Bleaching agent

DR. NISHAT SHARMIN ZINIA

Tooth discoloration
It is defined as any change in the hue, color or translucency of a tooth
due to any cause.

Color of healthy teeth is primarily determined by the translucency and

color of dentin and is modified by :
• Color of enamel covering the crown.
• Translucency of enamel which varies with different degrees of calcification.
• Thickness of enamel which is greater at the occlusal/incisal edge of the tooth
and thinner at the cervical third.
Classification of Discoloration
1. Intrinsic discoloration
2. Extrinsic discoloration
3. Combination of both
 Etiology of tooth discoloration
Intrinsic stains
• Pre-eruptive causes
- Diseases
1. Alkaptonuria
2. Hematological disorder
- Erythroblastosis fetalis
- Congenital porphyria
- Sickle cell anemia
3. Diseases of enamel and dentin
Developmental defect in enamel formation
- Amelogenesis imperfecta
- Fluorosis
- Vitamin and mineral deficiency
- Chromosomal anomalies
- Inherited disease
- Tetracycline
- Childhood illness
- Malnutrition
- Metabolic disorder
 Defects in dentin formation
- Dentinigenesis imperfecta
- Erythropoietic porphyria
- Tetracycline and minocycline (excess intake)
- Hyperbilirubinemia
4. Liver disease

- Medications
1. Tetracycline Stains And other antibiotic use
2. Fluorosis Stain
 Etiology of tooth discoloration
Intrinsic stains
• Post-eruptive causes
1. Pulpal Changes
2. Trauma
3. Dentin Hyper Calcification
4. Dental Carriage
5. Restorative Materials and Operative Procedures
6. Aging
7. Functional and Para Functional Changes
 Etiology of tooth discoloration
Extrinsic discoloration
1. Daily Acquired Stains
1. Plaque
2. Food and Beverages
3. Tobacco Use
4. Poor oral hygiene
5. Swimmers Calculus
2. Chemicals
1. Chlorhexidine
2. Metalic Stains
Fluorosis staining manifests as :

• Gray or white opaque areas on teeth .

• Yellow to brown discoloration on a smooth enamel surface.
• Moderate and severe changes showing pitting and brownish
discoloration of surface.
• Severely corroded appearance with dark brown discoloration and loss
of most of enamel.
Classification of tetracycline staining according to developmental
stage, banding and color (Jordun and Boksman 1984)
• First degree (mild) – yellow to gray , uniformly spread through the
tooth. No banding.
• Second degree (moderate) – yellow brown to dark gray , slight
banding, if present.
• Third degree (severe) – blue gray or black and is accompanied by
significant banding across tooth.
• Fourth degree – stains that are so dark that bleaching is ineffective,
totally.
Traumatic discoloration Fluorosis

Staining due to metallic restoration

Fluorosis
Tetracycline staining Tetracycline staining
Staining due to tobacco use
Traumatic discoloration

Functional tooth wear

 Bleaching
Bleaching is defined as whitening of a tooth through the application of
chemical agents to oxidize or reduce the organic pigmentation in the
tooth.

Goal of bleaching is to restore the normal color of a tooth by

decolorizing the stain with a powerful oxidizing agent also known as a
bleaching agent.
 Bleachig agents
Most commonly used bleaching materials are:
1. Hydrogen peroxide
2. Sodium per borate
3. Carbamide peroxide

Hydrogen peroxide and carbamide peroxide are mainly indicated for

extracoronal bleaching, whereas sodium perborate is used for
intracoronal bleaching.
Hydrogen peroxide
• It is a clear, colorless, odorless liquid stored in light proof amber
bottles.
• Should be stored in dark and cool place (refrigerator). It is unstable
and should be kept away from heat.
• If stored properly , it’s shelf life is 3 to 4 months but decomposes
rapidly in presence of organic debris and an open air.
• Used in concentration between 5 and 35 percent.
• Hydrogen peroxide can be classified as organic and inorganic.
Hydrogen peroxide
• Caustic and burns tissue on contact , releasing toxic free-radicals,
perhydroxyl anions or both.
• Should be handled carefully to prevent direct contact with mucous
membrane.
• Can be used alone or in combination with sodium perborate.
• H2O2 has a lower molecular weight and hence can penetrate dentine
and release oxygen that breaks down the double bond of inorganic
and organic compounds inside the tubules.
Hydrogen peroxide
• Care should be taken in handling it because it can cause chemical
burns on the area of contact.
• Concentration ranging from 25-38 % is recommended for in-office
bleaching.
• Concentration ranging from 3-7.5 % is recommended for home
bleach.
Mode of Supply of Hydrogen Peroxide
Solution : Various concentration of H2O2 are available, but 30% to 35%
stabilized solutions are the most commonly used. They can be used
either alone or mixed with sodium perborate.

Gel : Also available in the form of Silicon dioxide gels containing various
concentrations of hydrogen peroxide (6-38%).
Recently introduced is the Opalescence xtra boost which contains
38% H2O2 for quicker results and which doesn’t even require light
activation (syringes).
Sodium perborate
• It is a stable oxidizing agent available as white powder, normally supplied in
a granular form that has to be ground into a powder before using.
• Types : Mainly three types-
1. Sodium perborate monohydrate
2. Sodium perborate trihydrate
3. Sodium perborate tetrahydrate
• They vary in oxygen content which determines their bleaching efficacy.
• It is stable when dry but decomposes in the presence of acid, water or
warm air to form sodium metaborate, H2O2 and nascent oxygen.
Sodium perborate
• Their pH is alkaline and it depends on the amount of H2O2 released
and the residual sodium metaborate.

• It is more easily controlled and is safer than concentrated H2O2.

Therefore it is the material of choice in most intra-coronal bleaching
procedures.
Carbamide peroxide
• Also known as urea hydrogen peroxide.
• It exists in the form of white crystals or as a crystalized powder
containing approx 35% H2O2.
• Used in concentration ranging from 3 to 45 percent.
• Commercially available preparation has 10% carbamide peroxide.
• It is mostly used in home bleaching technique with concentration
ranging from 10-30%(equivalent to approximately 3.5%-8.6% H2O2).
Carbamide peroxide
• It decomposes into urea, ammonia, carbon dioxide, and hydrogen
peroxide.
• Some preparation contain carbopol (a water soluble polyacrylic acid
polymer)which is used as a thickening agent. It prolongs the release
of active peroxide and improves shelf life.
• For gel preparation glycerine,propylene glycol, sodium stannate,
phosphoric or citric acid and flavoring agents are added.
• It lacks toxicity and minimal side effects combined with both
cleansing and bactericidal properties.
Mechanism of Bleaching
• Mechanism of Bleaching is mainly linked to degradation of high
molecular weight and complex organic molecule to low molecular
weight and less complex molecules that reflect less light resulting in a
reduction or elimination of discoloration.
• Hydrogen peroxide acts as a strong oxidizing agent through the
formation of free radicals, reactive oxygen molecules and hydrogen
peroxide anions. These reactive molecules attack the long chained,
dark-colored chromophore molecules and split them into smaller, less
colored and more diffusible molecules.
Bleaching Techniques
• For vital teeth
• Home bleaching technique/night guard vital bleaching.
• In-office bleaching
- Thermocatalytic
- Nonthermocatalytic
- Microbrasion.
• For nonvital teeth
- Thermocatalytic in office bleaching
- Walking bleach /intracoronal bleaching
- Iside/outside bleaching
- Closed chamber bleaching/extracoronal bleaching
• Laser-assisted bleaching.
Home Bleaching Technique/Nightguard
Bleaching
• Commonly used solution for nightguard bleaching
- 10% carbamide peroxide with or without carbopol
- 15% carbamide peroxide
- Hydrogen peroxide (1-10%)
Home Bleaching Technique/Nightguard
Bleaching
• Tray Fabrication
-Nature of material used for fabrication of bleaching tray is flexible
plastic. Most common tray material used is ethyl vinyl acetate.
-Standard thickness of tray is 0.035 inch.
• Treatment Regimen
-Patient is instructed to brush the teeth before tray application.
-Patient is instructed to place enough bleaching material into the
tray to cover the facial surfaces of each tooth to be bleached. After
seating tray in mouth the extra material is carefully wiped away.
• A 10-15% carbamide peroxide is used. It degrades to 3%hydrogen peroxide
and 7% urea.
• Wearing the tray during day time allows replenishment of the jel after 1 to 2
hours for maximum concentration. Overnight used causes decrease in loss of
material due to decrease salivary flow at night.
• While removing the tray patient is asked to remove the tray from second
molar region in peeling action. This is done to avoid injuries to soft tissues.
• Patient is instructed to rinse off the bleaching agent and clean the tray.
• Duration of treatment depends upon original discoloration, duration
of bleaching, patient compliance and time of bleaching
• Patient is recalled for periodic checkups for assessing bleaching
process.
• Total treatment time using an overnight approach is usually 1-2
weeks.
• It is recommended that only one arch be bleached at a time
beginning with the maxillary arch.
• Maintenance after tooth bleaching
• Additional rebleaching can be done every 3 to 4 years if necessary with
duration of 1 week.
• Side effects
- Gingival irritation
- Soft tissue irritation
- altered taste sensation
- tooth sensitivity
• Advantages of home bleaching technique
1. Simple method for patient to use.
2. Simple for dentists to monitor.
3. Less chair time and cost effective.
4. Patient can bleach their teeth at their convenience
• Disadvantages of home bleaching technique
1. Patient compliance is mandatory.
2. Color change is dependent on amount of time the trays are worn.
3. Chances of abuse by using excessive amount of bleach for too many hours
per day.
In-Office Bleaching Technique
• Pumice the teeth to clean off any debris present on the tooth surface.
• Isolate the teeth with rubber dam and protect the gingival tissues
with orabase or vaseline.
• Position protective eyeglasses over the patient’s and operator’s eye.
• Saturate the cotton or gauze piece with bleaching solution (30-35%
H2O2) and place it on the labial surface of the teeth. Bleaching gel can
also be used instead of solution which can be better controlled.
• Apply heat with a heating device or light source. The temperature
should be controlled between 125o F to 140o F(52o C to 60o C).
In-Office Bleaching Technique
• Re-wet enamel surface in between every 4 and 5 minutes. The
treatment time should not exceed 30 minutes.
• Remove solution with the help of wet gauze.
• Irrigate teeth thoroughly with warm water.
• Instruct the patient to use a fluoride rinse daily for 2 weeks.
• Second and third appointment is given after 3 to 6 weeks.
• Evaluate the effectiveness of bleaching by using the same shade guide
used pre-operative assessment. Repeat the procedure if necessary.
• Advantages of in-office bleaching
- Patient preference.
- Less time than overall time needed for home bleaching.
- Patient motivation.
- Protection of soft tissues.
• Disadvantages of in-office bleaching
- More chair time.
- More expensive.
- More frequent and longer appointment.
- Unpredictable and deterioration of color is quicker.
- Dehydration of teeth.
In office Bleaching Technique
Home Bleaching Technique
Non-Vital Tooth Bleaching
Intracoronal Bleaching/Walking Bleach of Nonvital Teeth
It involves use of chemical agents within the coronal portion of an
endodontically treated tooth to remove tooth discoloration.

Steps:
• Take the radiographs to assess the quality of obturation.
• Evaluate the quality and shade of restoration, if present.
• Evaluate tooth color with shade guide.
• Vaseline should be applied to the gingival tissues.
• Isolate the tooth with rubber dam.
Non-Vital Tooth Bleaching
Intracoronal Bleaching/Walking Bleach of Nonvital Teeth
• Prepare the access cavity, remove the coronal gutta-percha, expose the
dentin and refine the cavity.
• Place mechanical barriers of 2mm thick, preferably of glass ionomer
cement, zinc phosphate cement, IRM, polycarboxylate cement or MTA on
root canal filling material.
• Mix sodium perborate with an inert liquid (local anaesthetic, saline, water)
and place this paste into pulp chamber.
• Place a temporary restoration over it, at least 3mm in thickness. Apply
pressure with the gloved finger against the tooth until the filling has set
because filling may get displaced due to release of oxygen.
Non-Vital Tooth Bleaching
Intracoronal Bleaching/Walking Bleach of Nonvital Teeth
• Recall the patient after 1-2 weeks.
• Repeat the treatment until desired shade is achieved.
• After obtaining the desired results, pulp chamber is rinsed, dried,
etched and composite is placed.
Non-Vital Tooth Bleaching
Thermocatalytic in-office bleaching
• Isolate the tooth to be bleached using rubber dam
• Place bleaching agent(superoxol and sodiam perborate separately or in
combination) in the tooth chamber
• Hit the bleaching solution using light curing unit
• Repeat the procedure till the desire tooth color is achived
• Wash the tooth with water and seal the chamber using dry cotton and
temporary restorations
• Recall the patient after one to three weeks
• Permanent restoration of tooth with composite
Non-Vital Tooth Bleaching
Inside/outside bleaching technique
• Asses the obturation by taking radiographs
• Isolate the tooth and prepare the access cavity by removing gutta-percha
2mm to 3 mm below the cementoenamel junction
• Place the mechanical barrier, clean the access cavity and place a cotton pellet
in the chamber to avoid food packing into it
• Check the fitting of bleaching tray and advise the patient to remove the
cotton pellet before bleaching
Non-Vital Tooth Bleaching
• Instructions for Home Bleaching-
Bleaching syringe can be directly places into the chamber before sitting the tray
or extra bleaching material can be placed into the tray space corresponding to
tooth with open chamber
• After bleaching tooth is irrigated with water, cleaned and again a cotton pellet is
placed in the empty space
• Re-assessment of the shade is done after 4 to 7 days
• When the desired shade is achieved, seal the access cavity with composite
restoration after at least two weeks
Non-Vital Tooth Bleaching
Closed Chamber/ Extra corronal bleaching
In this technique instead of removing existing restoration the bleaching paste is
applied to the tooth via bleaching tray

Indications of closed chamber Technique

• In case of totally calcified in a traumatized tooth
• As a maintenance bleaching treatment several years after initial intra coronal
bleaching
• Treatment for adolescents with incomplete gingival maturation
Laser-Assisted Bleaching Technique
Following LASER have been approved by FDA for tooth bleaching:
1. Argon laser.
2. CO2 laser.
3. GaAlAs Diode laser (Gallium Aluminum- Arsenic).
Laser whitening gel contains thermally absorbed crystals, fumed silica
and 35% H2O2. In this technique, gel is applied and is activated by light
source which activates the crystals present in gel, allowing dissociation
of oxygen and therefore better penetration into enamel matrix.
Recent technique:
KTP(Karium-Titanium-Phosphoric acid) which is a type of
Nd.YAG laser seems to be appropriate for bleaching of tetracycline
stained teeth. This laser does not increase temperature much that’s
why KTP is suitable for vital bleaching without damage to pulp tissue.
Effects of bleaching:
Tooth Hypersensitivity
Tooth sensitivity is common side effect of external tooth
bleaching. Higher incidences of tooth sensitivity are seen after in office
bleaching with hydrogen peroxide in combination with heat.

Cervical Resorption
Cervical root resorption is a possible consequence of
internal bleaching and is more frequently observed in teeth treated
with the thermo-catalytic procedure especially when a higher than 30%
concentration of H2O2 is used.
Cervical Resorption
During thermo-catalytic bleaching hydroxyl groups may be
generated especially when EDTA has been used previously to clean the
tooth. These hydroxyl groups stimulates cells in the cervical PDL to
differentiate into odontoclast cells which begin root resorption.

Effects on enamel
Studies have shown that 10% carbamide peroxide decreased
enamel hardness.
Effects on dentin
Bleaching has shown to cause uniform change in color
through dentin.

Effect on pulp
Penetration of bleaching agent into pulp results tooth
sensitivity. Studies have shown that 3% H2O2 can cause:
• Transient reduction in pulpal blood flow.
• Occlusion of pulpal blood vessels.
Effects on cementum
Cervical resorption and external root resorption in teeth have
been seen in teeth treated by intracoronal bleaching using 30-35%
H2O2.

Effects on soft tissues

A high concentration of H2O2 is caustic to mucous
membrane and may causes burns to gingiva.
Genotoxicity and Carcinogenicity
Hydrogen peroxide releases free radicals (hydroxyl radicals,
perhydroxyl ions, superoxide anions) which are capable of attacking DNA.

Uneven results
If teeth are overly stained in one area before bleaching, the post
bleaching results might be rather uneven. Lacking post bleaching instruction,
patients could also fail to realize that they might need to avoid certain types
of foods initially to avoid quickly re-staining their teeth.
Toxicity
The acute effects of hydrogen peroxide ingestion are dependent
on the amount and concentration of hydrogen peroxide solution
ingested.
Signs and symptoms usually seen are ulceration of the buccal
mucosa, esophagus and stomach, nausea, vomiting, abdominal
distention and sore throat.
Advantages of bleaching
- Safe procedure
- No anaesthetic required
- No tooth reduction
- Least expensive of treatment alternatives
Disadvantages of bleaching
- Normal tooth color may not be restored
- Effective only in certain cases
- Extended treatment time