Bleaching Discolored

Teeth
 Bleaching is more conservative than
restorative approach.
 Before any procedure to correct any
discoloration:
1. Diagnosis must be made (determine the
causes and location of stains)
2. Put the correct treatment plan (external
or internal bleaching is required).
Causes of discoloration
I. Natural or acquired stains.
II. Iatrogenic stains.
Causes of discoloration
I - Natural or acquired stains.
1. Pulp necrosis.
2. Intra pulpal hemorrhage .
3. Age .
4. Calcific metamorphosis .
5. Developmental defects.
Causes of discoloration
II- Iatrogenic stains.
1. Endodontically related
stains.
2. Coronal restoration.
I - Natural or acquired stains.
1 - Pulp necrosis.
 Bacterial, mechanical or chemical
irritation of the pulp may result in
necrosis.
 Tissue disintegrated products penetrated
the dentinal tubules and discoloration of
the surrounding dentine occurs.
 This type of discoloration can be bleached
INTERNALLY.
I - Natural or acquired stains.
2 - Intra pulpal hemorrhage .
 Trauma to teeth will lead to intera-pulpal
hemorrhage and lyses of red blood cells.
 Blood disintegration products, as iron sulfides
penetrated the tubule and stain the surrounding
dentine.
 If the pulp becomes necrotic, discoloration
persists .
 This type of discoloration can be bleached
INTERNALLY.
I - Natural or acquired stains.
3 - Age .
 In elderly patients, color changes in crown
occurs physiologically as a result of:
A. Excessive dentin apposition.
B. Thinning of enamel.

 This type can be bleached EXTERANLLY.

I - Natural or acquired stains.
4 - Calcific metamorphosis .
 It is extensive formation of irregular secondary
dentine in pulp chamber or canal wall.
 Usually follows trauma disruption of the blood
supply will lead to the destruction of the
odontoblasts, which are replaced by cells that
form irregular dentine.
 The crown gradually decreases in translucency
may have yellowish discoloration.
 The pulp is vital, but if the patient requires color
correction, we do R.C.T + INTERNAL bleaching.
I - Natural or acquired stains.
5 - Developmental defects.
a) Endemic fluorosis:
 Due to ingestion of a large amount of fluoride
during formation produce defect in mineralized
structure result in hypoplasia.
 The teeth are not discolored on eruption, but
appear chalky, their surface is porous and will
gradually absorb stains from any chemicals in
the oral cavity.
 This case can be bleache EXTERANLLY.
I - Natural or acquired stains.
5 - Developmental defects.
B - Systemic drugs:
 The drug binds to calcium, which is then
incorporated into the hydroxylapatite crystal
in both enamel and dentine,
 Discoloration from tetracycline ranges from
yellowish to brownish- dark gray(depend).
 According to severity of the attack:
1. EXTERANLLY if mild.
2. Intentional R.C.T + ENTERNAL bleaching
if severe.
Discoloration from
tetracycline
II- Iatrogenic stains.
1 - Endodontically related stains:
A - Pulp tissue remnants.
Usually the pulp horn remnants in the
crown cause discoloration. So the pulp
horns always should be included in the
access cavity.
B - Obturating material:
Incomplete removal of obturating material
and sealers remnants from the pulp
chamber, leads to staining.
II- Iatrogenic stains.
1 - Endodontically related stains:
C - Intra-canal medicaments:
Most medicaments cause internal
staining.
To avoid in between visits use only
cotton pellet without medicaments.
II- Iatrogenic stains.
2 - Coronal restoration:
A - Metallic restoration.
The dark colored elements of
amalgam will turn dentine dark gray.
Such stains are difficult to bleach and
tend to re-discolor by time.
So amalgam should not be placed in
coronal cavity of anterior teeth.
II- Iatrogenic stains.
2 - Coronal restoration:
B- Composite restoration.
 Micro- leakage of composite causes
staining of the open margin, which allows
chemicals to penetrate between the
restoration and the tooth to stain the
underlying dentine.
 To avoid put a layer of zinc phosphate
cement on labial dentin and then
composite is applied.
 Bleaching materials
 Hydrogen peroxide
 Sodium perborate
 Carbamide peroxide
 Hydrogen peroxide
This medicament is a good oxidizer,
used in high concentration (35% ,
called superoxol perhydrol).
Used mainly for external bleaching.
These high conc. Solutions must be
handled with care because:
1. They are unstable.
2. Release oxygen quickly.
3. May explode.
 Hydrogen peroxide

 So they should refrigerated and

kept in a dark container.
 They are caustic chemicals and will
burn the tissue they contact.
 H2O2 now available as a gel.
 Sodium perborate

Available in powder form or in

various commercial
combinations.
Used for internal bleaching
(walking bleach).
 Sodium perborate

In presence of:

Sodium metaborate
A - Acid
B - Worm air Decomposes Hydrogen peroxide
to
C – water Nascent O2
 Carbamide peroxide
Known as urea hydrogen
peroxide 3-15%
Used for external bleaching.
They affect the bond strength of
composite and their marginal seal.
 Bleaching techniques
Internal (non-vital) technique
External (vital) bleaching.
 Types of Internal (non-vital)
technique:
Thermo catalytic technique
Ultra-violet photo-oxidation
Walking bleach
 Internal (non-vital) technique:
Indications:
1) Discoloration of pulp chamber
origin.
2) Dentine stain.
3) Stains not amenable to external
bleach.
 Internal (non-vital) technique:
Contraindications:
1) Superficial enamel stain.
2) Sever dentine loss.
3) Carious or discolored
composite.
 Thermo catalytic technique:
 This technique involves placing the oxidizing
chemical in the pulp chamber and then apply
heat.
 Heat is supplied by:
 Heat lamps (15 inch away from pt).
 Flamed instrument.
 E.H.D, which are manufactured to bleach
teeth.
 Ultra-violet photo-oxidation
30-35% hydrogen peroxide solution is
placed in the pulp chamber on a
cotton pellet.
Followed by a 2-minute exposure to
ultra- violet light which is applied to
the labial surface and causes the
release of oxygen.
 Walking bleach
It is the most accepted way
because:
It requires less chair time.
More comfortable and safer for
the pt.
 Steps for walking bleach:
1- A radiograph is taken for:
 Assess the condition of the periapical
area.
 Assess the quality of the R.C.T.
2 - Clinical examination:
 Check quality of coronal restoration and
any defective restoration should be
replaced.
 Steps for walking bleach:
3 - The tooth color is evaluated with a
shade guide and a clinical photo is taken
at the beginning and through the
procedure.
4 - The tooth is isolated with a rubber dam.
5 - If superoxol will be used, protect the
oral mucosa by cream as cocoa-butter,
which is applied to gingiva before placing
 Steps for walking bleach:
6 - The restorative material is removed unfit
just below the cervical margin:
A. Remove all the obturating material
from the chamber.
B. The dentist should check that all pulp
horns are properly exposed.
C. Use a solvent as chloroform on a cotton
pellet to dissolve any remnants of
sealers.
 Steps for walking bleach:
7 - Layer of stained dentine is carefully
removed toward the facial aspect of the
chamber with a round bur.
This step is optional only when:
a. Stains seem to be metallic.
b. In the 2 or 3 appointment, when
bleaching does not seem to be
sufficient.
 Steps for walking bleach:
8 - Put 2 mm of cement base on the obturating material of
the R.C.S.
9 - The walking bleach is prepared by:
A. Mixing sodium perborate with inert liquid as water,
saline, or anesthetic S.
B. With plastic instrument, pulp chamber is packed with a
paste.
C. Excess liquid is removed by tamping a cotton pellet.
D. Excess paste is removed from undercuts in the pulp
horns with an explorer.
 Steps for walking bleach:
10 - Thick mix of ZOE is a applied against
the bleaching paste of 3mm at least to
ensure good seal.
11 - The patient is recalled one month
later and the procedure is repeated until
the desirable color is reached.
 When to: bleach?
Internal bleaching may be performed at
various intervals following R.C.T.
However the walking bleach may be
performed at the same appointment as
the obturation is finished.
 Final restoration after bleaching
 The pulp chamber and access cavity restored
with light shade of zinc phosphate cement
and the composite from lingual access .
 Bleaching with H2O2 may affect bonding of
composite to tooth, so we subject tooth to
catalase for 3 minutes, this will remove all
residual H2O2.
 Complications of internal
bleaching
1 – External resorption:
 Internal bleaching may induce external
cervical root resorption, as 30% H2O2
diffuses through the dentinal tubules at the
cervical part, causing damage to cementum
and peridontium causing resorption.
 Complications of internal
bleaching
2 - Coronal fracture:
 Due to increasing brittleness of the coronal tooth
structure, especially when heat is applied due to
desiccation of dentine and enamel.
3 - Chemical burns:
 30% H2O2 is caustic and will cause chemical burn
and sloughing of the gingival.
 External (vital) bleaching.
Types :
1 - Thermo- bleaching + photo-bleaching
same as internal bleaching (but on
enamel surface).
2 - Laser- activated bleaching:
This kind of techniques activates H2O2
to release nascent oxygen.
 External (vital) bleaching.
Types :
3 - Mouth guard bleaching (home bleaching)
 Generally used for mild discoloration.
 Numerous products are available for home
use 1.5 – 10% hydrogen peroxide in gel
form or 10-15% carbamide peroxide.
 External (vital) bleaching.

Indications:

1. Light enamel discolorations.

2. Mild tetracycline stains.
3. Endemic fluorosis stains.
4. Age related discolorations.
 External (vital) bleaching.
Contradictions:

1) Severe dark discoloration.

2) Sever enamel loss.
3) Hypersensitive teeth.
4) Caries, large or poor restoration.
 (home bleaching) Technique:

1 - Alginate impression is taken.

2 - Bleaching agent is placed in the space
of the teeth to be bleached in the mouth
guard then re-inserted in the mouth
after it was checked for fit first.
 (home bleaching) Technique:

3 - The patient is informed how to us the

bleaching agent and how to wear the guard.
The procedure is performed 3-4 hours a day.
Some dentists recommend that it should be
worn at night for long term esthetic result.
 Treatment extends 4-24 weeks.
 Recall patient every 2week for monitoring.
Complications of vital bleaching
I - Postoperative pain:
a - Immediate sharp shooting pain lasting
24-48 hrs.
b - Long-term sensitivity to cold for long
time.
Treatment:
a) Desensitizing tooth paste.
b) Fluoride application.
Complications of vital bleaching
II - Pulpal damage:
- Real pulp damage is rare, except if not
following contraindications:
1- Young age.
2- Carious cavity not restored.
3- Defective restoration.
Complications of vital bleaching
III- Mucosal damage:
- H2O2 is irritant and causes peroxide related ulcer.
- To prevent use cocoa-butter on mucosal surface.

Treatment:
1 - Extensive water rinses until the whiteness is
reduced.
2 - Surface anesthetic ointment for the patient.
Thank you