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Nonvital Bleaching:
General Considerations and
Report of Two Failure Cases
Didier Dietschi, DMD, PhD
Senior Lecturer
Department of Cariology and Endodontics
University of Geneva
Geneva, Switzerland
Adjunct Associate Professor
Department of Comprehensive Care
Case Western Reserve University
Cleveland, Ohio

Correspondence to: Dr Didier Dietschi

Department of Cariology and Endodontics, University of Geneva, Rue Barthlemy-Menn 19, 1205 Geneva, Switzerland;
phone: 41 22 757 16 06; fax: 41 22 757 44 89; e-mail: ddietschi@vtx.ch.

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Abstract
This paper describes the rationale and

trated with two cases of rapid discoloration

procedures for noninvasive treatment of

relapse. The possible reasons for treat-

discolored nonvital teeth using the walk-

ment failure are examined and show

ing bleach technique. The limitations of

that current knowledge regarding the

this procedure and, in particular, the un-

origin and prevention of discoloration is

predictable color stability following non-

limited.

vital bleaching are discussed and illus-

(Eur J Esthet Dent 2006;1:5261.)

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a
Fig 1

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b
(a and b) Preoperative view of the maxillary left central incisor, with posttraumatic vitality loss, prior to

endodontic treatment.

New realities and

treatment strategies

Nonvital tooth bleaching

Nonvital tooth bleaching is primarily indi-

The dramatic improvement in the oral

cated for traumatized discolored teeth in

health of the overall population, as well as

the esthetic zone that present with minimal

a widespread concern for dental esthetics,

or no coronal tissue loss and for other

has brought minimally invasive treatment

more severely decayed endodontically

options to the forefront. Chemical treat-

treated teeth (Figs 1a and 1b). The basic

ments of discolored or simply dark teeth

principle of bleaching is to alter structural-

are part of a modern and comprehensive

ly organic stains or pigments (which are

treatment

teeth.

large molecules) by the action of an oxidiz-

Bleaching offers a conservative and es-

ing agent, most frequently hydrogen perox-

thetic solution to problems that formerly

ide (H2O2) or derived products.24 Nonvital

could only be approached by invasive and

bleaching can be applied only on previ-

expensive conventional restorative options

ously endodontically treated teeth and in

such as full crowns. Since patients also re-

the absence of periapical pathology.

approach

for

anterior

tain their teeth for a much longer period of

Different protocols have been proposed

time, it has become increasingly important

to bleach nonvital teeth: the conventional

to preserve the long-term biomechanical

walking bleach technique, the power (chair-

potential of restored teeth by minimizing

side) nonvital bleaching technique, and a

loss of tooth structure. Therefore, the entire

modified home bleaching technique.510

spectrum of dental procedures has been

reviewed in light of the so-called progressive approach concept,1 which gives priority to noninvasive procedures.

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Fig 1 (continued)

(c and d) After the root was filled with a nonstaining cement, the cavity access is cleaned

to about 1.5 mm below the anatomic collar; the correct level is controlled with a periodontal probe.

Walking bleach technique

with extreme thinning of residual dentin

The walking bleach technique includes

walls (eg, teeth that were endodontical-

the following steps:

ly treated at an early stage of development), a lower H2O2 concentration (3%

1. Elimination of all residual organic tis-

to 10%) or even distilled water11 current-

sue, endodontic sealer, or restorative

ly is recommended, primarily to reduce

material from the pulpal chamber,

the risk of cervical root resorption.12

which could either block the penetra-

4. Placement of a provisional filling made

tion of the bleaching agent or hasten

of a eugenol-based cement (eg, IRM,

discoloration relapse. Caution must be

Dentsply; Fig 1f) or composite (with the

used while treating the critical cervical

necessary precaution of obtaining prop-

area in order to prevent a perforation or

er curing of the material).

excessive thinning of the dentinal walls.

This preparation should extend 1.5 to

The release of oxidizing ions will take

2 mm below the anatomic collar (Figs

place over approximately 10 days; there-

1c and 1d) in order to allow bleaching

after, the efficacy of the bleaching mixture

of the cervical area.

is rather limited, and it must be replaced

2. Protection of the remaining endodon-

with new material. A satisfactory reduction

tic filling with a cement (zinc phosphate

of tooth discoloration should be obtained

or glass ionomer, or composite when

after three to six procedures (Fig 1g).

a eugenol-free endodontic sealer was

used).

Other considerations

3. Placement of the bleaching mixture,

Many literature reports have associated

made of sodium perborate powder or

cervical root resorption with nonvital bleach-

fine granulate and H2O2 at a concentra-

ing, with incidence ranging from 1% to

tion of 3% to 30% (Fig 1e). In cases

13%.1317 This phenomenon is considered

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to be the result of atypical healing following

injury to the periodontal ligament cells,
leading to an activation of bone resorption

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Case reports and stability
of the bleaching effect

cells. In the absence of early diagnosis, it

Figures 1 and 2 show the immediate satis-

usually leads to extraction or a combined

factory effect achieved by the application of

orthodontic-restorative treatment (if allow-

the nonvital walking bleach technique, as

ed by the root length). The thermo-catalytic

well as results over 5- and 9-year periods,

activation of the bleaching mixture, which

respectively. Both teeth have been root

formerly was part of the protocol, is no

filled with nonstaining cement so that sub-

longer considered necessary and is even

sequent release of inorganic pigments

thought to be dangerous because it is like-

from the root cement could be excluded. A

ly associated with lesions of the periodon-

relapse of the discoloration was neverthe-

tal tissues due to excessive heat.12 When

less observed quite rapidly after comple-

using 30% H2O2, it might be necessary to

tion of the treatment, with a severity increas-

extend the protection placed over the en-

ing proportionally to the follow-up period

dodontic filling to all walls where bleaching

(see Figs 1h, 1i, 2c, 2d, 2f, and 2g). The es-

action is not desired. The author, however,

thetic improvement obtained through the

has never observed an occurrence of root

bleaching of discolored nonvital teeth has

resorption, despite the routine use of 30%

been discussed in the literature.1821 These

H2O2 for nonvital bleaching over a 20-year

clinical studies have reported a relapse

period, as also stipulated by Baratieri.12

incidence of 10%, 25%, and 40% after 2,

Root resorption following nonvital bleach-

5, and 8 years, respectively. The nature

ing also is likely related to aggressive

and origin of the pigments involved in the

preparations in the cervical area leading

discoloration process prior to as well as

to unobserved root perforation. Consider-

after the loss of vitality and endodontic

ing that lower H2O2 concentration or dis-

treatment or relapse phenomenon is only

tilled water also provides a satisfactory

partially known. Hemoglobin and pulp rem-

color correction of nonvital discolored teeth,

nants are believed to be the main sub-

this popular and more conservative proto-

stances from which colored compounds

col should now be preferred.

originate,3 but it is not clear whether the

Fig 1 (continued)

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(e) A mixture of 30% H202 and sodium perborate is placed inside the clean pulp cham-

ber and (f) covered with either a eugenol-based cement or a composite. (g) Five bleaching sessions were necessary to achieve a satisfactory color correction. (h) The 3-year postoperative recall revealed a moderate color
change. (i) Five years following the first nonvital bleaching, the discoloration relapse is complete, and the patient
has requested a new bleaching procedure (j).

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reoccurrence of the discoloration is the re-

tryways for external stains (see Fig 1j), but

sult of the progressive transformation of the

this approach was unsuccessful. Although

same organic material or caused by the

the related literature does not provide pre-

penetration of new pigments from the oral

cise parameters for predicting color stabili-

cavity.

ty following a nonvital bleaching treatment,

Once a relapse had occurred in the case

the authors own experience suggests that

shown in Fig 1, an attempt was made to im-

a rapid and significant color change follow-

prove the color stability following a second

ing vitality loss or endodontic treatment is

bleaching phase by sealing the dentin in

usually a negative factor for the long-term

the access cavity and all other possible en-

success of nonvital bleaching.

Fig 2

(a) Preoperative view of the maxillary right central incisor. The canal was filled with a nonstaining cement.

(b) Satisfactory color correction following three nonvital bleaching sessions using 30% H202 and sodium perborate. (c) Two-year postoperative view, showing a minor discoloration relapse. (d) A severe discoloration relapse
is observed at the 4-year postoperative recall. (e) The tooth is re-treated, using the same conservative bleaching
procedure, followed by adhesive sealing of the entire access cavity. (f) Three years later, a discoloration relapse
is again observed. (g) Four years after the second nonvital bleaching treatment, a restorative solution to the recurrent and severe discoloration was required to address the patients esthetic concerns.

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Alternative nonvital tooth

bleaching methods

Conclusion

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Nonvital bleaching is the most desirable

The use of carbamide peroxide was pro-

noninvasive approach to the problem of

posed as an alternative to the walking

discolored anterior nonvital teeth. The

bleach technique to treat nonvital teeth. The

walking bleach technique has a well-

carbamide peroxide gel can be used in-

documented protocol, and there is suffi-

stead of the traditional mixture with the

cient evidence of its efficacy. However, the

other steps remaining unchanged,9 or it

stability of the color correction achieved by

can be placed in a tray, keeping the pre-

this technique is not predictable, and some

pared tooth open during the bleaching

cases may undergo a rapid discoloration

phase, as a modified home bleaching

relapse, as documented in this paper.

technique.10 The patient will have to clean

Since the exact mechanisms responsible

the canal and prevent food from being

for the initial discoloration and relapse are

compacted into the pulpal chamber. One

not precisely known, presently no ideal

should, however, exercise caution when

protocol can be proposed to overcome this

using this technique, considering the short

limitation to the application of nonvital

time necessary for a reinfection of the canal

bleaching; further research is therefore

from the oral flora. There is no comparative

needed to improve the long-term stability

study regarding the in vivo efficacy and

and success rate of this technique.

stability of the color correction achieved by

this method versus the classic walking
bleach technique.
Power bleaching (chairside) is used by
some clinicians, but its efficacy seems rather
unpredictable and limited by the short application time of the bleaching agent (usually
30% oxygen peroxide in a gel form).

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References
1. Dietschi D, Dietschi JM. Current
developments in composite
materials and techniques. Pract
Periodontics Aesthet Dent
1996;8:603613.
2. Fasanaro TS. Bleaching teeth:
History, chemicals, and methods used for common tooth
discolorations. J Esthet Dent
1992;4:7078.
3. Frysh H. Chemistry of bleaching. In: Goldstein RE, Garber
DA (eds). Complete Dental
Bleaching. Chicago: Quintessence, 1995:2533.
4. Nathoo SA. The chemistry and
mechanisms of extrinsic and
intrinsic discolorations. J Am
Dent Assoc 1997;128:6S10S.
5. Pearson H. Bleaching of the
discolored pulpless tooth. J Am
Dent Assoc 1958;56:6468.
6. Spasser HF. A simple bleaching technique using sodium
perborate. N Y State Dent J
1961;27:332334.
7. Chandra S, Chawla TN. Clinical
evaluation of various chemicals
and techniques of bleaching of
discolored root filled teeth. J
Indian Dent Assoc
1972;44(8):165171.

8. Baratieri LN, Ritter AV, Monteiro

S, Caldeira de Andrada MA,
Vieira LCC. Nonvital tooth
bleaching: Guidelines for the
clinician. Quintessence Int
1995;26:597608.
9. Vachon C, Vanek P, Friedman
S. Internal bleaching with 10%
carbamide peroxide in vitro.
Pract Periodontics Aesthet Dent
1998;10:11451154.
10. Liebenberg WH. Intracoronal
lightening of discolored pulpless teeth: A modified walking
bleach technique. Quintessence Int 1997;28:771777.
11. Steiner DR, West JD. Bleaching
pulpless teeth. In: Complete
Dental Bleaching. Goldstein
RE, Garber DA (eds). Chicago:
Quintessence, 1995:101136.
12. Baratieri LN. Clareamento de
Dentes. In: Odontologia
Restauradora: Fundamentos e
Possibilidades. So Paulo: Santos, 2001:674722.
13. Harrington GW, Natkin E. External resorption associated with
bleaching of pulpless teeth. J
Endod 1979;5:344348.
14. Lado EA, Stanley HR, Weisman
MI. Cervical resorption in
bleached teeth. Oral Surg
1983;55:7880.

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ht

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DIETSCHI
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n

e ss e n z

15. Cvek M, Lindwall AM. External

root resorption following
bleaching of pulpless teeth with
oxygen peroxide. Endod Dent
Traumatol 1985;1:5660.
16. Latcham NL. Postbleaching
cervical resorption. J Endod
1986;12:262265.
17. Latcham NL. Management of a
patient with postbleaching cervical resorption. A clinical
report. J Prosthet Dent
1991;65:603605.
18. Friedman S. Internal bleaching:
Long-term outcomes and complications. J Am Dent Assoc
1997;128:26S30S.
19. Holmstrup G, Palm AM, Lambjerg-Hansen H. Bleaching of
discoloured root-filled teeth.
Endod Dent Traumatol
1988;4(5):197201.
20. Friedman S, Rotstein I, Libfeld H,
Stabholz A, Heling I. Incidence
of external root resorption and
esthetic results in 58 bleached
pulpless teeth. Endod Dent
Traumatol 1988;4(1):2326.
21. Glockner K, Hulla H, Ebeleseder
K, Stadtler P. Five-year follow-up
of internal bleaching. Braz Dent
J 1999;10(2):105110.

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