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Bleaching:

Is it safe and effective?


PhD

Gary R. Goldstein, DDS, and L. Kiremidjian-Schumacher,


Kriser Dental Center, New York University, New York, N.Y.

It has been well documented that bleaching whitens teeth, but has its safety been documented? This paper reviews bleachings predictability, esthetics, longevity, and side effects. A discussion of the bleaching reaction on teeth and soft tissue raises concerns over the safety of the procedure. (J PROSTHET DENT 1993;69:325-8.)

t has been well-documented that teeth can be bleached.-7 The in-office techniques using 30% to 35% hydrogen peroxide (HP) have been advocated for many years, but their popularity has been limited because of the caustic nature of the solution and the need for meticulous rubber dam placement. The new at-home mouthguard applied procedures with carbamide peroxide (urea hydrogen peroxide, perhydrit, hyperol, or perhydrol-urea) are easier to use and do not require placement of a rubber dam.s In a 1990 Clinical Research Associates (CRA) survey,g 52 % of the 9846 respondents were using the technique, which was first published by Haywood and Heyman,a g or a modification of it. The CRA newsletter reviewed seven products in July 1989 and 10 in December 1989.O,I1 Today, the number of products being marketed directly to patients or through the dentist to the patient is growing daily. Late night and cable television, lay magazines, and newspapers all promot.e regionally and nationally marketed brands.

situation, because the patient might decide that the result did not justify the fee.

Is bleaching

esthetic?

In most patients, where superficial stains are removed, the answer is yes (Figs. 1 and 2). But in stains requiring prolonged treatment, the answer is not always clear. The teeth appear whiter but are chalky and dull (Figs. 3 and 4), and consequently the patients stain problem has been traded for a flat, dull, and unrealistic look.

Does it last:?
Indications are that it probably does not. Most authors conclude that retreatment is necessary! with Goldstein and Feinman et ali3 recommending retreat,ment in 1 to 3 years., I;3 Holmstrup et a1.14 reported that 20.3;~ of bleached teeth showed an unacceptable recurrence of discoloration after 3 years and Friedman et al. had a 21; esthetic failure. Walton et al. reported a return of discoloration as early as 1 week. Meyers et al.: reported a return of color in 4 days.

Is bleaching

predictable?

The literature indicates that bleaching is not predictable. In a study by Nathanson and Panna only a third of the subjects showed marked changes. Goldstein stated that the exact shade cant be predicted. In the CRA survey,9 14% of those who used the at-home technique were not satisfied with the results. The number one reason for dissatisfaction was that the profoundness of the bleach was unpredictable. Studies by the authors were unable to predict to what degree a tooth could be bleached.12 The patients teeth in Figs. 1 and 2 were successfully bleached with the same technique and for the same length of time as the patients teeth in Figs. 3 and 4. With the exception of the dull appearance of the enamel as a result of preetching, little whitening is evident in the second patients teeth. This unpredictability is undesirable in a fee-for-service

Are there si.de effects?


The occurrence of external cervical resorption associated with bleaching of nonvital teeth has been well documented., sSz6 Pulpal responses to bleaching have been studied and found to be extensive but most likely reversible., 27-31
Most investigators report some posttreatment sensitivity, l, 6.g,S. 28which dissipates with time. All of these studies were performed with 30 % to 35 ; HP for approximately 20 minutes with a once-a-week exposure. No studies have been done with 3c; HP with a 3- to 8-holrr daily exposure

for several weeks. A study by Ledoux et alYs showed bleaching with 30% HP causes extensive structural changes in rat dentin and
enamel. Titley et a1.s used a 30-minute exposure of 35% HP on human d.entin and found an intact, smear layer with

aProfessor and Director of Prosthodontic Research, Division of Restorative and Prosthodontic Sciences. bProfessor, Department of Oral Medicine and Pathology. Copyright 6 1993 by The Editorial Council of THE JOURNAL OF PROSTHETIC DENTISTRY. OOZZ-3913/93/$1.00+.10. 10/l/43228

a dense amorphous precipitate. Ruse et ai.: demonstrated that other than increasing the nitrogen content, there were
no other sign&cant changes in the elemental composition of the bovine enamel studied. Torneck et a1.s showed a

decrease in the bond strength of composite resin bonded to


bovine enamel bleached with 30 r HP. They hypothesized

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2. Postoperative photo of in-office bleached teeth after three sessions shows positive results. Fig. 3. Preoperative photo of stained teeth. Fig. 4. Postoperative photo of in-office bleached teeth after three sessions shows chalky white appearance of teeth.

Fig. Fig.

1. Preoperative photo of stained teeth.

that this was the result of the presence of residual peroxide or peroxide-related substances at or near the enamel surface. Responses of soft tissue to exposure to HP have been re35-3s Rees and Orth36 reported two patients who ported. g-11* had oral ulcerations after using 3% HP for 1 to 2 minutes, three to five times daily. Martin et al.37 used 1% HP dropped continuously onto dog gingiva and showed edema in the epithelial layer after 6 hours, vacuolization after 24 hours, and destruction and sloughing of the cornified layers after 48 hours. Dorman and Bishop3* produced edema in dog tongues with a dilute HP (3 % ) solution after a single 30-minute exposure. How does it work?

employs carhamide peroxide as a vehicle for the delivery of HP (10 % carbamide peroxide in the presence of water releases 3.5% HP). A low concentration of HP requires an increase in exposure time. The rate of the reaction: 2H202 > 2H20 + O2 is dependent on the HP concentration and the levels of salivary peroxidase. If a large amount of HP is present where a zero-order reaction occurs, the time required to clear the HP is proportional to its concentration. The longer it takes to clear the HP, the greater the exposure time to reactive oxygen species. Although it is possible that 02, which has two unpaired electrons in its outer shell, can pick up two electrons simultaneously, the more likely scenario calls for consecutive one-electron transfers involving free radical (Os-, superoxide) intermediates. 3g-41 The superoxide then reacts with HP in the Haber-Weiss Reaction, Os- + HsOs > 0s + OH- + . OH, producing the hydroxyl ( . OH) radical.40s41 This reaction occurs slowly at physiologic PH.~ HP can penetrate enamel and dentin.> 3oIt is also mobile and can

The exact mechanism is unclear. Bleaching is an oxidation reaction whereby the substance to be bleached donates electrons to the bleaching agent, and it can be performed to a degree by any oxidizing agent. Dental bleaching procedures use HP because it is unstable and will easily decompose to water and oxygen. The at-home procedure

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diffuse through the soft tissue to vulnerable parts of a ce11.42 The slow breakdown of HP in an environment containing ferric and ferrous ions will produce strongly reactive intermediary ions and oxygen, with both probably contributing to the bleaching process. Is it safe? In a January 1991 literature search, we found 246 citations in cross-referencing HP with toxicity. Oxygen has toxic effects.40,43It has been known to damage plants, animals, and aerobic bacteria in concentrations greater than in normal air. Even 21% oxygen has damaging effects.*O The oxygen paradox is that while it is essential for higher life forms, it is toxic to all aerobes.** Free radicals interact with and can destroy whatever is near them,*, 45-4g and they are known carcinogens.40v *I, 43,5o The superoxide radical plays a major role in the toxic effects of oxygen. 51Fridovich has stated that Oz- is a commonly encountered intermediate of oxygen reduction in both biotic and abiotic systems and that this free radical constitutes a threat to the chemical integrity of living cells.: Weitzman et a1.35 stated that hydrogen peroxide can, by itself, induce pathologic changes frequently associated with neoplastic lesions; it may also augment carcinogenesis associated with 9,10-dimethyl 1,2 benzanthracene (DMBA). DMBA is a known carcinogen analogous to the polycyclic aromatic hydrocarbons found in tobacco.34Their study used hamsters with the buccal pouches painted with 3: HP or 305 HP twice weekly for 19 to 22 weeks. A 0.25 0 DMBA solution was also painted on selected groups twice weekly on days other than when the HP was applied. What would the results have been if the HP was allowed to contact the tissues for 3 to 8 hours every day as is currently advocated in the at-home technique? Smokers are the most likely candidates for successful bleaching. Telling them to stop smoking during the bleaching exposure probably will not reverse the previous damage. Dyskeratosis and carcinoma in situ are the precursors of malignancy. They will not be reversed in a short period of time after the cessation of smoking. What is the effect of the HP exposure on these highly susceptible cells? SUMMARY Bleaching is an effective method of whitening teeth. It is not predictable and has a sufficient history of adverse effects to warrant concern by the profession. Above all, procedures used in dental practice should preserve and protect the oral tissues environment. To date the clinical safety of bleaching has not been demonstrated. Most of the published research indicates that there should be concern for its safety when used in prolonged treatment. CONCLUSIONS To justify bleaching on the grounds that it is cosmetic and not therapeutic, and as such does not need to meet

Food and Drug Administration (FDA) standards, is turning a blind eye to its prolonged contact wit,h oral tissues and to the possible aspiration and inhalation of HP and its byproducts. The FDA has not accepted that argument and has requested safety studies for the at-home products. If the possibility of harm exists, it is dentistrys obligation to explore it first, not react to the problem if and when it occurs. Chakwan Siew, PhD, head of the ADA Research Institutes Department of Toxicology said, These products work, but at what cost down the road?2 Wisely, the ADA Council of Dental Therapeutics has not granted acceptance to any of the whiteners.
REFERENCES
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DR. GARY GOLDSTEIN KRISER DENTAL CENTER 345 EAST 24~~ STREET NY, NY 10010

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