2. Restorative
Dentistry
MANAGEMENT OF
TOOTH
DISCOLOURATION

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

4. COLOUR
Tooth colour affected by:
 individual interpretation
 time of day
 patient positioning/ angle tooth is viewed at
 hydration of tooth (always take shade at start
of appointment)
 skin tone (make-up)
 surrounding conditions (e.g. lighting in clinic)

5. CLASSIFICATION OF TOOTH
DISCOLOURATION
 Extrinsic discolouration
 Intrinsic discolouration

6. AETIOLOGY OF DISCOLOURATION
Extrinsic Discolouration:
 Stains (chromogens) that lies on/attach to the
tooth surface or in the acquired pellicle, or
 The incorporation of extrinsic stain within the
tooth substance following dental development. It
occurs in enamel defects and in the porous
surface of exposed dentine (‘stain
internalisation’).

7. AETIOLOGY OF DISCOLOURATION
Extrinsic Discolouration:
E.g.
•Plaque, chromogenenic •Smoking / chewing
bacteria tobacco
•Mouthwashes •Beverages (tea, coffee,
(chlorhexidine) red wine, cola)
•Foods (curry, cooking oils
and fried foods, foods with
colorings, berries,
beetroot)
• Antibiotics (erythromycin,
amoxicillin-clavulanic acid)
• Iron supplements

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

9. AETIOLOGY OF DISCOLOURATION
Intrinsic Discolouration:
Pre-eruptive: Post-eruptive:
Disease: Trauma (e.g. pulpal
•Haematological diseases haemorrhagic products)
•Liver diseases Primary and secondary
•Diseases of enamel and caries
dentine (e.g. Amelogenesis/ Tooth wear
Dentinogenesis imperfecta)
Dental restorative materials
Medication:
•Tetracycline, other antibiotics Ageing
Fluorosis stains (excess F) Chemicals
Enamel hypoplasia (trauma Antibiotics
or infection) Minocycline (used to treat
acne)

10. Types of Discoloration Colour Produced
Extrinsic (Direct stains)
Tea, coffee and other foods Brown to black
Cigarettes/cigars Yellow/brown to black
Plaque/poor oral hygiene Yellow/brown
Extrinsic (Indirect stains)
Polyvalent metal salts and cationic antiseptics Black and brown
e.g. Chlorhexidine
Intrinsic
(Metabolic causes)
e.g. Congenital erythropoietic porphyria Purple/brown
(Inherited causes)
e.g. Amelogenesis Imperfecta Brown or black
e.g. Dentinogenesis Imperfecta Blue-brown (opalescent)
(Iatrogenic causes)
Tetracycline Banding appearance:
classically yellow, brown, blue, black or grey
Minocycline Grey
Fluorosis White, yellow, grey or black
(Traumatic causes) Brown
Enamel hypoplasia Grey black
Pulpal haemorrhage products Pink spot
Root resorption
(Ageing causes) Yellow
Internalized
Caries Orange to brown
Restorations Brown, grey, black

11. MANAGEMENT OF DISCOLOURED
TEETH
Treatment options:
1.No treatment
2.Removal of surface stain
3.Bleaching techniques
4.Operative techniques to mask underlying
discolouration
 Veneers
 Crowns

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

13. To bleach or not to bleach?

14. GENERAL INDICATIONS
 Generalised staining
 Ageing
 Extrinsic stain - Smoking and dietary stains
(tea/coffee etc)
 Fluorosis
 Tetracycline staining (? in combination with
restorative techniques)
 Traumatic pulpal changes
 White spots
 Brown spots (not as good response)

15. CONTRAINDICATIONS
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)
If patients cannot afford changing existing
restorations post-bleaching

16. Effects on
Soft tissues
Cervical resorption
Pulp
Hardness of teeth
Tooth coloured restorations
Adhesive bond strength
-changes composition of enamel and dentine,
therefore defer definitive adhesive
restorations until 2 weeks (at least 10 days)
after bleaching completed

17. BLEACHING
Definition
“any treatment procedure
or method a dental
professional might prescribe
to whiten the color and
brighten your teeth”
10-15% carbamide peroxide
used as a oral disinfectant
since late 1960s – LONG
CLINICAL HISTORY

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

19. MATERIALS
1. Hydrogen peroxide (HP): H2O2
2. Carbamide peroxide: CH6N2O3 much more
stable than hydrogen peroxide, hence it’s
preferred use
• Urea stabilises and buffers HP – shelf life!
• A 10% Carbamide peroxide solution contains
3% HP, 7% Urea
1. Tetrahydrate sodium perborate: NaBO3
(Borax) mixed with water- decomposes to HP.

20. MATERIALS
 Why 10% CP most widely used?
• 10% is the only bleaching concentration
approved by the FDI
• Majority of clinical data on 10%, if a lawsuit
ensued – could be criticized for using
something less well “tested”
• Higher concentrations= increased sensitivity
and harmful effects

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

22. MODE 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 O-
radicals. The 3 or 4 most H2O
active free radical species are H2o2
OH-
OH- 95%, OOH- 2.3% & O-
O2
2.3%.
OOH-

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

24. Before and after

25. LEGAL SITUATION
 The situation at present is that it is illegal in
the UK to supply a product for the purpose of
tooth whitening, if that product contains or
releases more than 0.1% Hydrogen Peroxide.
 Companies are able to supply as a “chemical”
only i.e. without instructions for use in
bleaching
 10% CARBAMIDE PEROXIDE RELEASES
~3% HYDROGEN PEROXIDE
SO ESSENTIALLY IT’S ILLEGAL PRACTICE...

26. LEGAL SITUATION
However
Chief Dental Officer Statement 2000:
“The Department of Health would not
seek to interfere with a dentist’s
therapeutic decision to utilize a
bleaching technique where a dentist
considers this to be in the best interests
of the patient’s overall oral health care”

27. LEGAL SITUATION
Tooth whitening update (September 2011)- Dental
Protection:
• New European Directive allowing dentists to legally
supply products for tooth whitening, which release or
contain up to 6% hydrogen peroxide , provided that
the patient has been examined by a dentist and the
first treatment has been performed by the dentist or
under his or her direct supervision.
• Once in place (due for publication in October 2011),
the UK Government is obliged to amend the
Regulations to reflect this within 12 months.
• 6% HP limit will allow dentists to use 18% CP

28. GENERAL DENTAL COUNCIL
GDC
 The GDC believes that it is illegal for non-dental
professionals to be offering tooth whitening
treatment.
 We advise any member of the public wanting tooth whitening to
speak to their dentist.
 In our view tooth whitening amounts to the practice of dentistry.
The carrying out of dentistry by non-registrants is a criminal
offence. We are committed to protecting the public by
investigating and prosecuting people who are not registered
with us and who perform, or provide clinical advice about, tooth
whitening
BEWARE
http://www.smilestudiowirral.co.uk/procedure.html
http://www.circlesmk.co.uk/pages/teeth.html

29. ETHICAL CONSIDERATIONS
 The end point is fixed for all teeth and this
must be explained fully to the patient.
 The Professional should explain the various
treatment options, incuding bleaching
alternatives such as toothpastes, OTC, at
home tray and in-office so that an informed
decision can be made.
 You must not lead a patient to believe that in-
office bleaching will yield better results than
home bleaching.

30. LIVERPOOL UNIVERSITY DENTAL
HOSPITAL
At the LUDH, our bleaching protocol states:
“tooth bleaching should only be done
if there is a real, clearly-defined
clinical need to provide this form of
treatment and not merely for the
cosmetic aspirations of a patient”.

31. Bleaching: Part II
Walking Bleach/ Non-
Vital Bleaching

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

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

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

35. BEFORE AND AFTER:

36. EXAMPLE NON-VITAL BLEACHING

37. EXAMPLE NON-VITAL

38. EXAMPLE NON-VITAL

39. NON-VITAL BLEACHING

40. NON-VITAL BLEACHING

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

42. NON-VITAL BLEACHING
1. History taking & examination
2. Examine the radiograph to establish adequate RCF
3. Take shade and photograph
4. Rubber dam isolation- single tooth
5. Remove all filling material and gutta percha 2-3mm
apical to CEJ (Williams/PCP 2 probe used).
6. All restorative material must be removed to allow
bleaching agent to contact the internal tooth structure.
7. Mix RMGIC and place 2mm thickness to assure a seal.
Light cure for 20s.
8. Express Carbamide Peroxide into the cavity (use a small
tip, e.g. the tips used for acid etch).

43. NON-VITAL BLEACHING
9. Place tiny cotton pellet into gel. Leave 1.0 to 1.5mm of
space to accommodate the provisional restoration.
10. Place a GIC provisional restorative material to seal the
access opening, check occlusion.
11. Repeat the procedure every 3 to 7 days until the desired
color change is achieved.
12. Remove provisional restorative material and bleaching
material to level of GI sealing material. Rinse and clean
access opening. Place a temp restoration.
13. A definitive resin composite restoration of a light colour
should not be placed before 14 days after the bleaching
process.

44. “INSIDE-OUTSIDE” BLEACHING
Essentially same technique as Non vital bleaching
1. Pre-op radiograph (assess endo)
2. Re-open access cavity
3. Ensure chamber free of GP
4. Seal off the root filling with resin-modified GIC
5. Place the 10% gel (may be higher) into a single
tooth tray with labial and lingual reservoirs.
6. Insert tray into the mouth. Remove excess as
necessary. This should be kept in position for at
least 2 to 3 hours and preferably overnight.
7. Clean the access cavities out with a toothbrush
or interproximal brush.

45. “INSIDE-OUTSIDE” BLEACHING
8. No limit to how many times the material can be
changed and changing the material every 2 to 3
hours will probably speed up the process.
9. The access cavity should ideally left open for no
longer than necessary (suggested 3 days?)
10. The chamber should be cleaned out thoroughly
and temporised.
11. A definitive resin composite restoration of a light
colour should not be placed until 14 days after
the bleaching process.

46. Part III
Home Bleaching

47. LUDH- PROTOCOL 1- Home Bleaching
(aka Night Guard Vital Bleaching)
 Make a diagnosis of the cause(s) of
discolouration and record this in the notes.
 Treatment plan: Discuss the various
alternative treatment options to bleaching
teeth, e.g. no treatment, veneers, crowns.
 Check that the patient is not allergic to
peroxide or plastic.
 Identify the teeth for bleaching
**check their periapical status on radiograph.

48. PROTOCOL 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

49. PATIENT INFORMATION

50. PATIENT INFORMATION
Using the 10% CP
(Home Bleaching )
1. Brush teeth and floss as normal before each use.
2. 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 deeper and front parts
of the tray. (No more than ½ a syringe). Place gel in
the tray on the cheek and the tongue side of the
back teeth.
3. Seat the tray over the teeth and press down firmly.
4. A finger, a tissue, or a soft toothbrush should be used
to remove excess gel that will flow beyond the edge
of the tray.

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

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

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

54. SENSITIVITY
Cause:
•Passage of
hydrogen peroxide
through enamel
and dentine to the
pulp
•Manipulation of
teeth
55% to 75% of patients experience sensitivity

55. SENSITIVITY
At risk patients:
 Large pulp chambers
 Exposed root surfaces
 Abfraction, attrition,
erosion, abrasion lesions
 Over wearing of trays
 Improper fit of trays
 High concentrations of
bleaching agent
 No long-term effects in
the literature

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

57. MAKING THE TRAY
• Take alginate impressions of arch(es) to be bleached
• Technician to cast up and block-out the labial
aspects of the teeth to be bleached if using
reservoirs- recommended (lab technicians add
flowable composite onto labial aspects of teeth)
• Make a thin vacuum-formed soft tray from a
thermoplastic material
• Check this carefully on the model to ensure there are
no sharp areas of the tray that might irritate the
gingival margins.

58. TRAY DESIGN

59. TRAY DESIGN

60. LABORATORY PRESCRIPTION:
Please:
1. Pour study models in dental stone
2. Place composite resin on labial surfaces on
e.g. UR5-UL5, LR5-LL5 (+/- palatal
surfaces), kept short of gingival margins
3. Make upper and lower full arch, 1mm
thickness, soft pull down bleaching trays
which are well adapted and trim to the level
of the gingival margins

61. REFERENCES
DENTAL PROTECTION POSITION STATEMENT ON WHITENING
Dr Van Haywood and Dr Harald Heymann published the original
technique, called Nightguard Vital Bleaching, in an article in
1989
http://www.dentalprotection.org/United_Kingdom/News_And_Information/P
osition_Statements/20061014_ps_whitening.aspx
School of Dental Sciences - Liverpool University Dental Hospital
Protocols for Tooth Bleaching/Whitening (AJP)
Suliman 2004 - Dental Update papers (links on vital)

62. FURTHER READING
1. Greenwall, Linda. Bleaching techniques in restorative dentistry :
an illustrated guide
2. Haywood, Van B. TitleTooth whitening : indications and
outcomes of nightguard vital bleaching / Van B. Haywood;
Quintessence Publishing, 2007.
3. Van Haywood’s article: Frequently Asked Questions About
Bleaching; Compendium / April 2003
4. GOLDSTEIN, Ronald E Complete dental bleaching; 1995;
Quintessence
5. Sulieman M. An Overview of Bleaching Techniques: 1. History,
Chemsitry, Safety and Legal Aspects. Dent Update 2004; 31:608-
616
6. Sulieman M. An Overview of Bleaching Techniques: 2. Night
Guard Vital Bleaching and Non-Vital Bleaching. Dent Update
2005; 32: 39-46

63. LUDH- PROTOCOL 1
 Make a diagnosis of the cause(s) of
discolouration and record this in the notes.
 Discuss the various alternative options to
bleaching teeth, for instance, veneers,
crowns and post crowns.
 Check that the patient is not allergic to
peroxide or plastic.
 Identify the teeth for bleaching
**check their periapical status on radiograph.

64. PROTOCOL 2
• Record the shade of the
discoloured teeth and write that
in the notes.
• Photograph if possible (with
shade tab)
• Record that in the notes and
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-
give leaflets

65. PROTOCOL 3
• Check for the presence of composites, veneers, crowns at adjacent and
opposite teeth and warn patients that these will not change colour with
bleaching and may need to be redone if bleaching is undertaken as the
colour mismatch may become much more apparent following bleaching.
• If possible draw a diagram to remind the patient of the presence of such
restorations and keep a copy in the notes.
• The teeth will change colour with bleaching but the existing composites,
veneers, or bridges will not change colour.
• If it is subsequently necessary to make these the same colour as the
bleached teeth, significant numbers of restorations may need to be
redone.
• White spots will become whiter in initial stages, but almost always
revert.
• Record in the notes that this has been discussed

66. PROTOCOL 4
 Advise the patient that the necks of the teeth may
take longer to lighten.
 If there is a lot of recession – must inform pt root
surfaces may not bleach
 Temporise carious teeth and leaking restorations.
Very old amalgam fillings may leave a dark purple
colour on the bleaching tray. It is prudent to polish
these restorations with conventional multibladed
tungsten carbide burs before commencing.
 Bleaching should not be undertaken whilst patients
are known to be pregnant or breast-feeding.

67. HISTORY (adapted from data in
Haywood)
Year Authors Innovation
1799 Macintosh Chloride of lime is invented - Called bleaching powder
1884 Harlan 1st Hydrogen peroxide use
Used 35% HP inside tooth and suggested 25%HP with heated
1958 Pearson lamp
1961 Spasser Perborate sealed within tooth - "walking bleach"
Thermocatalytic Technique - pellet saturated with suoperoxyl
1965 Stewart and heated with an instrument inside pulp chamber.
In office bleaching using 30% H2O2 and heat from bleaching
1987 Feinmann light
1989 Croll Microabrasion technique
1989 Haywood and Heyman 10% CP used in trays overnight "Nightguard Vital Bleaching"
1990 Bleaching products available OTC - contraversial !
Bleaching materials were investigated and the FDA called for
1991 safety studies. Ban was lifted after 6months
1991 Numerous authors Power bleaching using 30% HP and light activiation
1996 Rayto Laser tooth whitening
1997 Settembrini et al Inside-Outside bleaching technique
1998 Carrilo et al Open pulp chamber with CP inside