Management of Intrinsic Discolouration in Permanent Anterior Teeth in Children and Adolescents

Question 1

prior to commencing tx need

4

Answer 1

Accurate diagnosis
Specialist led treatment plan
Informed consent
Pre-operative records

Question 2

consent

remember
5

Answer 2

Continuous process

Informed

Written information advisable

Inform of long term maintenance for life (££)

Child or young person involvement or led depending on age and competence
* Should be near or at age of Gillick competence, so include

Question 3

6 things that should be in the pre-op records for all discoloured teeth

Answer 3

Standardisation of recording of aesthetic procedures
* Clinical photos
* Shade
* Sensibility testing, check for sensitivity
* Diagram of defect
* Radiographs if clinically indicated
* Patient assessment e.g VAS etc
On level 5 we use the “SHADE” sheet- this is audited

Question 4

tx options for discoloured teeth in children/adolescents

6

Answer 4

Enamel microabrasion

Bleaching
* Vital (surgery Vs home)
* Non vital (‘inside outside’ technique Vs ‘walking bleach’ technique)

Resin Infiltration (ICON)

Localised composite restoration

Veneers
* Composite
* Direct (free hand/putty guide)
* Indirect (lab made)

Do nothing
* If pt has little desire to proceed with tx, Even under parental pressure

Question 5

what is microabrasion

Answer 5

removal of the surface layer of opaque enamel

Question 6

disadvantages of microabrasion

6

Answer 6

Removes enamel
* Sensitivity
* Teeth may become more susceptible to staining

HCl acid compounds are caustic

Requires protective apparatus for patient, dentist and dental nurse

Prediction of treatment outcome is difficult, (teeth may appear more “yellow” as the normal colour of crown revealed under white opacity)

Must be done in dental surgery

Cannot be delegated

Question 7

advantages of microabrasion

9

Answer 7

Easily performed

Conservative

Inexpensive

Teeth need minimal subsequent maintenance (care with food and drinks after)

Fast acting

Removes yellow-brown, white an multi-coloured stains

Effective

Results are permanent

Can use before or after bleaching as an adjunct

Question 8

clinical technique for microabrasion

Answer 8

PPE – patient and team

Soft tissue protection (protroleum jelly)

Rubber dam – essential (use wedgets)

Sodium bicarbonate guard – HCl acid is really traumatic to gingivae

Clean teeth with pumice and water

HCl pumice slurry in slowly rotating rubber cup – 5secs
* Maximum 10x5 second applications (prevent removing too much enamel)
* NB sodium bicarb behind teeth
Wash direct into aspirator after every 5 second application, review colour and shape

Fluoride varnish application (remineralisation and sensitivity)
* Profluorid (white) etc not Duraphat (yellow – affect colour)

Polish with finest sandpaper disc

Final polish with toothpaste

Question 9

why sandpaper discs used for polishing in microabrasion

Answer 9

SEM evidence shows a compacted, relatively prismless layer of surface enamel.
This changes the optical properties of the enamel so that areas of intrinsic discolouration become less perceptible

Question 9

why sandpaper discs used for polishing in microabrasion

Answer 9

SEM evidence shows a compacted, relatively prismless layer of surface enamel.
This changes the optical properties of the enamel so that areas of intrinsic discolouration become less perceptible

Question 10

cases where microabrasion can be used

Answer 10

• decalcification after ortho
• trauma to primary incisor (knocked primary and affected permanent development)
• fluorosis

can be used in conjuction to composite additions

Question 11

dental tx and enamel loss

Answer 11

5-10 micron – prophy with toothpaste
5-50 micron – prophy with pumice
5-50 micron – ortho bracket bonding/debonding
10 micron – acid etching
100 micron – 10 x 5 secs HCL pumice microabrasion

Question 12

proprietary kits for microabrasion

Answer 12

Opalustre (Ultradent)- packaged in purple syringes. 6.6% HCl acid and silicon carbide particles in a water soluble paste. Comes with specialised rubber cups with bristles.
* Video of this technique at https://www.youtube.com/watch?v=wNzdGIhTaHY

Prema Kit 10% HCl acid in a preparation of fine grit silicon carbide particles in water soluble paste

Must still isolate the teeth

Follow manufacturers instructions, most can be used more than once on same tooth but must be vigilant re enamel thickness. Difficult to get info on number of microns removed per application, they estimate as 25-75 microns per treatment

Question 13

reviewing microabrasion

Answer 13

Teeth are dehydrated after procedure

Warn patient to avoid highly coloured food and drinks for at least 24 hours
* Mayber recommend up to a week
* Avoid anything that would stain a white tshirt

Review patient 4- 6 weeks after microabrasion and take post op photographs
* Can provide a second course, if first was successful

Question 14

bleaching permanent teeth in children

can be done when

Answer 14

‘Products containing or releasing between 0.1% and 6% hydrogen peroxide cannot be used on any person under 18 years of age except where such use is intended wholly for the purpose of treating or preventing disease.’ GDC 2014
* So this includes discolouration due to hypomineralisation, trauma, fluorosis etc etc

Question 15

bleaching options

2 groups of 2 techniques

Answer 15

Vital bleaching (external vital bleaching)
* Chairside- ‘power bleaching’
* Night guard vital bleaching- ‘at home’

Non- vital (dead tooth) bleaching (internal non-vital bleaching)
* ‘inside outside’ technique
* ‘walking bleach’ technique

N.B: effects of dental bleaching are NOT permanent!!

Question 16

chairside vital bleaching

Answer 16

Uses unstable, rapidly reacting hydrogen peroxide usually 15-38% (equivalent to 75% carbamide peroxide).
* Greater risk to soft tissues and eyes and sensitivity, and more expensive

Question 17

nightguard vital bleaching

Answer 17

10% carbamide peroxide gel

Tray design
* Cut windows in customised tray over any teeth you do not want to bleach e.g. veeners, caries
* No gingival tissue coverage
* Can have reservoirs

Instructions to patients
* Brush teeth thoroughly
* Apply a little gel to tray
* Set over teeth and press down
* Remove excess
* Rinse gently, do not swallow
* Wear overnight (or for at least 2 hours)
* Remove brush try with brush and rinse with cold water
* Sensitive toothpaste may be required

timescale approx 3-6 weeks, keep going until acceptable colour

Question 18

when can restorations be done after vital bleaching

Answer 18

need 2 weeks to allow colour to settle before commencing restorations

Question 19

side effects of vital bleacing

Answer 19

sensitivity - common 15-65% of adults

gingival irritation - more common in higher concentrations

Question 20

sensitivity due to vital bleaching

adults vs adolescents

how

Answer 20

related to the easy passage of hydrogen peroxide through intact enamel and dentin (reaching the pulp in five to 15 minutes) and to the bleaching tray, which causes sensitivity in 20% of patients

Several randomised control trials by Donly have shown that tooth sensitivity was relatively minor in adolescent patients in comparison to reported sensitivity among adult patients, despite greater than normal hydrogen peroxide concentrations being used (6.5%, 9%, 10%).
* This could be attributed to the increased enamel quantity and quality of the adolescent teeth and also to the larger pulp complexes in adolescent patients’ teeth which allow faster recovery from the acute inflammation experienced during a sensitivity episode

Importantly, this sensitivity is usually manageable - Tooth mousse

Question 21

carbamide peroxide breakdown mechanism

Answer 21

10% carbamide peroxide
to
3% hydrogen peroxide and 7% urea
to (via catalases and peroxidases)
water, ammonia and CO2

Question 22

bleaching in amelogenesis imperfecta

Answer 22

won’t make teeth uniform

mask white patches - but can make them whiter

Question 23

nonvital bleaching advantages

6

Answer 23

Simple
Tooth conserving
Original tooth morphology
Gingival tissues not irritated by restoration
Adolescent gingival level not a restorative consideration
No laboratory assistance for ‘walking bleach’

Question 24

tooth selection for non vital bleaching

4

Answer 24

Adequate root filling
* no clinical disease
* no radiological disease

Anterior teeth without large restorations

Not amalgam intrinsic discolouration

Not fluorosis or tetracycline discolouration

Question 25

2 methods for non-vital bleaching

Answer 25

Walking bleach
* oxidising process allowed to proceed gradually over days

‘Inside-out’ method
* 10% carbamide peroxide gel, can seal in if co-op an issue

Question 26

clinical procedure non vital bleaching

walking bleach

Answer 26

root filling removed below CEJ

clean with ultrasonic

bleaching agent on cotton pledget

cover with dry cotton pledget

seal with GIC/RMGIC

Question 27

walking bleach applications

frequency
regression

Answer 27

Renew bleach – ideally no more than 2 weeks between appointments

If no change after 3-4 renewals stop

6-10 changes total

Regression 50% at 2-6 years (Staining reappeared)

Question 28

non vital ‘inside out’ bleaching process

Answer 28

Access cavity of tooth open

Do not necessarily need GI lining

Custom made mouthguard (cut windows in guard of the teeth you don’t want to bleach!)

Patient applied bleaching agent to back of tooth and tray

Patient keeps access cavity clean, replacing gel removes food debris etc – need good co-op

10% Carbamide peroxide is bleaching agent of choice

Worn all the time except eating and cleaning

Gel changed every 2 hours or so except during the night

Question 29

restoration of pulp chamber afer non-vital bleaching procedures

2

Answer 29

Non setting calcium hydroxide paste for 2 weeks, seal in with GIC. Then:

Either: White GP and composite resin – facility to re-bleach
Or: Incrementally cured composite –no re-bleaching but stronger tooth.

veer or crown prep if regression

Question 30

non vital bleaching potential complications

5

Answer 30

External cervical resorption
Spillage of bleaching agents into oral cavity etc
Failure to bleach
Over bleach
Brittleness of tooth crown (susceptible to #)

Question 31

2 ways to prevent external cervical resorption in non-vital bleaching procedures

Answer 31

Layer of cement over GP
* Prevents bleaching agent from getting to external surface of root (not for inside-out technique)
* Can prevent adequate bleaching of cervical area

Non setting calcium hydroxide in tooth for 2 weeks before final restoration
* Reverses any acidity in PL that might have occurred if above had happened, so prevent ECR

Question 32

short term bleach exposure to soft tissues

Answer 32

minor ulceration/irritation

plaque reduction aids wound healing

Question 33

possible long term bleach exposure to soft tissue issues

3

Answer 33

delayed wound healing
periodontal hamr
mutagenic potential

Question 34

tooth mousse

adjunct to microabrasion and bleaching

Answer 34

Recaldent™ CPP-ACP (casein phosphopeptide – amorphous calcium phosphate) milk derived protein

Evidence not great

Suggested use from manufacturer:
* After bleaching -2 weeks home application
* Poorly demarcated hypomineralised lesions, Mild / moderate fluorosis
* After microabrasion and for 4 weeks home application (pea size at night before bed)

Question 35

resin infiltration is

Answer 35

infiltration of enamel lesions with low-viscosity, light curing resins

Surface layer is eroded, lesions desiccated and a resin infiltrant is applied.
Resin penetrates lesion driven by capillary forces
Infiltrated lesions lose their discoloured appearance and look similar to sound enamel.

Question 36

resin infiltration process

Answer 36

Bleaching tried first and no satisfactory result
Pretreatment rinsing can cleaning of teeth (dam on)
Etch applied and rubbed in
* Leave to act for 2 mins
Rinse off
Dry and apply icon-dry
* Let it act for 30 secs

Visual inspection – insufficient result/lesion not accessible
2nd etch process
Dry and apply icon-dry and let it act for 30 secs
Visual inspection – still not sufficient result
3rd etch process
Dry and apply icon-dry, act for 30secs
Visual inspection – now good masking of white spots, lesions now accessible

Optional insertion of separation sheets
Infiltration
* Apply icon infiltration
* Let it act for 3mins
* Remove excess material
* Without separation film: use dental rolls and flossing
* Light cure 40secs
* Second infiltration – compensate for polymerisation shrinkage
* Leave to infiltrate for 1min
* Blow off excess
* Light cure 40secs
* Polish

Question 37

to reduce or not to reduce enamel

veneers considerations
6

Answer 37

Aesthetics
Relative tooth position
Masking dark stain
Age
Psyche
Plaque removal

Question 38

not enough enamel reduction issues

veneers

Answer 38

Overcontouring increases plaque retention and stagnation at the gingival margin, especially in those with poor oral hygiene.

bond strength of composite resin to enamel is significantly increased after partial removal of buccal enamel

Question 39

composite veneers can be

Answer 39

direct
indirect e.g. BellGlass