Bleaching & Restorations of discolored teeth in Pediatric Dentistry

Dr Susmita Shah
III MDS
Department of Pediatric & Preventive Dentistry
Bleaching and Restoration
of Discolored teeth in
Pediatric Dentistry

Contents:
1. Introduction
2. Colour Perception
3. Classification & Causes of tooth
discoloration
4. Bleaching
I. Definition
II. History
III. Indication/Contraindications
IV. Ideal properties
V. Bleaching materials
VI. Over the counter products
VII. Various Bleaching technique
s
5. AAPD guidelines.
6. Other treatment options
7. Summary
8. Bibliography

1. INTRODUCTION
Dental aesthetics, including tooth color, is of great importance for majority of the people and any
discoloration or staining can impact the quality of life negatively. (Majeed A et al, 2015)
In a study, 32% of a group of 2,495 children were dissatisfied with their tooth color, 19% of par
ents were dissatisfied with their child’s tooth color, and only 9% of dentists felt the subjects had
unsatisfactory tooth color. (Shulman JD et al,2004)
8/7/2021 3
There has been a major increase in demand for dental esthetic treatments, including tooth whiten
ing. One recent change in vital tooth bleaching has been the development of home treatments, w
hich are available in some countries without a prescription. (Gerlach RW et al. 2003)
Sean S. Lee, Wu Zhang, D. Harvey Lee, Yiming Li. Tooth Whitening in Children and Adolescents: A Literature Revie
w. Pediatr Dent 2005; 27:362-36

2. COLOUR PERCEPTION
8/7/2021 4
• Basic understanding- elements of tooth colour
• Gradation of colour occurs in an individual tooth from the gingival margin to the incisal edge of
the tooth.
• The gingival margin often has a darker- close approximation of the dentine below the enamel.
• In most people canine teeth are darker than central and lateral
• The viewing conditions are extremely important and variables such as the light source, time
of day, surrounding conditions and the angle the tooth is viewed from affect the apparent
tooth colour.
• Light is composed of differing wavelengths and the same tooth viewed under different cond
-itions will exhibit a different colour, a phenomenon known as metamerism.
A. Watts, M. Addy. Tooth discolouration and staining: a review of the literature. British Dental Journal 2001; 190: 309-316

8/7/2021 5
Color as described
by Munsell
HUE
Descriptive term to enable one to disting
uish between different families of colour,
for example reds, blues and greens.
VALUE
The relative lightness and darkness of a
colour on a scale from black to white.
CHROMA
The degree of colour saturation and describes the stren
gth of a colour as it changes, for example, from pink to
crimson.
A. Watts, M. Addy. Tooth discolouration and staining: a review of the literature. British Dental Journal 2001; 190: 309-316

3. CLASSIFICATION & CAUSES OF TOOTH
DISCOLORATION
8/7/2021 6
Accoring to Van B.
Haywood, W. Frank
Caughman, Ronald E.
Goldstein
Localized Stains Generalized Stains
John I Ingle, Leif K Bakland-Textbook of Endodontics. 6th edition 2008
Aging, Pulpal necr
osis, intrapulpal h
aemorrage, Calcifi
c metamorphosis,
Drugs, Diseases
Foods, beverages, m
outh rinses, tobacco
products, restorative
material, chomogeni
c microorganisms.

According to Ilan Rostein &
Yiming Li
Extrinsic Stains
lies on the tooth surface or in
the acquired pellicle.
Intrinsic Stains
occurs when the chromogens
are deposited within the bulk
of the tooth, which maybe of
local or systemic origin

Extrinsic causes of tooth discoloration
8/7/2021
Manuel ST, Abhishek P, Kundabala M, Etiology of tooth discoloration- a review. Nig Dent J V
ol 18 No. 2 July - Dec 2010
9

Depending upon colors extrinsic stains can be
classified as-
8/7/2021 11
Suchetha A, Khawar S, Mundinamane DB, Apoorva SM, Bhat D, Govindappa L. ALL ABOUT
DENTAL STAINS: A REVIEW (PART I) Annals of Dental Specialty Vol. 4; Issue 2. 2016

8/7/2021 13
Extrinsic reddish black stains in a
patient with the habit of chewing
pan
Manuel ST, Abhishek P, Kundabala M, Etiology of tooth discoloration- a review. Nig Dent J
Vol 18 No. 2 July - Dec 2010
Extrinsic black stains due t
o high concentration of iro
n in the water source
Internalised tobacco stains

8/7/2021 14
John I Ingle, Leif K Bakland - Endodontics 6th edition; 2008
Intrinsic causes of tooth discoloration
Patient Related
• Pulp Necrosis
• Intra-pulpal hemorrhage
• Dentine hyper-calcification
• Age
• Developmental defects
• Drug related defects
Dentist Related
• Endodontically related
• Restoration related
According
to Ilan
Rotstein

8/7/2021
Sean S. Lee, Wu Zhang, D. Harvey Lee, Yiming Li. Tooth Whitening in Children and Adolescents: A Literature
Review. Pediatr Dent 2005; 27:362-36 15
Pre-eruptive causes of
intrinsic discoloration

Post-eruptive causes of
intrinsic discoloration

Management Options For Discolored Teeth
8/7/2021 17
Bleaching-
vital/non vital
Micro-abrassion
Composite resin
restorations
Laminates/Veneers

4. BLEACHING
8/7/2021 18
• The lightening of the colour of tooth through the application of a chem
ical agent to oxidize the organic pigmentation in the tooth.
• The color-producing stains are typically organic compounds that possess
extended conjugated chains of alternating single or double bonds and
often include heteroatoms, carbonyl and phenyl rings in conjugated system,
and are referred to as chromophores.
• Bleaching is the chemical degradation of the chromogens.
Joshi SB. An overview of vital teeth bleaching. J Interdiscip Dentistry 2016;6:3-13.

Year Details
The pursuit of whiter teeth dates back to the Babylonian era
1300s It was the most sought dental treatment apart from extractions. The enamel was abraded with a coarse
metal file and a solution of “aquatortis,” a nitric acid solution, was applied to whiten the teeth.
1300s-1800s to early 1900s sixty published documents about bleaching
1860s- Haywood VB, 1992 Vital teeth were bleached using oxalic acid on the external surfaces of the teeth.
Fisher G, 1911, Atkinson C, 1892. Later, hydrogen peroxide (HP) or pyrozone was used instead of oxalic acid.
1913 to 1940- few articles were published due to the World War I, era of depression, and the World War II
1960s- Dr. B. Klusemeir accidently, a home bleaching technique was stumbled
1992- Haywood and Heymann in their article described this technique 20 years later as nightguard vital bleaching (NGVB).
1990s- Bartlett D.,2001 HP was introduced in a gel form. () Currently, HP is used in office as gels or in a powder–liquid form in t
he concentrations ranging from 15% to 40%. (Ontiveros JC,2011)
(Omni International, Albertson, NY,
USA)
“White and Brite” was introduced as a new home bleaching product. Subsequently, many whitening pro
ducts surfaced.
History

8/7/2021 20
COMPOSITION OF COMMERCIAL
BLEACHING AGENTS
ACTIVE INGREDIENT
1) Hydogen Peroxide-HP
2) Carbamide Peroxide-CP
3) Sodium percarbonate is another
source of HP
INACTIVE INGREDIENTS
1) Thickening agents- Carbopol (carboxypolym
ethylene), Polyx
2) Carrier- Glycerin, Propylene glycol
3) Surfactant and pigment dispersant
4) Preservatives- Sodium benzoate and methyl
propyl paraben
5) Flavorings
6) Additives- Potassium nitrate, Fluoride, ACP-C
PP

8/7/2021 21
Bleaching
Intracoronal
(non-vital bleaching)
Walking bleach
In office
thermocatalytic
Extracoronal
(vital bleaching)
In office vital
At home vital
Bleaching techniques

8/7/2021 23
a. Intracoronal non-vital bleaching
Walking bleach technique
• Indications
Discoloration of pulp
chamber
Dentin discoloration
• Contraindications
Superficial enamel discoloration
Defective enamel formation
Severe dentin loss
Presence of caries
Discoloured composites
Welbury R. Duggal M. Hosey M. Paediatric Dentistry. 4th edition. 2014. Oxford universotiy press.
1. Non- Vital bleaching techniques:

• Expected outcome is to be discussed with patients.
• Assess Peri-apical tissues radiographically.
• Assess quality and shade of any restoration present and replace if defective.
• Evaluate teeth colour with shade guide take photographs for future comparison.
• Isolate the toot with rubber dam
• Protect gingiva with Orabase or Vaseline.
• Clean teeth with pumice and water.
• Remove all restorative material from the access cavity expose the dentin and refin
e the access.
• Remove root filling to 2 mm below the level of the dentogingival junction.
8/7/2021 25
Welbury R. Duggal M. Hosey M. Paediatric Dentistry. 4th edition. 2014. Oxford universotiy press.

2. Removal of gutta perc
ha 2mm below CEJ with
GG drills
3. Placement of barrier (
capsulated light cured gl
ass ionomer cement)
8/7/2021 26
Bleaching techniques in restorative dentistry- Linda Greenwall
1. Rubber dam applicati
on with widgets
4. Etch the pulp chamber with 37% ph
osphoric acid for 30-60 seconds wash
and dry. This will facilitate the ingress
of the hydrogen peroxide.
6. Placed in the coronal spac
e with the help of pluggers f
ollowed by placement of cot
ton wool over the mixture.
5. Sodium perborate (mixed
with hydrogen peroxide) is
prepared in a wet sand like
mix
Temporary dressing(non-s
etting calcium hydroxide)
is given to prevent escape
of oxygen and bonding a
gent is applied over it.
Given for 2 weeks.
Seal with glass ionomer
cement.

TITLE AUTHOR &
JOURNAL
LOE ABSTRACT
Bleaching primary
teeth with 10% car
bamide peroxide
David H. Brantl
ey, Katheryn P.
Barnes, Van B.
Haywood. Pedi
atr Dent 23:51
4-516, 2001
IV Bleaching teeth with 10% carbami
de peroxide in a custom fitted tra
y has been popular for more than
10 years. However, primary teeth a
re seldom considered for bleachin
g due to the need for compliance
by the child and the natural white
ness of the primary teeth. This rep
ort describes an indication—teeth d
arkened from trauma—as well as th
e technique and outcome for bleac
hing discolored primary teeth.

8/7/2021 29
LEVEL OF EVIDENCE 4

8/7/2021 32
LEVEL OF EVIDENCE 4

b. THERMOCATALYTIC IN OFFICE BLEACHING
8/7/2021 34
Bleaching techniques in restorative dentistry- Linda Greenwall 20
02. martin Dunitz Ltd London.
• This technique involves placement of the oxidizing agent, generally 30%
to 35% H2O2 in the pulp chamber followed by heat application either by
electric heating devices or specially designed photoflood lamps for 5min.
• This process should be continued until the desirable results are achieved.
Should not be repeated for more than 5-6 times. Care should be taken th
at the temperature of the heating device does not exceed 114F.
• Metal clamps should not be used. Recall the patient in a week to assess t
he color after rehydration.

ADVERSE EFFECTS
8/7/2021 35
Bleaching techniques in restorative dentistry- Linda Greenwall 2002. martin Dunitz Ltd London.
External cervical
root resorption
• most commonly
noticed complication
• cemento-enamel
junction is defective
• 35% H2O2 may
denature the
dentin.
Chemical burns
• 35% H2O2 is caustic
and may cause
chemical burns and
sloughing of the
gingiva.
• Use Vaseline or
orabase and rubber
dam or with opal
dam.
Coronal fracture
• Increased
brittleness of the
coronal tooth
structure,
particularly when
heat is applied, is
also thought to
result from
bleaching.
• Due to dessication
of the dentin and
enamel

Post bleaching tooth restoration:
• Permanent restoration of the tooth is essential for long-term successfu
l bleaching. Coronal microleakage especially that of lingual access restora
tion and a leaking restoration may lead to rediscolouration. Therefore, a c
omposite restoration is advised as early as possible.
• This should be planned 1 or 2 weeks after complete removal of the ble
aching materials. This time period is for the elimination of residual per
oxides.
• The use of catalase for 3 min has been proposed for the removal of resi
dual peroxides where adequate bonding can be acquired.
8/7/2021 37
Bleaching techniques in restorative dentistry- Linda Greenwall 2002. martin Dunitz Ltd London
.

• It is also called chair side bleaching, power bleaching, laser,
dentist administered /applied, assisted/dentist supervised
• There are various techniques for bleaching vital teeth dependi
ng on the degree of staining.
• In-office
• Mouth guard or Night guard or At-home
Louis I grossman. “Endodontic practice”, 13th edn, lea & febiger, 1991: 289-312.
8/7/2021 39
1. Vital bleaching technique

8/7/2021 40
PATIENT SELECTION FOR VITAL
TOOTH BLEACHING
Patient’s lifestyle
Current levels of
tooth sensitivity
Type of
discoloration
Baseline shade
of the teeth
Time available
for bleaching

In-office vital bleaching
Indications:-
• Light enamel discoloration
• Mild tetracycline discoloration
• Endemic fluorosis discoloration
• Age related discoloration
Contraindications:
• Severe dark discolorations
• Severe enamel loss
• Proximity of pulp horns
• Hypersensitive teeth
• Presence of caries
• Large/ poor coronal restorations
8/7/2021 41

Technique
• Take radiographs to detect the presence of caries, defective restorations and pr
oximity to pulp horns.
• Evaluate tooth colour with shade tabs by taking photographs at all the appoint
ments.
• Apply Vaseline or oraseal and then isolate with rubber dam by using waxed de
ntal floss or widgets for additional sealing. Unwaxed dental floss acts as a wick
and would absorb the H2O2 and possibly burn the tissues.
• Avoid using metal clamps, as they are subjected to heat and causes sensitivity.
8/7/2021 42
Bleaching techniques in restorative dentistry- Linda Greenwall

• Do not inject a local anesthetic.
• Position protective sunglasses over the patient’s and operator’s ey
es.
• Clean the enamel surface with pumice and water.
• For the darkest or most severely stained areas acid etch with 37%
phosphoric acid for 60 seconds, wash and dry.

• Place a small amount of 30 to 35% H2O2 solution into a dapen dish. Apply the H2O2 liquid on the
labial surface of the teeth using a small cotton pellet or a piece of gauze. Bleaching gel can also be
used instead of solution which can be better controlled.
• Apply heat with a heating device or light source(13-15 inches i.e. 33-38 cm from patients teeth). Th
e temperature should be controlled that the patient should not feel any discomfort, usually betwee
n 125F and 140F (52C to 60C).
• Rewet the enamel surface with H2O2 as necessary. If the tooth becomes too sensitive, discontinue
the bleaching procedure immediately. Do not exceed 30 min even if satisfactory results are not obt
ained.
• Heating can be carried out by thermostatically controlled electric heating device or a stainless steel
instrument such as Woodson No.2 heated over flame.
• Polish the teeth using Shofu stones. Apply fluoride drops for 2-3 min.
8/7/2021 44

8/7/2021 45
PRE-OPERATIVE ISOLATE WITH GINGIVAL DAM
POST OPERATIVE

8/7/2021 47
POSTOPERATIVE INSTRUCTIONS
FOR VITAL BLEACHED TEETH
Avoid acidic drinks, fruits, tea,
coffee, and smoking for 48
hours post bleaching
Don’t get disappointed- as
shade relapse can happen
Quicker the drop of shade,
more is the rebound.
In in-office bleach, shade
regression of about half a
shade tends to occur within a
week or 10 days
postbleaching

8/7/2021 48
POSTOPERATIVE SENSITIVITY
18% to 78%
(Tredwin CJ et
al,2006)
is
transient
no
long-term
effects.

8/7/2021 50
MAINTENANCE OF BLEACHED TEETH
Patients are recommended to use a whitening toothpaste and dental floss with a powered tooth
brush.
Food, beverages, and habits that stain the teeth should be evaded.
Women are advised to wear a brighter shade of lipstick to make the teeth appear whiter.
A touch up is a must to restore the shade.
Depending on the relapse, the touch up is recommended in 6 months or after a year or 2.

8/7/2021 51
1. LIGHT / LASER Activation
•Halogen- curing Lights
•Plasma Arc Lamps
•Xenon–halogen Technology
•Diode Lasers
2. Chemical Activation
3. Dual Activation
4. Ultrasonic Technology
5. Assissted/ Waiting Room Technique 6. Compressive Bleaching Technique
7. Combining Bleaching Techniques

8/7/2021 52
Demetron 501 (Kerr Dental Ltd., Peterborough, UK) has been used for activating
many different bleaching systems such as Pola Office (SDI, Victoria 3153, Australi
a) and Quick White Net (DMDS UK, Canterbury, UK).
The light in its bleaching mode is applied for 30 s/tooth; the application inc
ludes three 10- min passes.
Products such as Opalescence Xtra (Ultradent Products, South Jordan, Utah, USA
) have carotene mixed within the bleaching agent, which allows for conversion o
f light energy into heat. This heat increases the further breakdown of HP into fre
e radicals by increasing its activity.[Jorgensen MG et al, 2002]
Halogen-curing Lights

8/7/2021 53
Plasma Arc Lamps
Plasma arc lamps significantly contribute to effective bleaching using HP without ther
mal changes as it releases energetic ions, free electrons, and hydroxyl radicals.
[Hegde M et al, 2012]
Activation is by three 10-min passes with whitening mode activation for 3 s/tooth.
A burst of lower intensity light with a gap of 5 s may be used to activate both arches tog
ether with a 10-min pass in a full-smile adaptor. [Sulieman M. 2005]

8/7/2021 54
Xenon–halogen Technology
It is a xenon–halogen light having a blue-green spectrum.[Jorgen
sen MG et al, 2002]
A full-smile illuminator is kept a few centimeters ahead of teeth in
the usual protocol of three 10-min passes to activate 35% HP.

8/7/2021 55
Nearly, 35–50% HP may be used for tooth bleaching in combination with
830 nm or 980 nm diode lasers.
The blue dye present in the powder absorbs thermal energy from the light so
urce to heat up the gel causing an increased breakdown, thus increasing its a
ctivity.
Three 10-min passes are used at 1–2 W of energy for 30 s/tooth. Eye protecti
ve glasses are a must with the use of lasers.
Diode Lasers

8/7/2021 56
Woodpecker Wireless Cordless LED
Curing Light Lamp Teeth Whitenin
g Optical Fiber LED.C
Rs 21,142/-
Dental LED Light Lamp Accelerator
Mobile Oral Teeth Bleaching White
ning Machine
$142
Approx Rs 9500/-

8/7/2021 57
TITLE AUTHO
R & JO
URNAL
L
O
E
AIM METHOD RESULT CONCLUSION
S
Extern
al blea
ching
therap
y with
activat
ion by
heat, li
ght or
laser—
A syst
ematic
review
Wolfg
ang B
uchall
aa, Th
omas
Attin
Dental
Materi
als 2
3 ( 2
0 0 7
) 586–
596
1
B
External bleaching proced
ures utilizing highly conce
ntrated 30–35% hydrogen
peroxide solutions or hydr
ogen peroxide releasing a
gents can be used for toot
h whitening. To enhance o
r accelerate the whitening
process, heat-activation of
the bleaching agent by lig
ht, heat or laser is describ
ed in the literature. The ai
m of the present review ar
ticle was to summarize an
d discuss the available info
rmation concerning the eff
icacy, effects and side effe
cts of activated bleaching
procedures.
Information fr
om all origina
l scientific full
papers or revi
ews listed in
PubMed or IS
I Web of Scie
nce (search te
rm: (bleaching
OR brightenin
g OR whitenin
g OR colour)
AND (light O
R laser OR he
at OR activati
on)) were incl
uded in the r
eview.
Existing literature rev
eals that activation o
f bleaching agents b
y heat, light or laser
may have an adverse
effect on pulpal tissu
e due to an increase
of intra-pulpal temp
erature exceeding th
e critical value of 5.5
◦C. Available studies
do not allow for a fi
nal judgment wheth
er tooth whitening c
an either be increase
d or accelerated by
additional activation
Therefore,
applicatio
n of activ
ated bleac
hing proc
edures sh
ould be cr
itically ass
essed con
sidering t
he physic
al, physiol
ogical an
d patho-p
hysiologic
al implica
tions.

8/7/2021 58
Opalescence Xtra Boost (Ultradent Products, South Jordan, Utah, USA) has g
els placed within two syringes.
One syringe contains 38% HP and the second syringe contains a proprieta
ry agent.
When mixed, the gel is chemically activated. The agent increases the pH to 7,
enhancing the activation of the bleach.
It is used for three passes of 10–15 min each. The teeth are lightened by 6–
10 shades.
Chemical Activation

8/7/2021 59
Ferrous and manganese sulfate have been added to the bleaching gel to a
llow for chemical and light activation, respectively.
An example of the same is Hi Lite (Shofu Dental Products, Tonbridge, Kent, U
K). The bleaching
time is, thus, reduced to 7–9 min.
The HP gel changes color from blue to green to cream, and finally, chalky on
completion of activation. A maximum of 6 passes are recommended in a sessi
on.
Dual Activation

8/7/2021 60
Using ultrasonic energy, an expedite method of in-office bleaching has been
recently introduced.
SoniWhite Whitening System (DMDS UK, Canterbury, UK) utilizes ultrasonic
energy to enhance bleaching by placing 6–7.5% HP within custom-made tr
ays in either arch for approximately two cycles of 5 min each.
It is thought that ultrasonic energy may result in an increased production of
free radicals.
Ultrasonic Technology

8/7/2021 61
Assissted/
Waiting Room Technique
(DenMat)
Compressive Bleachin
g Technique
(Miara)
Combining Bleac
hing Techniques
A combination
of both in-offic
e and home bl
eaching
Enables the permeation of
nascent oxygen radicals th
rough the enamel under g
uided pressure
Involves using a custo
m- made tray to place 35
% HP bleaching gel and s
ealing of the edges with li
ght-cured resin material.
A halogen or plasma arc la
mp is used for activation.
35% of CP was used cautiousl
y under close
supervision.
To initiate home bleaching a
nd accustom the patients to
handle the trays.
The tray is placed in the patie
nts’ mouth and the patients ar
e asked to be seated in the
waiting room for 30 min.

8/7/2021 62
37.5% HP
May be light activated 35% HP
May be light activated
Rs 3000/-
6 patients Rs 6000/-

8/7/2021 65
https://www.sdi.com.au/en/pola-office-/

8/7/2021 66
TITLE AUTHO
R & JO
URNAL
L
O
E
AIM METHOD RESULT CONCLUSIONS
Effect o
f Two I
n-office
Whiteni
ng Age
nts on
the Ena
mel Sur
face In
Vivo: A
Morph
ological
and No
n-conta
ct Profil
ometric
Study
M Ca
denar
o M,
Bresch
i, Nuc
ci, Ant
oniolli
Visinti
ni, Pra
ti, Mat
is, Len
arda.
Opera
tive D
entistr
y, 200
8, 33-
2, 127
3
B
This study
evaluated t
he morphol
ogical effec
ts produce
d in vivo b
y two in-off
ice bleachi
ng agents
on enamel
surface rou
ghness usi
ng a nonco
ntact profil
ometric an
alysis of ep
oxy replicas
.
Eighteen subjects were selected and randoml
y assigned to two treatment groups (n=9). T
he tooth whitening materials tested were 38
% hydrogen peroxide (HP) (Opalescence Xtra
Boost) and 35% car-bamide peroxide (CP) (Re
mbrandt Quik Start). The bleaching agents w
ere applied in accordance with manufacturer
protocols. The treatments were repeated four
times at one-week intervals. High precision i
mpressions of the upper right incisor were ta
ken at baseline as the control (CTRL) and aft
er each bleaching treatment (T0: first applicat
ion, T1: second application at one week, T2: t
hird application at two weeks and T3: fourth
application at three weeks). Epoxy resin replic
as were poured from impressions, and the su
rface roughness was analyzed by means of a
non-contact profilometer (Talysurf CLI 1000).
Epoxy replicas were then observed using SE
M. All data were statistically analyzed using
ANOVA and differences were determined wit
No signi
ficant dif
ferences
in surfac
e rough
ness wer
e found
on enam
el replica
s using e
ither 38
% hydro
gen per
oxide or
35% car
bamide
peroxide
in vivo.
This in vivo s
tudy support
s the null hy
pothesis that
two in-office
bleaching ag
ents, with eit
her a high co
ncentration o
f hydrogen o
r carbamide
peroxide, do
not alter ena
mel surface r
oughness, ev
en after multi
ple applicatio
ns.

8/7/2021 67
At- home/ Night guard
bleaching
Indications
• Superficial enamel
discolorations
• Mild yellow discolorations
• Brown fluorosis
discolorations
• Age-related discolorations
Contraindications
• Severe enamel loss
• Hypersensitive teeth
• Presence of caries
• Defective coronal restorations
• Allergy to bleaching gels
• Bruxism
• Pregnant and lactating
mothers
• Smoking

8/7/2021 70
Howard E Strassler. Vital Tooth Bleaching
: An Updte. Continuing Educatio. 2006

8/7/2021 71
TITLE AUTHOR &
JOURNAL
L
O
E
AIM METHOD RESULT CONCLUSIONS
Influen
ce of t
ooth bl
eachin
g on d
ental e
namel
microh
ardness
: a syst
ematic
review
and me
ta-anal
ysis
Jaine Za
nolla, A
manda B
rites, Dei
si Carnei
ro, Alber
t Schiave
to, Marg
areth Co
utinho,
Aust De
nt J
. 2017 S
ep;62(3)
:276-28
2
1
b
Several studies have investigat
ed the effect of bleaching on
dental tissues. The evaluation
of the effect of home bleachi
ng with 10% carbamide pero
xide is important for assessin
g alterations in enamel micro
hardness that may affect den
tal health in terms of resistan
ce to masticatory forces. This
meta-analysis was performed i
n order to determine scientific
evidence regarding the effects
of home vital bleaching with 1
0% carbamide peroxide gel on
the microhardness of human d
ental enamel.
A systematic electronic l
iterature search was con
ducted in the PubMed
and Web of Science dat
abases using search ter
ms. Two independent re
searchers evaluated the
information and metho
dological quality of the
studies. Inclusion and e
xclusion criteria were es
tablished for article sele
ction; further, only studi
es published in English
were selected.
Thirteen
studies t
hat met
all the in
clusion a
nd exclu
sion crit
eria wer
e selecte
d and u
nderwen
t statisti
cal analy
sis.
The results of
this meta-an
alysis showe
d no signific
ant changes
in enamel mi
crohardness
when using t
he 10% carb
amide peroxi
de bleaching
gel over peri
ods of 7, 14,
and 21 days

8/7/2021 72
TYPES OF WHITENING SYSTEM
Whitening
toothpaste
Over- the- coun
ter whitening
strips and gels
Whitening
rinses
Tray-based
tooth
whiteners
In-office
bleaching

8/7/2021 73
Whitening toothpaste
Rs. 125
Rs. 324
Rs. 300-350
Rs. 6,088
Rs. 1891
Rs. 2802
Rs. 83
Rs. 5000-
Rs. 5300
Rs. 203
Rs. 90-Rs. 150

8/7/2021 74
Over-the-counter whitening strips and gels
Whitening Strips
-are thin layers of 5.3% or 6.5% HP gel on polyethylene
strips, shaped to cover the anterior teeth from canine to ca
nine.
-5.3% strips are applied twice daily for 30 min and
6.5% HP for 30 min in a day be used for 14 days.
-As the strips require no dispensing, an error at this stage
is avoided and is hassle-free as it is disposed after every u
se.
Whitening gels
-comprise peroxide, which is applied with specific bru
shes directly onto the surfaces of the teeth. They are
recommended to be used for 20–30 min, twice a day
for 14 days.
-The brushes are discarded as per the manufacturer’s i
nstruction, which reduces microbial contamination an
d peroxide inactivation.

8/7/2021 75
Remove from package.
Center tray on arch.
Gently suck down or swallow.
Remove outer tray.
Suck down or swallow again.
Wear 6% for 60 to 90 minutes, 10% for 30 to 60 min
utes, and 15% for 15 to 20 minutes.
Rs. 7,200
Rs. 1,099
Rs. 2,185

8/7/2021 76
Rs. 2000 to Rs. 2800
Rs. 800
Rs. 500-800

8/7/2021 77
Whitening rinses
The rinse comprises HP, which reacts with the sta
ins, lightening the tooth by 1–2 shades.[Carey
CM. 2014]
Manufacturers recommend rinsing for 3 mont
hs twice daily for 60 s each.
Joshi SB. An overview of vital teeth bleaching. J Interdis
cip Dentistry 2016;6:3-13.
Rs. 7,100
Rs. 5,140
Rs. 3,999

8/7/2021 78
The AAPD encourages:
• The judicious use of bleaching for vital and non-vital teeth.
• Patients to consult their dentists to determine appropriate methods f
or and the timing of dental whitening within the context of an individ
ualized, comprehensive, and sequenced treatment plan.
• Dental professionals and consumers to consider side effects when co
ntemplating dental bleaching for child and adolescent patients.
• Further research of dental whitening agents in children.
The AAPD discourages full-arch cosmetic bleac
hing for patients in the mixed dentition.
Policy on the Use of Dental Bleaching for Child and Adolescent Patients.AMERICAN ACADE
MY OF PEDIATRIC DENTISTRY. REFERENCE MANUAL V 36 / NO 6 14 / 15
5. AAPD Guidelines

8/7/2021 79
MICRO ABRASION MEGA ABRASION
Combined chemico-mechanical
approach- combination of mega-
abrasion, microabrasion and power
bleaching or home bleaching
COMPOSITE
RESTORATIONS
LAMINATES/
VENEERS
6. OTHER TREATMENT OPTIONS

8/7/2021 80
Etching with37% phosphoric
acid
Pre Operative
Post operative
MICROABRASION
CASE 1
I Anand Sherwood. Fluorosis varied treatment options. J Conserv Dent | Jan-Mar 2010 | Vol 13 | Issue 1

8/7/2021 81
A: A teenage girl had idiopathic white enamel demineralization o
f her maxillary central incisors;
B: After dental of the stained enamel; C: Before treatment, the pa
tient received eyeglasses for protection and the teeth were isolat
ed with
a rubber dam;
D and E: Opalustre microabrasive product was applied and comp
ressed upon the enamel surfaces, using a was applied with high t
orque, but very slow speed, to prevent splattering. The compoun
d was applied three times on each of the three teeth for intervals
of 60 seconds. The teeth were rinsed with water/air spray after e
ach application;
F: The teeth was applied to the treated enamel surfaces and left i
n place for 4 minutes;
G: The treated incisors are shown immediately after enamel micr
oabrasion
CASE 2
Sundfeld RH et al. Microabrasion in tooth enamel discoloration defects: three cases with
long-term follow-ups. J Appl Oral Sci. 2014;22(4):347-54

8/7/2021 82
mild-to-moderate fluorosis and hypoplasia related to traumatic dental inj
ury before treatment. Note the white (tooth 8) and yellow (tooth 9) stains
diagnosed as trauma-induced stains in the incisal third of the central incis
ors.
CASE 3
MIGUEL ANGEL MUÑOZ et al. Alternative Esthetic Management of Fluorosis and Hypoplasia Stains: Blending
Effect Obtained with Resin Infiltration Techniques.Journal of Esthetic and Restorative Dentistry. 2012

8/7/2021 83
A–B, Application of conventional rubber dam and erosion of the surface layer with 15% HCl (Icon-etch,
DMG);
C, subsequently, the etching gel is thoroughly washed away (30 seconds) using water spray;
D, lesions desiccated by application of ethanol (Icon-dry, DMG) for 30 seconds and subsequent air-dryi
ng;
E, application of the resin infiltrant for 3 minutes (Icon-infiltrant, DMG);
F, after removal of surplus material, the area is light-polymerized for 40 seconds. After this, a second co
at of the resin infiltrant is applied, and it was polymerized (or light-curing) after a 1-minute delay.

Improved esthetic result after 4 months. Some trauma-induced staining on t
he central incisors can be observed probably due to being too deep.

85
Journal of Indian Society of Pe
dodontics and Preventive Den
tistry | Volume 35 | Issue 4 | O
ctober-December 2017
Fig 1
Fig 4
Fig 3
Fig 2

8/7/2021 86
MEGA-ABRASION
CASE 1
S. Ardu, N. Benbachir, M. Stavridakis, D. Dietschi, I. Krejci. A combined chemo-mechanical approach for aesthetic manage
ment of superficial enamel defects. BRITISH DENTAL JOURNAL VOLUME 206 NO. 4 FEB 28 2009

8/7/2021 88
Combined chemico-mechanical approach
Initial view of a patient with seve
re DF.
Mega-abrasion performed with a 105-lm fine diamond
bur.
Surface finishing. (Sof-Lex discs
, 3M ESPE)

8/7/2021 89
Photopolymerizable resin dam
.
Application of an in-office ble
aching agent. (38% H2O2,Ultr
adent Products)
Microabrasion. (Opalustre, Ultr
adent Products)
Application of desensitizing a
gent. (Fluorinated protector)

Facial view after removal of the photo
polymerizable rubber dam.
Facial view after application of the resi
n infiltration. (Icon, DMG Products)

8/7/2021 91
COMPOSITE RESTORATION
Sundfeld RH et al. Microabrasion in tooth enamel discoloration defects: three cases with lon
g-term follow-ups. J Appl Oral Sci. 2014;22(4):347-54

Veneer & Laminate
• A veneer is a thin sheet of material placed on the front surface of the tooth, used for aesthetic purposes and
protection. It is usually a thin layer of restorative material replacing the enamel.
• When multiple thin layers of wafer thin shells are chemically bonded to the tooth structure it is called lamin
ate veneer. "lamination" is the process which refers to joining the materials together.
• Veneers are usually the material of choice for a conservative, esthetic approach as they are tooth coloured re
storations in order to the give the patient a perfect smile. This in turn improves the self esteem, confidence t
hus boosting the social life of the patient.
• They were first used in 1928 by a California dentist Charles Pincus for changing the appearance of an act
ors teeth temporarily for a film shooting.
Karishma Ravinthar, Jayalakshmi. Recent Advancements in Laminates and Veneers in Dentistry. Research J. Pharm. and Tech 2018; 11(2):785-787. doi: 10.5958/0974-360X.
2018.00148.8

Karishma Ravinthar, Jayalakshmi. Recent Advancements in Laminates and Veneers in Dentistry. Research J. Pharm. and Tech 2018; 11(2):785-787. doi: 10.5958/0974-360X.
2018.00148.8

• Clean restoration with acetone if tried in with resin-based system.
• Rinse with water if used water soluble medium for try in (glycerine)
• Etch with porcelain etchant (10% HF acid) for 1-3 min.
• Apply porcelain primer 60 sec.
• Prepared veneer should be placed in a light proof box until ready for ce
mentation.
• Isolate the tooth, clean with rubber cups & pumice/soap, place mylar stri
ps (to avoid etching adjacent teeth)
• Cementation of both central incisors first then lateral and cuspids of one
side then another side.
• Finishing and polishing.

8/7/2021 95
VENEER RESTORATION
PRE OPERATIVE
I Anand Sherwood. Fluorosis varied treatment options. J Conserv Dent | Jan-Mar 2010
| Vol 13 | Issue 1
Tooth preparation POST OPERATIVE

8/7/2021 96
SUMMARY
Individual teeth have an inherent lightness potential (ILP) beyond whi
ch they do not lighten despite further bleaching. It is currently impos
sible to predict the ILP from looking at the teeth.
Determining the duration and concentration regimens more appropri
ate for children based on age and dentition type is in the best interes
t of dentistry and the health of our future adults.
Whitening time of an individual treatment should not be extended in
an attempt to increase effects

8/7/2021 97
1. Sean S. Lee, Wu Zhang, D. Harvey Lee, Yiming Li. Tooth Whitening in Children and Adolescents: A Litera
ture Review. Pediatr Dent 2005; 27:362-36
2. A. Watts, M. Addy. Tooth discolouration and staining: a review of the literature. British Dental Journal 20
01; 190: 309-316
3. John I Ingle, Leif K Bakland-Endodontics. 6th edition 2008
4. Manuel ST, Abhishek P, Kundabala M, Etiology of tooth discoloration- a review. Nig Dent J Vol 18 No. 2
July - Dec 2010
5. Suchetha A, Khawar S, Mundinamane DB, Apoorva SM, Bhat D, Govindappa L. ALL ABOUT DENTAL ST
AINS: A REVIEW (PART I) Annals of Dental Specialty Vol. 4; Issue 2. 2016
6. Norma Suely Falcão de Oliveira Melo , Regina Paula Guimarães, Vieira Cavalcante da Silva , Antonio Adil
son Soares de Lima. Green teeth resulting from neonatal. Pediatric polska. 2015(155-160).
BIBLIOGRAPHY

8/7/2021 98
7. Suzana Sommer, Magagnin K, Kramer PF, Tovo,MF ,Bervian J .Green Teeth Associated with Neonatal Hyper
bilirubinemia Caused by Biliary Atresia: Review and Case Report. J Clin Pediatr Dent 35(2): 199–202, 2010
8. S.B. Patil, S. Hugar, S. Patil . Green teeth associated with hyperbilirubinemia: a case report. European Jour
nal of Paediatric Dentistry. 15/2-2014
9. Stephen A. Fayle* / Maxine A. Pollard. Congenital erythropoietic porphyria — Oral manifestations and den
tal treatment in childhood: A case report. Ouintessence Int ¡994:25:551-5
10. Bhavasar R, Santoshkumar G, Prakash BR. Erythrodontia in congenital erythropoietic porphyria. J Oral Maxi
llofac Pathol 2011;15:69-73.
11. Siekert RG, Gibilisco JA. Discoloration of the teeth in alkaptonuria (ochronosis) and parkinsonism. Oral Su
rg Oral Med Oral Pathol 1970; 29:197-199.
12. Peter JM Crawford, Michael Aldred, Agnes BlochZupan. Amelogenesis imperfecta. Orphanet Journal of Ra
re Diseases 2007: 2:17
BIBLIOGRAPHY

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13. DAVID BIXLER, PATRICK M. CONNEALLY, ARDEN G. CHRISTEN. Dentinogenesis Imperfecta: Genetic Varia
tions in a Six-Generation Family. J Dent Res. 1969. Vol 48 No. 6.
14. Halima Abukabbos , Faisal Al-Sineedi . Clinical manifestations and dental management of dentinogenes
is imperfecta associated with osteogenesis imperfecta: Case report. The Saudi Dental Journal (2013) 25, 15
9–1651.
15. Arun Kumar, Vijay Kumar, Janardhan Singh, Anita Hooda, Samir Dutta. Drug-Induced Discoloration of Te
eth: An Updated Review. Clinical Pediatrics; 2012; 51(2) 181–185.
16. Joshi SB. An overview of vital teeth bleaching. J Interdiscip Dentistry 2016;6:3-13.
17.Welbury R. Duggal M. Hosey M. Paediatric Dentistry. 4th edition. 2014. Oxford universotiy press.
18.Bleaching techniques in restorative dentistry- Linda Greenwall 2002. martin Dunitz Ltd London.
19.Howard E Strassler. Vital Tooth Bleaching : An Updte. Continuing Educatio. 2006
20.Policy on the Use of Dental Bleaching for Child and Adolescent Patients.AMERICAN ACADEMY OF PEDI
ATRIC DENTISTRY. REFERENCE MANUAL V 36 / NO 6 14 / 15.
BIBLIOGRAPHY

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