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External Bleaching Therapy With Activation by Heat, Light or Laser

External Bleaching Therapy With Activation by Heat, Light or Laser

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dental materials 23 (2007) 586596
available at www.sciencedirect.com journal homepage: www.intl.elsevierhealth.com/journals/dema
External bleaching therapy with activation by heat,light or laser—A systematic review
Wolfgang Buchalla
a
,
b
, Thomas Attin
a
,
b
,
a
Department of Preventive Dentistry, Periodontology and Cariology, University of Z¨ urich, Plattenstrasse 11, CH-8032 Z¨ urich, Switzerland
b
Department of Operative Dentistry, Preventive Dentistry and Periodontology, Georg-August-University G¨ ottingen, G¨ ottingen, Germany
a r t i c l e i n f o
 Article history:
Received 17 October 2005Received in revised form4 March 2006Accepted 9 March 2006
Keywords:
PeroxideBleaching ActivationHeatLaserLight
a b s t r a c t
Objective.
Externalbleachingproceduresutilizinghighlyconcentrated30–35%hydrogenper-oxide solutions or hydrogen peroxide releasing agents can be used for tooth whitening. Toenhanceoracceleratethewhiteningprocess,heat-activationofthebleachingagentbylight,heat or laser is described in the literature. The aim of the present review article was to sum-marizeanddiscusstheavailableinformationconcerningtheefficacy,effectsandsideeffectsof activated bleaching procedures.
Sources.
Information from all original scientific full papers or reviews listed in PubMed or ISIWeb of Science (search term: (bleaching OR brightening OR whitening OR colour) AND (lightOR laser OR heat OR activation)) were included in the review.
Data.
Existing literature reveals that activation of bleaching agents by heat, light or lasermay have an adverse effect on pulpal tissue due to an increase of intra-pulpal temperatureexceeding the critical value of 5.5
C. Available studies do not allow for a final judgmentwhether tooth whitening can either be increased or accelerated by additional activation.
Conclusion.
Therefore, application of activated bleaching procedures should be criticallyassessed considering the physical, physiological and patho-physiological implications.© 2006 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
1. Introduction
1.1. In-office-bleaching therapies
With in-office applied bleaching therapies, discolored, vitalteeth can be successfully whitened mostly by using highlyconcentrated bleaching regimens. In-office-bleaching pro-cedures seem to be an appropriate alternative to home-bleaching applications with trays, foils or gels, especially inthe case of very severe discolorations, discolorations of sin-gle teeth, lack of patient compliance or if a rapid treatment isdesired. In-office-bleaching could also be applied as a kind of boost therapy, thereby initiating the bleaching process, whichmightbecontinuedafterwardsbyhome-bleachingprocedures
Corresponding author
. Tel.: +41 44 634 3271; fax: +41 44 634 4308.E-mail address:thomas.attin@zzmk.unizh.ch(T. Attin).
[1,2].It should be noted that a single application of in-office-bleachingisusuallynotsufficienttoachieveoptimalbleaching results[3].This means that the in-office-bleaching procedure has to be repeated several times during an appointment orthat even multiple appointments are needed to obtain opti-mal results. In-office-bleaching is usually performed using bleaching agents with high concentrations (30–35%) of H
2
O
2
.Due to the high peroxide concentration, the gingiva shouldbe protected by rubber dam or alternatives, such as speciallydesigned light-curing isolating pastes[4].Most descriptions in the literature of successful appli-cations of in-office-bleaching therapies are case reports orstudies, in which no comparisons to well-approved meth-ods, such as home-bleaching-procedures have been done
0109-5641/$ – see front matter © 2006 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.dental.2006.03.018
 
dental materials 23 (2007) 586596
587
[3,5–8].However, in a randomized clinical study Auschill et al.[9]were able to show that both home-bleaching procedures(10% carbamide peroxide gel tray application or 5.3%-H
2
O
2
-impregnated strips) and in-office-bleaching with 35% H
2
O
2
without heat-activation may be used to brighten teeth sixshadesonthevitacolorscale.Withthein-office-procedurethedesired six grades were achieved after only 3.1
±
0.5 applica-tions of 15min each, whereas 31.8
±
6.6 applications of 30mineach were needed with the strip and 7.1
±
1.9 applications for8h each were necessary when using the carbamide peroxidegel.Frequencyandseverityofsideeffects,suchastoothhyper-sensitivity or gingival irritation, were similar for the threeapproaches as reported by the study participants. However,subjective acceptance of the procedure was slightly higher forsubjects treated with the carbamide peroxide agent as com-pared to the two remaining groups. Scanning electron micro-scopic pictures (2000
×
-magnification) of the bleached toothsurfaces did not show any alterations, which might have beenattributedtothebleachingproceduresinanyofthetreatmentgroups. This finding corroborated the results of a previousin vitro-study in which the same bleaching agents had beenapplied[10].In contrast to the results of the study performed by Auschill et al.[9],a recent study showed lower brighten- ing of teeth treated by in-office-bleaching (35% H
2
O
2
, no heatapplication) as compared to a 14-day application of 10% car-bamide peroxide in a tray[11].In this study, the two bleach- ing techniques were directly compared in the same patientusing an intriguing split-mouth-design. This design allowedfor treatment of three anterior teeth each with either the car-bamideperoxideagentorthein-office-application,whichwasadopted for six periods of 10min each on 2 different days.
1.2. Heat-activated bleaching therapies
To accelerate the bleaching process, the bleaching agent canbe additionally heat-activated. This idea of power bleaching dates back to 1918, when Abbot[12]reported the use of high- intensity light to increase the temperature of hydrogen per-oxide. Mostly, application of heat, light or lasers is used toincrease the temperature of a bleaching agent applied to thetoothsurface.Theapplicationofaheatedspatula(30–55
C)orofanextraorallyheatedbleachinggelisalsodescribed[13,14].Theeffectivenessofthesemethodsasappliedwithvitalteethhas been described in several clinical reports, animal stud-ies and reviews without showing evidence of irreversible sideeffects[14–34].In the study by Nathanson and Parra[34],the majority of patients (70%) reported post-operative discomfortin the form of a mild sensitivity that did not last more than24h. Interestingly, the authors did not find differences in thediscomfortlevelsamongyoung,12-year-oldsubjectsandolderpatients included in their study. It should be noted that in thereports mentioned above the duration of heat activation wasmostlylimitedtoshortperiodsasrecommendedbymanufac-turers of bleaching agents or heat-generating devices. Despitethenon-existentincidenceofreportedirreversibleside-effectsdue to external bleaching, it should be noted that Glickman etal.[35]published a case report of a patient who suffered an acute flare-up of sensitivity in a tooth following vital bleach-ing. This case emphasizes the importance of assessing pul-pal status before initiation of an external bleaching therapy.Withrespecttointernalbleachingofnon-vital,endodonticallytreated teeth, it is well-known that heat application increasesthe risk of development of external, cervical resorption[36,37].
1.3. Background of the present review
Surveyingthescientificliterature,itbecomesevidentthatonlyfew randomized, controlled clinical studies exist, which dealwith the application of activated procedures for whitening of vital teeth. The present review is based on a systematicliterature search in PubMed or ISI Web of Science with the fol-lowing search term: (bleaching OR brightening OR whitening ORcolour)AND(lightORlaserORheatORactivation).Allorigi-nalscientificfullpapersorreviewsfulfillingthesearchcriteriawere included in the review, abstracts dealing with the topicwere not taken into consideration. To allow for estimation of the benefit of the activation, special attention was given tostudies in which activated bleaching procedures were com-pared to non-activated.Firstly, an overview about the principles of bleaching acti-vation with light, heat or laser is provided.
2. Principles of activation in external bleaching
From a scientific point of view, data on mechanisms of actionand efficacy of laser, light and heat-activated dental bleach-ing are still limited. In this chapter, the basic principles andpossible mechanism of action of these bleaching procedureswill be discussed. An overview of light sources for activationof bleaching procedures described in the literature and avail-able on the market is presented inTable 1.It is common to alldescribedlight-activatedbleachingprocedures,thatlightisusedinadditiontotheapplicationofableachingproduct(suchas a bleaching gel) rather than on its own. It is the effect thelightorheathasonthechemicalbleachingproduct(gel)ratherthan on the tooth substance itself and the chromophores itcontains that may lead to an increased bleaching effect.
2.1. Thermocatalysis
The release of hydroxyl-radicals from peroxide is acceleratedby a rise in temperature according to the following equa-tion: H
2
O
2
+211kJ/mol
2HO
. This is in accordance withan increase in speed of decomposition of a factor of 2.2 foreach temperature rise of 10
C. Due to the increased releaseof hydroxyl-radicals (thermocatalysis), an increase in effi-cacy is conceivable. However, the useful range in temperatureincrease is limited because of possible damage to the dentalpulp as described below in greater detail.If light is projected onto a bleaching product, such as ableaching gel, a small fraction is absorbed and its energy isconverted into heat. Most likely, this is the main mechanismof action of all light-activated bleaching procedures. In orderto increase light absorption and, as a result, heat conversion,some bleaching products are mixed with specific colorants,e.g. carotene. The orange-red color of carotene increases theabsorption of blue light. In order to increase the absorption of 
 
 5  8   8  
dntamati  a s 2  3  (    2 0 0  7  )      5 8   6    5  9 6  
Table 1 – Overview of light sources
Light source Main source of lightemissionWavelength afterfiltering (typical)(nm)Power output at exitwindow (typical) (mW/cm
2
)Power at tooth surface(typical) (from Hein et al.[41])(mW/cm
2
)Properties and risks when used forlight-activated bleaching 
QTH lamp
(
quartz–tungsten–halogenlamp
)
and derivatives
(
e.g.with xenon gas filling
)
Incandescent light: heatedtungsten filament
380520 (violet-blue) 4003000 Resin curing lights: >100;bleaching lamps: <80Filtered broad band light source;readily absorbed by carotene (redcolor); thermal damage cannot beexcluded with high-power lampsor long irradiation duration
Plasma arc lamp
(
xenondischarge lamp
)
andderivatives
(
e.g. mercuryadded
)
Luminescent light: lightemission by recombinationof electrons with ionizedxenon atoms
380–580 (near UV-violet-blue-green)6002000 Filtered broad band light source;readily absorbed by carotene (redcolor); thermal damage cannot beexcluded with high-power lampsor long irradiation duration
Metal halide lamps
(
dischargelamps filled with metalhalides, mercury andargon
)
Luminescent light: lightemission by recombinationof electrons with ionizedmetal atoms
Bleaching lamps: <80
LED
(
light emitting diode
) 430490 (blue) 2002000 ? Narrow band light source, notfiltered; readily absorbed bycarotene (red color); thermaldamage cannot be excluded withhigh-power lamps or long irradiation duration
Laser Wavelength (typical)(nm)Power output at exit window(typical) (mW/cm
2
)Properties and risks when used for light-activatedbleaching 
 Argon-ion laser
(continuous wave or pulsed) 488 (blue) e.g. 1100 Limited penetration depth into dental hard tissue; readilyabsorbedbycarotene(redcolor);riskofthermaldamagerel-atively low
 Argon-ion laser
(continuous wave or pulsed) 514 (blue-green) ?
a
Low absorption in water and tooth mineral; absorption inhemoglobin; risk of thermal damage relatively low
KTP laser
(kalium-titanyl-phosphate crystal fre-quency doubled Nd:YAG laser, pulsed)532 (green) e.g. 3000 Relatively low absorption in water and tooth mineral; highabsorption in hemoglobin; medium penetration depth intodental hard tissue

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