Vital bleaching – tetracycline staining
Ashish Soneji presents a case of tooth whitening with a familiar complication.
JW is a 45-year-old gentleman who I have been treating over the past nine months. He initially presented with a broken LR6. He was seeking aesthetic improvement of his dentition using the most minimally invasive method.
The patient had a chipped LR6 and hated the colour of his teeth.
Patient has broken his lower right first molar. It was not painful but sharp to his tongue. He had the tooth temporarily repaired.
He has always had ‘smoker’s teeth’ from as long as he can remember. The patient wanted them to look whiter and also doesn’t like the band that runs across the middle of them. Having sought many cosmetic opinions he was told that tooth whitening wouldn’t work. He was told that he would have to consider veneers to improve the appearance.
The patient’s primary concern was the colour of his teeth. Also, the dark band running across the incisal third of the upper and lower arch. As identified from his history he was seeking a minimally invasive solution to improve the appearance of his dentition. Treatment options were presented starting with the most minimally invasive first, home bleaching. As suggested by Leonard, Compdenium (2003) there was 86% satisfaction using home bleaching for tetracycline stains.
The rationale for using home bleaching for this particular case is that the evidence suggests treatment can be effective. However, it can require prolonged use of up to six months or longer. That is for grade 3+ staining or higher (Haywood et. Al, 1997).
Therefore patient expectation was lowered as to when the result could be achievable. The patient was happy to carry out bleaching over this time frame.
Any patient concerns were addressed explaining the commonly seen side effects are tooth sensitivity and gingival irritation. These are usually mild to moderate and transient. Data suggests there are no long-term health risks and the use of 10% carbamide peroxide gels are safe and effective (Li Y and Greenwall LH, 2013).
The product used for home bleaching was 10% Opalesance as it is the most widely researched. The methodology was fabrication of upper and lower non-scalloped bleaching trays with reservoirs. I requested that the patient apply bleaching from LL6 to LR6 and to be worn everyday overnight. The choice of reservoirs were due to the high viscocity of the tooth whitening gel to allow better distribution and evidence suggests it may allow the material to work for longer. Review appointments were carried out monthly.
The mid-treatment clinical photographs were taken at five months. It took almost six months to achieve the desired results. Ultimately, the patient was delighted to see an improvement from pre-operative shade C4 to post-operative B1 Vita shade (Figures 1 and 2).
On reflection, the use of a scalloped tray may be beneficial to prevent gingival irritation during long-term home bleaching. Since this case I have completed further CPD with Enlighten. The time interval to achieve the desired result can be shortened by using a combination of two weeks at 10% and four weeks at 16%. This is a treatment method I will consider for my next tetracycline case.