ESTHETIC DENTISTRY

A modified inside/outside bleaching technique for nonvital

discolored teeth: a case report
François Reitzer*, DMD/Claire Ehlinger*, DMD/Maryline Minoux, DMD, PhD

Over the past decades, the walking bleach technique using so- that the access cavity is left open. To overcome this disadvan-
dium perborate was considered a safe and effective method to tage, the present authors propose to seal the bleaching agent
bleach nonvital discolored teeth. However, sodium perborate in the access cavity instead of leaving the latter open. Through
has been classified as carcinogenic, mutagenic, and toxic for a clinical case, this paper presents and discusses several aspects
reproduction by European Union legislation. Its use is therefore of this protocol, including the clinical steps, the design of the
prohibited since April 2015. The initially described inside/out- bleaching tray, and the treatment of potential recurrences. The
side bleaching technique, combining internal and external ap- present authors believe that the protocol proposed in this arti-
plication of 10% carbamide peroxide, is an alternative to the cle is easier to use for the patient. Moreover, it prevents the
walking bleach technique using sodium perborate. While good accumulation of food debris in the access cavity and avoids the
esthetic results and low risks of external cervical resorptions colonization of coronary dentin by bacteria. (Quintessence Int
have been associated with this technique, its main drawback is 2019;50:802–807; doi: 10.3290/j.qi.a43248)

Key words: carbamide peroxide, case report, inside/outside bleaching technique, sodium perborate, walking bleach technique

Discoloration of anterior teeth is an esthetic concern for many study on 95 teeth, good or acceptable results were observed in
patients.1 On pulpless teeth, intrinsic dyschromia often results 89% of the cases. After 3 years, 79.7% of these teeth maintained
from post-traumatic hemorrhage or pulp necrosis. Inadequate good or acceptable results. No fracture or resorption occurred
endodontic access cavity leaving persistent necrotic tissue in in the treated cases.10
the pulp horns is also a source of dyschromia.1-4 However, sodium perborate has been classified as carcino-
Tooth whitening is a conservative alternative to more inva- genic, mutagenic, and toxic for reproduction (CMR substances)
sive treatments such as veneers or crowns.5 Several techniques by European Union (EU) legislation. Its use is therefore prohib-
have been described to bleach discolored nonvital teeth.3-7 The ited by Article 15 of Cosmetics Regulation 1223/2009, since
principal active agent is, however, always hydrogen peroxide. April 2015.11 In response to this restriction, the search for an
This can be directly applied to the tooth or be released from alternative technique is essential.
carbamide peroxide or sodium perborate.3,6 The use of carbam- An inside/outside bleaching technique combining inter-
ide peroxide or sodium perborate has the advantage of pro- nal and external application of 10% carbamide peroxide was
moting a gradual release of hydrogen peroxide, thereby redu- initially described by Settembrini et al12 in 1997. In this tech-
cing the risk of side effects associated with a massive release of nique, a protective barrier is placed on the gutta-percha in the
bleaching molecules.5,6,8 The walking bleach technique using root canal to seal off the latter from the pulp chamber. A cus-
sodium perborate in combination with distilled water was con- tom bleaching tray with a reservoir on the labial surface of the
sidered a safe and effective method, associating good esthetic discolored tooth is then given to the patient, who is instructed
results with absence of external cervical resorption.7,9,10 In a to inject 10% carbamide peroxide in the access cavity left

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 Reitzer et al

1a 1b

1e 1f 1g

1c 1d 1h

1i 1j

Figs 1a to 1k Modified inside/outside bleaching technique.

(a and b) Initial clinical appearance. (a) Patient’s smile. (b) Intraoral
view of the maxillary incisors. Note the grayish discoloration of the
maxillary right central incisor. (c) Preoperative radiograph of the
maxillary right central incisor. (d) Periapical radiograph taken after
the endodontic treatment. (e) Intraoperative view of the access cavity
after reducing the root filling 1.5 mm below the cementoenamel
junction. (f) Intraoperative view of the zinc oxide–eugenol cement
barrier. (g) Intraoperative view of 10% carbamide peroxide placed in
the access cavity. (h) Design of the tray used for the nonvital tooth
bleaching. (i) Bleaching tray applied to the teeth. (j and k) Post-
operative appearance. (j) Intraoral view of the maxillary incisors.
1k (k) Patient’s smile.

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2a 2b

2c 2d

2e 2f

Figs 2a to 2f Follow-up. (a to c) Clinical appearance 18 months after the treatment. (a) Intraoral view of the
maxillary incisors. (b) Black and white picture showing the reduced value of the maxillary right central incisor
compared to the contralateral tooth. (c) Patient’s smile showing a slight recurrence of dyschromia on the maxillary
right central incisor. (d to f) Clinical appearance after 5 nights of external bleaching. (d) Intraoral view of the
maxillary incisors. (e) Black and white picture showing that both maxillary central incisors have similar values.
(f) Patient’s smile.

open and in the tray reservoir, before inserting the tray into Case report
the mouth.4,12-14
A clinical case is presented in which the patient was treated A 19-year-old woman presented to the endodontic depart-
with a variant of the initially described inside/outside bleach- ment due to a grayish discoloration of her maxillary right cen-
ing technique. The proposal is to seal 10% carbamide peroxide tral incisor. The patient had a history of trauma 5 years previ-
into the access cavity instead of leaving the latter open. It is ously, which induced pulp necrosis associated with intrinsic
suggested that this protocol is easier to use for the patient and discoloration of the tooth (Figs 1a to 1c). An endodontic
prevents accumulation of food debris in the access cavity. treatment followed by an inside/outside bleaching technique

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 Reitzer et al

was proposed to the patient and written consent was of products with a concentration greater than 6% is prohib-
obtained. ited.15 In addition, the use of sodium perborate has been for-
The maxillary right central incisor was isolated with rubber bidden since April 2015.11 Together, these EU directives pose a
dam and the access cavity was designed to include the mesial new challenge in the field of nonvital tooth bleaching.
and distal horns. After performing the endodontic treatment, The inside/outside bleaching technique using a low concen-
the access cavity was provisionally filled with Cavit (3M Espe) tration of carbamide peroxide (between 10% and 16%) is an
and a periapical radiograph was taken (Fig 1d). interesting alternative to the walking bleach technique using
The patient was seen 1 week later to begin the bleaching sodium perborate. This technique, initially described by Settem-
procedure. The tooth was isolated with rubber dam before brini et al12 and then applied by other authors, has been re-
removing the provisional restoration from the access cavity. ported to be associated with good esthetic results and no exter-
The gutta-percha in the root canal was reduced 1.5 mm below nal cervical resorptions.13,16,17 Another advantage is the use of a
the cementoenamel junction (CEJ) by a heated plugger (Fig 1e) single product for internal and external bleaching.4,14
and a 2-mm barrier of zinc oxide–eugenol cement (Dentsply) Nevertheless, this technique has the disadvantage of leav-
was placed over the remaining gutta-percha to protect both ing the access cavity open. Accumulation of foodborne depos-
the root canal and the CEJ from the diffusion of the bleaching its can then occur. To limit this, the patient is instructed to rinse
agent (Fig 1f ). The access cavity was then filled with 10% carba- the access cavity and to place a fresh cotton pellet after each
mide peroxide (Fig 1g) and sealed with zinc oxide–eugenol meal.12,16 While useful, this procedure cannot completely pre-
cement. vent the deposition of food debris, which may reduce the effec-
In the previous session, an alginate impression of the maxil- tiveness of the bleaching. In addition, microorganisms can col-
lary arch was taken and the dental laboratory technician was onize the exposed dentinal tubules which, due to the complex
asked to create a bleaching tray with a specific design, including: histology of the dentin, cannot be entirely decontaminated.5,7,18
■ a reservoir on the labial surface of the maxillary right cen- Furthermore, careful case selection is necessary since the
tral incisor administration of the bleaching agent is based on the patient’s
■ holes in the labial surfaces of the adjacent incisors (Fig 1h). compliance and dexterity.13,14
To overcome these disadvantages, the proposal is to seal
After testing the fitting of this tray (Fig 1i), it was given to the the bleaching agent in the access cavity. One critical step of this
patient, who was instructed to inject the bleaching gel in the protocol is the placement of the provisional restoration over
reservoir and to wear it overnight (5 to 6 hours). the bleaching agent, which can be difficult due to the texture
The patient was reviewed for check-ups weekly, without of the latter. To facilitate this procedure, some cotton fibers can
replacing the product in the tooth. After 3 weeks, the esthetic be placed between the bleaching agent and the provisional
result was good (Figs 1j and 1k). The bleaching gel was removed restoration. Here, a zinc oxide–eugenol cement was used, but
from the endodontic access cavity, which was provisionally it is also possible to bond a composite resin. If this alternative is
restored by placing calcium hydroxide covered by Cavit. Two chosen, the enamel margins of the access cavity should be
weeks later, the definitive composite restoration was placed. A etched with 37% phosphoric acid prior to the application of the
routine follow-up was then conducted every 6 months. bleaching gel. Cotton fibers covered with bonding agent
Eighteen months after the treatment, the tooth remained should then be applied on the carbamide peroxide and light
asymptomatic but showed a slight recurrence of dyschromia cured before placing the composite.5
(Figs 2a to 2c). This recurrence was treated by 5 nights of exter- The tray used in the bleaching technique described
nal bleaching with 10% carbamide peroxide, placed in the tray included a reservoir on the labial surface of the tooth to be
used for the initial treatment (Figs 2d to 2f ). treated and holes in the labial surfaces of adjacent teeth.19 The
aim of this design was to induce selective bleaching of the dis-
colored pulpless tooth, by avoiding accidental diffusion of the
Discussion
bleaching agent on unaffected teeth. A bleaching tray in which
In 2011, EU legislation established a legal framework for bleach- the labial surfaces of adjacent teeth were completely removed
ing products containing hydrogen peroxide. Cosmetic prod- has also been described.19 However, leaving a thin band of
ucts containing or releasing between 0.1% and 6% hydrogen material at the cervical edge of the tray has the advantage of
peroxide may only be sold to dental practitioners and the use increasing its stability.19

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Like the inside/outside bleaching technique originally de- External cervical resorption is a major concern when
scribed, the present protocol presents a risk of overbleaching performing nonvital tooth bleaching. Occurrence of this ad-
of the treated tooth.4,14 If this happens, a new complete-cover- verse effect has been reduced by using walking bleach pro-
age tray should be made to bleach the adjacent teeth and cor- tocols associated with the placement of a cervical barrier,
rect the color difference. The same approach can be used if, in and the delivery of low concentrations of hydrogen per-
addition to the pulpless discolored tooth, the patient wishes to oxide.5,7,13,14 Alteration of the enamel by external application
bleach his/her entire dental arch. In this case, simultaneous of peroxide carbamide is another concern of bleaching pro-
bleaching of vital teeth and a nonvital tooth with the access cedures. The effect of 10% to 16% peroxide carbamide on
cavity left open has been described.16 However, treating the enamel is, however, controversial; while some studies have
nonvital tooth first before bleaching the adjacent teeth can described slight morphologic, mechanical, or chemical
avoid an increased color disparity in case of a nonresponse of modifications,20,21 other studies have shown no effect.20,22
the discolored nonvital tooth to bleaching.12,19 These discrepancies have been attributed to the protective
The recurrence of discoloration after the initial bleaching effect of the saliva, which may promote tooth remineraliza-
procedure is frequent.10 In this case report, a slight rediscolor- tion, thereby counteracting the effect of bleaching prod-
ation appeared 18 months after the treatment. This recurrence ucts on dental hard tissues.20-22
was treated by 5 nights of external bleaching using 10% carba-
mide peroxide applied with the tray created for the initial
Declaration
bleaching procedure. This protocol allows easy correction of a
rediscoloration, in a conservative way. The authors deny any conflicts of interest related to this study.

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 Reitzer et al

François Reitzer François Reitzer* Assistant Professor, Université de Strasbourg,

Faculté de Chirurgie Dentaire, Strasbourg, France

Claire Ehlinger* Assistant Professor, Université de Strasbourg,

Faculté de Chirurgie Dentaire, Strasbourg, France

Maryline Minoux Professor, Université de Strasbourg, Faculté de

Chirurgie Dentaire, Strasbourg, France

*Co-first authors

Correspondence: Dr Maryline Minoux, Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Sainte Elisabeth, 67 000 Strasbourg,
France. Email: [email protected]