Hey hey! So, a little while back I attended one of the Ultradent Key Opinion Leader meetings, and I learned SO MUCH! That’s one of the best parts about these events. This particular meeting taught me a new way of thinking about my patients with discoloration. Should I be reconsidering some of my bleaching cases and their protocol? Today we’re talking about internal and external bleaching of teeth and what to consider when you approach bleaching—hint: it’s not all about time savings, friends. It’s about what’s healthiest and safest choice for every patient and every tooth.
Let’s dig into that, shall we?
To Bleach, or Not To Bleach?
THAT is the question. I often get patients with discolored teeth who come to me wanting some internal bleaching. Whether or not I go through with it is determined on a case-by-case basis. 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 involving pulp canal obliteration after trauma, internal bleaching is not my treatment of choice. I don’t think it’s the most conservative nor the most effective option for my patient, and it definitely isn’t worth the possibility of compromising a tooth.
Now, one can argue that you can access the tooth to create your own chamber and do internal bleaching that way, but I’d prefer to avoid that if possible. I think it’s best to leave that supporting dentin alone. And if aesthetics are a concern, well, the look of the tooth can be improved with a veneer. Easy-peasy.
Tooth Story: Tooth #9
Let’s look at this tooth, for example, so I can walk you through my thought process and treatment plan. The first thing to notice is that this patient has no pain, but is concerned about the slight discoloration of tooth #9.
There’s no known trauma history, but you can see by the lingual retainer that she has a history of ortho. Her radiograph also indicates 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. Nothing major, but definitely something. All of her probings were within normal limits, she had no pain to percussion, and had no response to cold. Good feedback so far.
But just because the tooth didn’t respond to cold doesn’t mean it’s necrotic or dead. (While we’re on the subject, my free Pulpal and Periapical Diagnosis Checklist is really helpful for acing your diagnoses. Just sayin’.) The pulp here is simply calcified and shielded. Ah,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.
Let’s Talk Pulpy Stuff!
Now, before you go any further, I want to take you back to the basics. More pressing than breaking down how long internal or external bleaching takes or if it’s even possible given the tooth’s anatomy, I think it’s WAY more important to think about WHY the tooth is discolored.
Because that’s going to be crucial when it comes to figuring out the way forward.
Do you remember the function of the pulp? Well, it’s to lay down dentin.
After trauma, the pulp overreacts. All it knows how to do is complete its job faster—so it starts to lay down a lot of dentin super fast! 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 and External Bleaching of Teeth: Let’s Talk Strategy
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.Â
Next time you have a patient like this walk through your door, try this:
- 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 (ideally this will only take a week or so!).
- If you see that the tooth isn’t bleaching, then you can increase the concentration of your bleach to Opalescence PF 35% for one week (to be used overnight).
I don’t have a follow-up on this case, because her general dentist is doing the treatment. 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. You know what that means? This is something you can do!
There is no need to refer this patient out because it’s either a veneer or external bleaching. 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 that on?
And how do you manage the applications of internal and external bleaching of teeth in your practice?
As dentists, a lot of our work requires patience and applying our expert judgment and guidance. It’s all about making our patients’ teeth stronger and healthier!
Drop your thoughts on bleaching in the comments!
–Â Sonia
Opalescent bleach for external bleaching chair side
Yes, I recommend using Opalescence for cases like this. Thank you!
-Sonia
How will you make a custom tray with that reservoir on that darker tooth?Will you ask the lab to do it or just like night guard tray in office..Didn’t quite understand how you would make this tray..Do u hv any photos?
Hi there, this is an in office bleaching tray, so there is no need to send it to the lab.
Once you make the cast, you will need to add some material on the tooth that needs to be bleached to bulk it up on the facial aspect. Something like Opaldam would work great in this case!
This will make a reservoir around that tooth so more bleach can be held in that area of the tray. Then after using a vacuum former to make the tray, you will simply cut out the plastic area from the adjacent teeth. Bleach will only be used for that one tooth for the week.
I hope that helps!
-Sonia
If it’s had root canal therapy, we remove the coronal tooth structure and use a superoxol pellet.
That’s right! Thanks for reading.
-Sonia
How long does the bleaching last? Is there a risk to doing it again repeatedly every time it relapses at some point or is a veneer more conservative long term?
Sneha,
When done right, it will last a very long time if not forever. There is always a risk of cervical resorption when doing internal bleaching so one needs to be careful and really follow all the rules.
Best,
Sonia
Hi! This exact happened to me but I don’t want to be invasive to the tooth. When external bleaching is done in a tooth like this is it permanent or as time passes will be discolored again?I’ll have mine externally bleached next week. Please advise
Rebeca,
There is always a chance for relapse and you may have to do more bleaching in the future.
-Sonia
I have been whitening teeth for over 30 years. My first comment is that a single anterior veneer or for that matter two anterior veneers on centrals is hard/hard especially on women with thin biotype and show their teeth like Marie Osmond. My first line of treatment is exactly what you have recommended and it always seems that this discoloration is deep and they are stubborn, so warn the patient. It sometimes can take six weeks. My second line of treatment is if the tooth has a previous root canal I make the same kind of tray for the individual tooth but I also make a full whitening tray for the other teeth (patients always want all of their other teeth whiter). I then have the patient in and remove the filling and gutta percha to below the cervical line. I then use Fuji II to seal over the gutta percha. We then do in office Laser whitening on this individual tooth (used to use Zoom Whitening). We also place the rubber dam, microetch with a Danville Prep-Start and acid etch the tooth for 30 seconds both inside and out. I then provide an irrigation syringe, syringe/s of whitening gel and instruct the patient on cleaning out the internal of the tooth, using the whitening gel and tray. I tell the patient to contact our office when the darkened tooth is lighter than the adjacent teeth. When this is the case we have them in and discuss further whitening if the desire is for overall lighter teeth and we close the access opening with the lightest color composite that we can find. I have tried the walking bleach treatment many times and have never had successful results but that may be just me. My third line of treatment is for teeth such at the one in your patient. We pulp test the tooth and take a cone beam and determine whether there is the possibility of any pulp being present. Usually the patient has whitened elsewhere and are frustrated by the tooth still being dark. If I feel there is no pulp then I do a root canal preparation and go through the procedure above. Have overall had excellent success but not always, the teeth always lightened but sometimes not to the patient’s satisfaction. I maybe just lucky but I have never had any resorptive defects develop on any of these teeth. Thanks for the subjects that you present to us.
Michael,
Awesome feedback. Thank you for posting!
-Sonia
If it’s had root canal therapy, we remove the coronal tooth structure and use a superior pellet.
Thanks for your comment.
-Sonia
Nice article, thanks for sharing such a great content!
You ever get a follow up on results?
I was punched in cheek 23 years ago. My front tooth went numb since. I had a couple dentists confirm it is dead and xrays reveal it has filled in nicely with dentin. Root canal was not recommended. My dead tooth is not a dark brown. It looks yellow and grey depending on light and most people don’t notice.
My dentist recommends a veneer as internal bleaching is risky.
However I still hate the idea of removing enamel and perpetually having to whiten teeth to match veneer. This external bleaching sounds like it might work.
Jonathan,
I would trust your dentist, sometimes the veneer is the only way. But, it sounds like your issue is esthetic only and if the color doesn’t bother you, then there is no need to do any treatment.
I hope this helps.
Sonia