CLINICAL TOOTH BLEACHING The inside/outside bleaching technique LINDA GREENWALL Reprinted from INDEPENDENT DENTISTRY September 2000CLINICAL - TOOTH BLEACHING The inside/outside bleaching technique | By Linda Greenwall BDS, MGDS RCS, MRD RCS, MSc, FFGDP. With bleaching still a controversial and topical issue, Linda Greenwall | provides a summary of a simple yet | effective technique Lightening non-vital teeth car day intracoronally and sealing in the bleaching materia be difficult. The stan- nique relies on applying the bleaching agent into the access cavity using a temporary restoration These temporary restorations are often difficult to retain in the access cavity of the tooth as the oxygen hich is liberated by the bleaching procedure push asd sha eading praia bai aa dr wich wil no eu a clo ange A nen | tal woth The tecigue simple and alec | depends on the existence of an excelent root carl arene wih 5 Nermcel ado peta satclgg Th atrium vl be ested dtl ieee 1997). The technique combines the intrac bleaching technique with the home bleaching technique. I is used to light fen non-vital teeth in a simple manne: The access cavity is 30 that he bleaching material (which is nor eee mally 10% carbamide peroxide) ean bbe placed into the pulp chamber, while the bleaching tray is applied to the tooth to retain the material on the tooth, Bleaching can thus take place internally and externally at the same time (Figures | and 2). At pre- sent there are few clinical studies (Carlo et al, 1998) and anecdotal case reports published on this tech nique. However, the simplicity and effectiveness of this technique war 104 ROOT TREATED TOOTH GUTTA PERCHA PROTECTIVE GLASS IONOMER BARRIER. PLACED BLEACHING MATERIAL ‘Figure 1The borer placement n @ noreital tooth prior tothe ‘commencing the insdeoutride Bleaching technique -ant description and discussion. THE PROCEDURE: PREPARATION OF THE, BARRIER The nen-vital tooth is prepared in the same manner as intracoronal bleaching It is essential to have a preoper ative Xray to verify the existence of an excellent root canal treatment. The tooth can be isolated with rubber dam in preparation for the meticulous removal of the: ‘existing extracoronal restoration, However utilisation of the dental dam is not mandatory as the bleaching mate- rial is nat caustic (Liebenberg, 1997). As in the intra coronal technique, the gutta percha is removed to 2 3mm below the cemento-enamel junction (CE). The ‘object of the gutta percha removal is to provide space for over the gutta percha to prevent the bleach escaping into the root canal system at the CE}, Conventional lass lonomer or a resin modified glass ionomer can be © barrier (Figure |). protective barriers placed used as a barrier (Figure 4b) (Settembrini etal, 1997), Resonarve Arsene Acree. Vout? No Sires 2000ING GEL INSIDE TRAY ‘COTTON Wool PEL- LET (OPTIONAL) ‘ACCESS CAVITY ‘THE INSIDEIOUTSIDE TECHNIQUE: THE ANTERIOR ‘TOOTH WITH BLEACHING TRAY SEATED OVER AN OPEN INTERNAL ACCESS CAVITYCTHE GLASS IONOMER FORMS A BASE AND BARRIER AND SEALS THE GUTTA PERCHA FROM THE ORAL ENVIRONMENT DURING TREATMENT WITH THE CARBAMIDE PEROXIDE BLEACHING MATERIAL. gure 2Showing the proxi vw of the tooth nthe Insidelotside Bleaching technique. The Bleaching toy canbe placed on the tooth to retin the bleaching mata. The bleaching ‘materiel is placed diet into the access covity and elo onto the Decal urfoee ofthe tooth It has been suggested that a calcium hydroxide plug approximately Imm in thickness is placed over the exposed gutta percha. This prophylactic step aims to ‘maintain an alkaline medium because cervical resorption has been associated with a drop in pH at the cervical level (Liebenberg, 1997). A periapical radiograph can be taken at this stage to check that the barrier has been well placed, but this is not mandatory CLEANING THE ACCESS CAVITY The access cavity is cleaned and any remaining pulp horn constituents removed. The access cavity can be ctched merely to clean the internal surface. It does not enhance the bleaching effect. A cotton wool pellet is, placed into the access cavity to avoid food packing igure 2). SHADE ASSESSMENT “The preoperative shade is taken both of the non-vital tooth colour and the surrounding teeth and noted in the patient's records or on the bleaching record sheet INSTRUCTIONS FOR HOME BLEACHING “The bleaching way is checked for fit and comfort (Figure 4e). The patient is instructed not to bite with the ante: rior tooth during the duration of the treatment (Carilo tal, 1998) The patient is sent home with the bleaching instructions, and enough bleaching materials The cotton pollet in the access cavity is removed with a toothpick before bleaching. The bleaching syringe can be applied directly into the open chamber (Figure 5a) prior to seating the bleaching tray, or the bleaching material can bbe applied into the tray with extra material into the space for the tooth with the open chamber (Figure 44), v toothbrush or paper tissue. After the bleaching session. the tooth is irrigated with a water syringe and a fresh cotton wool pellet is inserted back into the tooth. tient is instructed to remove the excess with a ‘2 meal, the tooth was again irrigated with water to ‘ensure the absence of debris and a fresh cotton wool pellet is inserted. TREATMENT TIMING IF the patient ean change the solution every two hours, five to eight applications may be all that itis necessary to achieve the desired lightening This may take a matter fof days. The more often the solution is changed, the quicker the bleaching will take place. Nightly application will be slower than twice dally application. It has been advised that unless the tooth is severely discoloured, the bleach should be applied ducing the day so that the lightening can be better controlled. Figure 3: Before commencing Bleaching treatment. radiograph ‘shouldbe tent check the inegty ofthe rat canal Even fo teoth appear to be nom-vital ein this figure may not be, This ‘discoloured tooth stil vito. should not be intetionelly Aevelied if gies a postive response 2 vay texting. A {ifort Bleaching technique con be amplayed auch at home leeching or power bleaching to achiev lightening 105106 CLINICAL - TOOTH BLEACHING ‘gure 4a:The appearance ofthe tooth before treatment. This petit had sustained an injury tothe tooth ot age 12.The tooth hod deitelied@ yer later and required root canal treatment At the pie was 19 year a4 the tooth war ung and requred further retment Bleaching alone would not rlv the patient's requirements ofthe dor tooth wos considerably shorter and ‘there hed been incomplete pingial meturtion around thi oath ear decided to undertake Mooching treatment fist followed by crown lengthening ofthe upper left contra Tit wor followed by 0 porcelain veneer Ie could Be argued that would be uncesry to undertake Bleaching treatment fist however bleaching ‘treatment woud help achieve © more natural sede of porcelain fend 9 more aesthetic restoration Figure 44:The bleaching matva i pled drecy inte the Bleaching rey arnt the tooth REASSESSMENT OF THE SHADE AND BLEACHING RESULTS ‘The patient returns in th to seven days. The shade changes are assessed. I sufficient lightening has occurred the bleaching procedure may be terminated.The longer the tooth has been discoloured, the longer it can tak for the bleaching treatment to remove the discoloura tion (Carlo et al, 1998), The darker the tooth, the Figure deThe Borer ighe-cured Figure dtThe acces covity wor opened up and the gutta percha removed. A barr wes placed using li-cured glo fanomer restoration Figure dT Bleaching troy lopped ta the teeth longer it will take to lighten SEAL THE ACCESS CAVITY 7 with a temporary dress: the final restoration may need to be 1 for two weeks to allow the oxygen to diss ‘om the tooth and to allow the bend strength of the enamel/composite to improve (Carillo etal, 1998). itisFigure 4The rest oftero shade change from Ad to AZ gure The access cv x soaled wing 0 packeblegast Ianomer materia! Figure th The occlusion checked Figure 4:'The reel ofter home Bleaching. The crown lengthening in hon endeecion ered the pagrs is endrpsng eof Figure 4:8 dlagnosic wax up showing the shop ofthe inl revtoration not possible to wait two weeks to place the final restoration, catalase can be placed into the access cay ty by using a sponge pledget for three minutes (Lebenberg, 1997). The catalase is an enzyme, which acts to remove any latent hydrogen peroxide by pro- rmoting the reactions involved in the decomposition of, hydrogen peroxide into water and oxygen (Rotstein 1993) Resokene& Asmar Pcrct NOwMe 2 Na.B Serpe 2000 The access cavity is first imnigated with sodium hypochlorite to flush out any remaining debris, The cavosurface margin, the enamel surrounding the access cavity can then be cleaned using catalase. The cavity and the pulp chamber dentine are etched for 15. seconds with 37% phosphoric acid according to a cho- sen adhesive protocol. Dentine bonding agents are then applied. Bonding agents containing acetone are pre- 107CLINICAL - TOOTH BLEACHING Figure Sa:The bleaching syringe with a fine tip canbe applied drei into the ecco cavity ferred in this situation as they have been shown to reverse the effects -of bleaching on enamel bond strengths. The access cavity is sealed with a composite restoration using incremental build-ups of composite and a flowable composite at the base, over the glass jonomer: & condensable glass ionomer restoration can bee placed immediately (Settembrini et al, 1997) over the barrier (Figure 4g) and a shallower composite restoration placed after two weeks.The thicker base of lass ionomer can sometimes mask the residual dis: colouration ifthe non-vital tooth has not fully bleached to match the adjacent teeth REVIEW The tooth should be periodically reviewed and a rad: ‘graph taken annually to check for any signs of a cer cal inflammatory process Benefits of the insideloutside technique: + More surface area is available both internally and ‘externally forthe bleach to penetrate +A lower concentration (10% carbamide peroxide ‘with neutral pH) of the bleach is used Figure St-The appearance ofthe teeth before reetment ‘gure SeThe eppeorance ofthe teeth two weeks oftertreetment + It will hopefully eliminate the incidence of cervical resorption that has been reported with the conven: tional intracoronal bleaching technique as most of the potential factors for resorption are reduced. + The need to change the access cavity dressing is eliminated as the access cavity is left open. (The oxy ‘Ben that was released from the tooth used to biow out the temporary dressing from the tooth. The oxygen can escape normaly and there is no build up of pres- sure) + Treatment time is reduced to days rather than weeks (Liebenberg, 1997) if repeated replenishment is used «The patient can discontinue once the desired colour has been achieved + Using catalase prior to placement of the restoration can eliminate residual oxygen + No heat is required to activate the bleaching mater ia. RISKS + The potential for cervical resorption is reduced but sill exists + Non-compliant patients: as the technique is a‘igure ba:The appeorence of the teeth before treatment. The pper lf lateral tooth wos tracted with the autsideinside bleaching reotment The acces cavity wos sealed efter one wea ofthe ovtidoide weatment The ret ofthe teeth ‘were whitened uring the home Bleaching technique patient-applied technique, it requires the patient to return to have the access cavity filed. Dentists should be careful in thei patient selection and patient educa tion to ensure that they return to have the final restora tion placed (Carillo et al, 1998) + Although some degree of manual dexterity is required by the patient to place the syringe into the access cavity the patient's desire to achieve a whiter tooth counteracts this problem +The tooth could be over-bleached through over zeal- ‘ous application ofthe bleaching material by the patien However as a matrix is used to apply and retain the bleaching material the colour of the other teeth can be lightened evenly to correct the colour mismatch, Its ‘thus essential to have regular reviews at frequent inter- vals to assess the colour change taking place + Shade stabilisation cccurs over a two week period (2 slight rebound darkening can be expected as with all bleaching procedures one to two weeks later the shade ‘ean shift by one shade darker) INDICATIONS * Indications can include treatment for adolescents Fesomme & Ane with incomplete gingival maturation + A single dark non-vital tooth where the surrounding, teeth are sufficiently ight. IF this is the case, a window can be cut into the tray at the adjacent teeth to help, the patient identify where to place the bleach. An over- sized provisional crown form (Wahl, 1992) can be used by there is difficulty retaining the crown (Carillo et al 1998), OTHER OPTIONS FOR NON.VITAL TEETH Non-vital teeth can be bleached using the bleaching tray at home using 10% carbamnide peroxide in a closed chamber technique. This may take longer than a vital tooth because of the nature of the discolouration and the haemosiderin stained dentine. The benefits of thie technique are that rather than removing an existing sound restoration, the bleaching material is applied 10, the tooth via the bleaching tray (Frazier, 1998). This technique may be the treatment of choice when pro viding a top up" treatment or a maintenance bleaching treatment several years after the inital bleaching treat ment took place, REFERENCES Carlo A. Trevina MA, Hayaood VB (1998), Simultaneous bleaching of vital teeth and an open-chamber non-vital tooth with 0% carbamide peroxide, Quiessence International 29(10): 643 ‘Cavghiman WE, Frazer KB, Haywood VB (1999), Carbamie peroxide whitening on nonital single discoloured teeth ‘case ports Quinessonce Imernational 30(3): 155-161 Frazer KB (1998), Nightguard vital bleaching to lighten a restored, nonwital discoloured tooth, Compendium of Continuing Education in Derry. August 98): 810-813 -RWH (1997). Ineracoronal lightening of éscoloures pulpless tecthe A modifed walking bleach technique Quintessence international 28: 771-777 Rotsten L Zaklind M, Mor C et al (1991). In vitro effeacy of sodum perborate preparations used for intracoronal bleaching of dscoloured non-ital teth Endedont Dental Traumatology 14): 177-180 Rotsten | Mor C, Fe ran (1993), Prognosis of intracoronal bleaching with sodium perborate preparations in vitro (One.yer st Journal of Endedontoogy 1090 CLINICAL - TOOTH BLEACHING | TABLE I:TREATMENT OPTIONS FOR BLEACHING NON-VITAL TEETH Intracoronal bleaching: the material is sealed into the access cavity during in office visits and requires frequent changing of dressings Intracoronal bleaching technique + Sodium perborate and water sealed into the tooth (Rotstein et al 1991, 1993) | Mosited intracoronal bleaching technique using different products sealed into the teath such as + Various increasing Hychogen Peroxide concentrations and Sodium Perborate in combination + Sealing 35% carbamide peroxide nto the tooth + Sealing 10%, [5% or 20% carbamide peroxide into the tooth (Vachon et al 1998) Intracoronal bleaching using the thermocatalytc technique or other forms of heat or heating instruments (not recom mended: included for completeness) Open chamber bleaching: combining intra and extracoronal bleaching, the material is applied into the pulp chamber directly and retained with a home bleaching matrix Inside! Outside technique with bleaching tray using + 10% carbamide peroxide (Settembrini etal, 1997; arilo etal, 1998; Caughman et a, 1999) + 5% 16% 22% ciering concentrations + 35% carbamide peroxide - asisted bleaching in tray Closed chamber bleaching - extracoronal: the bleaching material is placed on the external sur- faces of the tooth Other options + Power bleaching using 35% hydrogen peroxide + Nightguard vital bleaching using 10%, 15% or 20% applied only to the nonvvital tooth in the tray (Frazer 1998) «Assisted bleaching applied to the extemal surface on its own or via a bleaching tray “The choice of which bleaching agent to use depends on the nature of the discolouration and the severity ofthe exist ing discolouration Previous reports of cervical resorption following internal bleaching noted more problems when heat ‘was applied to the tooth and when the tooth was previously traumatised prior to revitalisation To avoid cervical resorp- tion.it may be prudent to avoid high concentrations of hydrogen peroxide and heat. Rotsten | (1993), Role f catalase in the elimination of resiual_ | Wahl Mj (1992).At home bleaching ofa single tooth, Journal of hydeogen peroxide following tooth bleaching. Journal of Prosthetic Dentistry 67 (2): 281-282 Endodomtlogy 192 557-569 Setter L Gul} Kam Scherer (1997) A technique for Linda Greenvall i author ofthe textbook Blesching nonutltesthsnscloutic bsehing Jounal af Bleaching Techniques in Restorative Dentistry: an Iustoted Guide published by Martin Dunitz Ie will be out in October 2000.To order a copy, please contact Robert Peden on 0207 482 2202 or e-mail info@duniez.co. the American Dental Assciaan 28, September |283-1284 Vachon C. Vanek P Friedran § (1998). Internal bleaching with 10% carbaride peroxide in vitro, Practical Perio ond Aesthetic Dentistry 10(9)s 185-1154