Tooth whitening outcomes may be optimized when different bleaching techniques are combined.


For patients with generalized physiological tooth discoloration and darkened endodontically treated teeth, internal tooth whitening of these nonvital teeth followed by at-home whitening of both arches is the recommended treatment. 

Dentists must inform their patients about the expected outcomes of each procedure and provide an evidence-based choice.



The dental professional often treats patients who have generalized discoloration of vital teeth as a result of physiological aging or extrinsic factors and one (or several) darkened endodontically treated tooth. 

However, discolored nonvital teeth do not usually respond to external tray whitening as well as vital teeth do, with the exception of recent discolorations. 

This clinical technique illustrates a combined technique in which a darkened nonvital tooth is first treated with internal whitening to reach a tooth color similar to that of the remaining vital teeth, followed by at-home whitening of both arches with 10 % carbamide peroxide in a custom-fi tted tray. 

Clinical Technique

This clinical case involved a 31-year-old patient whose chief complaints were the discoloration of a maxillary right canine and the “yellow look” of the other teeth. 

The medical history was not contributory to dental treatment. Upon clinical and radiographic exam, the patient was informed that the discoloration on tooth #6 was related to the respective root canal treatment. 


Patient was also informed that internal whitening might result in color relapse after some time. The small risk of external root resorption associated with this procedure, as described in Chap. 8 , was also mentioned to the patient. 

The treatment plan included intra-coronal whitening of tooth #6 followed by restoration with an adhesively luted glass fiber post and a resin-based composite direct restoration. 

The next step in the treatment plan would be at-home whitening of both arches with 10 % carbamide peroxide in a custom-fi tted tray. 

Tooth #6 would be evaluated 6 months after the restoration to decide if a full-coverage ceramic restoration might be needed. The patient accepted this treatment plan. 



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