|Year : 2015 | Volume
| Issue : 3 | Page : 187-190
Walking bleach in primary teeth
Athimuthu Anantharaj, Prasannakumari Patil, Sudhir Ramakrishna, Ramya Jagadeesh
Department of Pedodontics and Preventive Dentistry, D.A.P.M. R.V. Dental College, Bengaluru, Karnataka, India
|Date of Web Publication||4-Aug-2015|
Department of Pedodontics and Preventive Dentistry, D.A.P.M.R.V. Dental College, CA 27, 24th Main, JP Nagar 1st Phase, Bengaluru, Karnataka
Dental bleaching, also known as tooth whitening is a common procedure in dentistry. Dental bleaching in primary teeth has been reported with less frequency when compared to permanent teeth. Various methods are available for bleaching of both vital and nonvital teeth. The present article reports a clinical case of a 4-year-old girl who had discolored tooth 61 following pulpectomy procedure. Intra-coronal bleaching using sodium perborate with walking bleach technique was the treatment of choice. After a follow-up period of 3 weeks, an improvement in the discoloration was noticed.
Keywords: Esthetic, dental bleaching, intracoronal bleaching, sodium perborate
|How to cite this article:|
Anantharaj A, Patil P, Ramakrishna S, Jagadeesh R. Walking bleach in primary teeth. SRM J Res Dent Sci 2015;6:187-90
| Introduction|| |
Esthetic problems in childhood and adolescence can have a significant effect on psychosocial development and interaction with peers. Impairment in the esthetics, demands for dental treatment to improve the tooth color for re-establishing patient's smile.
Bleaching of the teeth has become increasingly important as there is growing concern and search for beauty and harmony over last few years. The use of a variety of bleaching techniques has attracted more interest because these are noninvasive, relatively simple to carry out and completed with less chair time. 
Bleaching can be done extracoronally and intracoronally. The literature describes a number of different substances used for bleaching primary teeth including various combinations of hydrogen peroxide, carbamide peroxide and sodium perborate in conjunction with different heat and light sources. There is a paucity of reported case of bleaching in the primary dentition. This case report throws light on the importance of bleaching in discolored pulpectomized primary teeth using sodium perborate with walking bleach technique.
| Case Report|| |
A 4-year-old girl reported to Department of Pedodontics and Preventive Dentistry at D.A.P.M.R.V Dental College, with the chief complaint of pain in the lower right tooth. On examination, dental caries was noticed with 55, 54, 52, 62, 64, 65, 75, 71, 81, 82, 85 and deep dentinal caries with 84, 51, 61. Amalgam restoration was seen on 74 and 84. Intraoral periapical (IOPA) with 74 revealed secondary caries. Mild discoloration and abscess were seen with 61 [Figure 1]. IOPA revealed resorption of root apex [Figure 2]. A diagnosis of severe early childhood caries was made.
|Figure 1: Preoperative picture showing dental caries with respect to anterior teeth and mild discoloration of 61 with abscess|
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Pulpectomy was performed using zinc-oxide eugenol (ZOE) obturating material (Deepak Enterprises, Mulund, Mumbai, India) with respect to 84, 51 and 61. Glass ionomer restoration (GC Corporation, Tokyo, Japan) was done for 52, 62 and stainless steel crown were placed for all the primary molars [Figure 3], [Figure 4]a and b. The 5 months follow-up showed increased discoloration of 61 which was of concern for the parent and the patient [Figure 5]. After evaluating the possible treatment option and owing to the presence of full coronal structure, treatment option of walking bleach was decided.
|Figure 4: (a and b) Complete rehabilitation of anterior and posterior teeth|
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|Figure 5: Exaggerated discoloration was noticed 5 months after completion of pulpectomy with 61|
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After removal of ZOE from the cementoenamel junction (CEJ), 2 mm thickness of glass ionomer cement (GIC) was placed in the pulp chamber as a leak proof plug. The base was shaped according to the epithelial attachment of gingiva. The base was made dome shape and keeping the barrier incisal to the CEJ. This was followed by placement of sodium perborate trihydrate (Loba Chemie, Mumbai, India) powder mixed with saline  [Figure 6] and the tooth was again temporarily restored with GIC [Figure 7]. After 7 days, the color of tooth was not satisfactory. The temporary GIC and bleaching paste was removed, which was then followed by thorough irrigation and bleaching agent placement was repeated. After 2 weeks of follow-up, color change was noticed and was considered satisfactory [Figure 8]. Then the pulp chamber was irrigated, access filling was done with GIC. The Patient is being followed up.
| Discussion|| |
Discolored or carious primary teeth require treatment as they need to last till the permanent teeth erupt. It is seen that people at a younger age desire whiter teeth. Also, girls place more emphasis on their teeth shade than boys. When planning treatment, dentists should take into consideration esthetic objectives in addition to function, structure and biology.
In the present case, the patient gave a history of swelling in relation to 61 since 5 days, clinical examination showed dentoalveolar abcess. IOPA revealed resorption of the root apex. All these findings indicated the pulp was nonvital. Discoloration of 61 in the present case may be due to the necrosis of the pulp. Decomposition of the pulp tissue is probably the most common cause of tooth discoloration, particularly if the pulp is necrotic. 
Primary teeth with intrinsic discoloration after pulpectomy may be treated by a number of methods including crowns, facings, and abrasion. Composite veneering may reflect the discoloration of the tooth. In order to overcome this, composite resin must be opaque and thick which may compromise esthetics.  However, the best esthetic outcome would be obtained by maintaining the natural tooth. Intracoronal bleaching in pulpectomy treated primary dentition may be considered as one of the viable options. This is done without sacrificing additional tooth structure and has psychological benefit on children. Hence, the treatment plan for discolored pulpectomized primary tooth in our case was intracoronal bleaching.
The most common root canal filling materials for primary teeth are ZOE, iodoform and Ca(OH) 2 pastes. ZOE is said to have anti-inflammatory and analgesic properties that are very useful after a pulpectomy procedure. Success rates ranged between 82% and 86% with ZOE obturation material.  Considering this ZOE was used as obturating material in the present case. It has been reported that resorbable pastes cannot prevent leakage into the apical region completely. Leakage of bleaching material may result in external root resorption. To prevent this, GIC base was applied on the ZOE obturating material 1 mm incisal to CEJ.  In the present case, a 2-mm thick GIC was placed which is in accordance with the literature. 
A number of different materials are used for bleaching primary teeth including various combinations of hydrogen peroxide, carbamide peroxide and sodium perborate in conjunction with heat and light sources. Arýkan et al.  described the treatment of a darkened primary tooth with sodium perborate using the walking bleach technique and its 1-year clinical and radiographical follow-up showed no signs of any pathology. Sharma et al. performed successful intracoronal bleaching in discolored young permanent and primary teeth using sodium perborate and water. Two months postoperative radiograph revealed no signs of external resorption and perfect coronal seal clinically. Bussadori et al. reported bleaching of devitalized two primary teeth using 35% hydrogen peroxide activated by photo polymerizer that showed immediate satisfactory results. Ganesh et al. compared the intracoronal bleaching efficiency of 10% hydrogen peroxide against 10% carbamide peroxide in an in-vitro study in primary incisors and concluded that hydrogen peroxide group showed superior results.
The literature describes carbamide peroxide, hydrogen peroxide and sodium perborate are effective intracoronal bleaching materials. Treatment with 30% hydrogen peroxide reduced the microhardness of both enamel and dentin. Sodium perborate appears to be a less damaging bleaching agent.  Alteration in microhardness using sodium perborate is nonsignificant.  Sodium perborate used over a long period is considered safe and has a better bleaching efficacy than 35% carbamide peroxide.  Thus, sodium perborate was the material of choice in our case.
Ari and Ungör  showed that there was no statistical significant difference between the groups treated with three different type of sodium perborate; monohydrate, trihydrate, tetrahydrate at 7, 14, 21 days. Other materials can also be tried with various combinations. By the 3 rd week, the satisfactory esthetic result was obtained using sodium perborate. However, discoloration was persistent in the cervical area of the crown. Since the smile line of the patient coincided with cervical line as well as mother and child expressed their satisfaction, hence no further treatment were carried out.
| Conclusion|| |
Intracoronal bleaching of discolored primary teeth using sodium perborate is a good alternative, esthetic modality for young children after pulpectomy. Because of the shortened chair time associated with this technique, it may be appropriate for younger children. However, usage of the other esthetic option can also be considered.
| References|| |
Arikan V, Sari S, Sonmez H. Bleaching a devital primary tooth using sodium perborate with walking bleach technique: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:e80-4.
Rotstein I. Tooth discoloration and bleaching. In: Ingle J, Bakland L, editors. Endodntics. 5 th
ed. Hamilton: BC Decker Inc.; 2002. p. 845-60.
Bleaching of discoloured teeth. In: Chandra BS, Gopi Krishna V, editors. Grossman's Endodontic Practice. 12 th
ed. New Delhi: Wolters Kluwer; 2010. p. 342-60.
Brantley DH, Barnes KP, Haywood VB. Bleaching primary teeth with 10% carbamide peroxide. Pediatr Dent 2001;23:514-6.
Praveen P, Anantharaj A, Venkataraghavan K, Rani P, Sudhir R, Jaya AR. A review of obturating materials for primary tooth. Streamdent 2011;2:42-4.
Sharma DS, Barjatya K, Agrawal A. Intra-coronal bleaching in young permanent and primary tooth with biologic perspectives. J Clin Pediatr Dent 2011;35:349-52.
Bussadori SK, Roth F, Guedes CC, Fernandes KP, Domingues MM, Wanderley MT. Bleaching non vital primary teeth: Case report. J Clin Pediatr Dent 2006;30:179-82.
Ganesh R, Aruna S, Joyson M, Manikandan, Deepa. Comparison of the bleaching efficacy of three different agents used for intracoronal bleaching of discolored primary teeth: An in vitro
study. J Indian Soc Pedod Prev Dent 2013;31:17-21.
Lewinstein I, Hirschfeld Z, Stabholz A, Rotstein I. Effect of hydrogen peroxide and sodium perborate on the microhardness of human enamel and dentin. J Endod 1994;20:61-3.
Umanah AU, Sede MA, Ibhawoh LO. Clinical efficacy of 35% carbamide peroxide and sodium perborate in intracoronal bleaching of discoloured non-vital teeth. J Med Biomed Res 2013;12:96-104.
Ari H, Ungör M. In vitro
comparison of different types of sodium perborate used for intracoronal bleaching of discoloured teeth. Int Endod J 2002;35:433-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]