Successful Bleaching of Teeth with Dentinogenesis

Imperfecta Discoloration: A Case Report jerd_379 3..10

AVINASH S. BIDRA BDS, MS*

FLAVIO URIBE, DDS, MS†

ABSTRACT
Dentinogenesis imperfecta (DI) is a hereditary condition that can cause discoloration of teeth in
addition to other dental abnormalities. Patients often present to the dentist with a main goal of
improving their esthetics. A myriad of treatment options have been described for this condition.
This clinical report describes the management of a young adult with DI who desired improve-
ment in dental esthetics after orthodontic treatment. As a result of his condition, the patient’s
dentition exhibited the classic generalized dark amber opalescence. A 14% hydrogen peroxide
gel was used for bleaching of the maxillary and mandibular teeth, performed by the patient at
home. The patient was followed at different intervals, and the improvement in teeth shade was
significant and remained stable at 3.5 years. No adverse effects were observed. This article is
the first case report in the literature describing the long-term follow-up of teeth bleaching in a
patient with DI.

CLINICAL SIGNIFICANCE
Teeth bleaching may be considered as the first choice of treatment in dentinogenesis imperfecta
patients. If successful, it offers a simple, conservative, and economical solution to satisfy the
esthetic requirements of these patients.
(J Esthet Restor Dent 23:3–11, 2011)

INTRODUCTION types for diagnostic purposes.3 authors have discussed the dental
Type I refers to affected teeth in management of this condition, and

D ental abnormalities related to

dentinogenesis imperfecta
(DI) have been extensively
patients who also have osteogen-
esis imperfecta. Type II refers to
affected teeth as an isolated dental
a gamut of options has been pro-
posed. These include carbamide
peroxide bleaching,9 complete
described in the literature.1–8 They trait, and Type III refers exclusively coverage crowns,10–12 veneers,13
include short bulbous crowns, to affected teeth of a racial isolate stainless steel crowns,14 overden-
short roots, obliterated pulp cham- in southern Maryland, and is tures,15,16 and dental extractions
bers, and a dark amber opales- known as the “Brandywine followed by fixed implant
cence of all teeth.3–8 The condition Isolate.” Patients with DI are often therapy.12 The broad range of
is hereditary and there is no cure. concerned about their appearance treatment options reported in the
DI has been classified into three and long-term dental care. Several literature probably suggests

*Assistant Professor and Maxillofacial Prosthodontist, Department of Prosthodontics,

University of Texas Health Science Center at San Antonio, TX, USA
†
Associate Professor and Program Director, Division of Orthodontics,
University of Connecticut School of Dental Medicine, Farmington, CT, USA

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that different levels of severity of foundation for progress in clinical health. Clinical and radiographic
DI exist among different patients. science, independent of basic sub- examination confirmed the other
Therefore, there is a need for clas- jects or epidemiological insights.17 findings related to the condition
sification of DI based on different The purpose of this case report is (Figure 2). Photographs were
degrees of severity to recommend to describe the successful use of taken and the patient’s diagnostic
treatment guidelines based on the 14% hydrogen peroxide for casts were mounted on a semi-
category of the condition. bleaching the teeth of a young adjustable articulator.
adult with DI.
Esthetic outcome is an important The patient’s anterior teeth posi-
barometer by which a patient tions and proportions were estheti-
measures success and satisfaction CASE REPORT cally acceptable. Therefore, it was
of dental therapy. Often, a conser- A 23-year-old white male was understood that treatment for this
vative treatment option may referred by his orthodontist patient would mainly be directed
satisfy the patient’s goal of requesting a prosthodontics consul- toward improvement of the shade
esthetic therapy. Therefore, it is tation to improve his dental esthet- of the teeth. The challenges of
important for a clinician to first ics. The patient had been restorative dentistry because of his
exhaust the conservative treatment undergoing orthodontic treatment DI condition were explained to the
options before proceeding to inva- for the past 3 years in combination patient; he was also educated
sive treatment. Bleaching is one with orthognathic surgery. He had about the importance of attempt-
such option that has been well been diagnosed with Type II DI ing conservative treatment mea-
documented in the literature. several years ago and was aware of sures prior to undertaking
However, there is only one case his condition (Figure 1). The comprehensive treatment. There-
report that has described the use patient desired improvement of his fore, it was decided to first attempt
of bleaching in a DI patient.9 The dental appearance, especially the bleaching therapy for his teeth.
authors of this article had used a color of his teeth. Clinical assess- The patient’s existing orthodontic
10% carbamide peroxide bleach- ment revealed that the severity of vacuum-formed retainers were
ing agent successfully, but the DI was mild to moderate but had trimmed along the scalloped
period of follow-up was only 6 an impact on the esthetic appear- outline of the cervical margins of
months. There are no clinical ance of the teeth. The shade of the the teeth. The patient was pre-
trials or other reports for bleach- maxillary anterior teeth was deter- scribed a 14% hydrogen peroxide
ing in DI patients. mined as 5M1 using a shade guide. bleaching agent (Perfecta REV,
(Vitapan 3D Master Shade Guide, Premier Dental, Plymouth Meeting,
Though the prominence of Vident, Brea, CA, USA). The man- PA, USA) for use 15 minutes twice
evidence-based medicine has grown dibular anterior teeth appeared daily. The patient was given
larger, case reports are still consid- much darker and had a polychro- written and verbal detailed instruc-
ered important as they have a high matic appearance with multiple tions about usage of this agent and
sensitivity for detecting novelty and white spots in the cervical region. informed of the potential sensitiv-
form the basis for detecting new Minimal wear was noted on the ity of his teeth. He was also
concepts, etiological clues, side occlusal surfaces of the teeth. The advised to clean excess gel immedi-
effects, and new treatments;17 fur- patient did not have any dental ately in order to prevent bleaching
thermore, case reports lay the caries and had sound periodontal and irritation of the gingiva.

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 BIDRA AND URIBE

A B

Figure 1. A. Pretreatment frontal image of the teeth in protrusion showing the grayish-amber-like discoloration. B.
Pretreatment close-up smile of the patient. C. Pretreatment full-face smile of the patient.

The patient was first seen after a

2-week interval and reported that
he had been performing the bleach-
ing regularly, as directed. Improve-
ment in the shade of the teeth was
noted, especially in the maxillary
region (Figure 3). The patient was
encouraged to continue the same
regimen and was seen again after 2
months. The shade of all teeth
showed significant improvement
compared to his baseline condition
Figure 2. Panoramic radiograph demonstrating classic
features of dentinogenesis imperfecta. The metal hardware
(Figure 4). However, the cervical
represents history of orthognathic surgery. region of the mandibular teeth

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A B

Figure 3. A. Two weeks after start of bleaching treatment: frontal image. B. Two weeks after start of bleaching treatment:
close-up smile.

A B

Figure 4. A. Two months after start of bleaching treatment: frontal image. B. Two months after start of bleaching
treatment: close up smile.

appeared to have improved lesser after bleaching. He was advised to patient was satisfied with the
than the maxillary teeth. The wipe off any excess bleaching gel improvement in the shade. He did
patient reported transient sensitiv- that extruded on the gingiva imme- not notice any further worsening
ity of all his teeth. The sensitivity diately after application; subse- of his adverse symptoms. At this
was described by the patient as quently, he was advised to use the stage, the patient was advised to
generalized and mild to moderate bleaching agent, once per day. discontinue the bleaching treatment
in nature and lasted for a short (Figure 5). Thereafter, the patient
period after each bleaching experi- The patient was seen again after was seen on annual recalls, since
ence. The patient also noted sensi- two more months and further initiation of treatment (Figure 6).
tivity of his mandibular gingiva improvement was noted. The At a 3.5-year follow-up, the shade

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 BIDRA AND URIBE

A B

Figure 5. A. Post-treatment frontal image (4 months after start of treatment). B. Post-treatment month: close-up smile (4
months after start of treatment).

A B

Figure 6. A. Twelve-month follow-up after completion of treatment: frontal image. B. Twelve-month follow-up after
completion of treatment: close-up smile.

remained stable (Figure 7). The any adverse reactions such as loss DISCUSSION

shade was recorded on the maxil- of surface morphology of the Shade of the teeth has been
lary anterior teeth as 1M1 enamel, chronic sensitivity of teeth regarded as the most important
(Vitapan 3D Master Shade Guide, and gingiva, or pulpal damage factor for patient’s perception of
Vita) (Figure 8). However, the cer- related to the bleaching therapy. dental attractiveness.18 This may be
vical region of the mandibular The patient was very satisfied with especially true for patients with a
teeth remained refractory since the the esthetic outcome of treatment condition like DI. Therefore, it is
4-month recall. The patient’s teeth and chose not to pursue any paramount that a dentist should
remained vital and did not have supplemental restorative treatment. first attempt conservative

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A B

Figure 7. A. Three-and-a-half-year follow-up: frontal image. B. Three-and-a-half-year follow-up: close up smile. C.

Three-and-a-half-year follow-up: full-face smile.

modalities (such as bleaching) to with posterior bonded-onlays, por- aggressive treatment option for a
attempt to ameliorate the teeth celain veneers, and fixed implant young adult. The success of
shade. This improvement may be therapy. Complete coverage crowns bleaching therapy in this patient
sufficient for many patients and in DI patients carry a risk of frac- precluded the need for these alter-
preclude them from undergoing ture due to the brittle nature of native modalities of treatment,
elaborative dental therapy. In our teeth;5,7,12 bonded restorations which could have resulted in enor-
patient, multiple treatment options including veneers are challenging mous expenses and have been
were considered as “definitive” to bond, and endodontic therapy time-consuming for the patient and
alternative solutions to satisfy the and crown-lengthening procedures the clinician.
patient’s esthetic needs. They are very difficult in these
included options such as full- patients.12,19 Finally, full-mouth Bleaching therapy has generally
mouth rehabilitation with complete extractions and fixed implant been dealt with increased skepti-
coverage crowns, anterior crowns therapy may be deemed as an cism due to lack of well-controlled

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 BIDRA AND URIBE

vative in using the agent in order

to prevent bleaching and irritation
of his mandibular gingiva by
excess material that could escape
when assisted by gravity. However,
as the patient’s smile does not
reveal this region, the issue was
less of a concern to the patient and
the clinician.

CONCLUSION

Figure 8. Shade taken at a 3.5-year follow-up shows shade Patients with DI condition present
1M1 on the shade guide (Vitapan 3D Master, Vita). with different degrees of severity.
Compare with pretreatment shade of 5M1 (Figure 1A).
There is a need for classification of
DI based on different degrees of
severity to recommend treatment
trials and high-quality scientific pulp chambers. It is also
guidelines based on the category of
data. Additionally, long-term data important to note that the toler-
the condition. This case report
has not been well reported in the ance level to hydrogen peroxide-
described the successful use of
literature.20 In spite of this fact, based bleaching gel is different
hydrogen peroxide bleaching in a
this was the first option of choice among individuals; therefore,
young adult with mild to moderate
used on this patient, as it was at-home use of 14% concentration
DI condition. The shade of the
deemed to be the most conserva- gel may not be necessarily appli-
teeth significantly improved and
tive of all the treatment options cable to other cases. A higher con-
was stable at 3.5 years. Future
available. Hydrogen peroxide was centration such as 35% was not
clinical trials are needed to investi-
used as a bleaching agent, as it used through an in-office proce-
gate the efficacy of hydrogen per-
has been well documented in the dure, as controversy exists about
oxide bleaching in DI patients.
literature.20 It was decided to use its effects on the surface of the
This simple, conservative, and eco-
this agent supplied as a 14% con- enamel after repeated usage.21,22
nomic treatment modality may tre-
centration gel, through a home-
mendously contribute to the
based protocol. The manufacturer Though the general shade of all
quality of life of these patients.
recommends the use of this agent teeth improved significantly, the
on a normal dentition for 15 cervical region of mandibular
minutes once daily in order to anterior teeth was the most refrac- DISCLOSURE AND

prevent any insult to the pulp. tory. A possible explanation for ACKNOWLEDGEMENTS

However, our patient was advised this could be that this region did The authors report no financial
to use it twice daily for 8 weeks, not experience the same amount of interests in any of the products
due to his DI condition and the exposure to the bleaching agent described in this article.
fact that penetration to the pulp compared to other areas of differ-
chamber was not considered to be ent teeth. This may have happened The authors thank Dr. Jonathan C.
an issue due to the obliterated as the patient was probably conser- Meiers DMD, MS and Dr. Sergio

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imperfecta discoloration: report of a case. 19. Pettiette MT, Wright JT, Trope M. Denti-
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