Bleaching Discolored Endodontically Treated Teeth by Dr. Terry Shaw

One of our most-followed Townies explains how to treat endodontically treated discolored teeth

by Dr. Terry Shaw

Case 1

This 60-year-old patient tripped over her cat and whacked her left central. The luxated tooth moved 2 mm palatally, and although the patient could “straighten it” by closing her teeth together to move it back into place, after a few weeks the tooth also was obviously discoloured (Figs. 1 and 2), which finally inspired her to come in. I performed a root canal treatment, then placed some Opalescence Endo whitening gel (Ultradent) inside the tooth to help whiten it.

Before injecting the 35% hydrogen peroxide gel, I placed a plug of Ketac-Cem glass ionomer cement (3M) using an endodontic orifice locator, and let the GI cement harden in the tooth at the crestal bone level. This is important to prevent the bleach from migrating out the canal and irritating the apical tissues—even if you think it’s well sealed, the bleach will still get past the cemented gutta-percha!

Fig. 1

Fig. 2

Fig. 3: One week after treatment, the tooth was bleached whiter than the adjacent teeth.

Figs. 4 and 5: The tooth will probably regress slightly over time.

Fig. 6: Access opening.

Fig. 7: Tooth with first increment in place.

Fig. 8: Composite added.

Fig. 9: Finished.

Fig. 10: On the X-ray, you can see the glass ionomer plug between the gutta-percha and the composite restoration.

The patient told me she thought her tooth had been moved down out of the socket slightly—because this appeared to be the truth, I shaved a bit off the tooth when I finished adjusting it after placing the restoration.

Case 2

Fig. 11: An old RCT with lots of discoloration.

Figs. 12–14: Cleaning out the old composite and stained material.

Fig. 15: After removing the old stain and placing glass ionomer over the gutta-percha at the crestal level. Looking better already!

Fig. 16: X-rays at the start.

Fig. 17: The patient lives more than 200 miles away, so they returned after nearly one month so I could continue the restoration work.

Fig. 18: Old restoration and decay removed from adjacent tooth.

Fig. 19: Incisal view.

Fig. 20: Pulp chamber with first increment added.

Fig. 21: Larger increment added to distal, lingual and buccal surfaces.

Figs. 22 and 23: Adding composite. I included a little over the buccal incisal enamel, which I will finish to a featheredge margin.

Figs. 24–26: Finished restoration.

 

Case 3

Fig. 27: Three root canals staining badly. For what it’s worth, I always clean out the gutta-percha after I do my root canal treatment to the crestal bone level, and place composite in the canal from the crestal bone level to the palatal or occlusal surface. I strongly believe doing so reinforces the tooth, and they very seldom break. I find these last for many years, rather than placing a post and doing a crown prep and crown. Much less tooth structure is removed—and I have many that are 40 years old and have never been touched.

Fig. 28: Canals cleaned out. Lateral had a lot of black material in it

Fig. 29: The centrals were nonvital and had no pulps visible on the X-ray. I tried to access them but couldn’t find any canal.

Fig. 30: Teeth with glass ionomer over access area and bleach in canals, plus etch composite temps in lingual.

Fig. 31: Etched composite restorations in the lingual.

Fig. 32: Four weeks went by because this fellow works in the west of Canada for three to four weeks at a time.

Fig. 33: Most teeth became much whiter. The lateral had some labial composite I hadn’t seen, so I decided to rebleach it and also restore the centrals with composite.

Figs. 34 and 35: All cleaned out.

Fig. 36: The lateral is still dark.

Fig. 37: Centrals restored.

Fig. 38: Lateral being rebleached for one more week.

Fig. 39: After one week, restoring the distal of the patient’s left central before doing his lateral.

Fig. 40: You’ll notice that his lateral is palatal to the central, so I decided to add composite to the lateral and move the labial surface forward, so it looks more even and blends better with his other teeth. (Plus, I could get the color whiter because the tooth didn’t bleach as well as his centrals.)

Figs. 41 and 42: The lateral was also quite round, so I flattened it as well.

 

Fig. 43: Before we started.

Fig. 44: Definitely looking better!