Internal bleaching versus crowns: Conservative for the win

Do you recall the video about the bleaching versus restorative option given to a young patient with a history of trauma on teeth nos. 9–11 that subsequently led to darkening of the adjacent teeth and the need for endo on no. 10? The patient was given these options:

• Endo on nos. 9–11 with internal bleaching
• Endo on no. 10 (initial reason for consultation with the endodontist) and crowns on nos. 9–11 (with possible endo needed later)

The approaches to this case are multifold, but the overall theme can be summed up into a generalized, singular, conservative approach.

First, it’s internal bleaching for the win, because once you take a bur to a tooth, you can’t go back. The patient is young, and if the bleaching doesn’t work, then veneers are the next best thing...followed by full-coverage crowns.

Most of you would complete endo on no. 10 and monitor the vitality of nos. 9 and 11, which, as we can likely surmise, will need endodontic treatment at some point due to the initiation of darkening upon presentation. Until then, external bleaching may keep things at bay, assuming the patient is agreeable to this approach. Internal bleaching can then be initiated on all three teeth, but the patient may or may not be satisfied with this since it would need to occur on the left half of the midline. Veneers may then do the trick, but cosmetic matchup with nos. 6–8 could be tricky.

Many make a good point when they say that crowns really are the better option since endo is done on the tooth and standard of care dictates this. Others argue that keeping as much tooth as possible—since these teeth are essentially virgin—is the most pragmatic way to go.

Here’s what we must keep in mind: there is no one-size-fits-all answer. Variables include symptoms, patient perspective, input, financial resources, home-care habits, etc. If you start out conservatively, having a fallback option is not a bad thing to consider; however, there are cons in that it is more expensive cumulatively should you need to keep “falling back” on those options.

Having an honest, forthright discussion with the patient will drive the ultimate decision. We can do a lot of things to teeth in our profession, but the question that is so often forgotten is: What does the patient want? It seems simple, but how many times do we have patients come to us because the “other dentist down the street didn’t listen”?

Hearing different options, weighing it all out, and being fluid in the decision-making process will get us far and keep our patients happy. I’ll take that—all day, any day!

Cheers, my friends! Dr. Stacey

Editor’s note: This article first appeared in Through the Loupes newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe to Through the Loupes.

Stacey L. Gividen, DDS, a graduate of Marquette University School of Dentistry, is in private practice in Hamilton, Montana. She is a guest lecturer at the University of Montana in the anatomy and physiology department. Dr. Gividen is the editorial codirector of Through the Loupes and a contributing author for DentistryIQ, Perio-Implant Advisory, and Dental Economics. She serves on the Dental Economics editorial advisory board. You may contact her at [email protected].