5. Internal Bleaching Flashcards
Etiology of Tooth Discoloration
• Various etiologies for discoloration.
• “Any change in the hue, color, or translucency of a tooth due to any cause.”
• Great differences in severity, localization, and appearance.
• ____ discolorations are incorporated into the tooth structure.
• ____ discolorations are attached to the tooth surface.
• Intrinsic and extrinsic discolorations may exist in ____ and can affect enamel, dentin, or the pulp.
• Tooth discolorations may be ____, related to patient behavior, age, and disease, or caused iatrogenically by dental and medical treatment.
Before conduct any type of procedure need to know ‘what happened to this tooth’
• What is reason that have the problems that have in teeth/mouth?
○ Need to know etiology of discolorations:
• Can be any changes in hue, color, translucency, etc.
Can have both intrinsic and extrinsic discoloration: • Intrinsic is incorporated into the tooth structure
○ Internally involved
• Extrinsic is the tooth surface
^based on which can figure out whether should address via internal bleaching or external bleaching
• External bleaching can be done at home, bleaching applied to tooth ____
• Internal bleaching bleaching agent applied ____ of tooth
○ Inside dentin and pulp chambers
instrinsic
extrinsics
combination
hereditary
surface
inside
Extrinsic discoloration can be: • Black • Brown ○ \_\_\_\_ causes brown discoloration • Sometimes used by perio if trying to target periodontitis or even for endo, prescribe .12% chlorhexidine (aka peridex) oral rinse for specific time • If use for too long (more than 1 week), can cause \_\_\_\_ of tooth color by attaching to tooth surface • Not permanent it is fixable • Yellow • Green
^color often caused by what you drink e.g. coffee, can also be caused by smoke
chlorhexidine
browning
Intrinsic discoloration of multiple teeth:
• most likely occurs during ____ and/or dentin formation during tooth development
enamel
Systemic intrinsic causes
• May have heard about in peds classes
AI, DGI, and DD:
• Affect ____ teeth during tooth development
“Porphyria, erythroblastosis fetalis, all those” are genetic, systemic causes of multiple tooth discoloration
“This is not our real target disease for discoloration but I want you to know what the systemic reasons are”
multiple
Systemic Intrinsic causes
Here are more causes of intrinsic ____ reads list on slide.
We will go a little further about drug related causes.
discoloration
The last chart the “kind of chart endodontists can actually target and fix” (I think she is saying this is the most important chart for endo internal bleaching because it’s intrinsic stains on single teeth which is what endo deals with when doing RCT):
• ____ • Brown • ____ • White
The factors include:
• ____ restoration
• Coronal restoration
• ____ restoration like a filling/obturation material
• Trauma
• ____ caries
These often affect single teeth and discolor them. We can fix these chairside.
We will now go through these factors one by one so we can address what causes these problems and how internal bleaching can fix them.
black yellow amalgam endodontic dental
What causes pulp necrosis?
• Dental caries
• Trauma
○ Trauma can be a real, accidental trauma
○ Trauma can also be iatrogenic for example if the filling was too deep, or if exposed the pulp during treatment
Mechanical, bacteria, and chemical can all be contributing factors that cause pulp necrosis.
If pulp necrosis happens…
• The bacteria start to cause necrosis and the tissue starts to disintegrate and
bacterial products can be released into the pulp chamber
○ These released colored compounds may penetrate the ____ and
start to stain the dentin structures
• Degree of discoloration is directly linked to how long the pulp has
been under ____ without treatment
• The longer the discolored compounds have been in the pulp chamber the greater the ____
• Pulp necrosis can happen without ____
○ This occurs often in older, aged population
○ It creates an inflammatory reaction and patient sometimes doesn’t know why all of a sudden their tooth has turned to yellow or darker brown
• This discoloration can be chief complaint
Long term ____ can cause more darker and more severe discoloration
Success rate of this bleaching is very ____
• We can bleach chemically with bleaching agent
○ Shows long term success rate
○ Can do RCT and internal bleaching
• Will show examples at end of class
dentinal tubules necrosis discoloration pain good
Intrapulpal hemorrhage is mostly associated with impact injury or trauma to the tooth
• Results in disruption of ____and have hemorrhage and lysis of
erythrocytes
○ Certain “blood integration byproducts” we presume the ____ component in the blood can penetrate dental pulp and start to stain surrounding dentin
The stain tends to increase with ____ (similar to pulp necrosis)
• Difference between the two is that:
○ In internal hemorrhage case, the pulp maintains ____ (mostly)
• Over time, the tooth can turn to yellow but the pt still responds to pulp
vitality tests such as:
• ____ test, electric pulp test
• E.g. kid fell and over next few days tooth gets discolored and do pulp vitality tests and get response, your conclusion is that tooth is vital.
- In these cases, there is no need to do ____
- Don’t do RCT just because of discoloration
- BUT if patient INSISTS that they want to fix this discoloration to meet the patients expectation for esthetics ‘you may need to do ____, if patient insists they want to fix the tooth color’
- If you did external bleaching on a case like this, it would not work. You NEED to do ____ bleaching
Internal bleaching success rate in these cases is \_\_\_\_.
blood vessels
iron
time
vitality cold RCT intentional root canal internal high
Calcific metamorphosis
• Another type of the body’s reaction to the trauma
○ The body starts to release a lot of mineralized (
tertiary calcification shrink calcification yellow
vitality RCT external internal veneer
Developmental defects
• Discoloration of enamel and dentin happening during tooth formation
Endemic fluorosis ingesting excessive amount of fluoride during tooth formation
• Produces defect on mineral tissue most likely ____ matrix ○ Results in ____ enamel
• The degree of staining depends on the degree of the ____
○ When the tooth is erupted and the crown has chalky surface this is because of ____ enamel
• The hypoplastic, porous enamel can be more affected by chemicals in
drink and food thus they can easily stain
• To treat this: we can do ____ bleaching but it is more prone to be rediscolored
○ Must inform patient that bleaching might be successful, but may need to rebleach it. Not ____ result especially if drink coffee.
Tetracycline:
• Use in perio clinic often
• In development of tooth, ingestion of tetracycline binds ____ and causes
discoloration in the dentin
○ Can become ____ to dark grey
• Depends on amount and frequency of the tetracycline as well as the patients age and development
• ____ bleaching can be considered but might not be successful because of the very dark color
• Can do ____ bleaching, but again, these teeth are vital so would be getting rid of vitality
Enamel hypoplasia, enamel hypocalcification
• Similar to endemic fluorosis b.c has less developed enamel structure, more porous enamel
○ Can do ____ bleaching but may discolor again as teeth are constantly exposed to chemicals from food and drink
enamel
hypoplastic
hypoplasia
hypoplastic
external
permanent
calcium
dark brown
external
internal
external
These are related to our own dental procedures therefore, they are preventable. You can also plan how to fix it.
You can plan external or internal, and can give more predictable outcome to the patient.
Filling for endo:
• Obturation uses guttapercha and sealers
○ ____ can cause discoloration
• If you get sealers above ____ the color can leach from the material (especially sealers containing zinc oxide eugenol and “plastics”(?)) these sealers can be darker when ‘exposed to the outside’
• These materials can stain the ____
• Must remove material ____ to the gingival margin
• This is why must measure clinical crown length from the gingival margin to the edge of the crown
• Must remove obturation material below the ____ • It depends on what kind of sealer material you use
• Mostly metallic based or ZOEbased material used very hard to bleach these ____ rate not that high
sealers CEJ dentin cervical margin success
Access cavity preps:
• E.g. upper incisors make ____ shape following outline of tooth
○ But some doctors can find the root canal without making that triangle, but rather making small round opening they can still reach apical foramen BUT they often still leave pulp tissue in the chamber
• To remove all of the pulp in the chamber, MUST do the ideal access cavity prep
• ESPECIALLY ____ have pulp horn extending to corner of tooth so can’t do round access, need to do triangular.
• If make access cavity carefully, this can easily be ____
• If do access again, just extend endodontic access and can then do the ____
traingle
upper incisors
avoided
bleaching
nother case of Iatrogenic staining:
• Metallic restorations like amalgam
○ Even if remove the restoration, the color is already very dark • ____ to bleach these restorations
• If want good outcome would probably have to do ____ or coronal restorations to fix
hard
crowns
Composite restorations may leak at the ____
• The margins of composite stain over time and allow the discoloring agents to penetrate into dentinal tubules of the tooth
○ This is microleakage resulting in staining
• The ____ agent cannot fix composite shade!
○ Need to do bleaching ____, then do composite shade based on bleaching
____
• E.g. picture in middle class 3 yellow restoration if pt doesn’t like composite or tooth shade in general, need do bleaching first then composite
margin
bleaching
first
result
First, need to do diagnosis
• Need to first find ____ of discoloration
○ Based on this can plan whether doing external or internal
• Need to manage patients ____ (rate of success, if will need
multiple visits should be discussed at beginning of treatment)
• Vitality tests:
• If tooth is nonvital need to do ____ first prior to internal bleaching
• If RCT already done but coronal restoration is leaking remove the
old ____ and may need to retreat the RCT
Need to record must know the baseline
• Use shade guide to find the baseline of the current color of the tooth
• Want to harmonize the tooth colors so must record adjacent tooth colors
• Take photographs to keep record
etiology
expectations
RCT
material
