Question 11: Trauma to central incisor, resulted in discoloration, mention management

and side effects of bleaching (root resorption)?

Trauma to the tooth causes intrinsic type of discoloration due to either:

 Enamel hypoplasia Yellow brown or white
 Pulp haemorrhage products Grey brown or black
 Root resorption. Pink spot

Inadequate awareness of discoloration potential of endodontic procedures and materials

may results in tooth discoloration.
Intra-endodontic procedures:
 inadequate removal of pulp tissues (RBC haemosiderin haemolysis
ironblack ferric sulphate+ hydrogen sulphide by bacteria grey discoloration
 Root canal irrigants (NaOCL with CHX dark brown parcipitate, NaOCL +MTAD
brown)
 Intra-canal medicaments (Ledermix paste, triple antibiotic paste, formocresol)
 Endodontic filling materials (GP, pink, AH26 epoxy resin sealer green and then
black, grey MTA)
Post-endodontic procedures:
 Metallic posts and restorations
 Improper selection/application of tooth-coloured restorations
 Improper selection/application of crowns and veneers

Management of internal discoloration:

1- Removal of the cause.
• Adequate extension of the access cavity and removal of the cause of the
discoloration (e.g. remaining pulp tissue, medicament, root canal filling material or
defective coronal restorations) is required before internal bleaching. (Abbott 1997).
2- The tooth should then be re-evaluated because the colour may become satisfactory once
the cause has been removed.
3- Non-vital bleaching:
Peroxide chemistry: release free radicles that Breaks down double bonds in chromophore
structure of organic molecules to produce simpler molecules that absorb less light and
change the stain to a lighter colour.

 Walking bleaching: The current technique involves sealing in 10% carbamide

peroxide instead of sodium perborate without needing to mix the product, simply
syringing the gel into the cavity and reviewing the patient in 3 days. (Sulieman
2008):
1- Record initial shade (ideally with photograph of shade tab)
2- Complete RCT and remove GP 2mm below the CEJ to enable a barrier of
GIC / ZnOE to be placed to the level of the CEJ
3- Removal of the smear layer within the access cavity prior to bleaching enhances
the penetration of the bleaching agents into the dentine but this is somewhat
controversial (Attin et al. 2003, Plotino et al. 2008)
4- Place cotton wool soaked with 10% carbamide peroxide in access cavity and
temporize
 5- Review and replace weekly for 3 weeks
6- If shade improvement satisfactory restore with composite 2 weeks after last
bleaching session (to dissipate residual oxygen within the tooth structure)
7- Photograph of new shade

 Inside/outside bleaching: This technique is a combination of internal bleaching of

non-vital teeth with the home bleaching technique:
1- Construct suckdown splint with labial and palatal reservoir for tooth or teeth
requiring bleaching only
2- Remove GP 2mm below the CEJ to enable a barrier of GIC (e.g. Chemfil Rock) to
be placed to the level of CEJ (This stage is critical to limit cervical resorption and
must be placed accurately)
3- Give patient suckdown and syringe of bleaching agent (10% carbamide peroxide)
with instructions on placement
4- Patient to apply gel within the access cavity and suckdown splint for designated
tooth / teeth to be bleached only
5- Patient to change gel every 2 hours
6- Review 3-5 days
7- If shade improvement satisfactory clean access cavity to remove plaque biofilm
with sodium hypochlorite and a periodontal ultrasonic followed by water from 3
in 1 to remove residual irrigant
8- Restore with composite after 2 weeks (to dissipate residual oxygen within the
tooth structure)
9- Photograph of new shade

Generally, the short- and long-term prognosis of internal bleaching is favorable and
acceptable to the patient, as long as the coronal restoration is maintained with no marginal
breakdown that could lead to further discolouration
(Rotstein et al. 1993, Glockner et al. 1999, Abbott & Heah 2009)

Other treatment options:

If bleaching does not provide satisfactory outcomes:
More invasive aesthetic treatment such as the placement of a labial porcelain veneer or a
full coverage ceramic crown may be indicated.

(Ahmed et al, 2012)

Bleaching agents in high concentrations (such as 30% of hydrogen peroxide) combined with
heat (thermocatalytic technique) increase the risk for external invasive root resorption.
(Dahl & Pallesen 2003)

Cervical root resorption : (Invasive cervical resorption):

• Characterized by its cervical location and invasive nature
• Clinically obvious pinkish color in the tooth crown.
A clinical classification has been developed as a guideline for treatment planning and for
comparative clinical research:

Classification of Root Resorption By Lindskog 2006

• Trauma induced tooth resorption;
Surface.
Pressure.
Orthodontic.
Replacement.
Transient apical (Internal).
• Infection induced tooth resorption;
Internal inflammatory.
External inflammatory.
Communicating internal and external.
Hyperplastic invasive tooth resorption;
Internal invasive resorption.
Coronal invasive.
Cervical invasive.

Classification of Root Resorption By Andreasen

• Internal Resorption;
Inflammatory Resorption.
Replacement Resorption.
Transient Apical Resorption.
• External Resorption;
Surface Resorption.
Inflammatory Resorption.
Replacement Resorption.