“White as Snow”

Conservative
Esthetic
Procedures

Valencia McShan, DDS,MA

Department of Restorative Dentistry
Meharry Medical College, School of Dentistry
 Bleaching (Tooth Whitening)
•  Most effective, economical and minimally
invasive approach to whiten discolored
teeth
 Learning Objectives
After completion of this lecture, the
student will be able to:
•  Explain the science of vital bleaching
techniques to achieve optimal
results.
•  List the indications and
contraindications of bleaching
•  Explain the risks and benefits to
bleaching
•  Describe how to perform vital
bleaching
 Why do people want whiter teeth?

•  See models, celebrities with

white teeth
•  Increased self-esteem
•  Signifies good health and
healthy lifestyle
•  Studies have shown that
people who are perceived as
attractive receive preferential
treatment and are judged
more positively.
v  Talamas SN, Mavor KI, Perrett, DI. Blinded by beauty; attractiveness bias and
accurate perceptions of academic performance. PLoS One. 2016;
11(2);e0148284.
 Why do people want whiter
teeth?
•  Patient’s are more esthetic-minded
•  Over the past two decades, tooth whitening or
bleaching has become one of the most popular
esthetic dental treatments
 Benefit to the Dentist
•  There are significant economic
advantages to offering whitening
services.
•  Members of the American Academy of
Cosmetic Dentistry
. bring in an average
of $25,000 annually from teeth
whitening alone
•  Dental boards have encouraged state
legislators to push back on the
explosion of teeth whitening products
and services, which is an $11 billion
industry.
•  The U.S. Food and Drug Administration
classifies peroxide-based teeth
whiteners as cosmetics, not controlled
substances.
 Shades of Teeth
•  Teeth are polychromatic (Louka 1989)
•  Tooth discoloration is determined by the color of the
dentin
•  Shade varies among the gingival, incisal, and cervical
areas according to the thickness, reflectance, and
translucency in enamel and dentin
•  Teeth are naturally grayish yellow, grayish white or
yellowish white
 Shade Guide
(Hue)A (reddish brown)-A1, A2, A3, A3.5,A4
(Hue)B (reddish yellow) (B1,B2,B3, b4)
(Hue)C (gray) (C1, C2, C3, C4)
(Hue)D (reddish gray) (D2, D3, D4)
M1, M2, M3

•  As chroma is increased, the

value is decreased
•  Chroma and
value(brightness/darkness)
are inversely related.
•  Higher numbers on the Vita
Classic shade guide
represent increased chroma
(intensity/saturation of
hue).
 Shade
Guide

Hue

Chroma

Value
 Shades of Teeth
•  With age, the color of teeth changes due to
increase dentin thickness and decrease in
enamel thickness
•  Tooth discoloration affect men 31% more
than women 21% (Ness et al. 1977)
 Tooth Structure
•  Enamel is semipermeable
•  Dentin contains tubules which
communicate with the pulp

Passage of
molecules
 Discoloring

ü  The lightening of the color of a tooth through

the application of a chemical agent to oxide
the organic pigmentation in the tooth.

Bleaching
Composition of the Bleaching Agent

Oxidizing Agents used to Whiten Teeth:

•  Hydrogen Peroxide (vital and non-vital teeth)
•  Carabamide Peroxide (vital and non-vital teeth
•  Sodium Perborate(non-vital teeth )
•  Sodium percarbonate (non-vital teeth)
Hydrogen Peroxide
•  Strong oxidizer
•  Active ingredient used in tooth
whitening
•  Can be applied directly or can be
produced by a chemical reaction
from carbamide peroxide or sodium
perborate
•  Available in different concentrations
(5%-40%)
•  At high concentrations, it is caustic,
burns tissues and can release free
radicals resulting in cellular damage
What is the Composition of the Bleaching Solution?

ü Compromised of carbamide peroxide which reacts with water to

form hydrogen peroxide and urea.
ü  When carbamide peroxide comes in contact with the outer enamel
surface, it breaks down into water and oxygen, which diffuses
through the organic content of enamel.
ü This causes oxidation of organic pigments that are mainly located
within dentin, which results in a reduction or elimination of the
discoloration
ü  Carbamide peroxide has about 1/3 strength of hydrogen peroxide.
Mode of Action of Carbamide Peroxide
•  The carbamide peroxide (CP) penetrates into the tooth
•  Broken down into urea and hydrogen peroxide (HP) 1 
•  The urea further breaks down into ammonia and carbon dioxide.
•  The role of urea is to prolong the shelf-life of the product.
•  The HP breaks down into oxygen and water and liberates the
chemically reactive free radical perhydroxyl (HO2-) with great
oxidative power.
Oxygen molecules from the whitening agents react with the
discolored molecules in enamel and dentin, breaking the
bonds that hold them together.
Hydrogen Peroxide vs Caramide Peroxide
•  Hydrogen peroxide has a different safety index and effect
on tissue than carbamide peroxide
•  Carbamide peroxide is more stable than hydrogen
peroxide; 1-2 year self life compared to only a few weeks
with hydrogen peroxide
•  10% solution of hydrogen peroxide is ~3.5 hydrogen
peroxide and 6.5% urea
•  Concentrations higher than 10% carbamide peroxide may
cause increased tooth sensitivity, tissue irritation and tooth
surface alterations
Bleaching Solution
•  10% CP corresponds to about
3.5% HP
•  20% CP corresponds to 7% HP
•  30% CP corresponds to about
10.5% HP.
•  The peroxide not only removes
discoloration from within the
enamel, it also changes the color
of dentin itself.4
Components in Bleaching Gel
Chemical Reason for inclusion
Hydrogen peroxide Active ingredient
Carbamide peroxide Source of hydrogen peroxide
Sodium perborate Source of hydrogen peroxide
Stabilizer, and increases the pH, which is less irritant to
Urea soft tissue
Increased antibacterial effect
Increases viscosity, so that the product is retained in
Glycerine the bleaching tray
Increases viscosity, decreases breakdown in saliva and
Carbopol (polyacrylic acid polymer) slows release of oxygen
Surfactant – promotes wetting by lowering surface
Alcohol ethoxylates or sodium xylene sulphonate tension or to solubilize one of the ingredients, such as
an insoluble fragrance
Decreases sensitivity by occluding the dentinal tubules
with calcium phosphate
Amorphous calcium phosphate (ACP)
 Components in Bleaching Gel
Potassium nitrate Decreases sensitivity by altering nerve conduction

Decreases sensitivity by occluding the dentinal tubules

Fluoride (e.g. sodium fluoride)
Promotes remineralization
Provides caries resistance
Neutralizers Alkaline substances to create neutral pH
Flavorings Increases patient acceptability

Converts light energy to heat so increasing the

activation of hydrogen peroxide by speeding up its
Carotene dissolution into free radicals in products intended to be
exposed to light energy
 Additives
•  Alter the handling characteristics of the product
•  Various ingredients added to promote thickness
(car, stickiness or viscosity
•  Glycerin, glycol and toothpaste materials (base
material)
•  Flavoring
 Bleaching Process
•  The oxidizing agent reacts with the organic material in the
spaces between the enamel crystals and the organic dentin
•  It breaks down the giant pigment molecules that absorb light
that cause the darkening of the tooth
•  Smaller molecules are formed, which reflect light, decreasing
the intensity of the color of the tooth
How Does the Bleaching Solution Work?

ü  The peroxide in the bleaching gel penetrates into the

microporosities in the enamel and breakdown the
stains in dentin.(oxidation process)
ü  pH of carbamide peroxide is 6.5-7
 Bleaching Process

Monocycline

•  The whitening process (bleaching) is designed to

enable the oxidizing agent to penetrate into the
tooth to allow a chemical reaction to occur and
dislodge or decolor the chromatic particles
CLASSIFICATIONS OF TOOTH
DISCOLORATIONS
 What Causes Tooth Discoloration?

•  Color molecules called

chromophores join together,
increasing the chromophore
bonds and causing the tooth
to look dark.
•  The color molecules collect
on the surface of the teeth
(extrinsic stains) and the
inside of the teeth (intrinsic
stains).
Classification of Tooth Discolorations

The causes of tooth discolorations need to be carefully

ascertained prior to tooth whitening for better
predictability and to inform the patient about the
prognosis of treatment
 Causes of Tooth Discoloration
Tooth discolorations can be a result
of:
•  Enamel mottling
•  Trauma
•  Developmental hypoplasia
•  Age-related extrinsic enamel
staining
•  Thinning of enamel with
subsequent dentin shine-through
•  Staining of teeth due to smoking
or food and beverage ingestion
Classification of Tooth Discolorations

Tooth discolorations are

classified as:
•  Extrinsic
•  Intrinsic
Classification of Tooth Discolorations
•  Extrinsic discolorations are
superficial on or within the surface
of the enamel.
•  Examples of extrinsic
discolorations of the enamel
include: Fluorosis, enamel
hypoplasia (“white spots”), and
superficial discoloration due to
smoking or food and beverage
ingestion
•  Caries can be both an intrinsic
and extrinsic discoloration.
 Causes of Extrinsic Staining
(Located on Surface of the Tooth):

•  Smoking
•  Plaque
•  Poor oral hygiene
•  Food and beverages
•  Chemicals (chlorhexidine stain)
 Causes Intrinsic Staining (Within the Tooth)

•  Tetracycline staining-chelates with

calcium
•  Minocycline (used in acne treatment)-
can affect permanent teeth
•  Fluorosis
•  Amelogenesis imperfecta
•  Endodontic staining (trauma)
•  Dentin hypercalcification
•  Age related
 Causes Intrinsic Staining (Within the Tooth)

•  Dyes from foods (chromogenic

foods)-tea; coffee, red wine; colas
•  Jaundice in infancy(bilirubin)
•  Hematological disorders
–  Porphyria(purplish-brown teeth)  a
group of disorders that can cause
nerve or skin problems
–  Erythroblastosis fetalis (destroys RBC)
abnormal presence of erythroblasts
in the blood of a newborn.
•  Dental caries
•  Restorations
 Tetracycline Staining
•  Broad-spectrum bacteriostatic antibiotic
•  Occurs during odontogenesis
•  Causes unsightly discoloration of both primary and
secondary dentitions (Thomas and Denny 2014).
•  The discoloration varies according to the type of
tetracycline used
•  The staining effects are a result of chelation of the
tetracycline molecule with calcium ions in
hydroxyapatite crystals, primarily in the dentin (Swift
1988).
•  Monocycline causes tooth discoloration by
chelating with iron to form insoluble complexes
 Tetracycline

Tetracycline calcium orthophosphate complex

 Tetracycline Staining
•  Tetracycline incorporates into the enamel and
dentin.
•  Chelation occurs at the mineralizing predentin–
dentin junction via the terminal capillaries of the
dental pulp (Patel et al. 1998).
•  The brown discoloration is a result of photo-
oxidation, which occurs on exposure of the tooth to
light.
•  Adult-onset tooth discoloration after long-term
ingestion of tetracycline and minocycline has also
been reported (Sánchez et al. 2004)
Tetracycline Staining Classification
Tetracycline Staining
Four Degrees of Tetracycline Staining:
•  1st degree (mild)-uniform light brown, yellow to
grey stain that responds well to bleaching; No
banding

•  2nd degree-yellow brown to dark gray that also

responds well to bleaching
 Tetracycline Staining
•  3rd degree(severe banding)-dark gray or
blue stains with marked banding. This
type of staining may require bleaching in
combination with some veneering
technique

•  4th degree-extremely dark stain that would

not benefit from bleaching
Tetracycline Staining
Causes and Therapy of Tooth Discoloration

Causes and therapy of tooth discoloration

Types of discolorations
A Mild tetracycline discoloration (bleaching time: three months).
B Mild tetracycline discoloration.
C Strong tetracycline discoloration (bleaching time: six months).
D Fluorosis with brown color changes.
E White spot discolorations after orthodontic treatment.
F Nonvital tooth.
Courtesy of Van B. Haywood
 Fluorosis
•  Ingestion of excessive fluoride in the drinking
water or from overuse of fluoride supplements
(Ismail and Hasson 2008) or fluoride toothpastes
(Shannon 1978)
•  Occurs within the superficial enamel and
appears as white or brown patches of irregular
shape and form
 Fluorosis
Manifests clinically in three different ways:
1.  Simple fluorosis-brown pigmentation with smooth
surface
2.  Opaque fluorosis-gray or white flecks
3.  Fluorosis with pitting-defects in the enamel surface, and
the color appears to be darker.(Nathoo and Gaffar
1995).
 Enamel hypoplasia
•  Developmental defective enamel.
•  Due to inherited condition; congential amelogenesis
imperfecta
•  Surface of the tooth is porous and readily discolored
•  Enamel surface may be whitened with varying degrees
of success which is dependent upon the severity and
extent of dysplasia.
 Enamel hypocalcification
•  Distinct brownish or whitish area found on the
buccal aspects of teeth.
•  The enamel is well formed and the surface is
intact.
•  Most can be removed with whitening in
combination with microabrasion.
 Whitening and Tooth Discolorations
•  The management of yellow, light
brown, and orange stains due to
aging, genetics, and stains caused
by chromatogenic foods and drinks
is highly successful.5 
•  It usually takes 3 to 4 weeks per
arch to bleach teeth depending on
the level of staining.
•  The treatment of brown, orange,
and white stains promoted by
fluorosis and stains caused by
nicotine are slower to respond to
tooth whitening.
Whitening and Tooth Discolorations
•  Some superficial fluorosis stains cannot be completely
removed with bleaching
•  Mottled enamel appearance of fluorosis can be treated
with a combined microabrasion-macroabrasion
technique and then finished with vital bleaching.

Fluorosis. A, Mild form of fluoride mottling, exhibiting white opaque flecks

near the incisal edges with the surface remaining smooth and intact. B,
Moderate form of fluoride mottling with ridges of hypoplasia and white and
brownish enamel. C, Severe form of fluoride-induced hypoplasia and
discoloration with associated cracking and chipping of the enamel.

(From Sapp JP, Eversole L, Wysocki G: Contemporary oral and maxillofacial

pathology, ed 2, St Louis, 2004, Mosby.)
Patients want the dentist to do this
to whiten their teeth
CLASSIFICATION OF
BLEACHING TECHNIQUES
Bleaching Techniques
 Types of Bleaching
•  Extra-coronal bleaching
–  Vital teeth
–  In office or take home
•  Intra-coronal bleaching
–  Non-vital teeth
–  In office
Extra-Coronal Bleaching
The process by which an oxidizing solution is
placed onto the enamel surface of the teeth in an
attempt to lighten the color of the teeth.
Extra-Coronal Bleaching
Extra-coronal Bleaching Techniques used:
•  In Office Vital Bleaching Technique
•  Dentist Prescribed- Home Applied Technique
Four Categories of Tooth Whitening
(Extra-Coronal)

Tooth Whitening market has evolved into four

categories:
1.  Professional applied (in-office)
2.  Dentist prescribed/dispensed (patient home
use)
3.  Consumer-purchased/over the counter (OTC)
4.  Other non-dental options
 Extra-Coronal Bleaching

Factors to Consider before Bleaching:

•  Age of the patient
•  The nature and the location of the stain
•  Concentration of the active ingredient
•  Treatment time and frequency of bleaching
•  Patient’s expectations
 Extra-Coronal Bleaching
Indication:
•  Patient with discolored teeth-must determine
cause of discoloration first
 Indications for Extra- Bleaching
•  Patient dissatisfaction with tooth shade
•  Mild tetracycline staining
•  Mild fluorosis
•  Mild hypocalcification
•  Combination staining
Contraindications for Extra-Coronal
Bleaching
Contraindications for Extra-Coronal Bleaching
•  Pt with unrealistic expectations
•  Pregnant women/Nursing mothers
•  Children under 14 years of age
•  Pt allergic to hydrogen peroxide or other ingredients
contained in bleaching product
•  Heavy smokers
•  Deciduous teeth
•  Teeth with pathology-caries, periodontal disease, perio-
radicular lesion
•  Pt with tooth hypersensitivity
•  Pt with severe loss of enamel due to attrition, erosion,
trauma
 Contraindications for Extra-Coronal
Bleaching

•  Teeth with severe type IV tetracycline staining

•  Faculty restorations or teeth with extensive caries
•  Teeth with pitted enamel due to enamel hypoplasia
•  Exposed cementum and root surfaces
•  Teeth with a history of thermal sensitivity
•  Young children with large pulp chambers
•  Pregnant or nursing mothers
•  Poorly motivated or uncooperative patients
•  Patients with TMJ or bruxism-aggravated by use of
bleaching trays
Side Effects to Extra-Coronal Bleaching
•  Increased sensitivity as concentration of peroxide increases
•  Chemical burns form bleaching gel
•  Overbleaching-result in chemical and morphological changes in
enamel structure leading to porosity, pitting
•  Bleachinorexia-obsession with having whiter teeth
•  Reduced bond strength (especially with sodium perborate)
•  Reduced enamel micro-hardness immediately after bleaching-
reversed by saliva in 3-4 weeks
 Other Considerations:
•  Concerns have been raised regarding the effect of whitening
on enamel microhardness, composite bond strength, and
genotoxicity.
•  In-vitro studies showed a decrease in enamel microhardness;
•  Clinical studies did not show any difference in enamel
hardness after tooth whitening.
•  Majority of studies showed a reduction of resin composite
bond strength when that procedure is performed within 1 day
after tooth-whitening treatment.20 
•  Research studies recommend delaying placement of resin
composite restorations from 1 to 3 weeks after tooth
whitening.20 
•  It is common practice to wait at least 2 weeks in order to
avoid any debonding of material and to stabilize tooth color. 
 Other Considerations:
•  Hydrogen peroxide is genotoxic in-vitro, but such activity is not
expressed in-vivo.
•  Clinical studies have not shown the development of pre-
neoplastic or neoplastic oral lesions.
•  Overall, tooth-whitening products are safe for use by the human
population.21,22
 Guarded Prognosis for Extra-
Coronal Bleaching
•  History of sensitive teeth
•  Translucent teeth at incisal edge
•  Extremely dark teeth in the gingival 1/3 visible when
smiling
•  Exposed root surfaces
•  Extensive white spots that are visible
•  Temporomandibular disorder (TMD) or bruxism
•  Patients who smoke (need to forgo tobacco during
bleaching process; hydrogen peroxide is a known
carcinogen)
Dentist Prescribed- At Home
Bleaching Technique
•  Trays are customized to fit the patient
•  Some at-home products that have the ADA Seal of
Acceptance contain a concentration of 10% carbamide
peroxide.3
•  These products work quickly.
•  Depending on the severity of the tooth discoloration,
some products are used twice daily for 2 weeks and
others are used overnight for 1 to 2 weeks.7
•  Mouth trays are made in 1 office visit.
•  These treatments are effective with many kinds of stains,
and the improvement can be as much as 6 shades with
long-lasting results10
•  These may cause temporary sensitivity.
Dentist Prescribed- At Home
Bleaching Technique
Dentist Prescribed-Home Applied Technique:
•  Patient wears a night guard containing 10-20%
carbamide peroxide for a specific time period
•  Bleaching process can take 2-6 weeks if trays are worn
2-3 hrs/day or overnight using 10% peroxide
•  Efficacy is 2-10 shades of color modification
•  1-2 shade rebound after 2-4 weeks
•  Severe staining (tetracycline) may take 6-12 months of
whitening process
•  Current data suggest that a combination of in-office and
dentist dispensed at-home bleaching trays may be the
most effective for teeth difficult to whiten.
 Dentist Prescribed- At Home
Bleaching Technique
•  Dentist-prescribed and home-applied by the patient using a
fitted tray.
•  The 10% concentration of CP used in trays overnight has been
considered the “gold standard.”
•  Most common whitening procedure, and the literature heavily
supports the efficacy and safety of this method.12
•   More recently, HP products have been introduced for day-wear
trays.
•  HP is active for 30 to 60 minutes. CP is active for up to 10 hours,
with about 50% of the active agent being used in the first 2
hours.
•  Research as shown that there is no difference in whitening
efficacy when the trays are made with or without a reservoir.14
Dentist Prescribed Bleaching
Power Bleaching (In-Office
Bleaching )

25% hydrogen peroxide whitening gel (Zoom! Discus

Dental, Inc., Culver City, CA, USA)
POWER BLEACHING (IN-OFFICE
BLEACHING )
Factors Affecting In-Office and At-Home Bleaching

•  Surface cleanliness-ensure maximum contact with the tooth

•  After dental prophylaxis, bleaching should be delayed for
several days to reduce possibility of sensitivity
•  Concentration of peroxide-higher the concentration, more
rapid the lightening effect; not linear effect
•  It is concentration- and time-dependent
•  In-office bleaching materials supplied in concentrations of
35% hydrogen peroxide; high as 50%
•  Tissue contact results in immediate chemical burn(35-50%)
•  At-home bleaching agents usually 10% carbamide peroxide
(3.4% hydrogen peroxide)
•  Carbamide peroxide ranges from 5%-35%
Lights/Laser for power bleaching currently available on the market
Products for power bleaching currently available
 Advantages and Disadvantages to Power
Bleaching/Professionally Applied

Power Bleaching
Advantages:
• Well-known procedure
• Good results
• Few side effects
• Short chair time
• Patient collaboration not required
Disadvantages:
• Very concentrated bleaching agent
• Can cause irritation
• Use of the dental chair
• Cannot be delegated to the patient
• Onset of severe hypersensitivity in some cases (zingers)
• Increased costs if light-emitting devices are purchased
 Power Bleaching/Professionally Applied

•  15% to 35% concentrations of hydrogen peroxide and

sometimes involve a light or laser to accelerate the
whitening process.
•  Many research studies have shown that the use of a
light or laser is optional, but for some patients the use
of the device enhances their experience.
•  Concentration is higher than at-home and OTC
products.3
•  Teeth brighten 10 shades in approximately an hour,1
and results are immediate compared with at-home
treatments, which may take 2 to 4 weeks.3,10
•  Some treatments may require more than one office
visit; the average number of visits is 3.2
 Zingers

“Zingers” are caused by overexposure to heat from the professional whitening

lamps that do not control temperature, causing a rise in the intrapulpal
temperature.
 Power Bleaching (In-Office Bleaching )

•  Chemically activated, so no light is

needed
•  Powerful 40% hydrogen peroxide gel
•  Opalescence tooth whitening gel
contains PF (potassium nitrate and
fluoride)
•  Fresh chemical for each application
•  Precise delivery
•  Easy to see for complete removal
•  Two 20-minute applications for a total
of 40 minutes of treatment time
(Opalescence Xtra Boost Kit, Ultradent, South
Jordan, UT, USA)
Opalescence tooth whitening gel contains PF (potassium nitrate and fluoride),
which helps maintain the health of enamel throughout the whitening process.
Formulated to prevent dehydration and shade relapse
Opalescence Go take-home whitening comes in 6%, 10%, and 15% Hydrogen
Peroxide concentration and with mint, melon or peach flavor.
Opalescence PF take-home whitening comes in 10%, 15%, or 35%
Carbamide Peroxide concentration and with mint, melon or regular flavor.
Activation of the Power Bleaching
(In-Office Bleaching )
Paint on Rubber Dam
Application of the Bleaching Gel
Laser or Light-Assisted In-Office
Bleaching
•  Claimed to enhance the action of hydrogen peroxide
•  Some products recommend use of argon lesion wavelength of
488 nm for 30 seconds
•  Another technique uses a CO2 laser, then use of argon laser for
deeper penetration
•  Pulpal irritation and necrosis have been demonstrated after use
of CO2 laser use
•  ADA does not recommend use of CO2 laser for bleaching.
•  High-intensity lights have not shown to be superior
Side Effects of Extra-Coronal Bleaching
Side Effects to Extra-Coronal Bleaching:
•  Increased sensitivity as concentration of peroxide
increases
•  Chemical burns form bleaching gel
•  Overbleaching-result in chemical and morphological
changes in enamel structure leading to porosity, pitting
•  Bleachorexia-obsession with having whiter teeth
•  Reduced bond strength (especially with sodium
perborate)
•  Reduced enamel micro-hardness immediately after
bleaching-reversed by saliva in 3-4 weeks
 Side Effects of Extra-Coronal Bleaching
Tissue Irritant
•  Studies have shown that hydrogen peroxide is an irritant and also
cytotoxic
•  Concentrations of 10% hydrogen peroxide or higher is potentially
corrosive to mucous membranes or skin and can cause a burning
sensation and tissue damage ( turns the tissue white)
•  Clinical studies have also observed a higher prevalence of gingival
irritation in patients using bleaching materials with higher
concentration
•  Rehydration and application of an antiseptic ointment (Orabase B,
Colgate Oral Pharmaceutical)
•  Reassure the patient that it is not permanent; slight patient
discomfort; use rubber dam
Side Effects of Extra-Coronal Bleaching

Small superficial burns

 Side Effects of Extra-Coronal Bleaching

Tooth Sensitivity
•  Data indicates that extra-coronal bleaching treatment in the dental
office or at home may cause short-term tooth sensitivity and/or gingival
irritation
•  Studies have shown that this is due to the peroxide concentration and
the contact time
•  Mitigated by remineralization with fluoride, potassium nitrate or sodium
citrate (numbing effect on nerve transmission)
•  Place potassium nitrate in tray for 10-30 minutes before or after
bleaching
•  Have the patient to shorter the duration and/or frequency of treatment
•  Interrupt the process for a day or more to allow the teeth to recover
•  Desensitizing toothpaste
 Tooth Sensitivity Management

•  Patients experiencing tooth sensitivity can be instructed to

wear the whitening tray every other night, or to wear it a
couple of hours a day instead of overnight.
•  apply desensitizing gels with potassium nitrate, potassium
fluoride, or high-concentration fluoride toothpaste in the
tray and wear it for 30 minutes prior to treatment.
•  A reduction in the concentration of carbamide peroxide
 Tooth Sensitivity Management
•  Patients experiencing tooth sensitivity can be
instructed to wear the whitening tray every other
night, or to wear it a couple of hours a day instead of
overnight.
•  Apply desensitizing gels with potassium nitrate,
potassium fluoride, or high-concentration fluoride
toothpaste in the tray and wear it for 30 minutes prior
to treatment.
•  A reduction in the concentration of carbamide
peroxide
External and Internal Whitening of
Teeth

•  External and internal whitening can also be used

in combination. The walking whitening method
can be combined with the single-tooth tray,
allowing the patient to whiten externally using
10% to 20% CP.
BLEACHING PROTOCOL
 Treatment Planning and Patient Education

•  An understanding of the cause of discoloration is

necessary to predict course and duration of
treatment
•  At-home or in-office bleaching is based on patient
preference, financial situation and ability and
willingness to comply with treatment protocol
•  Patient’s other dental problems must be
addressed first before bleaching
•  Shade of other restorations placed will not be
altered by bleaching
•  Bleaching should be performed before any
esthetic restorative procedures
•  Discuss with the patient the decision to bleach,
procedure agreed upon and predicted outcomes;
record in patient’s chart
 Treatment Planning and Patient Education

•  If a patient presents with moderate to deep caries

lesions, a resin-modified glass ionomer (RMGI) can be
placed as a “protective restoration” during bleaching.
•  Patient is able to minimize possible pulpal insult
•  Can also bond appropriate shade of composite for
esthetics.
 Orthodontic Considerations
•  White spot lesions and caries from improper oral
hygiene during orthodontic treatment can be
significantly reduced by utilizing bleaching materials.14
•  Preventive approach to prevent dental caries
•  Cleanse the teeth and gingival tissue from bacteria and
plaque during orthodontic treatment.
•  As the teeth continue to shift during orthodontic
treatment, new trays are fabricated approximately every
2 to 3 months
 Caries Control
•  Useful in patients with reduced salivary flow from
radiation therapy.
•  Bleaching gel serves as a"fluoride gel carrier”
•  Bleaching products containing urea, such as carbamide
peroxide, elevate the pH of the mouth
•  Stops or slows the process of tooth decay

Custom tray used with 10% carbamide peroxide and worn Patient injects 10% carbamide peroxide into an area
nightly for caries control in elderly patients. that is difficult to clean with conventional methods.
 References
•  14. Haywood VB. Orthodontic caries control and bleaching. Inside Dentistry. 2010;6(4):36-50.

•  15. Leonard RH Jr, Austin SM, Haywood VB, et al. Change in pH of plaque and 10% carbamide peroxide
solution during nightguard vital bleaching treatment. Quintessence Int. 1994;25(12):819-823.

•  16. Leonard RH Jr, Bentley CD, Haywood VB. Salivary pH changes during 10% carbamide peroxide
bleaching. Quintessence Int. 1994;25(8):547-550.

•  17. Bentley CD, Leonard RH, Crawford JJ. Effect of whitening agents containing carbamide peroxide on
cariogenic bacteria. J Esthet Dent. 2000;12(1):33-37.
 Patient Evaluation
During the patient’s clinical examination, the following questions regarding
tooth discoloration should also be answered:

1.  What tooth, group of teeth, or dental arch is/are affected by

discoloration?
2.  What is the extension of the color change on the dental surface?
3.  What is the dental shade (expressed in the Vita Classical or 3D Master
coding system)? The shade color can be either visually or
instrumentally recorded.
4.  Is it a superficial, external staining or an inherent discoloration of the
tooth structure?
5.  Is it a uniform discoloration, or does it appear as colored or opaque
bands, spots, or lines on the dental surface?
6.  Are there any restorations (composite fillings, veneers, crowns), and
what is their chromatic appearance in comparison with the natural
dentition? Would the patient want them replaced after bleaching if they
do not match the final dental color?
 Bleaching Protocol
Procedure:
ü  Determine the origin and severity of the staining in
patient’s teeth
ü  Consult with the patient and documentation of any
medications, history of allergies, past problems with
tooth sensitivity, history of periodontal disease, diet
or unusual habits that may compromise treatment
results
ü  Informed consent obtained and expected outcome
discussed with the patient; the goal is for the patient
to expect results but not miracles!
 Bleaching Protocol
Protocol for Bleaching:
ü  Prophylaxis is performed on the patient
ü  Prior to bleaching, an initial shade (baseline shade) is
obtained using the VITA shade guide.
ü  The shade needs to be taken three times; by the
student, the patient and by the instructor(baseline
shade)
ü  Pre-treatment photographs should be taken
 Protocol for Making the Night-Guard
•  Make a maxillary alginate impression of the patient and
pour in die stone.
•  After the stone has set, trim the cast in a horseshoe shape
with a thin base
•  Use the block-out material provided in the bleaching kit
and place a thin layer on the teeth, following the contours
of the teeth.
•  It is not extended into the embrasures and terminates
1.0mm short of the gingival area and incisal edge)
•  Fabricate the night guard and evaluate it to make sure the
edges are smooth. Try in the night guard on the patient
and evaluate the fit and comfort around the tissue, gingival
and tongue
Trim Models
Place spacer and make tray
Tray Reservoir
Econo-Vac Forming Machine

1 Heating element that softens the thermoplastic resin

Handles to pull down plastic

Vacuum to mold plastic to tray after it is pulled down

Bleaching Tray Fabrication
Bleaching Tray Fabrication
Bleaching Tray Fabrication
Bleaching Tray Fabrication

Custom trays should not impinge on the soft tissues, as this

will cause gingival irritation and patient discomfort.
Bleaching Tray Fabrication
Bleaching Tray Fabrication
Bleaching Tray Fabrication
 Bleaching Protocol
Protocol for At-Home Bleaching:
ü  The patient will take home four vitals of bleaching
gel
ü  It is necessary for the patient to wear the bleaching
tray for two hours per day for two weeks or
preferably at bedtime.
ü  Make sure the patient is instructed to brush their
teeth before inserting the tray.
Bleaching Protocol
Patient instructions:
ü  In the morning after eating, brush and floss
ü  Place bleaching solution into the tray ( a thin line) and set the
tray over the teeth.
ü  Excess may be expectorated without taking the appliance out of
the mouth or wipe with a cotton tip applicator.
ü  Wear during the day
ü  At lunch, remove the appliance, brush and floss and repeat
ü  Can be worn at bedtime instead of during the day.
 Bleaching Protocol
•  The patient should be advised to avoid any citrus fruits and
juices
•  According to the manufacturer, citrus fruits and juices have
a tendency to lower the pH of the oral cavity. This lowering
of the pH tends to decrease the effectiveness of the
oxidizing solution.
•  Also, due to their ability to stain, smoking, red wine and
caramel-colored soft drinks should be avoided.
Follow up Instructions with the Patient
•  Avoid coffee, tea, blueberries, red wine, cranberry
juice, grape juice and tomato sauce
•  No smoking
•  If teeth become sensitive, skip bleaching every day
and reduce to every other day
•  Potassium nitrate-containing toothpaste before
bleaching and throughout the bleaching therapy
patients manage tooth sensitivity.
•  Use desensitizing agent such as potassium nitrate,
fluoride, take NSAID or prescribe MI paste
Factors Affecting In-Office
and At-Home Bleaching
 Factors Affecting In-Office and At-Home Bleaching

•  Higher the temperature, the faster rate of oxygen released

and faster rate of reaction
•  Temperatures elevated to an uncomfortable level may
result in tooth sensitivity or irreversible pulpal inflammation
•  Bleaching materials always applied without anesthesia to
avoid overheating the tooth
•  pH of hydrogen peroxide in bleaching is 9.5 to 10.8
•  Most carbamide peroxide gels approved by ADA have a
pH of 7
•  Carbamide peroxide breaks down to hydrogen peroxide
and urea when applied
•  Urea raises pH in the oral cavity above 8 for a number of
hours
Factors Affecting In-Office and At-Home Bleaching

•  Degree of bleaching is directly related to the

amount of time the bleaching agent contacts the
tooth
•  The longer the contact, the more lightening will
occur ( plateau reached)
•  Longer the bleaching agent contacts the tooth,
greater likelihood of tooth sensitivity
•  Efficiency of hydrogen peroxide is increased in a
sealed environment (non-vital teeth)
Side Effects of Bleaching on Tooth Structure and
Restorations
Primary factors that influence the efficacy of whitening
are:
•  Concentration of hydrogen peroxide gel
•  Contact time of the gel to the teeth

Secondary factors that increase efficacy of whitening are:

•  pH - the optimum range is 9.5-10.8, which produces a
50% greater result
•  To maintain pH, store in a dual-barrel syringe with a
pH Temperature - accelerates the reaction rate of
hydrogen peroxide
•  Environment
 Side Effects of Bleaching on Tooth Structure and
Restorations

ü  Low pH solutions can produce a detectable loss of

calcium from enamel surface; slight loss in surface
hardness (25um) –not seen clinically
ü  Composite restorations and crowns do not lighten with
bleaching.
ü  Bleaching should be done first before esthetic
restorations.
ü  Inform patients that existing esthetic restorations may
appear dark and unattractive
Side Effects of Bleaching on Tooth Structure and
Restorations

There should be a waiting period of 2 weeks:

ü  To allow the shade to stabilize
ü With a bleaching techniques, there is a transitory
decrease in the potential bond strength (25-50%) of
composite resins to bleached enamel and dentin
ü Results form residual oxygen or peroxide residue in
the tooth inhibits the setting of the bonding resin
precluding adequate resin tag formation in the
etched enamel.
The Potential Effects of Bleaching Agents on
some Restorative Materials

§  Wherever possible, bonding using any resin-based

composite to teeth which have been bleached should be
delayed for at least 2 weeks (and preferably longer if
possible) for the following reasons:
At Home (Consumer) OTC Whitening
Products
Consumer whitening products available for home
use include:
•  Gels
•  Chewing gums
•  Toothpastes
•  Paint-on-films
•  Strips
•  Whitening products are developed and
marketed according to the cosmetic regulations
of the FDA.12
 At-Home (Consumer) with OTC
Whitening Products
•  OTC products include whitening strips, paint-on brushes,
rinses, toothpastes, dental floss, and chewing gums.
•  The main advantage-low cost.
•  Strong evidence supporting the effectiveness of whitening
strips for removing intrinsic stains
•  Whitening toothpastes, gum, and floss aid in removal of
superficial stains
•  Rinses and paint-on brushes have some whitening effect, but
it is without clinical relevance.1
•  Users should be careful with self-applied whitening products
that contain peroxide, because they have the potential to
produce oral irritation and tooth hypersensitivity.
 At-Home (Consumer) with OTC
Whitening Products
•  Do not provide the same dramatic
improvement as seen with professional
treatment10 or supervised treatment.
•  OTC products containing 10% peroxide are
eligible for the ADA Seal of Acceptance.3
•  Effective for age-related staining and slight
diet-related staining.10
•  Their effectiveness can last 6 months, and
they can result in a 2-shade improvement
and can help maintain professional whitening
results.10
At-Home (Consumer) with OTC
Whitening Products
At-Home (Consumer) with OTC
Whitening Products
 Whitening Strips
•  Problem with OTC products; no examination
and diagnosis of cause of discoloration
•  Discolored teeth could be caused by abscess
or non-vital tooth, dental caries, internal
resorption, dark or stained restorations
•  Adhesive strips contain 6-14% of hydrogen
peroxide
•  Patient’s wear strips for 30 minutes; twice a day
•  Studies have shown the whitening strips to be
effective without significant tooth sensitivity or
tissue irritation
•  Less expensive than dentist-prescribed kits
•  Difficult to use with malaligned teeth
Gerlach RW. Shifting paradigms in whitening: Introduction oa novel system for vital
tooth bleaching. Compend Contin Educ Ednt 2000; 21 (suppl)S4-S9.
Gerlach RW, Bibb RD, Sagel P. Initial color change and color retention with hydrogen
peroxide bleaching strip. Am J Dent 2002; 15(1);3-7
 Whitening Gel
•  Applied with a brush applicator
•  Anhydrous solution containing 19%
sodium percarbonate or 18% carbamide
peroxide
•  Silcone polymer designed to form a film
that will cling to enamel
•  Results are comparable to or slightly better
than whitening toothpaste
 Whitening Toothpaste, Chewing
Gums
•  Produce whitening by removing
extrinsic or surface stains with
abrasive or peroxides
•  Prevent staining with chemicals
Crest White Strips Products Currently Available in the USA
 Exposure to Hydrogen Peroxide

Exposure to hydrogen peroxide Concentration Duration of used % exposure

In-office bleaching (tooth surface) 30-35 5 minutes
Bleaching of stained
root-filled tooth 30-35 30 minutes
‘Walking bleach’ 3.5 8 hours
Mouthrinse 1-3 5 minutes
Dentifrice 0.75 5 minutes
 Which Whitening Product to
Recommend?
•  The choice is based on the patient’s
preference, financial situation, and motivation
to comply with the treatment protocol.
•  Patients who desire to finish whitening in a
short period of time are good candidates for in-
office treatment
•  Patients who present with financial limitations
may opt to whiten using OTC products.
Bleaching Treatments
Activated Charcoal

There is no evidence that shows dental

products with charcoal are safe or effective
for your teeth, according to the September
2017 issue of the
Journal of the American Dental
Association.
 Paint-on Gel Tooth-Whitening Products Currently
Available on the Market

Product Manufacturer Active ingredient

Crest Night Effects Proctor and Gamble 19% sodium perborate

Mentadent Xtra White Unilever Oral Care 6% hydrogen peroxide

Polapaint SDI 8% carbamide peroxide

16.4% or 18% carbamide peroxide

Simply White Clear Whitening depending whether the product is
Gel Colgate-Palmolive for sale in Europe or the USA,
respectively. This product has now
been discontinued in the UK

VivaStyle Paint On Plus Ivoclar Vivadent 6% hydrogen peroxide

 Other Non-Dental Options
Non-Dental Whitening Venues:
•  Mall kiosks
•  Salons and spas
•  Passenger cruise ships
•  Non-Dental Whitening Venues have come under scrutiny
in several states and jurisdiction
–  (Florida, Iowa, Massachusetts, Nevada, New Jersey, Tennessee
and the District of Columbia)
•  In Europe and some other countries, it is illegal to
provide teeth whitening services at malls and other
venues.
Other Non-Dental Options
NON-VITAL BLEACHING
TECHNIQUE
 Non-Vital Bleaching of Teeth
•  Pulp responds to trauma in different ways.
•  It can survive, die, or undergo pulp canal
obliteration, which is also known as calcific
metamorphosis.10 
•  A radiograph of a single dark tooth should
always be taken, because teeth may undergo
pulpal necrosis without showing any
symptoms other than becoming dark.
•  Endodontically treated teeth are susceptible
to discoloration from blood products in the
dental tubules caused by trauma or
endodontic therapy.
•  Insufficient cleaning of the pulp chamber,
endodontic sealer, and dark or leaking
restorations in the access opening can cause
discoloration.
 Non-Vital Bleaching of Teeth
Indications:
•  Blood products caused by
trauma or endodontic therapy
 Intra-coronal bleaching technique(non-vital) in
office used:
ü  Thermocatalytic Technique
ü  Walking beaching Technique
Both methods commonly used in bleaching teeth
that have been root canal treated
Both methods used hydrogen peroxide or sodium
perborate or sodium percarbonate

Intra-Coronal
Bleaching
 Non-Vital Bleaching Techniques
Thermocatalytic technique:
•  Heat applied several times during a 30-
minute period to activate the solution into
pulp chamber then rinsed

Walking bleach technique:

•  Uses a mixture of 30% hydrogen peroxide
and sodium perborate to make a paste
which is sealed into the chamber over
several days
 Intra-Coronal Bleaching
Indication:
ü  Discolored pulpless teeth that have been
successfully threated endodontically
Disadvantage/Side Effects:
ü  External cervical resorption(root)
ü  Affects 7% of teeth that undergo internal bleaching
ü  Occurs mostly in patients 25 years of age and
younger
ü  Most had traumatic injury
 Possible causes of External Root
Resorption
Several factors may contribute external root
resorption:
•  Injury to the periodontal ligament (cementum
deficiency)
•  Infection
•  Lack of seal over the gutta-percha especially if using
heat or high concentration of hydrogen peroxide
•  High heat
•  High concentration of hydrogen peroxide
•  Recommend (sodium perborate or 10% carbamide
peroxide)
External Root Resorption
 Intra-Coronal Bleaching
Oxidizing Agents used to Whiten
Non-Vital Teeth:

Hydrogen Peroxide (Superoxol)

ü  Available in various strengths (35%
hydrogen peroxide-most common)
ü  Caustic and will burn tissues on
contact
Intra-Coronal Bleaching
Oxidizing Agents used to Whiten Non-Vital Teeth:
1. Sodium Perborate
ü  Available in various combinations
ü  When combined with water, decomposes to form
sodium metaborate, hydrogen peroxide and nascent.
ü  Easily controlled and safer than concentrated hydrogen
peroxide solutions
2.Sodium percarbonate
3. Hydrogen peroxide
4. Carbamide peroxide
 Walking Bleach Technique
ü  Thin layer of cement is placed over the
obturating material before application of the
bleaching agent
ü  Utilizes sodium perborate and inert liquid (water,
saline) to place inside the pulp chamber for
approximately 3-5 days.
ü  A protective barrier at the cementoenamel
junction (CEJ) will furthermore reduce the risk of
cervical root resorption and damage to the
periodontal ligament.
ü  Requires several treatments
ü  Called “walking bleach technique” because
patient walks around with the bleaching solution
in the pulp chamber.
Walking Bleach Technique

Left: The coronal part of the root canal filling is removed and barrier
placed.

Middle: Bleaching agent is inserted into the pulp chamber.

Right: The pulp chamber is closed with a temporary filling material (Cavit).
After multiple changes of the bleaching agent and an approx. two-week
total treatment period, the bleaching process is completed.
 Walking Bleach Technique
Protocol
• Correct root-canal treatment
• Initial photograph
• Preparation of the tooth: opening of the pulp chamber
and complete removal of foreign matter
• Removal of gutta-percha 3 mm apical to the gingival
margin
• Placement of a sealer over the gutta-percha, either
made of GIC (light color) or using adhesive techniques
Walking Bleach Technique
Thermocatalytic Technique
ü  Designed to drive the oxider into
the dentinal tubules of the tooth
with the application of heat
ü  More recent techniques utilized
light activated bleaching
preparations of 35% hydrogen
peroxide that does not use heat
(preferred method)
ü  In office technique
 Internal Bleaching
•  Internal bleaching is not long term in most cases
•  Within 1-5 years, only 35-50% of the teeth maintain lightening
•  Process must be repeated periodically
•  If sealed with composite resin, requires removal of resin each time
bleaching is attempted; recommend extra-coronal bleaching
 Inside-Outside Bleaching
Technique
•  Combines both internal and external bleaching
treatments
•  Includes the walking bleaching technique (inside)
•  Bleaching process continued from the outside using a
“single-tooth” bleaching tray.
MICRO-ABRASION METHOD
 What is Microabrasion?
•  Chemical use of (hydrochloric acid and silicon carbide
particles in gel) means to remove a small amount of
tooth enamel to eliminate superficial discoloration
resulting from extrinsic or intrinsic factors.
•  Does not bleach teeth
 History
•  1984-McColskey used pumice mixed
with 18% hydrochloric acid to remove
color changes on tooth surfaces
•  Six years later, Primier Company bought
the product, Prema (Primier Enamel
Micro Abrasion)
•  Prema consists of pumice mixed with
11% hydrochloric acid
•  Micro-abrasion can be combined with
bleaching
 Hydrochloric Acid
•  Very aggressive liquid
•  Used to remove superficial color changes (white
spots, fluorosis, tetracycline staining)
•  Elctron microscopic studies have shown that 18%
hydrochloric acid removes approximately 10um of
enamel in five seconds
•  Should be used for short time intervals (five
seconds
•  Repeated applications should not exceed 5 times
Procedure for Micro-abrasion Treatment
•  Isolate with rubber dam; Pt, dentist and assistant
should wear goggles
•  Apply the acid-pumice mixture to the teeth that are
discolored: 12-18% hydrochloric acid with pumice.
•  Polish the tooth for five seconds with a polishing cup
•  Suction off and rinse the acid-pumice mixture
immediately.
•  Evaluate the tooth
•  Repeat the process up to a maximum of four times
•  If no improvement after 2-3 times, do not continue to
treatment
•  Polish the teeth and apply fluoride treatment
Microabrasion.
A, Young patient with unesthetic fluorosis stains on central incisors. B and C, Prema compound
applied with special rubber cup with fluted edges. Protective glasses and rubber dam are needed
for the safety of the patient. D, Hand applicator for applying Prema compound. E, Stain
removed from the left central incisor after microabrasion. F, Treated enamel surfaces polished
with prophylactic paste. G, Topical fluoride applied to treated enamel surfaces. H, Final esthetic
result. (Courtesy of Dr. Ted Croll.)
17 year-old with chief complaint of “brown and white
spots on my front teeth.”

PRĒMA is placed upon tooth surface, after rubber dam

application.

Tip of PRĒMA polishing cup completes slow speed

microabrasion of both tooth surfaces.

PRĒMA suspension rinsed away with water spray.

Enamel Pro® fluoride topical gel, on a cotton swab,

used to fluoridate surface after microabrasion is
completed. ENAMELON® Preventative Treatment Gel
is also ideal for this purpose.5

Post treatment view, immediately after enamel

microabrasion using PRĒMA Microabrasion
Compound.

Developed by Dr. Ted Croll

Status before micro abrasion therapy Result of treatment
and bleaching
 What is Macroabrasion?
•  Removal of enamel defect using a fine-grit diamond bur.
•  With macroabrasion, caution should be exercised not to
remove excess tooth structure
•  Can use microabrasion and macroabrasion depending
upon the extent of the enamel defect.
 References:
Haywood VB, DiAngelis AJ. Bleaching the single dark tooth. Inside Dentistry. 2010;6(8):42-52.
Niederman R, Tantraphol MC, Slinin P, et al. Effectiveness of dentist-prescribed, home-applied tooth whitening. A meta analysis. J Contemp Dent
Pract. 2000;1(4):20-36.
Matis BA. Tray whitening: What the evidence shows. Compend Contin Educ Dent. 2003;24(4A):354-362.
Matis BA, Hamdan YS, Cochran MA, Eckert GJ. A clinical evaluation of a bleaching agent used with and without reservoirs. Oper Dent. 2002;27(1):
5-11.
Buchalla W, Attin T. External bleaching therapy with activation by heat, light or laser—a systematic review. Dent Mater. 2007;23(5):586-596.
da Costa JB, McPharlin R, Paravina RD, Ferracane JL. Comparison of at-home and in-office tooth whitening using a novel shade guide. Oper Dent.
2010;35(4):381-388.
Demarco FF, Meireles SS, Masotti AS. Over-the-counter whitening agents: a concise review. Braz Oral Res. 2009;23 Suppl 1:64-70.
Tredwin CJ, Naik S, Lewis NJ, Scully C. Hydrogen peroxide tooth-whitening products: review of adverse effects and safety issues. British Dent J.
2006;200(7):371-376.
Li Y. The safety of peroxide-containing at-home tooth whiteners. Compend Contin Educ Dent. 2003;24(4A):384-389.
. Attin T, Hannig C, Wiegand A, Attin R. Effect of bleaching on restorative materials and restorations—a systematic review. Dent Mater. 2004;20(9):
852-861.
Munro IC, Williams GM, Heymann HO, et al. Tooth-whitening products and the risk of oral cancer. Food Chem Toxicol. 2006;44(3):301-315.
Mahony C, Felter SP, McMillan DA. An exposure-based risk assessment approach to confirm the safety of hydrogen peroxide for use in home tooth
bleaching. Regul Toxicol Pharmacol. 2006;44(2):75-82.
Questions?