Discoloured Teeth and its Conservative

Management

Presented by : Manila Agarwal

Moderated by : Dr. Sylvia Mathew

1
 Contents

• Introduction
• Colour and colour Perception
• Classification and Etiology of discoloration
• Diagnosis
• Conservative management
• Conclusion
• References

2
 Introduction

▪ Tooth discolouration is defined as “ any change in the hue, colour,

or translucency of a tooth due to any cause; restorative filling
materials, drugs (both topical and systemic), pulpal necrosis, or
haemorrhage may be responsible.” (Ingle 6th edition)

▪ According to a recent study by Samorodnizky-Naveh, 37.3% of

subjects were dissatisfied with their dental appearance, and tooth
color was the main reason for about 90% of them

3
 Colour and Colour Perception
Colour of healthy teeth is determined by:
⮚ The colour of enamel
⮚ The translucency of enamel
⮚ Thickness of enamel – Greater: Occlusal/Incisal edge
- Thinner : Cervical third

Normal colour:
⮚ Primary teeth: bluish white
⮚ Permanent teeth: grayish yellow, grayish white or yellowish white
⮚ Elderly persons: more yellow or grayish yellow

Bleaching techniques in Restorative dentistry by Martin Dunitz

4
 Classification of discoloration
According to location of stains(Dayan et al 1983, Hayes et al
1986, Teo 1989)
• Intrinsic discolouration
• Extrinsic Discoloration
• Combination- Nicotine staining •Tooth discoloration
•Extrinsic

•Intrinsic
•Combination

5
Internalized discolouration(Vimal K Sikri)
• Enamel defects and in porous surface of exposed dentin
• Developmental defects like Fluorosis, Hypoplasia, Enamel
calcification
• Tooth wear and gingival recession

6
Classification of extrinsic Discoloration –
I. According to cause -
• Direct Stain –
- compounds incorporated into the pellicle layer
- basic color of the chromogen
- dietary sources and substances habitually placed in the mouth

Heavy tobacco and coffee stains reddish black stains - habit of chewing pan

Manuel ST; Etiology of tooth discoloration- a review; Nig Dent J Vol 18 No. 2 July - Dec 2010 7
• Indirect stain:
- Cationic antiseptics – Chlorhexidine(brown to black),
- Cetylpyridinium chloride
- Benzalkonium chloride

- Mouthwashes containing metal salts

Manuel ST; Etiology of tooth discoloration- a review; Nig Dent J Vol 18 No. 2 July - Dec 2010
8
II. According to presence of metals:
❑ Non-metallic Stains:
❖ Brown Stain:
- Thin,translucent, bacteria-free, pigmented pellicle
- Buccal surface of maxillary molars and on the lingual surface of the
mandibular incisors
- Deposition of tannin found in tea, coffee, and other beverages

❖ Tobacco stain:
- Tenacious dark-brown or black discoloration
- Cervical one- third to one-half of most teeth
- Deposition of coal tar products on the tooth surface

9
❖ Black stain:
- Facial and lingual surfaces of the teeth near the gingival margin
and diffuse patches on proximal surfaces
- Actinomyces species and Prevotella melaninogenica
- Stain - ferric sulfide - reaction between hydrogen sulfide

❖ Green Stain:
-Children (boys – 65% ; girls – 63%)
- Stained remnants of enamel cuticle
- Gingival half of maxillary anterior teeth
- Penicillium(fluorescent bacteria) and Aspergillus(fungi)

10
• Orange Stain (3%) -
- Serratia marcescens and Flavobacterium lutescens
-both facial and lingual surfaces of anterior teeth

11
❑ Metallic Stains:
❖ Black stain: iron, manganese, and silver
❖ Grayish stain : Mercury and lead dust
❖ Green to blue-green stain : copper and nickel
❖ Deep orange : Chromic acid fumes
❖ Black stain: Iron-containing drugs (in solution form)
❖ Brown stain: iodine solution and stannous fluoride
❖ Violet black: potassium permanganate mouthwash
❖ Greenish-black : mercury
❖ Golden brown: stannous fluoride

12
13
14
 Intrinsic Stains
1. Pre-eruptive (during Odontogenesis)
a. Disease: Alkaptonuria
Haematological diseases
Liver disease
Disease of Enamel and Dentin
b. Medication: Tetracycline stains
Other Antibiotics use
Fluorosis stain
2. Post eruptive (after Odontogenesis)
a. Trauma e. Smoking
b. primary and secondary caries f. Chemicals
c. Dental restorative materials g. functional and parafunctional
d. Ageing h.Minocycline

15
:
Pre-eruptive (during Odontogenesis):
Haematological diseases
1. Erythroblastosis Fetalis
-Green, brown or bluish
-Cause: lysis of erythrocytes and incorporation
of hemosiderin pigment in forming dentin

2. Congenital Porphyria:
⮚ Red/brownish discoloration
⮚ Under ultraviolet light – red fluorescence
⮚ Cause- overproduction of Uroporphyrin

16
3. Sickle cell anemia:
⮚ Cause: increased hemolysis of red blood cells
⮚ Green, brown or bluish – more severe than erythroblastosis fetalis

17
• Liver diseases:
⮚ Bilirubinaemia:
-Liver dysfunction
- Bilirubin pigmentation in deciduous teeth

Alkaptonuria:
⮚ Cause: complete oxidation of Phenylalanine and Tyrosine causing
increased level of Homogentisic acid
⮚ Dark brown in primary teeth
-

18
Develpomental defects in Enamel formation:
1. Amelogenesis Imperfecta

3 types: Hypoplastic
Hypomineralization
Hypomaturation
⮚ Yellow to brownish
⮚ Snow capped appearance
19
2. Fluorosis:
Oral manifestations:
⮚ Mild: Gray or white opaque area on teeth
⮚ Yellow – brownish discolouration
⮚ Moderate – pitting and brownish discoloration
⮚ Severe – corroded with dark brown discoloration

3. Vitamin deficiency:
Vit D deficiency: white patch hypoplasia
Vit C and Vit A deficiency: pitting type

20
4. Enamel Hypoplasia:

General :
⮚ Amelogenesis imperfecta
⮚ Prenatal or congenital Syphilis
⮚ Endemic Fluorosis
⮚ Vit C deficiency

21
Defects in Dentin Formation:
1. Dentinogenesis imperfecta:
- Gray to brownish violet to yellowish brown
with a characteristic usual translucent or
opalescent hue

2. Dentin Dysplasia:
- slight amber translucency of teeth

22
 Tetracycline stain:
Acc to Jordan and Boksman1984 -

Tetracycline + Calcium in Hydroxyapatite crystals Tetracycline Orthophosphate

23
Post eruptive:

Minocycline stains:
⮚ Chelates with iron to form insoluble complexes
with secondary dentin
⮚ Does not resolve after discontinuation
of the therapy
⮚ Milder than Tertracycline
⮚ Black

24
Pulpal changes: Pulpal necrosis
Pulpal haemorrhagre – grayish
- non-vital appearance
Calcific Metamorphosis – anteriors
- yellow-brown

25
Dental caries:
• Around areas of bacterial stagnation and leaking restorations
• Arrested caries- brown discoloration similar to that of pellicle

Restorative materials and dental procedures:

• Endodontic sealers – (van der burgt et al )
1. Grossman’s cement – orange/red stain
2. Diaket, tubuli seal – mild pink
3. AH26 – grey
4. Riebler’s paste – dark red stain

26
Restorative materials:
• Silver amalgam- corrosive changes and degradation
• Gold fillings – dark hues
• Composite resin- leak at margins
• Metal pins and pre fabricated posts – anteriors – visible underneath
composite
• Silver points- grey/pink appearance

27
Aging: Enamel changes – thinning and texture
Dentin deposition: secondary and tertiary
pulp stones
Salivary changes – salivary content and composition changes
(Solheim 1988)

Functional and Parafunctional Changes:

Tooth wear – darker appearance
• Erosion , Attrition and abfraction

28
Daily acquired stains:
• Plaque
• Tobacco use
• Food and beverages
• Poor oral hygiene
• Good oral hygiene – black type – children
• Swimmer’s calculus-
- yellow to dark brown stain
- facial/lingual/palatal surfaces of anteriors
Prolonged exposture to pool water (Rose and Carey 1995)

29
30
• Based on cause; Tooth discoloration usually occurs owing to
patient- or dentist-related causes.- [INGLE]

• Dental stains
• Dentist- related causes
• Endodonticallyrelated
• Pulp tissue remnantsIntracanalmedicamentsObturatingmaterials

• Restoration related

• Amalgam, Pins & posts, Composites

• Patient-related causes
• Pulp necrosis,Intrapulpalhaemorrhage, Dentinhypercalcification, Tooth formation
defects: -Developmental defects -Drug-related defects

31
 Diagnosis of Discoloration
• Dental history - previous dental treatment, oral hygiene practices,
use of mouthwashes, amount and scheduling of fluoride intake,
history of dental trauma
• Medical history (history of maternal or childhood diseases, use of
medications
• Family history (genetic disorders)
• Diet history (nutritional deficiencies, diet that can cause staining of
the teeth
• Social history (occupational exposure to metals, use of tobacco)

32
Scratch Test: - This test differentiates between extrinsic and intrinsic stains
⮚ Armamentarium used is dental explorer, scalars, or any other sharp
instruments
⮚ An extrinsic stain can be removed by use of these instruments while
intrinsic cannot be removed
Usually, if the removal is difficult the stain is considered tenacious

33
 Conservative Management

• Prevention
• Scaling
• Microabrasion
• Macroabrasion
• Bleaching
1. Extra- coronal Bleaching
2. Intra – coronal Bleaching

34
 Prevention

• Certain teeth discolorations can be prevented by following strict

oral hygiene practice
• Tobacco stains, coffee stains can be prevented by keeping a check
on habits
• Fixed appliances and the bonding materials increase the retention
of biofilm and encourage the formation of white spot lesions
• Management of these lesions begins with a good oral hygiene
regime and needs to be associated with use of fluoride agents

Samir et al, White Spot Lesions: Formation,Prevention and Treatment,

Vol 14, No 3,2008: pp 174-182
35
 Whitening toothpastes

Joiner, Whitening toothpastes: A review of the literature Jl of dentistry 38s (2010) e17-e2
36
Phosphate materials, such as
pyrophosphate, tripolyphosphate
and hexametaphosphate, tend to
have a strong binding
affinity for enamel, dentine and
tartar, and during adsorption
they have been shown to desorb
stain components.
Shellies et al,2007
A toothpaste containing 5% Hexa
meta phosphate as anion
was shown in clinical studies to
significantly remove
chlorhexidine/tea induced stain
versus control toothpastes
after 3 and 6 weeks product use
Gerlach et al,2002
37
 Microabrasion
• Conservative method for removing enamel to improve
discolorations limited to the outer enamel layer
• Sundfeld, et al (2007) - enamel microabrasion technique results in a
loss of enamel of around 25 to 200 μm, depending on the number
of applications and acids concentration

PREMA:
18%, 10% or 6.6 % 37%phosporicacid
hydrochloric acid gel and extrafine HCl +Silicon
and pumice pumice gel + Silicon
Carbide
+Silica gel

38
Sundfeld et al.; Microabrasion in tooth enamel discoloration defects: three cases with long-term
follow ups; J Appl Oral Sci; 2014
39
•Fragosoet al,microabrasionfollowed by polishing with diamond paste or
fluorideprophylaticpasteprovided higher hardness and bettersurface smoothnessof the enamel
•Segura, et al.showed thatenamel aftermicroabrasiontechnique is more resistant to
demineralization, it was also observed that there isless colonization by Streptococcusmutans 
• Miereles et al. showed thatenamel treated with Phosphoric acidproduced a rougher surface than enamel
treatedwithHCl
• Bezarraet alshowed thatboth acids (37% H 3 PO 4,18%HClwith pumice) can be used successfullywithout any
statistically significant clinical differences

40
 McInnes Microabrasion Technique

• McInnes in 1996- technique that combined HCl acid and hydrogen

peroxide to remove fluorosis stains- bleaching + chemical abrasion

•5 parts 30% hydrogen peroxide

•5 parts36% hydrochloricacid
•1 part ethylether
•0.2%

41
 Macroabrasion
• When the stains are very deep and intense some times the more
conservative treatments are not totally effective

• Macroabrasion may be an alternative in solving these cases

• This also is a technique for the treatment of surface stains & defects,
but utilizes a 12- fluted carbide bur or a micron diamond point at
high speed

• Adequate Air- water spray to be used  & light intermittent pressure

to be applied to avoid irreversible damage

• Microabrasion(gross) + Macroabrasion(finer)
microabrasion and macroabrasion By Dr. Vishaal Bhat 42
 Bleaching

According to Ingle 6th edition-

Bleaching is a treatment modality involving an oxidative chemical that
alters the light- absorbing or light- reflecting nature of material
structure, thereby increasing its perception of whiteness

According to Grossman-
Bleaching is defined as the lightening of the color of the teeth through
the application of chemical agent to oxidize the organic pigmentation
in the teeth

43
 Indications Contraindications
•Guarded
PatientPrognoses for bleaching
dissatisfaction with • Poor case selection
1. Sensitive teeth
tooth color • Dentin hypersensitivity
2. Extremely
• To extend dark gingival
esthetic lifethird
of of • Extensively restored teeth
tooth – visible
existing when smiling
crown • Hypoplastic marks and cracks
3. Exposed root surfaces
• Psychological benift – 10-14
4. Extensive • Defective and leaky
years –white spots self image
individual’s restorations-
5. Temoromandibular disorders/
Bruxism -metallic salts – silver amalgam
6. Translucent teeth -defective obturation
• Pregnancy/ lactation
• Unwilling to tolerate taste

Summit’s Fundamentals of Operative dentistry – 4th edition

44
 Bleaching Agents

• Hydrogen peroxide : 5-35%

• Sodium perborate
3 forms: Sodium perborate monohydrate
Sodium Perborate trihydrate
Sodium Perborate Tetrahydrate
• Carbamide Peroxide: 3- 45%
10% commercially used
• Over the counter(OTC)Bleaching Kits

45
 Mechanism Of Action
• Hydrogen Peroxide:

• Sodium Perborate:
superoxol
Sodium Perborate Sodium Metaborate + Hydrogen Peroxide +O₂

46
Carbamide Peroxide:
10% Carbamide Peroxide

6.5% urea 3.5% Hydrogen

peroxide

Ammonia Carbon
dioxide oxygen Water

47
Composition of commercial bleaching agents
1. Active Ingredient: Hydrogen peroxide and Carbamide Peroxide
2. Inactive ingredient:
a. Thickening agents:
❖ Carbopol (carboxypolymethylene)
⮚ 0.5% and 1.5%
⮚ Advantages :- Increases viscosity - better retention of bleaching gel in tray
(approx – 29 ml per arch)
-Increases active oxygen-releasing time of bleaching material

by upto 4 times (Rodrigues et al,2007)

❖ Polyx: Colgate platinum system
b. Carrier: Glycerin and propylene glycol
48
c. Surfactant and pigment dispersant

d. Preservative: Methyl, propylparaben, and sodium benzoate

⮚ accelerate - breakdown of hydrogen peroxide by releasing
transitional metals such as iron, copper, and magnesium

e. Flavourings :
⮚ Peppermint, spearmint, wintergreen, sassafras, anise
⮚ Sweetener such as saccharin

Mohammed Q. Alqahtani ; tooth bleaching procedures and their controversial

effects:literature review; the Saudi Dental Journal
49
Over the counter(OTC):
• Removes extrinsic stains only
• Tray systems, trayless systems, chewing gums, tooth pastes, Bleaching
strips and paint-on-products

1.Wearable bleaching device:- iPower:

⮚ Thermal diffusion technology
⮚ Accurate amount of thermal energy is delivered onto the bleaching gel
painted on patient’s teeth
⮚ Thermal gradient – increase the diffusion rate of bleaching agent into
enamel structure

50
2.Tooth Whitening Pen:
⮚ Fast and effective whitening
⮚ Whitening gel – pen like applicator
Problems with OTC
⮚ Listerine whitening pen– erosion
• Over use and white ice surface
of labial whitner stick
of teeth
- dissolution of enamel and loss of anatomy
• Exposed Dentin appears darker
3. H2O2 Strip system:
• More sensitivity
⮚ Trayless bleaching system
• These kits contain:
⮚ Thin strip precoated with an adhesive 5.3% Hydrogen peroxide gel
1. Acid rinse – citric or phosphoric acid –erosion
⮚ Worn for 30 min – removed
2. Bleaching and discarded
gel: acidic – twice
pH – between 1 and 2a day for 14 days
3. Post – bleach polishing cream: Titanium dioxide
( temporary painted white appearance)

Chewing gum
51
 Mechanism Of Action
H 2 O2 H+ + HO2-

H2O2 H+ + OOH and 2OH

H2O2 hydroxyl radicals (HO), perhydroxyl radicals (HOO),

perhydroxyl anions (HOO–) and superoxide anions (OO–)

Attack organic pigmented molecules by attacking double bonds

Change in double-bond conjugation smaller, less heavily pigmented

constituents
52
 Classification of Bleaching Procedures
Extra coronal bleaching (vital tooth)
1. In- office Bleaching – Thermocatalytic Vital tooth Bleaching
- Power Bleaching
- Non Thermocatalytic
- Microabrasion assisted
2. Dentist prescribed Home Bleaching(Night guard)

Intracoronal Bleaching(Non vital bleaching)

1. Thermocatalytic in- office technique
2. Walking bleach
3. Modified Walking Bleach
4.Combination
Laser assisted
53
 Historical background of bleaching
❖ 1799: chloride of lime (bleaching powder)
❖ 1848:1st attempt of non-vital bleaching
❖ 1860: Labarraque’s solution(chlorine and acetic acid)
❖ 1868: vital teeth – oxalic acid
❖ 1884: Harlan – First Hydrogen peroxide(discoloured teeth)
❖ 1893: Atkinson: 3% pyrazon and 25% pyrazon
❖ 1918: Abbot – high intensity light and Hydrogen peroxide
❖ 1961: Spasser – Walking Bleach technique
❖ 1965: Stewart – Thermocatalytic technique(non- vital)
❖ 1967: Nutting and Poe – Combination Walking Bleach technique
❖ 1968: Klusmier- Home Bleaching concept
❖ 1975: Chandra and Chawla- (Fluorosis stain)
54
❖ 1977-1979 :Tetracycline stains
❖ 1987: Feinman – In- office Bleaching(vital teeth)
❖ 1988: Munro – White+ brite( first commercial Bleaching product)
❖ 1989: Croll- Microabrasion ( 10% HCl + pumice)
❖ 1989: Haywood and Heymann – Night guard vital bleaching
❖ 1991: Power bleaching
❖ 1991: Garber and Goldstein – Combination bleaching- Power + Home
❖ 1996: Reyto – Laser tooth whitening(vital)
❖ 1997: Settembrini –Inside/outside bleaching
❖ Present day: Laser activated, light activated and Home bleaching

Bleaching techniques in restorative dentistry – Martin Dunitz

55
 Vital tooth bleaching
1. In – Office Bleaching
Preparation of patient:
• Standarized shade guide tab and photograph
(color of teeth matches the white of the sclera in their eyes)
• Propylaxis
• Protective cape and protective eye glasses
• Oraseal or orabase paste
• Rubber dam

56
Thermocatalytic Bleaching:
⮚ Use of heat alone or heat and light both
⮚ Heat units:
1. Heat light unit:
- A narrow beam of light is concentrated in one
section of mouth at 13-15 inches distance
- Calibrated rheostat controls it
2. Heat unit:
- Non-vital teeth: 60-70 degree celsius
- Vital teeth : 46-60 degree celsius

57
 • Sources of heat:
• Photoflood lamp
• Polymerization light
• Spirit lamp
• Commercial Bleaching Lights
• Light heat lamp
• Lasers – Argon and Diode

Different activating light sources:

• Quartz tungsten halogen curing light(40-60sec)
• Plasma arc(30sec)
• Rembrandt tooth whitening system (400-520nm )
• Beyond whitening accelerator(high intensity blue light: 480-520nm)
• The zoom- teeth whitening system(mercury metal halide light:300-
450nm)
58
•Saturate the cotton or gauze piece with 30-35% H2O2
•Temperature: 52 – 60 degreecelsius
•Selecting heat unit is positioned
•Photo lamp used- solution is applied every 4-5 min

•Heat unit- every heating cycle

•Treatment time – should not exceed 30 min

•Remove solution with help of wet gauge and irrigate with warm water for 1 min
•Polish teeth and apply neutral sodium fluoride gel

•3 appointments
•Scheduled 2-4 weeks apart

59
Power Bleach:

Indications:
Single tooth bleaching within arch
• Developmental or acquired stains
• Stains in enamel and dentin
• Mild to moderate Tetracycline stains

Advantages:
• Immediate result
• Preferred over home bleaching – wearing trays
- distaste
Disadvantages:
• Expensive
• Dehydration – falsely lighter shade immediately post treatment
Rehydration – slightly darker discoloration (rebound discoloration)

60
• Equipment needed:
1.Power bleach materials: 35% H2O2 , 35% Carbamide Peroxide
- Dual activated (35% H2O2 – light and chemically)
2. Tissue protector: Light activated liquid resins- (Paint-on-dam)
3. Energizing and activating source: -Conventional halogen lights
- Plasma arc lamps
- LED lights
- Xenon power arc light
- Lasers: Argon and CO2
4. Heat source: may not be necessary
5. Mechanical timer

61
 Plasma arc light: 6-7mm
Light cured protective away from gel
resin is placed around - Emits 3-s bursts of light
gingival margins - 3 times at 3 min
Bleaching material is intervals
applied (10-15 min)

Materials suctioned away

Teeth rinsed thoroughly

Bleach reapplied for

further 10 min Polished with diamond
polishing paste or
Process: repeated for 45 aluminium oxide discs
min to 1 hour
2 and 3 appointment scheduled after 3-6 weeks
nd rd

Conventional Power Bleaching Technique

62
Compressive Power Bleaching Techniques:

• Miara et al(2000): 35% H2O2 in Bleaching tray

sealing the edges with light cured resin
• Influences penetration of oxygen ions into tooth enamel

63
Dual Activated Technique:
⮚ Hi – Lite system: Light and chemical activation( Tetracycline stains)
⮚ Constituents:
1. Ferrous Sulphate: chemical activator (7-9min)
2. Manganese Sulphate: light activated(2-4 min)
3. H2O2: 19 – 35%
4. Blue – green indicator dye
Procedure:
⮚ Material placed on teeth
⮚ Left – 6 to 10 min – removed
⮚ Repeated again – 6 times per visit if required

64
Non-Thermocatalytic Bleaching:
⮚ Does not utilize heat sources
⮚ Solutions:
1. Superoxol(5 parts of H2O2+1 part of ether)
2. McInnes solution: 5 parts of 36%H2O2 +5 parts 30%H2O2+1 part
of 0.2%anaesthetic ether
3. Modified McInnes solution: 30%H2O2and 20%NaOH in 1:1
ratio with 0.2%ether
4. Self activating bleaching agents
5. Matsuba et al- 35%H2O2 0.4ml, CaO 0.12gm, Aerosil 0.32, 0.48 or
0.64 gms

65
 After rubber dam application

Paste is applied on teeth-5 min

Reapplication is done as required

Followed by copious irrigation of warm water and polishing

66
Microabrasion assisted bleaching:

⮚ Microscopic layer of enamel is eroded and abraded

⮚ 18%HCl with abrasives- pumice powder

⮚ Indications:
- Superficial stains but not for deeper stains
- Areas of Enamel Fluorosis
- Decalcification lesions – orthodontic treatment
- Multicolored stains

67
 Dentist prescribed bleaching(night guard)
Matrix bleaching/ At- home bleaching
⮚ Success rate for - Non- tetracycline stained teeth : 98%
- Tetracycline stained teeth: 86%

⮚ Commercial preparations:
1. 10% carbamide peroxide with carbopol(Proxigel, Ultralite)
2. 10% carbamide peroxide without carbopol(fast oxygen-releasing-
Glyoxide, Dentalite)
3. 15% carbamide peroxide- Nu smile
Indications:
4. 1-10% H2O2
• Age yellowing discoloration
• Mild tetracycline staining
• Very mild fluorosis
• Stains from smoking tobacco 68
Home Bleaching Trays:
Reservoir(spacer):
• Void or space in bleaching tray
• Receptacle for bleaching material
• Viscous material – better retained
• Disadvantage: tray – less retentive
- more bulbous and slightly thicker
- more material to fill tray
- occlusal interferences(mandible)
Placed on : Buccal/facial surfaces atleast 1mm from gingiva

Scalloped:follow tooth – gingiva interface and cut back 1mm

minimal soft tissue contact
69
• Non- Scalloped Straight Line Trays:
-Cut out 2mm over labial incisors
-Less traumatic, easier to use, better border seal
- Inter-proximal spaces filled in and cental thin reservoir in middle

• Trays with shortened borders(not ideal)

-Excessive gingival recession
-Pre existing sensitivity or gag reflex

• Trays with Windows:

- Windows – exclude certain teeth – around light teeth – single dark
teeth

70
1. Full vestibule upper and lower trays – not used
2. Scalloped/ Reservoir: minimal tissue contact desired
maxillary arch
3. Non – Scalloped/Non-Reservoir: maximum retention
mandibular arch
4. Facial/Buccal Scalloped Reservoir: taste and tongue irritation- problem
5. Scalloped Reservoir buccal and lingual surface: TMD patients
6. Scalloped non reservoir: fluid or paste materials
7. Non-Scalloped reservoir: tray with viscous material(mandibular)
8. Trays with a foam liner: may impinge on occlusion – not recommended

• Common tray material: Ethyl Vinyl Acetate(Eva)

• Common thickness: 0.035 inch
0.02 inch (thinner)
0.05 inch( bruxers)
71
Three basic regimens:
• Sleeping with tray filled with bleaching solution and solution is
changed every night
• Day – changing solution every 1.5 – 2 hours
• Polyethylene strips impregnated with 5.25% H2O2- also used
without tray

• Day time regimen: 1 to 3 weeks

• Night time regimen: 4 to 6 weeks

72
Dentist prescribed bleaching(night guard )
Take an
alginate Pour the
impression of impression
the whole with plaster
arch.
Trim the tray
in a straight
pattern on the Trim the cast
facial and
lingual side Disinfect the
tray with a
Mark the
cleaning
tooth to be
Instruct the solution in an
bleached
patient to ultrasonic
Deliver
cleaner the
place the
tray and home
bleaching gel
bleaching gel
only at the
(10%–
discolored
20%carbamid
tooth and
eperoxide gel)
wear the tray
overnight Evaluate the
color of the
tooth
73
Side effects of Vital Bleaching:
• Sensitivity
• H2O2 and HCl- affect adhesion of composites and GIC
• Caries progression
• Minor ulceration of gingival tissues

74
 Non vital tooth bleaching

Indication: not amenable to extracoronal bleaching

dentin discolorations
pulp chamber origin
Commonly used solutions-
• Hydrogen peroxide
- Superoxol(30%H2O2)
- pyrozone (25%H2O2 and ether)
- sodium perborate
- sodium percarbonate

75
Barriers:
• Guide : Labial Cemento-enamel junction
curves in incisal direction on proximal sides of teeth
• Flat barrier: proximal dentinal tubules unprotected

Cervical resorption

To block dentinal tubules –

lead from pulp chamber apical
to epithelial attachment -
internal bleaching agents stay
within access cavity

76
Barrier Transfer

• Transfer Periodontal Probe

– labial,mesial and distal
• Position of epithelial
attachment
• Subtracting 1mm from each
of three probings
• Internal level of barrier is
placed 1mm incisal to
external probing

77
• Facial view: Bobsled
Tunnel outline
• Proximally: Ski slope
outline

78
Preparation of the patient:
• Diagnose
• Record shade and photographs
• Record barrier probings
• Isolate the tooth
• Prepare and clean access cavity- necrotic debris etc
• Approx – 2-3mm of root canal restorative material is removed in
apical direction beyond CEJ
• Irrigate properly
• Transfer barrier probings
• Place barrier material – GIC , Cavit
- GIC: straight lentulo spiral mounted in latch type or slow hand piece
- Cavit: small cone on end of Plugger
• Introduce bleaching solutions
79
Thermocatalytically Activate Bleach:

•Superoxol
•Sodiumperborate

•Solution is heated- bleaching band

•And light heating units are employed

•Heat the solution for 2 min, Repeat it once

•Activate bleaching agent by repeatedly placing instrument against saturated cotton pellet
until bleach has evaporated
•Repeat this processupto3 times

•Sealed with temporary

Caldwell: heating bleach solution increase bleaching rate of 35% H2O2

about 200 times 80
81
Walking Bleach:
• Sealing a mixture of sodium perborate with water into the pulp
chamber of the affected tooth, a procedure that is repeated at
intervals until the desired bleaching result is achieved

⮚ Bleaching agent in pulp chamber – 28-48 hours to 7-10 days

⮚ Agents- superoxol , sodium perborate

82
•Familiarize the patient the causes ,procedure expected outcome

•Assess quality of endodonticobturation

•Status ofperiapicaltissues
•Endodontic failure or questionableobturation– always be retreated prior to
bleaching
•Assess quality of restoration present
•Cleaning pulp chamber and replacing defective restorations
•Use ofNaOCl
•Conditioning of the dentin surface of the access cavity with
37%orthophosphoricacid

83
•Evaluate tooth color with shade guide / clinical photographs for future
reference
•Isolate tooth with rubber dam ( prevent leakage of bleaching agent onto
gingival tissue
•Interproximal wedges and ligatures

•Remove restorative materials from accesscavity,exposedentin and refine access

•Verify pulp horns and areas containing pulp tissues are clean

84
 •Remove materials just belowlabio-gingival margin1–2mm below the CEJ
•Orange solvent/chloroform/xylene – dissolve sealer remnants

•Barrier transfer:
•Apply sufficient thick layer 2 mm ( protective cement –
polycarboxylate,zincphosphate,glassionomer,IRM,Cavitto
cover endodonticobturation

•Prepare walking bleach paste by mixing sodiumperborate+

water ( wet sand)
•Sodiumperborate+Superoxol

85
 •Thick well sealed temporary filling material ( IRM) to be
given( 3mm thick – good seal )
•Evaluate patient 2 weeks later and repeat it if necessary

Optional procedure – if initial bleaching is not sufficient ,strengthen walking

bleach paste by mixing sodium perborate with increasing concentrations of 3-
30% H2O2 instead of water

86
Modified Walking Bleach:
⮚ This technique is modified with a combination of 30% hydrogen
peroxide and sodium perborate sealed into the pulp chamber for
one week

⮚ Aldecoa and Mayordomo(1922)- tetracycline discoloration

- after desired result is obtained by walking bleach – mixture of
10% carbamide peroxide and sodium perborate- 4 to 6 weeks

87
Combination Bleaching technique:
⮚ Thermocatalytic in office non vital bleaching + walking bleach
regimen(sodium perborate and superoxol)

⮚ Synergistic effect

⮚ Effective 90% of cases

88
Inside/Outside Bleaching:
• Intracoronal + Home bleaching Technique
• More effective
• Difficult stains – single dark
• Decrease incidence of Cervical Resorption
Procedure:
⮚ Place mechanical barrier
⮚ Place cotton pellet in chamber
⮚ Check fitting of bleaching tray
⮚ Instructions : remove pellet before bleaching
- bleaching syringe directly placed in pulp chamber before seating tray
and excess – on tray
89
Side effects of non vital bleaching:
▪ External root resorption
- Irritating chemical diffuses via unprotected dentinal tubules and
cementum defects
- necrosis of cementum, inflammation of periodontal ligament,
finally- root resorption

90
Suggestions for safer intracoronal non vital bleaching:
• Isolate tooth effectively
• Protect oral mucosa
• Verify adequate endodontic obturation
• Use protective bariers
• Avoid acid etching
• Avoid strong oxidizers
• Avoid heat recall periodically

91
Laser assisted tooth whitening:
❑ Argon laser(488nm)

❑ Carbondioxide(10,600nm)

❑ GaAlAs diode laser(980nm)

Gallium-Aluminium-arsenide

❑ Photochemical laser whitening(Smart bleach)

92
 Argon Laser:Blue light - 480nm

Excites unstable and reactive H2O2molecules

Energy absorbed into all intramolecular bonds

es fall apart into extremely reactive ionic fragments – combine withchromophilicstructure of organ

93
Carbon dioxide laser(10,600nm)
⮚ Enhancing effect of argon laser
⮚ The laser penetrats only 0.1mm into water and H2O2 – absorbed
MOA-
Argon laser- activate bleaching gel

CO2 lasers – emit invisible infrared energy

( to achieve deeper penetration of the energized oxygen)

⮚ Discontinued- thermal effect on pulp

94
Diode Laser:
⮚ Semiconductor lasers(980nm)
⮚ Forms :
1. Infrared diode – 790nm
2. laser with blue light emission diode- 467mn
3. GaAIAs diode- works at different watts
(Gallium-Aluminium-arsenide)

95
Photochemical Laser whitening:
⮚ KTP Smart Bleach- new smart bleach technique
⮚ Photochemical not photothermal
⮚ Bleaching gel- alkaline(9.5)
⮚ Perhydroxyl radical – more reactive than superoxide
⮚ Tetracycline stains
Red quinone product – dimethylamino tetracycline

Resistant to oxidation by peroxide

But photo-oxidised by green light(512-540nm)

colorless
96
 Effects of Bleaching Process
• Effects on soft tissues:
- In-office bleaching (30–35% hydrogen peroxide) - produce soft-tissue
burns - tissue white
- Reversible
• Systemic effects:
- Gastrointestinal and mucosal irritation - burning palate and throat,
minor upsets in the stomach or intestines
• Effects on Enamel surface morphology and texture
-Increased porosity , demineralization and decreased protein concentration
-Organic matrix degradation
- Calcium loss

97
• Effects on Enamel surface hardness and wear resistance:
⮚ 10% carbamide peroxide and 7.5% hydrogen peroxide - change the
surface micromorphology of enamel(Sasaki et al.2009)

⮚ Nanohardness and elastic modulus of enamel after treatment - tray

and strip bleaching systems - decreased ( Azer et al. (2009)

⮚ de Arruda et al. (2012) : 35% hydrogen peroxide enhanced

reduction in hardness and histomorphologic changes in enamel
surfaces exposed to cariogenic challenge

98
• Effects on enamel chemical composition
- Increase H2O2 - microhardness of enamel decreased significantly
(Al-Salehi et al. (2007)

- Rotstein et al. (1996) and Tezel et al. (2007) proved that a

concentrated bleaching agent caused a significant loss of calcium
from the enamel surface

- Lee et al. (2006) - amount of calcium lost from teeth after 12 h of

bleaching treatment - similar to teeth exposed to a soft drink or
juice for a few minutes

99
• Effects on dentin:
- Pecora et al. (1994) - dentin microhardness decreased after
application of a 10% carbamide peroxide agent for 72 h

- Basting et al. (2003), the thickening agent (carbopol / glycerin)

decrease in dentin microhardness

- Tam et al. (2005) - direct exposure to 10% carbamide peroxide

decrease in flexural strength and flexural modulus of bovine
dentin

100
• Effects of dental bleaching on composite resin restorations

1. Surface properties and microhardness:

- 10–16% carbamide peroxide slight increase in surface roughness
and numbers of porosities of microfilled and hybrid composite
resins (Bailey and Swift, 1992; Turker and Biskin, 2003)

- 6% hydrogen peroxide gel to a hybrid composite in a cycling

protocol, weaken the impact of the hydrogen peroxide by formation
of a surface-protective salivary layer on the restorative material
(Schemehorn et al., 2004)

101
- Heated 30% hydrogen - composite color changes (Canay and
Cehreli, 2003)

-Color change - in chemically cured than in light-cured composites

(Inokoshi et al., 1996)

• Effects on marginal quality and microleakage

- Dye penetration test - in extracted teeth restored with composite
restorations, post-operative contact with 35% hydrogen peroxide or
10–16% carbamide peroxide gel - adversely affect the marginal seal at
both dentin and enamel margins (Crim, 1992; Ulukapi et al., 2003).

102
 Effects on the bonding of composite resin restorations to tooth
structure
⮚ Vital bleaching - alter protein and mineral content of enamel,
reduced bond strength (Perdigao et al., 1998)

⮚ Antioxidant (sodium ascorbate) - reverse the compromised bond

strength of teeth bleached with hydrogen peroxide or teeth treated
with sodium hypochlorite
(Lai et al. (2002)

103
⮚ (Adebayo et al., 2007; Gurgan et al., 2009; Moule et al., 2007)- BS
of bleached enamel was best when etch-and-rinse adhesives were
used

⮚ Sung et al. (1999) - alcohol-based bonding agent (OptiBond) - less-

compromised composite bond strength when the restorative
treatment is to be completed immediately after bleaching (10%
carbamide peroxide, Nite White Whitening System)

⮚ Vidhya et al. (2011) - grape seed extract (oligomeric

proanthocyanidin complexes [OPCs]), after bleaching with 38%
hydrogen peroxide and prior to bonding procedures on enamel,
completely neutralizes the deleterious effects of bleaching and
significantly increases bond strength

104
 Recent advances

1. Laser smile whitening systems:

-Purple gel – one to several teeth
- Laser light applied – 2min

2. Pearlinbrite Laser Whitening System:

-Energy transfer crystals
-ETC – absorbs laser energy and transfer it to Hydrogen peroxide
molecules of gel

105
3.Tooth Bleaching with non thermal atmospheric plasma:
• Effective bleaching without thermal change

4.Bleaching Technique modified by Casein Phosphopeptide

Amorphous Calcium Phosphate(CPP-ACP)
• Remineralization techniques in association with vital tooth
bleaching regimens such as using CPP-ACP based substances during
and after bleaching

5. Enzymatic Bleaching Dentrifice:

• Enzymatic activation
• Enzymes- bleaching catalyst
106
 Conclusion

• Discoloration of teeth is usually esthetically displeasing and

psychologically traumatizing
• In the present era, Dentistry has various options to treat
discoloured teeth
• So, to achieve the desired and favourable outcome- a thorough
knowledge of etiology, treatment options, products and its
properties is the Supreme demand

107
 References
• Ingles endodontics 6 th edition
• Cohens pathways of pulp -11 th edition
• Summits Fundamentals of Operative Dentistry -4 th edition
• Grossman’s Endodontic Practice- 12th Edition
• Complete Dental Bleaching- Goldstein
• Bleaching Techniques in restorative dentistry – Martin Dunitz
• Tooth whitening- indications and outcomes of night guard
bleaching – van B. Haywood
• Textbook of operative dentistry – Vimal K sikri
• Dahl et al, Tooth bleaching- a critical review. crit rev oral biol med
14(4):292-304 (2003)
• Samir et al, White Spot Lesions: Formation,Prevention and
Treatment, Vol 14, No 3,2008: pp 174-182
108
• Sulieman M. An overview of bleaching techniques: 3. In-surgery or
power bleaching. Dent Update. 2005;32(2):101-4
• Esthetic rehabilitation of discolored anterior teeth with porcelain
veneers Kamble Vaibhav et al, 2013
• Microabrasion and macroabrasion By Dr. Vishaal Bhat
• Sundfeld et al.; Microabrasion in tooth enamel discoloration
defects: three cases with long-term follow ups; J Appl Oral Sci; 2014
• The Chemistry and Mechanisms of Extrinsic and Intrinsic
Discolouration; Nathoo; 1997
• Watts, and M. Addy: Tooth discolouration and staining: a review of
the literature. British Dental Journal Volume 190 No.6 March 24
2001
• Manuel ST, Abhishek P, Kundabala M. Etiology of tooth
discoloration-a review. Nigerian Dent J 2010;18(2):56-63
109
110