Management of discolored teeth:current concepts and techniques

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Management of discolored teeth: current concepts & techniques:

Management of discolored teeth: current concepts & techniques By Sajid Ali JR II Dr Z A Dental College, AMU, Aligarh

Introduction:

Introduction Tooth discolorations are associated with many clinical and esthetical challenges. They can have an impact on a person’s self-image and self-confidence in today’s society, where most people place tooth color high. As professional we should make correct diagnosis and the choice of the most conservative treatment plan with an aesthetic outcome that is acceptable to the patient. This information is also important in order to explain the nature of the condition to the patient and to give him/her help to prevent or limit existing tooth discolorations, and when to consider whether or not to treat the condition .

causes:

causes Patient related Pulp necrosis Intrapulpal hemorrhage Dentin hypercalcification Age Tooth formation defects Developm-ental Drug-related

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Dentist related Endodontically related Restoration related amalgams Pins & posts Obturating materials Intracanal medication Pulp tissue remnants composite

Color of natural teeth?:

Color of natural teeth? Teeth are polychromatic. The color varies among the gingival, incisal , and cervical areas according to the thickness, reflectance of different colors and translucency in enamel and dentine. The color of healthy teeth is primarily determined by the dentine and is modified by: The color of the enamel covering the crown The translucency of the enamel which varies with different degrees of calcification The thickness of the enamel which is greater at the occlusal/ incisal edge of the tooth and thinner at the cervical third .

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The gingival margin often has a darker appearance because of the close approximation of the dentine below the enamel. In most people canine teeth are darker than central and lateral incisors and younger people characteristically have lighter teeth, particularly in the primary dentition The normal color of teeth is determined by the blue, green and pink tints of the enamel and is reinforced by the yellow through to brown shades of dentine beneath. .

Color and color perception:

Color and color perception The science of color is important in dentistry with regard to color perception and description, and can be improved with training . The viewing conditions are extremely important and variables such as the light source, time of day, surrounding conditions and the angle the tooth is viewed from affect the apparent tooth color. In judging tooth color it is best if the light source used is standardized to reduce the effects of metamerism . Light is composed of differing wavelengths and the same tooth viewed under different conditions will exhibit a different colour , a phenomenon known as metamerism .

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Generally, three common sources of light in clinics are available: Natural Fluorescent Incandescent Particular light sources are known to have an effect at characteristic ends of the spectrum Natural sunlight varies in its color , at noon the sky appears blue with minimal atmosphere to penetrate . Early morning and late evening sunlight has a red-orange tinge as the shorter wavelength blue light is scattered by the atmosphere and only red and orange rays penetrate.

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Incandescent light will accentuate the red-yellow end of the spectrum and weaken the blue end. A fluorescent light source has more energy towards the blue-green end of the spectrum and accentuates these colors accordingly.

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Specially developed color-corrected lights are available which help to reduce the effects of metamerism , by providing even colour distribution. The aesthetic aspects of tooth colour are difficult to quantify and colour perception is highly subjective and prone to individual variation. Disagreement between dentists in shade matching the same tooth has been documented by Culpepper , not only between dentists, but also the same dentist on different occasions.

Munsell system:

Munsell system Color components : Hue enable one to distinguish between different families of colour , for example reds, blues and greens .

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V alue Value is the relative lightness and darkness of a colour on a scale from black to white. High value = brighter (more white) Lower value = darker (more gray) Value of 0 = black Value of 10 = white

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Chroma Chroma is the degree of colour saturation and describes the strength of a colour as it changes , for example, from pink to crimson. Low chroma ≡ “ weak saturated” High chroma ≡ “ highly-saturated

Classification of tooth discoloration:

Classification of tooth discoloration The formation of intrinsically discolored teeth occurs during tooth development and results in an alteration of the light transmitting properties of the tooth structure. Alkaptonuria : Brown Discoloration I- INTRINSIC DISCOLORATION

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Congenital erythropoietic porphyria : R ed- brown discolouration of the teeth is the result and the affected teeth show a red fluorescence under ultra-violet light. King George III was said to have suffered with acute intermittent porphyria but with the later onset of this disorder his teeth are unlikely to have been affected.

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Congenital hyperbilirubinaemia : Yellow-green discoloration Amelogenesis imperfecta : In this hereditary condition, enamel formation is disturbed with regard to mineralization or matrix formation and is classified accordingly . The appearance depends upon the type of amelogenesis imperfecta , varying from the relatively mild hypomature ‘snow-capped’ enamel to the more severe hereditary hypoplasia with thin, hard enamel which has a yellow to yellow-brown appearance.

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Systemic syndromes: Defects in enamel formation may also occur in a number of systemically involved clinical syndromes such as Vitamin D dependent rickets, epidermolysis bullosa and pseudohypoparathyroidism . Barabas has reported areas of hypoplastic enamel , irregularities in the region of the amelo -dentinal and the cemento -dentinal junctions in Ehlers- Danlos Syndrome. In epidermolysis bullosa there is pitting of the enamel possibly caused by vesiculation of the ameloblast layer.

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Dentinogenesis imperfecta : Both dentitions are affected, the primary dentition usually more severely so. The teeth are usually bluish or brown in colour , and demonstrate opalescence on transillumination . The pulp chambers often become obliterated and the dentine undergoes rapid wear, once the enamel has chipped away, to expose the amelo -dentinal junction . Once the dentine is exposed, teeth rapidly show brown discolouration , presumably by absorption of chromogens into the porous dentine.

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Dentinal dysplasias : Type I dentine dysplasia - Amber discoloration Type II dentine dysplasia - Brown discoloration Tetracycline staining: The color changes involved depend upon the precise medication used, the dosage and the period of time over which the medication was given . Teeth affected by tetracycline have a yellowish or brown-grey appearance which is worse on eruption and diminishes with time. Exposure to light changes the color to brown, the anterior teeth are particularly susceptible to light induced color changes .

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chlortetracycline - slate grey discoloration. Oxytetracycline - creamy discoloration . under ultraviolet light affected teeth fluoresces , giving off a bright yellow color

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Fluorosis: The enamel is often affected and may vary from areas of flecking to diffuse opacious mottling , whilst the color of the enamel ranges from chalky tooth discoloration and staining white to a dark brown/black appearance .

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Enamel hypoplasia: There may be pitting or grooving which predisposes to extrinsic staining of the enamel in the region of tooth disturbed, often then becoming internalized.

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Pulpal haemorrhagic products: Grossman asserted in 1943 that the depth of dentinal penetration of iron sulphide determines the degree of discoloration .

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Root resorption : presenting feature is a pink appearance at the amelo-cemental junction

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Ageing: The natural laying down of secondary dentine affects the light-transmitting properties of teeth resulting in a gradual darkening of teeth with age.

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II - EXTRINSIC DISCOLORATION Non Metallic Metallic A re adsorbed onto tooth surface deposits such as plaque or the acquired pellicle. Associated with occupational exposure to metallic salts and with a number of medicines containing metal salts. Dietary components T obacco Mouthrinses Chromogenic bacteria M edicaments Iron - black Copper - green potassium permanganate - violet to black silver nitrate - grey stannous flouride – golden brown

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III - INTERNALISED DISCOLORATION Internalised discoloration is 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. The routes by which pigments may become internalised are: 1. Developmental defects 2. Acquired defects a) Tooth wear and gingival recession b) Dental caries c) Restorative materials

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Developmental defects: Developmental defects may expose dentine either directly or later increased enamel porosity as in hypoplasia and hypocalcification or early loss of enamel as in dentinogenesis imperfecta . Thus Chromogens are then able to enter the dentine directly or facilitated almost certainly by the tubule system. Internalised stain in enamel cracks

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Acquired defects: Tooth wear and gingival recession- As enamel thins the teeth become darker as the colour of dentine becomes more apparent. Once dentine is exposed the potential of chromogens to enter the body of the tooth is increased. Physical trauma can also result in bulk loss of enamel or enamel cracks, both of which facilitate internalisation of extrinsic stains Gingival recession with dentine discoloration

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Dental Caries: The initial lesion is characterised by an opaque, white spot. The hard, arrested lesion is black having picked up stain from exogenous sources

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Restorative materials including amalgam: Long standing amalgam restoration – dark blue discoloration

Diagnosis & Treatment Planning :

Diagnosis & Treatment Planning

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Complete medical history : Even though tooth whitening is inherently a cosmetic procedure, the dentist is fully responsible for the wellness of the patient as with any other dental treatment . pregnancy Tetracycline exposure It will be helpful for to know whether tetracycline has had any part in the discoloration of the teeth. This knowledge may change both the approach to, and prognosis of, treatment. Fluoridation Sensivity Habits

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Pretreatment picture: The dentist should take a picture before commencing any treatment; in fact, the photographic record should be made prior to removing the surface plaque from the teeth. This picture is then called the baseline.

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General oral examination: It involves inspection of the soft tissues, hard tissues, and a radiographic analysis. Also, the dental IQ of the patient can easily be determined at this time. This observation may provide clues to the patients future cooperation during the treatment phase, and to the likely retention of the result that hve been achieved through whitening. This is very good time to instill awareness of oral hygiene procedures and their imporatnce , since the patient is receptive and motivated to cooperate.

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Perform prohylaxis : Routine scaling and prophylaxis will eliminate the plaque, calculus and extrinsic staining. This step by itself may achieve a significant degree of tooth whitening, and provide enough reinforcement to the patient.

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Detailed examination and diagnosis: Once extrinsic staining has been eliminated, the patient and the dentition are re-evaluated. The dentist, now familiar with the patients dental and medical histories, is in much better position to evaluate the cause of dental discoloration. Once the etiology is established, the dentist can determine the likely prognosis of his choice of treatment, its duration, and any difficulties that may arise in its implementation.

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The use of tranillumination to evaluate the internal morphology of the tooth is helpful in determining the severity of the case. As the bright light passess through the different layers of enamel and dentin, it provides the information on the opacity and depth of any discoloration or hypocalcification . The light may also reveal incipient caries missed by other diagnostic means.

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Treatment plan: The nature of the problem is briefly described to the patient. A detailed discussion of the proposed treatment plan, the prognosis, benefits, potential problems, and the leghth of the treatment will serve to inform the patient adequately enough to decide on whether he is willing to proceed. The other most important thing is clear communication of the cost to the patient.

Treatment modalities for discolored teeth :

Treatment modalities for discolored teeth

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Treatment option to discolored teeth can vary depending on the cause and these may include: Avoidance of foods and beverages that causes stains Tooth brushing and flossing Professional tooth cleaning Enamel micro abrasion Composite resin restoration Veneers Bleaching

Tooth brushing & flossing:

Tooth brushing & flossing Effective tooth brushing twice a day with a dentifrice helps to prevent extrinsic staining. Most dentifrices contain an abrasive, a detergent, and an antitartar agent. In addition, some dentifrices now contain tooth-whitening agents.

Enamel micro abrasion:

Enamel micro abrasion Microabrasion involves the removal of a small amount of surface enamel and classically incorporates both ‘abrasion’ with dental instruments and ‘erosion’ with an acid mixture. The term “ abrosion ” has been used by some authors Indication : fluorosis post-orthodontic demineralisation localised hypoplasia due to infection or trauma, and idiopathic hypoplasia where the discoloration is limited to the outer enamel layer

Professional tooth cleaning:

Professional tooth cleaning Some extrinsic stains may be removed with ultrasonic cleaning, rotary polishing with an abrasive prophylactic paste, or air-jet polishing with an abrasive powder . However, these modalities can lead to enamel removal; therefore, their repeated use is undesirable

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There are 2 main technique for microabrasion hydrochloric acid/pumice technique phosphoric acid/pumice technique These techniques are simple to perform and the depth of enamel removed in 10 applications is approximately 100 μm . (0.1 mm .). Analysis of the effectiveness of microabrasion should be delayed for approximately one month post-treatment, as the appearance of the teeth will continue to improve during this time

Composite Resin Restorations:

Composite Resin Restorations Resin can be used either in 2 ways- to camouflage/replace discrete localised areas of abnormal enamel ( localised composites ) to cover the entire enamel surface (veneer ) Indication moderate to severe fluorosis, localised hypoplasia not responsive to microabrasion , chronological hypoplasia ,

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tetracycline staining, discoloration due to loss of vitality not responsive to non-vital bleaching, amelogenesis and dentinogenesis imperfecta , and idiopathic hypoplasia.

Composite Veneers:

Composite Veneers These are quickest and most economic method of obtaining an esthetic tooth . Require less time Cost effective Best candidate for the direct resin veneer is the monochromatic shaded tooth, since multicolored restorations are much more easily constructed in the laboratory.

Porcelain Veneers:

Porcelain Veneers Porcelain veneers are indicated for hypoplastic and discoloured teeth in patients aged 16 years and over, when techniques such as microabrasion , non-vital bleaching and composite resins have failed to produce a satisfactory clinical result.

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Advantages: Conservation of tooth structure: most of the preparations have their margins on enamel (depth of reduction between 0.3 -0.7mm), with / without involving the incisal edges. Esthetics : there is a greater possibility to control color and surface texture with ceramic than other materials. Porcelain can be stained both internally and superficially giving vitality to the restoration. Texture can be developed. Texture can be developed on the veneer surface to simulate that of adjacent teeth and can be maintained indefinitely Color stability : There is a dual fold advantage, as porcelain offers better inherent color control and a natural look as well as the ongoing stability of these colors.

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Bond Strength: The bond of the etched porcelain veneer to the enamel surface along with the silane coupling agent is considerably stronger than other veneering systems Periodontal Health : because of the highly glazed porcelain surface, there is less depository area for plaque accumulation as compared to other laminate systems. Resistance to abrasion: The wear and abrasion resistance is exceptionally high compared to composite and acrylic resins. Inherent Porcelain Strength : The veneer itself is rather fragile, but once it is luted to enamel, the restoration develops high tensile and shear strengths..

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Disadvantages: Time: The placing of Veneers is technique sensitive and therefore time consuming. Repair : The veneers cannot be easily repaired once they are luted to enamel. Removal of the restoration will require grinding it off the tooth surface. Technique Sensitive : the entire procedure is to be followed in a sequential manner. Carelessness at any stage can have a disastrous outcome. Change of shade: It is difficult to modify color once the veneers are luted in position on the enamel surface . Cost : The dental fee for a porcelain laminate can generally be equal to even more than the normal fee for an anterior full crow.

Bleaching (tooth whitening):

Bleaching (tooth whitening) Materials: Hydrogen Peroxide : Various concentrations of this agent are available, but 30 to 35% stabilized aqueous solutions ( Superoxol ) are the most common. Sodium Perborate : When fresh, it contains about 95% perborate , corresponding to 9.9% of the available oxygen. Sodium perborate is stable when dry. In the presence of acid, warm air, or water, however, it decomposes to form sodium metaborate , hydrogen peroxide, and nascent oxygen .

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Three types of sodium perborate preparations are available: monohydrate, trihydrate , and tetrahydrate . They differ in oxygen content, which determines their bleaching efficacy. Commonly used sodium perborate preparations are alkaline, and their pH depends on the amount of hydrogen peroxide released and the residual sodium metaborate . Sodium perborate is more easily controlled and safer than concentrated hydrogen peroxide solutions. Therefore, it should be the material of choice in most intracoronal bleaching procedures.

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Carbamide Peroxide : This agent, also known as urea hydrogen peroxide, is available in the concentration range of 3 to 45 %. popular commercial preparations contain about 10% carbamide peroxide, with a mean pH of 5 to 6.5. Solutions of 10% carbamide peroxide break down into urea, ammonia, carbon dioxide, and approximately 3.5% hydrogen peroxide. Bleaching preparations containing carbamide peroxide usually also include glycerine or propylene glycol, sodium stannate , phosphoric or citric acid, and flavor additive. Carbopol , a water-soluble polyacrylic acid polymer, is added as a thickening agent . Carbopol also prolongs the release of active peroxide and improves shelf life.

Bleaching technique:

Bleaching technique Non Vital bleaching : Walking bleach In office Thermocatalytic technique Vital bleaching: In office or power bleach Home applied, dentist prescribed or nightguard bleach

Non vital bleaching:

Non vital bleaching Walking bleach technique: The first description of the walking bleach technique with a mixture of sodium perborate and distilled water was mentioned in a congress report by Marsh and published by Salvas . The root filling should be reduced 1–2mm below the CEJ. To prevent diffusion of bleaching agents from the pulpal chamber to the apical foramen a base of temporary material of 2mm thickness is necessary. Sodium perborate ( tetrahydrate ) mixed with distilled water in a ratio of 2:1 (g/mL) is a suitable bleaching agent. In case of severe discoloration , 3% hydrogen peroxide can be applied in lieu of water. The bleaching agent should be changed every 3-7 days.

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Indication Discoloration of pulp chamber Dentin discoloration Discoloration not amenable to extracoronal bleaching Contraindication Superficial enamel discoloration Defective enamel formation Severe dentin loss Prescence of caries Discolored composites

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In office bleach: The in-office procedures can also be used when the walking bleach technique does not produce satisfactory results after 3– 4 applications. The carbamide peroxide gels or hydrogen peroxide at high concentrations (15%–35%)is applied by means of a bleaching tray and is placed directly on the tooth , without an access opening. Some authors suggest the whitening gel is applied by means of a bleaching tray to bleach both buccal surface and pulp chamber through the access opening .

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Thermocatalytic technique: This technique involves placement of 30%–35% hydrogen peroxide in the pulp chamber followed by heat application by electric heating devices or specially designed lamps. It has been observed that heat application causes a reaction that increases bleaching properties of the hydrogen peroxide. Heat application is repeated 3 or 4 times at every appointment, changing the pellet with “fresh” bleaching agent at each visit. When heat is applied, a reaction produces foam and releases the oxygen present in the preparation.

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Complications and Adverse Effects of nonvital bleach: External Root Resorption Chemical Burns . Damage to Restorations : Scanning electron microscopy suggests a possible interaction between composite resin and residual peroxide, causing inhibition of polymerization and an increase in resin porosity. This presents a clinical problem when immediate esthetic restoration of the bleached tooth is required. It is therefore recommended that residual hydrogen peroxide be totally eliminated prior to composite placement .

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Suggestions for Safer Bleaching of Endodontically Treated Teeth : Isolate the tooth effectively Protect the oral mucosa Verify adequate endodontic obturation . Use protective barriers . Avoid acid etching Avoid strong oxidizers . Avoid heat . Recall periodically.

Vital bleaching:

Vital bleaching Many techniques have been advocated for extracoronal bleaching of vital teeth. In these techniques, oxidizers are applied to the external enamel surface of the teeth . In office power bleach: This technique basically involves application of 30 to 35 % hydrogen peroxide and heat(52°C to 60°C ) or a combination of heat and light or ultraviolet rays to the enamel surface .

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Indications: Light enamel discolorationion Mild tetracycline discolorations Endemic fluorosis discolorations. Age related discolorations . Contraindication: Severe dark discolorations Severe enamel loss Proximity of pulp horns Hyper sensitive teeth Presence of caries Large/poor coronal seal

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Laser-Activated Bleaching Two types of lasers can be employed : the argon laser that emits a visible blue light and a carbon-dioxide laser that emits invisible infrared light . These lasers can be targeted to stain molecules and , with the use of a catalyst, rapidly decompose hydrogen peroxide to oxygen and water. Argon laser: best for removal of initial dark stains , such as those caused by tetracycline. However, visible blue light becomes less effective as the tooth whitens , and there are fewer stain molecules. carbon-dioxide laser interacts directly with the catalyst/peroxide combination and removes the stain regardless of the tooth color.

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Mouthguard Bleaching: This technique has been widely advocated as a home bleaching technique, with a wide variety of materials, bleaching agents, frequency, and duration of treatment 10- 15 % carbamide peroxide is recommended for this technique which releases 3% H2O2 and 7% urea. Carbopol is added as a thickening agent to extend the oxidation process . Make an alginate impression of the arch to be treated . Cast the impression and outline the guard on the model. It should completely cover the teeth.

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Place two layers of die relief on the buccal aspects of the cast teeth to form a small reservoir for the bleaching agent Insert the mouthguard to ensure a proper fit. Remove the guard and apply the bleaching agent in the space of each tooth to be bleached. Reinsert the mouthguard over the teeth and remove excess bleaching agent . The procedure is usually performed 3 to 4 hours a day, and the bleaching agent is replenished every 30 to 60 minutes.

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Indication: Superficial enamel discoloration Mild yellow discoloration Brown fluorosis discoloration Age related discoloration Contraindication Severe enamel loss Hypersensitive teeth Presence of caries Bruxism Allergy to bleaching agents

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Complication and adverse effects of vital bleach : Postoperative Pain. Pulpal Damage . Dental Hard Tissue Damage . Mucosal Damage . Occlusal Disturbances

Treatment options for different kind of discoloration :

Treatment options for different kind of discoloration

Alkaptonuria:

Alkaptonuria There is no reports describing how to treat the stained teeth caused by alkaptonuria . Bleaching should be tried first, but the blue or grey stains are difficult to change. When the stains do not respond to bleaching, they have to be either removed by abrasion or masked by restorative treatment.

Congenital erythropoietic porphyria:

Congenital erythropoietic porphyria To improve the aesthetics in teeth with red-brown porphyrin pigments deposited. The dental treatment options are crowns, facings and/or laminated veneers

Congenital hyperbilirubinaemia:

Congenital hyperbilirubinaemia The treatment for the condition is bleaching or placement of esthetic crowns

Amelogenesis imperfect:

Amelogenesis imperfect The common clinical problems are poor esthetics, tooth sensitivity, and extensive tooth wear. Management in affected children and adolescents have to be focused on improving esthetics, reducing sensitivity, correcting or maintaining vertical dimension and restoring the masticatory function AI may have psychosocial impact on young patients. Early diagnosis is therefore very important in order to offer proper preventive and restorative treatments over several phases. The “ temporay phase” starts soon after diagnosis in the primary or mixed dentition and is continued with a “transitional phase”, providing the patient with a functional and esthetic permanent teeth before the “permanent treatment phase” in adulthood

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The treatment of different AI types depends on the AI type and the phenotype of the affected enamel. The treatment can range from preventive care using sealants, tooth whitening, microabrasion , and bonded technique for esthetic improvement to prosthetic reconstruction.

Dentinogenesis imperfecta:

Dentinogenesis imperfecta Bleaching and prosthetic crowns

Tetracycline:

Tetracycline Haywood has shown that tetracycline-stained teeth may respond to long bleaching treatments, some tetracycline discolorations can require from 1 to 12 months of treatment every night. Extended treatment time can give sensitivity episodes. Leonard et al. (2003) stated in their study that nightguard vital bleaching indicates that tetracycline-stained teeth can be whitened successfully using a 6 month active treatment with 10% carbamide peroxide, and that shade stability may last at least 90 months post treatment

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P rognosis of vital bleaching D egree I - Good Degree II – Variable Degree III & IV - poor In cases where the teeth are severely stained in the gingival area and a bleaching treatment has no effect, porcelain veneers or placement of a crown will be options to restore esthetics and function. According to Haywood it is best to try bleaching first, and then abrasion, or bonded technique, because one of the mentioned treatment options may have a satisfactory effect and eliminate the need for more conventional treatments

Fluorosis:

Fluorosis The choice between different treatments depends on the severity of the fluorosis and may be determined by the Thylstrup and Fejerskov index. M ild fluorosis - bleaching . Moderate fluorosis - bleaching or in combination with microabrasion . Severe fluorosis - porcelain laminate veneers, restorations or crowns

Pulpal haemorrhagic product:

Pulpal haemorrhagic product It has been shown that the pinkish hue seen initially after trauma might disappear in 2-3 months if the tooth becomes revascularized . It is therefore wise to wait for 3 months before a bleaching treatment

Pulp necrosis:

Pulp necrosis Intracoronally bleaching is the treatment of choice. According to Plotino trauma- or necrosis-induced discoloration can be successfully bleached in about 95% of the cases, compared with lower percentages for teeth discolored as a result of medicaments or restorations Stains caused by metallic ions are difficult to remove with bleaching

Enamel hypoplasia:

Enamel hypoplasia Treatment options depend on the severity of EH and the symptoms associated with it.

Tooth wear and gingival recession:

Tooth wear and gingival recession To improve appearance of discolored roots of teeth, the exposure to bleaching materials requires usually treatments of long periods, longer than what is common for the bleaching of the enamel.

conclusion:

conclusion It is important that patients are aware of the different treatment options available for tooth discolorations and of course the consequences of these. An effective communication between the dental practitioner and the patient will prevent many misunderstandings and disappointments with the final result . In the management of patients with stained teeth it is very important to know and understand the mechanisms behind the tooth discoloration, and the clinical features of different types of tooth staining in order to make a correct diagnosis.

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Brown and yellow stainings are easier to change, while gray and blue stains are mostly resistant to bleaching and the discolorations located in the gingival area have a poor prognosis . There are no guidelines telling the dental practitioner when it is correct to carry out operative treatment. Therefore, in cases with esthetic problems, it is important to understand the self-perceived opinion of the patient in treatment planning.

Thank you:

Thank you

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