A case report by Dr. Clarissa Jänig

Anamnesis:

A 30-year-old female patient presented in our practice requiring urgent dental treatment. She was concerned about her discoloured central incisor, which made laughing a cause of great unhappiness for her. She explained her inhibition and asked how we might be able to help her improve her situation. I explained the various treatment possibilities, ranging from prosthetic solutions to a more conservative approach involving internal whitening of the endodontically treated upper left central incisor.

To ensure a homogeneous appearance I also suggested complete cosmetic tooth whitening for the upper and lower arches. I explained that the first step of the treatment would be to whiten the teeth so that the restorations which would be placed later would match the new tooth shade. Following this I suggested replacing the existing insufficient restorations and treating any carious lesions.

Between the first consultation and the planned tooth whitening appointment, the patient found out she was pregnant. As pregnancy and breastfeeding is an absolute contraindication for tooth whitening, the start of her treatment had to postponed.

Whilst the patient was still breastfeeding an old incisor filling broke out and the brown decay between the teeth became clearly visible. This resulted in the patient deciding to stop breastfeeding and start her treatment immediately.

Situation after pregnancy, revealing various carious lesions and secondary caries in the anterior area. Tooth 21 shows grey discolorations due to a root canal filling.

The Treatment Protocol:

It is a prerequisite for successful whitening of an endodontically treated tooth that there is no clinical or radiographic insufficiency. In order to verify the suitability of this tooth for internal tooth whitening I carried out an intraoral examination, a percussion test and an X-ray. The X-ray did now show any abnormalities so that the treatment could begin.

I started the treatment by creating an access cavity, removing the old palatinal restoration, to expose the existing root filling. The coronal third of the root filling was removed with a Gates drill, 2-3 mm below the gingival line. Then, a 2mm thick layer of Glass Ionomer was applied as cervical plug. Opalescence™ Endo whitening gel was applied into the cavity after the glass Ionomer plug had set.

Root canal filling after the opening of the tooth via the old trepanation opening and removal of the coronal third of the root canal filling.

Application of the Opalescence Endo 35% tooth whitening gel into the tooth.

To keep the material in place and to ensure its efficacy within the tooth, the applied hydrogen peroxide gel was covered with a foam sponge and then sealed with a temporary cement.

Temporary cavity closure with a temporary cement.

Following the treament I advised the patient to closely monitor the colour the treated tooth.

I always avoid whitening endontically treated teeth on Fridays as the response to treatment can vary greatly. The desired result may be archieved in less than 24 hrs. If the treatment is carried out over the weekend it is impossible to remove the whitening gel before the tooth becomes considerably ligher than the adjacent teeth.

In this case I was informed by the patient the following day that the treated tooth matched the shade of the adjacent teeth. I elected to leave the whitening gel in place for a further 48 hrs so that the treated tooth would apprear slighlty lighter than the other anterior teeth.

Opalescence Endo whitening was removed from the tooth after 72 hours. The tooth was then provisionally closed so that the restoration can be renewed matching the new tooth shade.

Situation after the whitening of the endodontically treated tooth with Opalescence Endo whitening. The tooth appears just a bit lighter, as the old filling and caries still have a discolouring effect on the tooth.

To whiten the entire upper and lower arches I used costom made trays with small vestibular resvoirs. I advised the patient how to apply Opalescence™ PF 10% whitening gel to these trays and to wear them for six to eight nights. The 10% carbamide peroxide gel oxidizes the discolouring molecules in the patient’s teeth within six nights and leads to an excellent result: tooth colour A1.

Custom-made patient trays with small reservoirs. The patient wore these trays for six nights, using the Opalescence PF 10% whitening gel.

Upper and lower jaw tooth whitening with individual trays and the Opalescence PF 10% carbamide peroxide gel.

Having archieved the tooth shade A1 the arch still appears irregular, aesthetically not pleasing. The old discoloured filling margins (secondary and intial caries) were not affected by the tooth whitening treatment. As a result of which futher restorative treatment was required.

Situation after the application of the Opalescence Endo whitening gel on tooth 21 and the whitening of the upper and lower archs—but before the replacement of the fillings and the conservative treatment.

The restorative treatment can be started after a period of at least two weeks have elapsed following the tooth whitening treatment. This ensures that the adhesive bonding is not inhibited by oxygen released during tooth whitening.

Initial replacement of the old fillings.

Finally the patients insufficient fillings and carious lesions were restored, bringing a bright smile to her face. Later she reported enthusiastically to us, that she now dares to laugh again and show her teeth. A direct result of this treatment. Various colleagues and relatives have noticed the results of this successful tooth whitening treatment and commented on it. The patient is very happy about having a new bright smile.

The patient's bright smile at the end of the treatment.

About The Author: Dr. Clarissa Jänig, Germany

• Graduated from the Dental Faculty of Bonn University
• In general dental practice since 2012
• Specialising in orthodontics