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.

Image of tooth #9 as a candidate for external bleaching

Radiograph of tooth #9 for external bleaching case

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. 

Next time you have a patient like this walk through your door, try this:

  1. 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.
  2. Use Opalescence PF 20% overnight until it whitens (ideally this will only take a week or so!).
  3. 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!

–  Sonia