GAP Australasian-Dentist Issue 80 Jul-Aug 19

Category AustrÀlÀsiÀn Dentist 59 n aÀ Box 1 Indications for bleaching in under-18- year-old patients 12 Indications for bleaching in under 18-year-old patients: u À Severe and moderate discolouration u À Enamel conditions u À White lesions, white markings and white flecks u À Brown, orange and yellow staining u À Coronal defects u À Molar incisor hypomineralisation (MIH) u À Hereditary factors u À Traumatised/non-vital discoloured anterior tooth/teeth u À Systemic diseases with dental effects (diseases of the liver, kidneys or haemorrhagic diseases) associated or resulting mental health conditions such as depression and suicide. 33 Furthermore underlying enamel quality or quantity defects commonly associated with the discolouration also renders the classification of disease appropriate Àt is essential that all treatment options are provided to the patient and parents seeking dental bleaching, including the Fig. 5 a) Labial view of white spot lesions present on both maxillary central incisors pre-treatment. Fig. 5 b) Labial view of the maxillary incisors following bleaching and use of resin infiltration Fig. 6 Labial view of the dentition in a patient with MIH option of no treatment. All risks and benefits associated with bleaching must also be discussed before commencing treatment and consent appropriately obtained. Àt should be expressed that further restorative treatment may be required post bleaching, for example microabrasion, resin infiltration and composite bonding where large enamel surface defects exist. 12, 34 Various factors relevant to the patient’s discolourations must be considered when determining the need and urgency for bleaching in the under-18 patients. Àome of these are listed in Box 2. Detailed history taking, initial examinations and appropriate radiographs are essential for accurate diagnosis, treatment planning and identification of risk factors and oral pathology. Àt is essential to identify any restorations in the aesthetic zone and explain to the patient that post bleaching these may no longer be a matching shade and thus are likely to require replacement. 35 Furthermore, discolouration, particularly intrinsic stains, may not simply be an aesthetic problem and bleaching may not be the appropriate or the best choice for treatment. 14 Àhis will be discussed later in the article. Bleaching treatment for the adolescent patient and patient groups is listed in Box 1. Severe and moderate discolouration As discussed previously, the psychosocial effects of discolourations can be extreme. Àevere discolouration can result from numerous aetiologies, including but not limited to: u Fluorosis (Figs 1, 2 and 3) u Discoloration caused by antibiotics or resulting from a child’s complex medical history (Fig. 4). Fluorosis can be effectively bleached, as shown in Figures 1, 2 and 3. Bleaching is most effective in class 1 to 3 of the tooth surface index of fluorosis and as such alternative treatment may be required for patients with severe flurorosis. 36 Àevere discolouration may require prolonged bleaching. 14 Àhis can be seen in Figures 1a and 1b, whereby after three weeks of bleaching treatment, the brown discolouration had reduced, however, had not completely resolved. Bleaching treatment was prolonged for an additional seven weeks and this eventually resulted in complete resolution of the brown discolouration (Fig. 1c). Àhe patient was delighted with the final result, despite the presence of the white lesions and as such chose no further treatment. Enamel conditions A range of enamel conditions result in discolouration and can be effectively treated with bleaching. Àhese include but are not limited to: u Amelogenesis imperfecta (see heredi- tary section) u Post traumatic opacities u Àdiopathic opacities u Chronological hypomineralisation u White markings or puffs on the lines of enamel maturation White lesions White spot lesions have numerous aetiologies. 37 Àome markings are chronologic in nature and appear as white lines that follow deposition of enamel such as amoxicillin or high temperature defects 38 which are shown in Figure 4. Bleaching treatment whitens the surrounding or background enamel of the white lesion, which reduces the contrast of the defect as demonstrated in Figure 5b. Àt has also been suggested that elevation of salivary Ph and flow rates following carbamide peroxide application 39 may alter the refractive index of the white spot by promoting remineralisation, however, further research is required.