Bleaching

Submitted by:
Anuja Bajracharya
PG Resident
Department of Conservative Dentistry and Endodontics

1
Contents
• Introduction
• History
• Factors affecting vital bleaching
• Types of discoloration and its management
• Bleaching materials
• Bleaching mechanism
• Composition of commercial bleaching agent
• Intra-coronal Bleaching
▪ Walking Bleach
▪ Thermocatalytic Bleaching
▪ Inside-outside bleaching technique
• Complications and adverse effect of intracoronal bleaching
• Extracoronal bleaching
In-office Extracoronal Bleaching
• Power bleaching
• Laser bleaching
• In-Office Tooth Whitening to Remove White or Dark Mottling IV.
• Focal bleaching technique

At-home bleaching
• Power Matrix Bleaching.
• Dentist Monitoring of Completely Home-Based Bleaching
• Home Bleaching without Dental Supervision (OTC Systems)
• Commercially available Bleaching Material
• Risk associated with external bleaching
• Combined bleaching
• Prognosis of bleaching
• Conclusion
• References

2
 Introduction

Aesthetics of the teeth is of great importance to patients, including tooth colour. Tooth
colour can be improved by a number of methods and approaches including whitening
toothpastes, scaling and polishing, bleaching, microabrasion, crowns and veneers.
Discolored teeth can often be corrected totally or partially by bleaching. Bleaching is
conservative, noninvasive, and inexpensive and the most opted treatment protocol by
the masses. Bleaching is a treatment modality involving an oxidative chemical that
alters the light-absorbing and/or light-reflecting nature of a material structure, thereby
increasing its perception of whiteness. Both intracoronal and extracoronal bleaching
techniques have been used to correct tooth color.

History
Initial Attempts at Bleaching

• 1877 - Chapple's first published dental report on tooth bleaching using oxalic
acid
• 1884 - Harwan used hydrogen peroxide as a bleaching agent
• 1888- Taft—calcium hypochlorite

Non-Vital Bleaching Initiated

• 1895 - Garretson uses chlorine to bleach non-vital teeth.

• 1911- Rosenthal—ultraviolet waves
• 1916 - Walter Kaine bleached fluorosed teeth using 18% HCL acid Modern
Bleaching Techniques Begin
• 1918 -Abbot used 35% hydrogen peroxide accelerated by heat from a light
source

Successful Non-Vital Bleaching

• 1958- Pearson—intrapulpal bleach

• 1967- Nutting and Poe—walking bleach

3
 • 1970 - Cohen is first to bleach tetracycline-stained teeth using 35% hydrogen
peroxide and a bleaching instrument
• 1978- Superoxol heat and light

Modern Techniques

• 1984 - Zaragoza bleached maxillary and mandibular arches simultaneously with

70% hydrogen peroxide + heat
• 1989 - Haywood and Heymann describe home bleaching using carbamide
peroxide
• 1989 - Croll introduces hydrochloric acid paste system for superficial enamel
discoloration
• 1995- Yarborough—laser-assisted beaching

FACTORS AFFECTING BLEACHING

1. Surface Cleanliness

All extrinsic stains and surface films must be removed from the tooth surface
before bleaching:

i. differentiate between intrinsic and extrinsic stains

ii. maximize the contact area between the whitening agent and the tooth
iii. minimize the chance of diluting the bleaching agent.

2. Concentration

 Higher conc. of carbamide peroxide produce a more rapid whitening

effect as well as increased tooth sensitivity.
 However, doubling the concentration does not double the speed.
 However, the dominant variable obtaining a satisfactory result is time—
not the concentration of the bleaching agent.

4
3. Use of a Light

 light-activated systems produced better immediate bleaching results

than non-light systems when lower concentrations of hydrogen peroxide
(15%-20%) were used.
 At higher concentrations of HP (25%-35%), no differences were noted.
 In addition, light-activated systems produced a higher percentage of
tooth sensitivity than the nonlight systems.
5. Temperature

 Higher temperatures increase the rate of oxygen radical release.

 Increasing in vitro the temperature of the bleach to 10° C doubled the
chemical reaction
 Speed of color change in tooth structure may not be altered
 Rise in temperature may lead to additional pulpal sensitivity.

6. Buffering Agents

 Carbamide peroxide decomposes into radicals and ions, including hydrogen

ions.
 The hydrogen ions acidify the environment.
 To maintain a more neural pH, buffering agents are added to the gel.
 These agents protect the pulp and promote the continued production of free
radicals resulting in the breakdown of the large, dark color molecules into ultra-
small colorless and white molecules.

7. Time

 The longer the duration of bleach exposure, the greater the degree of whitening.
 However, extended exposure to bleaching agents increases the likelihood of
sensitivity.
8. Gingival Tissue Irritation

 Gingival tissues can undergo an acute inflammatory reaction following

exposure to even small amounts of carbamide peroxide solution.
 Higher concentrations will temporarily blanch the gingival soft tissues.

5
  carbamide peroxide has been shown to reduce plaque and gingivitis scores

9. Potassium Nitrate

 Potassium nitrate is a common ingredient in desensitizing toothpaste

 Its mechanism of action is believed to be caused by an increase in the
extracellular potassium ion, which depolarizes nerve fibers and renders them
unable to repolarize.

10. Stability and Potency of Carbamide

 Carbamide peroxide can be stabilized by both chemical additives and/or thermal

stabilization
 Cold temperature storage is far more predictable to maintaining the potency,
effectiveness, and desired controlled instability of the product.
 Carbamide peroxide requires a controlled decomposition into hydrogen
peroxide and urea to effectively bleach teeth.
 refrigeration reduces the need for chemical stabilizers such as an anhydrous base
and “acidifiers,” allowing the whitening gels to be fully aqueous base and at or
above pH 7.49 Therefore although more inconvenient, thermal stabilization is a
far more predictable stabilization method because of the predictability of this
decomposition when placed in the warm mouth, than chemical stabilizers,
especially if the latter lacks activation agents that will trigger the neutralization
of the chemical stabilizer.

11. Chemical Accelerators

 Bleaching effectiveness is directly proportional to the concentration of free

radicals which are produced by the decomposition of carbamide peroxide.
 Chemical accelerators speed the breakdown of peroxide
 -by both breaking down chemical stabilizers
 -by producing their own ions and free radicals.
12. Whitening Gel Viscosity and Solubility

 Bleaching trays are open on the periphery

 So, carbamide peroxide gel is combined with a high viscosity, insoluble
anhydrous base.

6
  In-office gels are mixed with even higher viscosity base to prevent the gel from
running off the teeth.
 It exhibits high surface tension, causing less intimate microscopic adaptation of
the gel to the tooth surface, which can slow the absorption of gel into the
microstructure of the teeth.
 Therefore bleaching gel formulations must balance the safety of a higher
viscosity base with the undesirable diminution of surface wetting.

13. Sensitivity

 Postoperative tooth sensitivity is the most common side effect of tooth

bleaching.
 The duration of sensitivity was three or fewer days in 77% of patients.
 Sensitivity was greatest the first week of bleaching and then declined.
 Study suggest that inclusion of additives such as potassium nitrate and sodium
fluoride are effective in reducing tooth sensitivity but not soft tissue irritation.

TYPES OF DISCOLORATION AND ITS MANAGEMENT

Extrinsic Stains
 Tobacco
 Foods and beverages
 Medications

7
Intrinsic Stains

Pre-Eruptively Caused Discolorations

o Alkaptonuria
o Amelogenesis imperfecta
o Dentinogenesis imperfecta
o Endemic fluorosis
o Erythroblastosis fetalis
o Porphyria
o Sickle cell anemia
o Thalassemia
o Tetracycline staining

Post-Eruptively Caused Discolorations

 Age
 Dental metals
 Foods, beverages, and habits such as smoking
 Idiopathic pulpal recession
 Non-alloy dental material
 Traumatic injury

Extrinsic Stains

The Long-chain polysaccharides and proteinaceous materials forms a tenacious coating

on the exposed surface of teeth called the pellicle. These pellicle are easily stained.
Most severe stains occurs at the gingival margin and in the interproximal areas, which
are less accessible to tooth brushing. These pellicle displays many colors, ranging from
white to red to brown to green, and can become extremely opaque, depending on the
pigmentation source. •Extrinsic stains are routinely removed during standard
prophylaxis. Patients can remove this layer daily during brushing. Effective oral
hygiene instruction can help them to achieve maximum results for which soft brush and

8
low-abrasive toothpaste is sufficient. Occasionally patients must use toothpastes with a
relatively high index of abrasion or even a medium to hard-bristled toothbrush.

Intrinsic Stains

Intrinsic stains are the result of color changes in the internal structures of the teeth
caused by factors that are may be systemic or local in origin. Intrinsic stains more
difficult to treat than extrinsic stains but because of their distribution throughout the
tooth, they are more readily apparent. The difficulties in removing stains and the
expected degree of success depend on the type of discoloration being addressed. With
modern tooth-whitening procedures, most intrinsic stains can be removed. Composite
or porcelain veneers, porcelain crowns can be used if it does not respond to tooth-
whitening procedures. Intrinsic stains can be divided into:

1. Arising during odontogenesis: incorporate discolorations into the enamel or

dentin or by the inclusion of pigments to their structure

2. Occurring after tooth eruption: discoloring agents are integrated into the hard
tissues internally from the pulp chamber or extrinsically from the tooth surface

Classification of Discoloration
Most common classification for tooth discoloration was described by Nathoo and
defines three classes:

• Nathoo type 1 (N1): discoloring agent (chromogen) binds to tooth surface, with a
color similar to that of dental stains caused by chromogenic bacteria, coffee, tea, wine,
and metals.

• Nathoo type 2 (N2): discoloring agent is a Nathoo type 1 food stain that changes
color to darker after binding to tooth surface for a certain amount of time.

• Nathoo type 3 (N3): prechromogen or in its base state colorless material binds to
tooth and causes a stain after a chemical reaction that are often due to carbohydrate-
rich foods, stannous fluoride, or chlorhexidine.

9
 Fluorosis

Fluorosis is actually a form of enamel hypoplasia, hence the white spotting. Darker
discoloration is due to extrinsic staining of the hypoplastic enamel. During the tooth
formation, if there is exposure to high concentration of fluoride, there is metabolic
alteration in the ameloblast which leads to defective matrix and improper calcification.

Appearance

Staining is bilateral and affects multiple teeth in both arches

 Mild: intermittent white spotting, chalky or opaque areas,

yellow or brown staining of varying degrees
 severe cases: surface pitting of the enamel

Treatment Considerations:

Bleaching and acid/abrasion systems are effective for treating superficial fluorosis
stains. Bleaching works best for brown pigmentation on smooth enamel surface.
Bleaching less effective in opaque white spots as it further lighten the white spots. In
case of staining with pitting and surface defect, bleaching is used as adjunct preceding
bonding and veneering.

Tetracycline Staining

Tooth discoloration caused by incorporation of systemic tetracycline into tooth

structure was not reported until 1956.

Mechanism:

•First theory: It occurs by the joining of the tetracycline molecule with calcium through
a chelation process and a subsequent incorporation into the hydroxylapatite crystal of
the tooth during the stage of development.

10
•Second theory: Discoloration involves a binding of the tetracycline to tooth structure
by a metal-organic matrix combination of the tetracycline complex.

It is primarily deposited in the dentin because of the large surface area of the dentin
apatite crystals compared with enamel apatite crystals.

Appearance:

It may be yellow, yellow-brown, brown, gray, or

blue. It may be diffuse and in severe cases may
exhibit banding. It is bilateral and affects multiple
teeth in both arches. The hue and severity of tooth
discoloration depend on four factors associated with tetracycline administration:

1. Age at the time of administration:

• Anterior primary teeth: from 4 months in utero through 9 months postpartum.

• Anterior permanent teeth: from 3 months postpartum through age 7 years.

2. Duration of administration: directly proportional to the length of time the

medication was administered

3. Dosage: directly proportional to the administered dosage.

4. Type of tetracycline: Coloration has been correlated with the specific type of
tetracycline administered

a. Chlortetracycline: Gray-brown stain

b. Demethylchlortetracycline : Yellow stain

c. Doxycycline : Does not cause staining

d. Oxytetracycline: Yellow stain

e. Tetracycline: Yellow stain

Yellow tetracycline staining slowly darkens to brown or gray brown when exposed to
sunlight. Anterior teeth of children often darken first, whereas the posterior teeth,
because of reduced exposure to sunlight, darken more slowly. In adults, natural photo-
bleaching of the anterior teeth has been observed.

11
Tetracycline Staining Categories

1. Mild tetracycline staining

Mild staining can be light yellow, light
brown, or light gray and staining is uniform
throughout the clinical crown. No banding is
present

2. Moderate tetracycline staining

Moderate staining is more intense than mild
staining, banding is slight if present.

3. Severe tetracycline staining

Severe tetracycline staining is intense, and the
clinical crown may exhibit horizontal color
banding Bleaching generally is not performed
because of the time involved and the poor
prognosis. However, although less than ideal results are to be expected, the
outcome may be esthetically satisfactory to the patient. The yellow-brown to
brown component generally responds better than the blue to blue-gray
component.

Treatment Considerations:

Acid/abrasion techniques is not indicated for the removal of tetracycline stains.

12
Light yellow, yellow-brown, and brown stains:

 Bleaching shows good result in less than 4 sessions of in-office bleaching

 Or one series of dentist-monitored home bleaching

More extensive yellow or gray staining without banding:

• Responsive to bleaching but may take 5 or more in-office treatment

• Combination of both in-office and home bleaching

• Home bleaching alone takes 2-6 mths

Severe staining with dark gray or blue coloration with banding:

• bleaching may lighten teeth but bands may still be visible.

• Veneering technique may be necessary

Discoloration due to Aging

The natural process of gradual pulp withdrawal with the simultaneous formation of
secondary dentin causes the tooth to appear more yellowish-brown. This is the most
common indication for tooth whitening and results are the most rapid and predictable.
Standard vital tooth whitening treatment options are applicable

Staining of Pulp: Trauma

Discoloration of a root-fractured tooth might be a

sign of pulp necrosis, pulp canal calcification or an
internal bleeding with hyperaemia of the pulp
capillaries. One of the sequelae of trauma from
severe injuries is complete interruption of the blood
supply. An increased blood pressure may lead to the
rupture of capillaries and release of red blood cells
into the pulp chamber. The hemolysis of erythrocytes will result in the degradation of
hemoglobin into globin and the heme protein, containing an iron atom. The iron, in the

13
form of iron sulfides, may reach dentinal tubules, causing stains and discolorations in
the surrounding dentin. The shift from pink to greyish-blue takes approximately 2
weeks. A certain fading of the grey-blue tint can occur, or an opaque grey hue can
persist. If the pulp survives, the stain can disappear. Transient discoloration after other
types of traumatic injuries to the teeth is a well-known phenomenon.

Appearance: red, yellow, yellow-brown, brown

Treatment Considerations:

If tooth is vital, tooth whitening procedures is done. If tooth is non-vital, endodontic

therapy followed by non-vital bleaching. If vital tooth with internal resorption,
endodontic therapy followed by non-vital bleaching

Staining After Endodontic Therapy

Mechanism: Excessive hemorrhaging during pulp removal

or by decomposition of pulpal tissue following incomplete
extirpation.
Appearance: red, yellow, yellow-brown, brown, gray, or
black. Discoloration obviously is limited to the
endodontically treated tooth or teeth.

Treatment Considerations:

Acid/abrasion techniques are not indicated for stains of pulpal etiology. The bleaching
agent is directly placed into the pulp cavity. Staining by medications, sealers, and filling
materials generally is less amenable to bleaching than staining resulting from biologic
causes.

14
 Staining from Silver Amalgam

Mechanism: It is due to visibility of restoration through

relatively translucent tooth structure or direct staining of
tooth structure by leeching of amalgam corrosion
products. Threaded stainless steel pins or gold-plated
retentive pins can cause similar extremely dark stains.

•Appearance: tooth appears gray to black.

Treatment Considerations

These kind of discoloration is not routinely amenable to bleaching. Replacing with

composite restorative treatment is the usual solution.

• Discoloration due to

 Amelogenesis imperfecta
 Dentinogenesis imperfecta
 Erythroblastosis fetalis
 Porphyria

BLEACHING MATERIALS

The most commonly used peroxide compounds are hydrogen peroxide, sodium
perborate, and carbamide peroxide. The active ingredient in tooth bleaching materials
is peroxide compounds. For extracoronal bleaching, hydrogen peroxide and carbamide
peroxide is used. For intracoronal bleaching, sodium perborate is used. Sodium
perborate and carbamide peroxide decompose to release hydrogen peroxide in an
aqueous medium.

15
Hydrogen Peroxide

It is the simplest peroxide which is more effective at pH value that are close to the
dissociation constant. It is used in both in-office and at-home bleaching materials. In-
office bleaching materials has high concentrations i.e. 25% to 38%. At-home bleaching
products have 3% to 14% concentration. High concentration of hydrogen peroxide are
caustic and burns tissues on contact. It must be handled with care to avoid their contact
with tissues. For external bleaching procedure, rubber dam and additional block-out
isolation is mandatory to avoid iatrogenic complications.

Sodium Perborate

It is available as a monohydrate, trihydrate, and tetrahydrate, with varying contents of

oxygen. The active oxygen concentration in sodium perborate monohydrate is 16%, in
sodium perborate trihydrate is 11.8% and sodium perborate tetrahydrate oxygen is
10.4%. Sodium perborate is stable when dry. Sodium perborate dissociates into sodium
metaborate, hydrogen peroxide and nascent oxygen in presence of acid, warm air, or
water. When fresh, it contains about 95% perborate and 9.9% of the available oxygen.
They differ in oxygen content that determines their bleaching efficacy. Commonly used
sodium perborate preparations are alkaline. Their pH depends on the amount of
hydrogen peroxide released and the residual sodium metaborate. Sodium perborate is
more easily controlled and is safer than concentrated hydrogen peroxide as material of
choice in most intracoronal bleaching procedures.

Carbamide Peroxide

It is also known as urea hydrogen peroxide. It is an efficient bleaching agent which

break down into carbamide and hydrogen peroxide in aqueous solution. It exists in the
form of white crystals or as a crystallized powder containing approximately 35% H2O2.
In home-use bleaching, concentrations ranging from 10 to 30% is used, where 10%
most common. Bleaching preparations containing carbamide peroxide usually also
include

1. Glycerine or propylene glycol,

2. Sodium stannate,

16
 3. Phosphoric or citric acid,

4. Flavor additives.

5. Carbopol -thickening agent prolongs the release of active peroxide and

improves shelf life

There is releases of oxygen from hydrogen peroxide within seconds of contacting tooth
surfaces and remains active for 40 to 90 minute

BLEACHING MECHANISMS

H2O2 diffuses through the

enamel and dentin

produce free radicals

react with pigment

molecules breaking that
their double bonds

change in pigment molecule

configuration or size

result in changes in their

optical properties

17
Fig 1: Stylized cross-section of Fig 2: Staining liquids typically Fig 3: Once inside the
tooth structure showing white- consist of smaller molecules enamel and dentin, the
yellow enamel, yellower dentin, that can pass through the semi- smaller stain molecules
and reddish pulp. The semi- permeable membrane. Stains tend to form double bonds,
permeable layer that exists at may flow back and forth through becoming longer-chain
the enamel and dentin the membrane molecules.

Fig 4: The longer-chain stain Fig 5: The peroxide breaks Fig 6: oxygen ions attack the
molecules are now too big to down into water molecules double bonds of the long-
exit through the semi- and oxygen ions. chain stain molecules.
permeable membrane and
remain trapped in the tooth,
causing the teeth to look
yellower and darker.

Fig 7: short period of time, most of the stain has left the tooth
structures.

18
The shade rebounding due to the reformation of double bonds. In addition to the
chemical effect, other possible mechanisms include

• cleansing of tooth surface,

• Temporary dehydration of enamel during the bleaching process,

• Change of enamel surface.

COMPOSITION OF COMMERCIAL BLEACHING

AGENTS
The commercial bleaching agent consist of both active and inactive ingredients. The
active ingredient includes hydrogen peroxide or carbamide peroxide compounds. The
major inactive ingredients are:

1. Thickening agents

2. Carrier

3. Surfactant and pigment dispersant

4. Preservatives

5. Flavorings

6. Additives

1. Thickening agents

 Carbopol (carboxypolymethylene) is a high molecular weight polyacrylic

acid polymer which increases the viscosity and causes a slow release of
active oxygen from HP.
 Polyx: another thickening agent

2. Carrier

a. Glycerin: enhances viscosity and eases manipulation which has a disadvantage

of dehydration leading to loss of translucency and sore throat on swallowing

19
 b. Propylene glycol: maintaining moisture and dissolving other ingredients

3. Surfactant and pigment dispersant

 Increases the effectiveness of bleaching.

 allows the diffusion of HP across the gel and tooth boundary
 pigment dispersant holds the pigments within the gel in suspension

4. Preservatives
The preservatives used are:
a. Sodium benzoate
b.methyl propyl paraben
 Enhance the durability and stability of the gels
 Prevent bacterial growth within the gels.
 Have mildly acidic pH.

5. Flavorings
• increase the patient’s acceptance by improving the taste.
• For example, banana, melon, peppermint, spearmint, wintergreen, sassafras,
anise, and sweetener such as saccharine

6. Additives
To escalate the bleaching procedure and/or minimize its side effects,
various additives are incorporated:
a. Potassium nitrate

It is superior in comparison to other additives. It decreases the postoperative

sensitivity by halting the nerve from repolarizing after it has depolarized in the
pain cycle.

b. Fluoride

It increases the microhardness of the substrate enamel and result in lesser

demineralization without altering bleaching efficiency. It also maintains micro
tensile bond strength, assisting subsequent restorative procedures and
decreases sensitivity.

20
 c. Amorphous calcium phosphate - casein phosphopeptide

It reduces sensitivity by remineralization and enhances the bleaching outcome.

It also enhances the lustrous shine to the teeth. Patients using ACP-CPP gel
had lesser bleaching effect compared to those using potassium nitrate-modified
gel with similar reduction in sensitivity.

CLINICAL TECHNIQUES

Intracoroanal Bleaching

• Walking Bleach

• Thermocatalytic Bleaching

• Ultraviolet Photo-oxidation

• Inside/outside bleaching

Extracoronal bleaching

• In-office Extracoronal Bleaching

• Power bleaching

• Laser bleaching

• Focal bleaching technique

• At-home bleaching

1. Power Matrix Bleaching.

2. Dentist Monitoring of Completely Home-Based Bleaching

3. Home Bleaching without Dental Supervision (OTC Systems)

21
 INTRACORONAL BLEACHING OF
ENDODONTICALLY TREATED TEETH

It is successfully carried out in tooth with root canal therapy and discoloration. A
successful outcome depends mainly on etiology, correct diagnosis and proper selection
of bleaching technique.

Indications

1. Discoloration of pulp chamber

2. Dentin discoloration

3. Discoloration not amneable to extracoronal bleaching

Contraindication

1. Superficial enamel discolorations

2. Defective enamel formation

3. Severe dentin loss

4. Cracks and hypoplastic or severely undermined enamel.

5. Presence of caries

6. Discolored composites

7. Discoloration by metallic salts, particularly silver amalgam

Walking Bleach

The term “walking bleach” was first coined by Nutting and Poe in
1961. This technique is also known as Out-of-Office Bleaching
Technique. It refers to the bleaching action occurring between

22
patients’ visits. This technique should be attempted first in all cases requiring
intracoronal bleaching.

Walking Bleach Clinical Protocol

1. Evaluation of etiology and origin of stain

2. endodontic status of the tooth must be assessed clinically and radiographically

3. Checked for quality and shade of existing coronal restorations

4. Clinical photographs should be taken at the beginning, throughout, and at the

end of the treatment with the tooth next to a shade guide

5. Rubber dam isolation is mandatory.

6. Access cavity prepared: restorative filling materials, root-filling material and

sealer remnants, and necrotic pulp tissues remnants are completely removed.

7. Materials should be removed to a level just below the labial gingival margin

8. A protective layer of at least a 2-mm thickness should be placed over the root-
filling material. To avoid further pigmentation the protective layer should be
white or tooth colored. E.g. glass-ionomer cements, intermediate restorative
material (IRM), Cavit and Coltosol, resin composites, photoactivated temporary
resin materials such as Fermit, zinc oxide–eugenol cements, polycarboxylate
cements, and zinc phosphate cements

9. Sodium perborate is mixed with inert liquid such as distilled water to a wet sand
consistency.

23
 10. Plastic instrument or amalgam carrier can be used to place material in pulp
chamber

11. Excessive bleaching material removed and

12. carefully dapped with a cotton pellet

13. Temporary filling material of 3 mm thick with well-sealing margins placed

14. patient should recalled in 3 to 10 days

Spasser H.F. and Holmstrup G., et al., pioneered the combination of sodium perborate
and water. Nutting E.B. and Poe G.S. modified the technique by combination of sodium

24
perborate mixed with hydrogen peroxide. If no improvement after 3-4 attempts,
diagnosis and treatment plan should be reevaluated for a different etiology. A
permanent adhesive restoration should be placed about 1 to 3 weeks after the last
appointment. Schedule for yearly follow-ups to include a clinical examination and
periapical radiographs. Rotstein, et al. (1991) and Ari and Üngör (2002) verified that
no statistically significant difference in the esthetic results was found when the three
types of sodium perborate were used with water or 30% hydrogen peroxide in
intracoronal bleaching of pulpless teeth. Bizhang, et al. (2003) demonstrated in vitro
that sodium perborate mixed hydrogen peroxide was more effective than sodium
perborate mixed with water.

Thermocatalytic Bleaching

It is an In-Office Non-vital Bleaching Technique which

involves placement of 30% to 35% Hydrogen peroxide into
pulp chamber followed by heat application either by electric
heating devices or specially designed lamps. Heat application
creates foaming of the hydrogen peroxide, with a subsequent
release of free radical oxygen. This procedure is repeated in
three to four office visits. Intermittent treatment with cooling
breaks is preferred over a continuous session. Great care
needs to be taken to avoid overheating of teeth, periodontal
ligament, and gingival tissues. Vaseline, Orabase, or cocoa
butter gives additional thermal insulation. Due to the increased risk of cervical root
resorption, walking bleach technique is seen as more favorable today. Patient must be
informed about the risks and potential long-term consequences.

Technique

1. Fill the pulp chamber loosely with cotton fibers

2. Cover the labial surface with a few strands of cotton fibers in order to hold the
bleaching solution

25
 3. Place 35% H2O2 into the preparation with a syringe fitted with a stainless steel
needle
4. Expose the tooth to heat using either a modified photoflood lamp or a special
bleaching tool
5. After 5 minutes of heat and light exposure, remove the cotton and dry the
chamber.
6. Once again, repeat the above procedure until desire result obtained

Ultraviolet Photo-oxidation

This technique applies ultraviolet light to the labial surface of the tooth to be bleached.
A 30% to 35% H2O2 solution is placed in the pulp chamber on a cotton pellet and it is
exposed to ultraviolet light for 2-minute. This causes oxygen release, like the
thermocatalytic bleaching technique.

THE INSIDE/OUTSIDE BLEACHING TECHNIQUE

This technique was described in the American literature by Settembrini et al. in 1997
which is a modification of the technique that was later described by Liebenberg.
Bleaching gel is placed on the internal and external aspects of the discolored root-filled
tooth. Access cavity is left open during treatment so that the 10% carbamide peroxide
can be regularly changed. A custom-made bleaching tray keeps the bleaching agent in
and around the tooth.

Bleaching Tray fabrication

Take an alginate impression and construct an appropriate bleaching tray. Design the
tray so that there are palatal and labial reservoirs for the target tooth, and so that the
tray over the adjacent teeth is cut back to avoid the placement of the bleaching gel onto
the unaffected teeth. Check the bleaching tray for comfort and fit.

26
Endodontic Preparation

The access cavity restoration is removed. The coronal

aspect of the gutta-percha root filling is removed to 2–3 mm
below the cemento-enamel junction. A protective barrier ia
placed over the root filling i.e. glass ionomer cement, zinc
phosphate or zinc polycarboxylate.

Patient Instructions

Insert tip of bleaching syringe into access cavity and fill it with 10% carbamide
peroxide. Load appropriate reservoir within tray with a pea-sized amount of 10%
carbamide peroxide. Insert tray over the teeth and remove excess gel as necessary with

a tissue or soft toothbrush and rinse gently and do not swallow.

Bleaching Protocol

The gel should be changed inside the tooth and within tray every two hours. The tray
containing the gel should be worn overnight. After bleaching, patient should clean
access cavities out with a toothbrush or single-tufted brush. Unlike vital bleaching,
there is no limit to how many times the material can be changed as the patient is highly
unlikely to experience sensitivity. The bleaching procedure ceased when he/she is

27
happy with degree of lightening. The patient should be reviewed at 2–3 days to reassess
the degree of lightening.

PERMANENT RESTORATION OF TEETH FOLLOWING

INTERNAL BLEACHING

The cotton or bleaching paste should be remove and the preparation should be swabbed
throughout with acetone or xylol. The bleached crown should be air dried internally
and throughout to penetrate and seal the dentinal tubules and to maintain the tooth’s
translucency. Several coats of a clear dentin bonding agent should be used to prevent
recurrent coronal stain. The marginal walls should be etched with 35% phosphoric acid
to assure good mechanical bonding. A dental bonding agent should be applied and
cured before filling the cavity with composite resin restorative materials of the lightest
shade esthetically compatible with the tooth.

COMPLICATIONS AND ADVERSE EFFECTS FROM

INTRACORONAL BLEACHING

1. Cervical Root Resorption

It is caused by the highly concentrated oxidizing agent,

particularly 30 to 35% H2O2. The irritating chemical
diffuses via unprotected dentinal tubules and cementum
defects leads to necrosis of the cementum, inflammation of
the periodontal ligament and root resorption. This effect is
enhanced if heat is applied or in the presence of bacteria. It
is seen in 6% to 8% and 18% to 25% if heat activated. Previous traumatic injury and
age may act as predisposing factors.

The mechanism of resorption is pro-inflammatory agents activates reduced

nicotinamide adenine dinucleotide phosphate oxidase which produces superoxides that
react with hydrogen peroxide in the presence of inflammation. There is formation of

28
hypochlorous acid, N-chloramines, and reactive hydroxyl ions and leads to resorptive
process.

Hydrogen peroxide may reach the bone by diffusion via dentinal tubules, cementum,
and the periodontal ligament. Within the bone, low pH value of hydrogen peroxide at
high concentrations may facilitate osteoclastic activity. Natural defect at the CEJ,
cementum defects and unusual morphology at the CEJ, can favor the penetration of
hydrogen peroxide into the cervical area of a tooth. Free oxygen radicals break down
constituents of connective tissue (collagen and hyaluronic acid), periodontal tissue
destruction and root resorptions. Heat activation caused widening of the dentinal
tubules leads to diffusion of free radicals into the dentin and enhancement of resorptive
processes. It can be minimized by using sodium perborate with water instead of
hydrogen peroxide for internal bleaching techniques.

2. Chemical Burns

30% H2O2 hydrogen peroxide is highly caustic and causes chemical burns and
sloughing of the gingiva. When using such solutions, the soft tissues should always be
protected with Vaseline, Orabase, or cocoa butter.

3. Enamel and dentin damage

Number of in vitro studies reported changes in enamel microhardness and morphology,

as well as in the cementum. Peroxide components alter the proportions of organic to
inorganic hard tissue components bleached. Enamel surface shows increased porosity
and slight erosion when observed under SEM. Study by Zanolla et. al. on influence of
tooth bleaching on dental enamel microhardness showed that enamel microhardness
does not decrease after application of 10% carbamide peroxide gel for 6-8 hrs per day
over a period of 7, 14 or 21 days.

4. Inhibition on Resin Polymerization and Bonding Strength

Adhesive bond strength between glass-ionomer cements and composite resins to dentin
and enamel is temporarily compromised. It is due to remnants of peroxide or free
oxygen, which inhibit resin polymerization. Loss of enamel calcium and phosphorus
content and morphological alterations of the majority of the crystals of the surface

29
layer. Optimal bonding to bleached dentin and enamel was shown to be reestablished
after 3 weeks. Several remediation techniques have been suggested including

• dehydrating agents such as 80% alcohol

• Acetone-containing adhesives,

• Application of sodium hypochlorite

• Catalases

• Sodium ascorbate

• Alpha-tocopherol

• Calcium hydroxide medication

EXTRACORONAL BLEACHING

It may be used for whitening vital or nonvital teeth as well as a single tooth or whole
arch. Various techniques exist i.e. in-office and at-home methods. Dramatic
advancement in materials as well as techniques after at-home extracoronal bleaching
was first introduced. Research efforts and clinical advancements have also
revolutionized the in-office extracoronal bleaching technology.

Contraindications to Bleaching of Vital Teeth Using In-Office Techniques

1. Extremely large pulps, which may increase sensitivity.

2. Other causes of hypersensitivity: exposed root surfaces or the transient hyperemia
associated with orthodontic tooth movement.
3. Severe loss of enamel.
4. Teeth exhibiting gross or microscopic enamel cracking.
5. Extremely dark teeth, especially those with banding.
6. Teeth with white or opaque spots.

30
7. Teeth in which there are restorations that must be matched or, especially, teeth that
have been bonded or laminated.
8. Extensive restorations.
Koa et al. suggest strongly that bleaching materials never come in contact with
restorative materials
9. Patients who are perfectionists

Sequence of Treatment

1. Soft tissue management (prophylaxis).

2. Bleaching teeth.

3. Re-evaluation/restorative considerations.

4. Restorative treatment

In-office Extracoronal Bleaching

In-office or chair-side techniques are completely in the hand of the dental professional.
Almost all techniques involve the application of hydrogen peroxide gels of
concentrations between 25% and 38%. Liquid solutions at higher concentrations are
associated with higher complication rates of soft tissue damage. High concentrations of
hydrogen peroxide solutions are thermodynamically unstable and may explode if not
stored in dark bottles in a refrigerator.
Clinical Technique

1. Position complete eye protection on the patient and all operators.

2. Record the pretreatment shade.
3. Clean the teeth with flour of pumice in a prophylaxis cup
4. Place “liquid rubber dam” over the gingiva and polymerize with a curing light
according to the manufacturer’s instruction
5. Apply bleaching agent for the time and duration as specified in the
manufacturer’s instructions.

31
 6. After the appropriate bleaching time remove the gel with copious amounts of
water and suction
7. Repeat the procedure according to the manufacturer’s instructions if required.
8. When the procedure is complete, carefully remove the liquid dam and cheek
retractors

The pretreatment shade is recorded, The teeth are cleaned using flour of pumice, Petroleum jelly is applied to the lips.

A “liquid rubber dam” is placed over the exposed gingiva, The “liquid rubber dam” is polymerized with a curing light,
Bleaching agent is applied according to manufacturer’s instructions.

Copious amounts of water and suction is used to remove bleaching gel,

Postbleaching results following a single treatment.

Power Bleaching

Power bleaching refers to accelerated vital in-office tooth whitening procedures that
employ either xenon plasma arc-curing lights or lasers. For a delegated procedure,

32
liquid rubber dam is often applied in lieu of a sheet of rubber dam, which would require
active retention techniques, such as wedges, floss, or ligatures. Liquid rubber dam can
be applied easier without assistance, but it does not give additional protection to
gingival tissues or the mucosa.

Power Bleaching Clinical Protocol

1.Diagnosis must confirm that the discolorations can be resolved by external bleaching
2.Hygiene appointment prior to the bleaching session
3.Clinical photographs should be taken at beginning, throughout, and at the end of the
treatment
4.Wear proper protective eyewear
5.Teeth should be cleaned again with rubber cups and pumice.
6.The cheeks should be retracted with retractors or cotton rolls
7.Rubber dam isolation is mandatory.
8.This can be either liquid rubber dam or sheet rubber dam
9.Power bleach gel is mixed according to the manufacturer’s recommendation
10. Applied on the labial surfaces of the teeth in a 2- to 3-mm thickness
11. Each individual tooth is exposed for up to three passes for 3 to 10 s
12. The gel may stay on the teeth for another 3 to 5 minutes with light activation.
13. Gel is removed with a wet gauze and copious amounts of water
14. Teeth should be polished and a neutral pH sodium fluoride gel applied
15. The patient should be instructed that increased sensitivity of the teeth may be
present for 2 to 3 days and refrain from tobacco, coffee, tea, cola, and wine for a
period of 2 weeks.

33
 pretreatment shade is recorded,, The teeth are cleaned with flour pumice, Place the LiquidDam material.

isolate the area, The bleach is placed, The bleach is activated with the light

The bleaching agent is carefully removed with copious amount of water, Posttreatment
images The shade of the maxillary teeth serves a comparative

Bleaching Light

Light sources used for bleaching include conventional ultraviolet (UV) bleaching
lights, tungsten-halogen and Xe-halogen lights, plasma arc lamps, light-emitting diodes
(LED), or laser lights. These lights are offered in various forms i.e. freestanding, chair
mounted, or handheld; small, medium, or large; and of general or limited-range
wavelengths. The bleaching light has two possible modes of action:

 One is the stimulation of a photo-activating substance within the bleach

.i.e. photo-reactive catalyzes treatment to proceed more rapidly and
more effectively during light stimulation

34
  The other is a temperature increase that catalyzes a faster bleaching
reaction.

Baroudi and Hassan studied the effect of light on bleaching. The in-office bleaching
treatment of vital teeth did not show improvement with the use of light activator sources
for the purpose of accelerating the process of the bleaching gel and achieving better
results. (Nigerian Medical Journal; 2014)

A systematic review and meta-analysis on the effects of light on bleaching and tooth
sensitivity during in-office vital bleaching concluded that light may not improve
bleaching efficacy when high concentrations of hydrogen peroxide (25–35%) are
employed during in-office bleaching. Because the light-activated system increases the
risk of tooth sensitivity, dentists should use this system with great caution or avoid its
use altogether (journal of dentistry)

Laser bleaching

Laser bleaching was introduced in the mid1990s as an attempt to improve and

accelerate the bleaching process.

Types of Lasers

Many lasers have dental applications, including

• Diode,

• Carbon dioxide,

• Argon,

• Neodymium-doped: yttrium-aluminum-garnet (Nd: YAG),

• Erbium, chromium: yttrium-scandium-gallium-garnet (ErCr: YSGG) lasers

35
Diode laser
It is a solid active medium laser with wavelengths about 800 nm to 980 nm. It is highly
absorbed by pigmented tissue and are deeply penetrating, although hemostasis is not
rapid. It is relatively poorly absorbed by tooth structure.

Role of Lasers in the Bleaching Process

a. Enhance the efficiency of bleaching materials.

b. Catalyzes the oxidation reaction by providing additional energy for the more
rapid breakdown of hydrogen peroxide into its components
c. Serves to increase and speed the release of the oxygen ions into the stained tooth
surface.
d. laser energy heats the bleaching solution far more quickly and efficiently than
conventional heat sources

Advantages of Laser Bleaching

a. Work more quickly owing to a higher concentration of the active bleaching
ingredient or a more defined and localized release of the active oxygen ions in close
proximity to the tooth surface.
b. often used to jump-start more difficult cases such as tetracycline staining and
fluorosis

Disadvantages of Laser Bleaching

1. Equipment cost: lasers are expensive.
2. Chair side cost: the procedure, like all in-office bleaching treatment, is time-
consuming.
3. Postoperative sensitivity can be significant

36
Laser Bleaching Procedure

Patient is first assessed, teeth are isolated with a protective mucous membrane seal to protect the
gingiva, and the gel is placed in a 1- to 2-mm thickness on the buccal surface of the teeth to be
bleached.

The 488-nm argon laser light is applied for 30 seconds about 1 to 2 cm from the buccal surface
of each tooth, The teeth are then washed and rinsed and the bleach is re-applied up to five
more times in a single appointment, post-operative image

The teeth are then washed and rinsed and the bleach is re-applied up to five more times in a
single appointment. Postoperative photographs

Focal Bleaching Technique (FBT)

This technique in designed to reduce biological hazard of bleaching gel on dental tissue.
It is considered as direct application of minimal invasive dentistry concept on
bleaching. Drawing a bleaching map is a crucial step in FBT. It is drawn for each tooth
prior to bleaching, demarcating deeply, moderately and intermediately stained as well
as sound tooth region. FBT expands the bleaching from conventional process of shade
lightening to systemic balancing of color between the stained and normal tooth region

37
FBT PROTOCOL

A raw photograph is taken for drawing bleaching map

a= deeply stained;

b= moderately stained;

c= intermediately stained;

d=normal tooth area

Tissue protection measures: rubber dam,light cured- resin based gingival protector

Multistep bleaching process:

1. Start from region a: apply bleaching gel 3 times

successively for 20 mins per application
2. region b was treated twice
3. Region c just once
4. No application on region d

Preoperative view of a case of A marked reduction of the stain

opaque fluorosis combined with
brown discoloration treated with
the “power focal in-office vital
bleaching” protocol.
Postoperative view of the treated
can be observed on the deeply
case. The hand pointer shows a
and moderately stained regions
bleaching-persistent area
following the first step of the
treatment, in comparison with the
baseline stain

Advantages

• Marked reduction in demarcation between treated and sound region of the tooth

• decreases biological, histological and mechanical adverse effect on tooth substrate

• Decreases quantity of bleaching agent

• Reduces hazards of enamel cracking and infarction

38
In-Office Tooth Whitening to Remove White or Dark
Mottling
The occurrence of both white and brown mottling presents the greatest de-staining
challenge to the dentist. The spots may result from:

• Malformation,

• Developmental discoloration,

• Excessive consumption of fluoride during enamel formation,

• Secondary to orthodontics,

• Poor oral hygiene

• Post-orthodontic patients

Material:

1. Opalusture bleaching

• 6.6%HCL

• Silicon carbide micro-particles

c. Opalcup: prophy cup with bristle brush

39
post-orthodontic patient with residual adhesive material that has stained, All maxillary and mandibular anterior teeth are
treated with Opalustre.

teeth are polished with the custom-designed OpalCup. This is a prophy cup with bristle brushes in the polishing
concavity, The teeth are rinsed

After four in-office treatments, final post-treatment photographs

At-Home External Bleaching

It is the patient self-application of bleaching agents performed at home. It is
alternately referred to as “home bleaching” or “matrix bleaching. There are three
basic forms of matrix bleaching, involving different levels of dentist participation and
supervision:

1. Power Matrix Bleaching.

2. Dentist Monitoring of Completely Home-Based Bleaching

3. Home Bleaching without Dental Supervision (OTC Systems)

40
 Power Matrix Bleaching

It is a dentist-monitored night guard vital bleaching combined with in-office bleaching.

Stronger bleaching solutions with a heat/light device to speed the chemical reaction,
and a sequence of matrix treatments controlled by the patient provides the most
effective result seen to date.

Indications for Power Matrix Bleaching of Vital Teeth

1. Yellowed or discolored teeth in First degree and moderate Second degree.

2. Moderate yellow and/or brown tetracycline stains, intrinsic stains

3. Patients who are not candidates for in-office bleaching because of hypersensitive
teeth, time restrictions, financial considerations, or psychological objection to rubber
dam placement.

Contraindications for Power/Home Bleaching of Vital Teeth

1. Extremely hypersensitive

2. Allergic reactions

3. Lack of compliance

4. Severe discoloration

5. Teeth with extensive restorations

Clinical Technique

Tray fabrication
1. Pour the impression of the arch with fast-set plaster or dental stone.
Irreversible hydrocolloid must be poured shortly after making the
impression to ensure accuracy.
2. Trim the base of the cast parallel to the occlusal table on a model trimmer
to within a few millimeters of the gingival margins. The palate and tongue
areas are removed.

41
3. apply approximately 0.5-mm thickness of block-out material to the desired
labial surfaces to provide reservoir spaces in the tray as follows:
i. Approximately 1.5 mm from the gingival line
ii. Do not extend onto the incisal edges and occlusal surfaces
4. Heat the tray material on the vacuum former unit until it sags approximately
21⁄2 inches. Activate the vacuum and adapt the softened tray material over
the cast. Cool and remove the cast.

5. Trim the tray material carefully and precisely 0.25 to 0.33 mm occlusal from
the gingival margin with small tactile scissors. Scallop around the
interdental papilla
6. Place the tray on the cast and check the tray extensions. Gently flame polish
the edges one quadrant at a time with the torch

The base of the cast is trimmed parallel to the occlusal table to within a few millimeters of
the gingival margins. The palate and tongue areas are removed, Spacing for reservoirs is
created on the cast

The tray material is heated on a vacuum former unit, The tray material is trimmed.

The tray is flamed to facilitate adaptation to the cast.

42
Bleaching technique

a. Place a drop of solution in the appropriate space around each tooth

corresponding to the areas to be lightened
b. most common regimen is between 1 to 4 hours daily use from 4 weeks to 6
months
c. Some companies recommend wearing the matrix up to 20 hours per day with
the bleaching gel changed every 2 to 4 hour
d. Both H2O2 and carbamide peroxide are used as active ingredients for
professional at-home bleaching products
e. mostly containing 3% to 7.5% H2O2 or 10 to 22% carbamide peroxide
f. several companies manufacture a three-tier bleaching approach:
i. beginning with a 5 or 6% solution
ii. followed a week or so later with a solution percentage increased to 10
or 12%,
iii. finally to a 15 to 17% solution
g. more viscous solutions work best

Advantages

1. Little or none of the usual degradation of the lightening effect

2. Multiple appointments are lowered

3. Minimal exposure of the tissue to the bleaching agent

Dentist Monitoring of Completely Home-Based Bleaching

Certain patients prefer for the home treatment as an entity unto itself. Patient seek for
professional diagnosis and monitoring but wants to avoid as much as possible the costs
or the prolonged chair time. In providing a patient completely home-based bleaching,
one should focus on important features:

1. Diagnosis and evaluation of the appropriateness of bleaching

43
 2. That there are no contraindications to the use of bleaching

3. Precise fitting of a matrix to minimize exposure of tissue to the bleaching

agent

4. Monitoring of the potential adverse changes in soft tissues, teeth, and

restorations.

Home Bleaching without Dental Supervision (OTC Systems)

Many home bleaching products are available over the counter or through mail order,
internet, and television advertisements. Since, dentist often has little knowledge of the
composition of these products, their use, overuse, and abuse are a concern. The patient
should be informed about the risks.

Crest Whitestrips

5.3% hydrogen peroxide-coated polyethylene strip was

recently introduced to the market. The patient applies two
strips per day for 30 minutes each. A similar 6.5% hydrogen
peroxide coated strip is available by prescription.

44
 Higher successful bleaching is observed in younger patients due to the wider open
dentinal tubuli when compared to older patients. Gray or light yellow discolorations
may be easier to bleach than other discolorations. Well-sealing composite restorations
are recommended to prevent renewed discoloration. External bleaching may show
color regressions after 1 to 3 years.

Commercially available Bleaching Material

Power

1. Zoom! Discus

2a. Opalescence Xtra Boost

2b. Opalescence Xtra

1. Niveous Shofu

Assisted

1a. Opalescence Quick

1b. White Speed

2. Polazing SDI

Home

1. Opalescence/Opalescence PF

2a. Day White Excel 3

2b. Nite White Excel 3 Turbo

2c. Zoom Take Home

3. Nupro White Gol

4a.Poladay SDI

4b. treswhite

45
Zoom

The composition of Bleach is 25% hydrogen peroxide

gel and has pH of 8.9. It is activated by ultraviolet light
unit. The recommended total bleaching time is 60
minutes. Soft Tissue Protection is done using
Liquidam.

Consistency and Handling

Mixing tip automatically incorporates the ingredients

in the dual-barrel syringe to produce a viscosity just
enough flow to apply easily to teeth, but is not runny.
Coat lips with protective lip cream and remove the
syringe from the refrigerator at least six hours before use or preferably the previous
evening. Place the retractor and activate the light which requires 3 min warm-up cycle
before the actual whitening cycle can begin. Apply the bleaching agent over the tooth
surface. The unit will beep once as the timer approaches the final three seconds of the
three minute warm-up cycle.

Zoom! Take-Home

Its composition includes 4% and 6% hydrogen

peroxide with or without potassium nitrate.

Consistency and Handling

It is very thick, easy and precise dispensing into

tray with pH: 6.5-6.6 and mint flavor.

46
APPLICATION INSTRUCTIONS

• Brush and floss your teeth

• Twist the mixing cap clockwise to lock on the

end of the syringe

• Place a small amount of gel in each tooth compartment of the tray

• Zoom NiteWhite — Optimal results within one week

• 10%, 16% (CP) overnight or four to six hours

• 22% (CP) one to two hours nightly

• Zoom DayWhite — Optimal results within two weeks

• 9.5% (HP) 30 minutes, twice daily

• 14% (HP) 15 minutes, twice daily

Opalescence Xtra Boost

• Composition of Bleach: 38% hydrogen peroxide

gel

• Activation Unit/Mode:

 Chemical activation.
 The syringe of regular Opalescence
Xtra is “boosted” by mixing with a proprietary chemical activator.
 This mixing is done by linking the two syringes via a Luer-lock-type of
connection.

• Recommended Total Bleaching Time: 60-90 minutes

• pH: 7.6

•Soft Tissue Protection: OpalDam. White, light-cured resin

47
•Consistency and Handling: Viscosity has just enough flow to apply easily to teeth

•Use

i. After mixing, apply the material directly from the syringe for 10- 15 minutes
agitating the mixture every five minutes.
ii. At the end, suction the excess with a surgical aspirator tip.
iii. Do not rinse.
iv. Then re-apply up to five more times in 10-15 minute intervals for a maximum
total of six applications.

Opalescence/Opalescence PF

• Composition:

Opalescence: 10% carbamide peroxide.

Opalescence PF: 10%, 15%, and 20%carbamide

peroxide, 0.11% fluoride ion, and 3% potassium
nitrate

•Consistency and Handling: Very thick, sticky viscosity, helps to keep gel in contact
with the teeth

• pH: 6.3-6.6

• Flavors: Three: regular, mint, and melon

Method of application

48
• Opalescence 10%: 8–10 hours or overnight

• Opalescence 15%: 4–6 hours

• Opalescence 20%: 2–4 hours

• Opalescence Quick PF 45%: 15-30 minutes

polaoffice+

•Composition: 37.5% hydrogen peroxide

•pH : 6.5-8

•Technique

i. Clean teeth with a flour based pumice.

ii. Place cheek retractors and then cover exposed lip
surface with petroleum gel.
iii. Dry teeth and apply Gingival Barrier to both arches, slightly overlapping
enamel and interproximal spaces.
iv. Light cure in a fanning motion for 10-20 seconds
v. Dispense a small amount of gel on to a mixing pad until a uniform gel is extruded.
vi. Directly apply a thin layer of gel to all teeth undergoing treatment.
vii. Leave gel on for 8 minutes
viii. Suction off using an aspirator tip.
ix. Repeat the above steps 4 times
x. After the last application, suction and wash the gel off.

Poladay and Polanight

• Composition of poladay
• 3%, 7.5%, and 9.5% Hydrogen peroxide.
• Fluoride,
• Proprietary desensitizing agent,
• Chitosan

49
 Composition of polanight

 10.0-22.0% wt Carbamide peroxide

 < 40% wt Additives
 30% wt Glycerol
 20% wt Water
 0.1% wt Flavour

• Consistency and Handling: Very thick, sticky viscosity, helps to keep gel in contact
with the teeth.

• pH: 6.0-6.4

• Flavors: spearmint

Placement Procedure:

1. Place a small drop of gel into every compartment of the tray for the teeth
undergoing treatment.
2. Seat the tray, with the gel around the teeth.
3. Wipe away excess gel in mouth with a tissue or dry soft brush.
4. After treatment, remove tray. Rinse tray and mouth with lukewarm water.
5. Brush teeth.

50
 Risks Associated with External Tooth Bleaching

1. Tooth Sensitivity

The presence of hypersensitivity is an indication of inflammatory changes in the

dental pulp. It is reported in up to 50% of the teeth. It is mild to moderate and is
transient over a period of 2-3 days. Hydrogen peroxide may reach pulp chamber via
craze lines, enamel defects, as well as enamel and dentin cracks. Bleaching gels
containing 12% carbamide peroxide, > 30 μg of hydrogen peroxide were shown to
reach pulp chamber after tray applications for up to 7 hours. In at-home bleaching,
hypersensitivity increases with the frequency of changing the bleaching trays.
Glycerine causes dehydration of tooth structure during bleaching treatment and can
also result in tooth sensitivity. For the best immediate remediation, the bleaching
periods should be shortened. Both topical fluoridation and desensitizing toothpaste
may aid in reducing the hypersensitivity after bleaching. Desensitizers can be used
in addition to the bleaching gel. Active bleaching should be avoided whenever
restorations with ill-adapting margins or exposed dentin areas are present.

2. Gingival Irritation

It is the most commonly observed adverse effect. It occurs mild to moderate and
disappear after 2 to 3 days without causing significant discomfort for the patient.
For in-office bleaching, related to soft tissue exposures to excessive bleaching gel
or liquid hydrogen peroxide in amounts less than necessary to cause severe
discomfort or tissue damage. However, the warning signs is patient’s sensation and
air bubbles rising from the gingival margins.

Treatment:

The area should be copiously rinsed without delay. A vitamin E preparation

emergency dressing is applied that will provide an immediate anti-oxidative effect.
Topical anesthesia, limited movement, and good oral hygiene can increase the speed
of soft tissue healing. If at-home technique, gingival irritations related to badly
adapting trays.

51
 3. Enamel Damage

Several investigators reported alteration of enamel surfaces associated with bleaching

treatments, including:

•Increased porosity of the superficial enamel structure,

•Demineralization and decreased protein concentration,

•Organic matrix degradation,

•Modification in the calcium: phosphate ratio

• Calcium loss

The observed alterations of enamel surface varied among different products. They were
associated with products using acidic pre-rinse or gels of low pH. A 6-month clinical
study showed that long-term use of a bleaching gel containing 10% carbamide peroxide
did not adversely affect the surface morphology of human enamel. No clinical evidence
of adverse effects of the dentist-monitored at-home whiteners on enamel has been
reported. Haywood et al. (1990) reported no morphological changes in the enamel
surface after the application of 10% carbamide peroxide bleaching. Hegedus et al.
(1999) observed changes in the enamel surface after 28 h of bleaching with 10%
carbamide peroxide and 30% hydrogen peroxide, and found that the sample’s surface
became more irregular and surface grooves became deeper after bleaching treatment.
Sun et al. (2011) investigated the effects of acidic and neutral 30% hydrogen peroxide
on human tooth enamel in terms of chemical structure, mechanical properties, surface
morphology, and tooth color and concluded that neutral 30% hydrogen peroxide had
the same efficiency in tooth bleaching and caused less deleterious effects on enamel
than did the acidic 30% hydrogen peroxide (Journal of dentistry – 2011)

4. Effects of tooth bleaching on tooth restorations

Bleaching increase the solubility of glass-ionomer and other cements. It reduces the
bond strength between enamel and resin-based fillings in the first 24 hours. Hydrogen
peroxide residues in the enamel may inhibit polymerization of resin-based materials
and reduce bond strength. Thus tooth-bleaching agents should not be used prior to
treatment with resin-based materials.

52
Topcu, et al.: studied the influence of bleaching regimen and time elapsed on
microtensile bond strength of resin composite to enamel and concluded that immediate
and after 1-week of bonding of composite to bleached enamel compromises µTBS
irrespective of the type or concentration of the bleaching system used. It is advisable
that composite restorations on bleached enamel surfaces be performed after an interval
of at least 2 weeks, regardless of the concentration of bleaching agent used
(Contemporary Clinical Dentistry- 2017)

5. Mercury Release from Amalgam Restorations

Several studies have reported an increased mercury release from amalgam restorations
after the application of bleaching agents. Al-Salehi et al found no significant change in
the release of metal ions from bleached amalgam (10% CP for 24 hours). Because the
release of mercury, silver, copper and tin from the dental amalgams did not exceed the
limits defined by the World Health Organization, the authors concluded that bleaching
teeth with amalgam restorations is not a health hazard.

COMBINED BLEACHING
When combining bleaching with restorative dentistry, estimate the number of bleaching
treatments in the office or at home before an acceptable result will be affected in order
to calculate how long afterwards the restorative treatment could begin. Generally, this
occurs 2 to 3 weeks after the last bleaching treatment. For in-office bleaching alone,
this is about 2 weeks but if at-home treatments are included, then add an additional 4
weeks. Eight weeks from the onset of this combined bleaching approach is usual. Some
patients are happy with the bleaching regimen alone but others will desire bond ing or
laminates as the total treatment.

Bleaching Combined with Crowning

When crowns are anticipated but adjacent teeth are to be corrected with bleaching, wait
at least 2 to 3 weeks before taking the shade for the final crowns. In the event if shade
is to be taken prior to seeing the final bleaching result, choose a lighter shade.

53
Additional matrix or in-office bleaching may be necessary from year to year or after
several years.

Bleaching Combined with Orthodontics

It is generally preferred to bleach teeth before orthodontia

is initiated. If ceramic or metal brackets will be bonded to
the teeth because the bonding impregnates the enamel and
thus makes it more difficult to bleach. However, it is
acceptable to straighten the teeth first, remove the brackets, and clean the teeth of all
bonding materials before bleaching. If bleaching is to be
done after orthodontic treatment, a Prophy-Jet should be
used, then mild etching before the first bleaching
treatment. When a removable orthodontic positioner is
being used, bleaching solution can be added to one or both
arches in the clear orthodontic positioner. A breathing space can also be created in the
splint between the arches

Bleaching Combined with Periodontics

If patients has soft tissue problems, it should be treated first to control and reverse the
inflammation before bleaching is attempted. If advanced bone loss is present and
surgery required, perform an in-office power bleach under rubber dam before
periodontal therapy is undertaken easier for the tissue to hold the dam in place at the
CE junction. If root exposure present, mask those areas with artificial dam material and
seal the defects with composite resin.

Bleaching Combined with Bonding

Patients who have any leaking or defective restoration should be replaced prior to in-
office power bleaching. For partial veneer, match the final shade several weeks after
the last bleaching treatment. An alternative plan is to etch the defective margins and
seal the defects with composite resin to prevent leakage of the concentrated bleaching
solution.

54
 Prognosis of Bleaching

Thermocatalytic bleaching reported an 80% success rate after 1 year and a 45% success
rate after 6 years. Discolorations due to by trauma or pulp necrosis showed good
prognosis of around 95%. Discolorations due to medications or restoration had less
successful outcome. Discoloration caused by restorative materials has an uncertain
prognosis, particularly if metallic ions such as silver, mercury, copper, or iodine are
involved.

Conclusion

The colour of the teeth is influenced by a combination of their intrinsic colour and the
presence of any extrinsic stains that may form on the tooth surface. Good examination
and history will help to determine the etiology of discoloration so that appropriateness
of bleaching as a treatment can be considered. Bleaching agents techniques are effective
and conservative approaches to the removal of unaesthetic discolorations from vital and
nonvital teeth. As with all types of therapeutic modalities, proper diagnosis, and
treatment planning are essential. The bleaching process and their understanding of the
controversial issues regarding the effects of bleaching on teeth, resin composite, and
bonding, to help reduce the risks to patients. Vital tooth bleaching is an effective
treatment modality that can significantly change the appearance of teeth. Patient
satisfaction has been demonstrated after use of both professionally dispensed bleaching
treatments and OTC products. Its conservative nature and little risk makes it an
important part of an esthetic dentistry treatment plan.

References
• Kenneth W. Aschheim; Esthetic Dentistry: A Clinical Approach to Techniques and
Materials;Third Edition; Elsevier; 2015

• George Freedman;Contemporary esthetic dentistry; First edition; Elsevier; 2012

55
• Goldstein Ronald E. ; Esthetics in Dentistry; 2nd edition; B.C. Decker Inc; 1998

• Ingle John I., Bakland Leif K., Craig Baumgartner J.; Ingle’s Endodontics; 6th
edition; BC Decker Inc; 2008

• Bleaching Teeth: History, Chemicals, and Methods Used for Common Tooth
Discolorations;Toni S. Fusanaro; journal of esthetic dentistry; 1992

• New Advances in Tooth Whitening and Dental Cleaning Technology; Robert

Margeas; A Peer-Reviewed Publication; University of Iowa College of Dentistry

• An overview of vital teeth bleaching; Sonal Bakul Joshi; Journal of Interdisciplinary

Dentistry; 2016

• The bleaching of teeth: A review of the literature; Andrew Joiner; journal of dentistry;
2006

• An overview of vital teeth bleaching; Sonal Bakul Joshi; Journal of Interdisciplinary

Dentistry; 2016

• C. J. Tredwin, S. Naik, N. J. Lewi and C. Scully; Hydrogen peroxide tooth-whitening

(bleaching) products: Review of adverse effects and safety issues; British Dental
Journal Volume; 2006

• Managing Discoloured Non-Vital Teeth: The Inside/Outside Bleaching Technique;

NEIL J. POYSER, MARTIN G.D. KELLEHER AND PETER F.A. BRIGGS; Dental
Update – May 2004

56