Dental Traumatology 2014; 30: 396–399; doi: 10.1111/edt.12109
Evaluation of patient satisfaction after nonvital bleaching in traumatized discolored intact anterior teeth Saurabh K. Gupta, Payal Saxena Department of Conservative Dentistry and Endodontics, Government College of Dentistry, Indore, India
Key words: clinical effectiveness; traumatized discolored anterior tooth; intracoronal; non-vital bleach; patient satisfaction Correspondence to: Payal Saxena, Department of Conservative Dentistry and Endodontics, Government College of Dentistry, Sardar Patel Marg (opp. M.Y. Hospital), Indore, Madhya Pradesh 452001, India Tel.: +91 9302793700 Fax: + 91 731 2701608 e-mail: [email protected] Accepted 26 January, 2014
Abstract – Aim: This study evaluated patient satisfaction and clinical effectiveness of intracoronal bleach in traumatized anterior discolored intact teeth. Assessment of awareness and knowledge of the patient regarding treatment modalities for such cases was also performed. Material and method: Forty-one patients were included in the study. Walking bleach was performed using sodium perborate (tetrahydrate) after root canal treatment and proper cervical seal. Patient was recalled after 1 week for evaluation. The bleaching procedure was repeated again till the patient agreed for it. On each recall visit, shade evaluation was performed using the Vita Classic shade guide. On completion of treatment, the patients were questioned as to their satisfaction level. Statistical analysis was carried out using ANOVA. Results: 87.8% of the subjects were highly satisfied with the results obtained; 7.32% were satisfied, while 4.9% were not satisfied. Average number of appointments needed for highly satisfied group was 2.75, and average shade change obtained was 11.97. Significantly more number of appointments were needed for the older patients (P < 0.01) or patients with older trauma (P < 0.05)/discoloration (P < 0.05). Severity of discoloration did not affect the number of appointments (P > 0.05). Most of the participants (97.6%) were not aware of bleaching procedure. The aspect of this treatment, which satisfied them the most, was improvement of the tooth coloration followed by conservation of tooth structure while the most perplexing thing was the unpredictability of final shade achieved and lack of color stability. Conclusions: High level of patient satisfaction after non-vital tooth bleach treatment strongly supports this treatment modality to be a conservative treatment alternative for traumatized discolored anterior tooth.
There has been always a desire in us to get our teeth as white as possible. As we proceed in the future, this urge is constantly getting stronger as our society is getting more esthetic conscious. Aspiration to having whiter and brighter teeth has been an esthetic treatment most desired by participants in various studies (1, 2) dealing with their dental appearance and treatment. Tooth color is a critical factor influencing satisfaction with smile appearance, and single-tooth discoloration resulting from trauma is more so (2, 3). Single-tooth discoloration sets a sense of inferiority and embarrassment as single dark tooth stands out and, being distinguished easily, attracts the attention of the observer when compared to a smile with generalized darkening of teeth in which the attention is more toward other facial features (4). Although there have been many in vitro studies (5–7) investigating the effectiveness of intracoronal bleaching in anterior discolored teeth clinical studies are very few in number and data regarding patient satisfaction after the treatment are lacking. Therefore, this 396
study was undertaken to assess the patient satisfaction and clinical effectiveness with regards to intracoronal bleaching. This study also evaluated the general awareness and knowledge about the treatment modalities for traumatized discolored intact anterior tooth. Materials and method
Forty-one patients (22 males; 19 females) who visited our department seeking treatment of their traumatized discolored anterior tooth and met the inclusion criteria for this study were selected. Inclusion criteria consisted of non-vital anterior, discolored (but not due to caries) and periodontally sound tooth. Exclusion criteria included carious, previously root canal treated, periodontally compromised, fractured and grossly malformed tooth. Root canal treatment was carried out by either of the authors after patients’ consent following standard guidelines. Briefly, after rubber dam application, endodontic access was gained with an endodontic explorer © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Patient satisfaction after non-vital bleach (DG-16, Dentsply instruments, Surrey, UK). The working length was determined radiographically and confirmed with an apex locator (Propex II; Dentsply international, Surrey, UK). The root canals were cleaned and shaped using rotary Protaper files (Dentsply international) and were copiously irrigated with 2.5% sodium hypochlorite solution. Calcium hydroxide/distilled water paste was then placed as an intracanal medicament, if required. The root canals were obturated with corresponding Protaper gutta-percha and AH Plus sealer (Dentsply De Trey, Germany). A questionnaire assessing their personal history, history of discoloration/trauma and knowledge about the treatment was filled. Explanation about the bleaching procedure, indications, risks and benefits was presented, and a written consent with authorization was obtained from the patients. Before bleaching appointment, pretreatment shade evaluation was carried out and photographs were taken. Scaling and root planning was performed, and oral hygiene measures were rendered. Bleaching procedure
Walking bleach technique was used in this study following proper guidelines. After root canal treatment of the concerned tooth, the root filling material was reduced 1–2 mm below cervico–enamel junction and a cervical seal of 2 mm thickness was placed with glass ionomer cement keeping its shape as a ‘bobsled tunnel’ from the facial and as a ‘ski slope’ from the proximal (8). This was controlled using periodontal probe. Then sodium perborate (tetrahydrate) mixed with distilled water in a ratio of 2:1 (g ml 1) (9) was placed in the cavity with amalgam carrier, and a sound seal of 2 mm thickness was provided with resin composite using selfetch bonding technique. Patient was recalled after 1 week for evaluation. The bleaching procedure was repeated again. This was carried out till the patient agreed for it or till a shade lighter than the contralateral tooth was achieved to compensate for the posttreatment relapse up to a maximum of five times. If the patient insisted earlier termination of the treatment, the cause of withdrawal was noted. When the shade was lightened sufficiently, the access cavity was cleaned thoroughly and sealed with composite resin. Evaluation of shade change and patient satisfaction
On each recall visit, shade evaluation was performed using the Vita Classic shade guide (Vita Zahnfabrik).
397
One operator (GS) evaluated the outcome on all the patients and took the photographs using the same operatory, lightening, camera and technique. Numbers were assigned to each shade tab such that no. 1 was the lightest and no. 16 was the darkest. The teeth having darker shade than available in shade guide were designated as no. 17 in common (as in Fig. 2a). This shade was compared with the pretreatment shade, and shade change after each appointment was noted in units. On completion of treatment, the patients were questioned as to their satisfaction level. On the basis of Visual Analog Scale (VAS), satisfaction level was taken as 0–10. Scoring criteria were selected as 10 being highly satisfied (HS), 8–9 satisfied (S), 6–7 partially satisfied (PS) and ≤5 as not satisfied. Results
The analysis of patient satisfaction score showed that 87.8% (36/41) of them were highly satisfied with the results obtained; 7.32% (3/41) were satisfied, while 4.9% (2/41) were not satisfied. For highly satisfied group, the average number of appointments needed were 2.75, and average shade change obtained was 11.97 (i.e. a shade change of 4.97 per appointment was achieved) (Table 1). Result from highly satisfied group attained after one, two and three appointments, respectively, is presented in Fig. 1. Figure 2 shows a case of discoloration due to trauma since last 25 years. After four appointments, patient scored satisfaction level as 10. Average shade change attained for all the satisfied patients (HS+S) was 12.0. Although in most cases, treated tooth closely matched the shade of contralateral tooth, shade discrepancy of 0.25 (average) was found in highly satisfied group and was 2.34 in satisfied group as observed by the authors (Table 1). The two patients, who were not satisfied and discontinued the treatment, cited multiple appointments as the prime factor for their dissatisfaction. All the satisfied patients (HS+S) were grouped on the basis of number of appointments needed to bring their satisfaction. The results showed that significantly more number of appointments were needed for the older patients (P < 0.01; CD = 4.35), older trauma (P < 0.05; CD = 4.39)/discoloration (P < 0.05; CD = 2.93). Interestingly, the number of appointments required were not influenced by severity of discoloration as average shade change in single appointment was 11.34 and in four appointments was 12.5 (P > 0.05; CD = 1.12) (Table 2; Fig. 3).
Table 1. Evaluation of average shade change in different treatment groups on basis of satisfaction level achieved Satisfaction level
No. of patients % (n)
Average number of appointments needed
Average shade change
Average shade change/appointment
Highly satisfied Satisfied Partially satisfied Not Satisfied Total
87.80 7.32 0 4.9 100
2.75 3.67 – 1.5 2.76
11.97 12.34 – 7 11.76
4.97 3.45 – 5 4.86
(36) (3) (0) (2) (41)
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Difference from contralateral tooth shade after treatment 0.25 2.34 – 6.0 0.68
398
Gupta & Saxena
(a)
(c)
(e)
(b)
(d)
(f)
Fig. 1. Walking bleach in traumatized discolored tooth of three highly satisfied patients (a, c, e) preoperative conditions; (b, d, f) two weeks after 1, 2 and 3 appointments, respectively.
(a)
(c)
(b)
(d)
Fig. 2. Four appointment walking bleach, (a) preoperative condition, (b) after two appointments, (c) after three appointments, (d) two weeks after four appointments.
Table 2. Relationship between number of appointment required and patient’s age, year of discoloration/trauma and severity of discoloration No. of appointments 1 2 3 4 Mean P value CD
Total number of satisfied (HS+S) patients 4 12 15 10
Age (average in years)
Years of trauma (average in years)
Years of discoloration (average in years)
Average shade change
22.67 23.18 30.2 39.5 30.28 0.0004 4.35
6.0 5.36 9.2 17.8 10.08 0.0190 4.39
0.87 2.0 4.84 9.4 4.90 0.0421 2.93
11.34 11.45 13.13 12.5 12.0 NS 1.12
Most of the participants (97.6%) in our study were neither aware of the fact that their single discolored tooth could be bleached, nor of the veneer placement procedures (95.12%), which shows the lack of awareness among the general public. The most common treatment option they knew was placement of crown after reducing their teeth (78.1%) or extraction followed by replacement (48.8%).
The aspect of this treatment, which satisfied them the most, was improvement of the tooth coloration (48.8%) followed by conservation of tooth structure (43.9%) and procedure being performed while doing routine work (7.5%). The most perplexing thing about bleaching was the unpredictability of the final shade achieved (61%); this was followed by lack of color stability (39%). © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Patient satisfaction after non-vital bleach
Fig. 3. Relationship of number of appointments for non-vital tooth bleach with different parameters.
Discussion
The most common reason for single-tooth discoloration has been traumatic injuries to tooth, which is the case here also as most of the participants gave a history of trauma in relation to the discolored tooth. It was found that the tooth with recent history of trauma and teeth of young patients were more responsive to intracoronal bleaching procedure. It was also seen that the number of appointments required for obtaining a desirable shade was lesser in such participants. On the contrary, participants with old trauma history or older age group required more appointments, and the final shade obtained was compromised. These participants were then again given the option of extracoronal bleaching/veneer placement, which most of them refused as they were satisfied with the results obtained. The bleaching of non-vital teeth is a relatively lowrisk intervention to successfully improve the esthetics of endodontically treated teeth (10). This study attained an average shade change of 12.0 for all satisfied patients. The results showed that number of appointments for achieving satisfactory results were not dependent on severity of discoloration. The initiation of discoloration could not be accurately ascertained in our study as it is subjective to various factors, and there was a variable duration between its initiation and recognition. It is also a point of interest that, upon completion, some patients were satisfied even after having a shade difference with the contralateral tooth. The probable explanation for this can be that most of them were unaware of this treatment procedure and had come to the college with the intent of getting their tooth structure sacrificed for crown placement. The striking noticeable change in the color produced by bleaching their discolored tooth without sacrificing their tooth structure may be one of the important reasons for accepting this
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
399
discrepancy. This was particularly apparent in cases that had much darker shades than that present in the Vita Shade Guide and were designated by giving them number 17 (Fig. 2a). Additional to this, before the commencement of this procedure, the authors had informed them the limitations of the procedure clearly stating that final color cannot be predicted beforehand and the results could be less than satisfactory, which would have led them to accepting this discrepancy in shade. Whenever non-vital tooth bleaching is performed, there is always a concern that relapse occurs and tooth discoloration returns (11). This was one of the factor perplexing to the patients as been told beforehand. Presently, no ideal protocol can be proposed to overcome tooth relapse of non-vital bleaching (12). All the patients were instructed to attend regular recall visits for further evaluation. This study also highlights unawareness of the general public regarding treatment options for traumatized discolored intact anterior tooth. High level of patient satisfaction after non-vital tooth bleach treatment strongly supports this treatment modality to be a conservative treatment alternative for discolored anterior tooth. References 1. Qualtrough AJ, Burke FJ. A look at dental esthetics. Quintessence Int 1994;25:7–14. 2. Samorodnitzky-Naveh GR, Geiger SB, Levin L. Patients’ satisfaction with dental esthetics. J Am Dent Assoc 2007;138:805–8. 3. Akarslan ZZ, Sadik B, Erten H, Karabulut E. Dental esthetic satisfaction, received and desired dental treatments for improvement of esthetics. Indian J Dent Res 2009;20:195– 200. 4. Kershaw S, Newton JT, Williams DM. The influence of tooth colour on the perceptions of personal characteristics among female dental patients: comparisons of unmodified, decayed and “whitened” teeth. Br Dent J 2008;204:E9; 256–257. 5. Dietschi D, Rossier S, Krejci I. In vitro colorimetric evaluation of the efficacy of various bleaching methods and products. Quintessence Int 2006;37:515–26. 6. Carrasco LD, Guerisoli DMZ, Rocha MJA, Pecora JD, Fr€ oner IC. Efficacy of intracoronal bleaching techniques with different light activation sources. Int Endod J 2007;40:204–8. 7. Ari H, Ung€ or M. In vitro comparison of different types of sodium perborate used for intracoronal bleaching of discoloured teeth. Int Endod J 2002;35:433–6. 8. Steiner DR, West JD. A method to determine the location and shape of an intracoronal bleach barrier. J Endod 1994;20:304–6. 9. Holmstrup G, Palm AM, Lambjerg-Hansen H. Bleaching of discoloured root-filled teeth. Endod Dent Traumatol 1988;4:197–201. 10. Zimmerli B, Jeger F, Lussi A. Bleaching of nonvital teeth. A clinically relevant literature review. Schweiz Monatsschr Zahnmed 2010;120:306–20. 11. Deliperi S. Clinical evaluation of nonvital tooth whitening and composite resin restorations: five-year results. Eur J Esthet Dent 2008;3:148–59. 12. Dietschi D. Nonvital bleaching: general considerations and report of two failure cases. Eur J Esthet Dent 2006;1:52–61.
Evaluation of patient satisfaction after nonvital bleaching in traumatized discolored intact anterior teeth Saurabh K. Gupta, Payal Saxena Department of Conservative Dentistry and Endodontics, Government College of Dentistry, Indore, India
Key words: clinical effectiveness; traumatized discolored anterior tooth; intracoronal; non-vital bleach; patient satisfaction Correspondence to: Payal Saxena, Department of Conservative Dentistry and Endodontics, Government College of Dentistry, Sardar Patel Marg (opp. M.Y. Hospital), Indore, Madhya Pradesh 452001, India Tel.: +91 9302793700 Fax: + 91 731 2701608 e-mail: [email protected] Accepted 26 January, 2014
Abstract – Aim: This study evaluated patient satisfaction and clinical effectiveness of intracoronal bleach in traumatized anterior discolored intact teeth. Assessment of awareness and knowledge of the patient regarding treatment modalities for such cases was also performed. Material and method: Forty-one patients were included in the study. Walking bleach was performed using sodium perborate (tetrahydrate) after root canal treatment and proper cervical seal. Patient was recalled after 1 week for evaluation. The bleaching procedure was repeated again till the patient agreed for it. On each recall visit, shade evaluation was performed using the Vita Classic shade guide. On completion of treatment, the patients were questioned as to their satisfaction level. Statistical analysis was carried out using ANOVA. Results: 87.8% of the subjects were highly satisfied with the results obtained; 7.32% were satisfied, while 4.9% were not satisfied. Average number of appointments needed for highly satisfied group was 2.75, and average shade change obtained was 11.97. Significantly more number of appointments were needed for the older patients (P < 0.01) or patients with older trauma (P < 0.05)/discoloration (P < 0.05). Severity of discoloration did not affect the number of appointments (P > 0.05). Most of the participants (97.6%) were not aware of bleaching procedure. The aspect of this treatment, which satisfied them the most, was improvement of the tooth coloration followed by conservation of tooth structure while the most perplexing thing was the unpredictability of final shade achieved and lack of color stability. Conclusions: High level of patient satisfaction after non-vital tooth bleach treatment strongly supports this treatment modality to be a conservative treatment alternative for traumatized discolored anterior tooth.
There has been always a desire in us to get our teeth as white as possible. As we proceed in the future, this urge is constantly getting stronger as our society is getting more esthetic conscious. Aspiration to having whiter and brighter teeth has been an esthetic treatment most desired by participants in various studies (1, 2) dealing with their dental appearance and treatment. Tooth color is a critical factor influencing satisfaction with smile appearance, and single-tooth discoloration resulting from trauma is more so (2, 3). Single-tooth discoloration sets a sense of inferiority and embarrassment as single dark tooth stands out and, being distinguished easily, attracts the attention of the observer when compared to a smile with generalized darkening of teeth in which the attention is more toward other facial features (4). Although there have been many in vitro studies (5–7) investigating the effectiveness of intracoronal bleaching in anterior discolored teeth clinical studies are very few in number and data regarding patient satisfaction after the treatment are lacking. Therefore, this 396
study was undertaken to assess the patient satisfaction and clinical effectiveness with regards to intracoronal bleaching. This study also evaluated the general awareness and knowledge about the treatment modalities for traumatized discolored intact anterior tooth. Materials and method
Forty-one patients (22 males; 19 females) who visited our department seeking treatment of their traumatized discolored anterior tooth and met the inclusion criteria for this study were selected. Inclusion criteria consisted of non-vital anterior, discolored (but not due to caries) and periodontally sound tooth. Exclusion criteria included carious, previously root canal treated, periodontally compromised, fractured and grossly malformed tooth. Root canal treatment was carried out by either of the authors after patients’ consent following standard guidelines. Briefly, after rubber dam application, endodontic access was gained with an endodontic explorer © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Patient satisfaction after non-vital bleach (DG-16, Dentsply instruments, Surrey, UK). The working length was determined radiographically and confirmed with an apex locator (Propex II; Dentsply international, Surrey, UK). The root canals were cleaned and shaped using rotary Protaper files (Dentsply international) and were copiously irrigated with 2.5% sodium hypochlorite solution. Calcium hydroxide/distilled water paste was then placed as an intracanal medicament, if required. The root canals were obturated with corresponding Protaper gutta-percha and AH Plus sealer (Dentsply De Trey, Germany). A questionnaire assessing their personal history, history of discoloration/trauma and knowledge about the treatment was filled. Explanation about the bleaching procedure, indications, risks and benefits was presented, and a written consent with authorization was obtained from the patients. Before bleaching appointment, pretreatment shade evaluation was carried out and photographs were taken. Scaling and root planning was performed, and oral hygiene measures were rendered. Bleaching procedure
Walking bleach technique was used in this study following proper guidelines. After root canal treatment of the concerned tooth, the root filling material was reduced 1–2 mm below cervico–enamel junction and a cervical seal of 2 mm thickness was placed with glass ionomer cement keeping its shape as a ‘bobsled tunnel’ from the facial and as a ‘ski slope’ from the proximal (8). This was controlled using periodontal probe. Then sodium perborate (tetrahydrate) mixed with distilled water in a ratio of 2:1 (g ml 1) (9) was placed in the cavity with amalgam carrier, and a sound seal of 2 mm thickness was provided with resin composite using selfetch bonding technique. Patient was recalled after 1 week for evaluation. The bleaching procedure was repeated again. This was carried out till the patient agreed for it or till a shade lighter than the contralateral tooth was achieved to compensate for the posttreatment relapse up to a maximum of five times. If the patient insisted earlier termination of the treatment, the cause of withdrawal was noted. When the shade was lightened sufficiently, the access cavity was cleaned thoroughly and sealed with composite resin. Evaluation of shade change and patient satisfaction
On each recall visit, shade evaluation was performed using the Vita Classic shade guide (Vita Zahnfabrik).
397
One operator (GS) evaluated the outcome on all the patients and took the photographs using the same operatory, lightening, camera and technique. Numbers were assigned to each shade tab such that no. 1 was the lightest and no. 16 was the darkest. The teeth having darker shade than available in shade guide were designated as no. 17 in common (as in Fig. 2a). This shade was compared with the pretreatment shade, and shade change after each appointment was noted in units. On completion of treatment, the patients were questioned as to their satisfaction level. On the basis of Visual Analog Scale (VAS), satisfaction level was taken as 0–10. Scoring criteria were selected as 10 being highly satisfied (HS), 8–9 satisfied (S), 6–7 partially satisfied (PS) and ≤5 as not satisfied. Results
The analysis of patient satisfaction score showed that 87.8% (36/41) of them were highly satisfied with the results obtained; 7.32% (3/41) were satisfied, while 4.9% (2/41) were not satisfied. For highly satisfied group, the average number of appointments needed were 2.75, and average shade change obtained was 11.97 (i.e. a shade change of 4.97 per appointment was achieved) (Table 1). Result from highly satisfied group attained after one, two and three appointments, respectively, is presented in Fig. 1. Figure 2 shows a case of discoloration due to trauma since last 25 years. After four appointments, patient scored satisfaction level as 10. Average shade change attained for all the satisfied patients (HS+S) was 12.0. Although in most cases, treated tooth closely matched the shade of contralateral tooth, shade discrepancy of 0.25 (average) was found in highly satisfied group and was 2.34 in satisfied group as observed by the authors (Table 1). The two patients, who were not satisfied and discontinued the treatment, cited multiple appointments as the prime factor for their dissatisfaction. All the satisfied patients (HS+S) were grouped on the basis of number of appointments needed to bring their satisfaction. The results showed that significantly more number of appointments were needed for the older patients (P < 0.01; CD = 4.35), older trauma (P < 0.05; CD = 4.39)/discoloration (P < 0.05; CD = 2.93). Interestingly, the number of appointments required were not influenced by severity of discoloration as average shade change in single appointment was 11.34 and in four appointments was 12.5 (P > 0.05; CD = 1.12) (Table 2; Fig. 3).
Table 1. Evaluation of average shade change in different treatment groups on basis of satisfaction level achieved Satisfaction level
No. of patients % (n)
Average number of appointments needed
Average shade change
Average shade change/appointment
Highly satisfied Satisfied Partially satisfied Not Satisfied Total
87.80 7.32 0 4.9 100
2.75 3.67 – 1.5 2.76
11.97 12.34 – 7 11.76
4.97 3.45 – 5 4.86
(36) (3) (0) (2) (41)
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Difference from contralateral tooth shade after treatment 0.25 2.34 – 6.0 0.68
398
Gupta & Saxena
(a)
(c)
(e)
(b)
(d)
(f)
Fig. 1. Walking bleach in traumatized discolored tooth of three highly satisfied patients (a, c, e) preoperative conditions; (b, d, f) two weeks after 1, 2 and 3 appointments, respectively.
(a)
(c)
(b)
(d)
Fig. 2. Four appointment walking bleach, (a) preoperative condition, (b) after two appointments, (c) after three appointments, (d) two weeks after four appointments.
Table 2. Relationship between number of appointment required and patient’s age, year of discoloration/trauma and severity of discoloration No. of appointments 1 2 3 4 Mean P value CD
Total number of satisfied (HS+S) patients 4 12 15 10
Age (average in years)
Years of trauma (average in years)
Years of discoloration (average in years)
Average shade change
22.67 23.18 30.2 39.5 30.28 0.0004 4.35
6.0 5.36 9.2 17.8 10.08 0.0190 4.39
0.87 2.0 4.84 9.4 4.90 0.0421 2.93
11.34 11.45 13.13 12.5 12.0 NS 1.12
Most of the participants (97.6%) in our study were neither aware of the fact that their single discolored tooth could be bleached, nor of the veneer placement procedures (95.12%), which shows the lack of awareness among the general public. The most common treatment option they knew was placement of crown after reducing their teeth (78.1%) or extraction followed by replacement (48.8%).
The aspect of this treatment, which satisfied them the most, was improvement of the tooth coloration (48.8%) followed by conservation of tooth structure (43.9%) and procedure being performed while doing routine work (7.5%). The most perplexing thing about bleaching was the unpredictability of the final shade achieved (61%); this was followed by lack of color stability (39%). © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Patient satisfaction after non-vital bleach
Fig. 3. Relationship of number of appointments for non-vital tooth bleach with different parameters.
Discussion
The most common reason for single-tooth discoloration has been traumatic injuries to tooth, which is the case here also as most of the participants gave a history of trauma in relation to the discolored tooth. It was found that the tooth with recent history of trauma and teeth of young patients were more responsive to intracoronal bleaching procedure. It was also seen that the number of appointments required for obtaining a desirable shade was lesser in such participants. On the contrary, participants with old trauma history or older age group required more appointments, and the final shade obtained was compromised. These participants were then again given the option of extracoronal bleaching/veneer placement, which most of them refused as they were satisfied with the results obtained. The bleaching of non-vital teeth is a relatively lowrisk intervention to successfully improve the esthetics of endodontically treated teeth (10). This study attained an average shade change of 12.0 for all satisfied patients. The results showed that number of appointments for achieving satisfactory results were not dependent on severity of discoloration. The initiation of discoloration could not be accurately ascertained in our study as it is subjective to various factors, and there was a variable duration between its initiation and recognition. It is also a point of interest that, upon completion, some patients were satisfied even after having a shade difference with the contralateral tooth. The probable explanation for this can be that most of them were unaware of this treatment procedure and had come to the college with the intent of getting their tooth structure sacrificed for crown placement. The striking noticeable change in the color produced by bleaching their discolored tooth without sacrificing their tooth structure may be one of the important reasons for accepting this
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
399
discrepancy. This was particularly apparent in cases that had much darker shades than that present in the Vita Shade Guide and were designated by giving them number 17 (Fig. 2a). Additional to this, before the commencement of this procedure, the authors had informed them the limitations of the procedure clearly stating that final color cannot be predicted beforehand and the results could be less than satisfactory, which would have led them to accepting this discrepancy in shade. Whenever non-vital tooth bleaching is performed, there is always a concern that relapse occurs and tooth discoloration returns (11). This was one of the factor perplexing to the patients as been told beforehand. Presently, no ideal protocol can be proposed to overcome tooth relapse of non-vital bleaching (12). All the patients were instructed to attend regular recall visits for further evaluation. This study also highlights unawareness of the general public regarding treatment options for traumatized discolored intact anterior tooth. High level of patient satisfaction after non-vital tooth bleach treatment strongly supports this treatment modality to be a conservative treatment alternative for discolored anterior tooth. References 1. Qualtrough AJ, Burke FJ. A look at dental esthetics. Quintessence Int 1994;25:7–14. 2. Samorodnitzky-Naveh GR, Geiger SB, Levin L. Patients’ satisfaction with dental esthetics. J Am Dent Assoc 2007;138:805–8. 3. Akarslan ZZ, Sadik B, Erten H, Karabulut E. Dental esthetic satisfaction, received and desired dental treatments for improvement of esthetics. Indian J Dent Res 2009;20:195– 200. 4. Kershaw S, Newton JT, Williams DM. The influence of tooth colour on the perceptions of personal characteristics among female dental patients: comparisons of unmodified, decayed and “whitened” teeth. Br Dent J 2008;204:E9; 256–257. 5. Dietschi D, Rossier S, Krejci I. In vitro colorimetric evaluation of the efficacy of various bleaching methods and products. Quintessence Int 2006;37:515–26. 6. Carrasco LD, Guerisoli DMZ, Rocha MJA, Pecora JD, Fr€ oner IC. Efficacy of intracoronal bleaching techniques with different light activation sources. Int Endod J 2007;40:204–8. 7. Ari H, Ung€ or M. In vitro comparison of different types of sodium perborate used for intracoronal bleaching of discoloured teeth. Int Endod J 2002;35:433–6. 8. Steiner DR, West JD. A method to determine the location and shape of an intracoronal bleach barrier. J Endod 1994;20:304–6. 9. Holmstrup G, Palm AM, Lambjerg-Hansen H. Bleaching of discoloured root-filled teeth. Endod Dent Traumatol 1988;4:197–201. 10. Zimmerli B, Jeger F, Lussi A. Bleaching of nonvital teeth. A clinically relevant literature review. Schweiz Monatsschr Zahnmed 2010;120:306–20. 11. Deliperi S. Clinical evaluation of nonvital tooth whitening and composite resin restorations: five-year results. Eur J Esthet Dent 2008;3:148–59. 12. Dietschi D. Nonvital bleaching: general considerations and report of two failure cases. Eur J Esthet Dent 2006;1:52–61.
