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(Endodontics material and bleaching system (2 Dental Material II
Please refer to the slides while reading <slides 36-58>

lecture # 16

Material for root canal repair and peri-radicular surgery:
MTA: mineral trioxide aggregate; it has similar properties to calcium hydroxide, and it was developed to replace it in many applications: It has low solubility opposite to calcium hydroxide that can dissolve easily. MTA can be used for direct pulp capping over exposed pulp because it has similar properties; its alkaline, it has high PH, it can induce cementogenesis, or formation of hard tissue calcified barrier that close up any exposed area of the pulp. Sometimes they use it in what we call endodontic surgery; in these cases you do RCT and for many reasons it can fail, but instead of repeating the RCT, they cut off the inflamed area at the apex of the root, and clean the periapical tissue around that root, then they fill that part of the root with a material; they used to use amalgam, zinc oxide euginol, IRM material. But now they prefer to use MTA because it's biocompatible and antibacterial …ect.

They sit as they come in contact with moisture or water, and they sit slowly. They remain plastic for sometime which means you can manipulate them, or sometime to close up the area that was exposed or perforated. Sometimes when you're doing RCT for multi rooted teeth in the middle we got the furcation area; it’s the danger zone when we're doing RCT, so when the operator is not skillful enough or not paying attention to what he's doing, he can go to the furcation area and do perforation immediately into the PDL. Now instead of extracting the tooth, and if the area of
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exposure or perforation is not too big, we can attend to repair by placing MTA. MTA is a powder mixed with distilled water to form a paste and is packed against the bifurcation area (exposure area), and then after sometime the patient is reviewed to see if the area has closed up or not. this is one of the products it comes as a powder and its very expensive material (SLIDE 37), some of it is gray some is white powder it doesn’t matter.

Post and core system:
Why is it associated with this lecture? Because it's done in root canal treated teeth! You could never do post and core treatment or restoration for a badly destroyed tooth, if the tooth has badly RCT or RC filling, you want your tooth to have good RC filling ,so that it's sealed in the apical area, and the canal is well prepared to receive the post. If u remembers when we talked about metals we mentioned posts; we said that some of the posts could be made from metal, or non metallic that are made out of resin reinforced with fibers, some are made from ceramics. But generally all of them are used to restore badly destroyed root canal treated teeth. So your RC filling should be well condensed, no voids to the full length of the root canal system minus 1mm; we don’t fill completely to the apex we just fill 1mm shorter than the apex for reasons you will learn about next semester.

So if the RC filling is good you can remove part of it, place the post that has a core attached to it coronaly, on top of this core your crown will be cemented. So when you use these posts, you need to have good retention, you need to be able to retreat if the post by any chance is not done correctly, you need to rely on this post to distribute the
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stress all around, if there is a specific area where stress is concentrated; it will cause fracture in the root, you will end up with a vertical root fracture, so we need properly fabricated post, and proper preparation of the root canal system, that you will end up with a post that distributes the stress all around, and a core that provides retention for the crown for esthetic purposes.

You can either do custom made post; where you prepare the canal take an impression and send it to the lab and the lab fabricates the post and the core from metal. You can use prefabricated posts; that have burs specified for each post type, you drill with these burs and then immediately you can place the post in the canal like this one (SLIDE 39 left pic). So here you use a bur from the kit to drill inside the canal, and there is a post similar to the size of the bur, so the post is inserted in the canal, then you condense your filling around the parts that are extending coronaly, and they will retain your filling, until you prepare it and place a crown on top of it.

Now this one was fabricated by taking an impression (SLIDE 39 right pic), this part is the remaining gutta percha, the rest of the gutta percha was removed to make space for the post, so the canal was prepared, and then an impression was taken and you will learn these techniques later on in other course. So after taking the impression we send to the lab, the technician constructs the post and core attached to each other as one unit, post goes into the canal and the core in the crown of the teeth, and then on top of this will come the crown; the porcelain fused to metal crown.

NOTE: in custom made post you need to take two impressions; one for the post and one for the crown, while in prefabricated posts you need only one impression for the crown.
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Some of these posts are metallic, some are fiber reinforced resin, and some are from ceramics that are more esthetic and very strong and tough, these are prefabricated posts,They can be parallel, tapered, have a rough surface or smooth surface… Lots of types can be made from stainless steel, nicked chromium, and titanium.

Now fiber reinforced resin posts can be reinforced with carbon fibers, but they are unaesthetic because they give a black color, and the other is reinforced with glass fibers which are more esthetic, these posts because you need to bond them to dentin inside the RC system, they will be like one unit with the RC around, they will be able to distribute stress better because they act as one unit with the tooth, they are bonded by acid etching and bonding agent to the root system, so they will act as one unit with the root and this will distribute stress better, and less chance of root fracture ( fracture of root that have post in them is very common).

Teeth bleaching:
How does it work? Depends on the type of stain:

Extrinsic stains: because of drinking tea, coffee, and alcohol
especially wine, smoking… any kind of dye inside food or drinks can cause staining, they can penetrate inside enamel and cause staining.

Intrinsic stains: happens due to medication while the female
was pregnant, taking a tetracycline medication can cause staining in child's teeth, or while growing up and he only have primary teeth; so if he takes certain types of medications they can cause staining of the permanent teeth, also trauma can cause staining of the teeth, necroting pulp tissue; so if the pulp tissue dies, products of this pulp tissue from bacteria metabolizing these products can release materials that can stain the teeth.
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Each type of stain can be removed by specifically one material which is hydrogen peroxide; whether you apply it as hydrogen peroxide or included with another material, it can remove these stains, destroy them, oxidize them, and they can be washed away. Essentially you either use hydrogen peroxide, or other products, such as carbamide peroxide; when it's activated it will release hydrogen peroxide, so essentially hydrogen peroxide is the effective material.

Process of bleaching can be enhanced by using heat or light, so hydrogen peroxide maybe placed on teeth, to activate it or make the process of bleaching quicker they can subject it to heat or light Some systems don't contain hydrogen peroxide, they contain instead: sodium chloride, oxygen, natrium fluoride but they aren’t commonly used. They add other materials to reduce sensitivity, because most patients complain from sensitivity during bleaching, so these materials are fluoride and potassium nitrate.

Some stains do not need bleaching, you can just do polishing of teeth using abrasive paste, it will effectively remove the staining, and if it doesn't work bleaching might be necessary. Note: simple tooth brushing won't work.

In-office bleaching:
done by the dentist using 35% hydrogen peroxide and activated by heat or sometimes blue light, so its placed on teeth and you need to be aware of protecting the gingiva from the hydrogen peroxide because it's very irritant, so usually the dentist needs to place a rubber dam around all the teeth that need bleaching to protect the gingiva from the hydrogen peroxide liquid, and if it
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comes with contact with the gingival or the tongue… it can burn it and cause ulceration. Some of them are available as gel which is better because u can control it better because it won't over flow easily. Powder and liquid system is available and it contains light activators, so when you subject them to light they become activated and they work quickly and effectively to remove stains and oxidize them. Some products are made from carbamide peroxide in the form of a gel, and when it breaks down it will release hydrogen peroxide and causes bleaching.

Home bleaching:
10-16% carbamide peroxide, they are bleaching kits that you can buy from the pharmacy, and you can do it at home instead of going to the dentist, these systems provide the bleaching materials in syringes like a gel, and then you place it in a tray, then you place the tray in your mouth, and usually in 2 to 3 weeks the teeth become whiter. The patient can wear the tray with the bleaching material inside for half an hour or an hour in the morning and then an hour in the afternoon, or an overnight. And we usually ask the patient to continue the treatment till his teeth are a little bit whiter than he wants them to be because when you stop the treatment the teeth will become slightly darker because of stabilizing color of the teeth. Some products of bleaching are provided as crest white strips that are attached to labial surface of teeth, and you can wear them for half an hour twice a day.

Non vital bleaching:
Teeth that has endodonticly treated or suffered from necrosis of the pulp, this also can cause darkening of teeth. Sometimes if your Gutta Percha is extending coronaly it can also cause staining of
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the crown and this type of bleaching is called non vital bleaching because the tooth is non vital, it's root canal treated, it also called walking bleaching because the patient goes home then comes back later to repeat the treatment or end it. The material of choice for this sort of staining is called sodium peroxyborate; comes as a powder and it can be mixed with either water or hydrogen peroxide.

Where do you place it? in the access cavity, the root canal is filled with Gutta Percha and on top of it they place GIC to protect the Gutta Percha from the bleaching agent, and inside the cavity or the tooth they place the bleaching material and close it up, after a week or two they call back the patient maybe to replace the material and do it again or to remove the bleaching material and fill the tooth permanently. The trays that are used to place the bleaching materials are either supplied with the kit or you can go to a dentist to take an impression and the lab will make the tray for you. Staining can be cause by aging, can be genetic, tetracycline staining which can affect either one tooth or more depending on the period of time it was taken during tooth development, and of course smoking.

Side effects:
1- Irritation to the gingiva.
2-

Sensitivity.

3- Soreness of the muscles due to wearing of the tray. 4- Roughen of composite restorations. 5- In non vital teeth; placing the material inside the cavity, can cause internal root resorption if you use high concentration

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of the material, and you might end up with extracting the tooth. You cannot always do bleaching if the patient is: 1- Allergic to the material. 2- If his teeth is very sensitive. 3- If he doesn't want to replace composite filling because they are very expensive. Before bleaching you have to examine the patient, if they have any caries it should be treated, or any bad restorations should be replaced. After bleaching sometimes composite restoration need to be replaced, because their surface might be rough, and we need some period of time for color of the teeth to stabilize before we replace these composite fillings.

Taking care of these teeth needs some effort, the patient should be instructed not to smoke or to drink coffee or tea a lot if he wants to maintain the color of teeth for a long time, otherwise he will need to repeat the treatment in a few months.
Good Luck :) Sorry for any mistake, very few slides, but the DR. kept jumping from subject to another then back to the one before, I tried my best to organize it… Enjoy :S Written and summarized by: Ward Abu Nassar. 9.12.2011

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