BLEACHING

Attractive teeth have always been the typical patient’s primary concern.

Today with the advent of new materials and techniques dentist can meet the or even exceed the
expectation of the patients for beautiful smile with brighter and whiter teeth.

Bleaching has now become the most common esthetic treatment for the patients. Earlier bleaching
techniques and services were provided by special esthetic dentist. But now with the increase in demand,
bleaching has become integral component of every clinic.

Bleaching is simplest, least invasive, least expensive means available to lighten discolored teeth
and diminish or eliminate many stains in both vital and non-vital teeth.

Tooth discoloration affects both primary and permanent teeth with etiology being multifactorial.

Men > women

31% 21%

Bleaching is an inexact science, deals with numerous factors, dentist skills, and type of discoloration age
of the patient.

Management of discolored teeth

in office - thermocatalytic
-chemical
-Laser- Argon
-Co2
-KPT
-Plasma Bleaching

At home - Night guard bleaching

- Trays/foam bleaching
- Over-the –counter bleaching aids
- Toothpaste
-
Walking bleach, combination walking bleach, inside/outside technique.
Microabrasion
Macro abrasion
OTC - tray systems, trayless systems, Chewing gums, tooth pastes, paint on products, bleaching
strips.
Masking technique/ infiltration technique
Crowns veneers Laminates

Colours of Natural tooth:-

Teeth are polychromatic – colour varies from gingival,incisal cervical
-Varies according to thickness enamel, dentin

Primary teeth- bluish white

Permanent teeth- grayish yellow, white
Older teeth- darker, yellow

Etiology / cause of Discolouration Feinman 1987

An agent when stains or

damages the enamel surface of
the teeth.
 (A) EXTRINSIC DISCOLOURATION

Superficial changes affecting only ENAMEL

Tea/Coffee/ cocoa- Tannins

catechins
Polyphenol
Leucoanthocyanins
Nasmyth membrane- green

chlorhexidine– bleach/brown Local in origin, exogenous

Marijuana- Sharply delineated,rings around in nature. Deposited as a

the cervical position of teeth. result of Vander Waals

Iron tablets/ supplements forces, electrostatic

Nicotine / smoke/cigar/bidi/pipe
forces, hydration forces,
hydrophobic interaction
Tobacco chewing
and hydrogen bonds.
Red wine

swimmer’s calculus-prolonged exposure to

pool water

Feinmen 1987

Internal tooth structure penetrated

(B) INTRINSIC DISCOLOURATION by discolouring agent
May occur even before the tooth eruption
Tetracycline
Amelogenesis imperfecta Genetic Conditions.
Dentinogenesis imperfecta
Dentin dysplasia
Pulp necrosis
Endemic fluorosis
Hematological disorders

Erythroblastosisfetalis-brownish discolouration of RBC

 Thalassemia

Sickle cell anemia

Trauma- Dark pinkish immediately after trauma dark brown/ pinkish brown
few days later.
 Hemin
 Hematin
 Hematoidin
 Hematoporphymis
 Hemocidemrin
 Hemoglobin+hydrogen Sulphide(bacteria)—
iron sulphide(black)

Residual pulp tissue post RCT

Congenital Syphilis

Hereditary hypoplasia

Jaundice – congenital hyperbilirubinemia- Stains dentin yellow green

Porphyria -> purplish reddish

Vitamin C deficiency

Calcium phosphate deficiency

Alkaptonuria- genetic disorder of phenylalanine and tyrosine- brown

pigments

Calcific metamorphosis- Condition characteristics by rapid deposition of

hard tissue within root canal yellow

(C) IATROGENIC CAUSES

In-appropriate bleaching techniques

Intracanal medication –oils

-ledermix pastes
 Nitrate (eugenol-orange yellow stain)

Leaky composite restorations

Stannous fluoride treatment golden –browns

Tissue remnants in pulp

Root canal sealers

Corrosion of pins, silver cones

Amalgam-amalgam hue

Copper amalgam- bluish black –green.

D. AGING

Aging of tooth – depositon of secondary and tertiary dentin, pulp stones

- Flat loss of optical properties

- Yellow, darker, infarcts

- Loss of enamel-reflect amalgam more-> grayish appearance

of tooth -> results from attrition abrasion erosion.

- Food, tea, coffee stains accumulated over time.

Aging of Restoration-greyish discolouration

- Amalgam hue

(E) other classification

(I) Nathoo’s classification of Extrinsic discolouration (1997)

N1 type or direct dental stain: coloured materials

Chromogen build to the tooth surface and cause discoloration. The color of dental stain is same
as color of chromogen (Ex-tea coffee wine)

N2 type or direct dental stain:-

The chromogen change colour after binding. (Food stain when darker with age)

N3 type or indirect dental stain: colourless material or prechromogen binds undergoes

chemical reaction to cause a stain (stannous fluoride)

(II) pathologic--- Physiologic--- iatrogenic

 (III) exogenous --- endogenous

(iv) Metallic----Nonmetallic

(v)pre-eruptive---Post-eruptive

Tetracycline staining – yellow brown

Grey stains

-teeth susceptible during tooth formation.

- second trimester in utero till 8 yrs of age

-incorperate into dentin.

- chelate with calcium to form

[tetracycline orthophosphate] ---light----Photooxidation----
appears dark ,brown,grey

4 types: Jordon &K Boksman 1984

First degree: mild tetracycline staining: yellow to grey, uniformly spread, no banding

Second degree: moderate staining: yellow brown-dark grey no banding.

Third degree: severe staining: blue-grey, black with severe banding.

Fourth degree: intractable staining : so dark that bleaching is ineffective.

Minocycline staining - black/grey.

-medication taken by adult due to severe acne.

-discolouration in already formed teeth.

- absorbed from GIT chelates with iron-from insoluble

complexes +UV-> oxidative dissemation

- semi-synthetic 2nd generation derivative of tetracycline.

Fluorosis

Nattoo & Gaffar 1995 Black & McKay 1916

(1)- simple fluorosis First description of fluorosis(clinical description)

(2)-opaque fluorosis

(3)- Fluorosis with pitting

F> 4 ppm – drinking water

Fluorosis

More>> 3 months of gestation- 6 years

Staining depends on intensity +length of exposure.

Metabolic alteration in the ameloblast in young children

resulting in defective matrix improper calcification.

Range

Mild- white opaque spots to

Severe black/ brown with mottling & pitting--Mottled enamel.

Endemic enamel fluorosis.

Range

Yellow, brown, black, white

hypomineralised, porous –well-mineralised

Chalky-lustre

Root Canal Sealers

Van Der Burgt (1986)

Grossman’s cement

zinc oxide-eugenol Orange/ red stain

 Endomethasone

N2

Tubuliseal

Diaket Mild Pink

AH26---grey

BLEACHING

BLEACHING

----May be defined as the lightening of the colour of tooth through the application of a chemical agent to
oxidize the organic pigmentation in the tooth- GROSSMAN
----The treatment ,usually involiving an oxidative chemical that alters the light absorbing and / or light
reflecting nature of the material structure , thereby increasing its value(whiteners)-ADA

Bleaching is now in new phase of development.

1st phase-> provocative experimental modality.

2nd phase->performed on highly selected pts by dentist pioneering in field of esthetics

3rd phase-> acceptable treatment but provided by specialist dentist(phase of tetracycline staining ,
fluorosis)

4th phase-> in office/matrix bleaching routine techniques in dental clinic.

History

1799

Macintosh -> inverted bleaching powder-> chloride of lime

 1860

Labarraque’s solution

Liquid chloride of soda developed by Truman for non-vital teeth

1877

Chapple

Oxalic acid, hydrochloric acid for all type of discolouration

1889

Harlan-> hydrogen peroxide called as hydrogen dioxide.

1918

Abbot – used high intensity light that produce rapid temperature rise in
H2O2 to accelerate chemical bleaching.

1958
 Pearson

35% H2O2 inside the tooth non-vital.

25% H2O2 + 75% ether +lamp -> heat+light

1961

SPASSER

Walking bleach technique

Sodium perborate + water

Mixed+ sealed in non–vital tooth for 1 week.

1965

STEWART

Thermocatalytic technique

Pellet saturated with H2O2 inserted into pulp and heated with hot instrument.

1966

McInnes

abrasion -> hydrochloric acid-pumice abrasion

Originally developed by (Bouschar in 1965)

1967

Nutting & Poe

Combination walking bleach technique

30% HsOs+ sodium perborate

Into the pulp chamber for 1 week

1968

KLUSMIER

Incidental finding when treating for gum disease

Home bleach concept.

10% carbamide peroxide in custom fitted orthodontic positioners

he use glyoxide proxigel

1979

Harrington & Natkin

Report External cervical resorption with bleaching non-vital teeth

1982
 Abou-Rass

Intentional RCT+ internal bleaching for tetracycline stains

1987

Feiman- in office bleaching

30% H2O2+ heat ( bleach light)

1988

White & brite( 30% H2O2) first commercial product-> results of Munro findings

1989

Haywood & Heyman

Nightguard vital bleaching

10% carbamide peroxide in tray

1991

Goldstein and Garber

Combination bleaching—home and in office

1996

Reyto -> laser tooth whitening

 1997

Settembrini et al

Inside/outside bleaching

Bleaching material applied by patient directly into pulp chamber

and then bleaching tray seated into mouth. Tooth bleached from both inside and outside.

Advantages of Bleaching

Improved esthetics

Low cost

No loss of tooth structure

No need for continuous replacement-> restoration

No chipping /fracture of tooth/restorative material( as in veners/composites)

Less chair time

Increased patient compliance

Minimal invasiveness

When combined with other therapies?

(+) appropriate adjust

(+) synergistic effect

(+) improves the effect of therapy

(+) immediate improvement -> motivated the patient

(-) adds to cost

(-) lack of predictability

(-) adds to chair time.

Disadvantages of Bleaching

-Not a permanent effect-----Requires retreatment

Depends on tea, coffee consumption and smoking

-Require more than 1-2 session

-not effective for all forms of discolouration(tetracycline with banding)

-cannot correct opacity/ white spots in fluorosis.

-cannot alters the shape / form of the teeth.

-cannot be used when enamel is thin.

-post operative sensitivity.

-bleaching is unpredictable, can change the balance of smile.

-Effects the enamel bond strength- due to residual oxygen or peroxide that inhibit setting of bonding
resin

-delayed restorative treatment for at least 1 week.

CHEMISTRY OF BLEACHING

(A) HYDROGEN PEROXIDE / superoxol

Strength is designated by volume

Volume of O2 released by one

Volume of designated H2O2

27.5% H2O2 -> 100 volume

35% H2O2 -> 130 volume

50% H2O2 -> 200 volume

Weakly acidic

MOA: OXIDATION

Transforms an organic substance into chemical intermediates that are lighter in colour.

REDOX REACTION

H2O2- oxidizing agent- gives e-

Enamel/ dentin- reducing agent-accepts e-

H2O2 -> H2O°+O° H2O° >O°

(more potent free radical)

In order to promote formation of HO2° ions the solution should be alkaline.

9.5-10.8

Why should teeth be dry and free of debris??

In presence of salivary catalysts and enzymes.

2 H2O2 --- enzymes --------> 2H2O + O2

 Ineffective as bleaching agent

H2O2

Acidic pH Alkaline pH

HO2°< O° HO2°>O°

Reactions

H2O2 ->H2O+O° ------ acidic

H2O2 -> H+ HO2 ° ------ alkaline

Per hydroxyl

Action on dentin & enamel

Radicals(unstable/ electrophilic)

Xanthopterin

Yellow pigments Diffuse through organic matrix

Highly pigmented
Attack organic molecules C=C (yellow)
carbon ring
White Pigments compounds
Converted into hydroxyl
groups(alcohol)
(eucopterin Break double bonds

Convert to chains

Colourless
 Single bonds

Formation of simpler molecules(reflect less light)

What is saturation point?

darks pigmented carbon ring structures

At saturation point only hydrophilic Lightly pigmented unsaturated structure

colourless structure exist

Hydrophilic non-pigmented structure

SATURATION POINT

Over bleaching Break down of enamel matrix Decomposition of molecular structure

CO2+ water +urea Complete oxidation

Properties of H2O2

Clear liquid

Colourless/odourless

Unstable -> kept away from heat

3-4 months –shelf life

Stored in refrigerators

Caustic-> chemical burn on skin /mucous membrane.

Low molecular wt-> easily penetrate dentin

 [] used -> 5%- 35 % [(Recently 50% are also used)]

Peroxide (products of H2O2)

Organic inorganic

When H2 substituted When H2 substituted

with organic radical with metals.

(pyrozone : 25 % H2O2+ ether)

(B) CARBAMIDE PEROXIDE /CH6N2O3 /CPS

Urea hydrogen peroxide

Bifunctional derivative of carbonic acid

[]- 3-45%

Commonly used- 10% home bleaching

MOA-> 10% carbamide peroxide

Provide alkaline
environment pH 8 (CH4N2O) urea +6.65% ammonia+Carbon dioxide+3.35% Hydrogen Peroxide
 30% carbomide peroxide -> 10% H2O2

15% Carbamide Peroxide -> 5.4% H2O2

Potentiates action of
H2O2 20% Carbamide Peroxide -> 7% H2O2

(C ) SODIUM PERBORATE

Stable,white powder,supplied in granules form water soluble.

3 forms-> monohydrates

Trihydrates

Tetrahydrate

Sodium Perborate + H2O2 -> sodium metaborate H2O2 + O2 + free radicals

MOA
+

Moist tooth structure

Oxygen complexes

act on amino acid / O2 bonds of tooth structure.

Constituents of the bleaching Gels

(1) Bleaching agent- H2O2, carbamide peroxide, sodium perborate.

(2) Thickening agent- carbopol /Non Carbopol / polyx

(3) Urea

(4) Vehicle  glycerine,dentifrice, glycol

(5) Surfactant and pigment dispersants

(6) Preservatives
 (7) Flavouring agents

(8) Fluoride / Remineralizing agents

(2) Thickening agents

Carbopol (carbonypolymethylene) (B.F. Goodrich)

 It a polyacrylic acid polymer

Trolamine (neutralizing agent is added to reduce the pH to 5-7)

Actions

(+) release oxygen glow.

(+) extend the duration of action.

(+) enhance viscosity of material.

(+) thixotropic nature – better retention slow releasing gel

- Improves adherence to tooth.

(+) retards the effervesence

(+) thickens products stay on the teeth to provide necessary time for agent to diffuse into tooth.

(+) prevent saliva from breaking down H2O2.

polyx

- used in colgate platinum system

 composition undisclosed

(3) UREA

Action (+) sterilize H2O2

(+) elevate pH of solution.

(+) enhance other action

 Anticariogenic

 wound healing
(4) VEHCLE Glycol (Anhydrous glycerine)

(+) enhance viscosity.

(+) ease of manipulation.

(-) cause dehydration of tooth.

(-) swallowing may cause sore throat.

(5) SURFACTANTS & PIGMENT DISPERSANTS

increase Surface wetting keep pigments in suspension.

(6)PRESERVATIVES

citroxain

Phosphoric acid

Citric acid

Sodium stannate.

(+) sequestrate metal ions (Cu1Mg1Fe) that increase break down of H2O2.

(+)increase Durability & stability

(+) acidic in nature

(7) Flavouring agent
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OVER-THE COUNTER BLEACHING –KITS

(1) KITS has 3 components

Bleaching gel
Acid Rinse

Citric acid Applied usually for 2

phosphoric acid mins acidic pH
pH 1-2
 Post bleach polishing cream

Contain titanium dioxide that give

paint white appearance that is
temporary

(2) H2O2 strip

Trayless system

Thin strip pre- coated with an adhesive 5.3%

H2O2 gel.

Strip placed directly to the facial, buccal surface and

teethes for 30 mins.

Twice daily/ 14 days

Problems with OTC kits

Over use

Tooth erosion(labial surface)

 Patient may misdiagnose and self prescribe the kit for his condition which may be
inappropriate.

Patient may have existing pulpal exposure that may become exaggerated.

Patient determined to speed up the process may use it overzealously.

WHITENING TOOTH PASTES

Posses both

Therapeutic function Cosmetic function

Reduce caries

plaque removal

Reduce dentinal sensitivity Remove stain & increase whiteness of teeth

Prevent calculus formation

Uses

- To maintain teeth after bleaching

- Remove surface stains

- Prevent colour regression

Acc to Haywood (1996) they are of various types based on MOA

(1) More abrasive that usual

- Remove stain by “sanding “ the teeth

- Leads to abrasion of enamel

-teeth appear more yellow.

(2) chemical removal of surface pellicle

-removes surface pellicle that

- remove surface stain

-tartar control

-contains -> titanium dioxide

Surface phenomenon

Acts by entering the surface irregularities

Illusion of white teeth.

(2) Toothpaste containing peroxides [ ] -1.5% -10%

H2O2

Calcium peroxide

Sodium percarbonate

CPS

(4)Prophylaxis paste containing H2O2

-used by dentist

-H2O2 +pumice (lighten +clean)

Chemical abrasive
 (5)Toothpaste containing sodium bicarbonate

Small particle size

Penetrate into enamel

Clean inaccessible areas

(6)Toothpaste containing enzymes

Bromine remove pellicle layer

Per pain slow down development of plague.

(7) toothpaste with multiple components

May contain upto 14 active ingredients.

Advice : proper selection of toothbrush

pea size application of paste

prevent over vigorous brushing

start on side of dorminant hand to prevent recession and sensitivity

Ideal properties of home bleaching agents:-

-easy to apply( for max compliance)

- non acidic /neutral pH.

-improve esthetics(lighten the colour)

- remain in contact with oral tissues for short periods

-have adjustable peroxide [ ]

-use minimum quality of bleaching agent

-do not irritate /dehydrate oral tissues

-do not cause damage to teeth

-be well controlled by the dentist to customize the treatment to the patient’s needs.

Factor’s affecting bleaching

(1) Surface cleanliness: distinguish between intrinsic and extrinsic stain.

Debris minimize contact of bleaching agent on tooth.

(2) [ ] of agent : α

[ ] appointment increase time

(3) Shelf-life: CPS more stable than 1-2yrs> H2O2 weeks

(4) Temperature: α

Accelerate release of oxygen free radicals.

Reaction gets doubled with increase of 10°C.

High temperature- Sensitivity damage to pulp/PDL

X LA should not be administered

(5) pH: alkaline > acidic

H2O2 -9.5 -10.8

(6) Time: α: time (+) effieciency (+) Sensitivity (-)

(7) Sealed environment : H2O2 sealed in the across cavity maintain the required [ ] for active
bleaching.

(8) Additives : glycol

Glycerin reduce efficacy

dentifrice

(9) Amount of discolouration

Gender

Age patient factors

Intitial colour of tooth

Type of stain

Why does colour Regression or shade replace occur?? (haywood 1999)

Occur once 2 weeks

(1) Tooth is filled with O2 from oxidation process

This changes the optical qualities of the tooth to appear more opaque.

After 2 week O2 dissipated and tooth demonstrates actual lightened shade.

Teeth equilibrating to new actual shade.

(2) Previously oxidized substance may become chemically reduced and cause the tooth to
reflect old discolouration.

(3) Enamel may become remineralized with the staining molecule of original stain.

Effect of Bleaching agents on

Composite : (-) surface hardness may altered.

(-) surface roughening/ etching

(-) increase micro leakage

(-) removal of extrinsic stain around existing restoration

(-) Restoration may be replaced due to change in colour of tooth.

Amalgam : ( -) release of mercury from amalgam

( -) microstructural change in surface of amalgam

 GIC: (-) increase microleakage around GIC

(-) water sorption

(-) hydrolytic degradation

(-) alteration in matrix of GIC

IRM : H2O2 -> IRM -> crack and swollen

Provisional crown: (-) orange (methyl methacrylate )

Porcelain crown: (-) surface roughness.

Enamel : (-) reduce bond strength to enamel

(-) presence of residual oxygen

(-)delay restorative treatment for 2 weeks.

(-) inhibits polymerization of resin

(-) resin tags in bleached enamel are less in no, less defined and shorter than in
unbleached enamel

Cementum: walking bleach -> external cervical root resorption

 Pulp: transient reduction in pulp blood circulation.

Occlusion of pulpal blood vessels

Increased sensitivity.

Home bleaching: transient mild temperature sensitivity

dose related ✔ not pH Related X

Dentine : (+) colour change uniform and throughout dentin

(-) dentin bonding altered

Enamel : Ca/P ratio surface hardness

Erosion(mild & shallow)

roughness

Gingiva: Tissue sloughing

Chemical burn

Soreness

Irritation/ ulceration

Oral mucosa : home bleach ingested

Sore throat

Unpleasant taste

Burning palate
 Gastric irritation :laxative effect

Diagnosis & treatment planning

(1) Determine the etiology of discolouration

(2) Visual examination
(3) History (behavioural) – use of tobacco, nicotine
(4) Medical history (systemic problem/ medication)
(5) Water fluoridation/ address
(6) Informed consent
(7) Record baseline data -> video camera
 Photography
(8) Oral examination
Teeth -> hard tissue
 gums -> soft tissue
(9) Radiography of teeth to be bleached.
(10)Check soundness of teeth to be bleached
 Large pulp
 Recent restoration
 Recent orthodontic treatment
 Presence of deep microcrack -> prismatic effect
-> Uneven colour
(10) Determine Vitality of teeth.
Ice -> cold water-> air-> heat

->determine the type of bleach to be used.

(11) Perform complete prophylaxis (prophy jet 30)
(12) Bleaching technique
(13) post operation prophylaxis
(14) post op instruction
(15) photography
(16) photography at recall visit.

Contraindication of bleaching
Extremely large pulp
Exposed root surface
Ortho trt
Severe loss of enamel.
Presence of extensive restoration
Nursing lactating mother
Patient allergic to peroxides
In house bleaching -> incase of latex allergy, use latex-free rubber Dan

Lack of patient compliance

Transient hypersensitivity due to prolonged application.
Hypersensitivity reaction – sore throat
Irritation due to prior bleaching agent
Burning
Flat enamel – already loss of enamel reflective properties.

Indication of Bleaching
Fairly light stain -> yellowinnate colour or due to aging
 Brown

Even distribution of stain

Consistent on all teeth
No amalgam restoration /crown
Enamel -> evenly deposited
no pits/cracks
No need to change the tooth structure.
Bleaching in older patient
-They have severely worn enamel.
- shorten chain time
-low cost required
-lack of invasiveness
-pulp recessed – high temperature can be used
-old degraded amalgam restoration present
- have cumulative staining effect-> years of smoking, tea, coffee use.
-flat enamel.

Bleaching in younger patient

- Porous enamel – easy diffusion of H2O2.
- large pulp –sensitivity increase
-less attention to home care.
Before bleaching -> do not clean the tooth
 Advised useof disclosing tablets
 Use of rotadent devices advocated.
 IN OFFICE BLEACHING
Synonyms : chairside bleaching
Power bleaching
Laser bleaching
Assisted bleaching
Waiting room bleaching
Dentist administered bleaching
Applied bleaching.

Time :

In office bleaching -90 min 1-3 sessions

Home bleaching -90 min 3-5 weeks

do only one arch at a time more discoloured teeth should be

treated first.

Bleaching Materials for even distribution of stain

(1) 31%- 35 % H2O2 (gel/liquid) -> apply with gauze.

Paint on tooth directly with cotton

tripped application on uneven stain
 (2) Bleaching light

 Photoflood lamp

13-30 cm distance from  Illuminator – rheostat controlled solid state heating device with special
tooth. metal tips shaped to provide heating-> flat/ wand type

115°- 140° F ->wire tipe

-> Laser -> argon,CO2
ideally-(160 °F max)
->KPT
10°C below the discomfort -> curing lamps / bleaching lights/ halogen
temp 20-30 mins -> Dual activated bleaching system
-> plasma arc (light & chemical)
Xenon power as light
(3) 38 mm camera
(4) Safety glasses.
(5) Rubber Dam/gingidam/ waxed dental floss/ paint on dam

X[ neutralize the bleaching solution by swabbing with NaOCl 5.25% ]

Gel- 10-20% water rehydrate the tooth as it bleaching

For Non-thermocatalytic method

Chemical +light

No Heat

Ex. Hi Lite (Shofu) 35% H2O2 +using light

curing light-> 3-4 mins applied 1-2- mm thickness

For 7-9 mins

Blue green paste can be applied 6 times /contains ferrous sulphate ->
chemical activation

Oxidation

White contains

Managanese sulphate
 Brite smile

50% H2O2 + sodium perborate

Paste

Light+ chemical oxidation

Thermocatalytic method

Light 13-30 mm away (-)

20-30 mins heat cause liquid in dentinal tubules to

expand

outward flow of fluid.

Decrease Pulp circulation

+ damage to Odontoblast

Reversible pulpits

(1) Using bleaching light

Plasma arc light: clear glass bleaching probe attached to light

Emits heat-

Held at short distance from tooth

 Generate energy from high frequency electrical field

(2) Using heated instrument : stainless steel spatula

Heated over flame

Illuminator

(3) Using heated bleaching gels: gel heated by placing in warm water for 2-3 mins.

 Rembrandt products -> 35% CPS heated to 80°C and applied to tooth
directly

 Hot air

 Boil the bleach in crucible over flame

Advantages of in office bleaching

Single sitting-> immediate effect

 Better patient compliance

Require shorter time for desired effect

Remove tough stains (dark) more easily than home bleaching

No time for home bleaching, patients prefer chair side bleaching

Bleaching completely under control

Beneficial in patient who cannot wear trays or gags easily

Disadvantages of in office bleaching

More expensive

Increase chair time

One session may not be enough.

Teeth may get dehydrated -> false evaluation of actual colour change

Tissue burns can occur –patient + dentist+ assistant

H2O2 has short half time.

Colour regression quickens.

What is waiting room bleaching??

What is assisted bleach technique??

Used for both vital and non-vital teeth

Given by Miller 2000

Invented by DenMat when quick-start product was launched.

Use of 35% CPS in custom made bleaching tray.

Applied to tooth and

Patient made to wait in waiting room 30 mins

30 min later bleach suctioned off

Followed by rinsing of tooth

WHAT IS COMPRESSIVE BLEACHING??

Technique

Miara(2000)

Power bleaching can be made more effective if agent is compressed on tooth.

35% H2O in bleaching tray, seal the edges of tray with light use resin

Penetration of O2 into Tooth enamel-> improve tooth

shade

Laser bleaching

Introduced in an attempt to accelerate the bleaching process.

1996 -> approval of Ion laser technology by FDA (argon +CO 2)

Types of laser used for bleaching

Argon + CO2

488 nm 10600 nm

 KPT

 Diodes -> 980 nm

 Photochemical laser whitening -532 nm

MOA -> H2O2 -> break into active ingredients HO2° + O°

Catalyse the oxidation reaction

 Energy

(LASER)

(help in jump start in cases of difficult stains)

Disadvantages :- costly

Time consuming

Increase Post op. sensitivity

materials

Laser light -> 30 secs 1-2 cm from tooth

Laser bleaching gel -> 1 to 2 mm thick on buccal/labial surface to be bleached

Leave gel for 3 mins after light application

Acidic -> can be applied till 5 times.

Alternate technique

(1) Use argon laser first Laser Whitening gel

(2) Peroxide based solution

applied

CO2 laser used

 Mix of thermal absorption crystal +highly processed fumed
silica +35% H2O2

Absorb thermal energy

Better dissociation of O2

Advantage of argon laser

 Blue light

Absorbed by dark colour

Affinity to dark stains

Yellow brown
colour easily
removed

 Produce less thermal energy

Role of CO2 laser

 Enhance the affect of argon laser

Unrelated to colour of tooth

Emitted in form of heat

Argon laser -> activate the gel

 Blue light absorbed by dark stain

Tooth whitens

Argon laser -> less affection

CO2 laser

Emit invisible infrared energy

Deeper penetration of energized O2

Diode Laser

980 nm

Semiconductor laser

Infrared diode – 740 nm

Ga-AL-AS Diode : works at different watts.

Raise in surface temperature 36° C with 1 W-> 86°C with 3W

38% H2O2 used.

Photochemical Laser whitening

KTP smart Bleach

pH of bleach is Alkaline 9.5.

primary action -> photochemical ✔

not photothermal X
 produce more reactive per hydroxyl ions used in bleaching tetracycline stains

chelate formed between tetracycline and HA is

red quinine product

dimethyl amino tetracycline

Dimethyl amino tetracycline is resistant to oxidation from peroxide

1st action

But broken down by green light in usage of 512-540 nm

KTP laser have range of 532 nm

Photoxidation of quinine

KTP 532 nm
 Colourless

2nd action Rhodamine B red dye

KTP Present in bleaching gel

Thermal energy

Controlled heating of gel.

Examples of KTP system

(1) (Biolase) -> Laser smile whitening system

(2) Pearlinbrite laser whitening system with energy transfer crystal (ETC)

Recent Advancement

Tooth bleaching with non thermal atmospheric plasma

plasma – 4th state of matter.

-most abundant state in universal

-> hot plasma ( near quilibrium plasma)

High temp particles

Close to maximum degree of ionization.

 Cold plasma

-low temperature particles.

 -low degree of ionization

Lee (2009) -> cold/room temperature plasma can be complementary to conventional

method

Effective bleaching without thermal damage.

NIGHT GUARD VITAL BLEACHING

Matrix bleaching

Dentist prescribed home-applied bleaching .

Dentist supervised at home bleaching

At home bleaching

Haywood & Heymann coined the term night guard vital bleaching in 1989

Because patients bleached the teeth at night while they slept with trays in mouth.

Home bleaching is a simple technique whereby after an initial consultation with the dentist, a
mouth guard or a tray is made for the patients to bleach the teeth at home.
 D
Low cost
I
Inexpensive + simple
S
Effective
A
Fast
D
Allow dentist to monitor
V
A Lab fee inexpensive

N Patient bleach teeth at convenience

T Results 2 weeks

A Not a painful procedure

G
E
S

A (-)laxative effect on ingestion

D (-) decrease bond strength to enamel

V (-) Require increase patient compliance

A (-) trays may not be fitting

N (-)open to abuse

T (-) tray margins cause irritation

A (-) patient may ingest swallow the agent
G (-) depend on the time the tray is worn
E (-) difficult for patient who gag easily
S (-) gingival irritation/ soft tissue irritation

(-) altered taste sensation-metallic

(-) tooth thermal sensitivity

(-) shorten life of composite

indications
Mild generalizing staining
Age yellow discolouration ,
Acquired superficial stain
Mild fluorosis
Pulpal trauma
Patient with low expectation
Young patient with inherited grey or yellow hue
Single tooth
Trauma
Mild tetracycline staining

Contraindication

Severe tetracycline
Pitting hypoplasia
Fluorosis stain
Adolescent with large pulp
Patient with unrealistic expectation
Patient with inadequate /defective restoration
Pitted / thin/ eroded enamel
Abrasion / attrition / erosion of enamel
Deep surface cracks
# lines
Large anterior restoration
Teeth with periapical radiolucency
# ed /maligned teeth
DMBA
Lack of compliance
known
Smokers
carcinogen
Lactating/ nursing mothers/pregnant
elevated in
Sensitive teeth
presence of
Cervical abrasion
oxygenating
agent

Treatment
(1)
Maxillary arch should be bleached first
 Better retention of upper tray
 Effect of gravity
 Reduced effect of salivary flow

(2)Mandibular arch acts as control (3)
2 trays -> together cause TMJ occlusion problem
 (4)Max arch unsuccessful no waste of cost and time

Tray Designs

Full vestibule (u/L)

With reservoirs -> used with gels

Without reservoirs-> used with liquid.

Foam liners (impinge on occlusion)

With / without windows

Scalloped- anatomical cut out – (gels)

Non scalloped – without cut liquids honey like liquids

Straight line trays

Trays with shorted border

Trays with palatal extension

What is reservoir?

Void or space which has been created in the bleaching tray

-receptacle for fluid

Properties of ideal bleaching tray

- Strong enough to avoid damage

- Should not distort

- Bioinert material

- Should not cause irritation to soft tissue

- should not cause problems in occlusion TMJ

- smooth , well polished with no rough edges.

 - Fit comfortably, not feel too tight

- Not extend into deep undercut

- Correctly trimmed,allow free muscle movements.

- Easy to clean,rinse

- Not distort during storage

- Have good retention.

Sheets use: EVA ethyl vinyl acetate

Sheet

0.02 – 0.035 inch

Flexible 0.05- bruxism

Sof tray -0ultradent -0.035 inch

Spacer: light cured composite

Vacuum forming machine : drufomat –TE

Bleaching agent: 10 % CPS + carbopol

Results: daytime + night> night time > day time

Time : 2-6 weeks

Max wearing time : 12 hours

Allow tissue recuperation

Occlusal stabilization

(1)
Instruction: minor sensitivity common

(2)

Splotchy appearance initially

Later even

(3)

Discontinue if allergy /gingival irritation

INTRACORONAL BLEACHING

AAE 1998 -> Intracoronal bleaching of non –vital teeth involves the use of chemical agents within the
coronal portion of an endodontically treated tooth to remove tooth discolouration.

SPASSER-1961- sodium perborate + water 1 weeks

NUTTING & POE-1967 – sodium perborate + H 2O2 1 weeks ( modified walking bleach)

Sodium perborate - saline

When fresh +

Contain 95% Syngergistic -Distilled water wet sand consistency

Perborate 9.9 O2 -H2O2

-LA

Barrier – GIC

-RMGIC

ZnP
 Zn polycarboxylate

IRM

Cavit

✔✔This technique allows the patient to see their teeth in different light during their
daily activities.

✔✔Allow to evaluate colour over time.

indications

- Incomplete root canal therapy leading to discolouration

- Pulp degeneration

- Discolouration due to sealers

- -discolouration due to excessive hemorrhage at time of

extirpation

- Debris left in pulp horns

- Properly obturated tooth

GROSSMAN

Trauma-free RBC –Hemolysis –Hg

-Iron + H2S – Iron sulphide (black)

(RBS) (Bacteria)

Contradiction -> silver cone discoloration

extensive restoration.

Silver containing sealers.

Amalgam as post endorestoration

RESOPRTION

Harrington & Natkin 1979

Published a case of External cervical root resorption

With thermocatalytic method (H2O2 + heat)

incidence 6.9 % ( Friedman)

Resorption only at CES

More in cases where tooth became pulpless before age of 25

 Open dentinal tubules

Defect in CEJ in 10 % population

open dentinal tubules extend to PDL

when H2O2 + heat = evaporation of liquid

Travel more through Dentinal tubules

Inflammatory reaction
PREVENTION

(1) Proper Barrier Technique -> also called assurance sealing plug

From labial view it should appear

“bobbled tunnel”

Proximal view

“ ski slope” appearance

 Flat barrier leaves proximal dentinal tubules unprotected.

Unprotected Dentinal tubules

1)How to determine the depth of barrier?

Three periodontal probing are made with a custom transfer periodontal probe)

Labial

Mesial these determine positon of epithelial attachment from incisal

Distal edge.

The internal bevel of barrier will be placed 1 mm incisal to external probing of epithelial
attachment

Palatal portion of barrier =/ to or coronal to barriers proximal height.

-
(2)[ why an endodontic plunger should not be used with free liquid bleach in
pulp chamber??]

Uncontrolled temperature of instrument cause the liquid to boil out

Use cotton pellet saturated with H2O2

Materials used to clean H2O2 after treatment

-NaOCl

-catalase

-Sodium ascorbate

(3) Excellent endodontic treatment

-> prevents leaking of bleaching agent

(4) patient history

-> all cases of resorption occurs if tooth become pulpless before age of 25 and with use of H 2O2
+heat

(5)Do not etch

If barrier fails, etching increase potential of external cervical root resorption.

(6) Recall after every 6 months

Other disadvantage

Chemical burns

Damage to Restoration
COMBINATION BLEACHING TECHNIQUE

- Make it more effective

- Motivates patient

- More rapid results

- Help to treat a specific problem effectively

 Single dark tooth

- Used to treat difficult stains ex: tetracycline

- To treat stains of different origin in same tooth

INSIDE/ OUTSIDE BLEACHING

Internal/ external bleaching – settembrini 1997

Patient administered intracoronal – Liehenrrerg 1997

Bleaching

Modified walking bleaching

Combines intracoronal walking bleach (+)

+ home bleach
Barrier placed

Access left open

10% CPS placed into pulp chamber

Bleaching tray applied

When not bleaching

Place a cotton pellet in access cavity

Require change of cotton pellet after every meals

✔Quick non compliance of patient

✔2 hr for 5-8 days manual dexterity is required

✔Mostly night application only Misused, overzealous application

✔Bleach more surface area at a time Rebound darkening

✔Use 10% CPS

✔No heat is used

✔Patient can stop the treatment Once desired effect is reached.

CLOSED CHAMBER TECHNIQUE

“ Frazier 1998” 10% CPS intracoronally used in bleaching tray

COMBINED MATRIX TECHNIQUE

Ortho + bleaching

“Goldstein & salama “

Repositioning appliances to move teeth into more appropriate position (+) the matrix holds the
bleaching agents.

ABRASIVE TECHNIQUE

diamond stone alteration controlled colour enhancement through enamel

chemical physical microabrasion removal.

Kinetic energy penetration

 HCL -> removes 22-27 micron of enamel ( Goldstein and Garber)

Enamel microabrasion is a procedure in which a microscopic layer of enamel is simultaneously

Erodesd and abraded with a special compound leaving a perfectly intact enamel surface behind

Use to treat hypomineralised areas---- CROLL 1991

Also called “enamel dysmineralization”

MICROABRASION AGENT

Hydrochloric acid -> less than 200 micron enamel removed ~ 22-27micron

Acts as non selective and superficial layer

 HCl + pumice

 HCl +H2O2 + Ether (Mc Innes)

READ FROM GROSSMAN pg 507-519 and pg 502 only

INDICATION

Developmental intrinsic stain

Superficial enamel stain

Yellow/brown

Multicoloured stains( brown,grey ,yellow)

Hypoplastic /enamel dysmineralized

Enamel fluorosis

White patches/ white spots.

Decalcification lesion from plaque and ortho trt

Irregular surface textures

contraindication

Age related staining

Tetracycline staining

Enamel hypoplastic lesion

Amelogenesis imperfecta

Dentinogenesis imperfecta

Deep enamel & dentin stain

Kits Prema kit (Premier Dental Products)

10% HCl + fine grit silicon Carbide particle in water soluble paste applied
manually or handpiece.

Micro clean Kit ( cedia kit, frame)

5 bottles which are colour coded.

Blue: 10 % H2O2

Green: weak HCl gel

Red: [ ] HCl

Mauve : neutralizing gel NaHCO3

Orange: fluoride paste.

Opalustre : purple syringes containing HCl + silicon carbide micro particle in water soluble
paste.

Easy to perform

Inexpensive removes enamel

Conservative. Caustic

Fast acting. Can be done only in office

Minimal maintenance

MACROABRASION + ADJUNCT

Masking infiltration composite

12-16 flute composite finishing bur

30 fluted composite finishing bur

Masking / bonding/ remineralisation technique.

 MEGAABRASION

more radical removal of enamel to eliminate the defect.

Use coarse Diamond instrument

Neutral translucent composite is placed

Finish with polishing disk

CHAMELEON EFFECT – clentin provides the natural optical effects optical

effects of the tooth.

Natural Bleaching agents/ methods

 Eat crunchy food -> broccoli , celery, carrots cucumber

 Apple -> contains malic acid -> dissolves stain

 Rinse with water after eating -> Remove stain easily residual food
removed.

 H2O2 mouthwash

 Fruits-> strawberries

 Lemon / lemon +salt

 Raisin-> high level of saliva Production

 Cheese-> helps remineralise

 Milk yogurt

 Baking soda-> water+ salt -> paste -> brushing for 1 min.