BLEACHING WALKING

Hi Peter,
Here are the recommended steps for most intracoronal bleaching cases. These
can be modified for each individual case. Cheers. Ilan

GENERAL:
The walking bleach technique should be used in all situations requiring
internal bleaching. Not only is walking bleach effective, it also is the
safest and requires the least chair time.

STEPS IN BLEACHING:
1. Familiarize the patient with the probable causes of the discoloration,
the procedure to be followed, the expected outcome, and the
possibility of future rediscoloration. Patient's expectations should not be
raised to such a degree that disappointment may result.
Effective communication between the dentist and patient before,
during, and after treatment will avoid misunderstanding.

2. Record the shade of the discolored tooth with a shade guide and take
pictures. From this point the progress of the bleach can be followed.
Memory of both the patient and dentist is often unreliable.

3. Take Radiographs to assess the status of the periapical tissues and the
quality of root canal treatment. Treatment failure or questionable
obturation require retreatment prior to bleaching.

4. The quality and shade of any restoration present are assessed; if
defective, the restoration must be replace. Frequently, tooth
discoloration results from leaking or discolored restorations.

5. Isolate the tooth with a rubber dam. Interproximal wedges may also be
used for better isolation. If Superoxol is used (not
recommended for most cases!!!), protective cream (such as petroleum jelly,
Orabase or cocoa butter) must be applied to the gingival tissues prior to
dam placement.

6. Remove the restorative material from the access cavity. Refinement of
access and removal of all old obturating materials from the chamber
comprised a most important stage in the bleaching process. Pulp horns or
other "hidden" areas should be properly exposed and cleaned.

7. All materials should be removed to a level just below the gingvial
margin. Appropriate solvents are used to dissolve remnants of the
common sealers.

8. A sufficient layer of cement base (such as polycarboxylate, zinc
phosphate, glass ionomer or cavit at least 2 mm thick) is applied on the
root canal obturating material. This is essential to minimize leakage of
bleaching agents. The height of the base over the obturating material
should protect the dentin tubules and conform with the outline of the
external epithelial attachment.

9. It has been suggested that acid etching of dentin internally by
placement of phosphoric (or other) acid in the chamber to remove smear
layer and open the tubules will allow better penetration of the
oxidizer. It seems that this procedure is not very effective. The use of
any caustic chemical in the chamber is unwarranted, because periodontal
ligament irritation may result.

10. The walking bleach paste is prepared by mixing sodium perborate powder
and an inert liquid such as water, saline, or anesthetic solution to a
consistency of wet sand (approx. ratio: 2 g/ml). With a plastic instrument,
the pulp chamber is packed with the paste. Although sodium perborate mixed
with 30% hydrogen peroxide will bleach faster, in most cases the long-term
results are similar to those of sodium perborate mixed with water, and
therefore the former mixture should not be used routinely.

11. Excess of paste is removed from undercuts in the pulp horns and
gingival area. A cotton pellet is not used but a thick mix of zinc
oxide-eugenol (preferably IRM) is applied directly against the paste and
into the undercuts. The temporary filling is packed carefully to a
thickness of at least 3 mm to ensure a good seal.

12. The rubber dam is removed. The patient is informed that the bleaching
agent works slowly and that significant lightening may not be
evident for 2 or more weeks. It is common to see no change
initially, but dramatic results occur in successive days or after
a future appiontment and reapplication.

13. The patient is rescheduled approximately 3-4 weeks later and the
procedure is repeated if necessary.

14. If at any future appointment (third or fourth) progressive lightening
is not evident, further walking bleach treatments with a sodium perborate
and water solution may not prove beneficial. In such cases, additional
procedures may be attempted: (1) A thin layer of stained facial dentin is
removed with a small round bar. (2) The walking bleach paste is
strengthened by mixing the sodium perborate with increasing concentrations
of hydrogen peroxide (3 to 30%) instead of water. The more potent oxidizer
may enhance the bleaching effect. This stronger combination is not used
routinely because of the possibility that the more caustic agents may
permeat the tubules and damage the cervical periodontium, leading to
possible root resorption.

Prof. Ilan Rotstein

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You can be as relaxed as you wish.