In Vitro Assessment of a Gel Base Containing 2% Chlorhexidine as a Sodium Perborate’s Vehicle for Intracoronal Bleaching of Discolored Teeth

Irrigants and irrigation activation systems in Endodontics

Root canal infections are typically polymicrobial and involve strong bacterial interactions. The goal of endodontic treatment is to remove infected content from the root canal system to allow the healing of a pre-existing periapical lesion or to prevent infection of the periradicular tissues. Instrumentation alone is not capable of touching all of the root canal walls. Therefore, the irrigation process is an essential step in the endodontic treatment. However, due to the complex anatomy of the root canal system, this cleaning is very challenging. Although syringe and needle irrigation associated with the use of chemical substances is still the most used method, it does not guarantee optimal cleaning of the root canals. As a result, not only alternative irrigating substances but also numerous activation systems - which are technologies that aim to optimize the action of irrigating substances, both chemically and physically - have been developed. This work aimed to review the characteristics of both classic and current alternatives of irrigating substances and irrigation activation systems.

Assessing the bleaching effect of an experimental stabilized chlorine dioxide agent used for internal bleaching purposes

Aim: Assessing the intracoronal bleaching effectiveness of an experimental chlorine dioxide product, based on the walking bleach technique. Methods: Extracted bovine incisors were artificially stained with bovine blood and filled with zinc phosphate cement at cementoenamel junction level. Teeth were divided into 3 groups (n=10): (SP) sodium perborate added with distilled water, (CD) chlorine dioxide and (C) control – dry cotton inserted into the pulp chamber. Bleaching agents were used at 0, 7 and 14 days. VITA Easyshadetm (ΔEab) was used to analyze tooth color at the 7th, 14th and 21st days, based on the CIE2000 system. Data were analyzed through ANOVA and Tukey’s test. Results: There were no statistically significant differences in Δb, ΔE, ΔE00 and ΔWID between CD and the control group. These parameters have shown significant differences between CD and SP, which differed from the control. However, they did not show significant differences either in the control group or in CD at the 7th, 14th and 21st days. Values recorded for SP at the 7th day differed from those recorded at the 14th and 21st days. Δa has shown differences within the same group at the 7th, 14th and 21st days. There was no difference between groups, when they were compared at the same day (7th and 14th). The control group differed from SP at the 21st day. CD did not differ from the other two groups. ΔL did not show differences between groups and times. Conclusion: Stabilized chlorine dioxide (0.07%, at pH 3.5) should not be used as intracoronal bleaching agent along with the walking bleach technique.

Effectiveness and color stability of bleaching techniques on blood-stained teeth: An in vitro study

OBJECTIVE

Evaluate the effectiveness and color stability of bleaching techniques on blood-stained teeth.

MATERIAL AND METHODS

The teeth were stained by blood and allocated to groups: walking bleach, inside/outside, and in-office bleaching. L*, a*, b*, C*, h° color coordinates were measured using a clinical spectrophotometer at baseline, weekly (T1-T2-T3), and at 1-week (T4), 6-months (T5), and 1-year (T6) follow-up evaluations. ΔE ab * , ΔE 00 , and ΔWI D were calculated between sequential evaluation timepoints and between baseline and each evaluation timepoint. Color coordinates and WI_D differences in each timepoint and technique were analyzed by Wilcoxon Signed Rank, Kruskal-Wallis and Mann-Whitney U test, respectively. ΔE ab * , ΔE 00 , and ΔWI D were interpreted by color visual thresholds.

RESULTS

The techniques presented a significant increase in L* and WI_D and, a significant decrease in a* and b* until the completion of treatments. Statistical differences between the techniques for a*, b* and WI_D were observed from T1 until T3. All techniques demonstrated excellent effectiveness for ΔE ab * , ΔE 00 , and ΔWI D between baseline and each evaluation and follow-up timepoints. However, at T6, it was possible to identify a rebound effect for all techniques.

CONCLUSIONS

All bleaching techniques presented excellent effectiveness. The stability of the whitening produced was maintained for 6 months.

CLINICAL SIGNIFICANCE

Effective whitening of blood-stained teeth was achieved using walking bleach (sodium perborate), inside/outside (hydrogen peroxide - 7.5%) and in-office techniques (hydrogen peroxide - 35%). The bleaching techniques were effective after the completion of the treatments. A slight rebound was observed at 1 year follow-up.

Ten-Year Follow-Up of a Fragment Reattachment to an Anterior Tooth: A Conservative Approach

This report describes the 10-year follow-up data of a patient who underwent fragment reattachment to the maxillary central incisor after coronal fracture with pulp exposure as well as the procedures followed for functional and esthetic adjustments. A 9-year-old female patient presented at the clinic of dentistry at the State University of Rio de Janeiro with a coronal fracture and pulp exposure of the right maxillary central incisor that had occurred immediately after an accident. The intact tooth fragment was recovered at the accident site and stored in milk. The treatment plan followed was to perform direct pulp capping and tooth fragment reattachment. When the patient was 14 years old, adhesion between fragment and remaining tooth was lost, and fragment reattachment was performed. Five years later, the same tooth presented clinical discoloration and absence of sensitivity during pulp vitality tests. Subsequently, a new treatment plan was formulated, which included endodontic treatment, followed by nonvital tooth bleaching and light-cured composite resin restoration. An esthetic and natural-looking restoration was achieved. Tooth fragment reattachment is not a temporary restorative technique and requires functional and esthetic adjustments over time to maintain the biomimetic characteristics of traumatized anterior teeth and predictable outcomes.

Effects of Internal Bleaching on the Adhesion of Glass-Fiber Posts

Objective:

We evaluated the effects of internal bleaching on the adhesion of glass-fiber posts (GFPs) luted with different resin cements.

Methods:

Forty extracted human single-root teeth were endodontically treated and divided into four groups (n=10): G1- conventional resin cement (CRC); G2- self-adhesive resin cement (SARC); G3- bleaching + CRC; and G4- bleaching + SARC. Specimens were sectioned transversally into three slices to perform the push-out test at the coronal, middle and apical regions of the root canals. Data were analyzed using analysis of variance and Tukey's test (p<0.05).

Results:

The push-out bond strength of GFPs luted with SARC after bleaching (G4) was significantly lower than that of the other groups (p<0.001). We found no statistically significant differences in push-out bond strength among the other groups.

Significance:

Internal bleaching reduced the adhesion of GFPs luted with SARC. The adhesion of GFPs luted with CRC was not decreased after bleaching.

Chlorhexidine in Endodontics

Chemical auxiliary substances (CAS) are essential for a successful disinfection and cleanness of the root canals, being used during the instrumentation and if necessary, as antimicrobial intracanal medicaments. Different CAS have been proposed and used, among which sodium hypochlorite (NaOCl), chlorhexidine (CHX), 17% EDTA, citric acid, MTAD and 37% phosphoric acid solution. CHX has been used in Endodontics as an irrigating substance or intracanal medicament, as it possesses a wide range of antimicrobial activity, substantivity (residual antimicrobial activity), lower cytotoxicity than NaOCl whilst demonstrating efficient clinical performance, lubricating properties, rheological action (present in the gel presentation, keeping the debris in suspension); it inhibits metalloproteinase, is chemically stable, does not stain cloths, it is odorless, water soluble, among other properties. CHX has been recommended as an alternative to NaOCl, especially in cases of open apex, root resorption, foramen enlargement and root perforation, due to its biocompatibility, or in cases of allergy related to bleaching solutions. The aim of this paper is to review CHX's general use in the medical field and in dentistry; its chemical structure, presentation form and storage; mechanism of action; antimicrobial activity including substantivity, effects on biofilms and endotoxins, effects on coronal and apical microbial microleakage; tissue dissolution ability; interaction with endodontic irrigants; effects on dentin bonding, metalloproteinases and collagen fibrils; its use as intracanal medicament and diffusion into the dentinal tubules; its use as disinfectant agent of obturation cones; other uses in the endodontic therapy; and possible adverse effects, cytotoxicity and genotoxicity.

Effectiveness of carbamide peroxide and sodium perborate in non-vital discolored teeth

Objective: To evaluate the efficacy of 16% carbamide peroxide gel (CP16%), tetrahydrate sodium perborate (SP) and mixture (CP16% + SP), in walking bleaching of non-vital discolored teeth. Materials and methods: Sixty single-rooted human premolars with intact crowns were used and initial color was assessed using Vita shade guide and standardized photos. The teeth were stained using rabbit fresh blood for 18 days and photos of discolored teeth and color evaluation were performed. The teeth were divided into 4 groups (n = 15), according to bleaching agent used: G1) CP16% gel; G2) CP16% gel + SP; G3) SP + distilled water; G4: control. The bleaching agents were replaced twice at 7-day intervals for 21 days. All teeth were evaluated by two endodontists at days 0, 7, 14 and 21 and the color changes were assessed using Vita shade guide and standardized photos. The results were analyzed by Kruskal-Wallis and Dunn's tests (p=0.05). Results: The experimental groups presented statistically similar bleaching results (p>0.05) at the end of 7, 14 and 21 days. These groups presented significantly higher bleaching efficacy than control group (G4) (p<0.05). The mixture CP16% + SP promoted return of original color in 100% of teeth at the end of 21 days. Conclusion: It was concluded that three bleaching agents were effective in bleaching of stained teeth with blood products, especially at the end of 21 days.

Clinical efficiency of 2% chlorhexidine gel in reducing intracanal bacteria

This study evaluated the clinical efficacy of 2% chlorhexidine (CHX) gel on intracanal bacteria reduction during root canal instrumentation. The additional antibacterial effect of an intracanal dressing (Ca[OH](2) mixed with 2% CHX gel) was also assessed. Forty-three patients with apical periodontitis were recruited. Four patients with irreversible pulpitis were included as negative controls. Teeth were instrumented using rotary instruments and 2% CHX gel as the disinfectant. Bacterial samples were taken upon access (S1), after instrumentation (S2), and after 2 weeks of intracanal dressing (S3). Anaerobic culture was performed. Four samples showed no bacteria growth at S1, which were excluded from further analysis. Of the samples cultured positively at S1, 10.3% (4/39) and 8.3% (4/36) sampled bacteria at S2 and S3, respectively. A significant difference in the percentage of positive culture between S1 and S2 (p < 0.001) but not between S2 and S3 (p = 0.692) was found. These results suggest that 2% CHX gel is an effective root canal disinfectant and additional intracanal dressing did not significantly improve the bacteria reduction on the sampled root canals.

Effect of Intracoronal Bleaching Agents on Dentin Microhardness

The purpose of this in vitro study was to compare the effect of intracoronal bleaching agents associated or unassociated with chlorhexidine gel on dentin microhardness. Sixty human maxillary incisor crowns were divided into six groups, and bleaching agents were sealed into the pulp chambers as follows: sodium perborate + water (SPW), sodium perborate + 2% chlorhexidine gel (SP + CHX), sodium perborate + 30% hydrogen peroxide solution (SP + HP), 37% carbamide peroxide gel (CP), 37% carbamide peroxide gel + 2% chlorhexidine gel (CP+CHX), and water (W). After the bleaching procedure, microhardness testing was carried out on the dentin surface at three different levels: inner, middle, and outer dentin. The greatest reduction in microhardness was observed for the SP + HP group. No differences were observed between the SPW and SP + CHX group. The 2% chlorhexidine gel did not adversely affect dentin microhardness when associated with the tested bleaching agents. CHX might be considered as an antimicrobial vehicle during intracoronal bleaching.

Topographical, Diametral, and Quantitative Analysis of Dentin Tubules in the Root Canals of Human and Bovine Teeth

The aim of this study was to evaluate the number and the diameter of dentin tubules in root canals, in the cervical, middle, and apical thirds, of human and bovine teeth. Twenty-four single-rooted, human premolars were divided into four groups (n = 6): GH1, 10 to 15 years; GH2, 16 to 30 years; GH3, 31 to 45 years; and GH4, 46 to 80 years; and 24 bovine incisors were divided into four groups (n = 6): GB1, central; GB2, lateral first; GB3, lateral second; and GB4, lateral third. The crowns were removed from the specimens, which were then debrided, sectioned longitudinally in the vestibular-lingual direction, and submitted to ultrasonic cleaning. Scanning electron microscopic evaluations were made with 1,000x and 5,000x magnification. According to the root thirds, statistically significant differences were found both for the number and the diameter of dentin tubules, with the cervical third presenting the highest mean values for both specimen types. As regards the number of dentin tubules, it was observed that the bovine specimens presented a significantly higher mean value than the human specimens; this difference was not observed when the diameters of the two types were compared.