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What’s Up With Whitening?

An Update on Professionally
Dispensed Vital Tooth Bleaching
A Peer-Reviewed Publication
Written by Howard E. Strassler, DMD, FADM, FAGD
and Gregori M. Kurtzman, DDS, MAGD

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Educational Objectives
Upon completion of this course, the clinician will be able to
do the following:
1. List the different types of vital tooth bleaching systems.
2. List the esthetic conditions that can be treated with vital
tooth bleaching.
3. Describe the adverse reactions that have been associated
with vital tooth bleaching.
4. Describe the clinical technique for professional vital
tooth bleaching using a tray system.
5. Describe how to manage bleaching relapse.
Abstract
Professionally dispensed vital tooth bleaching techniques
include a variety of concentrations of hydrogen and carb-
amide peroxide, in-office techniques with and without light
or heat enhancement, professionally dispensed whitening
strips and tray bleaching. A predictable technique that does
not require wearing of trays for long periods of time improves
patient compliance. Tooth whitening with the latest genera-
tion of vital bleaching products is effective, safe and relatively
long lasting. Bleaching can be maintained through the use
of whitening toothpastes and bleaching toothpastes or with
yearly touch-up bleaching using the patient’s custom fitted
tray. Vital tooth bleaching is a viable, esthetic treatment for
the discolored dentition.
Professionally Dispensed Vital Tooth Bleach-
ing: An Update
Esthetic restorative dentistry includes many treatment mo-
dalities to change the appearance of teeth. Unfortunately, most
techniques involve the placement of restorations, which gen-
erally requires some tooth preparation and the need to replace
some of these restorations over the patient’s lifetime. With the
increased knowledge and interest by patients in having the
appearance of their teeth changed with esthetic dentistry, the
more conservative techniques have gained wider acceptance.
Changing the appearance of teeth to improve a patient’s smile
may include modifying tooth contours, shapes, color and po-
sition. Where the modification of tooth shape, contours and
position is necessary to achieve an improved esthetic result,
orthodontics and restorations may be indicated. When there
are no patient concerns about the appearance of the teeth and
smile other than color, the most conservative clinical tech-
nique is vital tooth bleaching.
Professionally dispensed vital tooth bleaching refers to
the materials used for vital bleaching that are dispensed in
the dental office. These techniques can include a variety of
concentrations of hydrogen and carbamide peroxide, in-of-
fice techniques with and without light or heat enhancement,
professionally dispensed whitening strips and tray bleaching.
This article will review the different systems, indications and
contraindications for vital tooth bleaching, adverse effects,
and describe a predictable technique for tray bleaching that
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does not require wearing of the tray for long periods of time.
Bleaching relapse is a reality. The article will also describe
ways for patients to maintain the whiter and brighter smile
that was created with vital tooth bleaching.
Bleaching is usually used to lighten teeth darkened by
intrinsic and/or extrinsic discoloration. In some cases normal
tooth color can be lightened to a whiter smile for those patients
who want to improve their esthetic appearance. However, not
all tooth discolorations are amenable to successful treatment
with vital tooth bleaching. Before making the decision to per-
form vital tooth bleaching, a thorough clinical examination
and evaluation of the existing oral conditions must be made
to establish a diagnosis. There will be times when radiographs
are necessary to establish and verify a diagnosis.
Diagnosis and clinical evaluation of tooth
discolorations
Tooth discolorations can be a result of enamel mottling, tet-
racycline staining, trauma, developmental hypoplasia, caries
demineralization, age-related extrinsic enamel staining, thin-
ning of enamel with subsequent dentin shine-through, and
staining of teeth due to smoking, food and beverage ingestion.
These types of tooth discolorations can modify the esthetics
of teeth so that patients find their appearance and the appear-
ance of their smile unacceptable.
Tooth discolorations can be classified as either intrinsic
(within the enamel and dentin) or extrinsic (on the surface
of the enamel). Intrinsic discolorations are deep within the
tooth, usually a dentin discoloration. Examples of intrinsic
tooth discolorations are tetracycline staining of the teeth and
endodontic staining. Extrinsic discolorations are superficial
and located in the enamel. Fluorosis and enamel hypoplasia
(“white spots”) are examples of extrinsic discolorations of
the enamel.
Mottled enamel, also know as enamel hypoplasia due
to fluoride or fluorosis, is caused when children ingest too
much fluoride during tooth development. This can be the
result of a child swallowing a fluoride-containing toothpaste
or a fluoride mouth rinse, or ingesting fluoride-containing
vitamins when the water and other beverages being ingested
have the minimal dose of fluoride necessary to provide enamel
protection. Fluorosis has a varied appearance depending on
the amount of fluoride ingested.1 Mild fluorosis usually has
the appearance of white flecking or spotting of the enamel or
white opaque areas on the enamel surface. When fluorosis is
moderate to severe, the enamel takes on a brownish appear-
ance (mottling) that can be combined white opaque spots
or pitting defects on the enamel surfaces. In cases of severe
fluorosis, the enamel has a very pitted, eroded appearance. In
addition, moderate to severe dental fluorosis can contribute to
the enamel being more susceptible to wear and fracture due to
the pitted and thinned edges of the teeth.
A patient with teeth that appear yellow, brown-orange or
blue-gray-brown, demonstrates the consequences of taking
tetracycline-based medications for the treatment of child-
hood infections.2,3 Tetracycline staining was first described in
1956.4 This intrinsic discoloration appears to be caused by the
binding of the tetracycline to the calcium in the enamel ma-
trix during mineralization.5,6 Tetracycline discoloration can
also present with the clinical appearance of banded staining,
with the darkest staining at the gingival third of the tooth due
to the thinness of the enamel in that area and the discoloration
within the underlying dentin. A differential diagnosis of tet-
racycline staining can be made by shining an ultraviolet light
on the teeth. If the teeth fluoresce, then the diagnosis is most
likely tetracycline staining.
In recent years, other medication-induced discolorations
have been observed. Unlike the characteristic tetracycline
staining that occurs during tooth development, these discol-
orations appear after the teeth are fully erupted in the mouth.
The staining has a bluish-gray appearance. Minocycline has
been implicated in the discoloration of the permanent denti-
tion after eruption of the teeth.7
Another cause of intrinsic discoloration of vital teeth is
trauma to the tooth during enamel formation.8 If the primary
tooth is traumatized, blood products in the soft tissue can be
incorporated into the mineralization of the permanent tooth
enamel matrix. These teeth have a yellow-brownish, opaque
appearance. Also, permanent teeth that are fully or partially
erupted when traumatized can become similarly discolored
and still maintain their vitality, or upon radiographic exami-
nation reveal an obliterated (narrowed) root canal.
The most prevalent forms of tooth discoloration observed
are extrinsic. Over time teeth become discolored with normal
yellowing and darkening, which has been referred to as age-
related discoloration.9 This occurs due to the fact that while
enamel appears to be a highly lustrous, hard crystalline sur-
face, it is in fact microscopically rough and permeable.10 These
microporosities result in enamel’s permeability over time and
can lead to staining due to smoking and ingested foods and
beverages. In many cases, the acidity of tobacco-containing
products, coffee, tea, tea with lemon, carbonated soda, energy
and electrolyte replacement beverages have the ability to etch
the enamel surfaces, leaving them more susceptible to stain-
ing. Also, as enamel ages in the mouth, the surface develops
micro- and macrocracks and fracture lines that are vulnerable
to staining. Over time the enamel crown is also at risk of phys-
ical loss of surface from the physical effects of wear created
by toothpastes, toothbrush bristles and eating rough foods.11
Erosion, a chemical process of dissolution of tooth substance,
can result from acid dissolution from ingested foods and bev-
erages. As the enamel thins, the more yellow-colored dentin
“shines through” the translucent enamel crown, leaving the
tooth with a more yellowed appearance.
Caries can create both intrinsic and extrinsic discol-
orations of teeth through acid demineralization. Once the
carious lesion has penetrated through the enamel surface
into the dentin, a dark, shadowy discoloration can appear as a
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shine-through phenomenon in the enamel. Once the bacterial
invasion responsible for the carious lesion has penetrated into
the dentin, restoration is necessary.12
Bleaching, a treatment for
the discolored dentition
Tooth bleaching was reported as early as 1877, but it has only
been in the last 30 years that the conservative treatment of the
discolored dentition with high concentrations of heated hy-
drogen peroxide has been accepted.13,14,15 Unfortunately, this
use of a heated, high-concentration hydrogen peroxide has
clinical problems and adverse reactions that include the need
for multiple office visits (five to seven) to attain an acceptable
result, tooth hypersensitivity, soft-tissue irritation due to the
high-concentration hydrogen peroxide seeping under the
dental dam, and significant chair time.
Over the past 15 years, other techniques for vital tooth
bleaching have been described. In 1989, a technique using
an at-home mouthguard (tray) with 10% carbamide peroxide
was described as successfully whitening teeth.16 This report
was followed by the introduction of other carbamide peroxide
products. Concerns about the safety, efficacy and longevity
of these bleaching techniques were initially expressed by the
United States Food and Drug Administration and the dental
profession.17,18,19 A number of reports have adequately ad-
dressed these concerns and have demonstrated the safety
and effectiveness of tooth whitening with peroxide prod-
ucts.20,21,22,23 By 1995, a survey of 8,143 dentists reported that
91% used vital tooth bleaching.24 Seventy-nine percent of the
dentists reported success with tooth whitening. Side effects
reported by the respondents included the following: 62.2%
noted tooth sensitivity 10.7% of the time, 45.9% reported
soft-tissue irritation 5.6% of the time, 2.1% noted systemic
effects 0.2% of the time, and 18.8% reported no side effects.
Bleaching vital teeth has become an extremely well ac-
cepted and successful procedure in dental practices, with tray
bleaching being the most popular. During the early introduc-
tion of tray (mouthguard) vital bleaching with carbamide and
hydrogen peroxide bleaching agents, studies demonstrated
the efficacy and safety of these agents.25,26,27,28,29,30,31 In all cases,
the agents evaluated lightened the color of the teeth safely and
effectively with minimal adverse reactions. In addition, when
the bleaching procedure was completed, any adverse reactions
that were reported during treatment were no longer present.
With the increased acceptance by the dental profession
of vital tooth bleaching and tooth whitening with other
products, the American Dental Association issued a report
in 1994 and revised in 1998 on the guidelines safety and ef-
ficacy criteria for peroxide-containing products that include
their use for tooth bleaching. Any product that meets these
criteria could receive the American Dental Association Seal
of Acceptance. To receive the seal, a company would have to
submit safety studies and two clinical trials that demonstrate
at least two value oriented shade increments of change when
the bleaching recommendations are followed.32 To date, all
the bleaching products to obtain the seal are 10% carbamide
peroxide products.
Professional vital bleaching started with custom-made
trays as vehicles to hold a 10% carbamide peroxide gel and
now includes a variety of different types of tray and trayless
systems that provide for the delivery of either hydrogen or
carbamide peroxide in a wide range of concentrations. When
comparing hydrogen peroxide to carbamide peroxide, the
approximate equivalent of 3% hydrogen peroxide equals 10%
carbamide peroxide. In the past decade a number of differ-
ent peroxide bleaching products have been introduced for
professional dispensing. There have been modifications in
the chemistry to make the available peroxide longer lasting
for overnight tray bleaching.33,34 Also, most manufacturers
have made available a range of higher concentrations of per-
oxides (both carbamide peroxide and hydrogen peroxide) to
decrease the wear time of the tray and/or decrease the time
necessary to achieve the final whitening result. Some higher-
concentration hydrogen peroxides have been targeted for
in-office bleaching.
Many of the earlier concerns over adverse reactions have
been addressed by manufacturers. Over the last decade
manufacturers have responded to clinician concerns about
issues of taste with better flavors for improved patient ac-
ceptance. Tooth sensitivity during bleaching has been the
highest reported adverse reaction. It has been demonstrated
that tooth sensitivity is transient. To minimize tooth sensi-
tivity, the clinician can recommend the patient decrease the
time the tray is worn the first week to no more than an hour
a day for carbamide peroxide products or for as little as 15
minutes a day for higher concentration hydrogen peroxides,
use lower concentrations of peroxide, employ bleaching gels
with desensitizing agents, have patients use a desensitizing
toothpaste in a tray for 30 minutes a day during the week prior
to bleaching, or use a professionally dispensed desensitizing
gel for use with bleaching.35,36
Over the years there has been controversy about what tray
is best. When tray bleaching was introduced, the trays were
fabricated from thin or thick, flexible vacuum-formed mate-
rials and thin rigid plastic materials. Some manufacturers cre-
ated a foam-lined tray, believing it would hold the bleach on
the teeth more effectively. From the current research, which
has evaluated a wide variety of tray configurations and types,
as well as the duration of wearing the tray, one can conclude
the following:
1. Thin, flexible, vacuum-formed materials are
the standard;
2. The use of spacers on the stone model to create reservoirs
is not necessary, but the use of reservoirs will lead to the
patient swallowing less of the bleaching gel;37,38
3. Scalloping the tray to follow the gingival contours is not
necessary when using a 10% carbamide peroxide, but
should be done for higher concentrations. Over-trim-
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ming the tray to leave a portion of the tooth uncovered is
not a problem;39
4. Custom fitted trays provide improved bleaching gel-
tooth contact;40
5. Most companies provide bleaching gel for a 2 week time
of application;
6. Higher concentrations of carbamide peroxide bleach
worn in a tray show faster initial improvements, but
over a 6 week period of time comparing 10% carbamide
peroxide to higher concentrations there is no difference
in the final result;41,42
7. The concept of teeth lightening to a final certain level has
been termed as the “inherent lightness potential” of a
tooth and there is an endpoint to how much lighter teeth
will get;43
8. In most cases moderate and dark tetracycline staining
can be treated with bleaching over an extended time of
3–6 months;44,45
9. Concern over the effectiveness of the bleaching potential
with overnight wearing of a tray has been addressed and
while wearing a tray overnight with a bleaching gel has
demonstrated a degradation in peroxide concentration
over time, the bleaching agent is still effective;46
10. 10% at-home carbamide peroxide bleaching gels are
clinically safe when exposed to enamel, dentin, root
surfaces, ceramics, cast metal and composite resins,
but there is one case report of greening of amalgam
during bleaching.47
In recent years, manufacturers have developed novel,
trayless methods of bleaching teeth. The first product in-
troduced professionally was Crest® Whitestrips® (Proctor &
Gamble, Cincinnati, OH) for in-office dispensing. Within
a year of the introduction of Whitestrips, a lower hydrogen
peroxide concentration was released as an over-the-counter
product. In the past six months, the concentration of the
professionally dispensed and OTC Whitestrips has been
increased, and other OTC strips have become available from
other manufactur­ers. One of the limitations of strips is the
limited surface area that can be whitened. Strips only cover
the anterior teeth, from canine to canine, and are difficult to
apply when a patient has misaligned teeth. In response to the
need for a trayless system that will both cover more teeth and
not be impeded by tooth misalignment, a tray-applied, thin-
membrane bleaching system, Trèswhite (Ultradent Products,
South Jordan, UT) was introduced. This novel trayless sys-
tem uses a 9% hydrogen peroxide and includes a gel barrier
at the gingival margin that ensures improved comfort when
being worn. The primary author has had a number of dental
students try this system and they have reported favorably on
the ease of use and whitening results. The benefits of a tray-
less system are numerous. It need only be worn 30 minutes
twice a day; there is no tray to fill, eliminating the possibility
of the patient putting too much or too little in, and the trayless
strip or membrane is disposable. Reports have shown strips to
be as effective as at-home tray bleaching.48
The first bleaching treatment to change the color of teeth
was an in-office procedure. Currently the most popular
systems for in-office bleaching use high-concentration
hydrogen peroxides and are often referred to as “one-hour
bleaching.” These high-concentration hydrogen peroxides
range from 25%–35%. In-office bleaching can be provided to
patients as either a one-visit one-and a half-hour treatment
or a multiple visit procedure. One of the light enhanced
bleaching techniques can be used or a paint-on bleaching
gel or solution. In-office professional whitening can be a
perfect complement to the at-home whitening system you
are using. There are many patients that cannot find the time
to apply trays or strips in their busy lives. In-office whiten-
ing offers them a chance to whiten their teeth in one or more
easy dental appointments.
How effective is in-office bleaching? Studies have been
done to compare in-office bleaching to at-home tray bleach-
ing. At-home tray bleaching usually gives the best final result.
The results of in-office bleaching with light enhancements are
controversial. While there are studies that have demonstrated
that the use of a light-activated/enhanced product provides
better whitening, other studies demonstrate that there is no
benefit to using an accessory light.49,50,51,52 An example of one-
hour bleaching with light enhancement is Den-Mat’s Rem-
brandt® which uses their Sapphire® PAC light (Den-Mat,
Santa Maria, CA) with whitening crystals. What differenti-
ates this light from other bleaching lights is that it is multiuse
and can be used to polymerize resin-based materials. A one-
hour whitening 35% hydrogen peroxide whitening product
that does not require a light is Perfection White® (Premier
Dental Products, Plymouth Meeting, PA).
Patient selection for vital tooth bleaching
When planning for successful esthetic treatment for tooth
discolorations it is important to select patients with condi-
tions that have the best prognosis for success with bleaching.
It has been reported that tooth discolorations with the best
prognosis for whitening are as follows:
1. Yellowing of the teeth without any systemic or develop-
mental cause (food, smoking, age staining);
2. Mild fluorosis staining;
3. Mild tooth-darkening due to trauma;
4. Mild tetracycline staining.53,54
It has been reported that moderate to severe tetracycline
discoloration can be lightened in shade with overnight use of
vital mouthguard bleaching over a period of 6 months.55
Many dentists are using vital tooth bleaching as an
adjunct to their esthetic bonding procedures. For patients
dissatisfied with tooth malposition and shape as well as with
discolorations, lightening the shade of teeth first with bleach-
ing makes masking tooth discolorations less difficult. It is
www.ineedce.com 5
important that before any bonding procedure that bleaching
be discontinued for at least one week before the restorative
treatment to prevent interference with bonding adhesion and
material setting.56,57,58,59
Vital tray bleaching with a high-concentra-
tion hydrogen peroxide system
Vital tray bleaching has been demonstrated to be highly ef-
fective and safe. One problem frequently encountered by
clinicians is patient compliance with tray bleaching. While
some products require as little as an hour a day and others
require overnight use, it has been shown that patient compli-
ance is higher for a shorter, less frequent wear period. Even
for Crest Whitestrips, the requirement is 30 minutes, twice
a day. Recently a novel, high-concentration (14%) hydrogen
peroxide, Perfecta® REV!™ (Premier Dental Products,
Plymouth Meeting, PA), was introduced for use in a tray. As
compared to most carbamide peroxide products that require
a mimimum of one hour a day for two weeks to achieve an ac-
ceptable result, Perfecta REV! requires only 15 minutes a day
for two weeks. In a recent report Perfecta REV! demonstrated
an average shade change of 9.42%.60 This study compared
Perfecta REV! to Crest Whitestrips. During the course of the
study the Perfecta REV! group reported sensitivity in 14% of
the subjects that resolved when the amount of gel placed in
the tray was decreased, compared to 42% of the subjects using
Crest Whitestrips.
Clinical technique: case studies
Patient compliance with vital tooth bleaching using trays can
be a significant issue. There has been a focus in recent years
on reducing wear time of trays through the use of higher-con-
centration bleaching gels. For this patient, compliance was a
past issue. With this in mind, a 14% concentration hydrogen
peroxide gel Perfecta REV! was chosen for this case.
The technique for vital bleaching with Perfecta REV! is
similar to other tray bleaching products using soft, thin, flex-
ible vinyl trays custom-fabricated to a patient’s casts made
from an alginate impression. For this case, impressions were
made with a double arch full tray (Alfa™ Triple Tray™, Pre-
mier Dental Products) impression with alginate. The casts
were poured with a fast set dental stone to allow for pouring of
both maxillary and mandibular quadrants quickly. (Figure 1)
Figure 1. Making impressions with alginate using an Alfa tray.
 After separation of the casts from the Alfa Tray, the casts Figure 4. Application of the Perfecta REV! into the bleaching tray
were inspected to be certain there were no irregularities, with small amounts of bleaching gel.
bubbles or distortions. For tray fabrication, the stone casts
were trimmed, leaving a minimal base to ensure an accurate
adaptation of the thin, soft-vinyl mouthguard/tray material.
A vacuum-adapted tray was fabricated with a vacuum unit.
Once the tray was vacuumed on the cast, it was trimmed on
the cast using a Tray Magic™ (Premier Dental Products,
Plymouth Meeting, PA) electric, soft-tray trimmer to leave
a scalloped tray that followed the free margin of the gingivae
on both the facial and lingual surfaces. All gingival tissue Figure 5a. Prior to bleaching.
was left uncovered by the tray. (Figure 2) By trimming the
tray on the cast, there is less concern about distortion that
occurs when trimming with scissors. Scalloping of the tray
is especially important with any of the higher concentration
bleaching gels.61,62

Figure 2. Scalloping and trimming the soft-vinyl bleaching tray

with a Tray Magic Handpiece.

Figure 5b. After two weeks of tray bleaching.

With the trays fabricated (Figure 3), they were tried in the
Figure 6a. Prior to bleaching.
patient’s mouth. The patient was instructed on the insertion
of the maxillary and mandibular trays and the cleaning of the
trays. The patient was observed placing the trays on her teeth.
As the wear time is only 15 minutes, the first wearing can be
done in the office so that all aspects of the treatment can be
demonstrated. In some cases patients will start by bleaching
the maxillary arch first.

Figure 3. Bleaching trays with scalloping fabricated.

Figure 6b. After two weeks of bleaching.

With the trays removed from the mouth, the placement

of the Perfecta REV! in the tray was demonstrated. (Figure
4) A small amount of gel was applied to each tooth area in the
well-adapted tray and inserted. The patient was shown how to
brush away any excess bleach with a soft-bristle toothbrush.
After 15 minutes, the tray was removed. A specially buffered
REV!™ Finishing Rinse was used immediately after the tray
was removed. The rinse is specially formulated to immediately
accelerate the breakdown of the remaining hydrogen peroxide
gel to boost the whitening effect. The rinsing effect also safely
removes any residual gel from the teeth and soft tissues. Ac-
cording to the manufacturer, the rinse contains a highly stable
form of Vitamin C to protect both hard and soft tissue from

6 www.ineedce.com
any free radicals and to promote healthy teeth and gingival
structures. The rinse also contains pentasodium triphosphate
to enhance the stain-removing ability of the bleach.
Bleaching can significantly change the appearance of
teeth. In order to demonstrate this improvement to patients
these authors will commonly bleach the maxillary arch first.
After the removal of orthodontic brackets, this teenage pa-
tient had areas of demineralization that created significant
tooth discoloration.
Using tray bleaching for two weeks produced a significant
whitening effect. (Figures 5a, b) In some cases, after a period
of time, a crown no longer matches the color of the adjacent
teeth. For these patients the use of tray bleaching for 2 weeks
can restore the color harmony between a crown and the adja-
cent teeth. (Figures 6a, b)
Summary
From all clinical and research accounts, tooth whitening with
the latest generation of vital bleaching products is effective,
safe and also relatively long lasting.24–30,32,49–51,63–66 Bleaching
relapse has been reported.With in-office bleaching, CRA
reported relapse of 41% at 1 year.67 For tray bleaching,
Haywood reported relapse of 26% at 18 months.68 Bleaching
can be maintained through the use of whitening toothpastes
and bleaching toothpastes (e.g., Rembrandt Plus, Oral B) or
with yearly touch-up bleaching using the patient’s custom
fitted tray.
Based upon the clinical results reported with professional
vital tooth bleaching, it is a viable, esthetic treatment for the
discolored dentition.69 Its conservative nature and little if
any risks make it an important part of an esthetic dentistry
treatment plan.
References
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safety of a home bleaching procedure. Quintessence Int. 27:383–388, 1996
28 Godder B, Kaim JM, et al. Evaluation of two at-home bleaching systems. J of Clin
Dent 5:86–88, 1994
29 Reinhart JW, Eivins SE, et al. A clinical study of nightguard vital bleaching.
Quintessence Int 24:379–384, 1993
30 Russell CM, Dickinson GL, et al. Dentist supervised home bleaching with
10 percent carbamide peroxide gel: a six month study. J Esthet Dent 8:
177–182, 1996
31 Haywood VB, Leonard RH, et al. Effectiveness, side effects and long-term status of
nightguard vital bleaching. J AM Dent Assoc 125: 1219–1226, 1994
32 American Dental Association, Council on Scientific Affairs. Acceptance program
guidelines for home-use tooth whitening products. Chicago: American Dental
Association, 1998.
33 Fasanaro TS. Bleaching teeth: history, chemicals and methods used for common
tooth discolorations. J Esthet Dent 4:71–78, 1992.
34 Haywood V. Nightguard vital bleaching: current information and research. Esthet
Dent Update 1(2): 20–23, 1990
35 Strassler HE. Tooth whitening—now and in the future: Part 2. Contemp Esthet
Restor Pract. 8(9):50–55, 2004.
36 Leonard, Jr. RH, Smith LR, Garland GE, Caplan DJ. Desensitizing agent efficacy
during whitening in an at-risk population. J Esthet Restor Dent 16:49–56, 2004.
37 Matis BA, Hamdan YS, Cochran MA, Eckert GJ. A clinical evaluation of a bleaching
agent used with and without reservoirs. Oper Dent 27:5–11, 2002.
38 Haywood VB. Nightguard vital bleaching; current concepts and research. J Am
Dent Assoc. 128:21S–25S, 1997.
39 Oliver TL, Haywood VB. Efficacy of nightguard vital bleaching technique beyond
the borders of a shortened tray. J Esthet Dent 11:95–102, 1999.
40 Haywood VB. Nightguard vital bleaching; current concepts and research. J Am
Dent Assoc. 128:21S–25S, 1997
41 Leonard RH, Sharma A, Haywood VB. Use of different concentrations of
carbamide peroxide for bleaching teeth: an in vitro study. Quintessence Int
29:503–507, 1998.
42 Matis BA, Mousa HN, Cochran MA, Eckert GJ. Clinical evaluation of bleaching
agents of different concentrations. Quintessence Int 31:303–310, 2000.
43 Matis BA, Mousa HN, Cochran MA, Eckert GJ. Clinical evaluation of bleaching
agents of different concentrations. Quintessence Int 31:303–310, 2000.
44 Leonard RH, Haywood VB, Eagle JC, Garland GE, et al. Nightguard vital bleaching
 of tetracycline-stained teeth: 54 months post treatment. J Esthet Dent 11:265–
277, 1999.
45 Matis BA, Wang Y, Jiang T, Eckert GJ. Extended at-home bleaching of tetracycline-
stained teeth with different concentrations of carbamide peroxide. Quintessence
Int 33:645–655, 2002.
46 Matis BA, Gaiao U, Blackman D et al. In vivo degradation of bleaching gel used in
whitening teeth. J Am Dent Assoc. 130:227–235, 1999.
47 Haywood VB, Heymann HO. Nightguard vital bleaching: how safe is it? Quintessence
Int, 22:515–523, 1991.
48 Gerlach RW, Gibb RD, Sagel PA. A randomized clinical trial comparing a novel 5.3%
hydrogen peroxide whitening strip to 10%, 15% and 20% carbamide peroxide
tray-based bleaching systems. Compend Contin Educ Dent 21(Suppl 29):S22–S–
28, 2000.
49 Li Y. et al. Effect of Light Application on an In-Office Bleaching Gel. J Dent Res 82
(Special Issue, AADR Abstracts): #895. 2003.
50 Luk K, Tam L, Hubert M. Effect of light energy on peroxide tooth bleaching J Am
Dent Assoc.135(2):194–201, 2004.
51 Papathanasiou A, Kastali S, Perry RD, Kugel G. . Clinical evaluation of a 35%
hydrogen peroxide in-office whitening system. Comp Cont Dent Educ 23:335–
346, 2002.
52 Basting RT, Rodrigues JA, Serra MC, Pimenta LAF. Shear bond strength of enamel
treated with seven carbamide peroxide bleaching agents. J Esthet Restor Dent
16:250–260, 2004.
53 Russell CM, Dickinson GL, et al. Dentist supervised home bleaching with
ten percent carbamide peroxide gel: a six month study. J Esthet Dent
8:177–182, 1996.
54 Haywood VB, Leonard RH, et al. Effectiveness, side effects and long-term status of
nightguard vital bleaching. J Am Dent Assoc 125: 1219–1226, 1994.
55 Haywood VB, Heymann HO. Response of normal and tetracycline-stained
teeth with pulp size variation to nightguard vital bleaching. J Esthet Dent
6:109–114, 1994.
56 Godwin JM, Barghi N, Berry TG, et al. Time duration for dissipation of bleaching
effects before enamel bonding. J Dent Res; 71:179 (Abstr 590), 1992.
57 Cvitko E, Denehy GE, Swift Jr EJ, et al. Bond strength of composite resin to enamel
bleached with carbamide peroxide. J Esthet Dent 1991; 3:100–102.
58 Machida S, Anderson MH, Bales DJ. Effect of a home bleaching agent on adhesion
to enamel. J Dent Res; 71:282 (Abstr. 1408), 1992.
59 Basting RT, Rodrigues JA, Serra MC, Pimenta LAF. Shear bond strength of enamel
treated with seven carbamide peroxide bleaching agents. J Esthet Restor Dent
16:250–260, 2004.
60 Koh S, Johnson CD, Turner S. Clinical evaluation of bleaching efficacy of two
different systems. J Dent Res 84 (Special Issue, abstracts), abstract #1795, 2005.
61 Strassler HE. Tooth whitening—now and in the future: Part 2. Contemp Esthet
Restor Pract.8(9):50–55, 2004.
62 Oliver TL, Haywood VB. Efficacy of nightguard vital bleaching technique beyond
the borders of a shortened tray. J Esthet Dent 11:95–102, 1999.
63 Oulette D, Los S, Case H, Healy R. Double-blind whitening nightguard study using
ten percent carbamide peroxide. J Esthet Dent 4:79–83, 1992.
64 Cooley RL, Burger KM. Effect of carbamide peroxide on composite resins.
Quintessence Int;22:817–821, 1991.
65 Hunsaker KJ, Christensen GJ, Christensen RP. Tooth bleaching chemicals. Influence
on teeth and restorations. J Dent Res; 69; 303 (Abstr. 1558), 1990.
66 Haywood VB, Houck VM, Heymann HO. Nightguard vital bleaching: effects of
various solutions on enamel surface texture and color. Quintessence Int; 22:775–
782, 1991.
67 Pathanasiou A, Kastali S, Perry RD, Kugel G. . Clinical evaluation of a 35% hydrogen
peroxide in-office whitening system. Comp Cont Dent Educ 23:335–346, Haywood
VB. Achieving, maintaining and recovering successful tooth bleaching. J Esthet
Dent 8:31–38, 1996.
68 Haywood VB. Achieving, maintaining and recovering successful tooth bleaching. J
Esthet Dent 8:31–38, 1996.
69 Ritter AV, Leonard RH Jr, St Georges AJ, Caplan DJ, Haywood VB. Safety and
stability of nightguard vital bleaching: 9–12 years post-treatment. J Esthet Restor
Dent 14:275–285, 2002.
8 www.ineedce.com
Author Profiles
Howard E. Strassler, DMD, FADM, FAGD
Dr. Howard Strassler is Professor and
Director of Operative Dentistry at the
University of Maryland Dental School
in the Department of Restorative Den-
tistry. He has lectured nationally and
internationally on techniques and selec-
tion of dental materials in clinical use and
esthetic restorative dentistry. He is a Fellow in the Academy
of Dental Material and Academy of General Dentistry, a
Member of the American DentalAssociation, Academy of
Operative Dentistry and International Association of Dental
Research. He is on the editorial board of numerous publica-
tions. He is a consultant and clinical evaluator to over 15 dental
manufacturers. Dr. Strassler has published over 400 articles
in the field of restorative dentistry and innovations in dental
practice and has coauthored seven chapters in texts. He has
presented over 425 programs throughout the United States,
Canada, and Europe. Dr. Strassler has a general practice in
Baltimore, Maryland that is limited to restorative dentistry
and esthetics.
Gregori M. Kurtzman, DDS. MAGD
Dr. Kurtzman is in private practice in Sil-
ver Spring, Maryland and is an Assistant
Clinical Professor at the University of
Maryland School of Dentistry, Depart-
ment of Restorative Dentistry. He has
lectured both nationally and internation-
ally on the topics of Restorative dentistry,
Endodontics and Dental Implant surgery and prosthetics and
has had numerous journal articles published in peer reviewed
publications. Dr. Kurtzman is on the editorial board of nu-
merous publications. He is a consultant and clinical evaluator
to multiple dental manufacturers. He has earned Fellowships
in the Academy of General Dentistry, the International Con-
gress of Oral Implantologists, the Pierre Fauchard Academy,
American College of Dentists, Masterships in The Academy
of General Dentistry and the Implant Prosthetic Section of the
International Congress of Oral Implantologists. Additonally,
a former Assistant Program Director for a University based
implant maxi-course Dr. Kurtzman has earned
Disclaimer
The authors of this course have no commercial ties with the
sponsors or the providers of the unrestricted educational
grant for this course.
Reader Feedback
We encourage your comments on this or any PennWell course.
For your convenience, an online feedback form is available at
www.ineedce.com.

1. Professionally dispensed vital
tooth bleaching refers to tooth
whitening products:
a. bought in the pharmacy.
b. purchased over the internet at
special web sites.
c. given to the patient in the dental office.
d. purchased from TV infomercials.
2. Esthetic conditions that can not be
treated with vital tooth bleaching
include the following:
a. tooth shape
b. tooth spacing
c. tooth misalignment
d. all of the above
3. Bleaching is a technique to lighten
the color of teeth darkened by:
a. intrinsic staining.
b. extrinsic staining.
c. forensic staining.
d. a and b
4. All the following are examples of
tooth discolorations due to intrinsic
staining except:
a. fluorosis.
b. enamel hypoplasia.
c. endodontic staining.
d. ingested food and beverage staining.
5. The most conservative treatment for
tooth discoloration is:
a. porcelain veneers.
b. composite resin veneers.
c. bleaching.
d. ceramic crowns.
6. Vital bleaching can treat all of the
following except:
a. mild fluorosis.
b. caries.
c. mild tetracycline staining.
d. discoloration due to trauma.
7. The most prevalent form of tooth
discoloration is caused by:
a. moderate to severe fluorosis.
b. aging and food and beverage ingestion.
c. moderate tetracycline staining.
d. endodontic staining.
8. Tetracycline staining clinically has
the appearance of:
a. brown-orange staining.
b. blue-gray-brown staining.
c. banded staining.
d. all of the above.
9. Teeth with _________ will fluoresce
when exposed to ultraviolet light.
a. fluorosis
b. mottled enamel
c. tetracycline staining
d. endodontic staining
10. Fluorosis is caused by the ingestion
of an:
a. milk.
b. excessive fluoride during tooth development.
c. antibiotic during tooth development.
d. stain producing beverages.
www.ineedce.com 9
Questions
11. Tooth bleaching was reported as 21. To increase patient compliance with
early as: wearing a bleaching tray recommend
a. 1877 they wear it:
b. 1918 a. every night for 2 weeks.
c. 1932 b. twice a day for one hour.
d. 1969 c. once a day for 15 minutes.
d. twice a day for 30 minutes.
12. The most commonly reported
adverse reaction of vital teeth 22. In-office bleaching:
bleaching is: a. must be done with a light source.
b. must be done without a light source.
a. bad taste of bleach.
b. gingival irritation. c. uses hydrogen peroxides in the 6–10% range.
d. with or without a light source can give a
c. tooth sensitivity during bleaching. whitening result.
d. that trays are difficult to insert.
23. Research supports a novel 14%
13. Choices for vital tooth hydrogen peroxide gel that demon-
bleaching include: strated an average shade change of:
a. mouthguard (tray) vital bleaching. a. 9.42
b. in-office bleaching. b. 7.04
c. strips for bleaching.
c. 2.46
d. all the above. d. no shade change
14. To receive the ADA Seal for whit- 24. An innovative method for scallop-
ening a manufacturer must submit: ing a vital bleaching tray is:
a. safety studies. a. a #12B scalpel blade.
b. two clinical trials demonstrating at least a b. a ceramic scissor with a curved blade.
2-shade difference. c. an electric heated tipped soft tray
c. a and b trimming device.
d. none of the above. d. a Swiss Army knife.
15. Scalloping of bleaching trays is 25. In the technique of tray bleaching
needed for: with a novel 14% hydrogen peroxide
a. in-office light enhanced bleaching. gel a patient must wear the tray:
b. at-home tray bleaching with high a. 2 times a day for an hour each for two weeks.
concentrations gels. b. at least 6 hours for two weeks.
c. providing the patient with a special effect of c. 15 minutes once a day for two weeks.
the tray. d. 1 hour a day for three weeks.
d. none of the above.
26. When using the novel 14% hydro-
16. Before the fabrication of bleaching gen peroxide professional at-home
trays, the stone model must be: system it is important to:
a. trimmed leaving a minimal base. a. use the buffered mouthrinse.
b. inspected for bubbles. b. not eat or drink for 2 hours.
c. inspected for irregularities. c. dip the tray in cold water.
d. all of the above. d. put the gel in the refrigerator.
27. Vital tooth bleaching with
17. Use of spacers on the stone model
to create reservoirs: patients with moderate to severe
tetracycline staining:
a. is not necessary.
b. must be done if you want to see results. a. has been ineffective.
b. has been beneficial when used over long
c. should only be done for the anterior teeth.
d. should only be done for the posterior teeth. periods of time.
c. must use a combined in-office technique.
18. Drawbacks to bleaching with d. should never be discussed with a patient.
Whitestrips are that they: 28. Vital bleaching with peroxide
a. only whiten the six anterior teeth.
b. are difficult to apply on misaligned teeth.
containing agents has been shown to:
a. be an effective treatment to lighten
c. a and b. discolored teeth.
d. none of the above.
b. have sufficient research to demonstrate safety
19. A common agent for in-office and effectiveness.
c. have several successful techniques.
bleaching is: d. all of the above.
a. sodium perborate.
b. sodium hypochlorite. 29. Bleaching relapse has been reported
c. calcium peroxide. to occur for both in-office and tray
d. hydrogen peroxide.
based bleaching.
a. True
20. To minimize tooth sensitivity b. False
recommend that the patient:
a. decrease time the tray is worn the first week. 30. Bleaching can be maintained
b. use lower concentration gels with a through the use of:
desensitizing agent. a. whitening toothpastes.
c. use a desensitizing toothpaste in the tray for a b. touch-ups with in-office system.
week before starting bleaching. c. touch-up bleaching with the patient’s tray.
d. all the above. d. all the above.
 ANSWER SHEET

What’s Up With Whitening? An Update on Professionally Dispensed Vital Tooth Bleaching

Name: Title: Specialty:

Address: E-mail:

City: State: ZIP:

Telephone: Home ( ) Office ( )

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.

Mail completed answer sheet to

Educational Objectives Academy of Dental Therapeutics and Stomatology,
1. List the different types of vital tooth bleaching systems. A Division of PennWell Corp.

2. List the esthetic conditions that can be treated with vital tooth bleaching. P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
3. Describe the adverse reactions that have been associated with vital tooth bleaching.
4. Describe the clinical technique for professional vital tooth bleaching using a tray system. For immediate results, go to www.ineedce.com
and click on the button “Take Tests Online.” Answer
5. Describe how to manage bleaching relapse. sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
P ayment of $59.00 is enclosed.
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If paying by credit card, please complete the
1. Were the individual course objectives met? Objective #1: Yes No Objective #4: Yes No following: MC Visa AmEx Discover
Objective #2: Yes No Objective #5: Yes No Acct. Number: _______________________________
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7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Do you feel that the references were adequate? Yes No

9. Would you participate in a similar program on a different topic? Yes No

10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________

11. Was there any subject matter you found confusing? Please describe.
___________________________________________________________________
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12. What additional continuing dental education topics would you like to see?
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___________________________________________________________________ AGD Code 017

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

AUTHOR DISCLAIMER INSTRUCTIONS COURSE CREDITS/COST RECORD KEEPING

The authors of this course have no commercial ties with the sponsors or the providers of
the unrestricted educational grant for this course.
SPONSOR/PROVIDER
This course was made possible through an unrestricted educational grant. No
manufacturer or third party has had any input into the development of course content.
All content has been derived from references listed, and or the opinions of clinicians.
Please direct all questions pertaining to PennWell or the administration of this course to
Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com.
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We encourage participant feedback pertaining to all courses. Please be sure to complete the
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All questions should have only one answer. Grading of this examination is done
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EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or companies mentioned
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necessarily reflect those of PennWell.
Completing a single continuing education course does not provide enough information
to give the participant the feeling that s/he is an expert in the field related to the course
topic. It is a combination of many educational courses and clinical experience that
allows the participant to develop skills and expertise.
All participants scoring at least 70% (answering 21 or more questions correctly) on the
examination will receive a verification form verifying 4 CE credits. The formal continuing
education program of this sponsor is accepted by the AGD for Fellowship/Mastership
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Many PennWell self-study courses have been approved by the Dental Assisting National
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© 2008 by the Academy of Dental Therapeutics and Stomatology, a division
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10 www.ineedce.com