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JOURNAL OF ENDODONTICS
Copyright © 1992 by The American Association of Endodontists
CASE REPORT
Adverse Response to Vital Bleaching
Gerald N. Glickman, DDS, MS, Howard Frysh, BDS, DDS, and Frank L. Baker, DDS
A case study is presented that described an acute
flare-up of a tooth following a vital bleaching pro-
cedure. The case illustrates (a) the importance of
assessing the pulpal and periradicular status of a
tooth prior to any vital bleaching procedure; and (b)
the alteration of the local adaptation syndrome by
the bleaching agent.
In-office power bleaching systems along with in-home "night-
guard"-type bleaching systems have recently surfaced as the
"new wave" of treating discolored vital teeth (1, 2). The in-
office power bleaching systems are administered by the clini-
cian and utilize high concentrations of hydrogen peroxide (30
to 35%), often in conjunction with a bleaching light or other
type of heat source, to lighten the teeth. The in-home matrix
or carder types use weaker solutions of hydrogen peroxide or
10 to 15 % solutions ofcarbamide peroxide in stents fabricated
from 0.020 coping material. These are placed and controlled
by the patient according to the individual instructions. Al-
though esthetic satisfaction produced by either method has
proven to be dependent on a number of factors including case
selection and patient expectations, these methods for bleach-
ing discolored vital teeth have proven to be relatively effective.
Recently, in-office bleaching systems using gels have been
developed to allow for a more controlled chairside delivery of
oxidizing agent (1). These systems simplify the application
and do not advocate the use of heat or light that could cause
pulpal problems. The viscosity of some of these gels is con-
trolled by the practitioner; the thicker the gel, the lower the
concentration of H202 delivered. A slower release of a less
concentrated form of hydrogen peroxide, such as 25 %, would
not only retard the penetration of hydrogen peroxide but also
reduce the possibility of delivering sufficient bleaching agent
to the pulp to cause irreversible pulpal damage. Although
studies (3, 4) have supported the penetration of bleaching
agents through enamel and dentin, there has been little doc-
umentation that these power bleaches can cause irreversible
pulpal damage as long as the materials are used properly and
the pulpal states of the teeth to be bleached are diagnosed as
normal.
The following report describes a case of an acute flare-up
following the use of a gel bleaching system on a discolored
351
Printed in U.S.A.
VOL. 18, NO. 7, JULY1992
maxillary central incisor. The case illustrates the importance
of determining the preoperative pulpal states prior to any
vital bleaching procedure and suggests that bleaching agents
in a vehicle gel can diffuse into the pulp system and cause an
alteration of both the pulpal and periradicular status of a
tooth.
CASE REPORT
A 28-yr-old man reported to the Baylor College of Dentistry
for evaluation of tooth 9. The patient stated that his
tooth had been bleached and that 24 h following the treat-
ment, he experienced intense pain and swelling. Upon further
questioning, he stated that a blow had been dealt to the
maxillary anterior region during a boating accident 10 yr
previously and that the tooth had been slowly discoloring
over the past 5 yr.
It was determined that a consultation with his dentist could
provide valuable information about the bleaching procedure
used. The following are details of the evaluation and bleaching
procedure as provided by the practitioner. The patient was
concerned about his discolored "front tooth" and wanted it
bleached. The dentist indicated that the tooth had a slight
brownish tinge and that it appeared to be normal radiograph-
ically (Fig. 1); no diagnostic tests were performed. After
consultation with the patient, a vital bleaching procedure was
done using the Starbrite Bleaching System (Stardent Labora-
tories, Salt Lake City, UT). Prior to placement of the gel
mixture, the patient's eyes and clothes were protected and the
maxillary anterior teeth were pumiced to ensure sufficient
debris and stain removal. Vaseline was used to protect the
soft tissues before placement of the rubber dam. The dentist
stated that Starbrite bleaching solution (35% H202) was mixed
with the gelling agent to a viscosity similar to that of phos-
phoric acid gel. The bleaching gel was then placed with a
cotton tip applicator in a 2-mm thick layer on both the facial
and lingual surfaces of tooth 9. After a period of 20 min, the
tooth was rinsed with water and air-dried. The dentist as well
as the patient stated that the tooth was significantly lighter.
He informed the patient that an additional appointment
would be necessary to try to achieve the desired esthetic
results. Twenty-four hours after the procedure, the patient
reported back to the dentist with pain and swelling associated
with the tooth. The patient's lip was slightly elevated and the
352 Glickman et al.
'\
FIG 1. Prebleaching periapical radiograph of tooth 9. The canal system
appears to be enlarged and there is discontinuity of the lamina dura
in the apical one third.
tooth was extremely painful upon percussion. The dentist
prescribed 500 mg of penicillin V (28 tablets) and 800 mg of
ibuprofen (12 tablets) and informed the patient to return if
the signs and symptoms did not dissipate.
At the time of examination at the dental school, the patient
was asymptomatic and there was no indication of swelling.
However, due to the recent episode of pain and swelling and
due to the past history of trauma to the region, a complete
evaluation of the pulpal and periradicular status of tooth 9
was made. There was no response to ice and no response to
the electric pulp tester (Analytic Technology, Redmond, WA).
The tooth was not tender to percussion or palpation. A new
periradicular radiograph was taken which clearly indicated
destruction of lamina dura in the apical one third with an
associated periradicular radiolucency (Fig. 2). A diagnosis of
pulpal necrosis with chronic periradicular periodontitis was
made. The tooth was planned for nonsurgical root canal
therapy.
Local anesthetic was administered. Upon access opening
no evidence of hemorrhage or vital pulp was found in the
canal. The canal was instrumented using a step-back tech-
nique. Due to canal weeping and apical resorption, a
Journal of Endodontics
FIG 2. Pedapical radiograph of tooth 9 taken 4 wk after bleaching.
There is obvious destruction of the lamina dura in the apical one third
and a periradicular radiolucency.
Ca(OH)jBaSO4 interim dressing was placed. The tooth was
sealed with a dry cotton pellet and an IRM (L. D. Caulk/
Dentsply, Milford, DE) temporary restoration.
At the subsequent visit, tooth 9 was reopened without
anesthesia and the Ca(OH)2 paste was removed with files. The
apical 1V_~mm extent of the Ca(OH)2 paste was left as an
apical plug. A #100 master gutta-percha cone was custom fit
using chloroform as a softening agent (Fig. 3). Lateral con-
densation with gutta-percha and Roth's 801 sealer (Roth Int.,
Chicago, IL) was used to obturate the canal system. An IRM
temporary restoration was placed to seal the access (Fig. 4).
A 6-month recall radiograph indicated healing of the
osseous defect and incomplete absorption of sealer (Fig. 5).
The patient was asymptomatic. Although the tooth had main-
tained its postbleaching color, the patient was advised to
return for a final bleach.
DISCUSSION
Bleaching vital teeth has become an integral part of the
practice of cosmetic dentistry. The increasing concern for a
"whiter" smile along with the advent of in-home, patient-
controllable procedures has led to the marketing of a number
of products which both the practitioner or patient can use
with ease in order to achieve an esthetic result. As with any
bleaching procedure, however, results cannot be guaranteed
and there are still many unknowns to vital bleaching (1, 2).
 Vol. 18, No. 7, July 1992
FfG 3. Master gutta-percha cone radiograph. Note apical plug of
Ca(OH)2.
These may include longevity of the bleach and the possible
need for additional bleaching procedures; the short-term and
long-term effects on the pulp, periradicular tissues, restorative
materials, and oral soft tissues, especially if multiple trials are
necessary; and the exact amount of time and concentration
necessary to achieve the desired results since studies demon-
strating optimum contact time and concentration have not
been done. Tooth hypersensitivity following vital bleaching
along with the possibility of cervical root resorption which
has been associated with nonvital bleaching are additional
concerns with any of the power bleaches or in-home bleaching
techniques.
The ability of substances to penetrate the enamel and
dentin and reach the pulp is relatively well established. In
1951, Bartelstone (5) demonstrated the existence of a pathway
from the enamel to pulp. In his study, radioactive iodine
penetrated intact enamel, dentin, and pulp of feline teeth with
subsequent uptake by the systemic circulation and the thyroid
gland. In 1987, with particular concern about the penetrability
of bleaching agents during vital bleaching techniques and its
potential effects on the pulp, Bowles and Ugwuneri (3) found
low concentrations (1 to 10%) of H202 in the pulp chambers
of extracted teeth following external application. These
amounts significantly increased upon the application of heat
(50"C) indicating that permeability increases with increases in
temperature. Bowles and Thompson (6) in 1986 also dem-
Adverse Response to Vital Bleaching 353
FiG 4. Postobturation radiograph of tooth 9.
onstrated that a number of pulpal enzymes became very
sensitive to combinations of H202 and heat, although the
actual quantities of H202 required for inhibition were quite
large. More significantly, in a recent study by Cooper et al.
(7) in 1991, it was demonstrated that even the 3 to 5% H_,O~
that is released from 10% solutions of carbamide peroxide
can reach the pulp.
Most reports (8-10) in the literature suggest that there are
minimal short-term risks (e.g. hypersensitivity) to pulpal tis-
sues following vital bleaching with 30% H202 and local heat
application. However, in order to reduce postoperative com-
plications and other risks case selection is critical. Therefore,
it is mandatory that before using any bleaching procedure the
following should be ascertained: a complete dental history
with particular attention to any previous trauma, a recent
preoperative radiograph of diagnostic quality, the clinical
condition of the crown including assessment of leaky resto-
rations, and, most important, the pulpal and periradicular
status of the teeth.
This study is the first reported cases of an acute exacerba-
tion of a chronic lesion following the application of an in-
office power bleach such as Starbrite. Although the gelling
agent reduces the effective concentration of H202 from 35%
to approximately 25% and there is no heat application, it can
be surmised that some concentration of H202 penetrated the
chamber and altered the existing pulpal and periradicular
state. Based upon the report from the patient's dentist, it was
354 Glickman et al.
FiG 5. Six-month recall. There appears to be some resolution of the
periradicular radiolucency and incomplete absorption of sealer.
concluded that this tooth, due to the past history of trauma,
the discoloration, and the "questionable" radiographic ap-
pearance of the prebleaching radiograph (Fig. 1), probably
had a necrotic pulp with chronic periradicular periodontitis
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Journal of Endodontics
at the time of the power bleach. The penetration of the
bleaching agent into the pulpal system without the use of heat
suggests that the agent itself was a sufficient noxious stimulant
to cause an alteration of the local adaptation syndrome as
proposed by Selye ( 1 l). This phenomenon is used by some to
explain the increased incidence of flare-ups following root
canal therapy on asymptomatic teeth with chronic lesions.
Pushing the necrotic debris/microorganisms beyond the root
end, for example, can be enough of an irritant to "stir up" a
lesion to which the host has adapted (12). Similarly the H202
that entered the quiescent "diseased" pulp in this case may
have been enough to upset the delicate balance between host
resistance and a disease process.
Dr. Glickman is associate professor, Department of Endodontics, Dr. Frysh
is assistant professor, Department of General Dentistry, and Dr. Baker is
assistant professor, Department of General Dentistry, Baylor College of Den-
tistry, Dallas, TX. Address requests for reprints to Dr. Gerald Glickman,
Department of Endodontics, Baylor College of Dentistry, 3302 Gaston Ave.,
Dallas, TX 75246.
References
1. Feinman RA. Reviewing vital bleaching and chemical alterations. J Am
Dent Assoc 1991 ;122:55-6.
2. Haywood VB, Heymann HO. Nightguard vital bleaching: how safe is it?
Quintessence Int 1991 ;22:515-23.
3. Bowles WH, Ugwuneri Z. Pulp chamber penetration by hydrogen per-
oxide following vital bleaching procedures. J Endodon 1987;13:375-7.
4. Fuss Z, Szajkis S, Tagger M. Tubular permeability to calcium hydroxide
and to bleaching agents. J Endodon 1989;15:362-4.
5. Bartelstone HJ. Radioiodine penetration through intact enamel with
uptake by bloodstream and thyroid gland. J Dent Res 1951 ;30:728-33.
6. Bowles WH, Thompson LR. Vital bleaching: the effect of heat and
hydrogen peroxide on pulpal enzymes. J Endodon 1986;12:108-12.
7. Cooper JS, Bokmeyer T J, Bowles WH. Penetration of the pulp chamber
by carbamide peroxide bleaching agents. J Endodon (in press).
8. Cohen SC. Human pulpal response to bleaching procedures on vital
teeth. J Endodon 1979;5:134-8.
9, RobertsonWD, Melfi RC. Pulpal responses to vital bleaching procedures.
J Endodon 1980;6:645-9.
10. Seale NS, Wilson CFG. Pulpal response to bleaching of teeth in dogs.
Pediatr Dent 1985;7:209-14.
11. Selye H. The part of inflammation in the local adaptation syndrome. In:
Jasmin G, Robert A, eds. The mechanism of inflammation. Montreal: Acta,
1953:53-74.
12. Seltzer S, Naidorf IJ. Flare-ups in endodontics: I. Etiological factors. J
Endodon 1985;11:472-8.
J. Bowser