I heard about this technique about 18
months ago but I've been waiting to find a suitable candidate for it. You do
see dark non vital teeth, but it's not a day to day occurrence. This case was
pretty severe and was surprising in that the tooth had already been root filled
adequately several years ago.
I suppose the most common way to do non vital
bleaching is the "walking bleach method" in which you remove gutta percha to
below the cervical level, seal and hen seal sodium perborate into the pulp
chamber. This dressing is then changed every 2 weeks until the colour change is
sufficient. I have had a bash at this technique and found it effective but very
slow. I think the problem is that the bleach you seal in looses potency very
quickly and most of the 2 weeks are redundant.
In/ Out bleaching is a variation to this
technique in which you ask the patient to syringe bleach into a sealed but open
access cavity and wear a bleaching tray to greatly speed up the process.
There is a fantastic journal article from
Dental Update on this technique. Managing Discoloured
Non-Vital Teeth:The Inside/Outside Bleaching
Technique: May 2004 by NEIL J.POYSE et al. You can get the PDF of this from
the BDA library for only £2.50. It is well worth a read and is a useful
guide to keep in surgery.
Quick overview
1) Make sure the root filling is adequate
or revise it. If the tooth needs a root filling first then make sure you have
removed all the pulp chamber especially the pulp horns.
2) Remove GP to below the cervical level
with heat plugger.
3) Seal the root filling with GIC, zinc
phosphate or zinc polycarboxylate.
4) Construct a, well fitting, suck down
splint with reservoirs buccal and labial to the target tooth.
5) Ask the patient to rinse then fill the
access cavity with 10% carbamide peroxide every 2 hours, before adding a small
amount of bleach to the tray and seating.
6) Review after 2-3 days. At this point
the bleaching should be completed and you can seal the access chamber
temporarily. The patient should be instructed to cease bleaching if the process
happens quicker than this. Slight overbleaching can be preferable as some
relapse is anticipated.
7) The final composite restoration should
not be placed until 1 week after bleaching is complete to ensure that the bond
is not effected by residual oxygen from the bleaching process.
Technique
drawbacks
1) The patient must be able to syringe in
the access cavity.
2) During the bleaching process there is a
increased risk of tooth fracture. This necessitates full time wear of the
bleaching tray and a soft diet which must be adhered to.
3) It has been shown, though only with
high concentration bleach (30% hydrogen peroxide with activating heat), that
there is a low incidence of cervical resorption.
Non vital bleaching
This
is a case I did the non vital bleaching on. I removed the GP to below
cervical level, then placed a seal of vitrebond (light cured GIC) and a second
layer of zinc phosphate. This was pretty belt and braces and I would probably
just use a capsule mix GIC to seal the GP. I think due to this, the seal was
too thick in the case I did. With a single GIC layer I might have been able to
bleach the very cervical area which is still a little dark on the follow up. I
also left the review of this patient for a week as I thought the tooth was so
dark it wouldn't be fully bleached before that. After a week the colour really
came up. It's likely it was probably fully whitened before I reviewed the case,
which means I left the cavity open for a few days longer than I needed to. We
also didn't stock 10% sodium perborate at the time, so I used 20% hydrogen
peroxide gel. Nothing I have read makes me worried that this concentration is
too high but I suppose it is always best to keep the risk of cervical
resorption as low as possible. Having said all that though I just think this is
the most amazing result for just a weeks bleaching and I think I would always
do the in/out bleach technique if possible when non vital bleaching.
To think this is such a simple procedure but the difference it makes to
the patient is huge. I love this type of dentistry!!
New material
The way I sealed the tooth was also interesting. I used a new material
by densply on the market called SDR, which I've heard some really good,
independent, reviews about. I'm not a material scientist and I am very
cautious of new materials so I will sit on the fence with this one
however I ordered a trial of the material as I was keen to use the
"flowable, bulk fill, reduced shrinkage material" A deep access cavity
liked this seemed the perfect place to experiment with it. My
observations were that the material was lovely to handle like a
slightly thick flow and certainly seemed to adapt well to the deep
access cavity. The material is quite translucent which I suppose is why
it can cure for a depth of 4mm in 20 secs and this means that for
posterior teeth you should layer conventional composite over the top.
I'll keep an eye out for independent reviews of the material but the
potential for this material if it does do what it says on the tin is
very exciting.
The best of luck for those, like me, starting their new jobs.
All the best
Chris O'Conner
Across
the nation a cornucopia of beeps, buzzes and sirens alongside a herald of clock
radios fire up to signal the start of a new day. For the vast majority of the
country it's just another day in the early August sunshine, but for those of us
in the dental fraternity (and indeed for our medical colleagues) it's a
different story - it's time for our new graduates to start work.
To
my mind we can put ourselves into one of three camps; those of us who have
forgotten quite what that first day was like, those who can tell you the name,
exact dental charting and favourite colour of all the patients they saw that
day, or there are those who are yet to experience that day.
What
does it hold in store? It is the beginning of the end? No, it's not even the
end of the beginning. For all those new graduates I hope what's written below
will be of some use as you take your first steps into the dental world of work
with a BDS attached to your name.
You make it what
it is
Some
with a habit for retaining useless information may remember this as a slogan
the BBC used during the nineteen nineties, but it says a lot about VT too. You
can go through the year ticking along, or make full use of the opportunity, to
try things - but don't adopt a Bear Grylls approach, the patient must always
come first.
A
cuppa goes a long way
T
he lady (or indeed gentleman, as it could well be in
these times of equal opportunities) with whom you share your surgery will
quickly become one of the most important people in your life - and not in that
way! Remember that time on the cons clinic when you were partnered with the
person who really didn't want to be there, and were more interested in
attempting to find an excuse to slope off early, didn't working with them make
your dentistry so much better? So keep your nurse on side, and perhaps even
offer to make her a brew, and in those first few weeks she'll get you out of a
few sticky spots!
Some of it must have stuck
After five years at dental school (you get less for ABH),
and reams of exams, projects and hours of clinical time you know more than you
think. Beware though that there is an ocean of new things to learn - and don't
expect to master it all in the first two weeks.
It will happen - to you
At some stage
over the first few weeks of VT there will be several 'oh bother', or words to
that effect moments; whether it's a patient refusing to numb up, you've created
a new canal straight through the furcation of an upper 6, or that you've
stunningly decoronated a lower 5 and already have a waiting room full to the
rafters. Try and avoid swearing in front of the patient, and remember it is not
the end of the world. Take a step back and give it a second look, you can often
get out, temporise and come back next week. Don't spend ages pondering your
decision, either you do something about it - or if you don't know what to do
find someone who does.
Bottom line -
enjoy it, by the time you've finished you won't even recognise the person who
you were on that first August day.
Tom Bysouth