BLEACHING.ppt

Bleaching of vital and non-vital
discolored teeth
Priya Mittal

INTRODUCTION
 Discoloration of tooth is one of the most frequent reason why a
patient seeks dental care.
 Tooth discoloration is usually esthetically displeasing and
psychologically traumatizing

Color of Natural healthy tooth
 Louka(1989)- Teeth are polychromatic
 Color varies among incisal, cervical area of teeth
 Color of healthy tooth - primarily determined by dentin
J cand dent assoc, 1989,55(1);28-32

Tooth Discolouration
Tooth discoloration is defined 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
location of stains
J Esthet Dent 1999; 11:291-99
Extrinsic Stain Intrinsic Stain
Direct Indirect Preeruptive Posteruptive

J Am Dent Assoc 1997; 128 Suppl: 6-10
Nig Dent J Vol 18 No. 2 July - Dec 2010
Extrinsic Causes of discoloration

N1 type dental stain or direct dental stain-
 Coloured material(chromogen) binds to the tooth’s surface &
causes discoloration.
 Color of chromogen is similar to that of dental stain.
N2 type dental stain or direct dental stain-
 Colored material (chromogen) changes color after binding to
tooth.
N3 type dental stain or indirect dental stain-
 Pre-chromogen binds to the tooth and undergoes a chemical
reaction to cause a stain.
Nathoo’s Classification(for extrinsic dental stain)
J Am Dent Assoc1997:128(4);35-9

INTRINSIC CAUSES OF DISCOLORATION – PRE ERUPTIVE

Post Eruptive causes

Intrapulpal haemorrhage
Pulp extirpation or severe tooth trauma
Rupture of blood vessels- hemorrhage in pulp chamber
Blood components flow into the dentinal tubules
Discoloration (Initially temporary color
change of crown to pink )
This is followed by hemolysis of red blood cells
iron reacts with hydrogen sulfates(produced by bacteria) to
dark colored iron sulfates, which discolor the tooth grey.
J Am Dent Assoc 1997;128:6S–10S

Calcific metamorphosis
 Traumatic injuries
Temporary disruption of blood supply occurs, followed by the
destruction of odontoblasts
These are replaced by undifferentiated mesenchymal cells that
rapidly form reparative dentin
Translucency of crowns of teeth gradually decreases
Yellowish or Yellow-brown discoloration.
Int Endod J 2003;36:313–29

TREATMENT MODALITIES FOR DISCOLORED TEETH
 Enamel microabrasion & macroabrasion
 Direct veneers - composite
 Indirect veneers-Ceramic or Composite
 Crown
 Bleaching - Vital or Non-vital

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
Ingle 6th Edition , pg no 1238

History
Bleaching techniques in restorative dentistry, Linda Greenwall, pg no 88-92
Year Name Material Used Discoloration
1848 Dwindle Chloride of lime Non-vital tooth
1860 Truman Chloride and acetic
acid Labarraque’s
solution (liquid
chloride of soda)
Non – vital teeth
1868 Latimer Oxalic Acid Vital teeth
1884 Harlan First used hydrogen
peroxide
All discoloration
1910 Prins 30% hydrogen
peroxide
All discoloration
1958 Pearson 35% hydrogen
Peroxide inside
tooth
Non-Vital teeth

1961 Spasser Walking Bleach
Technique (sodium
Perborate & water
sealed in pulp
chamber)
Non-Vital Teeth
1965 Stewart Thermocatalytic
Technique ( pellet
Saturated with
Superoxyl & heated
with hot instrument)
Non-Vital Teeth
1967 Nutting & Poe Combination walking
Bleach (Sodium
Perborate & 35 %
hydrogen Peroxide in
pulp chamber)
Non-Vital Teeth
1987 Feinman In-office / Power
Bleaching (30%
hydrogen peroxide &
heat from Bleaching
Light)
Vital Teeth

1989 Haywood & Heyman Night Guard
Bleaching
(10% carbamide
peroxide in tray)
All Stains, Non-Vital
& Vital Teeth
1990 Commercial Over
the counter products
Vital teeth
1991 Gaber & Goldstein Combination
Bleaching ( power
& home Bleaching)
Vital teeth
1996 Reyto Laser Tooth
Whitening
Vital teeth
1998 Carrillo Inside & outside
technique
Non-vital teeth

Present Day •Power gels for in office bleaching
Laser activated bleaching
•Home bleaching available in
different concentration & flavors
Dent Update 2010; 10: 101-108

18
 Hydrogen peroxide
 Sodium perborate
 Carbamide peroxide
 Thickening agent – Carbopol , glycerine or glycol
 Urea
 Surfactant
 Preservatives
 Flavouring Agents
 Fluoride
CONSTITUENTS OF BLEACHING GELS

19
Oxidation-reduction reaction / redox reaction
• Oxidizing agent (eg, hydrogen peroxide) has free radicals with
unpaired electrons, which it gives up, becoming reduced.
• Reducing agent (substance being bleached) accepts the electrons
and becomes oxidized.
MECHANISM OF BLEACHING
Complete Dental Bleaching, Goldstein, pg no 28-30

20
IONIZATION OF HYDROGEN PEROXIDE AT ACIDIC pH
H202 H20 + 0. (Weaker free radical)
H + (Lower percentage of stronger free radical)
H02
.
Hydrogen Peroxide action

IONIZATION OF BUFFERED HYDROGEN PEROXIDE (pH 9.5 to 10.8)
21
H202 H20 + 0.
H + H02
.
Higher percentage of stronger free radical

Sodium perborate action
 Occurs in the form of mono-, tri- (NaBO2 • H2O2 • 3H2O) or
tetrahydrate
 Stable - when dry
 In presence of acid, warm air, or water, breaks down to form
sodium metaborate, hydrogen peroxide, and nascent oxygen
 Sodium perborate safer than concentrated hydrogen peroxide
solutions
Gen Dent 1985;33:121–2

 Most commonly used concentration is 10%
10% carbamide peroxide(CH6N2O3)
3.35% H2O2 & 6.65% urea(CH4N2O)
 Contain either carbopol or glycerine base to slow down release of
hydrogen peroxide
 Bleaching ability equal to hydrogen peroxide (Lim et al. 2004)
Carbamide peroxide action
Int Endod J 37: 483–488 (2004)
J Prosthet Dent 69:325–328(1993)

Bleaching techniques
Non-vital
•Walking bleach
•Thermocatalytic
•Inside/Outside bleach
Vital
•In-office or power
•Night guard or at
home or matrix
bleaching
•Over the counter

Indications-
 Discoloration of pulpal chamber origin
 Discoloration of dentin
Contraindications-
 Superficial Enamel Discoloration
 Defective Enamel Formation
 Severe Dentin Loss
 Presence of Caries
 Discolored Composite
Non-vital bleaching
Dent Clin North Am 1989;33:319 –36

Preliminary Treatment
 Familiarize patient with expected outcome & possibility of future
discoloration
 Radiographs - to assess status of periapical tissue & quality of obturation
 Assess quality & shade of restoration if already present, if defective –
replace with temporary material
 Evaluate tooth with Shade guide & take clinical photographs at Beginning
of & throughout procedure
 Isolate tooth with rubber dam, interproximal wedges may be used for better
isolation
Int Endod J 2003;36:313–29
Quintessence Int 1995;26:597– 8

WALKING BLEACH TECHNIQUE
Barrier
Gutta percha removal

Barrier
 Root filling does not adequately prevent diffusion of bleaching
agents from the pulpal chamber to the apical foramen
 Hansen- Bayless and Davis - base is required to prevent radicular
penetration of bleaching agents
J Endod 1992;18:476–81
Am J Dent 1992;5:151– 4

 McInerney and Zillich - Cavit and IRM provided better internal
sealing than zinc phosphate cement
 Hansen-Bayless and Davis – Cavit more effective barrier to leakage
than IRM
 Hydraulic filling materials - most favorable cavosurface seal , when
compared with photoactivated temporary resin material (Fermit),
zinc oxide eugenol cement and zinc oxide phosphate cement
Barrier Material
J Endod 1992;18:376–8
Am J Dent 1992;5:151– 4
J Endod 2000;26:716–8

 Rotstein et al – 2-mm layer of glass-ionomer cement effective in
preventing penetration of 30% hydrogen peroxide solution in root
canal
 De Oliveira et al - application of RMGIC - better apical seal than
conventional GIC
 MTA as a barrier for non-vital bleaching
J Endod 2000;26:716–8
Journal of Clinical and Diagnostic research
2012 May (Suppl-1), Vol-6(3):527-529
Dent Traumatol 19: 309–313(2003)

PLACEMENT OF BARRIER
Proximal View
Incisally oriented dentinal tubules Proximal level of CEJ curves in an incisal
direction. A flat barrier, level with labial
CEJ, leaves a large triangle of unprotected
dentinal tubules.

BARRIER TRANSFER

Bobsled Tunnel Ski slope
Barrier outline forms
Complete Dental Bleaching, Goldstein, pg no 37

Bleaching Material
 Bleaching agents - most commonly used for whitening of root-filled teeth
are hydrogen peroxide, carbamide peroxide, and sodium perborate
 Hydrogen peroxide - as a whitening material at different concentrations
from 5%–35%.
 Carbamide peroxide - organic white crystalline compound formed by urea
and hydrogen peroxide and used in 3-15% concentrations.
mostly carbamide peroxide preparation include glycerin because this
makes it more chemically stable compared with hydrogen peroxide
 Sodium perborate - oxidizing agent available as a powder. Sodium perborate
is easier to control and safer than concentrated hydrogen peroxide solutions
JOE — Volume 34, Number 4, April 2008

Comparative studies-
 Rotstein et al 1993 - no significant difference in effectiveness
between sodium perborate mixed with 3% or 30% hydrogen
peroxide and sodium perborate– distilled water mixture
 Sodium perborate with 30% hydrogen peroxide was more effective
than mixing with water
 Shade stability of teeth - treated by mixture of perborate and water is
high in comparison with mixture of sodium perborate with 3% or
30% hydrogen peroxide
J Endod 1993;19:10 –2
Int Endod J 2002;35:433– 6
J Endod 2000;26:25– 8

 Aldecoa et al 1994 - good clinical success with mixture consisting of
sodium perborate and 10% carbamide peroxide gel
 Carrasco et al. 2003 - 37% carbamide peroxide shows the best
penetration into dentin, while sodium perborate mixed with 20%
hydrogen peroxide or 27% carbamide peroxide does not penetrate as
deeply into dentin
Quintessence Int 1994;23:83–9
Dent Traumatol 19: 85–89 ,2003

Thermocatalytic
 Placement of oxidizing agent 30% to 35% H2O2 in pulp chamber
followed by heat application – touch & heat system or heated
plugger
 Caldwell et al- Heat application causes a reaction that increases
bleaching properties of 35% hydrogen peroxide by increasing ion
concentration about 200 times
 Temperature range is between - 50-60ºC
 Bleaching should be limited to 5 min period
rather than long continuous period
Gen Dent 1985;33:121–2

Post bleaching tooth restoration:-
 After bleaching, - access cavity - restored with resin composite, which is
bonded by means of the acid-etch technique to enamel and dentin
 Remnants of peroxide or oxygen inhibit the polymerization of resin
composites.
 Optimal bonding to bleached dental hard tissue can be achieved-
 Calcium hydroxide dressing placed in the pulp cavity - period of about 3 weeks - for
buffering acid pH
 Dehydrating agents - alcohol and acetone-containing adhesives
 Anti Oxidant- catalase or ascorbic acid (10%)
J Esthet Dent 6: 157–161 (1994)
J Dent Res: 81: 477–481 (2002)

Application Time
 Camps et al. 2007- based on the diffusion rate of hydrogen in dentin – to
determine the ideal time point for reapplying bleaching agent.
 Because of different structure of young and old dentin,
 Ideal application time of 33 hours for young patients and
 18 hours for older patient
J Endod 33: 455–459 (2007)

Inside/outside Bleaching
 Bleaching agent application - both on external and internal surfaces of tooth
 Access cavity remains open during entire treatment process
 Vacuum-drawn splint is made with reservoirs buccal and palatal to tooth to
be bleached
 Patient is instructed in the use of the splint.
 Using syringe, the access cavity and the corresponding location of the
vacuum-drawn splint are filled with 10% carbamide peroxide (pea-sized
amount of bleaching agent). .
 Splint is worn at night – to protect the open tooth.
 After period of bleaching, the patient should clean the access cavity. Recall
is recommended every 2 or 3 days to monitor the color change
Schweiz Monatsschr Zahnmed Vol. 120 4/2010

 Advantage –
 low concentration of bleaching gel is sufficient to obtain the desired
effect
 Disadvantage-
 lack of bacterial control during bleaching.
 microorganisms can colonize dentin tubules,
 Danger exists with bleaching result & also the long-term success of the
endodontic treatment may be compromised
 Bizhang et al. 2003- success with the inside/outside technique
equal to walking bleach technique
Oper Dent 28: 334–340 (2003)

Adverse effects of non-vital bleaching

Cervical root resorption
 Incidence - varies greatly, from 1% to 13%
 Cervical resorption is mostly asymptomatic and is usually detected
only through routine radiographs
 Sometimes swelling of the papilla or percussion sensitivity can be
observed
Mechanism- irritating chemical diffuses via unprotected dentinal
tubules and causes necrosis of the cementum, inflammation of the
periodontal ligament and subsequently root resorption
Quintessence Int 30: 83–95 (1999)
J Am Dent Assoc 1997;128(spec iss):56 –9

PREDISPOSING FACTORS-
 Age –
Young age often have external resorption - hydrogen peroxide can more
easily penetrate into periodontium because of wide open dentinal
tubules in young teeth
 Temperature –
Application of heat (thermocatalytic method) leads to widening of
dentinal tubules and facilitates diffusion of molecules into the dentin
 lack of cervical seal
J Endod 1992;18:145– 8.

Comparative studies
 Thermocatalytic technique is used less because of the high risk of
external root resorption that is associated with heat application.
 Walking bleach technique with a sodium perborate– hydrogen
peroxide solution did not cause cervical resorption
 Carbamide peroxide has been more recently recommended for use in
intracoronal bleaching - 35% carbamide peroxide showed the lowest
levels of extraradicular diffusion, whereas 35% hydrogen peroxide
showed the highest, with sodium perborate having intermediate
values Int Endod J 2004;37:500–6
J Endod 1998;24:229 –32
J Dent Res 1983;62:956 –9

VITAL BLEACHING
Indications-
 Age yellowing discoloration
 Mild tetracycline staining
 Mild fluorosis
 Absorptive & penetration stains(tea & coffee)
Contraindications-
 Severe tetracycline staining
 Severe fluorosis
 Pitting hypoplasia
 Tooth surface loss due to attrition, abrasion & erosion

 Isolation - Application of rubber dam or liquid dam. Liquid dam- Light cure
resin barrier material
 Soft tissue retraction- cheek retractor with tongue guard
 Tissue protection - by gauze and cotton wool rolls placed inside the lips and
cheeks to keep them away from the gel
 Vaseline - on lips to reduce cracking of the lips and prevent them from
drying up
IN –OFFICE /CHAIR-SIDE / POWER BLEACHING
Dent Update 2005; 32: 101-108

 Carbamide peroxide - 35% or Hydrogen peroxide - 17–50%
 Application of gel (creamy consistency) – 2-3 mm layer on labial
surface of tooth ( in Smile Zone)
 Gel placement time- depending on product & concentration of agent
 Usually 10 min, range 3-20 min
 CYCLE – usually three ; 10 min cycles known as PASSES (3-4 , 20 min passes
if concentration of agent low)
Material Used-
Dent Update 2005; 32: 101-108

Activation-
 Curing Light , Laser
 Chemical reaction on mixing gel
 Dual activation System
Journal of Orofacial Research Volume 1: Issue 1: 2011

CURING LIGHTS
Diode Lasers
Xe-Halogen Technology
Metal Halide Lamp
Plasma Arc Lamp
Halogen curing light
Journal of Orofacial Research Volume 1: Issue 1: 2011

COMMERCIALLY AVAILABLE IN-OFFICE BLEACHING
PRODUCTS
Pola office 35 % hydrogen
peroxide
With or without light SDI
Dent Update 2008; 32: 101-108

Comparative studies-
 Some studies have shown - light activated/ enhanced bleaching
products provide better whitening
 Whereas other studies demonstrate that there is no benefit of using
an accessory light
J Am Dent Assoc 135(2):194–201, 2004
J Dent Res 85 (Special Issue A): Abstract no275, 2006
Am J Dent 18:194–197, 2005
J Esthet Restor Dent 21:336-347, 2009

Clinical case 3 - with Biolase diode laser system

 Also known as Matrix bleaching, Dentist prescribed/assisted home
applied bleaching, Dentist superwised at home bleaching
 Material Used- 1.5 to 10% hydrogen peroxide or 10 to 15%
carbamide peroxide, that degrade slowly to release hydrogen
peroxide
Night Guard Bleaching -
Dent Update 2005; 32: 101-108

Tray Fabrication

Bleaching Schedule
Bleaching techniques in restorative dentistry, Linda Greenwall, pg no 56

 Dunn 1988 – compliance of patient with wearing trays at night more
than day time.
 During day after 1-2 hrs – because of- occlusal pressure & increase
salivary flow – more loss of material in comparison to night
 Haywood 2000 – wearing tray at night is preferable
Compend Contin Educ Dent 1998;9(8);760-4
J Am Dent Assoc 2000;128;19s-23s

Over-the-counter products
Self-applied to teeth via -
 Strips
 Paint-on products
 Mouth rinse
Material used –
Whitening strips- 3-6 % hydrogen peroxide
Paint-on brush - 18% carbamide peroxide
Mouth rinse - 2% hydrogen peroxide for whitening
J Dent 2006;34:412–9.
J Dent Res , Abstract no. 1380, 2006

Comparative studies
 Whitening strips performed significantly better at whitening than
either a paint-on bleaching product or a nonperoxide whitening
toothpaste
 Whitening effect of home trays with a low concentration of
carbamide peroxide (5%), good in comparison to - paint-on product
(18% carbamide peroxide) and a 1% hydrogen peroxide toothpaste
were not as effective
 Whitening effect (probably extrinsic stain removal) when Colgate
Simply White (18% carbamide peroxide ) was compared to a
whitening toothpaste -Crest Vivid White( sodium hydroxide)
J Dent Res 84 ,Abstract no. 290,2005
J Clin Dent 15:112–117, 2004
Compend Contin Educ Dent 24:458–466, 2003

Tooth sensitivity-
 Incidence- 18%–78% of patients, either with at-home tray delivery
or in-office procedures
To minimize tooth sensitivity-
 Passive treatment - Decrease the time the tray is worn the first week,
to no more than 1 hour a day for carbamide peroxide products or for
higher concentration hydrogen peroxides, as little as 15 minutes a
day or use lower concentrations of peroxide
Adverse effects of Vital Bleaching
J Amer Dent Assoc 136:383–392, 2005
J Clin Dent 16:17–22, 2005

Active treatment
 5% KNO3 - effective desensitizer in toothpastes
 5% KNO3 desensitizing agents in bleaching gels.
 Addition of KNO3 to bleaching gels does not provide the sensitivity
relief that is seen with KNO3 in extended use with desensitizing
toothpastes
 Amorphous calcium phosphate (ACP) -effective desensitizer
 Recent research has shown that paste containing casein
phosphopeptide- amorphous calcium phosphate (CPP-ACP), has
been effective in reducing tooth sensitivity due to bleaching
J Esthet Restor Dent 18:301–304, 2006.
J Dent Res 85 (Special Issue A): Abstract no. 1369, 2006.
J Dent Res 85 (Special Issue A): Abstract no. 1943, 2006

Effect of Bleaching on Color Change and Surface Topography of
Composite Restorations
 Study was conducted to determine the effect of 15% carbamide
peroxide bleaching agent on color change and surface topography of
different composite veneering materials (Filtek Z350 (3M ESPE),
Esthet X (Dentsply India), and Admira (Voco, Germany)
 Surface Roughness- Esthet X showed maximum surface roughness
followed by Admira and Filtek Z350.
 Color change- Bleaching was effective in reducing the discoloration
to a clinically acceptable value in all the three groups
Shah N International Journal of Dentistry
Volume 2010, Article ID 695748

BLEACHING RELAPSE
Bleaching relapse has been reported
 In office bleaching- relapse of 41% at 1 year
 Tray bleaching - 26% at 18 months
 Studies have compared in-office bleaching to at-home tray bleaching
At-home, tray bleaching usually gives the best final result
Dental update, 28(6):1–2, 2004
Compend Contin Educ Dent 25:119–131, 2004
Quintessence Int 37:515–526, 2006

Maintaining Whitened Teeth – minimizing
bleaching relapse
 Use whitening toothpaste to remove surface stains
 Brush or rinse immediately after consuming stain causing beverages
or food
 Use straw to drink beverages that stain such as coffee, tea, red wine
 For women wear bright shade lipstick – blue/ pink based to make
teeth appear whiter
 Check whether there is need for touch up
J Esthet Restor Dent 14:275–285, 2002

Conclusion
 Goal of modern dentistry is maximum preservation of tooth substance with
excellent aesthetics.
 Bleaching alone or in combination with minimally invasive adhesive
dentistry fulfils this goal very often without need to progress to the much
more destructive techniques of veneers, crowns and bridges

Learn from yesterday, live for today, hope for
tomorrow. The important thing is to not stop
questioning.” -Sir Albert Einstein

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