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ORIGINAL ARTICLE
Comparison of the bleaching efficacy of
three different agents used for intracoronal
bleaching of discolored primary teeth: An in
vitro study
Abstract
Everyone wants whiter teeth to make them feel younger and
to provide beautiful smiles with the accompanying increase in
self-esteem. Bleaching is an established, simple, cost-effective
and conservative method for improving the color of the
discolored teeth. Aim: The aim of this in vitro study was to
compare the bleaching efficacy of 10% carbamide peroxide,
10% hydrogen peroxide and 2g sodium perborate as
bleaching agents on the artificially discolored human primary
maxillary central incisors. Materials and Methods: Forty
extracted human primary central incisors with intact crowns
were selected for the study. Pulpectomy was performed and
each tooth was artificially stained with 2 ml of fresh human
blood and centrifuged. The teeth were randomly divided into
four experimental groups of 10 teeth each and the baseline
color evaluation was performed. 0.04 ml of the bleaching
agent is syringed into the access cavity of the tooth and, in
the control group, 0.04 ml of distilled water was syringed
into the access cavity and it was sealed with IRM and placed
at 37°C in an incubator throughout the experiment. The
color of the bleached teeth was determined at 0, 7 and 14
days. The data obtained were analyzed using ANOVA and
Turkey’s test. Results: There was statistical significance (P =
0.00) among the carbamide peroxide, sodium perborate,
hydrogen peroxide and control groups after 7 and 14
days and a significance of P = 0.013 among the carbamide
peroxide, sodium perborate and hydrogen peroxide after
two bleaching sessions (day 14) was seen. Conclusions: The
bleaching efficacy of 10% hydrogen peroxide gel was more
effective than 10% carbamide peroxide and sodium perborate
in bleaching the artificially discolored primary teeth..
Key words
Bleaching, Primaryteeth, Hydrogenperoxide, Carbamide
Peroxide, Sodium Perborate
JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jan - Mar 2013 | Issue 1 | Vol 31 |
Ganesh R, Aruna S, Joyson M, Manikandan,
Deepa
Department of Pediatric Dentistry, College of Dental Surgery,
Saveetha University, Chennai - 600 077, Tamilnadu, India
Correspondence:
Dr. R. Ganesh, C/O S. Rajendran, 17/788,10th Sector, 59th
Street, K.K.Nagar, Chennai -600078, Tamilnadu, India.
E-mail: ganeshr1980@yahoo.co.in
Access this article online
Quick Response Code: Website:
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DOI:
10.4103/0970-4388.112394
PMID:
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Introduction
Everyone wants whiter teeth to make them feel younger
and to provide beautiful smiles, with the accompanying
increase in self-esteem. It is amazing that an appearance
change as simple and noninvasive as tooth whitening
has had so much influence on the profession and the
people we serve.[1]
Parents are aware of the cosmetic and esthetics of
anterior teeth of the children. Children, too, are
becoming more aware of their appearance because
they live in an era of acute peer evaluation. Children
want to be like everyone else; they want to avoid
ridicule and criticism from their peers. Much criticism
may be directed toward unsightly teeth and may be
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Ganesh, et al.: Comparison of the bleaching efficacy of three different agents
psychologically traumatic. Older children express their
desires for an esthetic smile to be like their peers.[2]
Intracoronal bleaching of discolored nonvital teeth in
young people offers advantages over more conventional
treatment involving partial or complete coverage
restorations. Perhaps the most important of these
advantages is conservation of tooth structure. The
younger teeth are easier to bleach because the tooth
substance has relatively greater permeability. [3]
Intracoronal bleaching provides satisfactory results and
it is relatively economic and visits are comparatively
short, making the technique readily acceptable to
children [Table A].[4]
Materials and Methods
Forty extracted human primary central incisors with
intact crowns were selected for the study [Figure 1c].
The armamentarium used were airotor, files, burs,
zinc oxide eugenol [Figure 1a], normal saline, IRM
[Figure 1b]. The bleaching agents used were 10%
hydrogen peroxide [Figure 1f], 10% carbamide
peroxide [Figure 1e] and 10%sodium perborate
[Figure 1d]. Teeth were then stored in physiologic
saline. Pulpectomy was performed and, the root canal
a b
f g
e
i j
Figure 1: (a-j) Armamentarium
18 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jan - Mar 2013 | Issue 1 | Vol 31 |
filling was reduced 1 mm apical to the cemento–enamel
junction and covered with IRM as protective base.
The teeth were placed in a test tube containing 2 ml
of fresh human blood [Figure 1g] and centrifuged at
3200 rpm for 20 min twice daily for 3 days [Figure
1h]. The teeth was placed in incubator [Figure 1i]
at 250C .
After artificial staining, the teeth are randomly divided
into four experimental groups of 10 teeth each and the
baseline color evaluation was performed. 0.04 ml of the
bleaching agent is syringed into the access cavity of
the tooth and, in the control group, 0.04 ml of distilled
water was syringed into the access cavity and it is
sealed with IRM and placed at 37°C in an incubator
throughout the experiment.
The color of bleached teeth is determined at 0, 7 and 14
days.[4] The color of each tooth is evaluated using vita
lumen shade guide [Figure 1j] under broad daylight
conditions. The Figure 2a shows the group 1(CP) and
Figure 2b shows the group2 (HP) before bleaching.
The Figure 2c and 2d shows the group 3(SP) and
control group before bleaching. The Figure 3a shows
the group 1(CP) and Figure 3b shows the group2 (HP)
after bleaching at the end of 14 days. The Figure 3c
c d
h
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Ganesh, et al.: Comparison of the bleaching efficacy of three different agents

and 3d shows the group 3(SP) and control group after statistically significant). The comparison of group 3
14days. The data are collected, tabulated and subjected (SP) with group 1 (CP) and group 2 (HP) and control
to statistical analysis. group showed significance in relation to the control
group (mean = -6.20, P-value = 0.00) (P-value <0.05
Results is statistically significant).
The results in Table 1 showed statistical significance
in control group, group 1 (CP), group 2 (HP), group 3 The comparison of group 2 (HP) with group 1 (CP),
(SP) (mean = -8.40, P-value = 0.00) (P-value <0.05 is group 3 (SP) showed high statistical significance in

Table A: Vita Shade Guide Evaluation

Vita tab B1 A1 B2 D2 A2 C1 C2 D4 A3 D3 B3 A3.5 B4 C3 A4 C4
Position 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Vita shade guide evaluation[4]

a b
a b

c d c d

Figure 2: (a-d): Before bleaching Figure 3:(a-d) After bleaching

Table 1: Multiple comparisons among the carbamide peroxide, sodium perborate, hydrogen peroxide and control groups after two
bleaching sessions (day14)
Group Mean difference Std. error sig. 95% confidence Interval
Lower bound Upper bound
Group1(CP) Group2(HP) 2.200 0.918 0.96 -.27 4.67
Group3 (SP) 0.000 0.918 1.000 -2.47 2.47
Control -6.200* 0.918 0.000 -8.67 -3.73
Group 2(HP) Group1 (CP) -2.200 0.918 0.96 -4.67 0.27
Group3 (SP) -2.200 0.918 0.96 -4.67 0.27
Control -8.400* 0.918 0.000 -10.87 -5.93
Group3 Group1 (CP) 0.000 0.918 1.000 -2.47 2.47
Group2 (HP) 2.200 0.918 0.096 -.27 4.67
Control -6.200* 0.918 0.000 -8.67 -3.73
Control Group1(CP) 6.200* 0.918 0.000 3.73 8.67
Group2 (HP) 8.400* 0.918 0.000 5.93 10.87
Group3(SP) 6.200* 0.918 0.000 3.73 8.67
Dependent Variable: DAY 1, *The mean difference is significant at the 0.05 level
Turkey HSD

Table 2: Multiple comparisons among the carbamide peroxide, sodium perborate and hydrogen peroxide groups after two bleaching
sessions (day 14)
Group Mean difference Std. error sig. 95% confidence Interval
Lower bound Upper bound
Group1(CP) Group2(HP) 2.200* 0.794 0.026 0.23 4.17
Group3 (SP) 0.000 0.794 1.000 -1.97 1.97
Group 2(HP) Group1 (CP) -2.200 0.794 0.026 -4.17 -.23
Group3 (SP) -2.200 0.794 0.026 -4.17 -.23
Group3 (SP) Group1 (CP) 0.000 0.794 1.000 -1.97 1.97
Group2 (HP) 2.200* 0.794 0.026 0.23 4.17
Dependent Variable: DAY 14, *The mean difference is significant at the 0.05 level Turkey HSD

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Ganesh, et al.: Comparison of the bleaching efficacy of three different agents

14.3 14.6 14.3

16 14.3 14.6 14.3 14.4 14.4 14.4 16
14 14
12 12 9.5

MEAN VALUES
8.9
MEAN VALUES

9.5 8.2 8.2

10 8.9 10 7.9
8.2 7.9 8.2
8 8 6
6
6 6
4 4
2 2
0 0
CP HP SP CONTROL CP HP SP

DAY 0 DAY 7 DAY 14 DAY 0 DAY 7 DAY 14

Graph 1: Comparison of bleaching efficacy of CP, HP, SP and control Graph 2: Comparison of bleaching efficacy of CP, HP and SP group
group

are accident-prone and have a significant number of

relation to group 1 (CP) (mean = -2.20, P-value =
0.026) and group 3 (SP) (mean = -2.20, P-value = anterior teeth that are traumatized,[9] the pulps become
0.026). The comparison of group 3 (SP) with group necrotic, causing discoloration of the teeth. Endodontic
1 (CP), group 2 (HP) showed significance in relation treatment and bleaching should be a viable treatment
to group 2 (mean = 2.20, P-value = 0.026) (P-value option for such teeth.[10]
<0.05 is statistically significant) alone in Table 2. This
shows that the bleaching efficacy of 10% hydrogen Reports on the bleaching of discolored nonvital
peroxide gel was more effective than 10% carbamide teeth were first described in the mid-19th century.[11]
peroxide and sodium perborate in bleaching the Chlorinated lime was recommended first for whitening
artificially discolored primary teeth. Graph 1shows of nonvital teeth,[12] followed later by oxalic acid and
Comparison of bleaching efficacy of CP, HP, SP and agents such as chlorine compounds and solutions. Next,
Control group. It shows no significant changes in sodium peroxide, sodium hypochlorite or mixtures
control group after 14 days. The graph 2 exhibits consisting of 25% hydrogen peroxide in 75% ether
the Comparison of bleaching efficacy of CP, HP and were used as bleaching agents.[13]
SP group after 14days and It also shows that there is
marked significance in HP group when compared to In 1961, Spasser [14] described the intracoronal
other groups. bleaching method of sealing a mixture of sodium
perborate with water into the pulp chamber and
leaving it in situ for 1 week. This was known as
Discussion “walking bleach.” Nutting and Poe[15] modified this
Teeth whitening techniques have seen renewed interest by using a combination of 30% hydrogen peroxide
from the dental profession as a result of the public’s and sodium peroxide sealed into the pulp chamber.
desire for whiter,[4] brighter teeth. In children and The most commonly used bleaching agents to produce
adolescents, partial or complete coverage restorations the desired esthetic color change are hydrogen
are difficult because of the instability of the gingival peroxide and sodium perborate, either used alone or in
margin, leading to deterioration in esthetics. [5] combination. More recently, 10% carbamide peroxide
Intracoronal bleaching provides a satisfactory result has also been recommended.[16]
until gingival maturation is complete. Younger teeth
are easier to bleach because the tooth substance has Hydrogen peroxide is used in dentistry as a whitening
relatively greater permeability and hence a lesser material at different concentrations, from 5 to 35%.
concentration of bleaching agents may be used.[6] Because of its low molecular weight, this substance
can penetrate the dentin and can release oxygen, which
Discoloration of nonvital teeth can occur through breaks the double bonds of the organic and inorganic
extrinsic and/or intrinsic factors. Among the intrinsic compounds inside the dentinal tubule.[17]
stains, intrapulpal hemorrhage and/or pulpal necrosis,
often associated with impact injuries of teeth, can be Carbamide peroxide is an organic white crystalline
successfully managed using intracoronal bleaching.[7] compound and is formed by urea and hydrogen peroxide
and is used in different concentrations. In a hydrophilic
Stewart Ho and Goerig[8] reported that deciduous teeth environment, it breaks down into approximately 3%
can also be successfully bleached. As young children hydrogen peroxide and 7% urea.[18]

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Ganesh, et al.: Comparison of the bleaching efficacy of three different agents
Sodium perborate is an oxidizing agent available as a
powder. It is stable when dry; however, in the presence of
acid, warm air or water, it breaks down to form sodium
metaborate, hydrogen peroxide and nascent oxygen.[19]
The results in this study indicate the statistical
significance between the control group with group
1 (CP) with group 2 (HP) and group 3 (SP) at day
7 and day 14. With CP and SP, there was a mean
improvement of six Vita Lumin shade tabs, whereas
group HP had a mean improvement of eight Vita
Lumin shade tabs. In contrast, the results from Lim
et al[20] study showed eight Vita Lumin shade mean
improvement in both the carbamide peroxide and the
hydrogen peroxide group and four Vita Lumen shade
improvement in the sodium perborate group. In fact,
approximately half of all teeth from the groups except
the control group underwent further color change, and
this was similar to the study by Lim et al. [20]
Thus, the present study demonstrated that hydrogen
peroxide (10%) was better as intracoronal bleaching
agent on artificially discolored primary anterior teeth
than sodium perborate (2g) and carbamide peroxide
(10%) after two bleaching sessions (day 7 and day 14).
Hence, the present study and the study by Stewart et al.
[8]
showed that intracoronal bleaching can be considered
as one of the ideal and conservative methods in treating
discolored primary teeth.
Conclusions
In the present in vitro study, 10% hydrogen peroxide gel
was more effective than carbamide peroxide (10%) and
sodium perborate (2 g) after two bleaching sessions (day
14) for intracoronal bleaching of artificially discolored
primary teeth. There was no color change in the control
group after 7 and 14 days.
The study showed statistical significance of hydrogen
peroxide in bleaching efficacy to be high when compared
with carbamide peroxide and sodium perborate at day 14.
In children, discolored primary teeth secondary to
trauma and minor developmental tooth discolorations
can be effectively treated with intracoronal bleaching.
Hence, the present study concludes that 10% hydrogen
peroxide can be used as an ideal and effective intracoronal
bleaching agent on discolored primary teeth in children.
“Every child is our treasure and every smile is our
pleasure”
JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jan - Mar 2013 | Issue 1 | Vol 31 |
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How to cite this article: Ganesh R, Aruna S, Joyson M,
Manikandan, Deepa Comparison of the bleaching efficacy
of three different agents used for intracoronal bleaching of
discolored primary teeth: An in vitro study. J Indian Soc Pedod
Prev Dent 2013;31:17-21.
Source of Support: Nil, Conflict of Interest: None declared.
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