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Corresponding author
Dr. Brigitte Zimmerli, Klinik fr
Zahnerhaltung, Prventiv- und
Kinderzahnmedizin,
Freiburgstrasse 7, 3010 Bern
Tel. +41 31 632 25 80
Summary Today, the bleaching of nonvital, solution, the effects of which can largely be
Fax +41 31 632 98 75
E-mail: discolored teeth is a low-risk routine treat- attributed to dehydration of the teeth. There
brigitte.zimmerli@zmk.unibe.ch ment for improving esthetics. This review ar- are still some open questions concerning the
Schweiz Monatsschr Zahnmed 120: ticle focuses on the etiology of tooth discolor- bleaching agents. Improved safety seems de-
306313 (2010) ations, different treatment techniques, and sirable with regard to adding thiourea as a
Accepted for publication: risks of bleaching procedures. Some tooth scavenger of radicals or newer materials such
7 July 2009
discolorations in endodontically treated teeth as sodium percarbonate. The thermocatalytic
are caused by dental treatments. The three technique, insufcient cervical sealing, and high
most popular techniques for nonvital tooth concentrations of bleaching agents should
bleaching are the walking bleach technique, be avoided, as this can increase the risk of
inside/outside bleaching, and in-ofce bleach- cervical root resorptions. Patients should be
ing. The walking bleach technique is a rela- informed about the low predictability of
tively reliable, fairly simple technique for den- bleaching success and the risk of recurrent
tists and patients. Inside/outside bleaching discoloration. The risk of cervical root resorp-
can be used additionally when internal and tion should be discussed with the patient.
external bleaching must be combined. In- There is a strong correlation between root
ofce bleaching seems to be a short-term resorption and dental trauma.
Recurrence
The recurrence rate in bleached, endodontically treated teeth
is relatively high, and the mechanism has not been completely
elucidated. Depending on the study, the reported recurrence rate
after two years is 10%, after ve years 25%, and after eight years
49% (Friedman 1997, Friedman et al. 1988, Holmstrup et al.
1988, Glockner et al. 1999). The outcome in another study is
sobering: six years after bleaching, a success rate of 45% was
documented; the conclusion was drawn that bleaching non-
vital teeth does not constitute a long-term solution in the
permanent dentition (Feiglin 1987). However, that study is Fig. 3 Baseline situation with Vita color key. Tooth 11 shows greater discol-
relatively old, and bacterial management during bleaching oration than the shade sample Vita C4.
procedures was not adequately performed. Moreover, the ll-
ings were largely placed without the adhesive technique, which
led to increased penetration of pigments. It is known that most
discoloration of nonvital teeth arises as a result of degradation
products of hemoglobin and pulpal tissue (Arens 1989). Then
as now, it is not clear whether the recurrence of discoloration
in bleached teeth is caused by the same substances or by pen-
etration of pigments from the oral cavity. Observations from
daily practice indicate that bleaching success has largely been
modest, or discoloration recurrence happened quickly if the
tooth became discolored relatively soon after endodontic treat-
ment (Dietschi 2006). In a long-term follow-up of 35 patients,
22 cases (62.9%) presented satisfactory results 16 years after
bleaching treatment (combined method: in-ofce bleaching
with subsequent walking bleaching). In 13 patients (37.1%),
the result was no longer satisfactory and obvious darkening
had taken place. No root resorptions occurred (Amato et al.
Fig. 4 Final documentation (same patient as in Fig. 3). Bleaching success is
2006). In contrast, another study using the same bleaching
satisfactory, but the discolored approximal composite restorations on 11 and
technique found darkening of up to four shades on the VITA
21 are even more obvious.
color scale in just under 50% of the 26 bleached teeth (Deliperi
& Bardwell 2005). In part, dentists judge bleaching success
much more critically than do patients. After a 5-year observa- teeth (Bussadori et al. 2006), the authors of the article reject
tion period, 75% of the cases were judged as successful by the this form of treatment due to lack of compliance and a high
dentist, while 98% of the patients were satised with the re- cost:benet ratio. This treatment approach does not seem prac-
sults (Glockner et al. 1999). tical. The patient must be informed that by preparing a new
access cavity, an increased risk of tooth fractures exists during
Technique treatment, and that the tooth to be bleached must not be
Prior to bleaching, each case should be photodocumented loaded too heavily (Baratieri et al. 1995).
(Fig. 1), including a color key (Fig. 3), to objectify the result There are basically three different options for lightening
and make treatment success veriable. The patient must be nonvital teeth: the walking bleach, inside/outside bleaching
informed of the risks of the treatment and alternative treat- and the in-ofce bleaching techniques. These three techniques
ment methods. It is important that the patient be aware that are presented in the following, including clinical procedure,
existing restorations may not be bleachable and therefore time requirements, and risks.
subsequent costs may arise if the old restorations no longer
match the color of the teeth after bleaching (Fig. 4). There is Walking bleach technique
no guarantee that bleaching will be successful. The patient This bleaching technique was rst described by Spasser (Spasser
must be asked about the usual allergies to composites, plastics, 1961). Sodium perborate is mixed with water into a paste and
latex, and peroxide. No bleaching agents may be used in preg- then inserted into the access cavity. Later, the technique was
nant or lactating women. Careful consideration is also called modied by mixing sodium perborate with hydrogen peroxide
for with children and adolescents. In every case, the permis- and inserting this into the access cavity (Nutting & Poe 1967).
sion of the parent or legal guardian is required, and the child It was subsequently shown that there is no difference in ef-
her- or himself must express the desire for bleaching treatment fectivity between these two methods (Holmstrup et al. 1988,
because of suffering from the discoloration of the nonvital Rotstein et al. 1991b, Ari & Ungr 2002). An improvement
tooth. A good cervical seal is decisive in young teeth, as the was found in vitro when sodium perborate was mixed with
diffusion rate of the bleaching agent through the tooth is much carbamide peroxide instead of with distilled water. It made no
higher than in older patients (Camps et al. 2007). Although difference if carbamide peroxide was used in concentrations
a case report exists on the bleaching of nonvital deciduous of 10% or 35% (Yui et al. 2008). In the walking bleach tech-
nique, rst a tissue-conserving access cavity is made such that tion time of 33 hours for young patients and 18 hours for older
the entire pulpal cavity is visible and cleanable (Fig. 5). The patients (Camps et al. 2007). After completion of bleaching
root-canal lling material is shortened 23 mm subgingivally. agent application, the results should be photodocumented,
This is controlled using a periodontal probe (Fig. 6). An imper- which also serves to evaluate long-term success (Figs. 2, 4, 7
meable base is laid on the root-canal lling material (resin- and 8). Instead of sodium perborate, carbamide peroxide or hy-
modied glass-ionomer cement [RMGIC], such as Vitrebond, drogen peroxide can also be used for the walking bleach tech-
or conventional GIC). The application of a RMGIC showed a nique, using the same procedure described above (Vachon et
better apical seal than conventional GIC (De Oliveira et al. al. 1998). 37% carbamide peroxide shows the best penetration
2003). The pulpal cavity must be free of root-canal lling ma- into dentin, while sodium perborate mixed with 20% hydro-
terial. The bleaching gel is inserted into the tooth and the gen peroxide or 27% carbamide peroxide does not penetrate
access cavity is sealed to the outside with a provisional lling. as deeply into dentin (Carrasco et al. 2003). In another study,
While investigating different provisional lling materials, the in order to improve penetration into dentin, the access cavity
question was also asked whether covering the bleaching agent was rst etched with phosphoric acid so that the dentin tu-
with rubber (small piece of rubber-dam) would additionally bules were slightly opened. However, this did not improve re-
improve the sealing of the cavity. The dye penetration test sults, at least with more highly concentrated bleaching agents
showed no signicant difference between the use of a rubber (Casey et al. 1989). Bleaching success seems largely dependent
covering and the direct provisional closure. Cavit and Coltosol on the application duration of the bleaching agent. For this
used as provisional restorative materials were better than Fer- reason, this bleaching method often performs better than the
mit, and this was better than zinc-oxide eugenol and zinc- in-ofce technique (Dietschi et al. 2006). After the desired
oxide phosphate cement (Hosoya et al. 2000). Ideally, a pro- bleaching result has been obtained or slightly surpassed, some-
visional adhesive restoration is placed, because this improves times an application of calcium hydroxide is recommended in
the seal against bacterial penetration. order to diminish oxygen inhibition of the polymerization of
After a few days, the bleaching result is examined and, if the denitive composite lling, and to counteract the increased
needed, bleaching agent is again inserted into the access cavity. permeability of the dentin caused by the bleaching agent
A recent study attempted based on the diffusion rate of hy- (Demarco et al. 2001) as well as raise the low pH value in the
drogen in dentin to determine the ideal timepoint for reap- cavity (Kehoe 1987). However, the authors of this article assign
plying bleaching agent. Given the different structure of young little clinical relevance to increasing the pH in this way due to
and old dentin, the researchers determined an ideal applica- the great buffering capacity of the dentin. The bond strengths
Fig. 5 The access cavity is kept as small as possible. Discolored dentin is not Fig. 7 Follow-up examination nine months after bleaching. During that pe-
removed. Same case as in Fig. 1. riod, the lateral incisors were widened using composite.
Fig. 6 The root lling material is shortened 23 mm subgingivally. The depth Fig. 8 Follow-up three months after bleaching. The patient did not want new
of the access cavity is checked with a periodontal probe. composite restorations.
of adhesive systems to dentin were not found to be negatively the treatment results are equal (Bizhang et al. 2003). A disad-
inuenced by sodium perborate, hydrogen peroxide or carb- vantage is the lack of bacterial control during bleaching. The
amide peroxide compared to the unbleached control group microorganisms can colonize the dentin tubules, and the danger
(Mller Arcari et al. 2007). This is contrary to other investi- exists that not only the bleaching result but also the long-term
gations, in which bleaching agents markedly reduced bond success of the endodontic treatment may be compromised.
strengths (Lai et al. 2002). Instead of a waiting interval be-
tween bleaching agent application and restoration, an ascorbic In-Ofce Bleaching
acid solution (10%) can be used to promote normal adhesive This method is well-known from bleaching vital teeth, but it
bond strengths (Lai et al. 2002). Additionally, it has been can also be employed for nonvital teeth. However, the predi-
shown that ethanol and acetone in the adhesive systems ne- cability of the method is rather low. Chairside, rubber-dam is
gate the inhibiting effect of bleaching agent on polymerization attached and 30% hydrogen peroxide is applied onto and in
(Barghi & Goldwin 1994, Sung et al. 1999). the tooth. Preparation of the access cavity and sealing of the
Hydrogen peroxide (30%) can have a detrimental effect on root-canal is performed as in the walking bleach technique.
the microhardness of enamel and dentin. For dentin, the hard- After an application time of 1520 minutes during which the
ness reduction was signicant after just a 5-minute application bleaching gel is moved, the gel is rinsed off and the procedure
time of the bleaching agent (Lewinstein et al. 1994). In con- is repeated, if necessary. The patient must wear protective
trast, the use of sodium perborate combined with hydrogen eyeglasses to prevent droplets from contacting the eyes. Regret-
peroxide did not alter the hardness. These results were further tably, the desired bleaching effect is often ephemeral, since the
conrmed in a more recent study. It was found that not only color lightening is predominantly produced by the tooths
35% hydrogen peroxide gel and 30% hydrogen peroxide solu- dehydration under the rubber-dam. This agrees with experi-
tion but also 35% carbamide peroxide gel decrease the micro- ence gained in bleaching vital teeth. Here, too, the long-term
hardness of the external dentin layer; this inuence was, success of at-home bleaching (longer application time by wear-
however, relatively slight. The application of sodium perborate ing a splint) is much better than that of in-ofce bleaching
(mixed with water or 30% hydrogen peroxide) in the pulp (Dietschi et al. 2006). An analysis of different bleaching
cavity had no inuence on the microhardness of dentin (Chng methods of vital teeth showed that patients prefer at-home to
et al. 2004). in-ofce bleaching due to the shorter treatment time at the
dentists ofce (Auschill et al. 2005). When using this method,
Inside/outside Bleaching a relatively large amount of hydrogen remains in the cavity
This technique was rst described by Settembrini et al. (Settem- due to the shorter, more concentrated application time; thus,
brini et al. 1997) and was later modied (Liebenberg 1997). the denitive closure of the access cavity should be performed
As the name implies, the idea is to apply bleaching agent both in a subsequent appointment. The remaining hydrogen can
on the external and internal surfaces of the tooth. The access also be completely eliminated in three minutes by applying
cavity remains open during the entire treatment process. One catalase or other substances (e. g., ascorbic acid) (Rotstein 1993,
advantage of this technique is that a low concentration of Lai et al. 2002).
bleaching gel is sufcient to obtain the desired effect. First, a
vacuum-drawn splint is made with reservoirs oral and vestibu- Discussion
lar to the tooth to be bleached. On the directly adjacent teeth,
the model is ground down slightly in order to ensure that the Given the appropriate indication, the bleaching of nonvital
bleaching splint ts these teeth tightly and prevents them from teeth is a relatively low-risk intervention to improve the esthet-
accidental exposure to bleaching gel. The tting accuracy of ics of endodontically treated teeth. Depending on the situa-
the splint is checked on the patient. The access cavity is made tion, the walking bleach technique can be an uncomplicated
as in the walking bleach technique. An impermeable base is and convenient method for both patients and dentists. In-
important in order to ensure that the root-canal lling material ofce bleaching can often only produce short-term success,
is sealed. The patient is instructed in the use of the splint. Us- based largely on the dehydration of the tooth. The risk of root
ing a syringe, the access cavity and the corresponding location resorption cannot be exactly determined given the available
of the vacuum-drawn splint are lled with 10% carbamide data. Nevertheless, it seems clear that dental trauma favors
peroxide (pea-sized amount of bleaching agent). The splint is cervical resorptions, and that this factor is probably more
inserted and the excess bleaching agent is removed with the important than the application of bleaching agent. Sufcient
ngertip or a cotton swab. The splint is worn at night also to cervical sealing and avoidance of the thermocatalytic method
protect the open tooth. After a period of bleaching, the patient can minimize the risk of resorptions. Further development of
should clean the access cavity. Recall is recommended every the conventional bleaching agents by adding radical scaven-
two or three days to monitor the color change. When the de- gers such as thiocarbamide or using sodium percarbonate
sired color has been attained, the access cavity is cleaned and seems promising in terms of minimizing the penetration of
then closed with a provisional restoration material (glass-iono- hydrogen into the periodontal space. Subsequent studies on
mer cement or polycarboxylate cement). A week later, the de- the factors which favor the recurrence of discoloration after
nitive restoration can be placed. Reasons for unsatisfactory bleaching are certainly indicated.
results can often be found in patient compliance. Especially if
the treatment duration is prolonged, the patients compliance Rsum
wanes (Poyser et al. 2004). This technique may be indicated
where simultaneous bleaching of nonvital and vital teeth is Le blanchiment des dents dont les racines ont t traites pour
possible and required (Carrillo et al. 1998). Although bleach- amliorer laspect esthtique chez le patient est un traitement
ing success with the inside/outside technique may be greater sans grand risque. Ce papier traite des causes de changements
in the rst few days than with the walking bleach technique, de couleur, des diffrentes techniques de traitement et des
after six months and the incident rehydration of the tooth, risques pour le patient. Quelques causes pour les dcolorations
peuvent tre inuences par le dentiste. Les trois mthodes les caux ou de substances plus rcentes comme le percarbonate de
plus populaires pour la dcoloration sont le walking bleaching, sodium. Lapplication de la technique thermo-catalytique, un
le inside/outside bleaching et la mthode de blanchir les dents scellage cervical insufsant et des mdicaments haute
directement dans le cabinet dentaire. La technique du walking concentration doivent tre vits parce que cela peut aggraver
bleaching est la technique la plus prouve et la moins pnible le risque de rsorption des racines cervicales. Il faut informer
tant pour le dentiste que pour le patient. La technique de inside/ les patients du faible taux de russite de ce traitement et du
outside bleaching peut tre applique en combinaison avec un risque dune nouvelle dcoloration. Le patient doit galement
blanchiment des dents vitales et non vitales. Il existe encore tre inform du risque de rsorption cervicale. Il existe une
des questions concernant les mdicaments pour la dcolora- grande corrlation entre rsorption de racines et traumatisme
tion. Des amliorations dans laspect de la scurit restent dentaire.
possibles avec laddition de thio-ure comme capteur de radi-
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