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

T. Attin, F. Paque¤, F. Ajam & A¤. M. Lennon
Department of Operative Dentistry, Preventive Dentistry and Periodontology, Georg-August Universita«t Go«ttingen, Go«ttingen,

external cervical resorption and the formation of che-
mical radicals is increased by application of heat. An
Attin T, Paque¤ F, Ajam F, Lennon A¤M. Review of the cur- intracoronal dressing using 30% H2O2 should not be
rent status of tooth whitening with the walking bleach technique. used in order to reduce the risk of inducing cervical
International Endodontic Journal, 36, 313^329, 2003. resorption. This review provides advice based on the
current literature and discusses how the walking
Internal bleaching procedures such as the walking
bleach technique can lead to successful whitening of
bleach technique can be used for whitening of disco-
non-vital root-¢lled teeth without the risks of side-
loured root-¢lled teeth. The walking bleach technique
is performed by application of a paste consisting of
sodium perborate-(tetrahydrate) and distilled water Keywords: bleaching, hydrogen peroxide, sodium
(3% H2O2), respectively, in the pulp chamber. Follow- perborate, tooth resorption.
ing a critical review of the scienti¢c literature, heat-
ing of the mixture is contra-indicated as the risk of Received 25 July 2001; accepted 23 January 2003

1995, Ernst et al. 1995, Glockner et al. 1997). This review
of the walking bleach technique describes the recom-
Discoloured teeth, especially in the anterior region, can mended procedures to help reduce the risks of complica-
result in considerable cosmetic impairment. Besides tions and to ensure a successful bleaching therapy.
invasive therapies, such as crowning or the placement
of veneers, the whitening of teeth is an alternative ther-
Indications for the walking bleach
apeutic method. In contrast to crowning or veneering,
whitening of teeth is relatively non-invasive and con-
serves dental hard tissue. Vital teeth can be whitened Dissemination of blood components into the dentinal
by the nightguard vital bleaching technique utilizing tubules caused by pulp extirpation or traumatically
carbamide peroxide gels as the bleaching medium induced internal pulp bleeding is a possible reason for
(Fasanaro 1992, Haywood 1992a,b, Attin & Kielbassa discolouration of non-vital teeth (Arens 1989, Goldstein
1995, Attin 1998). The whitening of root-¢lled teeth can & Garber1995). A temporary colour change of the crown
be carried out by internal whitening treatment (walking to pink can often be detected initially. Then, blood degra-
bleach technique) (Weisman 1968, Vernieks & Geurtsen dation products such as haemosiderin, haemin, haema-
1986, Arens 1989, Weiger 1992, Bose & Ott 1994, Beer tin and haematoidin release iron during haemolysis
(Guldener & Langeland1993). The iron can be converted
to black ferric sulphide with hydrogen sulphide pro-
Correspondence: Professor Dr Thomas Attin, Department of Operative duced by bacteria, which causes a grey staining of the
Dentistry, Preventive Dentistry and Periodontology, Georg-August Uni- tooth. Apart from blood degradation, degrading proteins
versita«t Go«ttingen, Robert-Koch-Str. 40, D-37075 Go«ttingen, Germany
(Tel.: þ49 551 392884; fax: þ49 551 392037; e-mail: thomas.attin@med. of necrotic pulp tissue may also cause discolouration. If the access cavity is prepared inappropriately, pulp tissue

ß 2003 Blackwell Publishing Ltd International Endodontic Journal, 36, 313^329, 2003 313

1999). Although no In these cases. Caldwell 1967. there is the dental surgery so that the e¡ect on the tooth was an observable di¡erence of colour on the tooth (Vogel restricted to a relatively short period of time.g. a restorative chlorine compounds and solutions (Taft 1878/1879. 2000). 1975). Frazier 1998). 1911. Aldecoa & Mayordomo 1992). 1998). Disco. sodium peroxide (Kirk should be used to seal the root ¢lling at the ori¢ce. cavity enables bacteria and staining substances to Chlorinated lime was recommended for the whitening penetrate into dentine. The ¢rst description of the walking louration caused by metallic ions (silver cones. Lemieux & Todd 1981.1984) or elec- when remnants of root-¢lling materials or medica. 36. dure. other reports recommended that the pulp cavity should be open during this bleaching therapy to enable Bleaching agents for the whitening of the penetration of the gel into the discoloured tooth root-filled teeth (Liebenberg 1997. Glockner & Ebeleseder1993). can be left in the pulp chamber in the pulp horns (Brown (pyrozone) (Atkinson 1892. Prinz 1924). may be another reason for discolouration. ing the pulp cavity. 1986. sodium hypochlorite (Messing 1971) or mixtures The decomposition of H2O2 into active oxygen is consisting of 25% hydrogen peroxide in 75% ether accelerated by application of heat. Walton et al. Serene & and root-canal treatment of the tooth in order to enable Snyder 1973. Attin & Kielbassa 1995). 313^329. bleaching reaction by activating the bleaching agent. Some authors proposed using light (Rosenthal 2002) or tetracycline-containing medicaments (e. Leendert et al. tric current (Kirk 1889. amal. Fields 1982. Wolfrathausen. by Marsh and published by Salvas (1938). Germany) (Kim et al. which bleach non-vital teeth. van der Burgt et al. cement. These discolourations arise 1970. Rotstein et al. Coronal disco. oxalic acid ¢lling the passage of bacteria through the tooth can be (Atkinson 1862. there are reports and studies on the successful sodium perborate and water to the tooth for a few days use of the walking bleach technique for correction of was re-considered again by Spasser (1961) and modi¢ed severely discoloured teeth caused by incorporation of by Nutting & Poe (1963) who used 30% hydrogen perox- tetracycline inthe dental hard tissue during pre-eruptive ide instead of water to improve the bleaching e¡ective- maturation of teeth (Hayashi et al. the advantages and disad. Bogue 1872) and other agents such as observed (Barthel et al. addition of sodium 314 International Endodontic Journal. 1893). Brown 1965. Harlan 1891). However. The whitening gel can considered as an alternative procedure. 1998. The use of an intracoronal ¢lling 1982. Therefore. be applied by a bleaching tray without an access open- ing. Hodosh et al. 2003 ß 2003 Blackwell Publishing Ltd . clinical use of external bleaching of non-vital root-¢lled vantages of this therapy should be assessed. Restorative teeth with carbamide peroxide gels (Putter & Jordan treatment options such as ceramic veneers should be 1989.Werner1989. In this proce- Internal discolouration of teeth represents the pri. H2O2) was also mentioned byAbbot 1985. Discolouration caused by root-¢lling materials Prinz (1924) recommended using heated solutions can be treated by bleaching depending on the staining consisting of sodium perborate and Superoxol for clean- substance (van der Burgt & Plaesschaert 1986). the bleaching medium was applied in penetration of the dental enamel takes place. Superoxol (30% root-¢lling materials (van der Burgt & Plaesschaert hydrogen peroxide. Abou-Rass ness of the mixture. Ledermix. Boksman et al. it should Reports on the bleaching of discoloured non-vital teeth be taken into consideration that an unsealed access were ¢rst described in the middle of the 19th century. Stewart 1965. An early description of hydrogen peroxide application louration of root-¢lled teeth can also be caused by some was reported by Harlan (1984/1885). some authors described the successful canal treatment have risks. Walking bleach technique Attin et al. Lederle Pharmaceuticals. 1993. of sodium perborate mixed with water or H2O2 contin- 1985. application of the bleaching agent into the pulp chamber. Anitua et al. As the methods of intentional devitalization and root. Swift 1992. bleach technique using a mixture of sodium perborate gam) cannot be removed by whitening treatments and distilled water was mentioned in a congress report (Glockner & Ebeleseder 1993). Merrell 1954. the mixture was left inthe pulp cavity for a few days mary indication for whitening of root-¢lled teeth (Arens and the access cavity was sealed with provisional 1989.b. 1983. and that even with a sound root of non-vital teeth (Dwinelle 1850). Carillo et al. heat (Brininstool 1913. Lake et al. 1986a. In addi. stance in¢ltrates the dentinal tubules. Westlake 1895) to accelerate the ments are left in the pulp chamber and the staining sub. 1980. This concept of application of a mixture of tion. and has been described many times as a This procedure starts with intentional devitalization successful technique (Nutting & Poe 1967. Davis et al. Later. material such as glass-ionomer cement or composite Atkinson 1879. Kielbassa & Wrbas 2000). In addition. ued till today. (1918). 1983. 1990. Faunce 1983. Dietz 1957) were used to 1965.

g. New for. Only fresh preparations should be uti- lized.1991. Hu«lsmann 1993). Floyd 1997). light mechanisms that provide protection from oxidative in£uence. H2O2 is also synthesized by the human body perborate mono-. Sinensky et al. Li 1998). Thus. & Davies 1988). Grossman et al. This means that impor. distilled water or H2O2 in di¡erent concentrations. the world-wide consump. by neutrophil granulocytes for destruction of either water or hydrogen peroxide is not di¡erent (Ari bacteria or by the human liver (Nathan 1987. Ingle1965. or high concentration of H2O2 and a long contact sodium perborate in the solid aggregate state as a cyclic period of H2O2 to tissue (Floyd & Carney 1992. the bleaching properties of H2O2. sodium perborate has been employed as an oxidi- ser and bleaching agent especially in washing powder and other detergents. Goldstein tathione peroxidase. (1991d. glu- metallic reaction partners (Feinman et al. 1988. Attin et al. existence of co-catalysts and reagents. Since ions. cool place. It can be concluded ducts are formed after the cleavage of H2O2 and are that no cancinogenic or cytotoxic risk results from responsible for the oxidative and reductive and therefore appropriate use of H2O2 in bleaching therapy (Li 1998). of tissue increases with age and existence of in£amma- mulae (Ro«mpp Lexikon Chemie 1991) characterize tion. tri. Bowles & Burns 1992. tri.or tetrahydrate mixtures with itself. which must be stored in a dark. peroxidases in saliva and plasma. proteins ness by comparing mixtures of sodium perborate with and nucleic acids (Floyd 1997). Some bacteria also produce H2O2 (Ryan tion of perborate (Fig. 1). catalases or the glutathione redox & Garber 1995).Tipton et al. e. The radicals can crack The chemical reaction mentioned above emphasizes unsaturated double bonds of long. Howell 1980. Gae- arise in an alkaline environment resulting in e¡ective tani et al. McKenna & U«ngo«r 2002). 1966. H2O2 is Sodium perborate (sp. Lowney 1964.1987. 2003 315 . coloured molecules that release of H2O2 by mixing sodium perborate and or reduce the coloured metallic oxides like Fe2O3 (Fe3þ) water is achieved without supplementary addition of to colourless FeO (Fe2þ). The thermocatalytic technique was proposed for many years as the best way of whitening non-vital root-¢lled teeth because of the high reactivity of H2O2 upon application of heat (Grossman1940. 1993) and Weiger et al.The released H2O2 can generate & Kleinberg1995). 1995. H2O2 is released during the decomposi. H2O2-releasing bleaching agents are therefore chemi- cally unstable. In this thermocatalytic proce- dure. Abram- son et al. formed that is further decomposed into di¡erent radicals or rahydrate is used as a H2O2-releasing agent. e.1985. Weine 1982.g. Cohen 1968). 1989. These pro. 313^329. 1907. 1995. In addition to this. (1994a) did (Moore et al. perhydroxy radicals preferably system (Tenovuo & Pruitt1984.) in the form of mono-. cotton pellets impregnated with 30^35% H2O2 were often used as temporary ¢llings (Weisman 1963. Kopp 1973. It should be appreciated that free H2O2. Several studies have reported bleaching e¡ective- radicals can cause oxidative e¡ects to lipids. temperature. Walking bleach technique hydroxide or light (Hardman et al.There are varietyof human regulatory di¡erent radicals or ions depending on pH value. tant cellular enzymatic reactions can be in£uenced Rotstein et al. n ¼ 3: trihydrate. 1984. peroxoborate (Table 1).Tewari & Chawla 1972. Chen et al. n ¼ 6: tetrahydrate ß 2003 Blackwell Publishing Ltd International Endodontic Journal. The whitening e⁄cacy of sodium However. of being mutagenic and cancinogenic. 1989) and therefore radicals are suspected not report any signi¢cant di¡erence in the e¡ectiveness Table 1 Old and new formulae (as cyclic peroxoborate) of sodium perborate Old formula New formula NaBO3n(H2O) 2  (NaBO2(OH)2)n(H2O) with n ¼ 1: monohydrate. 36. Brown1965. n ¼ 4: tetrahydrate with n ¼ 0: monohydrate. Maddipati et al.1993). In1990. Boksman et al. Figure 1 After adding water to sodium peroxoborate.or tet. n ¼ 4: trihydrate. 30^35% H2O2 is applied to the pulp cavity and heated by special lamps or hot instruments. The sensitivity tion of sodium perborate was 600 000 tonnes. bleaching agents (Goldstein & Garber 1995).

Walking bleach technique Attin et al. This is true for a sodium perborate sus. of dentine and cementum solubility is achieved (Rotstein coloured teeth. 1992a). Rotstein (g mL1).0^8. leads to a reduction of the surface microhardness 1993. Rotstein et al. of enamel and dentine. the microhardness of ing sodium perborate with 30% H2O2 was more e¡ective teeth was not in£uenced when treated by a mixture of than mixing with water (Ho & Goerig 1989. 1983. respectively. This suspen. between sodium perborate mixed with 3^30% H2O2 and this procedure led to long-term stability of the tooth the sodium perborate^distilled water mixture.g. a 10^12-fold reduction carbonate (2Na2CO3H2O2) can be used to bleach dis. becomes more porous by subsequent acid etching with Aldecoa & Mayordomo (1992) described good clinical 37% H3PO4. whitening therapy. bleach technique with a mixture of 30% H2O2 and Apart from an attack on the inorganic components of sodium perborate was as e¡ective as the thermocatalytic teeth. 36. the denaturation of collagen is presumed to be technique. these changes success rates when using a mixture consisting of sodium to enamel could have an in£uence on the adhesion of perborate and10% carbamide peroxide gel. According to these authors. (1993) tested the no signi¢cant change in the calcium:phosphate ratio in pH value of mixtures consisting of 2 g sodium perborate enamel.The precipitate is intensi¢ed and the enamel surface reported. 2000). the mixture of 30% H2O2 and perborate three components of teeth reduced signi¢cantly when showed an initial pH value of 7. et al. Further research on dentine observed when sodium perborate was mixed with water. However. 313^329. a suspension containing sodium perborate and water. 1992a. However. However. Therefore. percarbonate and water or 30% H2O2 had a good bleach. the pH of this mixture is alkaline. 1992a). However. It was also to the results of Ruse et al. Other surveys found that mix. There was no di¡erence is desirable because the whitening e¡ectiveness of buf. Weiger et al. This 316 International Endodontic Journal. 1994). the calcium:phosphate ratio in all the apparent. so that more frequent changes of the bleaching Influence of bleaching agents used for the agent may be necessary. 1987. Initially. it becomes acidic (Kehoe 1987. or a mixture of sodium perborate and 3% H2O2 pension mixed with water or H2O2.When 30% components of teeth correlate with a shift of the cal- H2O2 is mixed with sodium perborate in a ratio of 2 : 1 cium:phosphate ratio of apatite. If further et al. the mode of action of bleaching agents (Lado et al. Complications of the walking bleach technique are Ramp et al. sion was used as a temporary intracoronal ¢lling after It was hypothesized that alterations in dentine perme- application of a regular walking bleach paste with ability owing to whitening therapies may result in pro- sodium perborate and H2O2. Suspensions consisting of sodium et al.Warren et al. They observed stein & Friedman 1991). the whitening e¡ect of the second mixture can take longer. 2003 ß 2003 Blackwell Publishing Ltd . e. 1988a). H2O2. changes of composition or structure of the inorganic 30% H2O2 has a pH value between 2 and 3. sodium perborate and 30% H2O2 carried out under the 1990). This increase in pH or distilled water. dentine and cementum of teeth. a distinct increase of the pH value of 9^ cantly higher after use of 30% than after use of 3% 11was achieved. (1990) who found no change shown that the pH signi¢cantly increased with decreas. The highest initial pH was application of 35% H2O2. contributed to an acidic pH of the bleaching reagent. clinical after contact with a 35% H2O2 solution for several min- studies using sodium percarbonate have not been utes. in the calcium and phosphate content in enamel after ing concentration of H2O2. with 3% instead of 30% H2O2. Freccia et al. dentine and cementum after application of a and 1 mL of 10^30% H2O2 or distilled water. 1995). Rot. enamel. Scanning electron microscope photographs show a ing e¡ect on teeth which were arti¢cially stained in vitro precipitate formed on the surface of enamel specimens by iron sulphide (Kaneko et al. These ¢ndings do not correspond perborate used (mono-. between a pure 30% H2O2 solution and a suspension fered alkaline H2O2 is signi¢cantly higher than the e¡ect consisting of sodium perborate and 30% H2O2 (Rotstein of unbu¡ered H2O2 (Frysh et al. tri. (1996) determined the calcium:phosphate ratio in 30% H2O2 is added. The shade stability of teeth trea- walking bleach technique on tooth tissue ted by a mixture of perborate and water is as high as the shade stability of teeth in which a mixture of sodium A 30% H2O2 irrigation at both 37 and 50 8C temperature perborate with 3 or 30% H2O2 was used (Rotstein et al.or tetrahydrate). (1982) showed that the walking same temperature conditions (Lewinstein et al. The authors claimed that nounced bacterial contamination of dentine.7 depending on the 30% H2O2 was used. Ari & U«ngo«r 2002). composite restorations (Titley et al. 1996). In neutral or weak alkaline pH for all compositions was contrast to this. Generally. and cementum showed that loss of calcium was signi¢- Within a day. when mixing sodium perborate Other H2O2-separating agents such as sodium per.

1999. over. Therefore. An increased risk of the oral cavity. How. De¢cient restora- ever. Walking bleach technique contamination may contribute to the occurrence of that application of the bleaching agent often needs to external resorptions (Cvek & Lindvall 1985). tions should be identi¢ed before bleaching therapy and tleness of dentine could be detected by using a mixture should be replaced. How. it is important that the tooth is restored with high 1992. Colour of the tooth result- tine. accessible remnants of It is important to determine whether discolouration of pulp tissue is recommended (Attin & Kielbassa 1995). Ernst et al. These adverse e¡ects are signi¢cantly lower for this makes it di⁄cult to select the correct shade of ¢lling mixture of sodium perborate with either water or 30% material prior to bleaching. Gen- et al.6% the ¢lling material should be completely set before the H2O2) was applied in the vital bleaching therapy. A root-canal ¢lling should also prevent coronal^apical Whether bleaching increases the brittleness of teeth is passage of microorganisms or other substances. such of importance to the clinical outcome. Addi- tional cleaning of the cavity with 1^3% sodium hypo- Preliminary treatment chlorite for removal of di⁄cult. a radiograph should be takento check parison to the control group treated with water. which might have detrimental there are only a few reports on this topic. Prior to treatment. ing from bleaching cannot be reliably predicted and 2002). Seghi & Denry e¡ects on the apical tissue. of sodium perborate with 30% H2O2 (Glockner et al. Therefore. The patient should to remove the smear layer (Hu«lsmann 1993. as bleaching agents. 1988. possible complications and the fact penetrate more easily into the dentine and therefore ß 2003 Blackwell Publishing Ltd International Endodontic Journal. Aldecoa & Mayordomo erally. 36.1981. 2003 317 . it is advisable to hydrogen peroxide. Howell 1980. 1995). It is assumed that bleaching agents are able to treatment stages. The surface of In some reports. Therefore. severely discoloured dentine should be removed cautiously to prevent further weakening. the tooth is caused by internal staining. If the restorations are only discoloured. no fractures of whitened either apply temporary materials (for carious lesions or teeth were reported in studies on internal bleaching replacement of de¢cient ¢llings) before treatment or to (Brown 1965. Heling et al. Beer 1995). according to another study. they should be 1995). More. 1990. Holmstrup replace restorations after completion of bleaching. ing the whitened tooth colour. fracture may be expected when the tooth is already weakened by tooth tissue loss (Geurtsen & Gu«nay Preparation of the pulp cavity 1995). information should be given about the di¡erent 1995). conditioning of the dentinal surface of the tooth should be cleaned thoroughly to estimate the the access cavity with 37% H3PO4 is suggested in order degree of external discolouration. beginning of the bleaching therapy. the dentinal tubules. be informed that the results of bleaching therapies are Others advise cleaning the pulp cavity with alcohol not predictable and that complete recovery of colour is before application of the bleaching agent so that the den- not guaranteed in all cases (Baratieri et al. carious lesions should be restored. Feiglin 1987. Unfortunately. root-¢lling materials bleach technique and necrotic pulp tissue are removed completely. be repeated for obtaining optimal results. Abou-Rass 1998). 1995. The latter suspension did not change the dentine permeability for the microorganisms in com. existing restorations of 30% H2O2 than after use of a mixture of sodium per- and tooth substance borate and water. such as tensile and shear strength (Chng et al. renewed at the end of treatment with materials match- mental e¡ects on the biomechanical properties of den. 313^329. Generally. 30% hydrogen peroxide had detri. In particular. no increase in the brit. a de¢cient root ¢ll- (1992) observed a 30% reduction in fracture resistance ing should be replaced prior to bleaching therapy and of enamel when 10% carbamide peroxide gel (3. it should be appreciated that teeth can be weakened the bleaching agent and to avoid leakage of the agent into by removal of stained dentine. Anitua et al. quality ¢llings in order to ensure the e¡ectiveness of ever. Attin et al. Glockner et al. A thoroughly cleaned root authors concluded that the low pH value of the 30% canal and application of a dense root ¢lling are prerequi- H2O2 solution led to an acid-induced enlargement of sites for a successful outcome of root-canal treatment. tine becomes dehydrated (Werner 1989. Before preparation of the access cavity. The access cavity should be shaped in such a way that Clinical performance of the walking remnants of restorative materials. a rubber dam should be applied to protect the adjacent structures. The the quality of the root ¢lling. (1995) showed that the dentine permeability of Strepto- coccus faecalis was signi¢cantly higher after application Examination of root ¢llings.

H3PO4 does not improve the bleaching e¡ectiveness of The use of 30% H2O2 is not appropriate because of possi- either sodium perborate or of high concentrated H2O2 ble risks such as cervical resorptions (Friedman et al. Successful bleaching these agents are able to penetrate the dentine easily (Fuss becomes apparent after one to four visits. Therefore. margins of the cavity should be etched with 37% Root ¢llings do not e¡ectively prevent di¡usion of bleach. (1992b) demon. In this phase of treatment. so that no internal stabilization of the tooth is (Steiner & West 1994). In case of severe dies have shown that removal of the smear layer with discolouration. are more e¡ective following pretreatment. This avoids re-contamination with bacteria Application of the bleaching agent and staining substances and improves the stability of Sodium perborate (tetrahydrate) mixed with distilled the tooth. respectively. placed curves in an incisal direction. 313^329. Rotstein et al. in order to avoid over-bleaching (Geurtsen & Gu«nay 1995). it may not be advisable to remove should be instructed to evaluate the tooth colour on a the smear layer from the dentine of the pulp chamber daily basis and return when the bleaching is acceptable prior to bleaching. and occlusal adjustment may be required in order bleaching agents on the discoloured dentine should not to avoid overloading the tooth.1989. 2001). the impact of the 1995). With this method material. 1992). simpli¢es the application of the temporary ¢lling mate- tion of the proximal dentinal tubules unprotected.3% H2O2 can be applied in place of water. the access cavity should be restored with a composite which is adhesivelyattached to enamel and dentine. provided.1998). However. leaves a large por. be hampered by the cervical seal. tion of the barrier. A £at barrier. a good seal prevents H2O2 solution into the root canal. that is covered with a bonding material. This can be controlled by Before application of the bleaching agent. the enamel using a periodontal probe placed into the pulp cavity. about the increased risk of fracture (Baratieri et al. In addition. the cemento^enamel junction. 36. H3PO4 in order to enable an adhesive temporary ¢lling. Horn et al. The proximal cemento^enamel junction pellet. the patient should be informed ment de¢nes an internal pattern for the shape and loca. distal margins of the access cavity. agent as mentioned above (Weiger1992). (Casey et al. A cotton & West 1994). 1988. The intracoronal level of the pulp chamber is ¢lled with the sodium perborate the barrier is placed 1 mm incisal to the corresponding mixture and not with an adhesively attached restorative external probing of the attachment. If bleaching of the cer- vical region of the tooth is required a stepwise reduction Restoration of the access cavity and postoperative of the labial part of the seal and use of a mild bleaching radiograph agent is recommended for the ¢nal dressings (Rotstein et al. Smith et al. Cervical seal Temporary ¢lling The root ¢lling should be reduced 1^2 mm below the enamel^cementum junction. applied with an amalgam carrier or plugger and should sion of bleaching agents into the periodontium. and labial aspect of the tooth. age of the bleaching agent into the oral cavity. 1992b). Therefore. 1989). Therefore. The walking bleach technique requires a sound seal men (Costas & Wong 1991. Kinomoto et al. barrier location should be determined by probing the The temporary ¢lling is only attached to the enamel level of the epithelial attachment at the mesial. the coronal outline of the attach. The bleaching agent can be ment of dentine with acid may lead to an increased di¡u. to avoid It is often di⁄cult to insert ¢lling material on to soft leakage of bleaching agents in the periodontium (Steiner sodium perborate mixture or a cotton pellet. stu. level with on the sodium perborate mixture and then light-cured. Following bleaching. the labial cemento^enamel junction. Walking bleach technique Attin et al. The seal material re-contamination of the dentine with microorganisms should reach the level of the epithelial attachment or and staining substances. This can- strated that a 2 mm layer of glass-ionomer cement was not be guaranteed if temporary ¢lling materials are required to prevent penetration of a 30% concentrated used (Waite et al. ing agents from the pulpal chamber to the apical fora.1998). The rial. A sound restoration with sealed dentinal water in a ratio of 2 : 1 (g mL1) is a suitable bleaching tubules is a prerequisite to create a successful bleaching 318 International Endodontic Journal. the pretreat. as be changed every 3^4 days. However. However. The patients et al. around the access cavity with composite or compomer sealing the root ¢lling with glass-ionomer cement or restorative to ensure its e¡ectiveness and to avoid leak- composite is essential. 2003 ß 2003 Blackwell Publishing Ltd .

Attin & Kielbassa 1995). 1988b. There are di¡ering posite materials used for ¢nal restoration of the access opinions on whether teeth that respond rapidly to cavity (Demarco et al.1993). 2003 319 . as the wide open dentinal tubules of young ß 2003 Blackwell Publishing Ltd International Endodontic Journal. Barghi & Godwin 1994). Glockner et al. Despite many clinical reports. Furthermore. which 1997) that is caused presumably by di¡usion of staining are ¢lled with composite. 1991). darkening after internal in unbleached enamel (Titley et al. it is uncer- 7 days withwater is recommended to avoid the reduction tain whether darkening after bleaching is more probable of adhesion of composites to enamel (Torneck et al. radiographic inspection within the ¢rst year after cess. 1995). there are few evidence- ization of composite (Torneck et al.1992. It is assumed that remnants of peroxide or oxygen on the surface or pores of the tooth inhibit the polymer. Howell 1980). Discolouration caused by ing to prebleached dental hard tissue could be achieved restorative materials has a dubious prognosis (van der after a period of about 3 weeks (Cavalli et al. 1993.1970. Swift & Perdiga‹o1998). 36. Holmstrup et al. The formation of composite bleached tooth with the adjacent teeth is regarded as tags in bleached enamel is less regular and distinct than an optimal result. and dentine is temporarily reduced (Titley et al. the cavity can also be bleaching therapy as teeth that are stained for a short cleaned with catalase or sodium hypochlorite (Rotstein period of time (Brown 1965. Murchison et al. 1996). 1991). Adibfar et al. During this period. Feiglin 1987. Howell 1980. The negative in£uence ginal gaps between the ¢llings and the tooth. occasionally show marginal substances and penetration of bacteria through mar- leakage (Barkhordar et al. 2001. 1993. based studies on aesthetic dentistry (Niederman et al. Hodosh et al. bleaching (Table 2). ments or restorations (Brown 1965). 1990. Glockner operative radiographs after bleaching. 1965. 2001). 1995. Dishman et al. 1992. 1997. Dishman et al. 1981). However. given mend the use of composites with light colours. Colour stability 1989). Prognosis and complications during internal Toko & Hisamitsu 1993. bleached in young patients than in older patients erature regarding the time intervals for taking post. However. Glass-ionomer cement also has a reduced adhesion to bleached dentine (Titley et al. Baratieri et al. a the bleaching therapy does not result in complete suc. (Chandra1967. when the tooth is heavily or mildly discoloured (Brown 1991. Some after treatment in order to diagnose cervical resorption studies report that stained teeth can be more easily as early as possible. silver. 1999). Howell (1981) 1993. in case by the European Society of Endodontology (1994). No information is available in the lit. Some have presumed that teeth with a discolouration ing adhesives (Kalili et al. the colour cury. existing for several years do not respond as well to To dissolve remnants of peroxide. Some with the recommendations for postoperative radio- authors (Glockner et al. Josey et al. Burgt & Plasschaert 1986). 313^329. In accordance et al. 1990. 1994). Brown (1965) reported that of bleaching agents (Kehoe 1987. 1994. Garc|¤ a-Godoy et al.Titley et al. Optimal bond. Torneck et al. 1997). achieved by pretreatment of enamel with dehydrating 1995. bleaching of non-vitalroot-filled teeth 1996. Most reports present initial results following ture may in£uence composite adhesion (Ruse et al. It is worth of H2O2-containing bleaching agents on adhesion can noting that the opinion of the patient regarding the suc- be clearly reduced by moderate bevelling of the cavity cess of the therapy is often more positive than the opi- before acid etching (Cvitko et al. The adhesion of composites to bleached enamel bleaching is suggested. copper. 1992. This could bleaching can be observed occasionally (Friedman explain why access cavities of bleached teeth. agents such as alcohol and the use of acetone-contain. No scienti¢c study has a calcium hydroxide dressing should be placed in the yet directly compared the bleaching e⁄cacy in di¡er- pulp cavity for bu¡ering the acidic pH which can occur ently (for example greyish or yellowish) discoloured on cervical root surfaces after intracoronal application non-vital teeth. Attin et al. bleaching have a better long-term colour stability A radiograph of the bleached tooth should be taken (Howell 1981. It is less likely that changes in the enamel struc. 1998). Feiglin1987. Abou-Rass 1998) recom. graphic controls of endodontically treated teeth. A contact time of at least could not con¢rm this claim. The same can be nion of the dentist (Anitua et al. Walking bleach technique therapy (Baratieri et al. 1988). iodine) are extremely di⁄cult to stability of the bleached tooth should be controlled and remove or alter by bleaching. trauma or necrosis induced discolouration can be suc- The calcium hydroxide suspension temporarily placed cessfully bleached in about 95% of cases compared to into the pulp chamber after completion of the bleaching lower values for teeth discoloured as a result of medica- procedure does not interfere with the adhesion of com. Certain metallic ions (mer- Shinohara et al. Abou-Rass 1998). Complete colour matching of the 1990. 2001). 1990).

Table 2 Studies concerning the success rate of internal whitening treatment of non-vital root-¢lled teeth Period of Reference NumberMethod time (years) Success rate Remarks Abou-Rass (1998) 112 wbt: sp. 2003 Walking bleach technique Attin et al. 2% partial success) Assessment of the patient: 99.5% refractory discolouration) Chandra & Chawla (1972) 230 15 different techniques 1 93% success Failures were associated with insufficient fillings 7% failure Feiglin (1987) 20 Thermocatalytic: 130 vol H2O2 6 45% success Teeth of younger patients showed better Following wbt: sp.4% failure Aldecoa & Mayordomo (1992) 6 100% success (90% complete. 7. (1988) 58 Three different techniques 8 50%: successful Highest percentage of failures occurred (a) Thermocatalytic: 30% H2O2 29%: acceptable between 2 and 8 years after whitening (b) wbt: 30% H2O2 21%: failure treatment (c) Thermocatalytic þ wbt: 30% H2O2 Glockner et al. þ 30% H2O2 5^15 93% success Failure because of internal cervical deposit 7% failure which could be successfully bleached Anitua et al. 10% partial success) Brown (1965) 80 Thermocatalytic: 30% H2O2 5 75% success (39% complete. þ 30% H2O2 5 Assessment of the dentist: Ideal cases: anterior teeth without proximal 66% success of entire cases and restorations 84% success of ideal cases Success. 46% partial success) Following wbt: 30% H2O2 25% failure (17.5% no improvement. (1990) 258 wbt (sp. if optimal. very good or good result ß 2003 Blackwell Publishing Ltd Assessment of the patient: 92% success of entire cases and 98% of ideal cases Holmstrup et al.4% success 0. 26% acceptable) Three teeth with transient pain bleaching therapy 10% failure 69 3 79% success (49% good. 7% partial success) One failure: one tooth which was Following wbt: 30% H2O2 bleaching therapy 2% failure discoloured since 40 years . 30% acceptable) 20% failure Howell (1980) 41 Thermocatalytic: 30% H2O2 Immediately after 97% success (90% complete. (1996) 34 wbt: sp. (1988) 95 wbt: sp. þ mixture 55% failure success rates of 3/4 water and 1/4 130 vol H2O2 Friedman et al. þ 110 vol H2O2) 4 Assessment of the dentist: 100% success (98% complete. 36.320 International Endodontic Journal. þ water Immediately after 63% success (63% good. (1999) 86 wbt: sp. þ 30% H2O2 3 Entire cases: Success and ideal cases: see above 82% success 100% success in patients between 15 and 17% improvement 25 years of age 6% failure Ideal cases: 95% success 5% improvement 0% failure Glockner et al. 313^329.

A combination of internal bleaching procedures with one of the other causes is responsible for 13. Teeth with internal discolouration caused by root-canal medica- ments. 1999). In these cases. Anterior teethwith sev- insufficient filling eral approximal restorations occasionally show a less optimal result than teeth with a palatal access cavity only (Glockner et al. no changes in the tooth substance could be detected. 1983). however. 313^329. Complications Occurrence of external cervical resorption is a serious complication following internal bleaching procedures (MacIsaac & Hoen 1994. 2003 321 . 58% partial success) mended in order to get an optimal result. Lado et al. 5. This may be because of the fact that composites cannot be bleached (Monaghan et al. transplantation or periodontal surgery) and 3. 15.1992). sometimes swelling of the papilla or percussion sensitiv- 36 19 19 ity of the bleached teeth can be observed (Harrington & Natkin 1979. However.9% by intracoronal bleaching. 1996. However. Heller et al. sodium perborate.1% of cases the resorption was caused by orthodon- tic treatment. Furthermore. partly diagnosed many years after internal bleaching was applied (Harrington & Natkin Thermocatalytic: 30% H2O2 Thermocatalytic: 30% H2O2 Following wbt: 30% H2O2 1979. sp. 44% partial success) The only failure was associated with an bleaching success (Brown1965. Attin et al. 1992).6% of cervical resorption cases.g. 1983). root-¢lling materials or metallic restorations such as amalgam have a poor prognosis regarding bleaching success (Brown1965). Cervical resorp- tions often proceed in an asymptomatic way. replacing the existing restora- tions after ¢nishing the whitening treatment is recom- 100% success (42% complete. Walking bleach technique The only failure was successfully bleached again teeth enable a better di¡usion of the bleaching agent. Howell1981). Friedman 1997). the studies and case reports indicate that application of heat (thermocataly- tic method). One month after bleaching. 36.1% by surgery (e. Madison & Walton (1990) showed that the thermocatalytic  ß 2003 Blackwell Publishing Ltd International Endodontic Journal. lack of a cervical seal and the use of 30% Howell (1981) H2O2 are associated with the occurrence of cervical resorption. Heithersay (1999) analysed 257 teeth in 222 3% failure 5% failure No failure patients with cervical resorptions and discovered that in 24. experimental animal studies showed histological signs of resorptions only 3 months after internal thermocatalytic bleaching ther- apy with heated 30% H2O2 (Rotstein et al. Table 2 shows that teeth that were root-¢lled as a result of trauma often show cer- Tewari & Chawla (1972) vical resorption. 1997). not all studies con¢rm the age dependency of 97% success (53% complete. 1 2 5 Table 3 provides an overview of clinical studies and case reports in which the occurrence of cervical resorp- tion was observed. wbt: walking bleach technique.1% by dental trauma. In an experimental animal study. 1991a. Cervical resorption is mostly asymptomatic and is usually detected only through routine radiographs (Trope 95% success Intentional endodontic treatment of tetracycline-stained teeth. Lado et al.

The columns cervical seal. þ wbt: 30% H2O2 2 14 No No Yes Heithersay et al. 2003 Walking bleach technique Attin et al. sp. þ 30% H2O2 None ^ ^ ^ ^ Anitua et al. (1988) 69 wbt: sp.322 International Endodontic Journal. occurrence of trauma and application of heat refer to teeth which showed cervical resorption. Table 3 Occurrence of cervical resorption after internal bleaching procedures in clinical studies and case reports Number of Whitening Cases of cervical Age of patients Reference bleached teeth treatment resorption (years) Cervical seal Trauma Heat Clinical studies Abou-Rass (1998) 112 wbt: sp. wbt: walking bleach technique. þ 30% H2O2 1 15 No Yes No Harrington & Natkin (1979) 7 Thermocatalytic: 30% H2O2 Following wbt: sp. þ 30% H2O2 Cvek & Lindvall (1985) 11 Thermocatalytic: 30% H2O2 11 < 21 No Yes: 10 Yes Following wbt: 30% H2O2 No: 1 Friedman (1989) 3 No exact description 3 ? ? ? ? Gimlin & Schindler (1990) 1 wbt: sp. þ 30% H2O2 Latcham (1986) 1 wbt: Endoperox 1 8 No Yes No Latcham (1991) 1 wbt: Endoperox 1 14 No Yes No Montgomery (1984) 1 No exact description 1 19 ? Yes ? ß 2003 Blackwell Publishing Ltd The age of the patient means the age at the time of the whitening treatment. (1988) 58 (a) thermocatalytic: 30% H2O2 1 24 No No Yes (b) wbt: 30% H2O2 1 18 No No No (c) thermocat. (1986) 1 wbt: sp. þ 30% H2O2 7 14^29 No Yes Yes Lado et al. (1983) 1 Thermocatalytic: 30% H2O 1 44 No No Yes Following wbt: sp. . (1994) 204 Thermocatalytic: 30% H2O2 4 1: 10^15 No Yes Yes Following wbt: 30% H2O2 3: 16^20 No Yes Yes Holmstrup et al. sodium perborate. þ 30% H2O2 1 13 No Yes No Goon et al. þ110 vol H2O2 None ^ ^ ^ ^ Aldecoa & Mayordomo (1992) Friedman et al. ?: No statement. (1990) 258 wbt: sp. 36. 313^329. þ water None ? Yes Predominantly No Case reports Al-Nazhan (1991) 1 Thermocatalytic: 30% H2O2 1 27 No No Yes Following wbt: sp.

1994b). Neuvald & Consolaro 2000). mixtures of sodium perborate with 30% H2O2 or water. when a mixture of sodium perborate-tetrahydrate and It has been proven that formulations using either 30% water is used. on the radiograph. Lado et al. which later results in bacterial coloni.Increas. because macrophages stimulate both to 82% of the H2O2 (30% concentration) which was osteoclastic bone resorption and destruction of dentine applied in the pulp chamber. This could trigger in£ammation of adjacent tis. the penetration of H2O2 into resorption. 1976). Bleaching is per- Moreover. Harrington & Natkin et al. using the walking bleach technique. 1983).1983). Root-canal dressings consisting zation of the open dentinal tubules (Cvek & Lindvall of calcium hydroxide are able to induce a higher pH in 1985). 1981. temperature (Outhwaite et al. external root resorption (Goon et al. Cases have tiumvia dentinal tubules and directly induces an in£am. This observation may be explained by 1996. decreasing dentine thickness and high surrounding Al-Nazhan 1991). are more toxic for periodontal ligament cells as com. 2003 323 . a 2001). 1994). However. Hanks et al. Application of heat leads to widening of dentinal tubules and facilitates dif- Conclusions fusion of molecules in the dentine (Pashley et al. 313^329. dissemination of and cementum induced by lytic processes in periodontal H2O2 into dentine cannot be totally prevented using tissue (Jime¤nez-Rubio & Segura 1998). Other authors claim 1986). after bleaching. In£ammatory osteolytic lesions have a low-pH that di¡usion of H2O2 via dentine causes irritation in value that is optimal for hard tissue resorption the periodontium. tion is orthodontic tooth extrusion. 1991c). followed by restora- tion. 1986. cervical region of tooth. 1997). 1994) and radicals and 1990). application of heat resulted in generation of formed by temporarily placing a mixture of sodium per- hydroxyl radicals from H2O2 that are extremely reactive borate-(tetrahydrate) and water into the pulp chamber. The mechanisms responsible for resorption in The amount of H2O2 di¡usion is signi¢cantly lower bleached teeth have not yet been adequately explained. et al. Walking bleach technique technique supported the development of external et al. According to Rotstein the fact that sodium perborate inhibits the function of (1991). Webber 1983). Emery 1996). It is known that H2O2 can hydroxide can sometimes prevent progression of exter- di¡use through dentine (Pashley & Livingston 1978. Gimlin & Schindler Wang & Hume 1988. It is not advisable to use the thermocatalytic ß 2003 Blackwell Publishing Ltd International Endodontic Journal. (McCormick et al. and have been shown to degrade components of connec. 1991b. Friedman 1989. 36. shown that an intracoronal dressing with calcium matory resorptive process. Even if there is low-H2O2 di¡usion into adjacent pared to a perborate^water suspension (Kinomoto et al. nal resorption (Montgomery 1984. Koulaouzidou et al.1988). Attin et al. In the case of severe and refrac- cervical tissues is also increased after pretreatment of tory discolouration. Di¡usion of H2O2 to the staining substances. This mixture releases H2O2 which is able to react with tive tissue (Dahlstrom et al. In addition. tissues when sodium perborate solutions are applied. According to the authors. Cervical resorption can also be trea- dentinal tubules inyoung teeth (Schro«der1992). Latcham although this could not be veri¢ed. than in case of application of 30% H2O2 H2O2 alone or in combination with sodium perborate mixed with di¡erent sodium perborates (Weiger et al. only osseous regen- the low pH value of highly concentrated H2O2 can be eration of the defect and no dental hard tissue regenera- considered as tissue damage inducing factors (Friedman tion could be detected. A possible explanation is that H2O2 can more tion of the tooth with a post-retained crown (Latcham easily penetrate into the periodontium because of wide 1991. Tronstad sues and external resorption. 1986. However. tissue are supported by this treatment. (1981) assumed that reparative formations of hard (1979) suspected that H2O2 di¡uses into the periodon. However. the walking bleach technique the cervical region can be facilitated by cervical defects applied in that study with a sodium perborate^H2O2 or special morphological patterns at the enamel^cemen- solution did not cause cervical resorption even 1 year tum junction (Rotstein et al. Another possible therapy for external cervical resorp- ing therapy at a young age often have external resorp. lack of root cementum resulted in di¡usion of up macrophages. 3% H2O2 could be used instead of dentine in the pulp chamber with 5% NaOCl (Barbosa water. ted by direct restorations after gaining surgical access ing permeability of dentine is associated with both to the defect (Meister et al. (1983) presumed that application of sound cervical seal should be assured in order to prevent bleaching agents led to denaturation of dentine in the penetration of H2O2 through dentine (see above). dentine (Tronstad et al. Table 3 reveals that patients who had bleach. this Tooth extraction is often inevitable in cases of severe denatured dentine induces a foreign body reaction. This explains the increasing dissemination of H2O2 into Discoloured root-¢lled teeth can be successfully treated dentine with rise in temperature (Rotstein et al.

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