Tx of intrinsic discolouration Flashcards by Roisin Mousa

What is intrinsic discolouration

occurs beneath the surface of the tooth and occurs when stain causing-particles are able to work their way through the outer layer of your tooth and accumulate within enamel/dentine

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What is extrinsic staining

lies on the tooth surface usually caused by tannings

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What is required prior to commencing treatment

diagnosis
specialist led treatment plan
informed consent
pre-operative records

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What should patient be told to gain informed consent

diagnosis
treatment plan
risk of treatment (including risk of no success)

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What pre-operative records do we require

photos
shade sheet

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What is on the shade sheet

tooth to be treated
shade of defect
sensibility EPT
sensibility ethyl chloride

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What are the treatment options for intrinsic discolouration

enamel microabrasion
bleaching
resin infiltration (ICON)
localised composite restoration
veneers
crowns
do nothing

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What is microabrasion

o Removal of the surface layer of stained opaque enamel to reveal less stained enamel

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What are the advantages of microabrasion

 Easy
 Conservative
 Inexpensive
 Teeth need minimal subsequent maintenance other than taking care with staining food and drink
 Fast acting
 Removes yellow/brown, white and multicoloured stain
 Effective
 Permanent result
 Can use before or after bleaching

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What are the disadvantages of microabrasion

 Removes enamel - sensitivity and prone to stianing
 HCL acid - soft tissue damage
 Prediction of treatment outcome can be difficult as teeth may appear more yellow as the normal dentine shows through the opaque enamel
 Must be done in the dental surgery
 Cannot be delegated
 100 micron of enamel loss with microabrasion

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What is the clinical technique for microabrasion

 PPE worn by patient and team
 Teeth cleaned with pumice and water
 Soft tissue protected using Vaseline
 Rubber dam placed
 Sodium bicarbonate guard used for gingival protection
 HCL pumice slurry used in slowly rotating rubber cup
 Should be washed off after every 5 second application, review the colour and the shape
 To aid remineralisation, fluoride varnish should be applied
 Teeth should be polished with finest sandpaper disc
 Polish with toothpaste
 Review

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How long should the HCl be in contact with the tooth

microabrasion

5 seconds

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What is the maximum amount of applications of HCl to the tooth surface

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What is the name of the fluoride varnish used post-microabrasion

profluorid NOT duraphat

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Why is duraphat not used as the varnish of choice

microabrasion

it is yellow
tooth is more prone to stain post microabrasion
profluorid is white

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What is the benefit of polishing teeth with finest sandpaper disc

post microabrasion

it helps in changing the optical properties of enamel so that the area of intrinsic discolouration becomes less perceptible (prismless layer of surface enamel created)

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What should the patient be warned of (POI microabrasion)

Teeth are dehydrated after the procedure
Warn the patient to avoid highly coloured food and drinks for at least 24h, if not longer (avoid food/drinks that would stain a white shirt)

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When should the patient be reviewed

Review patient 4-6 weeks after microabrasion and take post-op photographs

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Can a second cycle of microabrasion be taken

Yes but only if maximum result hasn’t been achieved
if no change, second cycle should not be undertaken

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Can a third cycle of microabrasion be undertaken

no
second cycle is maximum

What are the 2 microabrasion kits

ultradent
prema kit

What does the GDC state in regards to children + bleaching

GDC stated that tooth whitening products exceeding 0.1-6% hydrogen peroxide shouldn’t be used on under 18s except for when used for the purpose of treating/preventing disease

fluorosis, AI, trauma ect all come under treatment of disease

What is the legal % of hydrogen peroxide that can be used by a dentist

6% unless for treatment/prevention of disease

What is the difference between carbamide peroxide and hydrogen peroxide

 Carbamide peroxide breaks down into hydrogen peroxide and urea in an aqueous solution
 10% carbamide peroxide turns into 3% hydrogen peroxide
 Eventually the hydrogen peroxide turns into water, ammonia and carbon dioxide

What are the 2 types of bleaching

vital and non-vital

What is vital bleaching

it is external bleaching can still be used on non-vital teeth (if for extrinsic staining)

What are the two types of vital staining

chairside home

What is chairside bleaching

o Uses unstable, rapidly reacting hydrogen peroxide usually 15-38% which is equivalent to 75% carbamide peroxide o It poses a greater risk of soft tissues and eyes

What is home bleaching

o Nightguard vital bleaching with 10% carbamide peroxide gel o Tray designed for bleaching, windows should be cut in the tray over any teeth that you do not want to use

What are the patient instructions for home bleaching

 Brush teeth  Apply gel to tray  Wear tray and remove excess  Rinse gently  Wear overnight  Brush teeth day  Keep going for 3-6 weeks until colour achieved

What are the side effects of bleaching

tooth sensitivity gingival irritation

Why is tooth sensitivity a less common side effects for younger patients

probably due to increased enamel quantity + quality and also larger pulp complexes in adolescent patients teeth which allows faster recovery from acute inflammation experienced

How does bleach cause tooth sensitivity

 Due to passage of hydrogen peroxide through intact enamel and dentine, reaching the pulp

What is non vital bleaching

internal bleaching

What are the advantages of internal bleaching

o Simple o Tooth conserving o Original tooth morphology o Gingival tissues not irritated by restoration o Adolescent gingival level not a restorative consideration o No lab assistance (only for walking bleach method)

What should we consider when deeming if a tooth is suitable for non vital bleaching

o Requires adequate root filling with no clinical/radiological disease o Anterior teeth without large restorations o Not intrinsic staining from amalgam o Not fluorosis or tetracycline discolouration

What are the 2 non vital bleaching methods

walking bleach inside out (combination)

What is the walking bleach technique | non vital bleaching

The oxidising process is allowed to proceed gradually over days

What is the technique for the walking bleach technique

* remove root filling 1-2mm below CEJ * seal root filling with GIC * place etch to open dentinal tubules for penetration * sodium perborate placed in pulp chamber * review patient every 3-4 days for replacement of bleach * calcium hydroxide dressing placed in pulp chamber for 2 weeks in the interim post bleaching * final definitive restoraiton placed

When should you stop replacing the bleach | for walking bleach technique

after 3/4 time if no change up to 6-10 times if change seen

What is the inside out technique

access cavity created 10% carbamide peroxide gel used

Describe the technique for the inside out technique (combination)

* Access cavity created * Access cleaned with ultrasonic * 10% carbamide peroxide gel placed within access * Appropriate part of bleaching tray covering outside of tooth filled with the gel and fitted into mouth * Should be changed every 2 hours and kept in overnight * Remove tray when eating and clean out access

What should the definitive restoration be | post nonvital bleaching

 White GP and composite resin placed to facilitate rebleaching  OR  Incrementally cured composite which does not leave room for rebleaching but allows for a stronger tooth  OR  Veneer or crown prep if regression

What are the complications of non vital bleaching

* external cervical resorption * spillage of bleaching agents * failure to beach * overbleach * brittleness of tooth crown *

How do we try and prevent external crevical resorption

prevent leakage of bleach to surrounding periodontium/external root surface by ensuring sealing material reaches ACJ (walking bleach technique) calcium hydroxide placement post-bleaching to reverser acidity + prevent bacterial penetration

What is resin infiltration's brand name

ICON

What is resin infiltration

o The surface layer is eroded, lesions are desiccated and a low viscosity resin infiltrant is applied o The resin penetrates the lesion by capillary forces o Infiltrated lesions lose their discoloured appearance and look similar to sound enamel

What should you consider when deciding if a veneer requires enamel preparation

 Aesthetic  Relative tooth position (instanding or outstanding)  Masking dark stain  Age  Psyche  Plaque removal