Restorative

Dentistry

MANAGEMENT OF
TOOTH
DISCOLOURATION

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)

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)

CLASSIFICATION OF TOOTH
DISCOLOURATION
Extrinsic discolouration
Intrinsic discolouration

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).

AETIOLOGY OF DISCOLOURATION
Extrinsic Discolouration:
E.g.
Plaque, chromogenenic
bacteria
Mouthwashes
(chlorhexidine)

Smoking / chewing
tobacco
Beverages (tea, coffee,
red wine, cola)
Foods (curry, cooking oils
and fried foods, foods with
colorings, berries,
beetroot)
Antibiotics (erythromycin,
amoxicillin-clavulanic acid)
Iron supplements

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

AETIOLOGY OF DISCOLOURATION
Intrinsic Discolouration:
Pre-eruptive:

Post-eruptive:

Disease:

Trauma (e.g. pulpal

haemorrhagic products)
Primary and secondary
caries
Tooth wear
Dental restorative materials
Ageing
Chemicals
Antibiotics

Haematological diseases
Liver diseases
Diseases of enamel and dentine
(e.g. Amelogenesis/
Dentinogenesis imperfecta)

Medication:
Tetracycline, other antibiotic s

Fluorosis stains (excess F)

Enamel hypoplasia (trauma or
infection)

Minocycline (used to treat acne)

Types of Discoloration

Colour Produced

Extrinsic (Direct stains)

Tea, coffee and other foods
Cigarettes/cigars
Plaque/poor oral hygiene

Brown to black
Yellow/brown to black
Yellow/brown

Extrinsic (Indirect stains)

Polyvalent metal salts and cationic antiseptics
e.g. Chlorhexidine
Intrinsic
(Metabolic causes)
e.g. Congenital erythropoietic porphyria
(Inherited causes)
e.g. Amelogenesis Imperfecta
e.g. Dentinogenesis Imperfecta
(Iatrogenic causes)
Tetracycline
Minocycline
Fluorosis
(Traumatic causes)
Enamel hypoplasia
Pulpal haemorrhage products
Root resorption
(Ageing causes)
Internalized
Caries
Restorations

Black and brown

Purple/brown
Brown or black
Blue-brown (opalescent)
Banding appearance:
classically yellow, brown, blue, black or grey
Grey
White, yellow, grey or black
Brown
Grey black
Pink spot
Yellow

Orange to brown
Brown, grey, black

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

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

Non/minimally invasive

May not improve

aesthetics significantly,
may require further Rx
Microabrasion- soft
tissue irritation/
excessive tooth prep
(technique sensitive)

Non/minimally invasive

Cost, limitation on
shade improvement (a
few shade lighter only),
may fail/ need
repeating, compliance
(home bleaching)

May achieve a more

aesthetic result

Destructive, irreversible
(tooth tissue removal),
changes natural shape
of teeth, cost,
maintenance, oral
hygiene compliance
(interdental cleaning)

Removal of surface
stain
-Scale and polish
-Microabrasion

Bleaching
-Home bleaching,
Walking bleach

Restorative treatment
-Veneers, crowns

-Extrinsic staining
-Fluorosis, white spot
demineralisation,
enamel hypoplasia

-See later slides

Severely discoloured
teeth, e.g. tetracycline
staining (may bleach
1st)
Unaesthetic tooth
morphology (e.g. AI/DI)
Heavily restored teeth

To bleach or not to bleach?

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)

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 dont bleach as readily as crowns)
If patients cannot afford changing existing
restorations post-bleaching

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

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

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

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

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

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

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

H2O
H2o2

OOH-

O2
OOH-

MODE 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.

OHOOOH-

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

DCB
DCB

BREAK DOWN THE

STAIN MOLECULES

SCB

SCB

Before and after

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 ITS ILLEGAL PRACTICE...

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

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

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

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 inoffice bleaching will yield better results than
home bleaching.

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.

Bleaching: Part II
Walking Bleach/ NonVital Bleaching

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.

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%)

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

BEFORE AND AFTER:

EXAMPLE NON-VITAL BLEACHING

EXAMPLE NON-VITAL

EXAMPLE NON-VITAL

NON-VITAL BLEACHING

NON-VITAL BLEACHING

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)

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).

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.

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.

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.

Part III

Home Bleaching

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.

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 proceduredemo use, give leaflets

PATIENT INFORMATION

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 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.

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.

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

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.

SENSITIVITY

Cause:
Passage of
hydrogen peroxide
through enamel
and dentine to the
pulp
Manipulation of
teeth

55% to 75% of patients experience sensitivity

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

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

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 reservoirsrecommended (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.

TRAY DESIGN

TRAY DESIGN

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

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)

FURTHER READING
1.
2.

3.
4.
5.

6.

Greenwall, Linda. Bleaching techniques in restorative dentistry :

an illustrated guide
Haywood, Van B. TitleTooth whitening : indications and
outcomes of nightguard vital bleaching / Van B. Haywood;
Quintessence Publishing, 2007.
Van Haywoods article: Frequently Asked Questions About
Bleaching; Compendium / April 2003
GOLDSTEIN, Ronald E Complete dental bleaching; 1995;
Quintessence
Sulieman M. An Overview of Bleaching Techniques: 1. History,
Chemsitry, Safety and Legal Aspects. Dent Update 2004; 31:608616
Sulieman M. An Overview of Bleaching Techniques: 2. Night
Guard Vital Bleaching and Non-Vital Bleaching. Dent Update
2005; 32: 39-46

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.

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 proceduregive leaflets

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

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.

HISTORY (adapted from data in Haywood)

Year
1799
1884
1958
1961
1965
1987
1989
1989
1990
1991
1991
1996
1997
1998

Authors

Innovation

Chloride of lime is invented - Called bleaching

Macintosh
powder
Harlan
1st Hydrogen peroxide use
Used 35% HP inside tooth and suggested 25%HP
Pearson
with heated lamp
Spasser
Perborate sealed within tooth - "walking bleach"
Thermocatalytic Technique - pellet saturated with
suoperoxyl and heated with an instrument inside
Stewart
pulp chamber.
In office bleaching using 30% H2O2 and heat from
Feinmann
bleaching light
Croll
Microabrasion technique
10% CP used in trays overnight "Nightguard Vital
Haywood and Heyman Bleaching"

Bleaching products available OTC - contraversial !

Bleaching materials were investigated and the FDA
called for safety studies. Ban was lifted after

6months
Numerous authors Power bleaching using 30% HP and light activiation
Rayto
Laser tooth whitening
Settembrini et al
Inside-Outside bleaching technique
Carrilo et al
Open pulp chamber with CP inside