seminar

1. Supervised by : DR.WIDAD ALI
PERSENTEED BY : DR. NOOR ALI

2. COLOURCOLOUR
 Teeth made of many colours, with natural gradation fromTeeth made of many colours, with natural gradation from
the darker cervical to the lighter incisal thirdthe darker cervical to the lighter incisal third
 Variation affected by thickness of enamel and dentine,Variation affected by thickness of enamel and dentine,
and reflectance of different coloursand reflectance of different colours
 Blue, green and pink tints in enamel, yellow through toBlue, green and pink tints in enamel, yellow through to
brown shades of dentine beneathbrown shades of dentine beneath
 Canine teeth darker than lateral incisorsCanine teeth darker than lateral incisors
 Teeth become darker with age (secondary/tertiaryTeeth become darker with age (secondary/tertiary
dentine, tooth wear/dentine exposure)dentine, tooth wear/dentine exposure)

3. COLOURCOLOUR
Tooth colour affected by:Tooth colour affected by:
 individual interpretationindividual interpretation
 time of daytime of day
 patient positioning/ angle tooth is viewed atpatient positioning/ angle tooth is viewed at
 skin tone (make-up)skin tone (make-up)
 surrounding conditions (e.g. lighting in clinic)surrounding conditions (e.g. lighting in clinic)

4. CLASSIFICATION OF TOOTHCLASSIFICATION OF TOOTH
DISCOLOURATIONDISCOLOURATION
 Extrinsic discolourationExtrinsic discolouration
 Intrinsic discolourationIntrinsic discolouration

5. AETIOLOGY OF DISCOLOURATIONAETIOLOGY OF DISCOLOURATION
Extrinsic Discoloration:Extrinsic Discoloration:
 Stains (chromogens) that lies on/attach to theStains (chromogens) that lies on/attach to the
tooth surface or in the acquired pellicle, ortooth surface or in the acquired pellicle, or
 The incorporation of extrinsic stain within theThe incorporation of extrinsic stain within the
tooth substance following dental development.tooth substance following dental development.
It occurs in enamel defects and in the porousIt occurs in enamel defects and in the porous
surface of exposed dentinesurface of exposed dentine

6. AETIOLOGY OF DISCOLOURATIONAETIOLOGY OF DISCOLOURATION
Extrinsic Discolouration:Extrinsic Discolouration:
E.g.E.g.
•Plaque, chromogenenicPlaque, chromogenenic
bacteriabacteria
•Mouthwashes (chlorhexidine)Mouthwashes (chlorhexidine)
•Smoking / chewing tobaccoSmoking / chewing tobacco
•Beverages (tea, coffee, redBeverages (tea, coffee, red
wine, cola)wine, cola)
•Foods (curry, cooking oils andFoods (curry, cooking oils and
fried foods, foods withfried foods, foods with
colorings, berries, beetroot)colorings, berries, beetroot)
• Iron supplementsIron supplements

7. AETIOLOGY OF DISCOLOURATIONAETIOLOGY OF DISCOLOURATION
Intrinsic Discolouration:Intrinsic Discolouration:
 Intrinsic discolouration occurs following aIntrinsic discolouration occurs following a
change to the structural composition or thicknesschange to the structural composition or thickness
of the dental hard tissues.of the dental hard tissues.

8.  INTRINSIC STAINSINTRINSIC STAINS
1. Tetracycline stains
1st
degree
2nd
degree
3rd
degree
4th
degree
2. Fluorosis stains
3. Trauma to tooth
4. Systemic condition
Jaundice
Amelogenesis imperfecta
Enamel hypoplasia due to deficiency of vitamin A,C,D.
5. Iatrogenic discoloration
Amalgam
Intracanal medicaments
(Kerr root sealer, Grossman sealer, Procosol sealer).

9. MANAGEMENT OFMANAGEMENT OF
DISCOLOURED TEETHDISCOLOURED TEETH
Treatment options:Treatment options:
1.1.No treatmentNo treatment
2.2.Removal of surface stainRemoval of surface stain
3.3.Bleaching techniquesBleaching techniques
4.4.Operative techniques to mask underlyingOperative techniques to mask underlying
discolourationdiscolouration
 VeneersVeneers
 CrownsCrowns

10. Treatment option Indications Advantages Disadvantages
No treatment Patient with poor oral
hygiene/ caries/ PA
pathology, large ant
restorations/crowns
Non invasive, no cost Will not address
patients aesthetic
concerns
Removal of surface
stain
-Scale and polish
-Microabrasion
-Extrinsic staining
-Fluorosis, white spot
demineralisation,
enamel hypoplasia
Non/minimally invasive May not improve
aesthetics significantly,
may require further Rx
Microabrasion- soft
tissue irritation/
excessive tooth prep
(technique sensitive)
Bleaching
-Home bleaching,
Walking bleach
-See later slides
Non/minimally invasive Cost, limitation on
shade improvement (a
few shade lighter only),
may fail/ need
repeating, compliance
(home bleaching)
Restorative treatment
-Veneers, crowns
Severely discoloured
teeth, e.g. tetracycline
staining (may bleach
1st
)
Unaesthetic tooth
morphology (e.g. AI/DI)
Heavily restored teeth
May achieve a more
aesthetic result
Destructive, irreversible
(tooth tissue removal),
changes natural shape
of teeth, cost,
maintenance, oral
hygiene compliance
(interdental cleaning)

11. TO BLEACH OR NOT TO BLEACH?TO BLEACH OR NOT TO BLEACH?

12. GENERAL INDICATIONSGENERAL INDICATIONS
 Generalised stainingGeneralised staining
 AgeingAgeing
 Extrinsic stain - Smoking and dietary stains (tea/coffee etc)Extrinsic stain - Smoking and dietary stains (tea/coffee etc)
 FluorosisFluorosis
 Tetracycline staining (? in combination with restorative techniques)Tetracycline staining (? in combination with restorative techniques)
 Traumatic pulpal changesTraumatic pulpal changes
 White spotsWhite spots
 Brown spots (not as good response)Brown spots (not as good response)

13. CONTRAINDICATIONSCONTRAINDICATIONS
Patients with high/unrealistic expectations
Decay and active peri-apical pathology (must be
resolved first)
Pregnancy/Breastfeeding
Sensitivity/cracks/exposed dentine
Existing crowns / large restorations (anteriorly)
Elderly patients with visible recession and yellow
roots (roots don’t bleach as readily as crowns)

14. EFFECTS ONEFFECTS ON
Soft tissuesSoft tissues
Cervical resorptionCervical resorption
PulpPulp
Hardness of teethHardness of teeth
Tooth coloured restorationsTooth coloured restorations
Adhesive bond strengthAdhesive bond strength
-changes composition of enamel and dentine, therefore defer-changes composition of enamel and dentine, therefore defer
definitive adhesive restorations until 2 weeks (at least 10 days)definitive adhesive restorations until 2 weeks (at least 10 days)
after bleaching completedafter bleaching completed

15. BLEACHINGBLEACHING
DefinitionDefinition
““any treatment procedure orany treatment procedure or
method a dental professionalmethod a dental professional
might prescribe to whiten themight prescribe to whiten the
color and brighten yourcolor and brighten your
teethteeth””
10-15% carbamide peroxide10-15% carbamide peroxide
used as a oral disinfectantused as a oral disinfectant
since late 1960s – LONGsince late 1960s – LONG
CLINICAL HISTORYCLINICAL HISTORY

16. BLEACHING TECHNIQUESBLEACHING TECHNIQUES
 Vital bleaching :Vital bleaching :
• Home use of 10 % (15%, 20% ALSO)Home use of 10 % (15%, 20% ALSO)
carbamide peroxide in a dental traycarbamide peroxide in a dental tray
• ““In office bleaching” (~30% carbamideIn office bleaching” (~30% carbamide
peroxide) carried out in single visit (photoperoxide) carried out in single visit (photo
initiation) plus additional home use ofinitiation) plus additional home use of
carbamide peroxide 10% to “top up”carbamide peroxide 10% to “top up”
 Non-vital bleaching :Non-vital bleaching :
• (A.k.a Walking bleaching)(A.k.a Walking bleaching)
• The ‘Inside/Outside’ method using 10 %The ‘Inside/Outside’ method using 10 %
carbamide peroxidecarbamide peroxide

17. MATERIALSMATERIALS
1.1. Hydrogen peroxide (HP):Hydrogen peroxide (HP): HH22OO22
2.2. Carbamide peroxideCarbamide peroxide: CH: CH66NN22OO33 much more stablemuch more stable
than hydrogen peroxide, hence it’s preferred usethan hydrogen peroxide, hence it’s preferred use
• Urea stabilises and buffers HP – shelf life!Urea stabilises and buffers HP – shelf life!
• A 10% Carbamide peroxide solution containsA 10% Carbamide peroxide solution contains
3% HP, 7% Urea3% HP, 7% Urea
1.1. Tetrahydrate sodium perborate:Tetrahydrate sodium perborate: NaBONaBO33 (Borax)(Borax)
mixed with water- decomposes to HP.mixed with water- decomposes to HP.

18. MATERIALSMATERIALS
 Why 10% CP most widely used?Why 10% CP most widely used?
• 10% is the only bleaching concentration10% is the only bleaching concentration
approved by the FDIapproved by the FDI
• Higher concentrations= increased sensitivityHigher concentrations= increased sensitivity
and harmful effectsand harmful effects

19. MODE OF ACTIONMODE OF ACTION
 Thought to be due to the ingress of oxidisersThought to be due to the ingress of oxidisers
and oxygenating molecules through enameland oxygenating molecules through enamel
micropores.micropores.
 Break/cleave pigment bonds and allowBreak/cleave pigment bonds and allow
molecules to diffuse through the toothmolecules to diffuse through the tooth
 &/or become smaller and absorb less light&/or become smaller and absorb less light
and hence appear lighterand hence appear lighter

20. MODE OF ACTION 2MODE OF ACTION 2
 When bleach is applied to the
tooth it passes from the incisal
edge to the apex of the tooth
through the enamel, dentin &
pulp chamber within 5- 15
minutes.
 Hydrogen Peroxide breaks
down very rapidly to water, an
oxygen ion and oxygen free
radicals. The 3 or 4 most
active free radical species are
OH- 95%, OOH- 2.3% & O-
2.3%.
H2O
OOH-
O-
OH-
H2o2
O2

21. MODE OF ACTION 3MODE OF ACTION 3 The oxygen molecules then
attach to the double carbon
bonds (colour stain molecules)
and break them down into
single carbon bonds, thus
disfiguring their internal colors.
 The Single carbon bonds
reflect light and therefore
make teeth appear brighter
and whiter. The changed
molecules are now translucent.
 The molecules may also now
diffuse through the pores more
readily because of their
reduced size
OH-
OOH-
O-
DCB
DCB
SCB SCB
BREAK DOWN THE
STAIN MOLECULES

22. BEFORE AND AFTERBEFORE AND AFTER

24. NON-VITAL BLEACHINGNON-VITAL BLEACHING
 Spasser (1961) - sodium perborate sealed within canalSpasser (1961) - sodium perborate sealed within canal
(walking bleach)(walking bleach)
 Nutting and Poe (1963, 1967) – combination walking bleachNutting and Poe (1963, 1967) – combination walking bleach
(perborate and HP)(perborate and HP)
 Now carbamide peroxide 10% used widelyNow carbamide peroxide 10% used widely
 Known as walking bleachingKnown as walking bleaching
 Indications:Indications:
To whiten endodontically treated, discolored teeth.To whiten endodontically treated, discolored teeth.

25. NON-VITAL BLEACHING-NON-VITAL BLEACHING- RISK:RISK:
• External (cervical) resorption, especiallyExternal (cervical) resorption, especially
when used with thermocatalytic activationwhen used with thermocatalytic activation
(heated instrument within pulp chamber)(heated instrument within pulp chamber)
• Heithersay found incidence increased whenHeithersay found incidence increased when
associated with trauma (3.9-9.7%) andassociated with trauma (3.9-9.7%) and
orthodontic treatment (24%)orthodontic treatment (24%)

26. CLINICAL RELEVANCE:CLINICAL RELEVANCE:
 Pre-operative radiographPre-operative radiograph
• ensure no pathology (external resorption)ensure no pathology (external resorption)
prior to commencing procedureprior to commencing procedure
• medico-legalmedico-legal
 Warn patient if previous orthodontic treatmentWarn patient if previous orthodontic treatment
or trauma- higher riskor trauma- higher risk
 Sealing GP with a 2mm RMGIC (minimum 2mmSealing GP with a 2mm RMGIC (minimum 2mm
to prevent ingress of bleach into pulp chamberto prevent ingress of bleach into pulp chamber

27. WARNINGSWARNINGS
 Warn patient:Warn patient:
• May not improve shadeMay not improve shade
• May reverse, and patient may need to repeat procedure inMay reverse, and patient may need to repeat procedure in
future at own costfuture at own cost
• May require other treatment: veneer/crownMay require other treatment: veneer/crown
• Tooth is hollow whilst carrying out bleaching and patient mustTooth is hollow whilst carrying out bleaching and patient must
be careful, do not bit into hard foods, tooth may fracture!be careful, do not bit into hard foods, tooth may fracture!
• Cervical resorption? Previous trauma/orthoCervical resorption? Previous trauma/ortho
• If temp filling lost must see dentist urgently (walking bleach)If temp filling lost must see dentist urgently (walking bleach)

28. NON-VITAL BLEACHINGNON-VITAL BLEACHING
1.1.History taking & examinationHistory taking & examination
2.2.Examine the radiograph to establish adequate RCFExamine the radiograph to establish adequate RCF
3.3.Take shade and photographTake shade and photograph
4.4.Rubber dam isolation- single toothRubber dam isolation- single tooth
5.5.Remove all filling material and gutta percha 2-3mm apical to CEJ.Remove all filling material and gutta percha 2-3mm apical to CEJ.
6.6.All restorative material must be removed to allow bleaching agentAll restorative material must be removed to allow bleaching agent
to contact the internal tooth structure.to contact the internal tooth structure.
7.7.Mix RMGIC and place 2mm thickness to assure a seal. Light cureMix RMGIC and place 2mm thickness to assure a seal. Light cure
for 20s.for 20s.
8.8.Express Carbamide Peroxide into the cavity (use a small tip, e.g.Express Carbamide Peroxide into the cavity (use a small tip, e.g.
the tips used for acid etch).the tips used for acid etch).

29. NON-VITAL BLEACHINGNON-VITAL BLEACHING
9.9. Place tiny cotton pellet into gel. Leave 1.0 to 1.5mm of space toPlace tiny cotton pellet into gel. Leave 1.0 to 1.5mm of space to
accommodate the provisional restoration.accommodate the provisional restoration.
10.10. Place a GIC provisional restorative material to seal the accessPlace a GIC provisional restorative material to seal the access
opening, check occlusion.opening, check occlusion.
11.11. Repeat the procedure every 3 to 7 days until the desired colorRepeat the procedure every 3 to 7 days until the desired color
change is achieved.change is achieved.
12.12. Remove provisional restorative material and bleaching materialRemove provisional restorative material and bleaching material
to level of GI sealing material. Rinse and clean access opening.to level of GI sealing material. Rinse and clean access opening.
Place a temp restoration.Place a temp restoration.
13.13. A definitive resin composite restoration of a light colour shouldA definitive resin composite restoration of a light colour should
not be placed before 14 days after the bleaching process.not be placed before 14 days after the bleaching process.

31. ““INSIDE-OUTSIDE” BLEACHINGINSIDE-OUTSIDE” BLEACHING
Essentially same technique as Non vital bleachingEssentially same technique as Non vital bleaching
1.1.Pre-op radiograph (assess endo)Pre-op radiograph (assess endo)
2.2.Re-open access cavityRe-open access cavity
3.3.Ensure chamber free of Gutta perchaEnsure chamber free of Gutta percha
4.4.Seal off the root filling with resin-modified GICSeal off the root filling with resin-modified GIC
5.5.Place the 10% gel (may be higher) into a single toothPlace the 10% gel (may be higher) into a single tooth
tray with labial and lingual reservoirs.tray with labial and lingual reservoirs.
6.6.Insert tray into the mouth. Remove excess as necessary.Insert tray into the mouth. Remove excess as necessary.
This should be kept in position for at least 2 to 3 hoursThis should be kept in position for at least 2 to 3 hours
and preferably overnight.and preferably overnight.
7.7.Clean the access cavities out with a toothbrush orClean the access cavities out with a toothbrush or
interproximal brush.interproximal brush.

32. ““INSIDE-OUTSIDE” BLEACHINGINSIDE-OUTSIDE” BLEACHING
8.8. No limit to how many times the material can be changedNo limit to how many times the material can be changed
and changing the material every 2 to 3 hours will probablyand changing the material every 2 to 3 hours will probably
speed up the process.speed up the process.
9.9. The access cavity should ideally left open for no longer thanThe access cavity should ideally left open for no longer than
necessarynecessary
10.10. The chamber should be cleaned out thoroughly andThe chamber should be cleaned out thoroughly and
temporised.temporised.
11.11. A definitive resin composite restoration of a light colourA definitive resin composite restoration of a light colour
should not be placed until 14 days after the bleachingshould not be placed until 14 days after the bleaching
process.process.

34. PROTOCOL 1- HOME BLEACHINGPROTOCOL 1- HOME BLEACHING
(AKA NIGHT GUARD VITAL(AKA NIGHT GUARD VITAL
BLEACHING)BLEACHING)
 Make aMake a diagnosisdiagnosis of the cause(s) ofof the cause(s) of
discolouration and record this in the notes.discolouration and record this in the notes.
 Treatment plan: Discuss the variousTreatment plan: Discuss the various
alternative treatment options to bleachingalternative treatment options to bleaching
teeth, e.g. no treatment, veneers, crowns.teeth, e.g. no treatment, veneers, crowns.
 Check that the patient is not allergic toCheck that the patient is not allergic to
peroxide or plastic.peroxide or plastic.
 Identify the teeth for bleachingIdentify the teeth for bleaching
**check their periapical status on radiograph.**check their periapical status on radiograph.

35. PROTOCOL 2PROTOCOL 2
• Record the shade of the
discoloured teeth and write that
in the notes.
• Photograph if possible (with
shade tab)
• Obtain patient consent
• Warn restorations will not
change colour*
• Take alginate impressions for
tray- lab prescription*
• Fit bleaching trays, ensure
good fit and comfortable
• Advise patient on procedure-
demo use, give leaflets

36. PATIENT INFORMATIONPATIENT INFORMATION

37. PATIENT INFORMATIONPATIENT INFORMATION
Using the 10% CPUsing the 10% CP
(Home Bleaching )(Home Bleaching )
1.1. Brush teeth and floss as normal before each use.Brush teeth and floss as normal before each use.
2.2. Advise the patient to remove the tip from the syringe containing the 10%Advise the patient to remove the tip from the syringe containing the 10%
carbamide gel and to extrude a little (~1mm) of the gel into the deepercarbamide gel and to extrude a little (~1mm) of the gel into the deeper
and front parts of the tray. (No more than ½ a syringe). Place geland front parts of the tray. (No more than ½ a syringe). Place gel in thein the
traytray on the cheek and the tongue side of the back teeth.on the cheek and the tongue side of the back teeth.
3.3. Seat the tray over the teeth and press down firmly.Seat the tray over the teeth and press down firmly.
4.4. A finger, a tissue, or a soft toothbrush should be used to remove excessA finger, a tissue, or a soft toothbrush should be used to remove excess
gel that will flow beyond the edge of the tray.gel that will flow beyond the edge of the tray.

38. PATIENT INFORMATIONPATIENT INFORMATION
5.5. Rinse gently and do not swallow. The tray is usually wornRinse gently and do not swallow. The tray is usually worn
whilst sleeping or a minimum ofwhilst sleeping or a minimum of 2 hours2 hours..
6.6. In the morning, remove the tray and brush the residual gelIn the morning, remove the tray and brush the residual gel
from the teeth. Rinse out the tray and brush it. Store it in afrom the teeth. Rinse out the tray and brush it. Store it in a
safe container.safe container.
 The patient should not eat, drink or smoke while bleachingThe patient should not eat, drink or smoke while bleaching
trays in mouth.trays in mouth.
 10% CP should not be exposed to heat (decomposes),10% CP should not be exposed to heat (decomposes),
sunlight or extreme cold. Store in a fridge and keep away fromsunlight or extreme cold. Store in a fridge and keep away from
reach of children.reach of children.

39. PATIENT INFO 2PATIENT INFO 2
• Advise the patient that it will probably takeAdvise the patient that it will probably take
about 2-6 weeks to achieve satisfactory resultabout 2-6 weeks to achieve satisfactory result
• Nicotine stain 1-3 monthsNicotine stain 1-3 months
• Tetracycline stain 2-6 months, sometimes 12Tetracycline stain 2-6 months, sometimes 12
• Further restorationsFurther restorations
may be requiredmay be required

40. POST WHITENING INSTRUCTIONSPOST WHITENING INSTRUCTIONS
 The Next 24 – 48 hours are important in enhancing &The Next 24 – 48 hours are important in enhancing &
maximizing whitening results.maximizing whitening results.
 Avoid substances which may stain teethAvoid substances which may stain teeth
 Such as: Red wine, coca cola, coffee, teaSuch as: Red wine, coca cola, coffee, tea
 SensitivitySensitivity: Teeth can be sensitive for 24-48 hours: Teeth can be sensitive for 24-48 hours
(esp after in office bleaching). It can range from a(esp after in office bleaching). It can range from a
dull ache in the teeth to sharp pains various teeth.dull ache in the teeth to sharp pains various teeth.
Take Panadol or Nurofen as required.Take Panadol or Nurofen as required.

41. SENSITIVITYSENSITIVITY
55% to 75% of patients experience sensitivity
Cause:
•Passage of
hydrogen peroxide
through enamel
and dentine to the
pulp

42. SENSITIVITYSENSITIVITY
At risk patients:At risk patients:
 Large pulp chambersLarge pulp chambers
 Exposed root surfacesExposed root surfaces
 Abfraction, attrition, erosion,Abfraction, attrition, erosion,
abrasion lesionsabrasion lesions
 Over wearing of traysOver wearing of trays
 Improper fit of traysImproper fit of trays
 High concentrations ofHigh concentrations of
bleaching agentbleaching agent

43. •Decrease wearing time/concentrationDecrease wearing time/concentration
•Desensitizing toothpasteDesensitizing toothpaste
•Potassium nitratePotassium nitrate
• works on the nerve of the toothworks on the nerve of the tooth
•10 - 30 mins in a tray10 - 30 mins in a tray
•Neutral Sodium FluorideNeutral Sodium Fluoride
•occludes the dentinal tubules ( 4-6 weeks)occludes the dentinal tubules ( 4-6 weeks)
•Relief gel,Tooth mousseRelief gel,Tooth mousse
•Amorphous Calcium PhosphateAmorphous Calcium Phosphate
TREATMENT OF SENSITIVITY