Dr.Puneet Goyal et al. / IJRID Volume 4 Issue 1 Jan.-Feb 2014
Available online at www.ordoneardentistrylibrary.org
ISSN 2249-488X
Case - report
INTERNATIONAL JOURNAL OF RESEARCH IN DENTISTRY
MANAGEMENT OF DISCOLORED NON VITAL TEETH WITH ENDODONTIC TREATMENT AND
BLEACHING-A CASE REPORT
1
Dr.Puneet Goyal* , Dr.Samriti Bansal1, Dr.Shaveta Bansal2, Dr. Prathibha Garg3
1. Department of Pediatric and Preventive Dentistry, Guru Nanak Dev Dental College and Research Institute,
Sunam (Punjab).
2. Department of Prosthodontics, Guru Nanak Dev Dental College and Research Institute
Sunam (Punjab).
3. Department of Pediatric and Preventive Dentistry, Guru Nanak Dev Dental College and Research Institute,
Sunam (Punjab).
Received: 22 Dec. 2013; Revised: 19 Jan 2014; Accepted: 23 Feb. 2014; Available online: 5 Mar 2014
ABSTRACT
Modern trends in cosmetic dentistry and media coverage of smile makeovers have increased public awareness of
dental aesthetics. Discolored anterior teeth are often perceived as an esthetic detraction. An array of treatment
alternatives like ceramics or composite veneering, bleaching, full coverage crowns macroabrasion and
microabrasion are available. Bleaching of endodontically treated intact teeth presenting with chromatic alterations
is a conservative alternative to a more invasive esthetic treatment such as placement of crowns or veneers.
Keywords: Trauma, Tooth discoloration, Triple antibiotic paste, MTA apical plug, Bleaching
INTRODUCTION
Modern trends in cosmetic dentistry and media coverage of smile makeovers have increased public awareness
of dental aesthetics. The ‘first impression’ craze has continually impressed upon the younger generation, the
importance of a bright white smile[8]. People now know that smile aesthetics plays a key role in their sense of
well-being, social acceptance, success at work and in relationships, and self-confidence. The aesthetic
expectations and demands of dental patients have increased substantially. Now, a glowing, healthy and vibrant
smile is no longer available only to millionaires and movie stars.
Discolored anterior teeth are often perceived as an esthetic detraction[5]. An array of treatment alternatives like
ceramics or composite veneering, bleaching, full coverage crowns, macroabrasion and microabrasion are
available. Most of these treatment modalities are expensive, need exclusive materials and the need of
specialized laboratories.8 Bleaching of endodontically treated intact teeth presenting with chromatic alterations
is a conservative alternative to a more invasive esthetic treatment such as placement of crowns or veneers. The
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Dr.Puneet Goyal et al. / IJRID Volume 4 Issue 1 Jan.-Feb 2014
purpose of this article is to present a brief history of bleaching and a case of discolored non-vital tooth which
was successfully bleached using combination technique.
Case Report
An 11-year-old female patient reported to Department of Pediatric and Preventive Dentistry, with a complaint
of discoloration of tooth in the upper front region(fig. I). Patient gave a history of trauma 3 years back to upper
front left tooth, following which patient had pain and reported to a private practitioner for the same. Root canal
treatment was done but the patient noticed slight change in color of the same tooth which increased gradually.
At present, she reported to our department with a complaint of discoloration of tooth .
On intraoral examination a severely discolored tooth 21 was found with a fracture involving enamel,
dentine and pulp, and no restoration or coronal seal was seen. No abscess or tenderness was found i.r.t 21. IOPA
radiograph revealed a poorly condensed obturating material extruding periapically but deficient in cervical half
of the root canal. The GP points were seen extruding 3-4mm beyond the apex. There was blunderbuss canal
with a periapical radiolucency measuring 4-5 mm in sagittal plane and 3mm in transverse diameter. No cervical
erosion or root resorption were seen(fig.II).
Treatment plan-
Retreatment of tooth included apical seal, obturation, bleaching and final restoration.
Retrieval of the extruded obturating material had to be carried out either in orthograde manner or retrograde
manner after rasing a periapical flap. Apical plug was planned using MTA followed by obturation and finally
bleaching of discolored crown and composite resin restoration of the fractured segment.
Debris was cleaned out of the open root canal space with irrigating solutions (5.2% NaOCl and normal
saline). Old obturating material was removed in an orthograde manner with the help of d-limonene based Gutta
Percha solvent (Carvene ,Prevest). Complete removal of GP points was achieved in orthograde manner,
avoiding periapical surgical procedure (fig.III). A frank pus discharge was seen during the procedure, thus
cleaning and shaping of the canal followed by placement of triple antibiotic paste was performed. After 3
weeks, periapical radiolucency was reduced and bone deposition was seen in trabecular pattern. Then, MTA
apical plug was obtained followed by obturation of the canal space and IRM (Dentsply, Caulk) placement
(fig.IV and V).
Patient was recalled after 15 days , to find the tooth asymptomatic with no pathological feature. Preoperative shade matching was done with VITA classical shade guide (VITA Zahnfabrik,H.Rauter GmbH and
co.,Germany) as C4. After the application of protective cream on the surrounding gingival tissue, the tooth was
isolated with rubber dam and the access was re-established by removing IRM .Coronal gutta percha was also
removed from canals about 2 mm apical to cervical line. The cavity was irrigated with NaOCl to remove smear
layer and debris. A plug of 2 mm thickness of a resin-modified glass ionomer (Vitremer, 3M ESPE) was
placed on top of the gutta-percha filling in a shape conforming to the shape of outer CEJ and 1mm incisal to it
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Dr.Puneet Goyal et al. / IJRID Volume 4 Issue 1 Jan.-Feb 2014
by external probing of the CEJ and epithelial attachment to prevent percolation of bleaching agent into the
cervical and apical region. A mixture of sodium perborate and superoxol(30% H2O2) was placed inside the
cavity and a gauze piece dampened with superoxol was applied on labial surface to facilitate external bleaching
. Then repeated application of
heated instrument against dampened gauze was done
until the bleach
evaporates, taking care that the temperature was less than the patient could tolerate comfortably usually between
50ºC -60ºC. The procedure was continued for five minutes with the gauze being changed every one minute
(fig.VI and VII).
The bleaching mixture was removed and cavity was rinsed with normal saline. The shade was recorded again
(C1)(fig.VIII). A fresh mix of sodium perborate and superoxol as walking bleach was placed in pulp chamber.
The excess was removed with dampened cotton and cavity was sealed with IRM to a depth of atleast 3mm to
ensure good seal. Patient was recalled after every 7 days to change the Walking bleach paste. After 3 visits, the
shade (A2) as desired was obtained (fig.IX). Later, Ca(OH)2 paste along with GIC was sealed for two weeks .
After 2 weeks, composite resin build up was done (fig.X). 3 months postoperatively, the tooth is asymptomatic
with no change in shade and IOPA revealed decreased periapical radiolucency and no cervical erosion (fig.XI).
Discussion
This report describes a case where orthograde root canal treatment, retreatment and apexification were done
prior to intracoronal bleaching for treatment of a discolored infected maxillary left central incisor before
apexification.
Persistent or secondary intraradicular infection is a major cause of endodontic failures. Retreatment of
poorly obturated root canals is sometimes a necessity in endodontic practice. Over the years, nonsurgical
endodontic retreatment has replaced apical surgery as the treatment of choice for cases of endodontic therapy
failure. Various techniques are employed to remove gutta-percha, including the use of hand or rotary
instruments with or without heat application, solvents, and/or ultrasound. Different solvents have been largely
used to empty the root canal. Among them, Orange oil is an excellent alternative solvent as compared to
potentially toxic solvents, being used either on eugenol zinc-oxide cement or to soften and dissolve guttapercha. The periapical radiolucency eventually disappeared following orthograde retreatment along with
placement triple antibiotic paste.
With the present case, the difficulty in obtaining apical stops to enable controlled obturation was overcome
by placement of mineral trioxide aggregate (MTA) after interim treatment with an antibacterial agent. Mineral
trioxide aggregate (MTA) could be considered for use as an apical plug over the long-term placement of
calcium hydroxide, known to stimulate calcific barriers (Heithersay 1975) and exert an antimicrobial action
(Stevens & Grossman,1983) because of an advantage of speed at which the treatment can be completed.
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Dr.Puneet Goyal et al. / IJRID Volume 4 Issue 1 Jan.-Feb 2014
Finally bleaching was considered as treatment of choice for management of discolored crown as it improve
the appearance of discolored teeth while preserving tooth structure, and it avoids more costly invasive dental
treatment.
Bleaching is not new!! The earliest effort to lighten teeth through bleaching took place more than a
centuries ago, with bleaching agent painted directly on the tooth surface or packed inside a vital tooth.
The exact bleaching/whitening mechanism is not fully understood but is thought to involve the ingress of
oxidizers and oxygenating molecules via enamel micropores along a diffusion gradient and via direct access of
dentine. These are believed to reduce or cause degradation of high molecular weight and complex organic
molecules that reflect a specific wavelength of light that is responsible for the color of the stain. The resulting
degradation products are of lower molecular weight and composed of less complex molecules that reflect less
light, resulting in a reduction or elimination of discoloration.
Occurrence of external cervical resorption is a serious complication after internal bleaching procedures.
Animal studies have shown histological evidence of resorption after 3 months of bleaching[2]. This is probably
caused by the oxidizing agent, particularly 30 to 35% hydrogen peroxide. A postoperative radiograph after
bleaching and regular follow -up radiographs are recommended to diagnose possible cervical resorption.
According to Hansenbayless and David, as root filling does not adequately prevent diffusion of
bleaching agents from the pulpal chamber to the apical foramen, a valid cervical seal is necessary to prevent
radicular percolation of bleaching agent. The shape of the cervical barrier should be similar to the external
anatomic landmarks, thus reproducing CEJ position and interproximal bone level. The shape from facial view is
“bobsled tunnel” outline and proximal outline resembles “skislope”[12].
Application of catalase for three minutes following intracoronal bleaching also eliminates residual
hydroxyl ions thus can prevent cervical resorption. Acidulated thio urea is also an effective scavenger of
residual hydrogen peroxide and hydroxyl radicals generated during intracoronal bleaching.
Conclusion
It can be concluded that science of bleaching has become an important and valuable part of esthetic dental
arena. It is adjunct in endodontic treatment to get good aesthetic results. Proper diagnosis, selection of bleaching
materials, placement technique, and an understanding of the biologic interaction with soft and hard tissues are
all factors that determine not only immediate success but also long term success, safety, and patient satisfaction
as well.
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REFERENCES
1) Rolly Shrivastava Agarwal, Suparna Ganguly Saha: Inside-Outside bleaching of discolored non-vital
teeth. International Journal of Dental Clinics. 2011; 3(3): 95-96.
2) Plotino G, Buono L, Grande NM, Pameijer CH, Somma F: Nonvital tooth bleaching: a review of the
literature and clinical procedures. J Endod 2008 Apr; 34(4): 394-407
3) Dahl J.E. and Pallesen U: Tooth Bleaching--a Critical Review of the Biological Aspects. Critical
Reviews in Oral Biology & Medicine. 2003; 14(4): 292-304
4) Alyson Wray and Richard Welbury: Treatment Of Intrinsic Discoloration In Permanent Anterior Teeth
In Children And Adolescents. International Journal of Paediatric Dentistry 2001; 11(4): 309-315
5) Brigitte Zimmerli, Franziska Jeger, Adrian Lussi: Bleaching of Nonvital Teeth- Clinically Relevant
Literature Review. Research and Science 2010: 120(4); 306-313
6) Nagaveni N.B., Umashankara K.V.
, Radhika N. B. , Satisha T.S. et al: Management of tooth
discoloration in non-vital endodontically treated tooth – A report of 6 year follow-up. J Clin Exp Dent
2011; 3(2): e180-3
7) Anuradha Rani , Manisha Gotarkar : Walking Bleach-still Relevant; A Review With — A Case Report.
Indian journal of dental research 2009:1(2); 32-37
8) Pratima Shenoi, Archana Kandhari, Mohit Gunwal:
Esthetic enhacement of discolored teeth by
macroabrasion and microabrasion and psychological impact on patient-a case series.Indian Journal of
Multidisciplinary Dentistry 2012: 2(1)
9) Prasanna Neelakantan, Nithya Jagannathan: Non Vital Bleaching – A Non Invasive Post Endodontic
Treatment Option: A Case Report. .Journal of Clinical and Diagnostic Research 2012 May (Suppl-1):
Vol-6(3); 527-529
10) M. Sulieman. An Overview of Bleaching Techniques:1: History, Chemistry, Safety and Legal Aspects.
Dent Update 2004; 31: 608-616
11) . Ilan Rotstein : Tooth Discoloration And Bleaching. Ingle I.J., Leif K. Bakland. “ Endodontics”, 5th
Edn, William & Wilkins, 2003: 845-860.
12) Goldstein R.E,Garber DA.: “Complete Dental Bleaching”, Chicago: Quintessence Publishing Co. Inc;
1995.
13) Greenwall L, Fredman G, Gordan VV. “Bleaching techniques in restorative dentistry: An Illustrated
Guide”.New York: Martin Dunitz; 2001.
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Dr.Puneet Goyal et al. / IJRID Volume 4 Issue 1 Jan.-Feb 2014
PHOTOGRAPHS
Fig.I
(showing discoloration of tooth 21)
Fig.II (. IOPA radiograph revealed a poorly condensed obturating material extruding periapically, deficient in
cervical half of the root canal. The GP points were seen extruding 3-4mm beyond the apex. There was
blunderbuss canal with a periapical radiolucency )
fig.III (Complete removal of GP points)
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Dr.Puneet Goyal et al. / IJRID Volume 4 Issue 1 Jan.-Feb 2014
fig.IV
fig.V
(showing MTA apical plug was obtained followed by obturation of the canal
radiolucency)
Fig.VI
and reduced periapical
fig.VII
(mixture of sodium perborate and superoxol(30% H2O2) was placed inside the cavity and a gauze piece
dampened with superoxol was applied on labial surface to facilitate external bleaching)
Fig.VIII[shade was recorded again (C1)]]
Fig.IX (. After 3 visits, the shade (A2) as desired was obtained)
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Dr.Puneet Goyal et al. / IJRID Volume 4 Issue 1 Jan.-Feb 2014
Fig.X( composite build up done )
fig.XI(after 3 months)
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