BLEACHING OF

TEETH
BY: DR.ANAM ASIF (B.D.S , R.D.S)
 Tooth discoloration is defines as “any change in the hue , color , or
translucency of a tooth due to any cause.

 Restorative filling materials , drugs (both topical and systemic), pulpal

necrosis, or hemorrhage may be responsible.
EXTRINSIC
CAUSES  2. Fluorosis stains

• Coffee and tea stains  3. Trauma to tooth

• Cigarette  4. systemic condition
• Diet  Erythoblastosis foetails
• Nasmyths membrane (seen in children  Jaundice
caused due to reduced enamel epithelium)
 Amelogenesis imperfecta
Intrinsic  Enamel hypoplasia due to deficiency of
 1. Tetracycline stains vitamin A,C,D.
 1st degree  5. latrogenic discoloration

 2nd degree  Amalgam

 3rd degree  Intracanal medicaments

 4th degree  (kerr root sealer, Grossman sealer, procosol

sealer).
 TETRACYCLINE STAINING:
 More susceptible during the second trimester in vitro to roughly 8 years after birth.

 Tetracycline molecules chelate with calcium and get incorporated into the hydroxyapatite
crystals.

 Severity of stains depends on the time and duration of drug administration.

 4 Degrees:
 1st Degree
 - Light yellow , brown stains
 - Uniformly distributed
 - No banding or localized concentration
 - Responds to bleaching in 2 r 3 session
 2nd Degree
 - Dark gray stains
 - Extensive than 1st degree
 - Responds to bleaching best bands will be evident.
 3rd Degree
 - Dark gray stains with banding 3rd Degree 4th Degree

 - Responds to bleaching best bands will be evident.

 4th Degree
 - Does not respond to bleaching
 FLUOROSIS:
 High concentration of fluoride in more than 4ppm cause moderate to severe discoloration.

 Prevalence – Premolars, 2nd molars and mandibular and maximum incisors .

 Types
 Mild fluorosis – Brown pigmentation on a smooth enamel surface

- Responds well to bleaching

 Moderate – opaque fluorosis appear gray with white flecks on enamel surfaces.
 Severe defects – with pitting and dark pigmentation with surface

- Does not respond to bleaching

 Traumatic injuries:
 Causes rupture of blood vessel in pulp. Causing diffusion of blood into dentinal tubules.
 Dark pink immediate after trauma and changes to pinkish brown after some days.

 Causes:
 Haemoglobin degrades into hemin , hematin , hematoiden and haemosidrin.
 Hydrogen sulphide produced by bacteria combines with hemoglobin & gives dark colour to
tooth
 Systemic Condition:

Erythroblastosis foetalis: (Rh factor incompatibility between mother and foetus)

characterized by – breakdown of erythrocytes.

Jaundice: Bluish green or brown stains in dentin caused by bilirubin or biliverdin.

Amelogenesis imperfecta: is a genetic condition which interfere with the normal

enamel matrix formation.

Enamel hypoplasia: caused by deficiency of vitamins i.e. A,C,D and calcium and
phosphorus.
 Latrogenic discolouration

a) Trauma during pulp extirpation – hemorrhage.

b) Failure to removal of all pulpal remnants.

c) Amalgam restoration cause – dark gray.

d) Gold – dark brown when combined with products of decay.

e) Break down of restoration i.e. acrylic , silicate and composite resins can cause the tooth to look grayer
and discolore

f) Silver containing root canal sealers i.e. “kerr root” , “grossman sealer” .
g) Volatile oils » yellowish brown stain.
 BLEACHING
 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.

 INDICATIONS:
 Discoloration of anterior teeth – after R.C.T.
 Tetracycline stains (mild)
 Fluorosis
 Haemorrhagic discolouration
 Discolouration due to ageing
 Medication discolouration
CONTRAINDICATIONS
 Hypoplastic or severely undermined enamel.

 Deep microcracks

 Sensitive teeth

 Opaque or white spots

 Extensive silicate, acrylic or composite restorations.

 BLEACHING MATERIALS
 The active ingredient in tooth bleaching materials is peroxide compounds.

 Currently a variety of bleaching materials are available, the most commonly used peroxide
compounds are:

 Hydrogen peroxide
 Sodium perborate
 Carbamide peroxide
 HYDROGEN PEROXIDE
 In-office bleaching concentration (typically 25% to 38%)

At home concentration (3% to 7.5%)

H2O 2 at high concentration

Caustic
burns tissue on contact
 SODIUM PERBORATE
 Sodium perborate (NaB03) is available in powdered form as various commercial preparations.
 When fresh, it contains about 95% perborate, corresponding to 9.9% of the available oxygen.
 Sodium perborate is stable when dry.
 In the presence of acid, warm air, or water, however, it decomposes to form sodium
metaborate , H2O 2, and nascent oxygen.
 Three types of sodium perborate preparations are available:
 Monohydrate
 Trihydrate
 Tetrahydrate
 Commonly used sodium perborate preparations are alkaline.
 Materials of choice in most intracoronal bleaching procedures
 CARBAMIDE PEROXIDE (urea
hydrogen peroxide)
 Exists in the form white crystals or as a crystallized powder containing approximately
35%H2O 2.
 It forms H2O 2 and urea in aqueous solution.
 Mostly used in home-use bleaching materials with concentrations raging from 10 to 30%
(equivalent to approximately 3.5% to 8.6% H2O 2)
 Bleaching preparations containing carbamide peroxide usually also include glycerine or
propylene glycol, sodium stannate, phosphoric or citric acid, and flavor additives.
 In some preparations, carbopol , water soluble polyacrylic acid polymer, is added as a
thickening agent
 Carbopol also prolongs the release of active peroxide and improves shelf lifw
 BLEACHING MECHANISM
 The mechanism is oxidation/reduction process called as “Redox process”.
 In this process the oxidizing agent has a free radical with unpaired electrons, which it gives up, becoming
reduced. The reducing agent (i.e. the substance being bleached) accepts the electrons and becomes
oxidized.
 REDUCING AGENT OXIDISING AGENT
 Tooth Bleaching material
 After the process
 Tooth is oxidized Bleaching material is reduced
(organic pigmentation of tooth oxidized)
 In addition to the chemical effect other mechanism include

cleansing of tooth surface

temporary dehydration of enamel during the bleaching process,
change of enamel surface.
 INTRACORONAL BLEACHING OF
ENDODONTICALLY TREATED TEETH
The methods most commonly employed to bleach endodontically treated teeth
are:

1. “walking bleach”
2. Thermocatalytic techniques.

Walking bleaching is preferred

 WALKING BLEACH
Coined by nutting and poe in 1961
Involves the following steps:
Familiarize the patient
 Radiographically assess the status
 Evaluate tooth color with a shade guide
 Isolate the tooth color with a shade guide
 Isolate the tooth with a rubber dam
 Remove all restorative materials from the access cavity, expose the dentin, and refine the access. Remove
all materials to a level just below the labial-gingival margin.
 Apply a sufficiently thick layer, at least 2 mm, of a protective white cement barrier.
 Prepare the walking bleach paste pack the pulp chamber with the paste.

Evaluate the patient 2 weeks later

 THERMOCATALYTIC
 This technique involves placement of the oxidizing chemical, generally 30% to 35% H2O 2
(Superoxol), into the pulp chamber followed by heat application either by electric heating
devices or specially design lamps

avoid overheating of the teeth the surrounding tissues.

 Intermittent treatment with cooling breaks preferred.
 In addition, the surrounding soft tissues should be protected with Vaseline, Orabase, or cocoa
during treatment to avoid heat damage.
 Potential damage – external cervical root resorption
 ULTRAVIOLET
PHOTOOXIDATION
 This technique applies ultraviolet light to the labial surface of the tooth to be bleached.

 A 30% to 35% H2O 2 solution is placed in pulp chamber on a cotton pellet followed by a 2-
minute exposure to ultraviolet light.
 ADVERSE EFFECTS
 External Root Resorption

 Chemical Burns

 Inhibition on Resin Polymerization and Bonding Strength

 RESTORATION OF
INTRACORONALLY
BLEACHED TEETH
 Restoration with a lightshade, light – cured, acid – etched composite resin.

 Placing white cement beneath the composite.

 Waiting for at least 7 days after bleaching, pior to restoring the tooth with resin composites,
recommended.
EXTRACORONAL BLEACHING
 Extracoronal bleaching may be used for whitening vital or nonvital teeth as well as a single
tooth or whole arch,

 It has experienced a dramatic advancement in materials as well as techniques after at-home

extracoronal bleaching was first introduced
 IN – OFFICE EXTRACORONAL
BLEACHING
 Bleaching procedures are performed in the clinic by a dental professional.
 Current commercial in – office bleaching materials are almost exclusively in the form of a gel,
with 25% to 38% H2O 2
 In – office extracoronal bleaching may be performed using a bleaching gel alone or gel with a
light.
 The light source can be a laser (e.g. argon CO2) , halogen, plasma arc, or light – emitting
diodes (LED).
 The wavelength may range from high ultraviolet spectra, low visible blue light spectra, to
invisible infrared spectra such as CO2 laser.
The light exposure is intended to enhance the bleaching efficacy by activating the bleaching gel
either through a specific catalyst or heat.
 LASERS:
 The action is to stimulate the catalyst in the chemical. There is no
thermal effect and less dehydration of enamel.
 ARGON LASER of 488 nm wave – length for 30 seconds to
evaluate the activity of bleaching gel. As the laser energy is
applied, the gel is left in place for 3-4 minutes and then removed.
This procedure is repeated for 4-6 times.
 Another product uses Ion laser technology. Argon laser is used as
describes before. Then CO2 laser is employed with another
peroxide solution to provide penetration of the bleaching agent into
the tooth to provide bleaching below the surface.
 Argon laser is in the form of blue light and is absorbed by dark
colour. It is an ideal instrument to be used in tooth whitening when
used with 50% H2O2. The affinity to dark colour ensures that the
yellow brown colour can be easily removed.
 CO2 LASER: It is unrelated to the colour of tooth and energy is
emitted in the form of heat. It is invisible and penetrates only 0.1
mm into water and H2O2 where it is absorbed.

This energy can enhance the effect of whitening after the initial
argon laser process.

DIODE LASER LIGHT:

A true laser produces from a solid – state source.
It is ultra fast , taking 3-5 seconds to activate the bleaching of agent.

 This type of laser produces no heat.

 OVER – THE – COUNTER ( OTC ) TOOTH BLEACHING PRODUCTS

Available directly to consumers.

Contains:
 Acid – citric or phosphoric acid
 Gel – acidic ph;applied for 2min
 Post bleach polishing cream – toothpaste containing titanium dioxide

WHITE STRIPS
 Which is a thin flexible polyetheline strips which contains 5.3% hydrogen peroxide in gel
form.

 The strips are used for 30 minutes twice daily for 14 days.
 ADVERSE EFFECTS FROM
EXTRACORONAL BLEACHING
Tooth Sensitivity
 Commonly observed clinical side effect during or after extracoronal bleaching of vital teeth,
with an incidence of up to 50%
 The sensitivity, usually mild to moderate and transient, often occurs during the early stages of
treatment and usually persists for 2 to 3 days

Enamel Damage
 The effect of extracoronal bleaching on enamel has been conducted mainly using in vitro
systems to examine changes in enamel surface microhardness and morphology.
 Most SEM studies showed little or no morphological changes in the bleached enamel surface.
Gingival Irritation
Commonly observed clinical side effect in extracoronal bleaching.
The gingival irritation is usually mild to moderate, occurring in 2 to 3 days of using the
bleaching gel

Mercury release from amalgam restorations

 The amount of mercury release may vary.

 Avoid extracoronal bleaching for teeth with extensive amalgam restorations.