Treatment of intrinsic discolouration in children and adolescents Flashcards
intrinsic discolouration in anterior teeth - treatment options
enamel micro abrasion
bleaching
- vital - surgery or home
non vital
- ‘inside outside’ technique
- ‘walking bleach’ technique
Resin infiltration technique (ICON)
localised composite resin
veneers
- composite - direct (free hand or putty guided) or indirect (lab made)
pre operative records required for all discoloured teeth
clinical photos
shade
sensibility testing
- check for sensitivity
diagram of defect
radiographs
- only if clinically indicated
patient assessment
microabrasion technique
PPE must be worn
patient must be wearing glasses as bib
clean teeth with pumice and water
apply petroleum jelly to gingiva
place rubber dam and wedjets
place sodium bicarbonate guard
- have more sodium bicarbonate available
dry dam and wedjets
rub HCL pumice slurry using slowly rotating rubber cup for 5 seconds
- max 10x 5 second applications
wash directly into aspirator after each 5 second aspiration
fluoride varnish application
- profluorid NOT duraphat
polish with finest soflex (sandpaper) disc
final polish with toothpaste
Why are sandpaper discs used to polish enamel following micro abrasion
it changes the optical properties of the enamel making areas of intrinsic discolouration less perceivable
micro abrasion indications
demineralisation after fixed orthodontic treatment
fluorosis
trauma to primary incisors
how much enamel is lost from the use of a prophy cup with toothpaste?
5-10 microns
how much enamel is lost from the use of a prophy cup with pumice?
5-50 microns
how much enamel is lost from orthodontic bracket bonding or debonding?
5-50 microns
how much enamel is lost from acid etching?
10 microns
how much enamel is lost from 10x 5 seconds of HCL pumice microabrasion?
100 microns
advantages of micro abrasion
easily performed
conservative
inexpensive
teeth need minimal subsequent maintenance
fast acting
removes yellow-brown, white and multicoloured stains
effective
results are permanent
can be used before or after bleaching
microabrasion disadvantages
removes enamel
HCL acid compounds are corrosive
requires protective apparatus for patient, dentist and dental nurse
prediction of outcome is difficult
must be done in dental surgery
reviewing micro abrasion -steps following procedure
dry teeth after procedure
warn patient to avoid highly coloured food and drinks for at least 24 hours
review patient in 4-6 weeks after procedure and take post op photos
non vital bleaching methods
inside out technique
walking bleach technique
active agent used in home vital bleaching and concentration?
10% carbamide peroxide gel
active agent and concentration used in chair side vital bleaching
15-38% hydrogen peroxide
instructions to patients on how to use vital home bleaching
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 tray and rinse with cold water
How long does vital home bleaching take to work?
approx 3-6 weeks
tell patient to keep going until acceptable colour
10% carbamide peroxide breaks down into…
3% hydrogen peroxide, 7% urea
- breaks down into water, ammonia and carbon dioxide
advantages of non-vital bleaching
simple
conserves tooth
original tooth morphology
gingival tissues not irritated by restoration
no lab assistance required for ‘walking bleach’ technique
non vital bleaching - indications
adequate root filling
no clinical or radiological pathology
anterior teeth without large restorations
no amalgam staining
no fluorosis or tetracycline discolouration
briefly outline the 2 non-vital bleaching methods
walking bleach
- oxidising process allowed to proceed gradually over days
inside out method
- 10% carbamide peroxide gel, can seal if co-operation is an issue
non vital ‘walking bleach’ technique steps
root filling removed to below gingival margin
cotton wool with bleaching agent placed within access cavity
- cover with dry cotton wool
access cavity sealed with GIC
walking bleach application and frequency
renew bleach ideally no more than 2 weeks between appointments
stop if no change after 3-4 renewals
- usually 2-3 appts required on average
walking bleach technique regression
50% at 2-6 years
combination “inside out” bleaching method
open access cavity
custom made mouthguard
- cut windows in guard of teeth you don’t want to bleach
patient applies bleaching agent to back of tooth and tray
- access cavity must be kept clean - replacing gel removes food debris etc
- 10% carbamide peroxide gel is used
mouthguard worn all the time except when eating and cleaning
gel changed every 2 hours except during the night
How to restore the pulp chamber following non-vital bleaching
non-setting calcium hydroxide paste for 2 weeks, seal with GIC
then either:
- place white GP in canal followed by composite resin - enables re-bleaching if required
- incrementally cured composite - no re-bleaching but stronger tooth
veneer or crown prep if regression
non-vital bleaching - potential complications
external cervical resorption
spillage of bleaching agents
failure to bleach
over bleaching
brittleness of tooth crown
how to prevent external cervical respiration
place a layer of cement over gp
- prevents bleaching area from getting to external surface of root (walking bleach technique only)
non-setting calcium hydroxide in tooth for 2 weeks before final restoration
- reverses any acidity that might of occurred if above had happened
short term effects on soft tissue of bleach exposure
- minor ulceration or irritation
- plaque reduction
- aids wound healing
potential long term effects on soft tissue of bleach exposure
- delayed wound healing
- periodontal harm
- mutagenic potential
what can be used as an adjunct to micro abrasion and bleaching?
tooth mousse
- PP-ACP milk derived protein
suggested use for 2 weeks after bleaching or for 4 weeks for hypominerilsed lesions or mild/moderate fluorosis)
- pea size at night before bed
What is resin infiltration?
infiltration of enamel lesions with low viscosity light curing resins
how does resin infiltration work?
surface layer is eroded, lesions are dried and a resin infiltrant is applied
resin penetrates lesion driven by capillary forces
infiltrated lesions lose discoloured appearance and look similar to sound enamel
veneers - considerations to make regarding enamel reduction
overcontoruing increases plaque retention and stagnation at gingival margin
- especially in patients with poor oral hygiene
bond stretch of composite resin to enamel is significantly increased after partial removal of buccal enamel