Lecture 12

Tooth Discoloration and Bleaching

Classification of discoloration
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1- Patient related causes

a) Pulp necrosis
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b) Intrapulpalhaemorrhage
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c) Dentin hypersensitivity
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d) Age
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2- Tooth related defects

a) Developmental defects
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- Enamel hypocalcification
- Enamel hypoplasia
b) Systemic conditions
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- Erythroblastosisfetalis
- High fever
- Thalassemia and sickle cell anemia
- Amelogensisimperfecta
- Dentinogensisimperfecta

3- Drug related defects

a) Tetracycline
U

b) Endemic fluorosis
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4- Dentist related causes

a) Endodontically related
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- Pulp tissue remanants

- Intracanal medicaments
- Obturating materials
b) Restoration related
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- Amalgam
- Pins and posts
- Composite

Patient related causes

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a) Pulp necrosis: Any irritation to the pulp may result in pulp necrosis and
U U

release of disintegration by-products. These may penetrate the dentinal tubules and
discolor the surrounding dentin. The degree of discoloration depends on how long the
tooth was necrotic. Treatment is by intracoronal bleaching.
b) Intrapulpal hemorrhage: Endodontics
When a tooth is subjected to trauma hemorrhage
occurs in the pulp. Erythrocytes undergo lysis to products as iron sulphides enter the
dentinal tubules and discolor the dentin. This discoloration is difficult to bleach and
may be reversible. Treatment is by intracoronal bleaching.
c) Dentin hypercalcification: Due to trauma the pulp may form dentin rapidly to
decrease the volume of the pulp. Such new dentin increases the yellow appearance of
the tooth. Treatment starts with extracoronal bleaching and if not beneficial more
aggressive treatment is needed as root canal therapy and intracoronal bleaching or
crown the tooth.
d) Age: In old aged teeth certain problems occur to the tooth as physiological
dentin apposition, thinning and cracking of enamel and incisal wear of the tooth.
These problems increase the color of the tooth which can be treated by bleaching.

Tooth related defects

a) Developmental defects
- Enamel hypocalcification: The enamel surface is intact with distinct white to
brown areas on the facial surface of the tooth.
- Enamel hypoplasia: The enamel surface is defective and porous. It may be
hereditary as amelogenesis imperfect or due infection, tumors or trauma. During
enamel formation, proper mineralization of the tooth is affected. Treatment can start
by bleaching and later conservative treatment to repair the porous surface.

b) Systemic conditions
- Erythroblastosisfetalis: It happens due to Rh incompatibility of blood in new
born babies. Large amounts of hemosiderin pigment are released and discolor the
dentin. Stain is usually green, brown or blue.
- Sickle cell anemia: It is an inherited blood dyscrasia. The discoloration is
similar to erthroblastosisfetalis but more severe.
- Amelogenesis imperfect: It causes yellow to brown discoloration.
- Dentinogenesis imperfect: It causes brown, yellow or gray discoloration
which should be treated by restorative procedures as composite buildup or crowns.

Drug related defects

There are certain drugs that when ingested the tooth color during its formation.
a) Tetracycline
In the 1960s Tetracycline was used to treat chronic obstructive diseases. It was
discovered to discolor teeth in children. Color change ranges from light yellow to
more darker gray to brown depending on the dosage, duration of intake and age of the
patient at time of administration of the drug.
Tetracycline binds to calcium and gets incorporated to hydroxyapatite crystals of
enamel and dentin. Treatment may be bleaching extracoronally or intracoronally after
intentional root canal therapy.
b) Endemic fluorosis
Intake of large amount of fluoride during tooth formation may produce defect in
enamel matrix causing hypoplasia. It is seen as white spots ranging from chalky
white to brown discoloration. Treatment is done by extracoronal bleaching with
restorative therapy of the porous surface.
c) Chlorhexidine
This is a surface stain after prolonged use of chlorhexine mouthwash. It ranges from
yellowish to brown color.

Dentist related causes

a) Endodontically related
- Pulp tissue remanants: If some pulp tissue remains in the pulp chamber
especially the pulp horn, discoloration occurs due to tissue and blood decomposition.
- Intracanal medicaments: Phenolic or iodofrm based medicaments may
discolor dentin.
- Obturating materials: After obturation, sealer and guttapercha have to be
removed from the pulp chamber to prevent tooth discoloration.

c) Restoration related
- Amalgam: Silver alloys with its tarnish may discolor the tooth structure which
is difficult to treat.
- Pins and posts: Metal pins and posts may show through the composite
restoration.
- Composite: Microleakage around a composite filling may discolor the tooth
due to the entrance of bacteria and fluids through the gap between the tooth and the
filling. Treatment is by replacing the filling.

Bleaching Materials
The main bleaching materials used now are:
Hydrogen peroxide: It is also called Superoxol (30-35%) is the most common
bleaching agent. It has a strong bleaching action but it is caustic and burns tissue in
contact.
Sodium perborate: It is a material that when dry is stable but in the presence of
water it decomposes to form sodium metaborate, hydrogen peroxide and oxygen. It is
safe and easily controlled so it is used in intracoronal bleaching.
Carbamide peroxide: It is also called urea hydrogen peroxide (3-45%). It is mostly
used in 10% and when it breaks down it forms about 3.5% hydrogen peroxide and
many by-products as urea, ammonia carbon dioxide.

Mechanism of bleaching action

Bleaching agents act on the organic structure of the dental hard tissues, slowly
degrading them to by-products as carbon dioxide. Inorganic molecules do not react
with the bleaching agents. This reaction is called oxidation-reduction reaction or
redox reaction whereby unstable peroxides convert to unstable free radicals which
oxides or reduce other molecules.

Bleaching techniques for endodontically treated teeth

Thermocatalytic technique
- Isolate the tooth with rubber dam.
- Place bleaching agent (H2O2 or sodium peroxide or both) in the tooth
chamber.
- Heat the agent with heat by a heat source (hot stick or light source).
- Repeat until bleaching gives satisfactory results.
- Wash the pulp chamber with water and seal the tooth with cotton pellet and
temporary material.
- After 2-3 weeks, recall the patient to analyze the bleaching results.
- Place suitable filling material to seal permanently the tooth.

Intracoronal/walking bleaching technique

- Take a radiograph to ensure good endodontic oturation.
- Isolate the tooth with rubber dam.
- Prepare an access opening and cleaning the pulp chamber from any
guttapercha or filling material.
- Place a barrier as glass ionomer cement of 2 mm thickness on the coronal
orifice to protect the dentinal tubules from penetration of the bleaching agent.
- Place a freshly mixed sodium perborate/water mix in the pulp chamber.
- Place a temporary filling to seal the access opening.
- Recall the patient after 1-2 weeks and repeat the treatment when needed.
- After completion of bleaching, close the access opening with composite
material.
- When discoloration is internal and external a combination treatment can be
done by:
a) Intracoronal bleaching and in-office bleaching (placing H2O2 on the facial surface
and placing a heat source)
b) Intracoronal bleaching and home bleaching using a night guard template and H2O2
gel.

Effect of bleaching agents on the tooth and surrounding structures

1- Tooth sensitivity
This is mostly seen with in office technique/ H2O2 with heat. This may be due to
penetration of the bleaching agent through enamel and dentin and junctions with
restorations.
2- Effect on enamel
Bleaching agents decrease enamel hardness but fluoride application restores
remineralization of enamel.
3- Effect on pulp
When the bleaching agent penetrates the enamel and dentin it will cause transient
reduction in pulpal blood flow.
4- Cervical resorption
When using H2O2 of more than 30% concentration, external cervical resorption may
occur.
5- Effect on composite
After bleaching, composite fillings may be affected by surface roughening of the
restoration. Tensile strength is decreased and microleakage is more possible to occur.