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Efficacy of 10 percent Carbamide Peroxide as an Intracoronal Bleaching

Agent in Nonvital Discolored Primary Teeth: An In Vitro Study

Article  in  Journal of Dentistry for Children · January 2017

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 JDC SCIENTIFIC ARTICLE

Efficacy of 10 percent Carbamide Peroxide as an

Intracoronal Bleaching Agent in Nonvital Discolored
Primary Teeth: An In Vitro Study
Miram Abd El Magied Shaheen, BDS, MSc 1
Mona Abdallah Elkateb, BDS, MSc, PhD 2
Niveen Samir Bakry, BDS, MSc, PhD 3
Omar Abd El Sadek El Meligy, BDS, MSc, PhD 4

ABSTRACT
Purpose: The purpose of this study was to evaluate, in vitro, the efficacy of 10 percent
carbamide peroxide used as an intracoronal bleaching agent in blood-stained primary
teeth.
Methods: Thirty extracted primary canines were stained using rabbit blood and ran-
domly divided into two groups of 15 teeth each. Stained teeth in the test group
were bleached intracoronally using 10 percent carbamide peroxide for 21 days. The
bleaching agent was replaced at days seven and 14. The control group was not sub-
jected to bleaching, and a cotton pellet damped with distilled water was placed in
the pulp chamber. Shade alteration from the prestaining value was evaluated using
a VITA Easyshade spectrophotometer at days zero, seven, 14, and 21.
Results: All specimens in the test group returned to the initial baseline shade, with
no significant differences from the prestaining values (P=0.097). Teeth in the control
group did not undergo any shade alteration after staining, with no significant differ-
ences noted from the prestaining values (P<0.001).
Conclusions: Intracoronal bleaching using 10 percent carbamide peroxide is an effec-
tive approach for whitening discolored extracted primary teeth.
(J Dent Child 2017;84(1):22-9)
Received November 2, 2016; Last Revision December 9, 2016; Revision December
13, 2016.
Keywords: carbamide-peroxide, dental bleaching, intrinsic discoloration

1
Dr. Shaheen is an assistant lecturer, Department of Pediatric Dentistry,
Faculty of Dentistry, Damanhour University, Damanhour, Egypt. 2Dr. 
Elkateb is a professor, Department of Pediatric Dentistry, Faculty of 
Dentistry, Alexandria University, Alexandria, Egypt, and professor,
Department of Pediatric Dentistry, College of Dentistry, Princess Nora  dren’s teeth have a microbial origin.1 However, some re-
bint Abdul Rahman University, Riyadh, Saudi Arabia. 3Dr. Bakry is a
professor, Department of Pediatric Dentistry, Faculty of Dentistry, Alex- 
andria University; and 4Dr. El Meligy is a professor, Department of 
Pediatric Dentistry, Faculty of Dentistry, at both Alexandria University,
Alexandria, Egypt and King Abdulaziz University, Jeddah, Saudi Arabia.
Correspond with Dr. El Meligy at omeligy@kau.edu.sa
D
iscoloration of primary teeth can occur through
extrinsic and/or intrinsic factors. It has been
generally accepted that extrinsic stains in chil-
ports have indicated that oral iron preparation or other
medications may be responsible for an additional type of
extrinsic stain.2 Intrinsic stains occur following a change
to the structural composition or thickness of the dental
hard tissues due to hereditary, systemic, or local factors.3

  22 Shaheen et al. Carbamide peroxide as a bleaching agent Journal of Dentistry for Children-84:1, 2017
 Cosmetic dentistry commands great attention today.
Pediatric and adolescent patients, in addition to their
parents, are seeking an attractive smile, especially when
discoloration causes psychosocial problems.4 One of the
most common causes for poor esthetics in primary teeth
is the traumatic injury that induces internal pulpal
bleeding. Cosmetic impairments can be treated with
several restorative treatment modalities, such as crowns
or veneers.5 However, dental bleaching may offer an alter-
native method that can be completed with conservation
of tooth structure, less chair time, low cost, and effective
results.6 Bleaching techniques may be performed either
extracoronally, intracoronally or via a combination of
both techniques. 7 In endodontically treated primary
teeth, both techniques can be used. However, in vital
primary teeth, bleaching is only done by external ap-
proach.8 Brantley et al.9 used external bleaching tech-
nique on primary teeth and reported that this technique
could be used on vital and nonvital teeth. The second
approach for bleaching nonvital teeth is the internal
bleaching technique, which has advantages over external
bleaching in that it avoids gingival irritation and in-
gestion of the bleaching material.10
Over the years, many bleaching agents have been
used with varying results, such as sodium perborate, hy-
drogen peroxide, sodium percarbonate, and carbamide
peroxide.11 The bleaching process can be activated by
adding energy to the peroxide compound in the form
of heat, light, or laser radiation.12 Weiger et al.13 used an
intracoronal bleaching technique to compare the effects
of various types of sodium perborate (mono-, tri-, or
tetrahydrate). They verified that the combination of
tetrahydrate sodium perborate with 30 percent hydrogen
peroxide or water led to similar esthetic results. Gokay
et al.14 also evaluated and compared radicular peroxide
diffusion from different concentrations of carbamide
peroxide bleaching gels (10, 17, and 37 percent) and a
mixture of 30 percent hydrogen peroxide and sodium
perborate on extracted permanent teeth. The results
showed that higher peroxide penetration occurred with
a mixture of 30 percent hydrogen peroxide and sodium
perborate than with carbamide peroxide bleaching gels.
They concluded that peroxide penetration of carbamide
peroxide gels was significantly lower than the mixture
of hydrogen peroxide and sodium perborate. They sug-
gested that carbamide peroxide might have less risk of
postbleaching external root resorption. Valera et al.15
evaluated in vitro the efficacy of 16 percent carbamide
peroxide gel, tetrahydrate sodium perborate, and a
mixture of both agents as intracoronal bleaching ma-
terials. The sample included 60 single-rooted, nonvital
discolored human premolars due to blood decompo-
sition. They reported that the three bleaching agents
were effective and led to similar bleaching results, with
no significant difference between them after 21 days.
Journal of Dentistry for Children-84:1, 2017 Carbamide peroxide as a bleaching agent
The literature has shown higher incidences of root
resorption when hydrogen peroxide is mixed with so-
dium perborate16 or any mixture of sodium perborate is
heated.17 Therefore, the use of hydrogen peroxide and
heating any mixture of sodium perborate is not recom-
mended in primary teeth.18 The American Academy of
Pediatric Dentistry (AAPD) supports the use of bleach-
ing for vital and nonvital primary teeth.18 Due to the
concern of the hydroxyl free radical and the potential
side effects from internal bleaching,19 the AAPD recom-
mends using the lowest effective concentration of the
bleaching agents.18
Studies concerning evaluation of the efficacy of
bleaching materials on primary teeth are limited. There-
fore, the purpose of this study was to assess, in vitro,
the efficacy of 10 percent carbamide peroxide gel as an
intracoronal bleaching agent of nonvital discolored pri-
mary teeth due to blood decomposition. The hypothesis
tested was that intracoronal bleaching, using 10 percent
carbamide peroxide, was not an effective approach for
whitening discolored extracted nonvital primary teeth.
METHODS
The Ethics Committee of the Faculty of Dentistry, Alex-
andria University, Alexandria, Egypt, approved the
research protocol. Verbal consent was obtained from the
children’s parents or guardians before extraction of the
primary canines. The verbal consent procedure was
approved by the same Ethics Committee.
This was an experimental in vitro study conducted on
30 primary canines that were extracted due to serial
extraction and /or unilateral premature loss. At least two
thirds of their labial surfaces and one third of their roots
were intact. They were collected from public hospitals
and the outpatient clinic of the Faculty of Dentistry,
Alexandria University.
Following tooth surface cleanings, roots were cut
four mm to the cementoenamel junction (CEJ), using a
carbide disk in a low-speed handpiece, in order to stand-
ardize the root length. Each sample was then embedded
within a resin block. A rubber base impression was made
for each specimen. For color standardization, a four- by
four-mm window was cut through the middle third of
the labial surface and the external surface of the impres-
sion was painted black (Figure 1). Teeth were stained
with rabbit blood (obtained from the animal lab at the
Institute of Medical Research, Alexandria, Egypt),
according to the modified staining method adopted by
Weiger et al.13 in 1994. Each tooth was placed in an
individual test tube containing two ml of the rabbit
blood and then centrifuged at 500 times gravity for 30
minutes, three times a day, in order to hemolyze the red
blood cells and allow the breakdown products to pene-
trate the dentinal tubules. The blood was replaced daily,
and the discoloration procedure was repeated for 18
Shaheen et al. 23

A B
Figure 1. Steps followed during impression making for sample prepa-
ration: (A) Heavy body impression, (B) Light body impression with 
a 4x4 mm window, and (C) External surface of the impression painted
with black color.
consecutive days in the Dental Biomaterials Depart-
ment, Faculty of Dentistry, Alexandria University. Each
specimen was rinsed thoroughly under water jet for two
minutes to remove excess blood pigments, and the pulp
chamber was dried with paper points and cotton pellets.
A pilot study was done using five extracted primary
canines to identify the proper technique for specimen
preparation, sealing the canal, the staining procedure,
application of the bleaching agent and shade evaluation.
It was done by one operator under the supervision of a
researcher.
The distance from the incisal edge of the tooth to the
CEJ on the labial surface was measured with a caliper. A
properly sized gutta-percha point was chosen to fit into
the canal orifice. The distance from the incisal edge of
the tooth to the CEJ was marked on the gutta-percha
point by bending its terminal end. Then, it was inserted
within the pulp chamber up to the level of the CEJ to
prevent ingress of the root canal sealing material into
the pulp chamber.
The cervical end of each specimen was sealed with
flowable composite. Next, the teeth were randomly di-
vided using the random bowl technique20 into two groups
of 15 teeth each, according to materials used inside
the pulp chamber. For Group 1, two mm of 10 percent
carbamide peroxide gel (Opalescence “PF,” Ultradent
Products, Inc., South Jordan, Utah) was injected inside
the pulp chamber from the lingual access opening. The
access opening was sealed with glass ionomer cement
(GIC). After seven days, a fresh bleaching agent was
reapplied into the pulp chamber and the procedure was
repeated every week, twice in the same session.21 For
Group 2, a cotton pellet damped with distilled water
was placed within the pulp chamber and the access
opening was sealed with GIC. Specimens of both
groups were stored in artificial saliva prepared at the
Faculty of Pharmacy, Alexandria University, consisting
24 Shaheen et al. Carbamide peroxide as a bleaching agent
A B
C
 
 
C D
Figure 2. Shade alteration during the bleaching pro- 
cedure in the test group: (A) Post-staining, (B) After 
7 days, (C) After 14 days, and (D) After 21 days.
of 1.5 mmol/L calcium, 0.9 mmol/L phosphates,
150 mmol/L potassium chloride, and 20 mmol/L caco-
dylate, buffered at pH 7.0. 22 It was kept inside an
incubator at 37 degrees Celsius during the entire ex-
perimental period.21
Tooth color was evaluated by means of an objective
method using a VITA Easyshade digital spectrophoto-
meter (VITA Easyshade R Spectrophotometer model
no. DEASYAS, Bad Säckingen, Germany).23 The original
tooth color and the shades immediately after staining
and during the bleaching procedure at days seven, 14,
and 21 were recorded (Figure 2). At each evaluation
period, tooth shade was measured three times consecu-
tively from the labial surface of the crown and the mean
was taken. Tooth color was evaluated according to the
Commission International de l´Eclairage (CIE).23 This
system assesses the color in three dimensions by calcu-
lating the values for L*a*b*, with: L* representing
lightness and ranging from zero to 100 black to white,
respectively; a* representing color and saturation of the
red-green axis; and b* signifying color and saturation
of the blue-yellow axis. The overall color change DE*
was calculated according to the following formula:
DE*=[ (L1*-L2*)2+(a1*-a2*)2+(b1*-b2*)2]1/2
Journal of Dentistry for Children-84:1, 2017
 Figure 3. Mean colorimetric measurements of L*a*b* values in test and control groups at different evaluation periods.

Here, L1*, a1*, and b1* indicate the mean shade values RESULTS
at the prestaining period and L2*, a2*, and b2* repre- The mean colorimetric measurements distribution of
sent the mean values at the poststaining and three suc- mean L*a*b* values in the control and test groups at dif-
cessive evaluation periods. ferent evaluation periods are shown in Figure 3. In the
According to this equation, the shade alteration at the test group, all specimens returned to their original color
prestaining period was zero. Student’s t test was used to after 21 days of bleaching, with no significant differences
compare between two groups; for comparing between observed from the initial tooth shade before staining. The
more than two groups, the F-test (analysis of variance) lightness L* values dropped immediately after staining,
was used. Tukey’s post hoc test was employed to compare then increased gradually during the bleaching procedure.
between subgroups. Statistical significance was set at the While the red-green a* and blue-yellow b* values de-
five percent level. Data were entered using IBM SPSS creased gradually until they reached the desired shade
20.0 software (IBM Corp., Armonk, N.Y., USA). after the third week, teeth in the control group did not
undergo color change after staining and no significant
shade alteration from the original tooth shade was
noted. The mean shade alteration values DE*
Table. Intra- and Intergroup Comparisons of Mean Shade   from prestaining measurements and those
Alteration (DE)* of the Prestaining Measurements and  recorded after the three successive evaluation
Three Successive Evaluation Measurements Between   periods between both groups are shown in the
Both Groups* Table and Figure 4.
The shade alteration from the prestaining
∆E†o ∆E†Pr-Ps ∆E†Pr1 ∆E†Pr2 ∆E†Pr3 P1
value DE*0 was null for each specimen. In the
Test group 0 41.10±0.98 27.61±2.62 10.41±1.82 0.50±0.17 <0.001†
test group, the color difference increased to
Mean±(SD) 41.1±0.98 immediately after staining DE*Pr-Ps.
The color difference between the initial base-
P2 <0.001† <0.001† <0.001† 0.097 line value and one week after bleaching DE*Pr1
Control group 0 41.37±3.03 41.16±2.85 41.25±2.85 41.35±2.97 <0.001† was 27.61±2.62. It decreased to 10.41±1.82
Mean±(SD) after the second week DE*Pr2 and decreased
to 0.50±0.17 after the third week DE* Pr3.
P2 <0.001 †
<0.001†
<0.001†
<0.001 †
The F-test showed significant differences be-
P3 1.000 0.385 <0.001† <0.001† <0.001† tween the different evaluation periods
(P<0.001). Tukey’s post hoc test also revealed
* Pr=prestaining measurements; Ps=poststaining measurements; P =P-value for 
1 significant shade alteration between the pre-
F-test (analysis of variance) comparing between different evaluation 
periods; P =P-value for post hoc test (Tukey’s) comparing prestaining value 
2
staining shade value DE*0 and those after each
and the value at each evaluation period; P =P-value for student’s t test com- 
3 of the poststaining values DE*Pr-Ps during the
paring test and control groups at different evaluation periods. first week DE*Pr1 and the second week DE*Pr2
† Statistically significant at P≤0.05. (P<0.001). No significant shade difference was

Journal of Dentistry for Children-84:1, 2017 Carbamide peroxide as a bleaching agent Shaheen et al. 25
 Figure 4. Mean shade alteration values “E*” from base line and the different evaluation periods in test and control groups.
detected between the prestaining and third week values
(P=0.097).
In the control group, the mean DE*Pr-Ps was 41.37±
3.03 following tooth coloration. After staining, teeth
in the control group did not undergo shade alterations
that differed significantly from the prestaining value
(P<0.001).
Student’s t test revealed no significant difference be-
tween the mean shade alteration after staining between
test and control groups DE* Pr-Ps (P=0.385). However,
the mean shade alteration values in the test group were
significantly different from those in the control group at
the three successive evaluation periods (P<0.001).
DISCUSSION
Extensive research has been conducted on bleaching non-
vital permanent teeth; nevertheless, few studies have been
conducted on the primary teeth. Ho and Goerig24 re-
ported that primary teeth can be successfully bleached.
As young children are accident-prone and have a signifi-
cant number of anterior teeth that are traumatized,25 the
pulps can become necrotic, causing tooth discoloration.
Endodontic treatment and bleaching should be a viable
treatment option for such teeth.  ness after applying 10 percent and 16 percent carbamide
In the present study, the primary tooth shade re-
turned to the initial prestaining values following the
application of 10 percent carbamide peroxide for 21
days, thus rejecting the null hypothesis. After three
successive weekly applications of the bleaching agent,
the lightness values increased gradually until they
reached the initial lightness by the end of the third
week. Regarding the red-green a* and blue-yellow
b* parameters, the values dropped gradually until they
returned to the prestained values, also after 21 days. The
increase in L* values represented an improvement in
tooth lightness. In contrast to the lightness, the reduction
26 Shaheen et al. Carbamide peroxide as a bleaching agent
in color and saturation of the red-green a* and blue-
yellow b* indicated an improvement in the tooth shade.
This observation is supported by Dietschi et al.,26 who
reported that the lower the red-green and blue-yellow
saturation, the whiter the tooth became.
A possible explanation for the improvement in tooth
shade is related to the oxidation-reduction reaction
that occurs during the bleaching procedure. Carbamide
peroxide, as it diffused within the dentinal tubules, breaks
down to produce free radicals and urea. 27 According
to Dahl and Pallesen,28 the nascent oxygen attacks the
complex highly pigmented carbon ring compounds
and converts them into short chain compounds that are
lighter in color. This reaction could be also enhanced
by urea, which allows the peroxide to remain in contact
with the tooth surface for longer periods.29
The results of the present study agree with Kugel et
al.,30 who showed that the use of 35 percent hydrogen
peroxide as an intracoronal bleaching material in non-
vital permanent teeth led to an increase in lightness and
a decrease in redness and yellowness after two weeks of
application. These findings also agree with the results of
Delfino et al.,31 who reported an increase in the lightness
and a drop in the redness-greenness and blueness-yellow-
peroxide in nonvital discolored permanent teeth for 21
days. However, Tsubura32 reported increased lightness
and decreased yellowness, with slight variation in redness,
after the clinical application of 10 percent carbamide
peroxide for three consecutive weeks on tetracycline-
stained permanent teeth. The variation between the later
study and the present study could be attributed to a dif-
ference in type of intrinsic discoloration, where tetracy-
cline discoloration has less of a redness-greenness color
saturation tendency than the discoloration that resulted
from blood degradation in nonvital teeth.33
Journal of Dentistry for Children-84:1, 2017
 Considering shade alteration from the initial prestain-
ing phase, significant improvement was observed after
seven and 14 days of bleaching. However, after 21 days,
the color difference showed no significant differences
noted in relation to the prestaining shade in 100 per-
cent of the test group specimens. This indicated that the
tooth color returned to its initial baseline shade after 21
days of bleaching with 10 percent carbamide peroxide.
The possible explanation for the gradual whitening of
tooth during the three successive application periods
could be related to reapplication of a fresh bleaching
agent within the pulp chamber every week.
Similar durations and frequencies of bleaching appli-
cations were also reported by Ho and Goerig.24 How-
ever, Kaneko et al.,34 in an in vitro study, reapplied the
fresh bleaching agent four times every five days. The
tooth shade of their specimens returned to the initial
prestaining values after applying sodium percarbonate in
discolored nonvital permanent teeth for 20 days.
Similar results were reported by Yui et al.,35 who eval-
uated the effectiveness of 10 percent and 35 percent
carbamide peroxide as intracoronal bleaching agents on
permanent artificially stained teeth. They found no sig-
nificant tooth shade difference between the prestain-
ing values and those after 21 days following bleaching.
Similar results were also reported by Valera et al.,15 who
evaluated the efficacy of 16 percent carbamide peroxide
as an intracoronal bleaching agent on nonvital artificially
stained permanent teeth. Although they used a different
carbamide peroxide concentration, all specimens in their
study also reached the initial values after three weeks.
The results of this study were also confirmed in an-
other in vitro study conducted by Ganesh et al.,36 who
compared the efficacy of 10 percent carbamide peroxide
and 10 percent hydrogen peroxide as intracoronal bleach-
ing agents in artificially discolored primary incisors. After
14 days of bleaching with 10 percent hydrogen peroxide,
there was no significant difference between the initial
tooth shade and post-bleaching shade. Teeth bleached
using 10 percent carbamide peroxide reached the original
shade after 21 days. The authors attributed the variation
in bleaching duration to the type of bleaching agent used,
with the 10 percent hydrogen peroxide showing a more
rapid whitening effect than the 10 percent carbamide
peroxide. However, the toxic effects of hydrogen peroxide
on the odontoblastic-like cells were not considered in
the later study. According to Lima et al.,37 hydrogen
peroxide produced a reduction in the odontoblastic-like
cells’ metabolism, with severe damage inflicted on the
cytoplasmic membrane. On the other hand, no toxic
effects were observed after the successive application of
10 percent carbamide peroxide.
Other studies reported satisfactory bleaching out-
comes but in shorter duration. When Perrine et al.38
used 10 percent carbamide peroxide intracoronally for
whitening discolored permanent teeth, only 65 percent
Journal of Dentistry for Children-84:1, 2017 Carbamide peroxide as a bleaching agent
of the teeth returned to their original shade after 14 days.
Lim et al.39 used a higher concentration of 35 percent
carbamide peroxide as an intracoronal bleaching mate-
rial in artificially stained permanent teeth. After 14 days,
100 percent of the teeth returned to their original shade,
with no significant differences noted in the prestaining
color. The authors concluded that, although satisfactory
results were obtained after 14 days using a high carbamide
concentration, the biological effects on dental and peri-
odontal tissues should be considered (e.g., damages to
the periodontal ligament, external cervical root resorp-
tion, etc.).
In a clinical study, Brantley et al.9 used 10 percent
carbamide peroxide to bleach traumatized discolored
primary teeth and reported effective bleaching outcomes
after only two weeks. The variation between the Brantley
study and the present one could be related to the severity
of tooth discoloration. Teeth in the Brantley study were
stained as a result of intrapulpal bleeding following
trauma, while in the present study teeth were deeply
stained subsequent to immersion and centrifusion within
the blood for a long period. According to Meireles et
al.,40 there is a significant relationship between the initial
tooth discoloration and the duration of the bleaching
procedure. The darker the tooth shade, the longer the
bleaching time required to reach the original shade.
Regarding the control group, no improvement in
shade was detected through the entire experimental
periods. After staining, the lightness values increased and
remained nearly unchanged throughout the complete
experiment, with significant differences noted between
them and the initial shade. Teeth in the control group
did not undergo any shade alteration after staining due to
the application of inactive distilled water in the pulp
chamber, which had no bleaching effect on the pig-
mented precipitated molecules. Similar results were re-
ported by Yui et al.,35 who evaluated the effectiveness of
different carbamide peroxide concentrations as intra-
coronal bleaching agents on permanent artificially stained
teeth. In their control group, no bleaching agent was
inserted in the pulp chamber and no improvement was
detected in all the specimens.
Significant differences in tooth shade alteration were
observed between test and control groups at the three
successive evaluation periods. This is likely related to the
whitening effect of the bleaching agent applied in the
test group. This finding was also confirmed by Ganesh et
al.,36 who did not detect any significant differences be-
tween the test and control groups at the initial and
poststaining evaluation periods. On the other hand,
significant differences were reported between them after
the successive application of the bleaching agents.
Shaheen et al. 27
CONCLUSION
Based on the results of this study, the following conclu-
sion can be made: peroxide gels during intracoronal bleaching. Int
1. Intracoronal bleaching using 10 percent carba-
mide peroxide proved to be an effective ap-
proach for whitening discolored extracted
primary teeth, which returned to their initial
shade after three successive weekly applications
of the bleaching agent for 21 days.
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