Management of Intrinsic Discolouration in Permanent Anterior Teeth in Children and Adolescents Flashcards
prior to commencing tx need
4
Accurate diagnosis
Specialist led treatment plan
Informed consent
Pre-operative records
consent
remember
5
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
6 things that should be in the pre-op records for all discoloured teeth
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
tx options for discoloured teeth in children/adolescents
6
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
what is microabrasion
removal of the surface layer of opaque enamel
disadvantages of microabrasion
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
advantages of microabrasion
9
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
clinical technique for microabrasion
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
why sandpaper discs used for polishing in microabrasion
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
why sandpaper discs used for polishing in microabrasion
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
cases where microabrasion can be used
- decalcification after ortho
- trauma to primary incisor (knocked primary and affected permanent development)
- fluorosis
can be used in conjuction to composite additions
dental tx and enamel loss
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
proprietary kits for microabrasion
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
reviewing microabrasion
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
bleaching permanent teeth in children
can be done when
‘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
bleaching options
2 groups of 2 techniques
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!!
chairside vital bleaching
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
nightguard vital bleaching
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
when can restorations be done after vital bleaching
need 2 weeks to allow colour to settle before commencing restorations
side effects of vital bleacing
sensitivity - common 15-65% of adults
gingival irritation - more common in higher concentrations
sensitivity due to vital bleaching
adults vs adolescents
how
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
carbamide peroxide breakdown mechanism
10% carbamide peroxide
to
3% hydrogen peroxide and 7% urea
to (via catalases and peroxidases)
water, ammonia and CO2
bleaching in amelogenesis imperfecta
won’t make teeth uniform
mask white patches - but can make them whiter
nonvital bleaching advantages
6
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’
tooth selection for non vital bleaching
4
Adequate root filling
* no clinical disease
* no radiological disease
Anterior teeth without large restorations
Not amalgam intrinsic discolouration
Not fluorosis or tetracycline discolouration
2 methods for non-vital bleaching
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
clinical procedure non vital bleaching
walking bleach
root filling removed below CEJ
clean with ultrasonic
bleaching agent on cotton pledget
cover with dry cotton pledget
seal with GIC/RMGIC
walking bleach applications
frequency
regression
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)
non vital ‘inside out’ bleaching process
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
restoration of pulp chamber afer non-vital bleaching procedures
2
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
non vital bleaching potential complications
5
External cervical resorption
Spillage of bleaching agents into oral cavity etc
Failure to bleach
Over bleach
Brittleness of tooth crown (susceptible to #)
2 ways to prevent external cervical resorption in non-vital bleaching procedures
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
short term bleach exposure to soft tissues
minor ulceration/irritation
plaque reduction aids wound healing
possible long term bleach exposure to soft tissue issues
3
delayed wound healing
periodontal hamr
mutagenic potential
tooth mousse
adjunct to microabrasion and bleaching
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)
resin infiltration is
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.
resin infiltration process
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
to reduce or not to reduce enamel
veneers considerations
6
Aesthetics
Relative tooth position
Masking dark stain
Age
Psyche
Plaque removal
not enough enamel reduction issues
veneers
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
composite veneers can be
direct
indirect e.g. BellGlass
