I was recently at the Ultradent Key Opinion Leader meeting, and I have to say I learned a lot! Specifically, it made me think about my patients with discoloration. Should I be reconsidering some of my bleaching cases and their protocol?
To Bleach, or Not To Bleach?
I often get patients with discolored teeth who come to me wanting some internal bleaching. There are cases where I will do it, and cases where I won’t. In my opinion — and some may disagree with me — internal bleach used in a root canal needs a canal or a chamber.
So for the cases in which there has been pulp canal obliteration after trauma, internal bleaching is not my treatment of choice. Why? Because I don’t feel like it is the most conservative or effective.
Now, one can argue that you can access the tooth to create your own chamber and do internal bleaching that way, but that’s not my treatment of choice. I like to leave that supporting dentin alone.
Tooth Story: Tooth #9
Let’s look at this tooth, for example, so I can walk you through my thought process and treatment plan. This patient has no pain, but is concerned of the slight discoloration of tooth #9.
She can’t remember any history of trauma, but you can see by the lingual retainer that she has a history of ortho. Her radiograph shows that tooth #9 is undergoing pulp canal obliteration (PCO).
The radiograph shows the PCO, but there is no sign of endodontic pathology. It’s interesting that she does have a bit of a chamber, though, and I can see a teeny-tiny canal if I look hard enough. All of her probings were within normal limits, she had no pain to percussion, and had no response to cold.
But just because the tooth didn’t respond to cold doesn’t mean it’s necrotic or dead. (Get my free Pulpal and Periapical Diagnosis Checklist for info on cold tests and more.) The pulp is just calcified and shielded. That’s why the tooth can’t feel the cold stimulus.
In fact, the pulp has to be vital in order for this process of PCO to occur. So in this case, the diagnosis is a Normal Pulp and Normal Apical Periodontium.
Now, before you go any further, I want to take you back to the basics. Do you remember the function of the pulp? It’s to lay down dentin.
So after trauma, the pulp overreacts. All it knows how to do is to do its job faster — so it starts to lay down a lot of dentin really quickly. And since dentin is yellow, these teeth tend to get a little more yellow.
It’s not the same process that is happening in other forms of tooth discoloration, and that’s why it’s harder to bleach internally.
Internal vs External Bleaching: What To Do About It
Can internal bleaching work in a case like this? Sure, but you have to take a lot of tooth structure away to get that done.
In the past, I would recommend a veneer for this type of tooth since it would be more conservative. But after this Ultradent KOL meeting and speaking to other clinicians, I am going to get even more conservative and say that this tooth can match the others with a good protocol of external bleaching.
Next time you have a patient like this walk through your door, try this protocol:
- Make a custom tray with a reservoir just on the darker tooth and remove the facial aspect on the adjacent teeth so that they don’t whiten.
- Use Opalescence PF 20% overnight until it whitens (hopefully one week).
- If you see that the tooth is not bleaching, then you can increase the concentration of your bleach to Opalescence PF 35% for one week overnight.
I don’t have a follow-up on this case, because her general dentist is doing the treatment (I will definitely get a follow up posted as soon as I can). But that brings up a great point: I get these cases referred to me all the time, and the truth is, this is a general dentist’s case. That means you can do it!
Why? Because it’s either a veneer or external bleaching. So there is no need to refer this patient out. If you get good at your testing and diagnosis (join E-School for help on that!), then this is something that you can 100% completely handle in your practice.
How do you feel about taking it on? Let me know in the comments.