title: Two-year clinical evaluation of nonvital tooth whitening and resin composite restorations.
abstract: BACKGROUND
  Adhesive systems, resin composites, and light curing systems underwent continuous improvement in the past decade. The number of patients asking for ultraconservative treatments is increasing; clinicians are starting to reevaluate the dogma of traditional restorative dentistry and look for alternative methods to build up severely destroyed teeth.
  
  
  OBJECTIVE
  The purpose of this study was to evaluate the efficacy of nonvital tooth whitening and the clinical performance of direct composite restorations used to reconstruct extensive restorations on endodontically bleached teeth.
  
  
  METHODS
  Twenty-one patients 18 years or older were included in this clinical trial, and 26 endodontically treated and bleached maxillary and mandibular teeth were restored using a microhybrid resin composite. Patients with severe internal (tetracycline stains) and external discoloration (fluorosis), smokers, and pregnant and nursing women were excluded from the study. Only patients with A3 or darker shades were included. Teeth having endodontic access opening only to be restored were excluded; conversely, teeth having a combination of endodontic access and Class III/IV cavities were included in the study. A Vita shade guide (Vita Zahnfabrik, Bad Säckingen, Germany) arranged by value order was used to record the shade for each patient. Temporary or existing restorations were removed, along with a 1 mm gutta-percha below the cementoenamel junction (CEJ), and a resin-modified glass ionomer barrier was placed at the CEJ. Bleaching treatment was performed using a combination of in-office (OpalescenceXtra, Ultradent Products, South Jordan, UT, USA) and at-home (Opalescence 10% PF, Ultradent Products) applications. Two weeks after completion of the bleaching, the teeth were restored using a combination of PQ1 adhesive system and Vit-l-escence microhybrid resin composite (Ultradent Products). Wedge-shaped increments were placed and cured using the VIP Light (Bisco, Inc Schaumburg, IL, USA) through a combination of pulse and progressive curing techniques.
  
  
  RESULTS
  All but one restoration were evaluated by two independent evaluators every 6 months during a 2-year period using modified US Public Health Service criteria. No restoration failed and "alpha" scores were recorded for all parameters but color stability, which was scored "bravo." Analysis of variance showed a significant shade change between baseline (mean=14.4+/-1.9) versus 2 weeks (mean=1.6+/-0.7) and 2 years (mean=2.8+/-1.7) (p<.0001). Although a significant shade change was observed between 2 weeks and the 2-year follow-up (p=.008), no significant difference was reported between the baseline and 2 weeks (12.9+/-2) versus baseline and 2 years (11.9+/-2.3).
  
  
  CONCLUSIONS
  Significant tooth lightening was reported after the completion of whitening therapy on devitalized teeth; shade rebound was reported in less than 50% of the treated teeth and was limited to a maximum of four shades. A microhybrid resin composite demonstrated excellent clinical performance in the restoration of all endodontically treated and bleached teeth after a 2-year evaluation period.
  
  
  CONCLUSIONS
  Nonvital tooth whitening is responsible for a significant change in color of endodontically stained teeth. Successful nonvital tooth-whitening therapy allows for conservative tooth preparation, preserving and reinforcing sound tooth structure. The proper use of modern adhesive systems along with resin composite restorations precludes the use of more extensive restorative treatment, delaying expensive crown and bridge procedures.
authors.affiliation: Tufts University School of Dental Medicine, Boston, MA, USA. simone.deliperi@tufts.edu
authors.forename: Simone
authors.initials: S
authors.lastname: Deliperi
authors.forename: David N
authors.initials: DN
authors.lastname: Bardwell
mesh_terms: D000077463:Carbamide Peroxide; D003116:Color; D003188:Composite Resins / Q000737:chemistry; D003737:Dental Cavity Preparation / Q000145:classification; D003743:Dental Enamel / Q000473:pathology; D003793:Dental Restoration, Permanent / Q000379:methods*; D003804:Dentin / Q000473:pathology; D017220:Dentin-Bonding Agents / Q000737:chemistry; D004338:Drug Combinations; D005500:Follow-Up Studies; D005899:Glass Ionomer Cements / Q000737:chemistry; D006801:Humans; D016877:Oxidants / Q000627:therapeutic use; D010545:Peroxides / Q000627:therapeutic use; D017797:Prosthesis Coloring; D019279:Resin Cements / Q000737:chemistry; D012390:Root Canal Therapy; D014073:Tooth Bleaching / Q000379:methods*; D014075:Tooth Discoloration / Q000628:therapy; D019553:Tooth, Nonvital / Q000628:therapy*; D014508:Urea / Q000031:analogs & derivatives / Q000627:therapeutic use
chemical_list: D003188:Composite Resins; D017220:Dentin-Bonding Agents; D004338:Drug Combinations; D005899:Glass Ionomer Cements; D016877:Oxidants; D010545:Peroxides; D019279:Resin Cements; D000077463:Carbamide Peroxide; D014508:Urea