How to treat discoloration of a single tooth. Predictable cosmetic treatment, no biological costs.
When it comes to treating a single discolored tooth, guidelines suggest that there should be a logical order of treatment options to achieve a satisfactory cosmetic outcome, starting with the least invasive. This is known as progressive smile design. Vital teeth whitening is a popular and non-invasive technique for treating individual discolored teeth.
In this day and age, where aesthetics are very important, teeth whitening has become a very popular option to correct discoloration.
The reader needs to understand the causes of single tooth discoloration and the treatment management for it.
Causes of Unique Teeth Discoloration
The most common causes of discoloration of a single tooth tend to be due to: local causes of intrinsic discoloration. Trauma to the teeth can lead to intrapulpal hemorrhage, which results in the entry of blood components into the dentinal tubules. Initially, this will appear as a pink discoloration, but over time, if pulp canal obliteration (PCO), also known as calcific metamorphosis or necrosis, occurs, this color darkens, resulting in a yellowish and then gray-black hue. PCO is defined by the deposition of secondary and tertiary dentin within the root canal space (1). The extent of the discoloration is directly related to the length of time the pulp has been obliterated or necrotic (2).
Clinical and radiographic evaluation of a discolored tooth
After a smile analysis, there are several techniques that are currently used to clinically evaluate the color and staining of a tooth, which can be divided into assessments subjective (visual) and objective (instrumental).
From a subjective point of view, the most common method is visual matching of shades compared to a commercial shade guide. Although this technique is simple and quick to use, the limitations of this method must be appreciated. Factors such as age, lighting, experience and eye fatigue can lead to variations in the results obtained by assessors. Instrumental assessment methods include the use of colorimeters, reflectance spectrophotometers and digital image analysis, but even these have their disadvantages, such as the cost and intrusive nature of the equipment(3).
Sensitivity tests should be performed, and the most reliable method is electric pulp testing. The high specificity of this test means that it is more likely to correctly identify vital teeth compared to the cold pulp test. It is important to use a control of a contralateral tooth when performing the sensitivity test to allow the patient to compare the sensation of a known vital tooth with that of the tooth being tested.
If the clinician suspects that the discoloration is due to PCO or necrosis, then a periapical radiograph is essential. However, in the case of pulpal necrosis, there may be no radiographic changes. Data show that only approximately 7-271% of teeth with PCO will progress to pulpal necrosis with periapical disease evident on radiograph.(1) Figure 1 and 2 PreseNTs the appearance of a patient who suffered a trauma in adolescence.
Consent
Except in certain ethical situations, teeth whitening is only permitted for people aged 18 years or older. The consent procedure for this treatment must be very robust, as patients must be very aware of the possible outcomes and associated risks, and expectations must be managed. They must be informed that the outcome cannot be guaranteed, that the time required to complete the treatment may be variable, and that relapses may occur.
Treatment options
Regarding the treatment of a single discolored tooth, guidelines suggest that there should be a logical order of treatment options to achieve a satisfactory cosmetic result, starting with the least invasive. This is known as progressive smile design.
Pink discoloration, sometimes encountered after trauma, is still reversible, and therefore monitoring and review may be the only requirement. Scaling and polishing It is also a good initial step so that any extrinsic stains can be removed and the true color of the tooth can be assessed.
Vital teeth whitening is a popular and non-invasive technique for treating discolored teeth on its own(2). However, if whitening is not effective, minimally invasive composite veneersThey can help mask the residual darkness of the tooth, or more invasive procedures such as ceramic veneers or full-coverage crowns can be placed.
Clinical techniques
There are several techniques that can be used when whitening a single dark tooth. The method I use most frequently is to whiten the discolored tooth first and then the rest of the arch.
Fingerprinting
The teeth are dried thoroughly with a 3-in-1 tip and impressions are taken using perforated metal trays with alginate. Hydrogum 5 from Zhermack®. At this stage, the assistance of the dental assistant is required to hold the cheek retractors to allow easy insertion of the loaded tray. The impressions should be examined to verify the presence of all teeth and to determine if there are any air bumps or drags.
Laboratory recipe
The lab prescription should call for upper and lower super-sealant silicone whitening trays with silicone scales, with palatal and labial reservoirs on the discolored tooth. Both canines in the arch should also have buccal and labial reservoirs, as these teeth are generally darker than the rest of the arch. Figure 3 features custom lab-made super-sealant whitening trays. While waiting for the whitening trays, the patient should take home Dental Serum to use, which reduces the risk of sensitivity with this procedure.
Installing the gutters
After the aligners arrive, they are checked accuracy of fit and sealing at the cervical margin. Make sure that there are no bubbles in this area, which would suggest a margin leak. The patient should be shown how to remove and insert the trays.
Patient compliance and instructions
The patient must use a carbamide peroxide gel (CP) 10% nightly for one to four weeks on the discolored tooth. A reevaluation of the tooth color should be scheduled with the dentist. If the single discolored tooth still requires additional whitening, then the patient can continue to do so, but if not, the remaining buccal surfaces of the arch can be whitened at the same concentration. Another reevaluation should take place, during which the patient may be given a 16% CP gel to be used for another 2 weeks on the trays.
Finally, a final re-evaluation is scheduled to determine the outcome of the treatment. Postoperative instructions are given for maintenance, as there is some risk that newly whitened teeth will regrow and discolor again, so a regimen of re-treatment should be established every 6 months, but for some patients this can be up to 3 years(4). In figures 4 and 5 The same patient is shown after treatment with Enlighten Tooth Whitening. Figures 6 and 7 compare the before and after photos and there is a dramatic improvement in the shade of the dark tooth. We can see here how this can greatly improve our patient's confidence while avoiding more invasive treatments such as veneers.
risks
Since the treatment of discolored teeth is done for cosmetic reasons, it should have more benefits than harms, and the consent procedure must be complete. Although the use of 10-16% carbamide peroxide strives to have the best results with a minimal amount of side effects, there are still some that do occur. The most common risk that occurs with vital teeth whitening is tooth sensitivity. The patient should be warned about this as it can affect compliance and therefore a dentist should always aim to keep this to a minimum, the use of dental serum helps with this. Gingival irritation is also a commonly reported problem and therefore it is important to ensure that the tray has a good and secure fit, is scalloped and free of sharp edges and resin chips(5).
Discussion
Vital whitening is a safe, minimally invasive, and cost-effective method for improving the appearance of uniquely dark teeth. Patient assessment and expectation management are essential. The treatment plan depends on each individual case, and patients should be informed about ongoing maintenance and associated costs.
Bibliography
- McCabe P, Dummer P. Pulp canal obliteration: an endodontic diagnosis and treatment challenge. International Endodontic Journal. 2011;45(2):177-197.
- Barber A, King P. Management of the discolored single tooth, part 1: etiology, prevention, and minimally invasive restorative options. Dental Update. 2014;41(2):98-110.
- Brook A, Smith R, Smith R, Lath D. Clinical measurement of tooth color and stain. International Dental Journal. 2007;57(5):324-330.
- Greenwall L. Tooth whitening: the last 25 years [Internet]. Moderndentistrymedia.com. 2018 [cited 7 September 2018]. Available at: http://www.moderndentistrymedia.com/mar_april2016/greenwall.pdf
- Pretty I, Brunton P, Aminian A, Davies R, Ellwood R. Vital Tooth Bleaching in Dental Practice: 3. Biological, Dental and Legal Aspects. Dental Update.
Source: enlightensmiles.com
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