Endodontics · patient case question
Tooth #8 has now been root treated. What is the MOST CONSERVATIVE way to improve its appearance?
Patient case: The Betel Quid Chewer
Patient: 44-year-old male
Chief Complaint: “One of my front teeth is much darker than the others.”
Background: Emigrated from South Asia. Chews betel quid daily for over twenty years. History of trauma to the upper front teeth in his twenties.
Medications: None
Vital Signs: BP 130/82 mmHg · HR 76 bpm · RR 16 · T 98.4°F
Findings: Generalized reddish-brown extrinsic staining of the dentition and mucosa. Gingival recession. Tooth #8 is uniformly grey-brown from within — clearly different in character from the surface staining — and did not respond to pulp testing. Root canal treatment on #8 has just been completed. The crown is otherwise intact with no caries and no restoration.
Show answer and explanation
Correct answer: D. Internal (non-vital, walking) bleaching
- A. External bleaching acts on the outer enamel and will lighten the ADJACENT teeth as much as or more than the affected one — the discrepancy can actually widen. It also does nothing for staining that originates within the dentine.
- B. A veneer requires irreversible facial enamel reduction and may still show the dark substrate through the porcelain without an opaquer. It is a reasonable fallback if bleaching fails.
- C. A crown removes the most tooth structure of any option and is not justified for a discoloured but otherwise INTACT crown. Reserve it for teeth that have lost substantial structure.
- D. CORRECT. This is intrinsic discoloration from pulpal haemorrhage products within the dentine of a SINGLE non-vital tooth. INTERNAL BLEACHING places the bleaching agent (sodium perborate with water, or carbamide peroxide) inside the pulp chamber, sealed under a temporary, and is refreshed every few days until the shade matches. It removes no tooth structure at all, which makes it the most conservative option by a wide margin. Success rates for traumatically discoloured non-vital teeth are high.
Note: Before internal bleaching, place a barrier — 2 mm of glass ionomer or RMGI over the gutta-percha at a level 1 mm apical to the CEJ. This is the single step that prevents external cervical resorption.