|Year : 2022 | Volume
| Issue : 2 | Page : 125-133
Prompt response to resin infiltration with or without bleaching in the treatment of teeth pigmentation and teeth discoloration
Nada Ahmad Alamoudi
Demonstrator in Restorative Department, King Khalid University, Abha, Saudi Arabia
|Date of Submission||12-Dec-2021|
|Date of Decision||13-Apr-2022|
|Date of Acceptance||17-Apr-2022|
|Date of Web Publication||27-Dec-2022|
Dr. Nada Ahmad Alamoudi
Demonstrator in Restorative Department, King Khalid University, Abha
Source of Support: None, Conflict of Interest: None
Discoloration and pigmentation of teeth are two common esthetic issues in dentistry that prompt patients to seek treatment as soon as possible. Overall, the etiology of discoloration and pigmentation is multifactorial, with different treatment options showing long-term effects. Such treatment options have been evaluated and shown to reduce tooth pigmentation and discoloration; however, the long-term effects of resin infiltration with or without bleaching at a 1-year follow-up are not investigated. Therefore, we presented a case report of two cases that were successfully treated using resin infiltration with or without bleaching, and both of these cases responded well by the end of 2 weeks, with lasting effects at 1-year follow-up. For the case report, the care checklist was used. Two females with discoloration and pigmentation of teeth presented to the King Khalid University postgraduate dentistry clinic who wanted to get treated for these conditions. After taking their personal, dietary, medical, and family history, performing oral examination, and tooth analysis, treatment plans were made for both cases. The first case was a 54-year-old female who presented with mild-to-moderate fluorosis, and she was successfully treated mainly with bleaching plus resin infiltration with positive findings. A faint line and discoloration were present before treatment that got disappeared after the treatment, and the smile of the patient also got improved. There was also a significant difference found in the frontal view of the teeth before and after treatment. In contrast, the other case was a 20-year-old young girl who presented with the chief complaint of white teeth pigmentation after finishing orthodontic treatment. She was mainly treated with resin infiltration with positive effects of treatment with improvements in the smile and favorable changes in the frontal view of teeth, reduction in pigmentation, and improvement in oral hygiene. The response to the treatment in both the cases was rapid, and it appeared at the end of 2 weeks. The findings of these two case reports reveal the significance of the persistent favorable effects of resin infiltration with or without bleaching at the follow-up of 1 year. However, more randomized clinical trials are required to confirm these findings in many patients.
Keywords: Case report, resin infiltration, teeth pigmentation and discoloration
|How to cite this article:|
Alamoudi NA. Prompt response to resin infiltration with or without bleaching in the treatment of teeth pigmentation and teeth discoloration. King Khalid Univ J Health Sci 2022;7:125-33
|How to cite this URL:|
Alamoudi NA. Prompt response to resin infiltration with or without bleaching in the treatment of teeth pigmentation and teeth discoloration. King Khalid Univ J Health Sci [serial online] 2022 [cited 2023 Mar 21];7:125-33. Available from: https://www.kkujhs.org/text.asp?2022/7/2/125/365763
| Introduction|| |
One of the most important interactive communication skills is a human's smile, where human teeth play a role. Several people consider the appearance of teeth very seriously, and any discoloration due to either pigmentation or any other unknown reason becomes a reason for dental treatment. This is because teeth are of particular cosmetic importance, and tooth discoloration is considered an esthetic problem by many individuals. Several studies reveal that such concerns are prevalent in adolescents. Therefore, it becomes vital for dentists to understand the causes of discoloration and pigmentation of teeth and their timely treatment tailored to the needs of each case.
In general, the etiology of teeth discoloration is multifactorial, including intrinsic and extrinsic factors. Besides, surface stains can also contribute to such discoloration due to actual changes in teeth material., Extrinsic discoloration may be caused by agents causing enamel staining or some type of damage to the enamel., Further, cigarettes, cigars, and pipes can cause yellow-to-black discoloration, mainly on the lingual surfaces of teeth. On the other hand, intrinsic discoloration results from the deposition of substances within enamel and dentin, resulting from tetracycline stains, trauma to teeth due to hemoglobin breakdown (gray or blue-gray color), and dental materials that are utilized in restorative dentistry and medicine. Besides, one of the critical intrinsic factors is due to fluorosis that the patient had in this case.
There are various treatment options available for the discoloration and pigmentation of teeth. Examples of such treatment modalities include but are not limited to the removal of surface stains through bleaching treatment followed by micro- and macroabrasions, veneering, and porcelain crowns., Bleaching is the least invasive and most common esthetic treatment among adults., Besides, resin infiltration with or without bleaching also shows favorable effects in improving pigmentation and discoloration. Such treatment options have been evaluated and have been shown to reduce fluorosis and white-spot lesions. However, the existing literature does not show clear evidence of such treatment options regarding the persistent effect of treatment by the end of 1 year. Therefore, we presented details of two cases that were successfully treated with bleaching plus resin infiltration or only resin infiltration, and both of these cases responded well by the end of 2 weeks with persistent effects at 1-year follow-up.
| Case Report|| |
Two cases of gingival pigmentation and tooth discoloration were presented to the King Khalid University postgraduate dentistry clinic. Both patients expressed their desire to have their discoloration and pigmentation removed by saying, “I want to remove white pigmentation from my teeth” and “I want to remove discoloration from my teeth.” The following sections go over the specifics of both the cases. For the case report, the CARE checklist was used.
Case 1: Discoloration of teeth due to fluorosis
A 54-year-old married female of Saudi nationality, housewife by occupation belonging to middle socioeconomic status, presented with a chief complaint of teeth discoloration with a history of sensitivity for a long time, worsening progressively. The patients' habits include biting sunflower seeds, regular toothbrushing once per day, and no use of meswak or cigarettes.
The patient's medical history is not significant except for taking Roaccutane tablets of 20 mg, and her father is diabetic and hypertensive. Her dental history is positive for extraction with restoration and root canal treatment (RCT) of some teeth, as depicted in [Figure 1], without any complications that occurred in the previous treatment. With respect to oral hygiene, a plaque control record was found to be 92% and a gingival bleeding index of 83%. The dietary analysis demonstrates that the patient eats one to two meals per day mainly comprising carbohydrates and consumes one cup of tea on average with two spoons of sugar per cup. With the above examination, the patient is classified as a moderate-risk patient.
|Figure 1: Extraction of #18, 28, 38. 36, 38. Rstorations of #11, 21, 22, 26, 27, 37, 36 RCT of #17, 16, 15, 21, 26, 37, 35. 47. RCT: Root canal treatment|
Click here to view
Pretreatment photographs of the patient's smile and different angles of teeth were taken, as shown in [Figure 2], whereas tooth analysis is shown in [Figure 3], which reveals the square form of teeth as far as form and contour are concerned. Besides, width-to-length ratio was found to be normal, and an esthetically acceptable difference was found in the incisal length that did not exceed 0.4. However, interincisional angle was abnormal with irregular tooth arrangement but normal tooth axes. There were papilla present on teeth with uneven incisional edges and asymmetric gingival margins, as shown in [Figure 4].
Therapeutic intervention for the patient
Overall, the main objectives of the treatment were to control the disease process; educate and motivate the patient to maintain oral hygiene; and restore gingival health, esthetics, and function. The focus was on teeth number 13, 12, 11, 21, 22, and 23. The various treatment options include starting with the minimally invasive treatment, i.e., bleaching, and if the patient does not respond to this option, we go for resin infiltration. If a patient does not respond to resin infiltration, we choose microabrasion, and in case of no response, we go for macroabrasion; if not respond, we go for restoration. If a patient does not respond to restoration, we do veneering, and in case of no response to veneering, we finally choose crowning. Different recommendations were made for different teeth based on tooth analysis, as shown in [Table 1]. For example, the existing evidence from a randomized controlled trial suggests that resin infiltration alone can effectively mask mild-to-moderate dental fluorosis in young adults, whereas in-office bleaching with 25% H2O2 before resin infiltration provides significantly better masking effects. Further, power bleaching enhances the resin infiltration masking effect of dental fluorosis. Although dentists used power bleaching in this study, due to complaints of sensitivity and active caries in our case, we selected the option of home bleaching with successful treatment.
Different treatment phases include phase 1 of emergency/preventive treatment, phase 2 of operative treatment, phase 3 of endodontic treatment, phase 4 of preprosthodontic/surgical treatment, phase 5 of prosthodontic treatment, and phase 6 of recall and maintenance. After phase 1 treatment, the plaque control record was found to be 20%, and the gingival bleeding index was 22% on the reevaluation of oral hygiene. Phase 2 treatment included home teeth bleaching of tooth #13, 12, 11, 21, 22, 23, 24, 33, 32, 31, 41, 42, and 43. It is not essential to restore all active caries lesions before home bleaching, and some evidence suggests that the use of carbamide peroxide may retard the progression of caries. Only those caries lesions that are sensitive or near the pulp would need to be restored before bleaching and then possibly later resurfaced. In this case, the patient did home bleaching for 1 week, and we waited for 10 days because the oxidation process usually prevents polymerization of resin infiltration. After waiting for 10 days, we did resin infiltration with successful, persistent, and favorable results.
Follow-up and outcomes
Posttreatment findings showed positive changes, as illustrated in the images below [Figure 4]. Pre- and posttreatment records for some of the pictures are shown in [Figure 4]. The upper row shows pretreatment images of teeth, and the lower row shows the posttreatment images after 2 weeks of treatment. For example, there was a faint line and discoloration that disappeared after the treatment, and the patient's smile also improved. There was also a significant difference found in the frontal view of the teeth before and after treatment, as shown in the second image of [Figure 4]. These findings reveal the successful effect of therapy in reducing the discoloration of teeth.
[Figure 5] below shows that there was discoloration before bleaching (1st picture), which disappeared after 10 days of home bleaching. Still, the faint line persisted for some time (second picture) until we did resin infiltration after waiting for 10 days. The faint line was disappeared after 10 days, followed by restoration of caries and defects (third picture). This resulted in the disappearance of faint lines and discoloration and reconstruction of shape. Furthermore, these results persisted at the end of 1 year of follow-up, which is a unique finding in this case, as shown in the last picture of [Figure 5].
|Figure 5: Effect of home bleaching and resin infiltration persisted at the end of 1 year|
Click here to view
Case 2 presentation: White-spot lesions
A 20-year-old young unmarried female student of Saudi nationality and from a middle-class background presented with the chief complaints of teeth pigmentation. While presenting to the dentist, the patient stated, “I want to remove white pigmentation from my teeth.” The pigmentation appeared after she finished orthodontic treatment, and there was no history of sensitivity.
Habits and oral hygiene revealed regular toothbrushing, no smoking, and miswak history with nonsignificant family and medical history. The diet analysis showed that she takes two to three meals per day, mainly carbohydrates. She also consumes tea, coffee, soft drinks, and juice with two spoons of sugar on average. The patient is classified as at moderate risk for dental caries based on the dietary history.
Pretreatment photographs of tooth analysis revealed that the form and contour of the teeth were squared, and the proportion for width to length was within normal ratios of 84.1% for #11 and 81.8% for #21. Further, an esthetically acceptable difference was found in the incisal length, which did not exceed 0.4. However, interincisional angle was abnormal, and the incisional edge was irregular, but tooth axes and teeth arrangement were normal though crowded with irregular zeniths, as shown in [Figure 6].
Teeth included #15, 13, 12, 11, 21, 22, 23, and 25. Treatment options included resin infiltration, bleaching, microabrasion, restoration, porcelain laminate veneer, and full-coverage restoration. Treatment options vary based on the tooth analysis and radiographic findings, as shown in [Table 2]. For this case, we only used resin infiltration because the color of the teeth was fine.
Follow-up and outcomes
Since there was no discoloration and tooth color was accepted by the patient, we only treated her with resin infiltration. The results of resin infiltration appeared immediately. Resin infiltration has been found effective for dental pigmentation. After resin infiltration, there were positive effects of treatment with improvements in the smile and favorable changes in the frontal view of teeth, reduction in pigmentation, and improvement in oral hygiene. The evaluation was done after 2 weeks with positive effects of treatment. Both pre- and posttreatment images are shown in [Figure 7]. The upper row shows the pretreatment pictures, whereas the lower row shows the posttreatment pictures. The results of treatment persisted even at the end of a 1-year follow-up.
| Discussion|| |
The case report presents two cases, one with fluorosis and another with white-spot lesions that were successfully treated with bleaching plus resin infiltration or only resin without bleaching. Both of these cases responded well to the persistent favorable effects of the end of 1 year. The first case did home bleaching for 1 week, and we waited for 10 days before starting the resin infiltration. This way, we were able to achieve successful results. The first case responded in 17 days, whereas the second case responded immediately. These findings are unique, though consistent, with existing literature on the role of resin infiltration during fixed orthodontic therapy. For example, the penetration of the low-viscosity resin into porous enamel of caries is found in in vitro studies., In addition, color-masking property with resin infiltration is documented using artificial carries models., The underlying process by which resin infiltration works for the discoloration is the hydrochloric acid erosion of the affected surface and infiltration of resin into the intercrystalline spaces of demineralized or hypocalcified enamel either due to dental fluorosis or any other condition that leads to discoloration.
Our findings regarding the positive effect of resin infiltration in removing the white spots and fain line due to dental fluorosis are consistent with other studies conducted before. For instance, Paris et al. conducted an in vitro study and documented that resin infiltration is appropriate to mask artificial white-spot lesions. Similarly, Senestraro et al. in 2013 reported that resin infiltration has a great potential to address white-spot lesions. The authors found that resin infiltration treated white-spot lesions with long-lasting effects seen after 8 weeks of treatment. Another study by Yetkiner et al. found comparable findings by revealing an improvement in color and stability of white lesions after being treated with resin infiltration. Similarly, a systematic review on the effectiveness of resin infiltration documented that this type of treatment can be helpful to treat white enamel discoloration in esthetically compromised areas. However, given the low-quality evidence, the review's authors proposed conducting further RCTs with long-term follow-ups. These positive effects of resin infiltration are enhanced by power bleaching for dental conditions such as declaration and fluorosis. For instance, a randomized controlled trial revealed that bleaching with 25% hydrogen peroxide before resin infiltration provides substantial masking effects in case of discoloration caused by dental fluorosis. Similarly, a systematic review (n = 6 trials) by Di Giovanni et al. found that resin infiltration appears to be the most appealing treatment for dental fluorosis without severe side effects, followed by microabrasion and bleaching. The authors concluded that evidence from clinical trials in humans suggests that resin infiltration may be more effective for the esthetic treatment of mild-to-moderate stains caused by dental fluorosis than microabrasion and bleaching. Similarly, Gugnani et al. undertook a randomized controlled trial where patients in the intervention arm were exposed to resin infiltration with increased infiltration time along with bleaching (35% hydrogen peroxide). The authors found a positive effect on the esthetics and noticed an improvement in the stains or opacities due to fluorosis. The authors concluded that resin infiltration can help dentists to plan and manage nonpitted fluorosis in a microinvasive manner.
In general, the literature on long-lasting follow-up (e.g., 1 year) is limited and more studies are required. However, few studies provide evidence of resin infiltration's long-term effects and durability. For example, one study conducted in 2020 assessed the long-term effects (at 1 year) of resin infiltration in patients who presented with nonesthetic white spots due to dental fluorosis. The findings revealed resin infiltration's favorable and steady effect with improved and persistent patient satisfaction. In addition, the treatment showed a satisfying resolution of dental lesions and satisfying answers for the treatment viability. Another randomized controlled trial on 20 subjects demonstrated that resin infiltration among patients with white spots was found to be durable for about 6 months without any adverse events. The findings showed that resin infiltration improved the esthetic appearance of demineralized teeth, and the effects were persistent at 6 months of follow-up. Another study by Cazzolla et al. found similar results for the durability of resin infiltration in improving the white-spot lesions. Unlike other studies, the authors assessed the effect of resin infiltration for up to 4 years and found favorable effects of resin infiltration in improving the white spots at 4 years. The authors found persistent effects of resin infiltration at 3, 6, and 12 months and 4 years with positive clinical and esthetic results. The authors concluded that resin infiltration appears to fill the therapeutic gap between invasive and noninvasive treatments for white-spot lesions.
Despite the promising evidence from existing case reports about the beneficial effects of resin infiltration in improving the esthetic appearance, one needs to be mindful of the contraindications and disadvantages of the treatment protocol followed in this study. While there are no major contraindications or disadvantages of resin infiltration, as the evidence suggests resin infiltration to be safe without adverse events, one needs to be cognizant of a few steps before using resin infiltration. For instance, one of the disadvantages of resin infiltration is the requirement for surface conditioning (e.g., with 15% hydrochloric acid) because the hyperpigmented surface layer of natural initial caries hinders resin penetration into the demineralized lesion body.,, In addition, one needs to consider a few reasons that may affect treatment success. These may be due to incomplete resin polymerization and depth of lesions.,, Since the therapy works on the principle of infiltration, it requires a very dry field and moisture-free environment. One of the limitations of the treatment protocol in this study is the lack of a comparison group, as researchers did not compare the treatment protocol with any other treatment in this study. Furthermore, both the cases were adult females. Therefore, the findings may not generalize to other groups such as children or males.
| Conclusion|| |
According to the two cases reported in this case report, resin infiltration with or without bleaching may be helpful in treating teeth discoloration and pigmentation in a timely manner. However, because treatment varies from tooth to tooth, a thorough tooth analysis, including history and oral examination, is required before deciding on a course of action. While this case report suggests that resin infiltration has beneficial effects with long-term results after 1 year, more randomized controlled trials are needed to control for known and unknown confounders before making any definitive conclusions about such treatments.
While assessing the patient's respective, we found that both the patients were satisfied with the treatment as the treatment improved their smiles and removed the discoloration as well as faint lines. With the improved smile, participants' self-esteem improved.
Informed consent was obtained from the patients for her treatment, and both patients allowed us to publish this work in a scientific journal.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2]