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Combined Technique for Bleaching Non-Vital Teeth with 6-Month Clinical

Follow-Up: Case Report

Article · June 2015

DOI: 10.23937/2469-5734/1510009

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 Izidoro et al. Int J Oral Dent Health 2015, 1:2
International Journal of
Oral and Dental Health
Case Report: Open Access

Combined Technique for Bleaching Non-Vital Teeth with 6-Month

Clinical Follow-Up: Case Report
Ana Claudia Santos de Azevedo Izidoro1, Gislaine Cristine Martins1, Cristian Higashi1,
Christiana Zander-Grande1, Lidia Yileng Tay1, João Carlos Gomes2, Nara Hellen
Campanha2 and Janaina Habib Jorge3*
1
Universidade Estadual de Ponta Grossa, Brazil
2
Department of Dentistry, Universidade Estadual de Ponta Grossa – UEPG, Brazil
Department of Dental Materials and Prosthodontics, Araraquara Dental School, UNESP - Univ Estadual Paulista,
3

Brazil

*Corresponding author: Janaina Habib Jorge, Department of Dental Materials and Prosthodontics, Araraquara
Dental School, UNESP - Univ Estadual Paulista, Araraquara, SP, Rua Humaitá, n°1680 Centro, Araraquara, São
Paulo, CEP: 14801-903, Brazil, E-mail: [email protected]/[email protected]

necrosis, deposition of blood components into the tubules after

Abstract
trauma or pulpectomy, and deposition of secondary dentin due to
Aim: The aim of this case report is to demonstrate the efficacy of aging or iatrogenic injuries [3,4]. Food and beverages such as coffee,
the combination of two techniques of dental bleaching (inside and
tea, red wine, carrots, oranges and tobacco are primarily responsible
outside) to deal with the aesthetics of the smile.
for giving rise to extrinsic stains [1,4].
Material and methods: The intra-bucal examination showed
the presence of a fistula in the vestibular region of the tooth 11 Dental bleaching offers a solution for conservative and aesthetic
and a darkening of the tooth crown. It was performed root canal problems instead of invasive repair options, such as crowns or
treatment and after completion, the process of internal bleaching porcelain veneers. Different protocols have been proposed for
using sodium perborate with hydrogen peroxide 20% (“walking bleaching non-vital teeth, [3,5] where the main bleaching technique
bleach” technique) was applied. External dental bleaching as a for these clinical situations involves placing oxidizing agents inside
complement of the tooth 11 was performed to correct a persisted
the pulp chamber in direct contact with the dentin, it’s called inside
color change after the completion of internal bleaching. After the
bleaching procedure, neutral fluoride was applied for 60 seconds bleaching [6]. Several substances have been used, such as oxalic acid,
and the surface of the enamel was polished. sodium hypochlorite, aluminum chloride, acetic acid, hydrogen
peroxide, sodium perborate and carbamide peroxide [3,6-11]. The
Conclusion: It was concluded that through the combination of the
thermocatalytic inside bleaching technique involves the placement of
techniques of dental bleaching is possible to solve the unsightly
problem of a non-vital darkened tooth and also achieve the result chemical oxidants in the pulp chamber, which can be activated by
desired by the patient. different heat sources in order to accelerate the whitening process
[12].
Keywords
Although this technique is effective, it was abandoned due to
Tooth bleaching, Esthetics dental, Hydrogen peroxide excessive heat, which may be responsible for the appearance of external
cervical resorption [13]. It has been hypothesized that hydrogen
Introduction peroxide penetrating through open dentin tubules can initiate an
inflammatory reaction which could result in root resorption. The
Tooth discoloration can be intrinsic, extrinsic or a combination use of “buffer ionomer” at the entrance of the root canal has been
of both. The discoloration is caused by the incorporation of recommended in internal dental bleaching in order to minimize
intrinsic chromatogenic material into the dentin and enamel during the occurrence of external resorption [2,5,13]. The walking bleach
odontogenesis or after teeth eruption [1,2]. The causes of intrinsic technique is an approach that uses no heat. This technique involves
discoloration in the pre-eruption are the administration of tetracycline, placing an active ingredient (such as 37% carbamide peroxide,
exposure to high levels of fluoride, trauma to the developing tooth, in
sodium perborate or sodium perborate combined with 5-35%
addition to hereditary diseases such as amelogenesis imperfecta and
hydrogen peroxide) within the pulp chamber, followed by sealing
dentinogenesis, and congenital erythropoietic porphyria [3].
the cavity [14]. The whitening process occurs between sessions, while
After dental eruption, the main causes of discoloration are pulp the bleaching agents are sealed into the pulp chamber. Depending on

Citation: Izidoro ACSA, Martins GC, Higashi C, Zander-Grande C, Tay LY, et al. (2015)
Combined Technique for Bleaching Non-Vital Teeth with 6-Month Clinical Follow-Up:

ClinMed Case Report. Int J Oral Dent Health 1:009

Received: April 25, 2015: Accepted: June 20, 2015: Published: June 23, 2015
International Library Copyright: © 2015 Izidoro ACSA. This is an open-access article distributed under the terms
of the Creative Commons Attribution License, which permits unrestricted use, distribution,
and reproduction in any medium, provided the original author and source are credited.
 Figure 1: Initial clinical view of the tooth 11 with splint and dark crown

Figure 3&4: Clinical and radiographic view of tooth 11 after endodontic

treatment

Figure 2: Presence of fistula in the periapical region due to necrosis of the

tooth 11

the etiology of the discoloration, a satisfactory reduction must occur

within three to six sessions [10].
Few reports have been published of the walking bleach technique
associated with the protocol of external bleaching [5,15,16]. Thus,
the purpose of this paper is to report through a case study, the
combination of inside bleaching carried out with sodium perborate
in combination with 20% hydrogen peroxide (endogenous technical)
with the outside bleaching technique using 35% hydrogen peroxide
(exogenous technical).
Figure 5: External dental bleaching done to improve a persistent slight
Case Report darkening after bleaching procedure

A 24 year-old man attended the State University of Ponta

Grossa’s clinic reporting trauma of the tooth 11 three months ago. He of the removal. In this space, it was inserted a layer of glass ionomer (R
suffered trauma during a football game, which caused tooth mobility Maxxion, FGM, Joinville, SC, Brazil) to seal the dentin tubules of the root
and gingival bleeding. Due to pain and tooth mobility, he went to canal, avoiding the contact of the sodium perborate with this region.
an emergency dental service where pulp cavity access and splint Because the cement-enamel junction is more coronal on the proximal
of the tooth was performed (Figure 1), which remained for three surfaces than on the buccal and lingual, ionomer layer was placed more
consecutive months because the patient stopped treatment. Clinical coronally on the proximais walls [5]. The bleaching agent was replaced
examination showed the presence of a fistula in the vestibular region twice, until obtain the desired color, with intervals of one week between
of tooth 11 (Figure 2) and darkening of the tooth crown (Figure 3). each session. Subsequently, the cavity was washed thoroughly and filled
As a treatment plan it was decided to remove the splint and finish the with glass ionomer (R Maxxion, FGM, Joinville, SC, Brazil).
endodontic treatment in three sessions (Figure 4). Patient signed an
After one week was performed complementation with external
informed written consent before the procedures.
dental bleaching of the tooth 11 to correct the minimal persistent
One week after endodontic treatment conclusion, began the process color change even after the completion of internal bleaching. This
of internal bleaching using powder of sodium perborate with 20% procedure involves gingival isolation with Top Dam (FGM, Joinville,
liquid hydrogen peroxide (Whiteness perborate, FGM, Joinville, SC, SC, Brazil) which was light cured for 30 seconds. Then the gel
Brazil). After removing the temporary restoration, the original color Whiteness HP Maxx (FGM, Joinville, SC, Brazil) was applied for 15
was recorded and then the gutta-percha was removed approximately minutes, this procedure was performed three times in one session
2mm from the cement-enamel junction in the apical direction. A (Figure 5). It was concluded that the bleaching procedure with enamel
millimeter explorer and radiographs were used to demonstrate the depth polish and neutral fluoride application for 60 seconds.

Izidoro et al. Int J Oral Dent Health 2015, 1:2 • Page 2 of 4 •

 Bleaching techniques should consider the biological and clinical
safety [17]. Biological security is related to the concentration of the
product and the time of application, clinical security is related with
the adverse effects that may occur such as irritation of soft tissues,
changes in enamel hardness and dentin permeability [17,18].
The use of 30% hydrogen peroxide associated to sodium perborate
was introduced in 1967 by Nutting and Poe, [14] this technique
was denominated “walking bleach”. According to these authors,
this combination would be more effective than sodium perborate
associated with water. However, the effectiveness and the damage
caused by bleaching have been discussed, particularly the external
resorption [2].
In injured teeth, bleaching techniques that uses less caustic
substances (hydrogen peroxide at low concentrations, or even
Figure 6: Use of a golden powder to remove the remaining resin in the teeth water associated with sodium perborate) should be used, instead of
that were splinted
using 35% hydrogen peroxide associated with heat (thermocatalytic
technique) [19]. The material in this case (sodium perborate with
hydrogen peroxide 20%) has a lower concentration of hydrogen
peroxide, and therefore it is less aggressive.
To avoid the occurrence of external resorption, different
techniques and materials have been proposed [3,20]. The most often
cited solutions in literature are putting a “buffer” of glass ionomer at
the root canal’s entrance, [15-20] the careful choice of the bleaching
agent and filling the pulp chamber with calcium hydroxide after
obtaining the desired color [3,5,20].
The “ionomer buffer” placed at the entrance of the root canal has
been advocated by several authors [2,13,21]. Its function is to reduce
the penetration of hydrogen peroxide into the dentin tubules, thus
minimizing the possibility of external resorption [5]. The indication of
calcium hydroxide placement into the pulp chamber after bleaching
procedure is based on its buffer capacity. It is believed that it is able to
Figure 7: Immediate result stabilize the acidic pH promoted by hydrogen peroxide, preventing
the occurrence of root resorption [22].
Often to get the desired aesthetics in vital teeth, it is necessary the
combination of two techniques, for example, external bleaching done
in office and home bleaching [23,24]. Likewise, in some cases, non-
vital teeth can be bleached with the combination of two techniques:
internal bleaching (“walking bleach”) and external bleaching in office
[16]. Actually, there are few reports in the literature about the benefits
of this association [5,15,25]. Its principal advantage is the quickness
of the result [5,26] and the less possibility of external root resorption
compared with the thermocatalytic technique.
External dental bleaching has some adverse effects as tooth
sensitivity, gingival irritation and in some cases, reversible pulpitis
[23,27,28]. In the case of non-vital teeth such effects do not occur,
but if the technique is not well developed, root resorption or external
resorption may occur [20,29,30], although it is more frequently
observed in teeth treated with the thermocatalytic technique
Figure 8: Result after 6 months of clinical follow up
[3,16,29]. According to Howell, the technique of non-vital bleaching
has an immediate success rate of 89.5% [31]. However, there is the
Finally, with a golden powder, the remnants of resins used for possibility of recurrence of discoloration, meaning that the result
splinting the anterior teeth were removed (Figure 6) and the enamel cannot be considered permanent. Many authors evaluated the
surface was polished with the aim of regularizing scratched surfaces recurrence of darkening in six years after the bleaching procedure
during the splint removal. The excellent immediate outcome can be and reported different percentages of recurrence [31,33]. While some
observed in figure 7, and after six months we can observe a slight articles have reported a success rate of 75% or more after five years,
recurrence of the darkening in figure 8, but the aesthetic result is still others report a success rate of only 45% after six years [32-34]. This
very satisfactory. results shows that a completely stable outcome seems to be very
difficult to obtain, however, in cases of re-darkening, a re-treatment
Discussion can be performed [16].
Before choosing the material and technique for internal dental In this case, a slight darkening can be observed after 6 months of
bleaching, you should consider the amount of remaining tooth follow up (Figure 8), but the aesthetic result is still satisfactory. Within
structure, quality of root canal treatment and health of periodontal the aesthetic possibilities for resolution of the case it was opted for
tissues [16]. The tooth of the clinical case reported in this paper tooth whitening. Dental bleaching offers a solution for conservative
presented all the necessary requirements for the indication of internal and aesthetic problems instead of invasive repair options. Bleaching
bleaching, as a good quality of endodontic treatment, a large amount may be responsible for the arising of external cervical resorption,
of tooth structure and root internal walls intact. which may require monitoring.

Izidoro et al. Int J Oral Dent Health 2015, 1:2 • Page 3 of 4 •

Conclusion 27. Collins LZ, Maggio B, Gallagher A, York M, Schafer F (2004) Safety
evaluation of a novel whitening gel, containing 6% hydrogen peroxide and a
With the case report presented and following all the indications commercially available whitening gel containing 18% carbamide peroxide in
an exaggerated use clinical study. J Dent 32: 47-50.
and contraindications of the techniques used, it was possible,
through the association of dental whitening techniques, to solve the 28. Goldberg M, Grootveld M, Lynch E (2010) Undesirable and adverse effects of
tooth-whitening products: a review. Clin Oral Investig 14: 1-10.
unsightly problem of the patient and achieve the result desired by him
immediately and after 6 months follow-up. 29. Patel S, Kanagasingam S, Pitt Ford T (2009) External cervical resorption: a
review. J Endod 35: 616-625.
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