Received: 4 September 2021

| Accepted: 16 February 2022

DOI: 10.1111/iej.13711

REVIEW ARTICLE

Present status and future directions – Managing

discoloured teeth

Bill Kahler1,2

1
School of Dentistry, The University Abstract
of Queensland, Brisbane, Queensland,
Managing tooth discolouration involves a range of different protocols for clinicians and
Australia
2
The University of Queensland Oral
patients in order to achieve an aesthetic result. There is an increasing public awareness
Health Centre, Herston, Queensland, in the appearance of their teeth and management of tooth discolouration may be inter-
Australia disciplinary and involve both vital and nonvital teeth. Vital teeth can be easily treated
Correspondence with low concentration hydrogen peroxide products safely and effectively using an
Bill Kahler, School of Dentistry, The external approach and trays. For endodontically treated teeth, the walking bleach
University of Queensland, 9th Floor
technique with hydrogen releasing peroxide products is popular. However, there is
141 Queen St, Brisbane 4000, QLD,
Australia. an association with external cervical root resorption with higher concentrations of hy-
Email: [email protected] drogen 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 associa-
tion 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 multi-
disciplinary 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.

KEYWORDS
bleaching, carbamide peroxide, external cervical root resorption, hydrogen peroxide, sodium
perborate, walking bleach technique

I N T ROD UCTI ON aetiology of the discolouration needs to be considered as

well as any underlying infection as there are different ap-
Managing tooth discolouration involves a range of clini- proaches for vital teeth when compared to endodontically
cal protocols in order to achieve an aesthetic result. The treated teeth which involve either external or internal

[Correction added on 11th May 2022, after first online publication: CAUL funding statement has been added.]

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2022 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd on behalf of British Endodontic Society

922 | wileyonlinelibrary.com/journal/iej Int Endod J. 2022;55(Suppl. 4):922–950.

KAHLER | 923

approaches to the tooth. Patient's expectations can also review which may also involve periodontal and prostho-
extend beyond just the colour of the tooth requiring prost- dontic rehabilitation, included ‘crown outcomes’, ‘crown
hodontic rehabilitation. While this review will consider survival’, ‘crown complications’ and ‘crown lengthening’.
the topic broadly, the focus will primarily be concerned
with endodontically treated teeth as trauma is a major
aetiology of tooth discolouration (Hattab et al., 1999). AETI OLOGY OF TOOTH
Tooth discolouration can also be considered as intrinsic DI SCOLO URATI ON
(staining) or extrinsic factors introduced by endodon-
tic procedures and the materials used in root filling the Tooth discolouration can be considered intrinsic, extrinsic
tooth (Ahmed & Abbott, 2012; Hattab et al., 1999; Krastl or a combination of both (Hattab et al., 1999). The col-
et al., 2013; Plotino et al., 2008). Tooth bleaching involves our of the tooth is primarily determined by the colour of
hydrogen peroxide which is either applied directly or pro- the dentine (Ten Bosch & Coops, 1995) and influenced
duced from a chemical reaction from sodium perborate by intrinsic and extrinsic impacts (Watts & Addy, 2001).
or carbamide peroxide. Prior reviews on nonvital bleach- The main aetiological factors are presented in Table 1
ing have been published (Attin et al., 2003; Plotino et al., (Adapted from Plotino et al. 2008 and Setzer, 2020).
2008) but since they were published, the European Union There are known causes for discolouration of endodon-
published a Cosmetic Directive (2011/84/EU) which con- tically treated teeth which include root canal irrigants es-
firmed that the bleaching products with concentrations pecially the combination of chlorhexidine when used in
above 0.1% hydrogen peroxide are not permitted for use combination with sodium hypochlorite that produces an
on people under the age of 18 years. This directive also insoluble dark brown precipitate, intracanal medicaments,
limited dentists to using a maximum concentration of antibiotic pastes, mineral trioxide aggregate (MTA) used
6% hydrogen peroxide for bleaching protocols (Official in perforation repairs and regenerative endodontic treat-
Journal of the European Union Council Directive, 2011). ments, endodontic sealers and provisional restorations.
While this application is limited to the European Union, Root canal materials that incorporate trioxide as a filler
similar regulations for bleaching are appearing inter- and radiopoacifier are particularly implicated (Walsh &
nationally (Australian Dental Board, AHPRA). As this Athanassiadis, 2007). AH 26 (Dentsply De Trey) contains
special edition of the International Endodontic Journal silver which can corrode and produce a grey/black disco-
addresses the present status and future directions in man- louration (Allan et al., 2001). The newer material, AH Plus
agement of discoloured teeth, the issue of bleaching must (Dentsply De Trey) contains zirconium oxide as the radi-
be considered not only for efficacy but in a potential new opacifier and has better colour stability over time (Walsh
regulatory framework. The effectiveness of bleaching with & Athanassiadis, 2007). Therefore. Ahmed and Abbott
lower concentrations of hydrogen peroxide and satisfying (2012) advocated for preventive measures to be taken to
patient's expectations in a new regulatory framework are reduce the risk of discolouration. These measures include
important considerations along with alternative treat- an appropriate access cavity, flushing medicaments with
ments that involve prosthodontic alteration to the teeth saline after their use, placing endodontic materials below
with associated tooth loss. Discoloured teeth are known the gingival margin and avoiding metallic restorations in
to impact on the quality-of-life issues for patients (Bonafé teeth as well as avoiding the potential for coronal leakage
et al., 2021). There are also increasing aesthetic demands if resin composites are placed too soon after the bleach-
on clinicians to provide ‘the perfect smile’ (Pavicic et al., ing process. Thomson et al. (2012) in a study that anal-
2018). ysed coronal colour change over a 12-month time frame
suggest alternative medicaments and sealers to Ledermix
(Lederle Laboratories) and AH Plus when there were aes-
LI T E RAT UR E S E ARCH thetic considerations. Krastl et al. (2013) also advised care-
ful application of endodontic materials carefully where
For the purpose of this review, a comprehensive literature there are aesthetic considerations. Furthermore, aesthetic
search was undertaken using PubMed and the Cochrane considerations should be considered in conjunction with
Library. Different keyword combinations were used in- biological and functional requirements of treatment.
cluding ‘bleaching’, ‘outcomes’, ‘vital teeth’, ‘non-vital Teeth that have sustained a traumatic incident with as-
teeth’, ‘walking bleach technique’, ‘hydrogen peroxide’, sociated intrapulpal haemorrhage often discolour as blood
‘sodium perborate’ and ‘carbamide peroxide’. The refer- components diffuse into dentinal tubules. Otherwise the
ence lists of the selected papers, previous review papers haemolysis of erythrocytes releases iron (Marin et al.,
and the recent chapters in textbook were also assessed for 1997) which often results in brown/reddish and black dis-
relevant literature. Other search terms relevant for the colourations especially following a traumatic event that
924 | MANAGING DISCOLOURED TEETH

TABLE 1 Intrinsic and extrinsic causes for discolouration of teeth

Extrinsic causes Intrinsic causes

Dietary: Wine, coffee, tea, carrots, oranges, liquorice, chocolate, Systemic causes
betel nut a) Drug related, e.g. tetracycline, minocycline used in RET
b) Metabolic, e.g. congenital erythropoietic porphyria, cystic fibrosis
of the pancreas, hyperbilirubinemia, thalassemia, amelogenesis
imperfecta, dentinogenesis imperfecta
Tobacco Local causes
a) Pulp necrosis, e.g. traumaIntrapulpal haemorrhage
b) Calcification of the canal following trauma
c) Remaining pulp tissue remnants following endodontic treatment
d) Root canal irrigants
e) Root canal sealers
f) Repair materials and secondary effects involving interactions with
NaOCl and/or blood
g) Endodontic materials such as amalgam, coronal leakage or MTA
and triple or double antibiotic pastes used in REPs
h) Coronal filling materials including temporary restorations, e.g.
IRM
i) Root resorption
j) Aging
k) Fluorosis
l) Caries
Mouth rinses, e.g. Chlorhexidine Resorptions. Invasive cervical – pinkish colour
Plaque, e.g. Chromogenic bacteria
Abbreviations: MTA, mineral trioxide aggregate; REPs, regenerative endodontic protocols.

results in pulp necrosis (Setzer, 2020). An important con- Poe (1963) improved the whitening efficacy by replacing
sideration is that teeth that maintain vitality may regain the water with 30%–35% hydrogen peroxide. Many dif-
normal colour (Andreasen & Kahler, 2015). In root filled ferent bleaching agents have been used and their type,
teeth, inadequate cleaning of the access cavity and pulp concentration, whether heat is also applied, and efficacy
chamber by leaving necrotic pulp remnants in pulp horns are listed in Table 2. Also, in the 1960s an orthodontist
or failure to adequately remove root filling pastes can also observed whiter teeth when 10% carbamide peroxide was
cause discolouration after root canal treatment. used in a tray for the treatment of gingivitis (Haywood,
Tooth discolouration has also been associated with 1991). Haywood and Heymann (1989) described the use of
regenerative endodontic protocols (REPs) that utilize tri- bleaching trays and 10% carbamide peroxide for lighten-
ple antibiotic pastes (TAPs) that contain minocycline and ing tooth colour in vital teeth.
MTA as an intracanal barrier over an induced blood clot
to the level of the cemento-enamel junction (CEJ) (Kahler
et al., 2014; Kahler & Rossi-Fedele, 2016). TOX IC I TY OF BLEACH IN G AGE NT S

Hydrogen peroxide exposure to the gingiva can induce

H I STO RY O F BLE ACHI NG T E ET H epithelial damage (Martin et al., 1968) with 25%–50% of
patients in clinical trials experiencing gingival irritation
Bleaching of nonvital discoloured teeth was first de- with the use of custom-made trays (Bruzell et al., 2013;
scribed by Truman, 1864. Harlan (1884) described the Leonard et al., 1997). There may also be an increase in
use of hydrogen peroxide for bleaching pulpless teeth tooth sensitivity with vital bleaching (Leonard, 1998).
whilst Abbott (1918) used Superoxol 30% hydrogen per- Tooth sensitivity is usually mild to moderate and transient
oxide in combination with electric light rays. Prinz (1924) lasting only a few days (Jorgensen & Carroll, 2002; Leonard
described heated solutions of sodium perborate and et al., 1997; Pohjola et al., 2002) but longer-term discom-
Superoxol in the pulp space. The ‘walking bleach tech- fort has been reported (Leonard et al., 1997; Tam, 1999).
nique’ was developed using sodium perborate and water Laboratory studies have reported that hydrogen peroxide
placed into the pulp chamber which was sealed into the penetrates enamel and dentine to enter the pulp space
root canal space (Salvas, 1938; Spasser, 1961). Nutting and (Thitinanthapan et al., 1999). The degree of penetration
TABLE 2 In vivo studies reporting the success rate of internal bleaching of endodontically treated teeth
KAHLER

Author(s) Number Bleaching agent Review (years) Success Complications/comments

Brown (1965) 80 Thermocatalytic: 30% H2O2, followed 1–5 75% success (39% complete, Severely discoloured teeth have less successful
by WBT: 30% H2O2 46% partial); 25% failure outcomes vs. moderate and slight
(17.5% no improvement, discolouration (75%–90%−100%)
7.5% refractory
discolouration
Tewari and Chawler 19 Thermocatalytic: 30% H2O2 5 95% success The only failure was successfully bleached again
(1972) 5% failure
Chandra and Chawla 230 15 different techniques 1 95% success Failures associated with insufficient fillings
(1972) 5% failure
Howell (1980) 41 Thermocatalytic: 30% H2O2, followed Immediate 97% success Tooth that failed was discoloured for 40 years
by WBT: 30% H2O2 assessment (90% complete, 7% partial)
post- bleaching 3% failure
Howell (1981) 339 Thermocatalytic: 30% H2O2, followed 1 97% success Discoloured tooth had a leaking filling and
by WBT: 30% H2O2 (53% complete, 44% partial, 3% bleached again successfully
failure)
19 2 100% success Colour regression in 50% after I year.
(42% complete, 58% partial)
Feiglin (1987) 20 Thermocatalytic: 130 vol H2O2 6 45% success Better outcomes for younger patients.
followed by WBT ¾ H2O2 and 55% failure Aesthetic regression with time
130 vol H2O2
Friedman et al., 1988 58 Thermocatalytic 30% H2O2, 8 50% success Most failures occurred between 2 and 8 years
WBT 30% H2O2, 29% acceptable post-bleaching
Thermocatalytic: 30% H2O2, followed 21% failure
by WBT: 30% H2O2
Holmstrup et al. (1988) 95 Thermocatalytic: 30% H2O2, followed Immediate 63% success Three teeth with transient pain
69 by WBT: 30% H2O2 assessment (63% good, 26% acceptable)
post- bleaching 10% failure
3 79% success
(49% good, 30% acceptable)
20% failure
Anitua et al. (1990) 258 WBT: SP + 110 vol H2O2 4 100% (90% complete, 10% All teeth were tetracycline stained and elective
partial) success RCT
Aldecoa and 534 WBT 6 Stable results All teeth were tetracycline stained and elective
Mayordomo (1992) RCT
Waterhouse and Nunn 21 WBT 30% H2O2 + SP granules 1.5 83% success Teeth discoloured with time
(1996)
|

Abou-Rass (1998) 112 WBT: SP + 30% H2O2 3–15 93% success All teeth were tetracycline stained and elective
925

7% failure RCT
 926 | MANAGING DISCOLOURED TEETH

depended on the concentration of the hydrogen peroxide

No incidence of resorption in this long-term study

No incidence of resorption in this long-term study

The EC approach reduced bleaching time by 50%
(Gökay et al., 2000). However, structural pulp damage

Rebleaching was associated with restoration

was not shown in human teeth exposed to 35% hydrogen
peroxide in vivo that were extracted and examined histo-
logically (Baumgartner et al., 1983; Cohen & Chase, 1979;
Robertson & Melfi, 1980). Hydrogen peroxide is only con-
Ideal cases were intact crowns

sidered a low risk to produce local carcinogenic outcomes

Complications/comments

with the IARC (1999) concluding there was inadequate

Stable at 1 year review

evidence in humans for the carcinogenicity of hydrogen
peroxide (Dahl et al., 2019).

Abbreviations: CP, Carbamide peroxide; EC, Extra-coronal; H2O2, Hydrogen peroxide; I-O. Inside-Outside technique; SP, Sodium perborate; WBT, Walking bleach technique.
failure

TREATM ENT P LAN N IN G O PTIO NS

The discoloured tooth/teeth can be a great challenge to

obtain pleasing aesthetic outcomes affecting the ‘smile
EC + 10% CP was as effective
as WBT (SP + 3% H2O2)

zone’. The causes and extent of the discolouration must

Success 100% (Good 87.1%
84% success in ideal cases

Significant improvement
Colour improved in both

be assessed. The vitality of the pulp, prior endodontic

Acceptable 12.9%)

treatment, signs and symptoms of infection will deter-

mine whether external or internal bleaching is advised.
69.9% success

100% success
37.1% failure

The colour of the root, the thickness of the gingiva and the
85% success
groups

tooth form are also important determinants on treatment

Success

choice.
Treatment options for improving the colour of teeth
Note: Adapted from Attin et al. (2003) and Plotino et al. (2008) and extended to 2021. Copyright clearance was obtained.

can include:
Review (years)

1. External bleaching – At-home external bleaching,

power bleaching, abrasion techniques, lasers.
0.5–5

0.4–1

2. Internal bleaching – Walking bleach, internal/external

0.5

0.5
16

25

bleaching, thermocatalytic bleaching.

5

3. Prosthodontic options – resin composite and ceramic

veneers, crowns.
EC 10% CP; WBT SP + 3% H2O2,

Mixture of SP + 120 vol H2O2

WBT 35% H2O2 + SP powder

Periodontal considerations such as root colour, tooth

shape and form should be considered in the treatment
EC + WBT 10% CP
WBT: SP + 30% H2O2

planning.
EC + WBT 10% CP
Bleaching agent

9: SP + 20% H2O2
8: I-O 10% CP

EX TERNAL B LEAC HI NG – AT-

35% H2O
35% CP

37% CP

HOM E EXT ER NAL BLEACH IN G,

POWER BLEAC HIN G, AB RASION
TECH NI QU ES, L ASERS
Number

Vital tooth bleaching is a technically easy and low-

255

cost method to improve tooth colour. Nightguard vital

86
61

35

38

60
17
3

bleaching is a safe procedure with satisfactory retention

(Continurd)

Abbott and Heah (2009)

of shade with only mild and transient side effects disap-

Bersezio et al. (2018a)
Glockner et al. (1999)
Bizhang et al. (2003)

pearing within days of treatment completion (Leonard,

Badole et al. (2013)

Amato et al. (2018)

Amato et al., 2006

Lise et al. (2018)

2000). There are increased demands from patients to im-

prove the colour of vital, natural teeth (Maran et al., 2018;
Author(s)
TABLE 2

Wilson et al., 2004). Whitening toothpastes are popular

with high public demand (Alkahtani et al., 2020). Studies
also reveal that many adults are dissatisfied with the
KAHLER | 927

appearance of their teeth (Alkhatib et al., 2004; Odioso IN TERNAL B LEAC HI NG –

et al., 2000; Qualtrough & Burke, 1994). There are three WALK IN G B LEAC H, IN TERNAL/
approaches generally used that include (1) in-office and EXTERNAL B LEAC HI NG,
professionally administered, (2) at home and profes- THERMO CATALYT IC B LEAC HING
sionally administered or (3) commercially available and
self-administered procedures that use products based Bleaching agents for whitening of root
on hydrogen peroxide or carbamide peroxide (Dahl & filled teeth
Pallesen, 2003; de Geus et al., 2016). The in-office ap-
proach allows for professional application to avoid Tooth bleaching utilizes hydrogen peroxide as the active
soft-tissue damage and potentially provide more rapid agent in an oxidative process that degrades larger discol-
aesthetic outcomes (Alomari & Daraa, 2010; Gurgan oured compounds and stains. Hydrogen peroxide can be
et al., 2010; Henry et al., 2013). Power bleaching ap- applied directly or produced in a chemical reaction from
proaches activate catalytic decomposition of the peroxide sodium perborate or carbamide peroxide (Budavari et al.,
products by heat or light to enhance the release of oxygen- 1989). Hydrogen peroxide releases free radicals (Gregus
based free radicals (Kashima-Tanaka et al., 2003; Maran & Klaassen, 1995), reactive oxygen molecules and hy-
et al., 2018). Light activation sources have included light- drogen peroxide anions (Cotton & Wilkinson, 1972).
emitting diodes, plasma arc lamps, halogen lamps and Tooth bleaching involves the chemical alteration of light-
lasers (Ontiveros, 2011). However, commercially claimed absorbing or light-reflecting properties and structure of
benefits of light in accelerated colour improvements was enamel and dentine stains. The reactive molecules break
not confirmed in a systematic review and meta-analysis down the long-chained, dark coloured chromophore mol-
(Maran et al., 2018). A further systematic review and ecules and split the double bonds into smaller, less col-
meta-analysis reported that the use of lower concentra- oured and more diffusible molecules (Dahl & Palleson,
tion hydrogen peroxide products produced similar colour 2003). The change in pigment configuration and size al-
changes to that of higher concentration products with ters the wavelength of the reflected light with the result is
less risk and intensity of bleaching sensitivity (Maran the stain appearing lighter in colour that is seen as whit-
et al., 2020). The use of trays and peroxide bleaching is ening (Frysh et al., 1995; Nathoo, 1997). However, after
safe to enamel surfaces (Mielczarek et al., 2008) although the bleaching procedure, the double bonds can reform the
other studies have shown damage with a significant de- chromogen molecules leading to a shade rebound effect
crease in enamel hardness (Akal et al., 2001; Araujo et al., (Setzer, 2020).
2013). In a recent review, new whitening products and The decomposition of hydrogen peroxide into active
technologies including nano-additives and different car- oxygen products is accelerated by heat, addition of sodium
rier systems may maximize the bleaching process and hydroxide and light (Chen et al. 1993, Hardman et al.
minimize structural enamel damage (Alkahtani et al., 1985). Hydrogen peroxide-releasing bleaching agents are
2020). However, dental bleaching can also be associated chemically unstable and should be stored in a dark, cool
with demineralization of remineralized carious lesions place or refrigerator (Plotino et al., 2008). Hydrogen per-
as, while the colour of the arrested lesion was improved, oxide has a low molecular weight which allows it to pen-
the risk of demineralization was increased, especially etrate dentine, release oxygen to break down the double
when associated with adhesive restorations (Al-Angari bonds of organic and inorganic substances within den-
et al., 2019). tinal tubules and stained dentine (Seghi & Denry, 1992).
Micro-abrasion uses peroxide products for shallow in- The thermocatalytic technique used to be considered
trinsic stains and superficial irregularities in the enamel the best approach because of the increased reactivity of
(Gupta et al., 2017). Successful long-term follow-up has the technique with application of heat by either special
been reported (Sundfeld et al., 2014). lamps or hot instruments (Abramson et al. 1966; Boksman
It is not the purpose of the current review to evalu- et al. 1984; Brown, 1965; Grossman et al., 1988; Grossman,
ate vital bleaching techniques comprehensively. Further 1940; Howell, 1980; Hulsmann, 1993; Ingle, 1965; Kopp,
information is available from existing papers (Alkahtani 1973; Tewari & Chawla, 1972; Weine, 1982). Studies relat-
et al., 2020; Joiner, 2006). Studies indicate that 1%–16% of ing to the efficacy of bleaching in vivo and in vitro are set
teeth undergoing calcific metamorphosis will require end- out in Tables 2 and 3.
odontic treatment so nonendodontic whitening of these Carbamide peroxide (CH6N2O3) breaks down into car-
teeth needs to be considered (Amir et al., 2001). Therefore, bamide and hydrogen peroxide in an aqueous solution.
external bleaching is indicated in the management of disc- It also produces urea (Budavari et al., 1989) which has a
oloured teeth (Figures 1–3). high pH that enhances the bleaching effect (Sun, 2000).
928 | MANAGING DISCOLOURED TEETH

(a) (b)

(c)

F I G U R E 1 (a) A periapical radiograph of a left maxillary central incisor with extensive obliteration of the canal. The tooth was
asymptomatic and nonresponsive to cold and electric pulp sensibility testing. Radiographically, there was no evidence of pathosis. (b) A
preoperative photo showing discolouration. (c) The tooth was managed with external bleaching protocols using 6% hydrogen peroxide and
customized trays (pola day/pola night; SDI Ltd.). The aesthetic outcome met the patient's expectation and improved the colour of all teeth in
the smile zone. Courtesy of Dr Michael Lewis

Carbamide peroxide crystals and powder contain H2O2 A recent systematic review and meta-analysis con-
in an approximate concentration of 35%. At 35%, there is cluded that carbamide peroxide, hydrogen peroxide and
slow extraradicular diffusion rates when compared to hy- sodium perborate all have a significant bleaching effect on
drogen peroxide and sodium perborate (Lee et al., 2004; discoloured root filled teeth. However, the efficacy of car-
Lim et al., 2004). Carbamide peroxide in contact with bamide peroxide, hydrogen peroxide and hydrogen per-
dentine releases oxygen products for 40–90 min in com- oxide combined with sodium perborate was better than
parison with hydrogen peroxide where the release is more sodium perborate used as the sole bleaching agent (Frank
instantaneous (Nathoo, 1997). et al., 2022).
Sodium perborate (NaBO3) is commercially available In Europe there are regulatory issues with the
as a stable dry powder or gel in monohydrate, trihydrate European Union producing a Cosmetic Directive
and tetrahydrate forms that have varying oxygen contents. (2011/84/EU) advising bleaching products should not
The bleaching efficacy is dependent on the oxygen con- release more than 6% of hydrogen peroxide and were not
tent (Weiger et al., 1994a). The perborate ion comprises to be used on people under the age of 18 years. However,
95% of the molecule and provides approximately 10% of there does appear to be a degree of latitude where the
the available oxygen. The H2O2 released generates differ- treatment is considered safe and necessary by the den-
ent radicals or ions depending on the pH value, light, tem- tist (Dahl et al., 2019).
perature, co-catalysts and addition of metallic reaction
products (Feinman et al., 1991; Goldstein & Garber, 1995).
Bleaching is effective in an alkaline environment with Walking bleach technique
the release of perhydroxyl radicals (Goldstein & Garber,
1995). Hydrogen peroxide release from sodium perborate Sodium perborate mixed with water is the most used
reaches peak concentration within 72 h and plateaus at technique for internal bleaching of root filled teeth.
3 days (Tran et al., 2017). It is considered safer than hy- Alternatively, enhancement with 30%–35% hydrogen
drogen peroxide for intracoronal bleaching (Setzer, 2020). peroxide has been described (Abbott & Heah, 2009;
KAHLER | 929

(a) (a)

(b)
(b)

(c)

F I G U R E 2 (a) A photograph of an 18-year-old girl with

moderate fluorosis. (b) A post-treatment photograph. The teeth
received a single visit in-office bleaching with Philips ZOOM
(Philips Oral Healthcare) Light Activator using Zoom White
Speed gel (25% Hydrogen peroxide). Superficial stains and plaque
were first removed using a prophy paste in a rubber cup. The lips F I G U R E 3 (a) A photograph revealing a discoloured right
were protected with sunblock cream, prior to placement of lip maxillary central incisor and mismatch rein composite restoration
retractors. Isolation of the gingiva was achieved by cotton rolls (b) A photograph after treatment of 30 min with a KTP laser
placed in the vestibule and light-cured resin barrier. The teeth (Smartlite; Deka) The laser is used to lighten the crown colour
received a total of 30 min application of bleach illuminated with of the enamel so translucent resin composite materials can be
ZOOM lamp on High intensity (190 mW/cm2) for 15 min, followed used with less or no need for opaquing agents which block light
by medium intensity (120 mW/cm2) for 15 min. One week later, transmission through teeth. (c) A photograph after replacement of
resin infiltration treatment was accomplished using ICON system the resin composite. Courtesy of Professor Laurence Walsh
for three etching cycles, followed by two resin infiltration cycles.
Courtesy of Professor Zafer Cehreli

is not always possible (Barateri et al., 1995; Rotstein,

Boksman et al., 1983; Nutting & Poe 1963,) but is less 2019). In fact, due to rebound in colour, the aim is for
commonly used due to concerns with invasive cervical the bleached tooth to be lighter than the adjacent teeth
resorption. The protocol for the walking bleach tech- (Attin et al., 2003; Plotino et al., 2008). Defective resto-
nique is outlined in Table 4 and elaborated below. Cases rations need to be replaced prior to bleaching and there
using different bleaching agents are depicted in Figures is the risk of post-bleach mismatch in colour as resto-
4–6. rations will not lighten with the bleaching procedure
(Greenwall-Cohen & Greenwall, 2019). The amount
of remaining tooth structure could dictate alternative
Steps 1–2: Patient discussion, clinical and treatment options.
radiographic assessment

A diagnosis of the aetiology of the discolouration is es- Steps 3: Access

sential as well as a discussion of the patient's aesthetic ex-
pectations. A periapical radiograph indicating the likely Under rubber dam, the pulp space is endodontically
absence of endodontic pathosis and an adequate root accessed to identify the mesial and distal pulpal horns
filling is mandatory prior to discussing bleaching. The to remove potential residual necrotic tissue that may
patient should be informed that bleaching outcomes are be a cause of the discolouration (Plotino et al., 2008).
not predictable and that complete restoration of colour Visualization should be enhanced by magnification and
930 | MANAGING DISCOLOURED TEETH

TABLE 3 In vitro studies on the efficacy of nonvital bleaching

Authors Bleaching agent Success Complications/comment

Ho and Goerig (1989) Group 1: New SP + 35% H2O2 93% success Colour regression after 6 months was
Group 2: New SP + 1-year old 73% success found in 4% of cases
35% H2O2
Group 3: New SP + distilled H2O 53% success
Group 4: Old SP + distilled H2O 53% success
Casey et al. (1989) Group 1: dentinal etching of the No statistical differences between None
pulp chamber + WBT 30% the 2 groups
H2O2 + SP
Group 2: No etching WBT: 30%
H2O2+SP
Warren et al. (1990) 35% H2O2, SP, 35% H2O2+ SP 35% H2O2 + SP was more effecting Effectiveness of the IRM cervical seal
in improving crown and root was questioned as root colour
colour improved whether IRM placed at
CEJ and 2 mm below CEJ
Rotstein et al. (1991) SP + 30% H2O2, SP + 3% H2O2, No significant differences between SP + H2O was recommended
SP + H2O the groups after 14 days to reduce the risk of cervical
resorption
Weiger et al. (1994a) 30% H2O2 + varying types of SP Success rates ranged between 46%
mixed with H2O or as a gel and 77%. Shorter bleaching
times than 3–7 days were
effective
Weiger et al. (1994b) SP + monohydrate (MH), Almost all teeth of the Risk of cervical resorption by using
trihydrate (TRH) or experimental groups showed SP tetrahydrate + H2O
tetrahydrate (TH) was mixed leakage of H2O2 and on the
with 35% H2O2 or H2O form of sodium perborate used
Lenhard (1996) 10% CP Most significant colour change The observed tooth colour change
occurred in the incisal section was dependant on the bleaching
of the crown, followed by time, the specific bleached
the middle and then cervical section, and the initial colour
sections
Leonard et al. (1998) 5%–10%–16% CP Higher concentrations of CP Lower concentrations of CP took
resulted in quicker colour longer to bleach teeth and
change achieved the same result with
extra time
Horn et al. (1998) 35% H2O2+SP Teeth bleached with35% H2O2+SP Presence or absence of the smear
Sterile H2O + SP were significantly lighter layer did not influence the
outcome of bleaching
Marin et al. (1998) 30% SP Most efficient removal of staining All bleaching agents were effective
occurred with 30% H2O2 with in 3 days
75% CP as effective.
Jones et al. (1999) 35% H2O2, 10% and 20% CP 20% CP resulted in the greatest None
colour change
Ari and Üngör (2002) Group 1: SP trihydrate + H2O No statistically significant None
Group 2: SP trihydrate + H2O differences between the groups SP can be successfully mixed with
Group 3: SP + tetrahydrate + H2O H2O rather than H2O2 for
Group 4: SP trihydrate + H2O2 effective bleaching
Group 5: SP trihydrate + H2O2
Group 6: SP tetrahydrate + H2O2
Joiner et al. (2004) 6% H2O2 H2O2 has no significant effect on None
microhardness of enamel and
dentine
KAHLER | 931

TABLE 3 (Continued)

Authors Bleaching agent Success Complications/comment

Camps et al. (2007) 20% H2O2 gel Diffusion of H2O2 was higher for Optimal renewal time for young
young teeth compared to older teeth was 33 h
teeth.
Yui et al. (2008) WBT: SP associated with CP was more
Group 1. SP + distilled H2O effective than H2O
Group 2. SP + 10%CP
Group 3. SP + 35%CP
Gökay et al. (2008) 10–17–37% CP or a mixture of Peroxide penetration of gels CP gels may carry less risk for
SP + 30% H2O2 was significantly lower than resorption
SP = H2O2
Cardoso et al. (2013) 37% CP gel with and without Ultrasonic activation of bleaching
activation, agents during internal
35% H2O2 with and without bleaching was no more effective
activation than without activation
Hansen et al. (2014) 35% H2O2 and delayed restoration Bleaching had a detrimental effect Restoration of bleached teeth should
on bond strengths be delayed for 1–2 weeks
Feiz et al. (2014) 45% CP gel, 45%SP + CP, CP gel and CP + SP gel Teeth tested were stained with resin-
SP + distilled H2O significantly better than based sealer
SP + H2O
Sağlam et al. (2015) WBT: SP + Nd:YAG laser, Laser application especially Enamel surface structure was not
SP + diode laser, SP alone Nd:YAG laser significantly affected
increased bleaching efficacy
Zoya et al. (2019) SP + distilled H2O; Extraradicular peroxide release Lower concentrations of H2O2 should
SSPC + distilled H2O, from SSPC was not significantly be used if used in conjunction
SP + 30% H2O2, SSPC + 30% different from SP with SP or SSPC
H2O2, 30% H2O2, distilled H2O
Papadopoulos et al., 35% H2O2, 35% H2O2 with and Er, Cr:YSGG laser irradiation
2021 without Er, Cr:YSGG laser on increased lightness only after
different power settings the first bleaching session and
after the second session was not
different to the control group
irrespective of the laser power
settings
Note: Adapted from Plotino et al. (2008) and extended to 2021.
Abbreviations: CP, carbamide peroxide; EC, extra-coronal; H2O2, hydrogen peroxide; SP, sodium perborate; SSPC, sodium percarbonate; WBT, walking bleach
technique.

illumination with either loupes or use of an operating than teeth with normal gingival architecture where the
microscope. sealing barrier placed at the CEJ has the added advan-
tage of minimizing the risk of invasive cervical resorp-
tion and damage to the periodontium (Steiner & West,
Step 4: Coronal seal of the root filling 1994). A barrier of at least 2 mm is recommended to be
placed on the root filling to prevent penetration of the
The sealing barrier should be placed 1 mm coronally to bleaching materials into the root filling (Costas & Wong,
the CEJ (Rotstein et al., 1992) and removal of the exist- 1991; Hansen-Bayless & Davis, 1992; Smith et al., 1992).
ing root filling may be required. The level of the barrier Barrier materials have included GIC-based liners (e.g.
can be determined by internal measurements to validate Vitrebond, Espe 3 M), Cavit and IRM with Cavit having
the placement of the intra-canal seal to match periodon- a superior seal to IRM which releases eugenol and can
tal probing of the epithelial attachment at the mesial, exacerbate the discolouration (Hansen-Bayless & Davis,
distal, labial and palatal aspects of the tooth (Plotino 1992). Cavit is easily removed and GIC-based liners can
et al., 2008). Therefore, teeth that have a gingival resto- be left in situ at the time of the final restoration (Setzer,
ration may allow bleaching agents to be placed deeper 2020).
932 | MANAGING DISCOLOURED TEETH

TABLE 4 Walking bleach protocol

Step Process Considerations

1 Patient discussion Informed consent. Discussion of options and risks, e.g. potential for
discolouration, mix-match in colour with adjacent teeth, invasive
cervical resorption.
2 Clinical and radiographic assessment Examination of defective restorations and/or caries. The presence of an
adequate root filling is mandatory with no evidence of pathosis or
recently root filled. Photographs prior to bleaching.
3 Access Under rubber dam isolation, the access cavity needs to remove all
restorative materials and root filling material, so a clean tooth
substance is visualized including the pulp horns. Do not remove
discoloured dentine.
4 Coronal seal of the root filling The root filling should be removed below the level of the gingiva. If the
root also requires bleaching an additional 2–3 mm of gutta-percha
should be removed. The root filling should be covered with a barrier
of glass–ionomer cement (e.g. Vitrebond), or 2 mm of Cavit or IRM.
5 Refinement and finishing of the access cavity The smear layer can be removed with a 10-s rinse of phosphoric acid
etch is controversial the smear layer may not be required to be
removed. Desiccating the dentine with air and ethanol could be
advantageous.
6 Bleaching material The pulp space is filled with a thick mix of sodium perborate and water
which can be condensed with an amalgam carrier or a Buchannan
plugger. Excess water can be removed with cotton pellets but leaving
the mix wet.
7 Provisional restoration A 2–3 mm layer of Cavit or IRM cement is placed and pressed into
undercuts and towards a clean cavo-surface margin.
8 Bleaching time The patient should return in 3–7 days to have more bleaching material
placed. A total of one to four procedures may be required until the
tooth is slightly lighter than the adjacent teeth.
9 Final restoration The access cavity is restored with an acid-etch composite restoration
placed 1–3 weeks after the last bleaching appointment. A post-
bleaching photograph and periapical radiograph is recommended.
Note: Adapted from Dahl et al., 2019.

Step 5: Refinement and finishing of the Step 6: Bleaching materials

access cavity
Sodium perborate (tetrahydrate) mixed with distilled
A final rinse with 1%–3% sodium hypochlorite for water is commonly used and recommended in recent
cleanliness (Attin & Kielbassa, 1995; Attin et al., 2003) textbooks (Dahl et al., 2019; Setzer, 2020). In jurisdictions
is recommended or alternatively alcohol to reduce sur- where sodium perborate is prohibited 18% carbamide per-
face tension as dehydrated dentine may allow greater oxide can be used instead of sodium perborate (Kelleher,
penetration of the bleach into the dentine. The use of 2014). If discolouration is severe, water can be replaced
37% phosphoric acid to allow greater penetration of with 3% hydrogen peroxide (Nutting and Poe, 1963). Some
bleach (Beer, 1995; Hulsmann, 1993) is controversial as authors have advocated against the use of 30%–35% hy-
studies have shown no improvement in bleaching out- drogen peroxide due to possible risks of cervical resorp-
comes when the smear layer was not removed (Casey tion and damage to the periodontium (Friedmann et al.,
et al., 1989; Horn et al., 1998). The use of acidic agents 1988; Kinomoto et al., 2001). However, others have used
as pre-treatment of dentine may have adverse effects 35% hydrogen peroxide without development of cervical
on the periodontium (Fuss et al., 1998). Therefore, re- resorptions over 5-year follow-up reviews (Abbott & Heah,
moving the smear layer could have a deleterious effect 2009). More rapid bleaching outcomes can be achieved
(Attin et al., 2003). with hydrogen peroxide, but similar results are achieved
KAHLER | 933

F I G U R E 4 (a) A preoperative (a) (b)

radiograph of a root filled left maxillary
central incisor with pathos. (b) The
tooth was successfully retreated. (c)
A photograph showing the extent of
discolouration. (d) A photograph of the
open assess cavity. Bleaching utilized the
walking bleach technique with sodium
perborate (Endoprep bleach; PDS)
mixed with water. (e) A post-treatment
photograph immediately post-bleaching
showing the bleached tooth having a
lighter colour than the adjacent teeth.
Courtesy of Dr Tom Fenelon

(c)

(d)

(e)

if sodium hydroxide is not used within short timeframes Step 9: Final restoration
of 2 weeks with sodium and carbamide peroxide (Ari &
Üngör, 2002; Holmstrup et al., 1988; Rotstein et al., 1991a, A final restoration with an acid-etch resin composite
1993; Vachon et al., 1998). following bleaching should be deferred for 1–3 weeks
(Cavalli et al., 2001; Shinohara et al., 2001, 2004; Unlo
et al., 2008) as adhesion of composite and glass–ionomer
Step 7–8: Provisional restorations and cement to enamel and dentine is temporarily reduced
bleaching time following bleaching (Dishman et al., 1994; Garcia-
Godoy et al., 1993; Josey et al., 1996; Murchison et al.,
Provisional seal/restoration is best achieved with more 1992; Swift & Perdigão, 1998; Titley et al., 1988, 1989,
durable materials such as resin composite. Temporary 1992; Toko & Hisamitsu, 1993). This is because rem-
materials have been shown to be inadequate (Waite et al., nants of peroxide and free oxygen have been shown to
1998) and loss of the provisional restoration would allow inhibit polymerization (Dishman et al., 1994; Torneck
recontamination of the pulp space. Patients should be ad- et al., 1990). It is not likely that change in the enamel
vised to monitor the colour change to minimize the risk of structure interferes with composite adhesion (Ruse
‘over-bleaching’ (Attin et al., 2003). There is the risk that et al., 1990; Torneck et al., 1990). However, the appear-
a tooth can substantially lighten compared to adjacent ance of composite tags in the hybrid layer in bleached
teeth. The goal is to achieve a slightly lighter tooth than enamel is less regular and distinct than in unbleached
the adjacent teeth as there is likely to be some reversion of enamel (Titley et al., 1991). This may be why access
colour over time. cavities restored with composite can be associated with
934 | MANAGING DISCOLOURED TEETH

(a) (b)

(c)

F I G U R E 5 (a) A preoperative radiograph of the maxillary central incisors that are root filled with no evidence of pathosis. (b)
A photograph of the right maxillary central incisor with a blackish discolouration. The left maxillary central incisor has a brownish
discolouration. Bleaching was done with the walking bleach technique using 35% hydrogen peroxide (Opalescence, Ultradent Products.
Inc.). (c) A post-treatment photograph. The resin composite restoration in the left central maxillary incisor has been replaced. The right
central maxillary central incisor was bleached in one appointment with the left central incisor requiring three appointments. There is a
slight disparity between the colour of the two bleached teeth

marginal leakage (Barkhordar et al., 1997). Several sug- Inside–outside closed bleaching
gestions to negate the influence of hydrogen peroxide
effects on bleached tooth structure are using dehydrat- This approach combines the walking bleach technique
ing agents such as 80% alcohol or acetone-containing with a single-tooth external tray bleach to speed up the
adhesives (Barghi & Godwin, 1994; Kalili et al., 1993), bleaching process and potentially reduce the number of
the application of sodium hypochlorite to dissolve the appointments required to lighten the colour of the tooth
remnants peroxide (Attin & Kielbassa, 1995; Rotstein (Haywood & DiAngelis, 2010). Considering most bleach-
et al., 1993), catalases (Rotstein, 1993), the antioxidant ing protocols are completed in one to three visits this
sodium ascorbate (Kaya et al., 2008; Lai et al., 2002) additional step involving external bleaching may not be
and alpha-tocopherol (Whang & Shin, 2015). Optimal necessary.
bonding to bleached enamel and dentine is restored
after 3 weeks (Cavalli et al., 2001; Shinohara et al.,
2001). In the interim period, calcium hydroxide placed Inside–outside open bleaching
in the access cavity may buffer the acidic pH that
could be present after bleaching (Baratieri et al., 1995; This approach allows the bleaching agent to be exter-
Kehoe, 1987). Calcium hydroxide following bleaching nally as well as inside the pulp chamber simultaneously
does not interfere with the adhesion of the composite (Liebenberg, 1997; Poyser et al., 2004; Settembrini et al.,
restoration (Demarco et al., 2001). 1997) and involves leaving the access cavity open and pro-
A post-operative radiograph after bleaching and reg- tecting the root filling with a base. The patient regularly
ular follow-up radiographs is advised by the European applies the bleaching agent (10% carbamide peroxide)
Society of Endodontology (2006). with a syringe into the access cavity and externally into a
KAHLER | 935

(a) (b)
Novel techniques – Lasers

Studies have shown that the use of lasers enhances the

bleaching process in the walking bleach technique when
sodium perborate and a Nd:YAG laser irradiation is used
(Sağlam et al., 2015). However, a recent study has shown
that while laser irradiation can accelerate the bleaching
process, the final results are not different to control groups
without laser irradiation irrespective of the laser power
settings (Papadopoulos et al., 2021). Refer to Table 3.

Novel techniques – Cold

(c) atmospheric plasma

A recent case report has used cold atmospheric plasma

applied into the access cavity of a root filled tooth with-
out the use of conventional hydrogen peroxide bleaching
agents (Pavelić et al., 2020). Cold atmospheric plasma is
obtained from dielectric barrier discharge where the glass
electrode functions as the primary electrode and the tooth
(d)
as the secondary electrode. Therefore, more sophisticated
equipment is required. The authors state that the differ-
ences between the standard walking bleach technique
and the cold atmospheric plasma approach is that a root
filling, protective cervical barrier and bleaching agent are
necessary, and resorption could still be a possible risk. In
the presented report the tooth was root filled.

F I G U R E 6 (a) A preoperative radiograph showing a left PROGN OSIS FOR BL EAC HIN G
maxillary central incisor calcified canal with an obliterated canal EFFIC AC Y
and a periapical radiolucency. (b) A periapical radiograph of the
tooth root filled. (c) A clinical radiograph revealing a brownish Table 2 sets out selected studies that have investigated
discolouration. (d) A clinical photograph of the tooth treated in bleaching efficacy. Many studies attest to the immediate
three appointments using the bleaching protocol as described in efficacy of bleaching to improve the discolouration with
Figure 5
lightening using a variety of different bleaching protocols
(Abbott & Heah, 2009; Amato et al., 2018; Anitua et al.,
1990; Brown, 1965; Holmstrup et al., 1988; Howell, 1981;
tray every 4–6 h with the patient reviewed after 2–3 days Waterhouse & Nunn, 1996). Studies have also shown col-
to assess the change in discolouration (Greenwall-Cohen our regression with time (Abbott & Heah, 2009; Brown,
& Greenwall, 2019). There is the potential for debris to ac- 1965; Feiglin, 1987; Friedman et al., 1988; Waterhouse &
cumulate into the access cavity. The advantages of both Nunn, 1996). Friedman et al. (1988) reported most fail-
inside–outside approaches are not clear considering the ures in the aesthetic outcome occurred 2–8 years post-
well documented efficacy of the walking bleach technique. bleaching. Colour failures were also associated with
However, many authors advocate for this technique and poor final restorations (Abbott & Heah, 2009; Chandra
state there is no evidence to associate the inside–outside & Chawla, 1972). It was also shown that severely discol-
bleaching protocol where low concentrations of hydrogen oured teeth are more difficult to bleach (Brown, 1965).
peroxide are used without heat with complications asso- It is reported that light yellow and grey discolourations
ciated with the walking bleach technique when higher are associated with better colour improvement than dark
concentrations of hydrogen peroxide may be used (Leith yellow and black teeth (Abbott & Heah, 2009). Studies
et al., 2009). have shown that there is high satisfaction after nonvital
936 | MANAGING DISCOLOURED TEETH

bleaching in anterior discoloured teeth (Gupta & Saxena, Heithersay et al., 1994; Lado et al., 1983; Rotstein et al.,
2014). In that study, 87.8% of patients were highly satis- 1991b). Predisposing factors include cementum defi-
fied with the bleaching outcome and only 4.9% of patients ciency exposing dentine, a periodontal ligament injury
not satisfied. However, their concerns included the un- and prior trauma (Baratieri et al., 1995; Esberard et al.,
predictability of the final shade and potential for colour 2007; Friedman et al., 1988; Harrington & Natkin, 1979;
regression. The high level of satisfaction may also be due Koulaouzidou et al., 1996; Tredwin et al., 2006; Trope,
to the fact that these were intact teeth that had a traumatic 1997). Approximately 10% of teeth have an incomplete
injury. Similar satisfaction rates (87.1% good and 12.9% ac- CEJ that exposes unprotected underlying dentine (Ten
ceptable) were reported by Abbot and Heah (2009). Cate, 1985). Hydrogen peroxide can penetrate to the
cervical area of teeth and these areas of defects in CEJ
morphology (Kopp, 1973; Neuvald & Consolaro, 2000;
CO N T R A INDI CATI ONS TO Rotstein et al., 1991b). Dental trauma can also dam-
B LE AC H ING OF EN DO DON T ICALLY age the CEJ exposing underlying dentine (Madison &
T R E AT E D T EET H Walton, 1990; Montgomery, 1984). Free oxygen radi-
cals that are the product of the bleaching process can
Teeth with extensive restorations may not respond as breakdown collagen and hyaluronic acid which may be
well to bleaching (Glockner et al., 1999; Howell, 1980). a pathological mechanism for resorption (Dahlstrom
Intracoronal bleaching is not indicated unless pulp patho- et al., 1997). These oxidizing agents can induce den-
sis is evident (Rotstein, 2019). tine protein denaturation (Lado et al., 1983) because of
changes in pH (Demarco et al., 2001; Gimlin & Schindler,
1990; Montgomery, 1984) and heat (Freccia et al., 1982;
CO M PL IC AT I O NS A ND RI S K S Harrington & Natkin, 1979; Madison & Walton, 1990).
Therefore, the application of heat and specifically the
Tooth bleaching can have adverse risks on hard and soft thermocatalytic technique in bleaching procedures is no
dental tissues including external cervical resorption, ad- longer advised (Setzer, 2020). A tooth that developed ex-
verse effects on adhesive bonding systems and dental ma- ternal invasive cervical resorption following trauma and
terial solubility (Anderson et al., 1999). bleaching is shown in Figure 7.
Inflammation may also be implicated in the aetiology
of external cervical resorption (Trope, 1977). However,
External cervical root resorption Heithersay (2004) argued that invasive cervical resorp-
tion was not activated by sulcular microorganisms and
External cervical root resorption is a serious complica- suggested the aetiology may involve a type of benign
tion of bleaching with peroxide compounds that can proliferative fibrovascular or fibro-osseous disorder in
result in tooth loss. External cervical resorption has which microorganisms have no pathogenic role but may
been reported in 6%–8% of cases which used 35% hy- become secondary invaders. It is thought that hydrogen
drogen peroxide and 18%–25% if the hydrogen peroxide peroxide compounds and free radicals must reach the
was heat activated (Cvek & Lindvall, 1985; Friedman, periodontal tissues through the dentinal tubules and
1997; Friedman et al., 1988; Harrington & Natkin, 1979; defects in cementum (Newton & Hayes, 2020; Wang &

(a)

(b)

F I G U R E 7 (a) A clinical photograph

of the bleached left maxillary central
incisor that had been bleached with
the walking bleach technique with
unknown medicaments. (b) A periapical
radiograph revealing external cervical
root resorption. Note the absence of any
intracoronal barrier and large access
cavity preparation. Courtesy of Professor
Geoffrey Heithersay
KAHLER | 937

Hume, 1988). Significant increases in the levels of bone bleaching is associated with external cervical resorp-
resorption markers RANK-L and IL-I ß were found in gin- tions are poorly understood (Attin et al., 2003; Patel
gival crevicular fluid of teeth treated with walking bleach et al., 2009). Hydrogen peroxide products placed into
where the bleaching agent was 35% hydrogen peroxide or the access cavity diffuse through dentinal tubules and
37% carbamide peroxide (Bersezio et al., 2018b). Further enamel to reach the external surfaces of the tooth and
study by the same group revealed that these inflammatory also the periodontal tissues (Palo & Bonetti-Filho, 2012).
mediators persisted for 3 months post-bleaching (Bersezio Therefore, placement of a base/seal is advised (Oliviera
et al., 2020). This is a potential sign of harmful effects from et al., 2003). More controversially, is the recommenda-
bleaching procedures. tion to remove gutta-percha to bleach the root in cases
The use of sodium perborate instead of hydrogen where root discolouration is visible through the gingival
peroxide may be a safer alternative (Madison & Walton, tissues. It is reasonable to expect a higher risk of invasive
1990). Sodium perborate mixed with water is less toxic to cervical resorption in these cases especially considering
PDL cells than 30% hydrogen peroxide or sodium perbo- the known defects in the CEJ in some teeth heightening
rate mixed with 30% hydrogen peroxide (Kinomoto et al., the risk association.
2001). All the studies in Table 5 investigated the association
Others advocate the use of carbamide peroxide (Lim of bleaching with invasive cervical resorption with the ex-
et al., 2004). The use of 35% carbamide peroxide has lower ception of Lise et al. (2018) that used 8%–10% carbamide
levels of extraradicular diffusion than comparable con- peroxide, used concentrations of hydrogen peroxide that
centrations of hydrogen peroxide. Carbamide peroxide re- are no longer legal in the European Union (European
sults in an alkaline pH in the tooth as it breaks down into Union produced a Cosmetic Directive [2011/84/EU]).
ammonia which has a reduced etching effect. The dissoci- Mavridou et al. (2017) in a study of 337 teeth with exter-
ation of carbamide peroxide is equivalent to 12% hydrogen nal cervical resorption reported an incidence 1% of cases
peroxide (Lee et al., 2004). However, carbamide peroxide where bleaching was identified as the sole predispos-
is most often used for external bleaching. ing factor. Unfortunately, this study did not identify the
Step 4 of the walking bleach technique advocates for a bleaching protocols used. However, as it was conducted in
2-mm protective barrier over the gutta-percha to the level Europe in 2010–2015 it is likely to be in accordance with
of the CEJ to prevent penetration of hydrogen peroxide the European directive where the concentration of hydro-
(Rotstein et al., 1992b). Heithersay et al. (1994) in a study gen peroxide products was legislated. Importantly, stud-
where the walking bleach technique employed a thermo- ies have shown that external resorption is associated with
catalytic approach and 30% hydrogen peroxide with no patients of a young age who have undergone bleaching
coronal protective barrier over the gutta-percha/AH26 (Abou-Rass, 1998; Aldecoa & Mayordomo, 1992; Anitua
root canal filling for 204 teeth reported an incidence of et al., 1990; Glockner et al., 1999; Harrington & Natkin,
invasive cervical resorption of just 1.96%. In that study, 1979; Heithersay et al., 1994; Holmstrup et al., 1988; Lado
for 84.37% of the teeth, the root filling was either at the et al., 1983). Also of significance, is that Amato et al.
level of the CEG or above. Only 18.63% of the teeth was (2018) in a study of 40 teeth followed for 40 years using
the root filling below the CEJ. The follow-up range was 10% carbamide peroxide with gutta-percha covered with
1–19 years with a median of 4 years. The four afflicted zinc oxide eugenol reported no incidence of external cer-
teeth also had a history of a traumatic injury. Abbott vical resorption.
&Yeah (2009) employed a walking bleach protocol with The risk of external cervical resorption using modern
35% hydrogen peroxide mixed with sodium perborate bleaching procedures is likely to be lower than prior stud-
in a study of 255 teeth where a cervical seal of 2.5 mm ies that used heat and higher concentrations of hydrogen
of Cavit and reported no teeth developed external cervi- peroxide (Newton & Hayes, 2020). Bleaching of root filled
cal resorption with a follow-up of 6 months to 5 years. teeth with the walking bleach technique is considered a
Current thinking suggests that the risk of external cervi- safe protocol with a low risk of invasive cervical resorption
cal resorption is a factor of the concentration of the hy- (Dahl et al. 2019; Newton & Hayes, 2020; Setzer, 2020).
drogen peroxide, whether a base/seal was placed to cover Treatment of invasive cervical resorption is not spe-
the root filling and if the action of hydrogen peroxide cifically discussed in this review but affected teeth can
has been enhanced by heat. The studies by Heithersay be with the use of direct restorations (Friedmann, 1989;
et al. (1994) and Abbott and Heah (2009) where there was Heithersay, 1999, 2007; Meister et al., 1986). After debrid-
a low to nil risk of external cervical resorption respec- ing the resorptive defect it is recommended to treat the
tively, suggest other factors are also involved. The prior resorptive defect with 90% trichloroacetic acid to induce
association with trauma is identified (Heithersay et al., sterile necrosis of remaining resorptive tissue (Heithersay,
1994). However, the mechanisms by which intracoronal 1999, 2007).
 938
|

TABLE 5 Incidence of cervical resorption following internal bleaching in endodontically treated teeth in clinical studies and case series

Cases of
Number Cervical Cervical Review
Reference of teeth Bleaching agent resorption Age of patients seal Trauma Heat (years)

Clinical studies
Friedman et al. (1988) 58 (a)TCC: 30% H2O2 1 24 No No Yes 8
(b)WBT: 30% H2O2 1 18 No No No
(c) TCC + WBT: 30% H2O2 2 14 No No Yes
(6.9% overall)
Holmstrup et al. (1988) 69 WBT: SP + water None Unknown Yes Yes Yes 3
Anitua et al. (1990) 258 WBT: SP + 110 vol H2O2 None — — — — 4
Aldecoa and Mayordomo (1992) 258 WBT None — — — — 6
Heithersay et al. (1994) 204 TCC: 30% H2O2 followed by WBT: 30% H2O2 4 (1.96%) 1:10–15 No Yes Yes 1–19
3: 16–20 No Yes Yes Median 4
Abou-Rass (1998) 112 WBT SP + 30% H2O2 None — — — — 5–15
Glockner et al. (1999) 86 WBT: SP + 30% H2O2 None Unknown Yes 4–6
Amato et al. (2006) 35 Mixture of SP + 120 vol H2O2 None 7–30 Yes Majority Yes 16
Mean age 13.2 84%
Abbott and Heah (2009) 255 WBT 35% H2O2 + SP powder None <10–60 Yes Majority 58.8% No 0.5–5
53.2% aged 11–20
Amato et al. (2018) 60 EC + WBT 10% CP None 18–35 Yes 35% No 25
Lise et al. (2018) 17 9: SP + 20% H2O2 None None Yes Unknown No 1
8: I-O 10% CP None None Yes Unknown No 1
Case series
Harrington and Natkin (1979) 7 TCC: 30% H2O2 followed by WBT: 30% H2O2 7 (100%) 15 No Yes No 2–7
Cvek and Lindvall (1985) 11 TCC: 30% H2O2 followed by WBT: 30% H2O2 11 (100%) <21 No Yes: 10 Heat 1
No: 1
Badole et al. (2013) 3 35% CP 0 19–35 Yes Yes No 0.4–1
Note: Adapted from Attin et al. (2003). However, case reports were not included due to potential of publication bias. Important to note bias in Harrington and Natkin (1979) and Cvek and Lindvall (1985) as specifically
reporting cases of cervical resorption.
Abbreviations: CP, carbamide peroxide; EC, extra-coronal; H2O2, hydrogen peroxide; I-O, inside–outside technique; SP, sodium perborate; TTC, thermocatalytic; WBT, walking bleach technique.
MANAGING DISCOLOURED TEETH
KAHLER | 939

Enamel and dentine damage successfully resolved with bleaching with sodium perbo-
rate mixed with 10% hydrogen peroxide (McTigue et al.,
Many laboratory studies have reported changes in enamel 2013). Bleaching with 35% hydrogen peroxide of a dis-
microhardness and morphology (Bitter, 1998; Chng et al., coloured tooth treated with REPs using TAPS and MTA
2005; Grazioli et al., 2018; Lopes et al., 2002; Murchison is shown in Figure 8. Calcium hydroxide resulted in sig-
et al., 1992; Rotstein et al., 1992a, 1996; White et al., 2002; nificantly less discolouration than TAP when used as an
Zanolla et al., 2017) and in cementum (Tong et al., 1993; inter-visit medicament (Nagata et al., 2014). Biodentine
Zalkind et al., 1996). It has been proposed that peroxide used as a coronal barrier may result in in less discoloura-
components alter the ratio of organic to inorganic hard tion than MTA (Bakhtiar et al., 2017). A laboratory study
tissue compounds (Heling et al., 1995; Lewinstein et al., also reported that Endocem resulted in less discoloura-
1994; Powell & Bales, 1991; Tong et al., 1993). However, tion than MTA materials. Furthermore, removal of the
this has been found to be concentration-dependent as 35% MTA was more effective at improving the discolouration
carbamide peroxide changed the inorganic composition of than internal bleaching with sodium perborate mixed
the enamel where lower concentrations of 10%–16% had with 3% hydrogen peroxide (Jang et al., 2013). Belobrov
no effect on enamel composition (Oltu & Gürgan, 2000). and Parashos (2011) also successfully bleached a vital dis-
However, even high concentrations of 30% hydrogen per- coloured traumatized incisor treated with a partial pul-
oxide and 30% hydrogen peroxide mixed with sodium per- potomy using white MTA. The tooth was bleached with
borate was associated with less morphological damage to sodium perborate mixed with saline.
the external surface of enamel than 37% phosphoric acid
(Ernst et al., 1996). The clinical significance of this altera- (a) (b)
tion in enamel composition and surface structure is not
clear. This is more of a consideration for external bleach-
ing and outside the scope of this review.

Inhibition of adhesive bonding

As discussed in Step 9 final restoration with an acid etch

adhesive restoration should be deferred for 1–3 weeks as
polymerization and bonding strengths of composite res-
ins to dentine and enamel are temporarily affected by the
oxygen released during bleaching (Cavalli et al., 2001;
Sinohara et al., 2001, 2004). This is important as failure of
(c)
the final restoration can cause future discolouration.

Gingival irritation

Gingival irritation is a greater concern for external bleach-

ing. However, protection of the oral tissues with rubber
(d)
dam is advised (Heithersay et al., 1994). The use of wedges
and blockout materials such as Orabase or Opal Dam to
properly seal the rubber dam to protect the gingival tis-
sues is also advocated (Rotstein, 2019; Setzer, 2020).

Regenerative endodontic and vital

F I G U R E 8 (a) A preoperative radiograph showing a left
pulp therapy technique complications maxillary central incisor with interrupted root development
indicating pulp necrosis. (b) The tooth as treated with regenerative
Tooth discolouration caused by TAPs can be reversed by endodontic protocols. (c) A photograph revealing blackish/greyish
the walking bleach technique with sodium perborate used discolouration. (d) A photograph of the tooth after three bleaching
as the bleaching agent (Kirchhoff et al., 2015). However, appointments using the protocol described in Figure 5. Reprinted
not all teeth treated with REPs that are bleached are in part from (Fida et al., 2021) with permission
940 | MANAGING DISCOLOURED TEETH

PRO ST H OD O NT IC OPT I ON S – Perdigão, 2021). Consistent perfect results are difficult to

R E S IN COM POSI TE AND CERAMI C achieve especially in the discoloured tooth because of the
V E N E E RS, CROWN S dark substrates of the crown and the root (Mandikos, 2021).
Masking the dark substrate of the crown/and or post can be
Prior reviews have indicated that direct composite veneers, improved by removing metal posts or masking posts with
porcelain veneers and crowns are alternatives to bleaching composite opacifiers (Figure 11). Masking the discoloured
(Greenwall-Cohen & Greenwall, 2019) (Figures 9–12). It is tooth with zirconium copings can present technical issues
important that patients are made aware of the more exten- and a higher incidence of chipping of feldspathic porcelain
sive loss of tooth structure, expense, risks and complications (Mandikos, 2021).
including repair and replacement with time (Alani et al.,
2015). Ceramic veneers had better outcomes than indirect
composite veneers in terms of survival rate and the qual- PERIO DON TAL CON SI DERATI O NS
ity of the restorations over a 10-year follow-up (Gresnigt – ROOT COLOU R, TOOT H SHAP E
et al., 2019). A recent study reported leucite-reinforced AND FO RM
glass–ceramic crowns had a survival rate of 79.6% after 11–
13 years with ceramic fractures responsible for most clini- Patients perception of root colour, tooth shape and form
cal failures (Zürcher et al., 2021). A systematic review and can involve changing the aesthetic appearance of the tooth
meta-analysis of feldspathic porcelain and glass–ceramic with periodontal surgery (Figure 12). This is a common
laminate veneers reported failures associated with debond- procedure in the aesthetic zone (Marzadori et al., 2018).
ing, fracture/chipping, secondary caries and severe marginal However, a recent systematic review reports complica-
discolouration (Morimoto et al., 2016). Direct composite tions of gingival rebound and whether biological width is
resin veneers are more affordable, less invasive and easier re-established (Al-Sowygh, 2019).
to repair than indirect porcelain veneers but are more likely
to sustain colour loss and over time. Furthermore, the aes-
thetic outcome of indirect porcelain veneers depends on PERFECTI ON ISM AND QUALI TY O F
the dentine adhesive and resin luting cements (Araujo & LI FE

Patients and dentist's expectations for aesthetic outcomes

(a)
can be high. There is an increasing public awareness for
lighter teeth and the word ‘Hollywood smile’ has entered
our lexicon. This may be a consideration for the walking
bleach technique where a lighter colour than the adjacent
teeth is the desirable outcome due to potential rebound in
colour. Pavicic et al. (2018) report that quality of life can be
improved with bleaching. However, patient's personality
traits and expectations should be considered in attaining
treatment outcomes. While the treatment of discoloured
teeth may involve an inter-disciplinary approach, the
perfect result may be unattainable, particularly for some
(b) patients with heightened expectations. The pursuit of per-
fection with porcelain may also not be predictable and
maybe very dependent on the clinicians' technical capa-
bilities which will be variable between different operators.

TH E EU ROPEAN U N ION AN D TH E
LAW

Due to the European Union directive (2012) it is either

not possible or there is reluctance by practitioners to
F I G U R E 9 (a) A photograph of vital teeth with mild fluorosis bleach discoloured teeth in patients under the age of 18
(b). A post-treatment photograph after management involved KTP (Trainor & Good, 2016; Walshaw et al., 2019). Despite
laser activation and resin composites. Courtesy of Dr Mark Gervais many recent textbooks advocating the use of sodium
KAHLER | 941

(a) (b)

(c)

(d)

F I G U R E 1 0 (a) A photograph of discoloured root filled maxillary central incisor which are inferior to the occlusal arch influencing the
aesthetic appearance. (b) The teeth after improved oral hygiene. (c) Colour selection with the teeth prepared for porcelain veneers. (d) A
photograph taken after cementation of the veneers. Courtesy of Dr Tony Rotondo

perborate, in Europe 10% carbamide peroxide should tooth whitening products did not comply with a
be used to comply with the European Union cosmetic European Union regulation. The European Network
directive. This is because the Cosmetic directive allows of Official Cosmetic Control Laboratories (OCCL) re-
for a maximum concentration of hydrogen peroxide of ported that only 71% of tested materials complied. The
6% where sodium perborate mixed with water releases European Directorate for the Quality of Medicines
7% hydrogen peroxide as opposed to 3.5% release when (EDQM) reported that most noncompliance issues re-
carbamide peroxide is used as the bleaching agent. lated to products exceeding the regulated concentra-
Furthermore, bleaching is prohibited for people under tion of hydrogen peroxide, the presence of carcinogenic,
the age of 18 years. Unfortunately, as many teeth darken mutagenic and toxic substances such as sodium perbo-
from dental trauma and children are generally the rate as well as labelling issues (Dentistry Today, 2019).
more at-risk group to traumatic events. There is a con- In Australia, 50% of consumers purchase do-it-yourself
cern that the directive may place dentists and patients whitening products at pharmacies and on-line outlets.
at risk of choosing more invasive and expensive proce- These products may not fully disclose product infor-
dures. Dental bleaching has been shown to be a safe and mation and/or mislead consumers (Australian Dental
effective means of lighten the colour of teeth and the Association, 2019). The use of nonvital bleaching is in-
risks of external cervical resorption with modern inter- creasingly regulated in many international jurisdictions
nal bleaching protocols involving lower concentrations (Grum, 2020). However, in the USA, most hydrogen per-
of hydrogen peroxide agents may be lower than earlier oxide bleaching agents are considered cosmetics rather
studies (Newton & Hayes, 2020). Nonvital bleaching pro- than drugs and hence do not require Federal Drug
vides predictable and conservative lightening of teeth Administration (FDA) approval. The safety and regula-
when compared to prosthodontic alternative treatment tory issues are the responsibility of the manufacturers
options. Further research is required. (Grum, 2020). Unfortunately, the European Directives
primarily concerned with materials considered cosmet-
ics also impacts on endodontically treated teeth and the
F UT U RE D I RECTI O NS concentration and type of materials used in walking
bleach protocols. In particular, this presents legal and
The increasing popularity of tooth whitening of vital ethical concerns when bleaching discoloured teeth in
teeth may see the use of bleaching agents that do not younger patients (Kelleher, 2014). Walshaw et al. (2019)
comply with legislation. Recently, in Europe, many share these concerns for the paediatric setting where
942 | MANAGING DISCOLOURED TEETH

(a) (b)

(c) (d)

(e) (f)

(g)

F I G U R E 1 1 (a, b) Improving prosthodontic outcomes by removing metal posts. (c, d) Masking metal posts and discoloured teeth with a
VMK crown. (e-g) Masking a discoloured maxillary right central incisor with a dual crown approach using a YTP Zirconium crown which is
then overlaid with a more translucent eMax crown. Courtesy of Dr Michael Mandikos

alternative therapies that involve tooth loss are consid- are chosen, issues other than tooth colour such as tooth
ered even at an early age. It is likely with many practices wear, prior restorations and gingival contour will influ-
emphasizing cosmetic dentistry, that adult patients will ence treatment selection decision- making processes as
enhance their smile with prosthodontic and periodon- bleaching approaches are generally safe and effective.
tal treatment when cosmetic approaches using bleach- The importance of informed consent and the risks and
ing agents fail to achieve a pleasing aesthetic result. It benefits of the alternative treatment protocols will re-
is also likely when more tooth destructive treatments main paramount for patient's and dentists.
KAHLER | 943

(a) (b)

(c)

(d)

(e)

F I G U R E 1 2 (a) A photograph of maxillary incisors revealing prior crown rehabilitation with short clinical crowns and gingival recession
showing discoloured roots in the root filled teeth. (b) A photograph revealing crown lengthening so the appearance of the teeth can be
improved. (c) A photograph of the new gingival position to allow teeth to have a more leasing height to width ratio. (d) A clinical photograph
showing the teeth prepared to the new gingival position. (e) A post-treatment photograph with porcelain crowns. Courtesy of Dr Tony Rotondo

CO N CLU S IO N ACKNOWLEDG EMENTS

My thanks to Professor Geoffrey Heithersay for his re-
Managing discoloured teeth involves a clear understanding view of the MS. Open access publishing facilitated by
and diagnosis of the aetiology of the discolouration and inter- The University of Queensland, as part of the Wiley - The
disciplinary management. There is commonly an association University of Queensland agreement via the Council of
with trauma, developmental and lifestyle considerations. Australian University Librarians.
Bleaching endodontically treated teeth can be consid-
ered a safe and effective protocol in the management of CON FLI CTS OF IN TEREST
discoloured teeth. The risk of external cervical root re- The author has no conflicts of interest to declare.
sorption may be lower with the use of sodium perborate
and a change from higher concentrations of hydrogen AUTHOR CONTRI BUTIO NS
products. However, the association between bleaching Bill Kahler was the sole author and responsible for the de-
and resorption remains unclear although there is likely sign and content of the manuscript.
to be a relation to prior trauma. It is prudent to avoid
thermocatalytic approaches and to use a base/sealer as a ETHICAL APPROVAL
protective barrier to cover the gutta-percha. The article is a review and did not involve human par-
It is likely, that there will be continued public interest ticipants. It therefore complies with the 1964 Helsinki
in lightening discoloured teeth. It is important that the pa- Declaration and its later amendments or comparable ethi-
tient can make an informed choice. cal standards.
944 | MANAGING DISCOLOURED TEETH

Anderson, D.G., Chiego, D.J., Glickman, G.N. & McCauley, L.K.

ORCID
(1999) A clinical assessment of the effects of 10% carbamide
Bill Kahler https://orcid.org/0000-0002-4181-3871 peroxide gel on human pulp tissue. Journal of Endodontics, 25,
247–250.
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