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Contemporary trends and techniques in tooth

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200403PPA Perdigao 4/15/04 3:33 PM Page 185

C O N T I N U I N G E D U C A T I O N 7

CONTEMPORARY TRENDS AND

TECHNIQUES IN TOOTH WHITENING:
A REVIEW

P E R D I G A O
Jorge Perdigo, DMD, MS, PhD*
Luiz Narciso Baratieri, DDS, MS, PhD
Gilberto Mller Arcari, DDS, MS

16
3

MARCH
The popularity of tooth whitening has increased with the advent of patient-applied,
peroxide-based whitening agents, as well as increased media influence. Peroxides
are considered effective and safe when used under professional supervision.
Whitening methods include those prescribed by a dental professional for the
patients at-home use, those applied by the dental professional in the office, a com-
bination of both, or methods available over the counter (OTC). This article reviews
the effect of contemporary whitening agents and illustrates the clinical application
of three methods prescribed by dental professionals.

Learning Objectives:
This article presents the use of three different types of whitening agents for
improved aesthetics. Upon reading this article, the reader should be able to:
Distinguish the difference between professionally administered in-office
and at-home tooth-whitening results.
Identify the effects of whitening agents on dental tissues.

Key Words: whitening, aesthetics, over-the-counter, at-home, in-office

*Associate Professor, Division of Operative Dentistry, Department of Restorative Sciences,

University of Minnesota, Minneapolis, Minnesota.
Professor and Chair, Department of Operative Dentistry, University of Santa Catarina,
Florianpolis, SC, Brazil.
Associate Professor, Department of Clinical Dentistry, University of Santa Catarina,
Florianpolis, SC, Brazil.
~
Jorge Perdigao, DMD, MS, PhD, 8-450 Moos Tower, 515 Delaware Street SE,
Minneapolis, MN 55455
Tel: 612-625-8486 Fax: 612-625-7440 Email: Perdi001@umn.edu

Pract Proced Aesthet Dent 2004;16(3):185-192 185

200403PPA Perdigao 4/15/04 3:33 PM Page 186

Practical Procedures & AESTHETIC DENTISTRY

N ew products and techniques that are less invasive

to dental tissues are now being used to fulfill rising
patient demands for aesthetics. The use of peroxide is
now generally accepted as a safe and effective treatment
for discolored teeth.1 When these discolorations com-
promise aesthetics, whitening may also be recommended
before a clinician can perform an anterior bonded restora-
tion (eg, porcelain veneers and direct bonding).2
Carbamide peroxide has been used as a bleach-
ing agent since 1989.3 Using a concentration of 10%
carbamide peroxide, vital bleaching became a standard Figure 2. Postoperative facial appearance following at-
technique also known as nightguard vital bleaching home whitening with 10% carbamide peroxide.
(Figures 1 and 2). This technique (ie, at-home bleaching)
allows the patient to use a tray whitening device at home,
while the results and concentrations are monitored by a
dental professional.
Other materials based on higher concentrations of
hydrogen peroxide are also available for in-office power
bleaching. More recently, polyethylene strips impregnated
with 5.3% or 6.5% hydrogen peroxide (OTC concen-
tration and dentist-prescribed concentration, respectively)
were introduced (Crest Whitestrips, Procter & Gamble,
Cincinnati, OH).
Figure 3. Preoperative evaluation demonstrates discol-
Effects of Whitening Agents on oration of tooth #8(11) following traumatic injury.
Although the canal space within the compromised tooth
Hard Dental Tissues was calcified, the tooth responded well to cold tests.
Carbamide peroxide has been used for many years as
an oral antiseptic before it was applied as a gel for home
bleaching.3,4 Numerous carbamide peroxide-based home Initially, tooth bleaching with peroxides (both hydro-
bleaching products have been introduced in the last 13 gen peroxide and carbamide peroxide) was performed
years for use with the nightguard bleaching technique. without a comprehensive understanding of the effects of
Carbamide peroxide is basically urea combined with the bleaching procedure on the structure and chemical
hydrogen peroxide.5 Both products are released when composition of the enamel surface. More recently, stud-
carbamide peroxide breaks down in contact with saliva. ies on enamel bond strengths and structural effects of
peroxide-based materials on enamel have been under-
taken.5-7 Several studies have shown that hydrogen per-
oxide- and carbamide peroxide-based bleaching agents
adversely affect the immediate bond strength of resins
to enamel.5,8-11 Bond strengths to dentin treated with hydro-
gen peroxide for 60 minutes followed by 37% phos-
phoric acid for 60 seconds (and vice versa) were
reported to be 0.0 MPa.12 Clinically, this decrease in
bond strengths is relevant because whitening is often
considered a preliminary treatment to improve the appear-
ance of teeth prior to the application of a bonded restora-
tion.13 Some authors have implied that the adverse effects
Figure 1. Preoperative appearance demonstrates severe
tooth discoloration in the maxillary anterior region. of peroxides on bonding are caused by residual oxygen

186 Vol. 16, No. 3

200403PPA Perdigao 4/15/04 3:33 PM Page 187
Figure 4. A resin spacer was added to the study model
over tooth #8 to facilitate development of a reservoir
within the whitening tray.
Figure 5. Two windows were cut in the areas correspond-
ing to teeth #7(12) and #9(21) so the teeth would not be
affected by the bleaching agent.
that inhibits resin polymerization,14,15 but roughening
the surface eliminates this adverse effect.16 Surface analy-
sis techniques have demonstrated that oxygen does not
accumulate within the near surface of enamel that has
been bleached with peroxides.6,17 Consequently, the
bond-strength reduction caused by bleaching with per-
oxide-based whitening agents is not associated with
the inhibition of resin polymerization by oxygen accu-
mulated within the enamel structure. The reduction in
enamel microhardness after two weeks of whitening with
10% carbamide peroxide may be responsible for the
decrease in enamel bond strengths, especially for gels
with low pH.7 At four weeks, the decrease in micro-
hardness was reversed.7
The action of bleaching agents on enamel may be
related to the fact that hydrogen peroxide is a strong
oxidizing agent that can remove stains from enamel and
dentin by oxygen-release mechanical cleansing.18 -21
Bleaching agents may also cause alterations in the chem-
Perdig~
ao
istry of hard dental tissues, inverting the ratio between
organic and inorganic components and increasing
solubility.22 In a recent energy dispersive spectrometry
study, the effects of 30% hydrogen peroxide on enamel
were found to differ from the effects induced by two
10% carbamide peroxide-based materials.23 While 30%
hydrogen peroxide resulted in a significant reduction in
the Ca:P ratio, neither a commercial 10% carbamide
peroxide gel nor an aqueous solution of 10% carbamide
peroxide resulted in significant changes in that ratio.23
Another study has shown that a 6-hour treatment of human
enamel with 10% carbamide peroxide results in a signifi-
cant loss of calcium compared with a water control, as
measured with the atomic absorption spectrophotome-
ter.24 These alterations in the chemical composition of
enamel may be transitory; their clinical relevance has
not been determined.
Effects of Whitening Agents on Soft Tissues
The carcinogenic potential of whitening agents has
raised some controversy.25 A court ruling resulted in a
ban of peroxide-containing tooth whiteners in the
United Kingdom.25 Oxidative stress can induce dam-
age in oral epithelial cells, resulting in premalignant
changes.26 The application of hydrogen peroxide and
DMBA (9,10-dimethyl -1,2-benzanthracene), a known
carcinogenic analogous to those found in tobacco smoke,
resulted in hyperkeratosis or carcinomas in the mucosa
of hamsters after 22 weeks, depending on the concen-
tration of hydrogen peroxide.27 A recent study, how-
ever, found that the chronic use of 35% carbamide
peroxide did not result in alterations of the cell cycle in
the oral mucosa of rats.28
Figure 6. The whitening tray was tried in. Note the space
allocated for the whitening reservoir on tooth #8.
PPAD 187
200403PPA Perdigao 4/15/04 3:34 PM Page 188
Practical Procedures & AESTHETIC DENTISTRY
Figure 7. Postoperative appearance following 2 weeks of
whitening with 10% carbamide peroxide. Note the
increased aesthetics and harmony between tooth #8 and
the adjacent dentition.
Figure 8. Preoperative appearance demonstrates the pres-
ence of tetracycline staining.
Concerning the pulpal tissue, teeth that were sched-
uled to be extracted for orthodontic reasons were
bleached with 10% carbamide peroxide for 4 hours or
left untreated.29 No significant differences were found
in the concentration of the enzyme heme oxygenase-1
(HO1) in the pulp. This enzyme HO1 is increased in
cells subjected to oxidative stress.
Based on current information, it has been concluded
that the use of dentist-monitored, at-home tooth whiten-
ing gels containing 10% carbamide peroxide carries
no carcinogenic risk and does not cause irreversible
damage to enamel.25,30 The safety of peroxides is cor-
roborated by the inclusion of at-home vital whitening in
the curriculum of the majority of dental schools in the
United States.31
At-Home Whitening
Nightguard vital bleaching using 10% carbamide per-
oxide gel is the most common whitening method applied
188 Vol. 16, No. 3
Figure 9. Right lateral view demonstrates severe staining
at the gingival regions in both the maxillary and mandibu-
lar dentition.
Figure 10. Left lateral appearance demonstrates discol-
oration throughout the entire buccal aspect.
by the patient while supervised by a dental professional
(Figures 3 through 7). Studies have shown that whiten-
ing of vital teeth is very effective, durable, and safe.32-
43
The literature has further indicated that peroxides
diffuse quickly into dentin reaching the pulp chamber.44
While tooth sensitivity seems to be the most common
adverse event with carbamide peroxide whitening, sen-
sitivity subsides with the termination of treatment.45
Sensitivity is generally associated with previous history
of sensitive teeth, increased frequency of application,
or the utilization of higher concentrations of carbamide
peroxide (eg, 20%).45,46 Although sensitivity may be a
result of the potential of carbamide peroxide to pene-
trate the pulp chamber, the rate of penetration depends
on the concentration and the commercial brand.47,48
Another factor that may affect sensitivity is the pH of
the bleaching gel. For whiteners used with the at-home
technique, the pH is within a range of 5.66 to 7.35.49
Sensitivity is also directly related to the frequency of
200403PPA Perdigao 4/15/04 3:34 PM Page 189
Figure 11. The teeth were isolated with a rubber dam to
protect the gingival tissues during in-office whitening.
Figure 12. Four applications of the whitening agent were
administered. The whitening material was placed for 15
minutes per application.
application of the gel patients who change the
whitening solution more than once a day report signif-
icantly more side effects than those who do not change
the whitening solution.50
Potassium nitrate and fluoride have recently been
added to the composition of certain whitening gels to
prevent sensitivity during treatment. One clinical study
demonstrated that potassium nitrate and fluoride added
to 10% carbamide peroxide gel reduced sensitivity over
a 2- week treatment period when compared to a 10%
carbamide peroxide gel without those two components.51
The use of reservoirs in the tray to allow for space
to retain the bleaching gel is a controversial issue.
Despite the recommendation of some manufacturers as
a light-cured block-out resin or a self-adhesive strip, the
use of spacers to create reservoirs for the bleaching
gel does not seem to increase the success of home
bleaching.52 The bleaching gel, however, remains active
for longer periods when reservoirs are used.53
Perdig~
ao
Figure 13. Postoperative facial view following the initial in-
office whitening session.
Figure 14. Note the harmonious whitening achieved
throughout the entire maxillary arch.
Power Bleaching
In 1918, a high-intensity light was first used to induce
a rapid increase in the temperature of hydrogen per-
oxide and thereby accelerate the whitening process.54
Lasers and high-intensity lights have been recommended
by some authorities for in-office bleaching despite the
disappointing results obtained in some studies.55 Power
whitening procedures are currently performed in-office
with concentrations of hydrogen peroxide in the range
of 15% to 40%. (Figures 8 through 15).56 The most
effective in-office whitening materials are those that
include a chemical catalyst: LumaArch (LumaLite Inc,
Spring Valley, CA; 35% HP, pH=5.5), Opalescence
Xtra Boost (Ultradent Products, South Jordan, UT; 38%
HP, pH=7.0); Zoom (Discus Dental, Culver City, CA;
25% HP, pH=7.9).56 When a chemical catalyst is
added to the hydrogen peroxide immediately prior to
bleaching, the oxygen is released rapidly, inducing the
whitening effect. Both LumaArch and Zoom use light
PPAD 189
200403PPA Perdigao 4/15/04 3:34 PM Page 190
Practical Procedures & AESTHETIC DENTISTRY
Figure 15. Lateral evaluation further verified lightening of
the previously discolored dentition.
Figure 16. Preoperative appearance demonstrates the
patients existing A2-shade. A slightly lighter shade was
desired at minimal cost.
sources exclusively for the bleaching treatment. For
Opalescence Xtra Boost, the use of light is optional.
Despite the recommendation, however, the application
of light does not significantly affect the rate of decom-
position of hydrogen peroxide for any of the three in-
office materials, as the whitening results are very similar
with and without irradiation with a light source.57 Heat
accelerates the release of oxygen, but these power
bleaching gels do not reach temperatures in the mouth
high enough to significantly increase the decomposi-
tion rate of hydrogen peroxide.57
The primary advantage of the in-office power
whitening technique compared to the at-home tech-
nique with a nightguard is that the former is not depen-
dent upon the patients compliance and the results can
be appreciated by the patient in the same session dur-
ing which the procedure is completed. On the other
hand, in- office procedures require extensive tissue iso-
lation and/or a resin barrier to prevent the gel from
irritating the soft tissues.
190 Vol. 16, No. 3
Figure 17. The patient was instructed to use one whitening
strip for 30 minutes, twice a day for 2 weeks.
Figure 18. Postoperative appearance demonstrates slightly
whiter dentition with satisfactory results.
Hydrogen Peroxide Strips
An OTC, 5.3% hydrogen peroxide-coated polyethyl-
ene strip (Crest Whitestrips, Procter & Gamble,
Cincinnati, OH) was recently introduced to the market.
According to the manufacturers recommendations, the
patient applies two strips per day for 30 minutes each.
A similar 6.5% hydrogen peroxide-coated strip is avail-
able by prescription. Clinical studies comparing the
whitening efficacy of 10% carbamide peroxide (which
breaks down in 3.5% hydrogen peroxide) with the effi-
cacy of the hydrogen peroxide-coated strips have
demonstrated that the polyethylene strips may be an
acceptable alternative to the nightguard method of at-
home whitening (Figures 16 through 18).46,58,59
Other Methods
An 18% carbamide peroxide (equivalent to 6.5% hydro-
gen peroxide) paint-on liquid is also available as an
OTC agent (Colgate Simply White Clear Whitening
Gel, Colgate-Palmolive, New York, NY). While clinical
200403PPA Perdigao 4/15/04 3:34 PM Page 191
studies have shown that this method can be effective,60
additional independent clinical studies are needed to
confirm its long-term impact on this therapeutic category.
Another OTC paint-on liquid is now available (Crest
Night Effects, Procter & Gamble, Cincinnati, OH) as a
19% sodium percarbonate bleaching film.61,62
Conclusion
A variety of whitening options are currently available
for patients seeking to enhance the appearance of their
smiles. When suggesting a professionally administered
whitening option, clinicians must be aware of the variety
of options currently available. Based on the patients exist-
ing condition and desired whitening effects, in-office, at-
home, or OTC modalities can be used to safely and
effectively address a variety of aesthetic concerns.
Acknowledgment
The authors do not have any financial interest or asso-
ciation with the manufacturers of the products mentioned
in this article.
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Dent Res 2003;82:B124.

192 Vol. 16, No. 3

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CONTINUING EDUCATION CE 7
CONTINUING EDUCATION

(CE) EXERCISE NO. 7

To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and complete as follows:
1) Identify the article; 2) Place an X in the appropriate box for each question of each exercise; 3) Clip answer sheet from the page and mail
it to the CE Department at Montage Media Corporation. For further instructions, please refer to the CE Editorial Section.

The 10 multiple-choice questions for this Continuing Education (CE) exercise are based on the article Contemporary trends and techniques in
tooth whitening: A review by Jorge Perdigao,~ DMD, MS, PhD, Luiz Narciso Baratieri, DDS, MS, PhD, and Gilberto Mller Arcari, DDS, MS.

This article is on Pages 185-192.

1. Contemporary whitening methods include:
a. Those prescribed by a dental professional for
at-home use.
b. Those applied by the dental professional in the office.
c. Over the counter (OTC) methods.
d. All of the above.
2. When reservoirs are used:
a. Success of home bleaching increases
b. The bleaching gel remains active longer.
c. The whitening process accelerates.
d. Success of home bleaching decreases.
3. Tooth sensitivity is generally associated with:
a. The pH of a bleaching gel.
b. An increased frequency of bleaching use.
c. The use of higher concentrations of carbamide peroxide.
d. All of the above.
4. The pH of at-home whiteners:
a. Is always less than 5.66.
b. Does not increase 9.62.
c. Ranges from 5.66 to 7.35.
d. Ranges from 7.35 to 9.62.
5. The use of dentist-monitored, at-home tooth
whitening gels containing 10% carbamide peroxide
carries no carcinogenic risk and does not cause
irreversible damage to enamel. There are no bleaching
products available that include more than 10%
carbamide peroxide.
a. Both statements are true.
b. Both statements are false.
c. The first statement is true, the second statement is false.
d. The first statement is false, the second statement is true.
6. The following have recently been added to the
composition of certain whitening gels to prevent
sensitivity during treatment:
a. Fluoride and DMBA.
b. DMBA and potassium nitrate.
c. Fluoride and potassium nitrate.
d. Potassium nitrate, DMBA, and fluoride.
7. Power whitening procedures are currently performed
in-office with concentrations of hydrogen peroxide:
a. Over 40%.
b. Between 15% and 40%.
c. Between 10% and 25%.
d. No more than 25%.
8. The most effective in-office whitening materials
are those that include a chemical catalyst added:
a. One hour prior to bleaching.
b. Directly to the teeth immediately after bleaching.
c. Immediately prior to bleaching.
d. No chemical catalysts exist.
9. One effective way to eliminate the adverse effects
of peroxides on bonding is:
a. By roughening the surface of the tooth.
b. By polishing the tooth prior to bleaching.
c. To skip bleaching the bonded teeth altogether.
d. Any of the above will prove effective.
10. Nightguard vital bleaching is also known as in-office
bleaching. Nightguard vital bleaching using 10%
carbamide peroxide gel is the most common whitening
method applied by the patient while supervised
by a dental professional.
a. Both statements are true.
b. Both statements are false.
c. The first statement is true, the second statement is false.
d. The first statement is false, the second statement is true.

194 Vol. 16, No. 3

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