JICDRO is a UGC approved journal (Journal no. 63927)

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CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 67-71

Management of discolored nonvital tooth by walking bleach technique: A conservative approach


1 Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, IMS, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Orthodontics, Faculty of Dental Sciences, IMS, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Conservative Dentistry and Endodontics, Buddha Institute of Dental Sciences and Hospital, Patna, Bihar, India

Date of Submission21-Oct-2019
Date of Decision05-Feb-2020
Date of Acceptance13-Feb-2020
Date of Web Publication29-Jul-2020

Correspondence Address:
Dr. Nidhi Singh
Faculty of Dental Sciences, IMS, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_52_19

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   Abstract 


Discoloration of teeth in the anterior region can cause considerable cosmetic impairment. One of the techniques which is commonly used for bleaching of endodontically treated teeth is “walking” bleach techniques, and it provides satisfactory results. Based on the clinical reports with nonvital tooth bleaching, it is a viable, esthetic treatment for the discolored tooth. Its conservative nature makes it an important part of an esthetic dentistry treatment. This case report presents two cases, in which nonvital bleaching was done by walking bleach technique. Regular follow-up after a period of 4 weeks showed a significant reduction in the discoloration of teeth.

Keywords: Aesthetic, bleaching agents, nonvital tooth bleaching


How to cite this article:
Singh N, Chaturvedi T P, Baranwal HC, Wang CK. Management of discolored nonvital tooth by walking bleach technique: A conservative approach. J Int Clin Dent Res Organ 2020;12:67-71

How to cite this URL:
Singh N, Chaturvedi T P, Baranwal HC, Wang CK. Management of discolored nonvital tooth by walking bleach technique: A conservative approach. J Int Clin Dent Res Organ [serial online] 2020 [cited 2020 Aug 5];12:67-71. Available from: http://www.jicdro.org/text.asp?2020/12/1/67/291114




   Introduction Top


There are two main types of whitening procedures-nonvital whitening which is done on a root-canal treated tooth; vital whitening is performed on vital teeth. In esthetic dentistry, bleaching of discolored nonvital, endodontically treated teeth is a very important procedure, and especially in the anterior region, which represents a great esthetic problem. For the whitening of teeth, bleaching is considered, an outpatient method, using high concentrations of hydrogen peroxide or carbamide peroxide. When these compounds contact with the tooth, they release active metabolites that diffuse in the enamel and dentin and oxidize the pigments, which are responsible for discoloration.

Spasser introduced the application of sodium perborate and water in the pulp chamber of root canal-treated tooth to bleach the discolored nonvital teeth in 1961.[1] In 1963, this technique was modified by Nutting and Poe. They replaced water by 30% hydrogen peroxide, which is called the “walking” bleach technique.[2] In 1980, Howell informed that acid etching the dentin internally would “open” the dentinal tubules which allow better penetration of the bleaching agent.[3] In 2017, Tran et al. evaluated that concentration of H2O2 rapidly peaked within 27 h and reached a plateau in 75 h and low levels of H2O2 were evident beyond 3 days and for at least 28 days.[4]

Bleaching agent is the mixture of sodium perborate and water in a 2:1 ratio (g/ml). Sodium perborate is stable and available in white crystalline form. It contains nearly 95% of perborate which corresponding to 9.9% of the available oxygen. It exists in several forms as sodium perborate monohydrate, sodium perborate trihydrate, and sodium perborate tetrahydrate. Hydrogen peroxide is used in dentistry in concentration between 5% and 35%, as whitening agents. It is classified into organic and inorganic. They are strong oxidizer that breaks down the double bond of inorganic and organic compound. It can easily penetrate dentin and release O2 inside the tubules because of low molecular weight.[5],[6]

Walking bleach procedure is simple and less invasive than restorative, as well as prosthetic treatment to improve the smile. The aim of this article is to review some of the application of these materials and present clinical cases to illustrate the scope and evaluate the efficacy of walking bleach technique in nonvital discolored endodontically treated teeth.


   Case Reports Top


Case 1

A 26-years-old female reported to the department of conservative dentistry and endodontics because of cosmetic dental problems in the upper left central incisor [Figure 1]. Dental history revealed a history of trauma. Preoperative intraoral periapical radiograph shows the extent of fracture to the pulp chamber. Hence, the root canal treatment was done [Figure 2]. A3.5 color was determined using Vita shade guide. Gutta-percha was removed to just below the cement enamel junction, and 2 mm thickness of glass ionomer cements (GIC) barrier was applied [Figure 3]. Sodium tetrahydrate perborate and saline were mixed in relation 2 g to 1 ml and prepared the creamy paste [Figure 4]. Using the amalgam carrier, the material was applied in the pulp chamber [Figure 5] and then covered with cotton pellets [Figure 6]. The tooth was coronally sealed with GIC (Ivoclar Vivadent) [Figure 7]. The same procedure was repeated every 1 week in two-time intervals. After 1 week, there was change in shade. After the 2nd week, the result was achieved, now the color was changed from A3.5 to A2[Figure 8]. After the completion of bleaching treatment, the pulp chamber was cleaned, dried, and suspension of calcium hydroxide was applied for 7 days to neutralize the acidic environment. The cavity was closed with a temporary filling material and called the patient after 7 days for permanent restoration with composite resin (Ivoclar Vivadent).
Figure 1: preoperative photograph of case 1

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Figure 2: obturation was done

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Figure 3: glass ionomer cements barrier was applied irt 21 of case 1

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Figure 4: sodium perborate was mixed with saline

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Figure 5: sodium perborate was placed with amalgam carrier

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Figure 6: sodium perborate was placed

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Figure 7: restored with glass ionomer cements

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Figure 8: after 2-week follow-up

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Case 2

A 19-years-old young adult was referred to the department of conservative dentistry and endodontics because of the discoloration of teeth in the upper central incisor [Figure 9]. Dental history revealed a history of trauma. The preoperative radiograph shows the extent of fracture to the pulp chamber and also periapical radiolucency was seen. Root canal treatment was done in relation to 11 and 21 [Figure 10]. A4 shade color was determined using Vita shade guide. GIC barrier was applied [Figure 11], and the radiograph was taken [Figure 12]. Sodium tetrahydrate perborate and 30% hydrogen peroxide were mixed in relation 2 g to 1 ml, and creamy paste was prepared and applied in the tooth pulp chamber. In this case, the same procedure was repeated every 1 week in three-time intervals. After 1st and 2nd week, the changes were seen. After 3rd week, the result was achieved, now the color was changed from A4 to C2[Figure 13].
Figure 9: preoperative photograph of case 2

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Figure 10: root canal therapy was done irt-11, 21

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Figure 11: glass ionomer cements barrier was applied irt 11, 21 of case 2

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Figure 12: radiograph was taken

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Figure 13: after 3 weeks, the result was found

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   Discussion Top


Clinically, when the patient visits the department with a nonvital discolored tooth, the dentist must make a decision to take one of three approaches, that is, to leave the tooth alone, to bleach it, or to give the crown. The bleaching procedure is less invasive than a prosthesis procedure. With the development of modern cosmetic dentistry, there are varieties of methods for bleaching which is used successfully in the treatment of single tooth discoloration. Ambulatory techniques (when high concentrations of hydrogen peroxide and carbamide peroxide are used) require different types of sources for gel activation such as light, heat or laser. Whitening of nonvital endodontically treated teeth by “walking” bleach technique is a time-consuming procedure which requires multiple visits.[7]

The most common causes for intrinsic tooth discoloration are intrapulpal hemorrhage, pulp necrosis, intracanal medicaments, obturation materials and sealers, and metallic restorations placed in the coronal access[8] such as AH 26, endomethasone, iodoform cement, and medicaments, which contain tetracycline and iodine.[9] Frequently, discoloration is also caused by metal ions released from silver points and amalgam.[10] During the degradation of blood products iron ions are released such as hemin, hemosiderin, hematoidin, hematoporphyrin etc., which react with hydrogen sulfite produces iron sulfide which is black in color and causes crown discoloration.[11] The crown discoloration is also caused by protein degradation of the necrotic pulp. During the proteolytic process, aminoacid compounds are released, which causes further decay and invasion of new bacteria.[12]

Cervical resorption is one of the complications that may occur after bleaching treatment of nonvital teeth.[13] To prevent this, after completion of root canal treatment, gutta-percha was removed to just below the cementoenamel junction, and the barrier was applied by GIC. When the bleaching procedure was completed, the acidic environment in the tooth cavity should be neutralized by placing calcium hydroxide suspension for 7 days.[14] This duration is necessary because of releasing remaining oxygen and dentin remineralization to stabilize the color and to provide adequate adhesion to the composite filling material.[14],[15] Amato et al. evaluated the chromatic stability of non-vital discolored teeth which subjected to the combined intracoronal bleaching technique and to endodontic treatment, at a distance of 16 years (1989-2005). In their study, after 16 years only 35 cases out of 50 cases could be evaluated. They found in 22 of these cases (62.9%) the color had remained stable and was similar to that of adjacent teeth which indicates a successful outcome of the combined bleaching technique. In 13 cases (37.1%) classified as failures because of marked color relapse. They were not found any cases of internal or external root resorption of their re-examined cases. By these results, they confirmed the validity of the combined intracoronal bleaching technique in terms of efficacy, rapid esthetic result, and safety.[16]

The case presented highlights the effectiveness of the nonvital bleaching by walking bleach technique to achieve a successful and predictable cosmetic outcome. Hence, it can be concluded that walking bleaching technique can be used as a treatment of choice to bleach the discolored nonvital endodontically treated cases as compared to prosthetic procedures. It is a less invasive and very efficient method to get desired results easily and feasibility.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Spasser HF. A simple bleaching technique using sodium perborate. NYS Dent J 1961;27:332-4.  Back to cited text no. 1
    
2.
Nutting EB, Poe GS. A new combination for bleaching teeth. J So Ca Dent Assoc 1963;31:289-91.  Back to cited text no. 2
    
3.
Howell RA. Bleaching discoloured root-filled teeth. Br Dent J 1980;148:159-62.  Back to cited text no. 3
    
4.
Tran L, Orth R, Parashos P, Tao Y, Tee CW, Thomas VT, et al. Depletion rate of hydrogen peroxide from sodium perborate bleaching agent. J Endod 2017;43:472-6.  Back to cited text no. 4
    
5.
Bowles WH, Ugwuneri Z. Pulp chamber penetration by hydrogen peroxide following vital bleaching procedures. J Endod 1987;13:375-7.  Back to cited text no. 5
    
6.
Adibfar A, Steele A, Torneck CD, Titley KC, Ruse D. Leaching of hydrogen peroxide from bleached bovine enamel. J Endod 1992;18:488-91.  Back to cited text no. 6
    
7.
Attin T, Paqué F, Ajam F, Lennon AM. Review of the current status of tooth whitening with the walking bleach technique. Int Endod J 2003;36:313-29.  Back to cited text no. 7
    
8.
Walton R. Bleaching discolored teeth: Internal and external. Principles and Practice of Endedontics. Chap. 24. Philadelphia: WB Saunders, 1989. p. 385- 97.  Back to cited text no. 8
    
9.
Davis MC, Walton RE, Rivera EM. Sealer distribution in coronal dentin. J Endod 2002;28:464-6.  Back to cited text no. 9
    
10.
Al-Salehi SK. Effects of bleaching on mercury ion release from dental amalgam. J Dent Res 2009;88:239-43.  Back to cited text no. 10
    
11.
Kaneko J, Inoue S, Kawakami S, Sano H. Bleaching effect of sodium percarbonate on discolored pulpless teeth in vitro. J Endod 2000;26:25-8.  Back to cited text no. 11
    
12.
Cardoso M, de Carvalho Rocha MJ. Association of crown discoloration and pulp status in traumatized primary teeth. Dent Traumatol 2010;26:413-6.  Back to cited text no. 12
    
13.
Patel S, Kanagasingam S, Pitt Ford T. External cervical resorption: A review. J Endod 2009;35:616-25.  Back to cited text no. 13
    
14.
Rahimi S, Shahi S, Kimyai S, Khayyam L, Abdolrahimi M. Effect of calcium hydroxide dressing on microleakage of composite restorations in endodontically treated teeth subsequent to bleaching. Med Oral Patol Oral Cir Bucal 2010;15:e413-6.  Back to cited text no. 14
    
15.
García-Godoy F, Dodge WW, Donohue M, O'Quinn JA. Composite resin bond strength after enamel bleaching. Oper Dent 1993;18:144-7.  Back to cited text no. 15
    
16.
Amato M, Scaravilli MS, Farella M, Riccitiello F. Bleaching teeth treated endodontically: Long-term evaluation of a case series. J Endod 2006;32:376-8.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]



 

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