J O U R S A I O k LSTHETIC DENTISTRY

Primarilv Research J

Efficacy of Six Months of Nightguard Vital

Bleaching of Tetracycline-Stained Teeth

VAN B . HAYWOOD, D M D '

RALPH H . LEONARD, DDS, MPH'
GENE L. D I C K I N S O N , DDS, MS'

have been successfully treated by

S ince the introduction of the
technique for nightguard vital
bleaching to the profession in
1989,' much new information has
become available about the
process. This bleaching process
uses a custom-fabricated carrier to
apply a 10% carbamide peroxide
material. Teeth that are inherently
extended treatment times.s The
purpose of this pilot study was to
determine if extending treatment
times to 6 months would produce
more noticeable lightening of
tetracycline-stained teeth.
MATERIALS A N D METHODS

discolored or have become dis- Patients whose teeth had moderate

E DITO R S ' NOTE:
At the 1996 Annual Meeting o f
the American Academy of Esthetic
Dentistry, the editorial board o f
the JED voted to reinstate a
research-oriented article in each
issue. We are pleased to present
Dr. Van Haywood's article and
look forward to your reaction,
and your research submissions.
colored by aging, fluorosis, or
chromogenic foodstuffs have been
reported to be lightened in 97% of
cases after 6 weeks of treatment
using this technique.2 During this
same 6 weeks of treatment, tetra-
cycline-stained teeth were lightened
in 75% of cases, but the lightening
was not to the extent of the previ-
ously mentioned non-tetracycline-
stained teeth.3 Another report
indicated that after 6 weeks of
treatment that was unsuccessful in
lightening teeth stained by heavy
pipe-smoking, extending treatment
an additional 3 months resulted in
a lightening comparable to the
lightening of the non-tetracycline-
stained teeth.4 Other discolorations
to severe tetracycline staining and
indicated a desire to pursue the
lightening of their teeth under the
extended conditions were exam-
ined to determine if they met the
inclusion criteria. Baseline evalua-
tions included a medical and dental
history and a radiograph of the
anterior incisor teeth.6 Patients
were included if they were over 18
years of age, had four or more
intact vital anterior teeth with no
restorations, had no health prob-
lems, and had no radiographic
evidence of pathology or unusual
pulp-size variations.' Ten patients,
ages 28 to 52 years (average 33 yr),
were accepted who completed
the appropriate University Human

'Associate Professor, Department of Oral Rehabilitation. Medical College of Georgia. Augusta. Georgia
'Clmicaf Assistant Professor, Department of Dental Ecology, University of North G r o b n a , Chapel Hill, North Czrolina
'Associate Professor. Director of Cfinicrrl Research. Department of Oral Rehabilitati~n.M e d i a l College of Georgia, Augusta. Georgu
Supported 6y educational grant from Ultradent Products fnc.. South Jordan. Utah.

VOIUWF 9. NllWBFR I 13
 JOIIRNAL O F kSTHFTI< DENTISTRY
Efficacy of Six Months of Nightguard Vital
Bleaching of Tetracycline-Stained Teeth
TABLE 1. PARTICtPANTS IN $-MONTH EXTENDED BLEACHING TREATMENT CATEGORIZED BY TRAY DESIGN AND
COMPLETED TREATMENT.
Patients In = 10)
Completed Discontinued
Treatment Treatment
Subjects Consent form and agreed
to the standardized treatment regi-
men. An alginate impression of the
maxillary arch was taken, using an
irreversible hydrocolloid (Jeltrate
Plus@,L.D. Caulk Co., Milford,
Delaware). A cast was made from
dental stone (Microstone@,Whip-
mix Co., Louisville, Kentucky),
and trimmed to eliminate the
vestibule and create a hole in the
palate. A 0.03s-inch soft tray
material (Sof-Tray@,Ultradent
Products Inc., South Jordon, Utah)
was used to fabricate the carrier
for the material. Typically, manu-
facturer’s instructions suggest
placing reservoirs approximately
0.5 mm in thickness on the facial
surfaces of the teeth to be treated
using a composite resin (LC
Blockout Resin, Ultradent) and
scalloping the carrier to follow the
contour of the gingiva to avoid
contact with the soft tissue.
14 1997
Tray Design
All Half No
In this study, carrier-design options
were varied as listed in Table 1.
The maxillary arch was divided
into left and right quadrants, and
combinations of scalloped/unscal-
loped and reservoirho-reservoir
carrier designs were used. Those
portions of the carrier that were
not scalloped extended 2 to 3 mm
onto the attached gingiva, but did
not engage undercuts or terminate
on the top of rugae. Reservoirs ter-
minated 1 mm from the attached
gingiva to allow for adaptation of
the nightguard to the tooth sur-
face. Upon insertion, both the
operator and the subject evaluated
the edges of the nightguard for
smoothness, and the covered tissue
for blanching, indicating pressure
on the tissue. Over-extended night-
guards were trimmed to eliminate
positive responses. Patients were
instructed in proper insertion and
removal techniques. Removal of
the nightguard was begun from the
most terminal tooth to avoid
trauma from fingernails to the
canine eminences8 Occlusal con-
tacts between the nightguard and
the mandibular arch were evalu-
ated visually, and the terminal
portions of the nightguard were
All Half
removed if needed, until anterior
contact of teeth was achieved.
Subjects were not dismissed until
they indicated comfort with the
nightguard and confidence with
the insertion process.
A viscous 10% carbamide per-
oxide material contained
in a syringe-delivery system
(Opalescence@,Ultradent) was dis-
pensed to each subject. Subjects
were instructed to place enough
material to fill the nightguard, with
minimal excess. Excess was
removed with a dry toothbrush or
finger, and expectorated. Patients
were instructed to brush and floss
their teeth at bedtime, then insert
the loaded carrier. The carrier
remained in place during sleep.
Subjects removed the carrier the
next morning, and did not apply
the solution during the day. The
mandibular arch was untreated as
a control. Pre-treatment photo-
graphs were taken, positioning a
shade guide tab of the original
tooth color in the photographs.
Subjects were given a log-form to
record the number of hours of
wear-time per night, and to record
any side effects for each application

Figure 1 . Left, Preoperative photograph of moderately tetracycline-stained teeth. Right, Extended treatment time of 6
months of bleaching with 10% carbamide. Patient alternated treatment a e r y third night to reduce sensitiuity.
period. Subjects were instructed to
discontinue treatment if any side
effects proved too uncomfortable.
Patients could contact a clinician at
the University if they had questions
or required additional product.
Otherwise, patients were not
recalled until they had completed
6 months of night-time wear.
At the 6-month recall appoint-
ment, photographs were taken,
log-forms were collected, and
subjects were examined and
questioned concerning their com-
ments and experience. Photographs
were taken comparing the maxil-
lary and mandibular teeth at an
end-to-end incisal position. A
post-treatment vinyl polysiloxane
impression was taken of the facial
surfaces of the maxillary and
mandibular teeth when positioned
end-to-end using a modified ante-
rior triple tray impression tray
(Triple Tray", Premier Dental Co.,
Norristown, Pennsylvania) in the
following manner:
The maxillary and mandibular
teeth were occluded in an end-
to-end position.
The gauze was removed from
the Triple Tray impression tray,
and the remaining curved tray
was painted with polysiloxane
tray adhesive.
Two impressions were made,
using a light-bodied polysilox-
ane impression material
(Reprosil", L.D. Caulk): the
first for cleaning the teeth, and
the second for evaluation of the
tooth surface.
Upon removal, the second
impression material was
allowed to set overnight, and
the impression was boxed with
a polysiloxane impression
material and poured in epoxy
resin.
Three randomly selected epoxy
replicas were sputter-coated
and examined in a scanning
electron microscope at 2 0 0 ~
and 2 0 0 0 ~magnification.
H A Y W O O D FT A 1
Photomicrographs were taken
of representative areas of the
facial surfaces of the maxillary
and mandibular teeth and com-
pared for variances.
RESULTS
Six of the original ten subjects
completed the 6-month treatment
regimen. One of the six subjects
did not wear the nightguard every
night because of tooth sensitivity,
but rather determined a comfort-
able application regimen to be
every third night. Average treat-
ment time for the 6 months was
952.8 hours (range, 568-1213 hr).
Approximately one half of a
syringe of bleaching material was
used per application. Patients who
completed the course of treatment
were satisfied with the amount of
lightening (Figures 1 4 ) . Log-forms
indicated that side effects were
experienced in a sporadic fashion
for 0 to 20 days of the treatment
period (average, 6 d). Side effects
consisted of tooth sensitivity
 Efficacy of Six Months of Nightguard Vital
Bleaching of Tetracycline-Stained Teeth

(4 patients) and gingival irritation

(2 patients). Four subjects discon-
tinued treatment after 1or 2
weeks, citing side effects of tooth
sensitivity (2),gingival irritation
(2),and/or throat irritatiodtaste
(2).There was no correlation
between the age of the patient and
the incidence of sensitivity. Among
those patients who completed the
course of treatment, scanning elec-
tron photomicrographs indicated
no obvious differences between the
facial surfaces of the treated
maxillary teeth and the untreated
surfaces of the mandibular teeth.
Clinical examinations did not
reveal any destruction or variation
of the normal surface texture of
the teeth, nor was there any dis-
cernable difference in surface
texture between the maxillary and
mandibular teeth. The color differ-
ence was the only change apparent.

DISCUSSION

The hypothesis for this pilot study

was that extending the treatment
time would allow more resistant
stains to respond to treatment.
Maximum treatment benefit was
obtained not only by extending the
number of treatment days, but also
by wearing the carrier at night. A
recently reported in vivo study
has indicated that. the peroxide
in Opalescence (Ultradent)
Figure 2. A, Preoperative photogrupb of moderately and Platinumm (Colgate Oral
tetracycline-stained teeth, with discoloration primarily at the
incisal half. B, Close-up preoperative photograph. Note the Pharmaceuticals, Canton,
premolar is not stained by tetracycline. C, Extended Massachusetts) is still present and
treatment time of 6 months of bleaching, with bleaching
material placed primarily on the incisors. D,Post-treatment active in the carrier after 4 hours
close-up. Note the lightening of the maxillary incisors is not of clinical treatment? Both prod-
as pronounced as that of the unstained maxillary premolar, ucts demonstrated over 60% of
but the color certainly is better than the color of the
untreated mandibular anterior teeth.

16 1997

Figure 3. Left, Preoperative photograph of mildly tetracycline-stainedteeth, with little discoloration at the gingival third.
Right, Extended treatment time of 6 months achieves excellent color change.
their material remaining at the
conclusion of this 4-hour study.
The results of this study would
confirm that the maximum benefit
for each application is achieved
from the maximum wearing of the
carrier. Night-time wear also seems
to increase patient compliance,
especially when long-term treat-
ment is required.'O
It was noted that if the neck of the
tooth (gingival third) was severely
discolored, the prognosis for light-
ening the complete tooth was
reduced (see Figure 4). Conversely,
if the neck of the tooth was only
mildly discolored, a more clinically
acceptable result was achieved (see
Figure 2, B and C, and Figure 3).
The best indicator of a good prog-
nosis is not the severity of the
discoloration, but the location of
the discoloration.
The patient sample size was small
due to the unknown outcome of
this long-term treatment pilot
study. Even though this is only a
small pilot study, carrier design did
not noticeably impact side effects.
However, the carrier design may be
important as it relates to the type
of bleaching material and the arch
being treated. If the bleaching
material is easily dissolvable, the
design for the carrier may have to
extend onto the gingival tissue to
help hold the material at the neck
of the tooth, and avoid dilution of
the material in the neck area by
saliva. Also, the design for a carrier
for the mandibular arch may have
to differ due to occlusal contacts,
higher papillae, salivary ducts, and
irritation to the tongue from irreg-
ular edges of the carrier.
HAYWOOD ET A L
Side effects of gingival irritation
and tooth sensitivity were similar
to those side effects seen in the
normal 6-week bleaching process.2
Some patients had no sensitivity at
all, or were only sensitive 1 to 4
days during the 6 months of treat-
ment. Also, as in the normal
bleaching situation, the sensitivity
was sporadic, and often disap-
peared with no change in treat-
ment. Total days of sensitivity
were 0, 1,3,4,20, and all for the
six patients completing the treat-
ment. Some patients were sensitive
in the first 2 weeks of treatment,
with no further sensitivity. Those
four patients who elected to
discontinue treatment were sensi-
tive in the first 5 to 20 days of
treatment. One patient was pro-
gressively sensitive, and had to
titrate wear time. All sensitivity
ceased upon discontinuation of
treatment. The most probable
cause of tooth sensitivity is a
V O I U Y F 9. N l l Y R F R I 17
 J O U R N A L O t k \ T H F T I l DkL;TI\TR\

Efficacy of Six Months of Nightguard Vital

BleachAg of Tetracycline-Stained Teeth

Figure 4. Left, Preoperative photograph of severely tetracycline-stained teeth, with dark discoloration at the gingival third
of the tooth. Right, Extended treatment time of 6 months lightened the incisal two thirds, but not the gingival third. The
patient was still pleased with the outcome.

reversible pulpitis. The pulp is
most likely irritated from the easy
passage of the carbamide peroxide
through the enamel and dentin and
into the pulp in IS minutes."
Tissue sensitivity can occur if the
tissue is abraded or cut, because
the peroxide can irritate the
wound. Irritated tissue can be a
result of abrasion from tray inser-
tion or removal, improperly fitting
trays, toothbrush trauma immedi-
ately before insertion, or normal
eating. A clinical finding of sensi-
tive teeth or frequent applications
(more than 1 per day) of bleaching
material are the only two reported
predictors of sensitivity.12
There were no interim color evalu-
ations during the 6 months of
treatment to determine the rate of
color change. This lack of recalls
was established in consideration of
convenience and compliance of the
patients, as well as the unknown
nature of the study. Patients
expecting to be in treatment for 6
months tended not to become dis-
couraged by the absence of early
changes. Recalls to evaluate early
changes in previous patients with
tetracycline-stained teeth had
prompted discouragement and lack
of compliance because there was
little or no change in the first 2 to
6 weeks. This discouragement was
avoided by eliminating the interim
recalls. However, patients reported
color changes occurring in the 2 to
6 month interval. Further studies
on the rate of change and the
stability of the color change are
needed.
There was no indicator as to how
rapidly the change would occur.
Patients did not notice differences
between quadrants that varied by
tray design. Whether a clinician
would perceive any differences in a
double-blinded study is unknown.
At least the lack of observation of
patients demonstrates that any
potential differences are clinically
insignificant. The purpose of the
reservoirs with Opalescence is
to avoid a tight-fitting tray,
which may contribute to tooth
~ensitivity.'~The reservoirs also
provide a space for the viscous
material to reside and for complete
seating of the carrier and contact
of the edge of the carrier against
the neck of the t00th.l~

18 1997

CONCLUSIONS
Nightguard vital bleaching does
not need to be limited to a 2- to
6-week treatment time. Extended
treatment times are more appropri-
ate for severely stained teeth. A
viscous 10% carbamide peroxide
that is retained in an appropriately
designed custom-fitted carrier is
desirable. Although the sample size
of this pilot study is too small for
statistical significance evaluations,
there is no immediate clinical cor-
relation with side effects to tray
design. Certainly less tissue contact
by the carrier and the bleaching
material has less potential for
tissue irritation from chemical or
mechanical means. Clinically, there
is no immediate correlation with
reservoirs to effectiveness of
bleaching. Apparently, reservoirs
are needed in scalloped trays with
viscous bleaching materials to
allow complete seating and adapta-
tion. The presence of reservoirs is
also intended to reduce the tight-
ness of the tray and minimize
potential tooth irritation.
No clinical enamel changes other
than color change were apparent
to either the operator or the
patient. More significantly, there
were no obvious enamel differ-
ences, other than normal tooth
variations, at 2 0 0 ~and 2 0 0 0 ~
magnification between treated
and untreated teeth.
Extended nightguard vital bleach-
ing time of 6 months, using a 10%
carbamide peroxide in a custom-
fitted soft carrier, can produce
clinically successful color changes
in tetracycline-stained teeth in
compliant patients. These patients
may not experience significant side
effects or may manage side effects
by alternating treatment nights.
Extended treatment times may
incur additional sensitivity.
Clinicians should be prepared
to both treat and educate
patients concerning sensitivity
to achieve compliance for extended
treatment.
ACKNOWLEDGMENT
Thanks to the University of North
Carolina School of Dentistry for
the clinical facilities, the Medical
College of Georgia School of
Dentistry for the SEM facilities,
and to L.D. Caulk for materials
support.
REFERENCES
Haywood VB. Heymann HO.
Nightguard wital bleaching. Quintessence
Int 1989: 2O:t 73-1 76.
Haywood VB, Leonard RH, Nelson CF,
Brunson WD. Effectiveness, side effects,
and long-term status o f nightguard vital
bleaching. J Am Dent Assoc 1994;
1 2s:121 9-1 22 6.
Ha wood VB, Leonard R H , Nelson CF.
E dectiveness of nightguard vital
'
bleaching.J Dent Res 1992: 71 :179.
H A Y W O O D ET AL
4. Huywood VB, Robinson FG. Vital tooth
bleaching with nightguard wital
bleaching. C u r Opin Cosmetic Dent
1997; January. (In press)
5. Croll TP, Snsa IS. Curbamide peroxide
bleaching of teeth with dentinogenesis
imperfecta discoloration: report of a cnse.
Quintessence Int 1995; 26:683-686.
6. Haywood VB. Update on bleaching: an
examination of nightguard vital
bleaching. Esthet Dent Update 1995;
661-52.
7. Haywood VB. Heymnn HO. Response
of normal and tetracycline-stained teeth
with pulp-size variation to nightguard
vital bleaching. J Esthet Dent 1994:
6:109-114.
8. Haywood VB. Commonly asked
questions about nightguard vital
bleaching. J Indiana Dent Assoc 1993;
72:28-33.
9. Nathoo SA, Richter R. Smith SE Zhang
YP. Kinetics of carbamide peroxide
degradation in bleaching trays. ] Dent
Res 1996; 75286. (Absh 2149)
10. Haywood VB. Bleaching tetracycline-
stained teeth. Esthet Dent Update 1996;
7:2S-2 6.
1 I . Cooper JS. Bokmeyer TJ. Bowler WH.
Penetration of the pulp chamber by
cnrbamide peroxide bleaching agents. J
Endod 1992: 18:3 15-3 17.
12. Leonard RH. Phillips C, Haywood VB.
Predictors for sensitivity and imitation in
nightguard vital bleaching.J Dent Res
1996: 75:379. (Abstr 2894)
13. Fisher DE. Method for bleaching teeth.
US Patent No. 5,098,303. Mar. 24. 1992.
14. Haywood VB. Leonard RH. Nelson CF.
Efficacy o//oom liner in 10% carbamide
peroxide bleaching technique.
Quintessence Int 1993; 24:663-666.
Reprint requests: Dr. Van 8. Haywood,
Medical College of Georgia. School of
Dentistry, Department o f Oral Rehabilitation,
Augusta, GA 30912- 1260
0 1997 Decker Periodicals