Influence of the internal anatomy on the leakage of root canals filled with thermoplastic technique.

OBJECTIVES: The aim of this paper is to evaluate the influence of the internal anatomy on the leakage of root canals filled with the thermoplastic technique. MATERIALS AND METHODS: The upper central incisors (UCI) and mesial roots of the lower molars (MRLM) (n = 12 each) were tested regarding leakage using the gas-enhanced permeation test (GEPT) after root filling. The quality of the root fillings was assessed using micro-computed tomography (µCT) by superimposing scans before and after treatment to calculate unfilled volume. The calculated void volume was compared between the groups and correlated to the measured leakage values. Data were analyzed using t test and Pearson's correlation tests (p < 0.05). RESULTS: The mean void volume did not differ between UCI and MRLM (13.7 ± 6.2% vs. 14.2 ± 6.8%, respectively). However, significantly more leakage was evident in the MRLM (p < 0.001). While the leakage correlated highly to the void volume in the MRLM group (R 2 = 0.981, p < 0.001), no correlation was found in UCI (R 2 = 0.467, p = 0.126). CONCLUSION: MRLM showed higher leakage values, which correlated to the void volume in the root canal fillings. CLINICAL RELEVANCE: Care should always be taken while doing root canal treatments, but attention to teeth with known/expected complex root canal anatomy should be considered.

Determining cutting efficiency of nickel-titanium coronal flaring instruments used in lateral action.

AIM: To develop a method to evaluate the cutting behaviour of nickel-titanium (NiTi) coronal flaring instruments. METHODOLOGY: BioRaCe BR0 (BR), HyFlex CM 1 (HY), ProFile OS No. 2 (PF) and ProTaper Sx (PT) instruments were used in simulated coronal flaring using a lateral action against bovine dentine blocks, at 250 and 500 rpm. Cutting efficiency was assessed by three methods: first, areas of notches produced by instruments were directly measured under a stereomicroscope. Second, dentine specimens were then analysed by surface profilometry to determine the maximum cutting depth and finally by microcomputed tomography to assess the volume of removed dentine. Data were compared using parametric tests with the significance level set at 0.05. RESULTS: For all three methods, HY and PF were the most and the least cutting-efficient instruments, respectively (P < 0.05). Significant differences were detected between 250 and 500 rpm for HY and PT (area); for BR, HY and PT (depth); and for BR and HY (volume). There were strong positive correlations between the results obtained with those three different methods with r-values ranging from 0.81 to 0.92. CONCLUSION: Measuring the amount of material removed in a specific time under stereomicroscopy is a simple and rational way to assess the cutting behaviour of NiTi rotary instruments in lateral action. HyFlex, manufactured with thermomechanically treated NiTi wire, was the most efficient instrument, and increased rotational speed was associated with increased cutting efficiency.

Impact of cross-sectional root canal shape on filled canal volume and remaining root filling material after retreatment.

AIM: To assess the impact of cross-sectional root canal shape (CSRCS) on the canal volume that can be filled and the root filling material that remains following a subsequent retreatment procedure. METHODOLOGY: A total of 15 extracted two-rooted human maxillary premolars and 15 mandibular first molars were used. Both root canals in the premolars (N = 30) and the distal root canal in the molars (N = 15) were prepared using ProFile instruments and filled by lateral compaction using gutta-percha and AH Plus sealer. Canals were later retreated using the last ProFile used for instrumentation followed by two ProFiles of increasing size. Teeth were viewed in a µCT scanner before and after each treatment step. Defined and validated threshold levels were used to differentiate empty root canal volumes, root dentine and root filling materials from each other. CSRCS was defined as the averaged ratio between bucco-lingual and mesio-distal canal diameter (round ≤ 1, oval 1-2, long oval 2-4 and flattened ≥ 4), determined for each 1 mm over the total root length. Data were averaged between the two canals in premolars, only the distal canals were assessed in molars. Parametric and non-parametric tests were used to statistically compare the data, alpha = 0.01. RESULTS: Canals in premolars had a round CSRCS after preparation (1.0 ± 0.0), whereas distal counterparts in molars were oval (1.6 ± 0.5). Significantly (P < 0.01) more canal volume could be filled, and significantly less filling material remained after retreatment in premolars compared with mandibular molar distal canals. There was a high correlation between CSRCS, filled canal volume and remaining filling material. CONCLUSIONS: The endodontic procedures under investigation were significantly influenced by the cross-sectional root canal shape.

Initial apical fit of K-files versus LightSpeed LSX instruments assessed by micro-computed tomography.

AIM: To compare the apical fit in two dimensions of the first K-file versus the first Lightspeed LSX instrument binding at working length after an initial crown-down preparation. METHODOLOGY: Twenty maxillary molars with fully developed roots and four separate root canals were selected. Canals were pre-flared with ProFile.04 taper instruments to three quarters of estimated working length. Working length was electronically determined using a size 06 K-file. Progressively larger K-files were inserted passively to working length. The first binding K-file was termed initial apical file (IAF). Then, the first binding LSX initial apical lightspeed-instrument (IAL) was determined. Teeth were scanned with and without instruments in place using micro-computed tomography. Cross-sections of the apical part of the root canals were analysed as follows: the largest and smallest diameters of the root canal and the diameter of the instrument were calculated and related to each other. Statistics were performed using Kruskal-Wallis test and Wilcoxon test. The alpha-type error was set at 0.05. RESULTS: Initial apical file sizes ranged from 8 to 30 and were lowest in second mesiobuccal and highest in palatal canals. IAL sizes ranged from size 20 to 40. The apical large canal diameter was assessed more accurately by the LSX instruments (P < 0.0001). However, the smallest available LSX instrument (i.e. size 20) did not reach working length in 39 of 80 canals. CONCLUSIONS: Instruments with a flat widened tip were found to determine apical cross-sectional diameter better than round, tapered instruments.

Hard-tissue debris accumulation created by conventional rotary versus self-adjusting file instrumentation in mesial root canal systems of mandibular molars.

AIM: To evaluate the accumulation of hard-tissue debris when using the Self-adjusting File (SAF) system in mesial roots of mandibular molars with isthmuses and to compare it with that occurring when the ProTaper file system was used. METHODOLOGY: Forty extracted human mandibular molars with joining mesial root canals and an isthmus between the two canals were randomly assigned to two experimental groups and scanned using micro-computed tomography. Root canals in the control group (N = 20) were instrumented using the ProTaper rotary system until F3. Irrigation with 1 mL of 3% NaOCl solution was applied after each instrument. Root canals in the experimental group (N = 20) were prepared using the SAF for 4 min, with continuous irrigation (3% NaOCl, 4 mL min(-1)). After rescanning, canals in both groups were further irrigated with 5 mL of 17% EDTA for 2 min. After final scanning, the per cent value of total canal system volume filled with hard-tissue debris was calculated. Statistical analysis was performed using Mann-Whitney U-test; the alpha-type error was set at 1%. RESULTS: Instrumentation of the root canals with ProTaper left 10.1% (IQR 5.2) of the total canal system volume filled with hard-tissue debris while preparation with the SAF left 1.7% (IQR 1.6). This difference was highly significant (P < 0.0001). After subsequent EDTA irrigation, these values were significantly reduced (P < 0.01) to 7.9% (IQR 4.1) and 1.3% (IQR 0.8) in the ProTaper and SAF groups, respectively. CONCLUSION: Preparation with the SAF system resulted in less hard-tissue debris accumulation in isthmus-containing root canal systems compared with instrumentation with ProTaper rotary files.

Accumulated hard tissue debris levels in mesial roots of mandibular molars after sequential irrigation steps.

AIM: To investigate the impact of sequential irrigation procedures on accumulated hard tissue debris (AHTD) levels in canal systems in mesial roots of human mandibular molars after instrumentation. METHODOLOGY: Based on pre-scans in a micro-computed tomography (µCT) system, 20 extracted human mandibular molars with joining mesial root canals and an isthmus between these were selected. Canals were instrumented using the ProTaper rotary system until the F3 instrument reached working length. A 1% NaOCl solution was applied during instrumentation, followed by a final 5-mL flush to working length. Subsequently, canals were irrigated with 5 mL of 17% EDTA. Thereafter, passive ultrasonic irrigation (PUI) was performed using 1% NaOCl on three occasions each for 20 s. Percent values of total canal system volume filled with AHTD were calculated based on high-resolution scans after each irrigation step. Data was compared using repeated measure anova followed by paired t-test for individual comparisons. Bonferroni's correction was applied for multiple testing; the alpha-type error was set at 1%. RESULTS: Instrumentation of the root canals in conjunction with 1% NaOCl irrigation left 6.9 ± 4.2 vol.% of the total canal system volume filled with AHTD. This value was significantly (P < 0.01) reduced to 4.9 ± 3.6 vol.% after EDTA irrigation. Subsequent PUI resulted in a further significant (P < 0.01) reduction to 3.7 ± 2.8 vol.%. CONCLUSIONS: In this quantitative study on AHTD reduction, a significant effect of EDTA and PUI was shown. However, approximately half of the debris that accumulated during instrumentation remained in the canal system.

Apical fit of initial K-files in maxillary molars assessed by micro-computed tomography.

AIM: To two- and three-dimensionally assess the fit of the first K-file binding at working length after a crown-down canal procedure. METHODOLOGY: Twelve maxillary molars with fully developed roots and four separate root canals were selected. Canals were pre-flared using ProFile 0.04 instruments to three quarters of estimated working length (WL). WL was electronically determined using an ISO 06 K-file. Progressively larger K-files were inserted passively to WL. The first binding file was termed initial apical file (IAF). On micro-computed tomography (microCT) scans, cross-sectional areas of IAFs and canals and the largest and smallest root canal diameters were measured 1 mm from instrument tips. Volumes of the apical 2 mm of the instruments and corresponding root canal sections were calculated, and file binding was assessed. RESULTS: IAF sizes ranged from ISO-size 0.08-0.30 and were lowest in second mesiobuccal and highest in palatal canals. Files bound in the apical 2 mm in 96% of the canals. The mean canal area filled by the instruments 1 mm from the tip was below 40% in all canal types, the filled volume below 50% (anova, P > 0.05). The mean ratio (+/-SD) between largest and smallest canal diameter was 3.0 +/- 2.6 for first mesiobuccal, 3.3 +/- 2.6 for second mesiobuccal, 4.1 +/- 3.5 for distobuccal and 1.6 +/- 0.4 for palatal canals, indicating oval to flattened cross-sections. CONCLUSIONS: Two- and three-dimensional analysis of microCT scans revealed that whilst IAFs bound in the apical area, their fit was poor, because their shape does not correspond to maxillary molar canal anatomy.

Fine-tuning of bioactive glass for root canal disinfection.

An ideal preparation of 45S5 bioactive glass suspensions/slurries for root canal disinfection should combine high pH induction with capacity for continuing release of alkaline species. The hypothesis of this study was that more material per volume of bioactive glass slurry is obtained with a micrometric material (< 5 microm particle size) or a micrometric/ nanometric hybrid, rather than a solely nanometric counterpart. This should correlate with alkaline capacity and antimicrobial effectiveness. Slurries at the plastic limit were prepared with test and reference materials in physiological saline. Total mass and specific surface area of glass material per volume were determined. Continuous titration with hydrochloric acid was performed, and antimicrobial effectiveness was tested in extracted human premolars mono-infected with E. faecalis ATTC 29212 (N = 12 per material). While the nanometric slurry had a 12-fold higher specific surface area than the micrometric counterpart, the latter had a considerably higher alkaline capacity and disinfected significantly better (Fisher's exact test, P < 0.05). The hybrid slurry behaved similarly to the micrometric preparation.

Impact of storage conditions on profilometry of eroded dental hard tissue.

The aim of the present study was to analyze in how far drying of eroded dentin and enamel surfaces influence the results of profilometrical determinations with a stylus profilometer. Each five dentin and enamel samples were eroded with HCl (pH 2.6, 2 min). Surface profiles of the samples were recorded with a stylus profilometer in three series. In series 1, the samples were measured while stored in water and in series 2, under ambient conditions (21 degrees C, 35% humidity). In series 3, samples were completely desiccated and then rewetted. Profilometry was conducted at various time intervals for a period of up to 181 min (series 1 and 2) and 72 h (series 3). Only the dentin samples were affected by the storage conditions. Stable profilometrical readings for the eroded dentin samples were only feasible when the specimens were stored in water during the complete period of the experiment, including the profilometrical measurement. Thus, for erosion experiments using profilometrical analysis with a stylus profilometer, it is advised to store and measure dentin samples under wet conditions.

Necrotic pulp tissue dissolution by passive ultrasonic irrigation in simulated accessory canals: impact of canal location and angulation.

AIM: To evaluate whether passive ultrasonic irrigation (PUI) of 2.5% NaOCl would dissolve necrotic pulp tissue from simulated accessory root canals (SACs) better than passive placement of the irrigant, when temperature was equilibrated between the two treatments. METHODOLOGY: Transparent root canal models (n = 6) were made from epoxy resin. SACs of 0.2 mm diameter were placed at defined angles and positions in the mid-canal and apical area. SACs were filled with necrotic bovine pulp tissue. PUI was performed five times for 1 min each with irrigant replenishment after every minute. Main canal temperature was measured after each minute, and a digital photograph was taken. In control experiments, mock treatments were performed with the same set-up without activation of the file using heated NaOCl to mimic the temperature created by PUI. Experiments were repeated five times. Digital photographs were analysed for the distance of dissolved tissue into the SACs in mm. Overall comparison (sum of dissolved tissue from all five accessory canals) between treatments was performed using paired t-test. Differences between SAC angulation and position after PUI were investigated using anova/Bonferroni (alpha < 0.05). RESULTS: Passive ultrasonic irrigation caused a rise in irrigant temperature in the main canal to 53.5 +/- 2.7 degrees C after the fifth minute. PUI dissolved a total of 6.4 +/- 2.1 mm, mock treatment controlled for heat: 1.4 +/- 0.6 mm (P < 0.05). No significant influence of SAC position or angulation was found. CONCLUSIONS: Passive ultrasonic irrigation promotes positive tissue-dissolving effects beyond a rise in irrigant temperature.

Apical sealing ability of Resilon/Epiphany versus gutta-percha/AH Plus: immediate and 16-months leakage.

AIM: To compare the long-term apical sealing ability of gutta-percha/AH Plus and Resilon/Epiphany. METHODOLOGY: The root canals of 90 single-rooted human mandibular premolars with single narrow root canals were prepared with ProFile 0.4 taper instruments to apical size 40. After each instrument, the canals were irrigated with 1% sodium hypochlorite. Subsequently, the teeth were randomly divided into four groups containing 20 teeth each. Additionally, 10 prepared premolars served as positive and 10 counterparts with intact crowns as negative controls. The root canals were filled with gutta-percha/AH Plus or Resilon/Epiphany using lateral or vertical compaction. Specimens were allowed to set for 7 days at 37 degrees C and 100% humidity. Subsequently, the root fillings were removed down to the apical 4 mm. Fluid movement was then assessed using a fluid transportation model and re-evaluated after 16 months of water storage. Leakage within and between groups was compared using nonparametric tests. RESULTS: Negative controls revealed no fluid movement and positive controls displayed gross fluid movement at both times of observation. At the immediate measurement, there were no significant differences between the experimental groups (Kruskal-Wallis, P > 0.05). Gutta-percha/AH Plus fillings retained their seal after 16-months storage (Wilcoxon, P > 0.05), whilst the Resilon/Epiphany groups lost their sealing capacity (Wilcoxon, P < 0.001). In these groups, 29 of the 40 specimens exhibited gross leakage similar to positive controls. CONCLUSION: Initially, Resilon/Epiphany root fillings prevented fluid movement to the same degree as gutta-percha/AH Plus counterparts, but showed more fluid movement when tested at 16 months.

Tubular sclerosis rather than the smear layer impedes dye penetration into the dentine of endodontically instrumented root canals.

AIM: To evaluate the effect of different root canal irrigating regimes on dentine penetration of Patent Blue dye. METHODOLOGY: Eighty extracted single-rooted human mandibular premolar teeth with narrow root canals were prepared using ProFile instruments. After each instrument, canals were irrigated with 1% sodium hypochlorite. Subsequently, teeth were randomly assigned to receive a 10 mL rinse of aqueous 17% (w/v) ethylenediaminetetraacetic acid or tap water for 2 or 10 min, followed by a final rinse with a 2% Patent Blue dye solution for 2 or 10 min (eight groups, n = 10 teeth per group). Teeth were then horizontally sectioned 3, 6 and 9 mm from the apex. Sections were digitally photographed and dye penetration was calculated as percentage of total dentine area using NIH Image J. Values were compared using one-way anova and Bonferroni correction with the alpha-type error set at <0.05. Representative tooth sections from all groups were further analysed using scanning electron microscopy. RESULTS: No significant impact of irrigating protocols on dye penetration was found. Dye penetration was significantly (P < 0.001) greater in the coronal than middle, and in middle than in apical root thirds. When observed microscopically, irrigant penetration was independent of the presence of a smear layer, but was rather a function of tubular sclerosis. CONCLUSIONS: Tubular sclerosis, a physiological phenomenon that starts in the third decade of life in the apical root region and advances coronally with age, was the main factor influencing penetrability of root dentine.

Assessment of a gel-type chelating preparation containing 1-hydroxyethylidene-1, 1-bisphosphonate.

AIM: To test an aqueous gel containing 1-hydroxyethylidene-1, 1-bisphosphonate (HEBP) regarding its interactions with sodium hypochlorite, its calcium binding capacity, and its potential in preventing the formation of a smear layer when used in conjunction with rotary root canal preparation. METHODOLOGY: The experimental aqueous gel consisted of (w/v) 2% alginate, 3% aerosil, 10% Tween 80 and 18% HEBP. Interactions of gel components with hypochlorite were assessed using iodometric titration and monochromatic ultraviolet spectrometry. Two commercial paste-type chelators containing ethylenediaminetetraacetic acid (EDTA) and peroxide (RC-Prep and Glyde) served as controls. Calcium-binding capacities were measured in mixtures with a Ca2+ standard solution buffered at pH 10 using a calcium-selective measuring chain. Finally, root canals of 16 extracted single-rooted premolars per group were instrumented using ProFile instruments dipped in the experimental gel, RC-Prep, or nothing. Additionally, canals were rinsed with 10 mL of a 1% NaOCl solution during/after preparation. Smear scores in instrumented teeth were monitored using scanning electron microscopy. RESULTS: None of the experimental gel components showed short-term interactions with hypochlorite, whilst EDTA, peroxide, RC-Prep and Glyde immediately reduced the hypochlorite in solution. The experimental gel chelated 30 mg Ca2+ g-1, compared with 16 mg Ca2+ g-1 and 11 mg Ca2+ g-1 chelated by RC-Prep and Glyde respectively. Smear scores obtained with the experimental gel were significantly (P<0.05) lower than with RC-Prep in coronal and middle root thirds, whilst no differences were observed in apical root thirds. CONCLUSIONS: Under the conditions of this study, an HEBP gel appeared advantageous over currently available products.

Root canal preparation with Endo-Eze AET: changes in root canal shape assessed by micro-computed tomography.

AIM: To evaluate the relative performance of Endo-Eze Anatomic Endodontic Technology (AET) stainless steel instruments when shaping maxillary molar root canals in vitro. Methodology Extracted human maxillary molars were scanned, before and after root canal shaping with Endo-Eze AET, employing micro-computed tomography (muCT) at an isotropic resolution of 34 microm. Three-dimensional root canal models were reconstructed and evaluated for volume, surface area, 'thickness' (diameter), canal transportation and prepared surface. Preparation errors such as apical zips, perforations and fractured instruments were visually determined from those models. Means were contrasted using anova and Scheffé post-hoc tests. RESULTS: Volume and surface area increased significantly and similarly in mesiobuccal (mb), distobuccal (db) and palatal (p) canals and gross preparation errors (n = 17) were found. Mean root canal diameters, 5 mm coronal to the apex, increased from 0.31 to 0.52, 0.35 to 0.50 and 0.50 to 0.70 mm for mb, db and p canals, respectively. Mean canal transportation ranged from 0.15 to 0.29, 0.15 to 0.27 and 0.21 to 0.33 mm for apical, middle and coronal root canal levels, respectively, with highest values found for mb canals (P < 0.003). Root canals were significantly straightened during preparation (P < 0.002). CONCLUSIONS: In summary, Endo-Eze AET instruments shaped root canals in maxillary molars with substantial canal transportation, particularly in mesiobuccal root canals. Preparation with this instrument removed high volumes of dentine, even though apical preparation was size 30. Based on the current results, Endo-Eze AET cannot be recommended for the preparation of teeth with curved root canals.

Enamel fluoride uptake of a novel water-based fluoride varnish.

Aim of the in situ-study was to evaluate fluoride retention in sound and demineralised enamel after application of a novel water-based fluoride (0.12% F) varnish Mirafluorid (Hager and Werken, Germany) compared to the resin-based varnish (2.26% F) Duraphat (Colgate, USA). Each five enamel specimens were prepared from 60 bovine incisors. In 150 of these specimens, incipient lesions were produced with acidic hydroxyethylcellulose (pH 4.8; 72 h), 150 specimens were not demineralised. The samples were equally (n=100) allotted to three groups (A: Mirafluord, B: Duraphat, and C: control). Each 80 specimens (40 demineralised and 40 sound) were varnished with either Mirafluorid or Duraphat or remained unfluoridated (controls). The other specimens were used for measuring base-line fluoride content of the respective tooth. Each six specimens (three demineralised and three sound) were fixed in intraoral appliances worn for 5 days by 10 volunteers in three series (A-C). During the experiment, the samples were brushed twice daily with fluoridated toothpaste. KOH-soluble and structurally bound fluoride (0-30 and 31-60 microm depth) was determined immediately, 1, 3 and 5 days after fluoridation. Fluoride uptake was calculated as compared to base-line content and statistically analysed. Immediately after fluoridation, uptake of KOH-soluble and structurally bound fluoride was similar for Mirafluorid and Duraphat in both demineralised and sound enamel. However, at day 1, 3 and 5 statistically significantly higher amounts of KOH-soluble and structurally bound fluoride were found in the samples treated with Duraphat. For Mirafluorid only the uptake for KOH-soluble fluoride and structurally bound fluoride in the first enamel layer (0-30 microm) of the demineralised samples was significantly higher compared to the controls (C). It is concluded that the novel fluoride varnish Mirafluorid deposits less KOH-soluble and structurally bound fluoride on both demineralised and sound enamel compared to Duraphat under in situ-conditions.

Comparison of root canal preparation using RaCe and ProTaper rotary Ni-Ti instruments.

AIM: To compare various parameters of root canal preparation using RaCe (FKG Dentaire, La-Chaux-de-Fonds, Switzerland) and ProTaper (Dentsply Maillefer, Ballaigues, Switzerland) nickel-titanium (Ni-Ti) instruments. METHODOLOGY: Fifty extracted mandibular molars with mesial root canal curvatures between 20 degrees and 40 degrees were embedded in a muffle system. All root canals were prepared to size 30 using RaCe or ProTaper rotary instruments in low-torque motors with torque control and constant speed of 300 r.p.m. (ProTaper with ATR Tecnika, Advanced Technology Research, Pistoia, Italy; RaCe with EndoStepper, S.E.T., Olching, Germany). In both groups irrigation was performed with 2 mL NaOCl (3%) after each instrument size. Calcinase-Slide (lege artis, Dettenhausen, Germany) was used as a chelating agent with each instrument. The following parameters were evaluated: straightening of curved root canals, postoperative root canal cross-sections, safety issues and working time. Cleanliness of the root canal walls was investigated under the SEM using 5-score indices for debris and smear layer. Statistical analysis was performed using the following tests: Wilcoxon's test for straightening and working time was used (P < 0.05); Fisher's exact test for comparison of cross-sections and root canal cleanliness (P < 0.05). RESULTS: Both Ni-Ti systems maintained curvature well; the mean degree of straightening was less than 1 degrees for both systems. Following preparation with RaCe, 49% of the root canals had a round or oval diameter and 50% an irregular diameter, ProTaper preparations resulted in a round or oval diameter in 50% of the cases. For debris, RaCe and ProTaper achieved 47 and 49% scores of 1 and 2, respectively; there was no significant difference. For smear layer, RaCe and ProTaper achieved 51 and 33% scores 1 and 2, respectively; no statistically significant differences were apparent for the coronal and middle sections of the root canals, but RaCe performed significantly better in the apical region (Fisher's exact test, P = 0.0392). Two roots lost working length with RaCe instruments, whilst ProTaper preparation resulted in two roots loosing working length and one fractured instrument. Mean working time was shorter for ProTaper (90.9 s) than for RaCe (137.6 s); the difference was significant (Wilcoxon's test, P = 0.011). CONCLUSIONS: Both systems respected original root canal curvature well and were safe to use. Cleanliness was not satisfactory for both systems.

Review of the current status of tooth whitening with the walking bleach technique.

Internal bleaching procedures such as the walking bleach technique can be used for whitening of discoloured root-filled teeth. The walking bleach technique is performed by application of a paste consisting of sodium perborate-(tetrahydrate) and distilled water (3% H2O2), respectively, in the pulp chamber. Following a critical review of the scientific literature, heating of the mixture is contra-indicated as the risk of external cervical resorption and the formation of chemical radicals is increased by application of heat. An intracoronal dressing using 30% H2O2 should not be used in order to reduce the risk of inducing cervical resorption. This review provides advice based on the current literature and discusses how the walking bleach technique can lead to successful whitening of non-vital root-filled teeth without the risks of side-effects.