that pres-
ented color regression in their work presented unsatisfactory restora-
tions. Even so, the mechanism that causes color regression in nonvital
teeth is not fully understood33 and if recurrence occurs, a new
bleaching treatment can be recommended.36
Four years is a considerable follow-up period, then a long stand-
ing follow-up as long as possible, approximating 10 and 20 years are
desired to confirm the clinical case success. As this technique is not
capable to be reproduced in laboratory using in vitro study model,
great number of case reports is extremely important to support state-
ments about the results obtained, such as the absence of cervical
resorption and color regression. Notwithstanding, this study highlights
an important aspect of the technique approached for the nonvital
tooth bleaching and should be considered when facing a clinical case
like mentioned.
4 | C O N CL U S I O N
For the presented case, the associated technique of tooth bleaching
using internal/external hydrogen peroxide was effective for the
devitalized tooth over a long period of time, able to recover the nat-
ural aesthetic of the tooth without presenting significant risks to
the patient. In addition, it was stable over the course of 48 months,
evidencing the success of the proposed bleaching treatment
protocol.
7
DISCLOS URE STATEMENT
The authors of this manuscript certify that they have no proprie-
tary, financial, or other personal interest of any nature or kind in
any product, service, and/or company that is presented in this
article.
OR CID
Alana C. Machado https://orcid.org/0000-0002-6015-2108
Felipe F. Jacintho https://orcid.org/0000-0003-1379-6450
Tais Scaramucci https://orcid.org/0000-0002-4445-6697
Maria Angela P. Sobral https://orcid.org/0000-0003-0976-3031
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How to cite this article: Machado AC, Braga SRM, Ferreira D,
Jacintho FF, Scaramucci T, Sobral MAP. Bleaching of severely
darkened nonvital tooth case report—48 months clinical
control. J Esthet Restor Dent. 2020;1–8. https://doi.org/10.
1111/jerd.12609