Microleakage in endodontically treated teeth: influence of calcium hydroxide dressing following bleaching

Present status and future directions - Managing discoloured teeth

Managing tooth discolouration involves a range of different protocols for clinicians and patients in order to achieve an aesthetic result. There is an increasing public awareness in the appearance of their teeth and management of tooth discolouration may be inter-disciplinary and involve both vital and nonvital teeth. Vital teeth can be easily treated with low concentration hydrogen peroxide products safely and effectively using an external approach and trays. For endodontically treated teeth, the walking bleach technique with hydrogen releasing peroxide products is popular. However, there is an association with external cervical root resorption with higher concentrations of hydrogen peroxide of 30%-35%. There are also regulatory considerations for the use of hydrogen peroxide in certain jurisdictions internationally. Prosthodontic treatments are more invasive and involve loss of tooth structure as well as a life cycle of further treatment in the future. This narrative review is based on searches on PubMed and the Cochrane library. Bleaching endodontically treated teeth can be considered a safe and effective protocol in the management of discoloured teeth. However, the association between bleaching and resorption remains unclear although there is likely to be a relation to prior trauma. It is prudent to avoid thermocatalytic approaches and to use a base/sealer to cover the root filling. An awareness expectations of patients and multidisciplinary treatment considerations is important in achieving the aesthetic result for the patient. It is likely that there will be an increasing demand for aesthetic whitening treatments. Bleaching of teeth has also become increasingly regulated although there are international differences in the use and concentration of bleaching agents.

Influence of intracoronal bleaching agents on the bond strength of MTA cements to composite resin and their surface morphology

The objective of the present in vitro study was to evaluate micro-tensile bond strength (µSBS) of MTA cements to composite resin using a universal adhesive after internal bleaching procedure, and to examine surface characteristics of MTA cements exposed to bleaching agents. MTA specimens were divided into three subgroups according to the bleaching agent used which were, 37% carbamide peroxide (CP), 35% hydrogen peroxide (HP), and no exposure as a control group (n = 12). After exposure to bleaching agent, composite resins were applied to MTA surfaces using a universal adhesive in self-etch mode. The specimens were exposed to a shear force until failure to evaluate bond strength. MTA surfaces were investigated using scanning electron microscopy (SEM) to observe the effects of the bleaching agents. Differences between groups were analyzed using two-way ANOVA test and intergroup comparisons were assessed with Tukey test (p < 0.05). Although there was a slight difference in bond strength between bleaching agents (CP and HP), no significant difference was found, irrespective of MTA cement. After the HP application, the bond strength values decreased approximately by half compared with the controls. SEM results demonstrated distinct morphological differences between the intact MTA surface (control) and treated MTA surface. Distinct micro-cracks, surface irregularities, and capillary voids formed due to the superficial dissolution caused by peroxides. Exposure to the intra-coronal bleaching agents had a negative influence on the surface morphology of MTA cements and their bond strength to composite resin.

Effect of Bleaching and Ca(OH)2 Dressing on the Bond Strength of Fiberglass Posts to Root Dentine

Objective The purpose of this study was to evaluate the effect of the intracoronary bleaching and calcium hydroxide (Ca(OH) ₂ ) dressing use, on the bond strength (BS) of fiberglass posts to root dentine.

Materials and Methods After root canal filling of 40 bovine incisors, a 2-mm thick cervical plug was fabricated 2 mm below the cementum–enamel junction. Seven days later, teeth were randomly distributed into four groups ( n = 10), as follows: G1 no bleaching, followed by immediate post cementation; G2 bleaching and immediate post cementation; G3 bleaching, dressing with Ca(OH) ₂ for 7 days, and post cementation; and G4 bleaching, no dressing, and post cementation after 7 days. The roots were transversally cut into 1-mm thick slices to perform the push-out test (0.5 mm/min). Failure modes were assessed under scanning electron microscopy.

Statistical Analysis The analysis of variance (two-way ANOVA) was performed, followed by the supplementary Tukey multiple comparison test ( a = 5%).

Results No significant difference for BS was observed among groups. Considering the different root thirds, G1 had higher BS values for the cervical third in comparison with the apical one ( p < 0.05). The most frequent failure modes were adhesive between cement/dentine (G1); cohesive at the post (G2 and G3), and mixed (G4).

Conclusions The BS of the fiberglass posts to root dentine was not affected by the intracoronary bleaching and the use of Ca(OH) ₂ dressing.

Preferences on Vital and Nonvital Tooth Bleaching: A Survey Among Dentists from a City of Southern Brazil

This study evaluated the preferences of general dentists regarding vital and nonvital tooth bleaching therapies and investigated whether the time of clinical practice and post-graduate training influence these options. A cross-sectional study was conducted using a questionnaire with closed questions applied to dentists (n=276) of a mid-sized city of the southern Brazil (Pelotas, RS). Information was collected regarding sociodemographic variables, level of specialization and time since graduation. In addition, options regarding bleaching therapies including the first choice of material, technique and clinical practice for vital and nonvital tooth bleaching therapies were included. Data were submitted to descriptive analysis and the associations were evaluated using chi-square and Fisher exact tests (α=0.05). The response rate was 68% (n=187). At-home bleaching therapy was broadly preferred (78.1%) over in-office (21.9%) bleaching. For at-home bleaching, most dentists answered to use 10% carbamide peroxide (CP) (40.2%) and >30% hydrogen peroxide (HP) (31.7%) for nonvital therapies. The majority of dentists with post-graduation training preferred at-home bleaching techniques (p=0.003). At-home bleaching therapy was also more indicated by younger dentists. No association was found between the choice for nonvital bleaching therapies and time since graduation (p=0.532) or continuous education (p=0.083). In conclusion, at-home bleaching was preferred over in-office therapies; 10% CP and >30% HP were chosen as first option agents to treat discolored vital and nonvital teeth, respectively. The time in clinical practice and the level of specialization affected dentists' choices only for vital tooth bleaching treatment.

Effect of calcium hydroxide on ph changes of the external medium after intracoronal bleaching

AIM

This in vitro study evaluated the effect of calcium hydroxide on pH changes of the external medium after intracoronal bleaching.

MATERIALS AND METHODS

A total of 50 extracted human premolars were prepared and filled with gutta-percha and endodontic sealer. The teeth were randomly divided into five groups according to the bleaching agents employed: (a) Sterile cotton pellet with distilled water (control group); (b) sodium perborate and distilled water; (c) sodium perborate and 10% carbamide peroxide; (d) sodium perborate and 35% hydrogen peroxide; (e) 35% hydrogen peroxide. The teeth were stored in vials containing distilled water and the pH values of the medium surrounding the teeth were analyzed. After 7-day storage, the bleaching agent was removed and replaced by calcium hydroxide, and the distilled water was changed, in which the teeth were kept stored for further 14 days. Measurement of pH of the external medium (distilled water) was performed 7 days after insertion of the bleaching agents, immediately, 7 and 14 days after insertion of the calcium hydroxide. Data were submitted to statistical analysis by the two-way ANOVA and Tukey,s test.

RESULTS

There were pH changes of the external medium at 7- day period after bleaching procedures. These results confirmed the diffusion of bleaching agents to the external medium.

CONCLUSION

Calcium hydroxide increased the external medium pH and was effective for pH alkalinization after intracoronal bleaching.

CLINICAL SIGNIFICANCE

Intracoronal bleaching of endodontically treated teeth may cause cervical root resorption. A possible explanation for this process is the passage of bleaching agents to the periodontal tissues yielding an inflammatory process. In an attempt to keep the neutrality of the periodontal pH, the calcium hydroxide has been recommended.Results of this study showed that this material should be always used after intracoronal bleaching.

pH-changes during intracoronal bleaching: an in vivo study

OBJECTIVES

This study aimed to measure pH changes during 14 days intracoronal bleaching with hydrogen peroxide/sodium perborate and carbamide peroxide/sodium perborate.

MATERIALS AND METHODS

Twenty patients presenting endodontically treated central maxillary incisors with color alterations were divided in two groups (n = 10): Group CP + SP: 37% carbamide peroxide + sodium perborate paste; Group HP + SP: 30% hydrogen peroxide + sodium perborate paste. The pH values were measured using a digital microprocessor at different times: Baseline, 2, 7 and 14 days. Data were analyzed with two-way ANOVA followed by Tukey's test (α = 0.05).

RESULTS

ANOVA showed p < 0.00 which indicated significant difference between the groups. The mean values (± sd) and the results of the Tukey´s test were: HP + SP/14 days-7.98 (±0.58)a; HP + SP/7 days-8.59 (±0.18)b; HP + SP/2 days- 8.83 (±0.32)bc; HP + SP/Baseline-8.83 (±0.01)bc; CP + SP/ Baseline-8.89 (±0.01)bc; CP + SP/14 days-9.11 (±0.58)cd; CP + SP/7 days-9.54 (±0.16)de; CP + SP/2 days-9.66 (±0.08) de. The group HP + SP resulted in significantly lower pH values compared with group CP + SP.

CONCLUSION

It can be concluded that both associations showed alkaline pH values; however, there was significant reduction in the pH values of the 30% hydrogen peroxide associated with sodium perborate after 14 days.

CLINICAL SIGNIFICANCE

The association of hydrogen peroxide and carbamide peroxide with sodium perborate paste presented alkaline characteristics during the 14-day evaluated period. Thus, regarding pH changes, both associations can be considered safe as intracoronal bleaching agents.

Effect of light-activated bleaching on the microleakage of Class V tooth-colored restorations

OBJECTIVE

In-office bleaching procedures utilizing highly concentrated 30%-35% hydrogen peroxide solutions or hydrogen peroxide releasing agents are used for tooth whitening. Some recommend that, to enhance the whitening process, light-activation of the bleaching agent should be performed. The current study evaluated the effect of plasma arc bleaching on the microleakage of Class V restorations restored with resin composite, compomer and resin-modified glass ionomer (RMGI).

MATERIALS AND METHODS

The buccal surfaces of 72 freshly extracted premolars were prepared with Class V cavities (4 x 2.5 x 1.5 mm) extended 1 mm apical to the CEJ. The prepared teethwere randomly divided into six groups. The cavities were restored with Single Bond and Z100 resin composite (Groups 1 and 2), Prompt L-Pop and F2000 compomer (Groups 3 and 4) and Vitremer RMGI (Groups 5 and 6), respectively. They were then thermocycled for 500 cycles. The samples from Groups 1, 3 and 5 were incubated at 37 degrees C and 100% humidity. Groups 2, 4 and 6 were bleached using in-office bleaching gel and the plasma arc bleaching unit, then incubated. All samples were sealed with nail varnish and immersed in 2% basic fuschin for 24 hours. The restorations were sectioned longitudinally and microleakage was evaluated using a scale ranging from 0 to 3. The data were analyzed using the Kruskal-Wallis test (alpha = 0.05).

RESULTS

No statistically significant differences between study groups were observed in both the enamel and dentinal margins (p > 0.05).

CONCLUSION

Plasma arc bleaching did not significantly affect the microleakage of existing tooth-colored restorations restored with Z100 resin composite, F2000 compomer and Vitremer RMGI.

Nonvital tooth bleaching: a review of the literature and clinical procedures

Tooth discoloration varies in etiology, appearance, localization, severity, and adhesion to tooth structure. It can be defined as being extrinsic or intrinsic on the basis of localization and etiology. In this review of the literature, various causes of tooth discoloration, different bleaching materials, and their applications to endodontically treated teeth have been described. In the walking bleach technique the root filling should be completed first, and a cervical seal must be established. The bleaching agent should be changed every 3-7 days. The thermocatalytic technique involves placement of a bleaching agent in the pulp chamber followed by heat application. At the end of each visit the bleaching agent is left in the tooth so that it can function as a walking bleach until the next visit. External bleaching of endodontically treated teeth with an in-office technique requires a high concentration gel. It might be a supplement to the walking bleach technique, if the results are not satisfactory after 3-4 visits. These treatments require a bonded temporary filling or a bonded resin composite to seal the access cavity. There is a deficiency of evidence-based science in the literature that addresses the prognosis of bleached nonvital teeth. Therefore, it is important to always be aware of the possible complications and risks that are associated with the different bleaching techniques.

Microleakage of glass-ionomer cement placed in association with non-setting calcium hydroxide

The purpose of this investigation was to determine whether non-setting calcium hydroxide [Ca (OH)2] cement placed in the root canal system of premolar teeth would affect the subsequent microleakage of a glass-ionomer restoration (GIC). Following selection, 62 human premolar teeth extracted for orthodontic reasons were accessed and root canals prepared according to a standardized procedure. The specimens were then allocated randomly into two major groups each of 30 teeth. Two other teeth were used as a positive and a negative control. The control group was restored with glass-ionomer cement following drying of the canal and placement of a cotton wool pledget. The test group had all canals dressed with non-setting Ca(OH)2 and then was subdivided, one set (n = 22) being restored following conditioning of the access cavity margins, the other (n = 8) having the margins cleaned with a hand excavator. Samples were assessed for microleakage using a two-point scoring system (leakage or no leakage) in conjunction with a clearing technique using AgNO3. Using Fisher's exact test, a statistically significant difference was found between the control and test groups (P < 0.05) but there was no significant difference between the excavated and conditioned cavities (P=0.55). It is concluded that contamination of access cavity margins with Ca(OH)2 during medication of a root canal interferes with the bond of GIC, resulting in increased microleakage in vitro.

Effect of bleaching on restorative materials and restorations—a systematic review

OBJECTIVE

Internal and external bleaching procedures utilizing 3-35% hydrogen peroxide solutions or hydrogen peroxide releasing agents, such as carbamide peroxide or sodium perborate, can be used for whitening of teeth. The purpose of the review article was to summarize and discuss the available information concerning the effects of peroxide releasing bleaching agents on dental restorative materials and restorations.

SOURCES

Information from all original scientific full papers or reviews listed in PubMed or ISI Web of Science (search term: bleaching AND (composite OR amalgam OR glass ionomer OR compomer OR resin OR alloy) were included in the review.

DATA

Existing literature reveals that bleaching therapies may have a negative effect on physical properties, marginal integrity, enamel and dentin bond strength, and color of restorative materials as investigated in numerous in vitro studies. However, there are no reports in literature indicating that bleaching may exert a negative impact on existing restorations requiring renewal of the restorations under clinical conditions.

CONCLUSION

Bleaching may exert a negative influence on restorations and restorative materials. Advice is provided based on the current literature to minimize the impact of bleaching therapies on restorative materials and restorations.

Sealing evaluation of the cervical base in intracoronal bleaching

Discoloration of non-vital teeth is an esthetic deficiency frequently requiring bleaching treatment. The purpose of this study was to evaluate in vitro the cervical base efficacy in order to prevent or to minimize the leakage along the root canal filling and into the dentinal tubules. Thirty-eight extracted single-root human teeth were used, which were biomechanically prepared, filled, and divided into three experimental groups: G1, a cervical base was applied (3 mm of thickness) below the cemento-enamel junction, with resin-modified glass-ionomer cement (Vitremer); G2, the base was done with glass-ionomer cement (Vidrion R); and G3 (Control), did not receive any material as base. A mixture of sodium perborate and hydrogen peroxide 30% was placed inside the pulp chamber for 3 days, and the access opening was sealed with Cimpat. This procedure was repeated thrice. Soon after this, a paste of calcium hydroxide was inserted into the pulp chamber for 14 days. All teeth were covered with two layers of sticky wax, except the access opening, and immersed in blue India Ink for 5 days. The results did not show statistically significant differences between the three groups concerning the leakage inside the dentinal tubules. Regarding the apical direction, a statistical difference (ANOVA P < 0.05) was observed among the experimental group G1 and control group G3. No statistically significant difference was observed between G2 and G3 groups. Therefore, the placement of a cervical base before internal bleaching procedures is still recommended.

Effect of nonvital bleaching with 10% carbamide peroxide on sealing ability of resin composite restorations

AIM

To (i) determine the effect of nonvital bleaching with 10% carbamide peroxide on the sealing ability of resin composite restorations bonded with a self-etching adhesive system; and (ii) compare the effects of antioxidant treatment and delayed restoration after bleaching on marginal seal.

METHODOLOGY

Forty-eight noncarious maxillary incisors were divided into four groups (n=12) after conventional root canal treatment was completed. In group 1, access cavities were restored with a self-etching adhesive system and resin composite. In the remaining three groups, 10% carbamide peroxide bleaching gel was placed into the access cavities for periods of 8 h per day for 1 week. They were then restored in the same manner as group 1. Group 2 consisted of specimens restored immediately after bleaching. Group 3 specimens were treated with the antioxidant, 10% sodium ascorbate, whereas group 4 specimens were immersed in artificial saliva for 1 week before restoration. Ten specimens in each group were then subjected to dye leakage; the remaining 2 specimens were examined in a SEM (Jeol/JSM 5200, Tokyo, Japan). The dye penetration was assessed with the standard scoring system. Statistical analysis was carried out using the Kruskal-Wallis and the Mann-Whitney tests.

RESULTS

Groups 1, 3 and 4 exhibited similar leakage patterns and significantly less leakage than group 2 (P<0.0083). SEM examination of groups 1, 3 and 4 specimens demonstrated close adaptation of resin composite to cavity walls, whereas group 2 specimens did not.

CONCLUSION

Nonvital bleaching with 10% carbamide peroxide adversely affected the immediate sealing ability of resin composite restoration; both 10% sodium ascorbate treatment and a 1-week delay in restoration following bleaching improved the reduced sealing ability of resin composite.

Review of the current status of tooth whitening with the walking bleach technique

Internal bleaching procedures such as the walking bleach technique can be used for whitening of discoloured root-filled teeth. The walking bleach technique is performed by application of a paste consisting of sodium perborate-(tetrahydrate) and distilled water (3% H2O2), respectively, in the pulp chamber. Following a critical review of the scientific literature, heating of the mixture is contra-indicated as the risk of external cervical resorption and the formation of chemical radicals is increased by application of heat. An intracoronal dressing using 30% H2O2 should not be used in order to reduce the risk of inducing cervical resorption. This review provides advice based on the current literature and discusses how the walking bleach technique can lead to successful whitening of non-vital root-filled teeth without the risks of side-effects.