Lasers Med Sci (2013) 28:1–6
DOI 10.1007/s10103-011-1037-4
ORIGINAL ARTICLE
Analysis of shade, temperature and hydrogen peroxide
concentration during dental bleaching: in vitro study
with the KTP and diode lasers
C. Fornaini & G. Lagori & E. Merigo & M. Meleti & M. Manfredi & R. Guidotti &
A. Serraj & P. Vescovi
Received: 21 July 2011 / Accepted: 30 November 2011 / Published online: 24 December 2011
# Springer-Verlag London Ltd 2011
Abstract Many dental bleaching techniques are now avail-
able, several of them using a laser source. However, the
literature on the exact role of coherent light in the biochem-
ical reaction of the whitening process is very discordant.
The aims of this in vitro study were: (1) to compare two
different laser sources, a KTP laser with a wavelength of
532 nm and a diode laser with a wavelength of 808 nm,
during dental bleaching, and (2) to investigate the relation-
ships among changes in gel temperature, tooth shade and
hydrogen peroxide (HP) concentration during laser irradia-
tion. Altogether, 116 bovine teeth were bleached using a
30% HP gel, some of them with gel only and others with gel
plus one of the two lasers (532 or 808 nm) at two different
powers (2 and 4 W). The KTP laser produced a significant
shade variation with a minimal temperature increase. The
diode laser led to a higher temperature increase with a
greater reduction in HP concentration, but the change in
shade was only statistically significant with a power of
4 W. At a power of 2 W, the KTP laser caused a greater
change in shade than the diode laser. No significant corre-
lations were found among temperature, HP concentration
and shade variation. The KTP laser appears to provide better
results with less dangerous thermal increases than the diode
laser. This might call into question most of the literature
affirming that the action of laser bleaching is by increasing
the gel temperature and, consequently, the speed of the
redox reaction. Further study is required to investigate the
C. Fornaini (*) : G. Lagori : E. Merigo : M. Meleti :
M. Manfredi : R. Guidotti : A. Serraj : P. Vescovi
Oral Medicine and Laser-assisted Surgery Unit, Dental School,
Faculty of Medicine, University of Parma,
via Gramsci,
14- 43126 Parma, Italy
e-mail: carlo@fornainident.it
correlations between the parameters investigated and efficacy
of the bleaching process.
Keywords Dental bleaching . Laser . Hydrogen peroxide .
KTP . Diode
Introduction
In recent years there has been a renewed interest in dental
bleaching techniques. Many people, often influenced by
intense communication media, wish to have a perfect white
smile and this is the reason why a huge amount of recent
work has been done to offer valid treatments to satisfy
patient needs [1]. Dental bleaching is achieved by an oxi-
dation–reduction reaction in which reactive oxygen species
and some free radicals released from the degradation of the
bleaching agent attack the long-chained, dark-coloured
chromophore molecules present in the dental tissues and
split them into smaller, less-coloured and more diffusible
molecules, producing the whitening effect [2]. Due to its
reactive properties, hydrogen peroxide (HP) is the main active
chemical component of most agents used in tooth bleaching
therapies. HP can be used in its pure form or as the final
product of the degradation of other bleaching substances, such
as sodium perborate and carbamide peroxide [3].
There are today several kinds of dental bleaching treat-
ments. Some of them, called “nonprofessional”, involve the
application of toothpastes and/or oxidizing agents with max-
imum HP concentration of 6%; these are normally carried
out by patients themselves. In contrast, “professional
bleaching” is always carried out under the supervision of a
dental practitioner, here the HP concentration can be up to
55% [4]. In the second case, we may distinguish “home
bleaching”, involving the nightly application of an individual
2 Lasers Med Sci (2013) 28:1–6
tray containing the agent, and “office bleaching”, performed
in only one session in a dental surgery by the application of the
bleaching gel directly onto the teeth [5].
Several sources of electromagnetic radiation have been
proposed to enhance the action of the gel: curing lamps,
LED lamps also and, since 1996, coherent light [6]. The first
wavelengths utilized were the argon (480 nm) and CO2
(10,600 nm) lasers, but today the Nd:YAG (1,064 nm),
diode (810 and 980 nm) and the potassium-titanyl-phosphate
(KTP, 532 nm) lasers are also used [7–11]. Many studies have
been carried out to investigate the possibility of improving the
dental bleaching technique using lasers but it is difficult to
establish which laser source is the most efficient because the
literature is quite conflicting. In fact, the studies have often
used different sources, different parameters, different devices
and different products to obtain dental bleaching, making
comparison of the various studies difficult [12].
The first aim of this research was to compare two different
laser sources, the 532-nm KTP and the 808 -nm diode laser, in
a preliminary experimental model in vitro to determine if,
during a dental bleaching process, there are any differences
resulting from the different wavelengths used as well as the
temperatures and photodissociative effects on HP. The second
aim was to see if there are any relationships among the three
parameters: external temperature, which is the temperature
that the gel reaches during the session of bleaching, shade of
the tooth and concentration of HP in the gel used, to highlight
possible photodissociative effects.
Materials and methods
Sample collection
The study samples comprised 116 bovine teeth that were
sectioned using a diamond cutter near the cervical line to
eliminate the root and their crowns reduced using a model
trimmer until their dimensions were similar to those of
human central incisors. The pulp of every sample was then
removed and, after polishing and clearing away the surface
pigmentation using a sodium bicarbonate spray (EMS,
Nyon, Switzerland), the teeth were stored in physiological
solution until use. Before testing, a small plastic stick was
fixed inside the pulp chamber and glued with a composite
resin in order to be able to fix the sample at the prearranged
distance from the laser source and the temperature probe.
In order to determine a baseline value for bleaching
obtainable using the gel, 26 samples were submitted to
dental bleaching without laser irradiation and in this proce-
dure the temperature was not recorded. The gel plus the
diode laser, which was applied in three sessions of 30 s each,
was used to treat 25 samples at 2 W and 26 samples at 4 W.
The KTP laser was used in the same way to treat 25 samples
at 2 W and 14 samples at 4 W. All 116 samples were treated.
Shade measurement
The colour (shade) of the teeth was measured using a
spectrophotometer (SpectroShade; MHT, Milan, Italy) to
eliminate the need for subjective evaluation using a colour
scale. This technique is based on the ΔE codification of the
CIE (Commission international de l’eclairage). ΔE is the
shortest distance between the colour being compared as
determined by the following equation:
$E ¼ $L2 þ $a þ $b
where L is the luminosity (from white to black), a corre-
sponds to the red–green axis (positive value indicates red,
negative indicates green) and b corresponds to the yellow–
blue axis (a positive value indicates yellow, negative indi-
cates blue). The ΔE value is expressed numerically and in
addition the SpectroShade system allows the selected shade
to be changed according to different ΔE values improving
accuracy in the initial shade selection [13].
The examined teeth were illuminated by LED light which
covered the entire visible spectrum. Thanks to its CCD
device, the spectrophotometer reads the light reflected from
more than 6 million points on the dental surface. The com-
puter is able to evaluate chroma and shade colour. In particular
three parameters are recorded:
Hue: Synonymous with the term colour, used to de-
scribe the pigments of a tooth or dental restoration (red,
blue or yellow).
Value: The relative darkness or lightness of the hue. The
greater the total amount of light reflected, the higher the
value. The scale of values ranges from 0 (pure black) to
10 (pure white).
Chroma: The intensity of the chromatic signal contrib-
uting to colour perception; it is similar to saturation.
Hue is the term for the pure spectrum colours commonly
referred to by the "colour names" which appear in the
circle or rainbow. In our experiments we used the L, h and
c scale and its relative ΔE [14].
During examination, the samples were laid on a grey
foam rubber base to eliminate light reflection.
Bleaching gel preparation
For all the tests, a self-prepared gel was used, obtained by
mixing a pure solution of HP with a gelling agent (Carbopol),
because most commercial products do not specify their exact
composition due to patenting. Several components might
influence the HP concentration and thus we used the self-
Lasers Med Sci (2013) 28:1–6
made agent with a very precise composition. In fact, during
preliminary tests, we noted that several commercial gels had a
different HP concentration from that stated. Moreover, several
producers use undeclared ingredients in their preparations,
such as colorants, preserving agents and catalysts, and this
could affect the analysis.
The gel was prepared by mixing 48 g HP solution (Carlo
Erba Reagenti, Rodano, Italy) and 2 g Carbopol, and the
final HP concentration was in the range 27–35%. The com-
ponents were mixed for 10 min in a plaster vacuum mixer.
The HP concentration was determined by titration with
permanganate using an automatic burette (Titrette; Brand,
Wertheim, Germany), using a 0.1 N solution of potassium
permanganate (Carlo Erba Reagenti) which itself is titrated
with 0.1 N sodium oxalate (Carlo Erba Reagenti). The pH of
the gel was determined using a portable pH meter (pH 340;
Hanna Instruments, Kehl, Germany). The recorded pH values
were 4.4 for the pure solution of 30% HP and 1.22 for the
Carbopol gel mixture. The gel obtained was used within 24 h
of preparation, and in this time period no significant variations
in HP concentrations were recorded.
Temperature measurements
During the bleaching sessions the increase in gel tempera-
ture was recorded using a thermocouple probe (Testo 735;
Testo, Lenzkirch , Germany). The distance between the laser
beam and the sample was fixed so that the laser spot had a
diameter of 8 mm and the distance between the sample and
the lens was 4 cm for the diode laser (XD-2; Fotona,
Ljubljana, Slovenia; 808 nm, 600-μm optical fiber) and
6 cm for the KTP laser (LASEmaR 500; Eufoton, Trieste,
Italy; 532 nm, 400-μm optical fiber). The laser beam was
directed at the centre of the sample to irradiate the entire
tooth surface. The thermocouple probe was also set in the
centre of the sample surface, measuring the rise in temper-
ature in both graphically and numerically.
HP titration
HP was titrated using a UV-visible spectrophotometer
(Genesys 10; Thermo Fisher Scientific, Waltham, MA) and a
quartz glass cuvette. A calibration line was calculated for the
gel used in the range of HP concentrations present in the
samples. The spectrophotometer allowed the absorption spec-
tra of HP before and after Carbopol addition to be checked to
ensure that the two compounds did not interfere significantly.
Bleaching process
Every sample was weighed on an analytical balance (Pioneer;
Ohaus, Parsippany, NJ; ±0.0002 g), then the colour was
measured and a layer of gel of approximately 2 mm thickness
3
was applied to the surface so that the sample was covered. The
sample was then weighed again to determine by subtraction
the weight of gel used. The gel remained in contact with the
tooth for 20 min and during this time, each tooth was irradi-
ated three times for 30 s each time, with at least 2 min between
each irradiation session to permit the gel temperature to return
to the earlier stage. During irradiation the samples were fixed
by means of the plastic mounting in a defined position. After
20 min, the gel sample was collected by washing with distilled
water and brought to a volume of 100 ml in a graduated flask.
The solution was mixed with a magnetic stirrer for 3 min to
completely dissolve the HP gel. The prepared solution was
immediately analysed by the spectrophotometer and the tooth
colour after the procedure read by means of the SpectroShade
device to allow the final and the initial colours to be compared.
ΔE was calculated using the specific software function in-
stalled in the device for comparing two measurements.
Statistical analysis
The data were analysed using Prism 5.03 software (GraphPad)
and Microsoft Excel, and the t-test and one-way ANOVA tests
were performed.
Results
In our experimental model we considered three parameters:
gel temperature, tooth colour and HP concentration. The
results are shown in the Figs. 1, 2, 3 and 4.
The diode laser produced gel temperature changes higher
than those with the KTP laser at both powers (2 W and 4 W).
The diode laser at 2 W caused an average gel temperature
increase of 19.95 ±1.45°C, whereas the KTP laser at 2 W
caused an increase of 10.25±4.62°C. The maximum gel
40
30
T°
20
10
0
2W
4W
2W
4W
E
E
TP
TP
D
K
K
IO
IO
D
Fig. 1 Gel temperature changes as a result of laser irradiation
4 Lasers Med Sci (2013) 28:1–6

80 35.0

32.5

60

% H2O2
30.0
T

40 27.5

25.0
20

2W

2W

4W

1
4W
SE

SE
TP

TP
4w

LA

A
2w

2w

E
4w

B
D

K
IO

IO
O
o
o

D
N

D
p
od
od

kt

kt
di

ax
di

ax
Fig. 4 HP concentrations during laser irradiation (Baseline is the HP
m
ax

ax

concentration of the gel before use, 30.865%)

T
m

T
T

Fig. 2 Peak gel temperatures during laser irradiation

temperature with the diode laser at 2 W was 43.08±1.78°C,
whereas the maximum gel temperature with the KTP laser at
2 W was 32±6.25°C. The diode laser at 4 W caused an
average gel temperature increase of 34.88±10.19°C, where-
as the KTP laser at 2 W caused an increase of 13.32±3°C.
The maximum gel temperature with the diode laser at 4 W was
74.91°C, whereas the maximum gel temperature with the KTP
laser at 4 W was 45.07°C. The differences in the results
between the two wavelengths were significant (p<0.05).
Shade was compared in terms of E values determined
before and after laser irradiation. The difference in the two
values, ΔE, represents the integration of luminosity, colour
and chroma, and is a concrete indicator of the changes in
5.0
4.5
4.0
3.5
E
shade. An increase in ΔE represents an increase in lumi-
nosity and a decrease in chroma indicates that the teeth have
become brighter. Generally bovine teeth are brighter than
human teeth and they show less variability in shade [15].
In this study, the teeth treated only with the gel (without
laser irradiation) showed a ΔE of 2.37±1.22, slightly lower
than values obtained in other in vitro studies. An explana-
tion might be that our agent was less active than neutral and
alkaline gels used in other studies because of its acidic pH.
Moreover, large standard deviation indicates a definite indi-
vidual variability. After irradiation with the KTP laser at
2 W, ΔE reached a mean value of 3.68±1.63, the best result
among the tested conditions, and significantly different from
the value obtained by bleaching without laser (see Fig. 3).
The ΔE value of the teeth treated with the gel plus the diode
laser at 2 W was not significantly different from the baseline
value (see Fig. 3). The ΔE value of the teeth treated with the
KTP laser at 4 W was 3.43±1.24, which was lower than the
value obtained with the KTP laser at 2 W. The ΔE value of
the teeth treated with the diode laser at 4 W was 3.43±1.24,
indicating a better performance, but this result was worse
than that obtained with the KTP laser at 2 W. The differ-

3.0 ences in ΔE values between the laser treatments were not

2.5 significant (p>0.05).

2.0
1.5 Discussion
4W
R

2W

4W
2W

The increases in gel temperature following KTP laser irradi-

SE

R
R
LA

ation were lower than those following diode laser irradiation,

SE

SE
SE

SE
O

LA

LA
LA

LA

in accordance with the literature [16–18]. The temperature of

N

TP

TP

the dental surface and pulp could rise to a dangerously high

D

D
K

IO

IO

level if an infrared laser were used.

D

Fig. 3 ΔE in relation to laser treatments (higher ΔE value0better The action of the KTP laser, whose wavelength is in the
result) visible portion of the spectrum, is the result of an interaction
Lasers Med Sci (2013) 28:1–6
between the agent in the gel (cromophore) and the staining
molecules in the enamel. The variable results with dental
bleaching procedures reported in the literature can be
explained by considering that whitening effects depend on
the cromophore, the nature of the enamel, the wavelength,
and the pH of the gel used. If the chromophore peak of
absorption is not matched exactly with the related wave-
length, there will be no benefit from adding a laser to the
treatment. Also from a clinical point of view, when the diode
laser is used to improve the result, the temperature increase
in the irradiated teeth should be born in mind. Indeed, we
have observed that the diode laser, in a similar manner to
others that work at similar or greater wavelengths, causes a
large increase in temperature of the dental surface. Many of
the factors that lead to the increase in temperature (and
consequently also of the pulp chamber) depend on the
professional experience of the clinician, such as bleaching
gel thickness, application time, distance between tooth and
application tip, bleaching gel characteristics (coloured or not
coloured), laser power, and interval between irradiation
sessions. Marcondes et al. used a Q-switched Nd:YAG laser
and recorded a lower increase in temperature in the pulp
chamber, although this not associated with a better bleach-
ing performance [19]. Goharkhay et al. experimented with a
gel which contained finely dispersed titanium dioxide,
which limited thermal transmission to the dental pulp
[20]. The use of this particular gel also improves, dental
bleaching because titanium dioxide works as a catalyst
for free radical production linked to HP.
These studies show an important relationship among gel
colour, laser wavelength, thermal transmission and clinical
efficacy. Furthermore, these studies indicate that the varia-
tion of the thermal energy alone does not affect dental
bleaching. Furthermore, the use of absorbing substances to
increase radiation absorption (and the temperature of the
bleaching gel) does not automatically improve the bleaching
result. On the contrary, the better results obtained using tita-
nium dioxide as a catalyst show that there is another way to
improve dental bleaching without the risk of damaging the
pulp. In fact, HP is absorbed on the surface of titanium dioxide
forming titanium hydroperoxide which is able to absorb vis-
ible radiation forming strongly oxidant radicals.
Conclusion
The primary aim of this work was to demonstrate that the
bleaching power of the KTP laser is higher than that of the
diode laser with la lower temperature elevation, and this
may contribute to the discussion about the role of the laser
in dental bleaching. Most of the literature on this subject
ascribes the action of lasers to a photothermally catalysed
redox reaction. Evidently other aspects must be implicated,
5
and elucidating these will be the aim of future in vitro
studies.
The second result is that the three parameters evaluated
(gel temperature, shade and HP concentration) are not relat-
ed, and this is important from a clinical point of view in
demonstrating the ineffectiveness of high powers and high
HP concentrations which only increase the risk of dental
damage without improving the bleaching process. Clearly,
research into improving dental bleaching techniques will
have to consider the composition of the agents used, and
the possibility of adding other chemical compounds to HP.
An example may be the use of titanium dioxide as an
adjuvant with HP.
In spite of the fact that the KTP laser has been used for
many years in general surgery, particularly in urology and
neurosurgery, its use in dentistry is limited mainly to bleach-
ing. Only recently its use has been described in oral soft
tissue surgery where it has several advantages, in particular
a great ablative capacity coupled with very high safety [21].
Due to its good absorption by several chromophores present
in oral soft tissues, the KTP laser may be recommended in
this kind of clinical application. Regarding the efficacy in
dental bleaching, further studies are necessary to establish
the precise correlations between gel pH, the agents able to
catalyse the redox reaction, and the laser wavelengths
utilized.
References
1. Dahl JE, Pallesen U (2003) Tooth bleaching – a critical review of
the biological aspects. Crit Rev Oral Biol Med 14:292–304
2. Garber DA, Goldstein RE, Goldstein GE, Schwartz CG (1991)
Dentist monitored bleaching: a combined approach. Pract Peri-
odontics Aesthet Dent 3:22–26
3. Sulieman M (2008) An overview of tooth-bleaching techniques:
chemistry, safety and efficacy. Periodontol 2000 48:148–169
4. Luna AJ, Nascimento CAO, Chiavone-Filho O (2006) Photo-
decomposition of hydrogen peroxide in highly saline aqueous
medium. Braz J Chem Eng 23:341–349
5. Nathoo SA, Gaffar A (1995) Studies on dental stains induced by
antibacterial agents and rational approaches for bleaching dental
stains. Adv Dent Res 9:462–470
6. Luk K, Tam L, Hubert M (2004) Effect of light energy on peroxide
tooth bleaching. J Am Dent Assoc 135:194–201
7. Strobl A, Gutknecht N, Franzen R, Hilgers RD, Lampert F, Meister
J (2010) Laser-assisted in-office bleaching using a neodymium:
yttrium-aluminum-garnet laser: an in vivo study. Lasers Med Sci
25:503–509
8. Kinoshita JI, Jafarzadeh H, Forghani M (2009) Vital bleaching of
tetracycline stained teeth by using KTP laser: case report. Eur J
Dent 3:229–232
9. Dostalova T, Jelinkova H, Housova D, Sulc J, Nemec M, Miyagi
M, Brugnera Junior A, Zanin F (2004) Diode laser-activated
bleaching. Braz Dent J 15 (Spec no):SI3–SI8
10. Polydorou O, Hellwig E, Hahn P (2008) The efficacy of three
different in-office bleaching systems and their effect on enamel
microhardness. Oper Dent 33:579–586
6 Lasers Med Sci (2013) 28:1–6
11. Wutter NU, Barroso MC, Pelino JE (2004) Dental bleaching effi-
cacy with diode laser and LED irradiation: an in vitro study. Lasers
Surg Med 35:254–258
12. Joiner A (2006) The bleaching of teeth: a review of the literature. J
Dent 34:412–419
13. Chu SJ (2002) The science of color and shade selection in aesthetic
dentistry. Dent Today 21:86–89
14. Sfreddo M, Mason E (2005) Valutazione dello sbiancamento den-
tale mediante spettrofotometria e SEM. Quintessenza Int 5:55–76
15. Glodberg M, Grootveld M, Lynch E (2010) Undesirable and adverse
effect of tooth-whitening products: a review. Clin Oral Invest 14:1–10
16. Kwon YH, Huo MS, Kim KH (2002) Effect of hydrogen peroxide
on the light reflectance and morphology of bovine enamel. J Oral
Rehabil 29:473–477
17. Nascimento EA, Machado AEH, Morais S (1995) Photochemical
hydrogen peroxide bleaching of eucalyptus organosolv pulp. J
Braz Chem Soc 6:365–371
18. Carrasco TG, Carrasco-Guerisoli LD, Fröner IC (2008) In vitro
study of the pulp chamber temperature rise during light-activated
bleaching. J Appl Oral Sci 16:355–359
19. Marcondes M, Paranhos MP, Spohr AM, Mota EG, da Silva
IN, Souto AA, Burnett LH Jr (2009) The influence of the Nd:
YAG laser bleaching on Physical and Mechanical Properties
of the Dental Enamel. J Biomed Mater Res Part B 90 B:388–
395
20. Goharkhay K, Schoop U, Wernisch J, Hartl S, De Moor R, Moritz
A (2009) Frequency doubled neodymium:yttrium-aluminum-garnet
and diode laser-activated power bleaching–pH, environmental scan-
ning electron microscopy, and colorimetric in vitro evaluations.
Lasers Med Sci 24:339–346
21. Fornaini C, Rocca JP, Merigo E, Meleti M, Manfredi M, Nammour S,
Vescovi P (2011)Low energy KTP laser in oral soft tissue surgery: a
52 patients clinical study. Med Oral Patol Oral Cir Bucal.
doi:10.4317/medoral.17428