BLEACHING

CONTENTS
I) Introduction
II) History
a) Vital bleaching
b) Non-vital
bleaching
III) Causes of Discolouration and
Indications
IV) Contraindications of Bleaching
Teeth
V) Mechanism of ction
VI) Histologic !ffects of Bleaching
VII) Treatment "lanning
VIII) Techni#ues for Vital Bleaching
I$) Techni#ues for Non-vital Bleaching
$) %eferences
I) INTRODUCTION
Bleaching is an age old treatment
&hose time has finally come' The techni#ue
has been (erformed for over a century' It is
one of the most documented clinical
techni#ues in dentistry and yet for reasons
un)no&n* it has esca(ed the acce(tance
that it deserves'
To define The lightening of the
color of the tooth through the alication
of che!ical agent" to o#idi$e the organic
ig!entation in the tooth i" referred to a"
%leaching&
The current trend to&ard cosmetic
dentistry has generated more interest in
bleaching as (atients are as)ing for &hiter
and more beautiful teeth' +ur society tends
to disli)e yello&ing of teeth that comes &ith
age or the various intrinsic stains that occur
develo(mentally'
"roducts to ,&hiten- teeth are
(lentiful in the mar)et (lace' Bleaching alone
can significantly change the a((earance of
teeth* sometimes in only one office visit and
almost less invasively and less e.(ensively
than (rocedures such as cro&ning* bonding
or veneering' There is no& little reason to
acce(t discoloured teeth &hen bleaching* in
con/unction &ith other cosmetic dental
techni#ue is no& readily available'
II) HISTOR'
Bleaching as yet another means to
achieve that da00ling smile is not ne&1 the
first re(orted cases date in the 23
th
century*
but it is less &ell )no&n and less understood
than bonding and veneers'
Hi"tor( of %leaching )ital teeth
V'M' Torres 4arago0a has re(orted
e.tensively about bleaching of vital
teeth' His re(ort sho&s the earliest
efforts at bleaching &ere focused
on the search for an effective
bleaching agent'
The first (ublication of bleaching &as in
2566 by Cha((le* the agent of his
choice &as o.alic acid'
Taft and t)inson suggested the use of
chlorine for bleaching'
In late 23789s* home bleaching using
28: carbamide (ero.ide &as
discovered by ;lusimer'
In 255<* Harlan (ublished first re(orts of
(ero.ide used in bleaching' He
called it hydrogen dio.ide'
1
In 253=* various (ractitioners began to
e.(eriment &ith electric current to
s(eed the (rocess of bleaching'
%ossental suggested the use of >V
&aves to hel( bleaching in 2322'
By 2325* bbot had introduced the
forerunner of the combination used
today1 ?u(ero.ol and an
accelerated reaction by heat and
light'
The techni#ue of nightguard vital
bleaching &ent technically unnoticed until
Hey&ood and Heymann described the
techni#ue in March 2353 and a similar
(roduct &as introdced by a manufacturing
com(any in the same month' The night
guard vital bleaching and over the counter
)its have )indled a resurgence of interest in
tooth bleaching'
Hi"tor( of %leaching non*)ital teeth
- s early as 25<5* non-vital tooth
bleaching &ith chloride of lime &as
(racticed'
- Truman is credited for introducing &ell
before 257<* the most effective method
of bleaching non-vital teeth* &hich used
chlorine from a solution of calcium
hydrochlorite and acetic acid' The
commercial derivative of this* )no&n as
@abarr#ue9s solution* &as a li#uid
chloride of soda'
- In 253=* Aarretson (ublished the first
re(ort of bleaching non-vital teeth''
- ?u(ero.ol BC8: HD+D) &as introduced
by a manufacturing com(any early in
the 23889s'
- In 23=8* "earson left the solution of
?u(ero.ol for D-C days in the (ul(
chamber'
- "yro0on Bether-(ero.ide) &as used
effectively for non-vital teeth in the late
23=89s and early 2378s'
- Nutting and "oe carried out the
a((roach of ,&al)ing bleach- in 2376'
They elected to use E?u(ero.ol9 instead
of E"yro0one9* for safety and combined it
&ith sodium (erborate to achieve
synergistic effect' They recommended
the use of sodium (ero.yborate
monohydrate because it released more
o.ygen than sodium (erborate' They
also advised that gutta(ercha be sealed
before the treatment is initiated and
sealed the solution in the (ul( chamber
for 2 &ee)'
III) CAUSES O+
DISCOLOURATION O+
INTRINSIC DISCOLORATION
!$T%IN?IC DI?C+@+%TI+N
IV)
V) INT!%N@I4!D
DI?C+@+%TI+N
VI) ?tains that occur
subse#uent to dental
develo(ment* entering hard
tissues through enamel
defects'
,II) TEETH AND INDICATIONS
-& E#trin"ic di"colouration
Definition F Discoloration (resent on the
enamel or a#uired (ellicle generally of
metallic or nonmetallic origin
2
- +ccurs &hen some agent literally stains
or damages the enamel surfaces of the
teeth' They are found on the outer
surface of teeth and are usually of local
origin &hich can be removed by oral
(ro(hyla.is'
- Cigarettes* cigars and (i(es &ill
(roduce a yello&ish bro&n to blac)
discolouration* usually in the cervical
(ortion of the teeth and (rimarily on the
lingual surfaces'
- Che&ing tobacco stains fre#uently
(enetrate the enamel (roducing a
dee(er stain'
- Coffee and tea cause severe tenacious
discolourations* usually bro&n to blac)
stains'
.& Intrin"ic di"colouration
Definition F Discoloration is a result of
change in the structural form or the
com(osition of dental hard tissues
These are stains &ithin the enamel and
dentin caused by the de(osition or
incor(oration of substances &ithin these
structures* such as tetracycline stains*
dentinogenesis im(erfect* a fluorosis by
(roducts released into the dentinal tubules
during illness Be'g'* bilirabin involved &ith
/aundice) trauma B(rimarily the brea)do&n of
haemoglobin)* or (igmentation esca(ed from
the medicaments and materials used in
restorative dentistry'
1) Tetracycline staining
Tetracycline staining &as first
re(orted in mid-23=8s* less than a decade
after &ides(read use of this antibiotic'
- Teeth are most susce(tible to
tetracycline discolouration during their
formation i'e' during the second
trimerster in utero to roughly 5 years
after birth'
- The tetracycline molecules a((ears to
chelate &ith calcium and becomes
incor(orated into the hydro.ya(atite
crystals'
- The tetracycline involves (redominantly
the dentin'
- ?everity of the stains de(ends on the
time and duration and the dosage of the
drug administration* so also the ty(e of
tetracycline'
Categories of tetracycline discolouration
According to Jordan and Boksman
Girst degree tetracycline stainingF
- is a light yello&* bro&n or gray staining'
- uniformly distributed throughout the
cro&n'
- no evidence of banding or locali0ed
concentration'
%es(onds &ell to bleaching in t&o
or three sessions'
?econd degree tetracycline staining'
- dar) or gray staining'
- e.tensive than first degree &ith no
banding'
%es(onds &ell to bleaching in < to
7 sessions'
3
Third degree tetracycline stainingF
- dar) gray or blue &ith mar)ed banding'
%es(onds to bleaching but bands
usually evident follo&ing even e.tensive
treatment' It may be removed &ith some
veneering techni#ue'
Gourth degree tetracycline stainingF
- Created to include those stains that are
too dar) to attem(t vital bleaching'
2) Fluorosis staining
- Mottled enamel that occurs &hen
children ingest e.cessive fluoride during
develo(ment of enamel and dentin'
- Damage occurs during develo(ment
usually during third month of gestation
through eighth year of life'
- High concentration of fluoride in e.cess
of 2((m Bmore than <((m H moderate
to severe discolouration) is believed to
cause a metabolic alteration in the
ameloblasts resulting in defective matri.
and im(ro(er calcification'
- "revalence H (remolars* D
nd
molars*
ma.illary incisors* canines* 2
st
molars
and mandibular incisors'
- There are t&o ty(es of damagesF
2' Discolouration'
D' ?urface defects'
Ty(es F
2' Si!le fluoro"i" staining a((ears as
bro&n (igmentation on a smooth
enamel surface'
- %es(onds &ell to bleaching'
D' Oa/ue fluoro"i" a((ears as flat gray
or &hite flee)s on enamel surface'
- %es(onds (oorly to bleaching
because tooth cannot be
bought to lightness in the
affected area'
C' +luoride "taining 0ith itting has dar)
(igmentation &ith surface defects*
necessitates bleaching follo&ed by
com(osite resin bonding'
3) Discolouration from pulp necrosis
4
a) Trauma-related discolouration

- Trauma can cause haemorrhage as
blood vessels ru(ture in the (ul(
chamber'
- Blood is hydraulically driven into the
dentinal tubules* &here the %BC
undergo hemolysis emitting
haemoglobin' Haemoglobin is degraded
releasing iron than forms a blac)
com(ound by combining &ith hydrogen
sulfide to become iron sulfide'
- Immediately after in/ury* cro&n remains
(in) as blood brea)s do&n' The tooth
becomes orange* then blue* then bro&n
or blac)'
b) "ul( degeneration &ithout haemorrhage
- Necrotic tissue contains various (rotein
degradation (roducts &hich create a
grayish bro&n discolouration of the
cro&n'
- This res(onds &ell to non-vital
bleaching techni#ue'
4) Iatrogenic Discolouration
Considered intrinsic because it
effects inner structure of the tooth'
a) Trauma during (ul( e.tir(ation
Haemorrhage'
b) Gailure to remove all (ul(al
remnants' %es(onds &ell to non-
vital bleaching techni#ue'
c) Medications and materials used in
dental restorations if they lea)'
d) Metal amalgams-reflect as a
discolouration through the enamel'

e) Brea)do&n of restorations such as
acrylics* silicate cements or
com(osite resins can cause the
tooth to loo) grayer and
discoloured'
f) ?ilver nitrates H cause blac) or
bluish blac) discolourations'
g) Volatile oils H cause yello&ish
bro&n stains'
h) Iodine-creates bro&n* yello& or
orange stains'
i) %oot canal sealers containing silver
causes blac) stains'
/) "ins cause blue grayish stains'
5) Discolouration as a symptom of
systemic condition
- !rythroblastic fetalis B%h incom(atibility
bet&een mother and foetus)
characteri0ed by brea)do&n of an
e.cessive number of erythrocytes H
degradation of these blood cells causes
intrinsic staining of dentin of develo(ing
teeth'
- Iaundice results in staining of dentin
bluish green or bro&n (rimary teeth by
bitrubin or biliverdin'
- "or(hyria Brare condition) H e.cessive
(igment (roduction infuses dentin and
ma)es (rimary and (ermanent teeth
(ur(lish bro&n'
5
- Aenetic conditions such as
amelogenesis im(erfecta interfering
&ith normal enamel matri. formation'
- c#uired illnesses such as cerebral
(alsy* serious renal damage and severe
allergies' Brain* neurologic and other
traumatic in/uries can interfere &ith the
normal develo(ment of the enamel'
- !namel hy(o(lasia caused by
deficiencies of vitamins * C* D and
calcium and (hos(horous during the
formative (eriod'
If these conditions cause tooth
deformity or &hite s(ots* they res(ond
(oorly to bleaching'
INTERNALI1ED DISCOLORATION
?tains that occur subse#uent to dental
develo(ment* entering hard tissues through
enamel defects'
6) Discolouration due to eredity and
dental istory
- ?ome (eo(le are genetically
(rogrammed to have lighter or dar)er
teeth'
- Dental caries may be seen as an
o(a#ue halo or as a gray discolouration'
Bleaching not effective until the cause
of discolouration is removed'
-
- Dee(er (igmentation as a result of
bacterial degradation of food debris in
areas of tooth decay or decom(osition'
If brea)do&n is re(aired* bleaching may
not be necessary'
!) Discolouration due to aging
2' More stains of coffee and food'
D' Due to &earing a&ay of enamel'
dvantage in older (atients (ul(
recession ma)es aging a boon in terms of
bleaching* since* it ma)es the (atient less
sensitive to the bleaching com(ound'
I,) CONTRAINDICATIONS O+
BLEACHING TOOTH
Bleaching should not be advised &hen the
(ertinent tooth hasF
2' Crac)s and hy(o(lastic or severely
undermined enamel'
D' !.tensive silicate* acrylic or com(osite
restorations'
- these teeth may not have enough
enamel to res(ond (ro(erly to
bleaching'
C' Discolouration by metallic salts*
(articularly silver amalgam* the dentinal
tubules can become virtually saturated
by these alloys causing stains that no
amount of bleaching can significantly
im(rove'
<' !nlargement of the (ul( or other
disease that ma)es the tooth sensitive
to bleaching solutions or may re#uire
s(ecial care and desensiti0ation'
6
,) 2ECHANIS2 O+ ACTION
Ho0 doe" %leaching 0or34
The mechanisms of bleaching are
not com(letely understood and may be
some&hat different for different ty(es of
stains'
- Gor stains in &hich (ellicle or other
organic substances a((ear on the
surface or subsurface of the tooth* the
bleaching agent may o.idi0e these
substances'
- The reason &hy etching sometimes
enhances the effects of bleaching may
&ell be that* this (rocedure removes
surface organic material and (enetrates
the enamel slightly* (ossibly e.(osing
slightly dee(er areas of enamel to
bleach'
- Je )no& that substances can (enetrate
the enamel and dentin* even into the
(ul( and it is (robably this mechanism
that allo&s the bleaching agents to do
their &or)'
- The use of high intensity lighting and
longer e.(osure times for the bleaching
agent may &or) to increase this
(ermeation'
- The mechanism by &hich bleaching
&or)s on the interior of teeth may be a
(rocess of o.idation in &hich the
molecules causing the discolouration
are released' The theories of
(hotoo.idation or ion e.change are both
claimed to be viable reactions'
- Gor non-vital teeth* the (ul( chamber
can be (ac)ed &ith a bleaching agent'
lthough some researchers have
(resented evidence that hydrogen
(ero.ide can (enetrate (ul( chamber
e.ternally to facilitate o.idation of the
staining agents* it is not )no&n &hether
it should affect the (roducts of
haemolysis or degraded substances'
- Hydrogen (ero.ide* in various
concentrations* is the (rimary material
currently used by the (rofession in the
bleaching (rocess' Current in office
techni#ues for vital teeth and the
,&al)ing bleach- techni#ue ty(ically use
C8-C=: concentration of HD+D' HD+D
naturally occurs in the body even in the
eyes* in lo& concentrations' It is
manufactured and regulated by the
body and often involved in &ound
healing' In higher concentrations* it is
bacteriostatic and in very high
concentrations is mutagenic* (ossibly
by disru(ting the DN strand' Ho&ever*
the body has mechanisms for
immediate re(air of natural damage* lo&
concentrations of HD+D do not cause
serious (roblems' The carcinogenic
ca(abilities of HD+D are more often
caused by other (ero.ide derivatives
and the body uses the (ero.idases and
other mechanisms for regulating HD+D'
- The mechanisms of action of HD+D in
tooth bleaching is considered to be
o.idation* although the (rocess is not
&ell understood' It is felt that the
o.idi0ers remove some unattached
organic matter from the tooth &ithout
dissolving the enamel matri. but also
may change the discoloured (ortion to a
colorless state' There is some concern
that continued long term treatment &ill
result in dissolution of the enamel
matri.* but re(orts to date on nightguard
vital bleaching techni#ues have not
su((orted this theory'

7
AT LO5 6H
HD oD HD+ K +BJea)er free
radical)

HKH+D B@o&er (ercentage of stronger
free radical)
AT HIGH 6H 78&9 * -:&;&)
HD oD HD+ K +BJea)er
free radical)

HKH+D Bhigher (ercentage of stronger free
radical)
- Tetracycline stains are more resistant to
o.idation because the molecule is
tightly bound to the mineral in the
enamel (rism matri. during formation
and hence is less accessible to
immediate action' Teeth stained &ith
tetracycline therefore re#uire (rolonged
treatment times before any results are
demonstrated and often are
unres(onsive to the (rocedure'
- The ma/ority of (roducts currently on
the mar)et for the nightguard vital
bleaching techni#ue use a 28:
carbamide (ero.ide solution' 28:
carbamide (ero.ide degrades into C:
HD+D and 6: urea and hydrogen
(ero.ide can be considered its active
ingredient' The urea may (rovide some
beneficial side effects because it tends
to raise the hydrogen ion concentration
B(H) of the solution'
- Gor non-vital teeth* the (ul( chamber
can be (ac)ed &ith a bleaching agent'
lthough some researchers have
(resented evidence that HD+D can
(enetrate (ul( chamber e.ternally to
facilitate o.idation of the staining
agents* it is not )no&n &hether* it &ould
affect the (roducts of haemolysis or
degraded substances'
- In the &al)ing bleach techni#ue for non-
vital teeth* sodium (erborate &as used
&ith hydrogen (ero.ide' ?odium
(erborate is a &hite (o&der &hich
decom(oses into sodium metaborate
and hydrogen (ero.ide releasing
o.ygen' Jhen mi.ed into a (aste &ith
HD+D* this (aste decom(oses into
sodium metaborate* &ater and o.ygen'
Jhen sealed into the (ul( chamber* it
o.idi0es and discolours the stain slo&ly*
continuing its activity over a longer
(eriod'
Teeth that have been discoloured
as a result of ingestion of high amount of
fluoride such as =((m in natural &ater do
not res(ond &ell to ordinary techni#ues of
bleaching' In cases of endemic fluorosis*
McInnes solution containing C8: HD+D* C7:
HCl acid and 8'D: anaesthetic ethers in the
ratio of =F=F2 is used' The anaesthetic ether
removes surface debris* the hydrochloric
acid etches the enamel and the HD+D
bleaches the enamel' The HD+D as
described earlier bleaches the enamel by
the (rocess of o.idation' The hydrochloric
acid (resent in the solution increases the
(enetration of the solution and hel(s in
faster action' But HCl acid has various
deleterious effects such as loss of contour*
irritation to gingiva and sensitivity of teeth'
Chen* $u and ?hing B233C) re(laced HCl by
D8: Na+H &hich also hel(s in
decom(osition of HD+D and enhances the
bleaching effect' Na+H is highly al)aline in
nature and therefore dissolves calcium at a
slo&er rate' The results suggests that 2F2
mi.ture of HD+D &ith D8: sodium hydro.ide
is a effective as old Mc Innes solution and
the calcium dissolved is much less &ith the
ne& McInnes solution'
study by Dr' Nangrani sho&ed
that use of +ld McInnes solution resulted in
loss of contour of the teeth' The time ta)en
by Ne& McInnes solution &as double than
8
that of +ld McInnes solution but it did not
sho& loss of contour of the teeth'
Dr' ?had&ala studied the amount of calcium
dissolution &ith +(alescence night guard
vital bleaching solution and +ld McInnes
solution and found out that +ld McInnes
solution caused less calcium dissolunts as
com(ared to Night guard vital bleaching
techni#ue' The (ossible reason for this could
be attributed to the fact that night guard vital
bleaching techni#ue uses bleaching action
&hch lasts for 7 hours for D &ee)s &hereas
McInnes solution has to be used for only
about D8 minutes BC-<* = min a((lication)'
,I) HISTOLOGIC E++ECTS O+
BLEACHING
- ?ince 23=2* it has been sho&n that the
bleaching (rocedures have (otentially
damaging effects on the (ul( and that
substances can (ass through enamel
and dentin and into the (ul('
- 2366* Ariffin and Aro&er re(orted that
+ld McInnes solution )e(t from D-2=
minutes on the teeth sho&ed lac) of
(enetration into the (ul( chambers' This
lac) of (enetration may be due to the
short e.(osure time tested'
- In 23=8* Jain&right and @emoine
sho&ed that the lo& molecular &eight of
HD+D and its ca(ability to denature
(roteins increases the movement of
ions through teeth'
This study &as further corroborated
in 2333 by C' Hegedus et al &ho stated that
(ero.ides affect not only the surface but also
the inner structure of enamel as a result of
its molecular &eight' They affect the organic
(hase of enamel' This inner o.idative effects
are more li)ely to occur in the subsurface
enamel &hich has more organic material'
Cohen and Chase B2363) re(orted
effects of HD+D and heat for vital bleaching'
Their conclusion &as using this techni#ue
for vital bleaching may be considered
harmless to (ul(al tissues' The ne.t year in
a similar study* %obertson and Melfi found
mild su(erficial inflammation in a signifiacnt
number of (ul(s'
,II) TREAT2ENT 6LANNING
!sthetic dentistry is es(ecially the
a((earance of the mouth as a &hole and not
sim(ly one or more (roblem teeth' Bleaching
may correct the (roblem or facilitate other
restorative techni#ues to correct the
(roblem' Bleaching is therefore the first ste(
in any treatment (lan' The e.act shade of
the bleached teeth cannot be (redicted' By
bleaching first* the advantage is that
unnecessary tooth reduction need not be
done and anatomic sha(e and form is
(reserved' Bleaching may need to be
re(eated every 2-C years to maintain
brightness of teeth'
6rearation for %leaching
2) %ecord )ee(ing and (hotogra(hs H
%ecord )ee(ing should begin at the
treatment (lanning stage' %ecords
should document decision for treatment
and alternative' It is absolutely essential
to ta)e ade#uate (hotogra(hs of a
(atients (reo(erative condition' No
amount of descri(tion can e.actly
de(ict* ho& the (atient loo)ed before
treatment' In addition* (hotogra(hs are
more reliable than memory in
documenting the (rogress of treatment'
D) Careful diagnosis* using radiogra(hs
and transilluminating techni#uesF In this*
the (ossibilities of any (eria(ical
abnormalities can be ruled out' Caries
and decalcified or hy(ocalcified areas
&ill be disclosed' The si0e and vitality of
the (ul( can be determined and the
o(acity* de(th and layers of stains can
be defined' lso* hy(ersensitivity of the
teeth should be ruled out'
C) +ral (ro(hyla.is and (olishing &ith
sodium bicarbonateF to rid teeth of all
surface stains* (la#ue and calculus' The
(atient should be (rotected &ith heavy
(lastic &ra( and safety glasses' In most
9
cases* anaesthetic must not be used'
%ather* then (atient should be able to
tell the dentist if lea)age occurs as the
heat becomes too intense' ll members
of the dental team should &ear
(rotective eye &ear* surgical rubber
gloves and mas)s'
<) "re(aration of teeth to be bleached '
Isolation &ithF
a) %ubber dam'
b) "rotective (aste-+rabase or
Vaseline a((lied to soft tissues'
c) Aau0e saturated &ith cold &ater
(laced under rubber dam'
d) "umice used to remove e.cess
stain or (rotective (aste'
e) Gloss is ligated interdentally to
(revent see(age of the bleaching
solution into the gums'
In"tru!ent"
- !arly a((roach used metal instruments
and delivered direct heat to the teeth'
"atterson develo(ed one such
instrument' dvantage is &hen
bleaching individual tooth as in non-vital
teeth'
- later develo(ment &as the use of
intense light to activate the bleaching
solution' Intense light has the
advantage of su((lying uniform heat to
at least ten teeth'
,III) BLEACHING O+ ,ITAL TEETH
There are at least three &ays of bleaching
vital teeth'
2) In office bleaching or (o&er
bleaching techni#uesF
Thermocatalytic method - @ight
- Heat
McInnes solution - +ld
- Ne&
D) Night guard vital bleaching'
C) +ver the counter (re(aration'
-& In office %leaching < 6o0er %leaching
Girst vital bleaching techni#ue'
D (roducts D acce(ted
?u(ero.ol B?ultan Chemists)
?tarbrite in office bleaching'
Gor tetracycline stains
Teeth are covered &ith gau0e
saturated &ith C=: HD+D'
The (ero.ide solution may be
activated by heat or light'
Bleaching light (ositioned 2C
inches from the teeth &ith the light
shining directly on them' rheostat
setting of = usually used'
Jhere heat is used a tem(erature
setting of <7-78LC for vital teeth'
The gau0e should be )e(t &et by
dis(ensing fresh bleaching solution
&ith a cotton s&ab'
The bleaching agent should be )e(t
in contact and lightMheat a((lied to
the teeth for C8 minutes'
!.cess solution rinsed off &ith
co(ious amounts of &arm &ater'
Brush and then (olish'
- t one time* it &as considered to
etch the teeth &ith (hos(horic acid
before bleaching* su((osedly to
enhance the effect' Ho&ever*
etching is not actually necessary'
- Tetracycline stains generally
re#uires =-28 visits' Best scheduled
every D-< &ee)s'
b) Gor fluorosis stains
- Because fluorosis stains causes
much more heterogenous (attern
of staining* the bleaching method is
more selective'
- Bleaching agent H +ld M Ne&
McInnes solution
10
7Acidic
!ediu!)
Al3aline
!ediu!)
Old
2cIn
ne"
Rat
io
Ne0
2cIn
ne"
Ratio
Bl
ea
chi
ng
en
a
m
el
a)
C8:
HD+D
=
(art
s
C8:
HD+D
2 (art
!t
ch
es
en
a
m
el
b)
C7:
HCl
=
(art
s
%e
m
ov
es
su
rfa
ce
de
bri
s
8'D:
ether
2
(art
D8:
Na+
H
2 (art
- fter (retreatment (rocedures are
carried out cotton a((licators
carrying fresh bleaching agent
a((lied for = minutes and re(eated
after an interval of 2 minute'
- ((lication &as re(eated till the
desired bleaching effect &as
observed'
- Jith +ld McInnes solution the
solution &as neutrali0ed &ith
ba)ing soda'
- Jarm &ater is flushed on the
enamel before rubber dam is
removed'
- "olishing is done to achieve a high
enamel luster'
DisadvantagesF
2) %e(eated
isolation is a (roblem'
D) "o&er bleach
only can be a((lied on anterior
teeth'
C) C=: HD+D is
caustic and should avoid
burning themselves or (atient'
<) Discomfort
during and sensitivity for a
&ee) after treatment'
=) No reliable &ay
of (redicting success'
.) Night guard %leaching 7NG,B=
denti"t re"cri%ed ho!e alied
techni/ue= denti"t ho!e %leaching or
!atri# %leaching)&
- Introduced by Hay&ood and
Heymann in 2353'
- Custom fitted (rosthesis filled &ith
28: carbamide (ero.ide is &orn
for fe& hours each day for a fe&
&ee)s'
- Carbamide (ero.ide com(osed of
a((ro.imately C: HD+D and 6:
urea' HD+D degrades into HD+D and
+D &hile urea degrades into
ammonia and C+D' ll these
materials occur naturally in the
body and are easily managed'
>sually 28: carbamide (ero.ide
solution &as used'
- @esser concentration of carbamide
(ero.ide B=: instead of 28 and
27:) can also be used' They ta)e
longer time but may lead to less
sensitivity as com(ared to the
higher concentration solutions'
- Carbo(ol BB'G' Aoodrich) is added
to this solution to ma)e it stic)ier*
and (rolong the o.ygen release'
11
This ty(e of material favours
overnight &ear'
- Gor (atients &ho find it
uncomfortable to &ear it overnight*
they are advised to (lace it D-<
hours before slee(ing'
Disadvantage is that the treatment
time is (rolonged'
ADA acceted %leaching roduct" for
NG,B
- Colgate "latinum +vernight
"rofessional Tooth Jhitening
system'
- Nite Jhite classic'
- +(alescence &hitening gel'
- "atterson Brand tooth &hitening
gel'
- %embrandt @ighter bleaching gel'
>) O)er the counter %leaching "("te!"
BegF (erfect ?mile ?ystem)
- ?hortly after the dentist home
systems &ere introduced* several
systems &ere sold directly to the
consumers'
- lso called Ehome bleaching9
systems but are more a((ro(riately
referred as +TC home bleaching
systems'
- ?ome of the earlier systems have a
C-ste( (rocedure'
an acidic (re-rinse'
a((lication of a lo&er strength
(ero.ide material &ithout a
(rosthesis'
a final a((lication'
- @ater develo(ed &ere home
systems &hich use same strength
of bleaching solution as the dentist
home system but a((ly the material
&ith a ,boil and form- mouthguard'
Ena!el 2icroa%ra"ion Techni/ue
+ne of the relatively ne&
techni#ues for removal of stains in endemic
fluorosis cases is the use of enamel
microabrasion techni#ue'
In 2327* Dr' Jalter ;ane* of
Colorado ?(rings* used 25: hydrochloric
acid &ith a &arm instrument to successfully
remove stains associated &ith endemic
fluorosis' ?ince 2327* numerous
investigators have used hydrochloric acid
alone on fluorosis stains' In 235<' Mc
Clos)ey described ;anes &or) and
demonstrated successful cases of his o&n'
He found that bro&n fluorosis stains can
(ermanently be removed by rubbing the
enamel &ith an 25: HCl acid soa)ed cotton
(ellet &ra((ed around and amalgam
condenser'
T&o years later Croll and
Cavananaugh develo(ed a similar techni#ue
that involves (ressure a((lication of 25:
HCl &ith (umice to achieve colour
modification' This &as called the enamel
microabrasion techni#ue' The chief
mechanism of stain removal &ould be
limited to enamel abrasion* rather than
enamel dissolution by the acid' Dr' Croll
believed that the acid abrasive action of the
com(ound gives the enamel surfaces* a
su(er fine (olishing as a microsco(ic layer
of enamel is removed' The freshly (olished
surface then develo(s a shiny glass li)e
te.ture* resembling a highly (olished
microfilled com(osite resin restoration* as
the tooth subse#uently reminerali0ed'
Iacobsson-Hunt B2355) re(orted
C8-second a((lications of the acid abrasive
com(ound using a mandrel and gear
reduction hand(iece on e.tracted human
teeth results in a enamel loss of less than
D88Nm' In 2353 ;endell re(orted that =
second a((lication of HCl acid (umice
mi.ture removes <7Nm of enamel &hich
should be considerably tolerated'
n im(ortant concern about the
safety of the hydrochloric acid (umice
12
abrasion (rocedure is the lo& viscosity and
high concentration of 25: HCl' To eliminate
this (roblem and ensure safety of this
techni#ue* the viscosity of the acidic solution
is increased by mi.ing 25: HCl acid &ith
#uart0 (articles so that the solution ta)es on
a &ater soluble gel li)e form' This came to
be )no&n as the modified 25: HCl acid
#uart0-(umice abrasion techni#ue'
The (rocedure is as follo&sF
2' The gingiva &as (rotected by a
layer of (etroleum /elly'
D' The involved teeth &ere isolated
&ith rubber dam'
C' fter the teeth &ere dried &ith air*
the (aste &hich consisted of 25: HCl
acid #uart0-(umice (articles* &as
a((lied &ith a cotton ti( a((licator to
the stained areas of enamel'
<' The (aste &as allo&ed to remain =
seconds and then for 28 seconds* the
enamel microabrasion &as effectuated
&ith a cotton s&ab (ressure'
=' fter 28 seconds* a mar)ed degree
of success &as obtained and the stain
&as removed'
7' fter 2= seconds of treatment* the
enamel of the teeth turned to a normal
shade'
6' t the end of the treatment* the teeth
&ere &ashed and dried before removal of
rubber dam &as neutrali0ed &ith a neutral
sodium gel'
In this (rocedure* the #uart0
(articles convert the acid into a gel form and
functions as an additional abrasive agent'
?i. months follo&ing this treatment on
several (atients sho&ed that the ob/ectives
of the treatment &as achieved'
The advantage of this techni#ue is
that it is relatively economical* involving no
laboratory costs* ma)ing this techni#ue
readily acce(table to children'
I?) BLEACHING O+ NON*,ITAL TEETH
"re(aration of the affected non-vital teethF
2) In office
bleaching'
D) +ut of office
bleaching B&al)ing bleach
techni#ue)'
C) +ther
bleaching techni#ues'
Isolation is done &ith a rubber dam'
The tooth is meticulously cleaned
internally'
!stablish a lingual o(ening of sufficient
si0e to (rovide access to the (ul(
chamber and orifice of the root canal'
slo&ly rotating bur is used to remove
debris and a surface layer of dentin
&ithin the (ul( chamber'
In endodontically treated teeth* root
canal filling material should be
removed to a de(th of D-Cmm a(ical to
the cervical line'
4inc (olycarbo.ylate cement* cavit or
0inc o.y(hos(hate cement can be
used to refill* 2-Dmm coronally to the
C!I'
Bleaching should never be
attem(ted on any tooth that does not have a
com(lete seal in the root canal' The agent
could esca(e through a (orous root canal
filling and cause the (atient e.treme
discomfort as &ell as (robably loss of tooth'
?urface stains visible on the inside
of the (re(aration are removed* the entire
(re(aration is s&abbed &ith chloroform or
acetone to dissolve any fatty material and
13
facilitate the (urification of the bleaching
agent into the tubules'
-) In*office %leaching 7Ther!ocatal(tic
techni/ue")
The (ul( chamber is filled loosely
&ith cotton fibres and the labial
surface is covered &ith a fe&
strands of cotton fibre to form a
matri. for retaining the bleaching
solution'
This is saturated &ith C=: HD+D
using a glass syringe fitted &ith a
stainless steel needle' The solution
should be discharged slo&ly to
saturate the cotton inside the (ul(
chamber and on the labial surface
e.cess should be &i(ed
immediately'
thin ta(ered ti( from a single
tooth bleaching instrument can be
inserted into the (ul( chamber' The
heated ti( is e.(osed for = minutes*
in a se#uence of 2 minute on 2=
seconds off'
It has been established by Cald&ell
that a non-vital tooth can be treated
to a tem(erature of 6CLC &ithout
causing the (atient discomfort'
n alternative to activate the HD+D
is the use of light and heat from a
heat and light bleaching (o&erful
light' The tooth is sub/ected to 7* =
minute e.(osures and one
re(lenishes the bleaching agent at
fre#uent intervals'
The heating instrument and cotton
can then be removed' %e(eat the
above (rocess <-7 times or for D8-
C8 minutes each time (lacing ne&
cotton fibres'
This techni#ue can be used alone
or in combination &ith &al)ing
bleach'
.) Out Office %leaching 75al3ing %leach)
Girst described by Nutting and "oe
in 237C'
This (rocedure consists of filling
the (re(ared chamber Bas
described (reviously) &ith a (aste
consisting of C=: HD+D and sodium
(erborate' Btheir effect is thought to
be synergistic)'
?odium (erborate is a &hite
(o&der &hich decom(ose into
sodium metaborate and HD+D
releasing +D' Jhen mi.ed into a
(aste &ith ?u(ero.ol* this (aste
decom(oses into sodium
metaborate* &ater and o.ygen'
Jhen sealed into the (ul(
chamber* it o.idi0es and
discoloures the stain slo&ly*
continuing its activity over a longer
(eriod'
small (ledget of cotton &ool is
(laced on the (aste and the cavity
is sealed &ith (olycarbo.ylate
cement )e(t under (ressure till the
cement sets'
The ma.imum bleaching is attained
D< hours after treatment'
The (atient should return in C-6
days'
If shade dar) then re(eat
(rocedure
light then (ermanent restoration
&ith silicate or AIC'
-Aenerally t&o treatment sessions
although in some cases one
treatment is sufficient'
>) Other !ethod" of non*)ital
%leaching
a) Inside-outside bleaching B@eonard and
?tettembrim et al 2336)
14
Gabrication of a study model'
@ight cured com(osite is (laced on the
model of the tooth or teeth to be
treated' This acts as a reservoir to be
created in a vacuum (rocessed
mouthguard &hose thic)ness usually
varies from 8'D8 and 8'C8 inch'
Mouthguard trimmed at the cervical
margins on the labial and lingual
(ortions and tried in the (atients
mouth'
The A" is the root canal is sealed off
from the (ul( chamber &ith AIC or
resin modified AIC'
"atient is taught ho& to in/ect 28:
carbamide (ero.ide into the canal
orifice and into the mouthguard &ith a
syringe'
!.cess C" gel can be removed by
brushing or using a (a(er tissue'
The (atient may either slee( &ith the
gel or remove the mouthguard after 2
or D hours' If the (atient (refers the
latter* it &ill ta)e a fe& days longer'
t the end of the daily treatment*
(atient rinses his or her mouth and
then (laces a cotton (ellet to (revent
food from getting into the o(ening'
n e.(lorer can be used by the (atient
to remove the cotton (ellet before the
ne.t (rocedure'
The total treatment (roceeds and
ra(idly concludes &ith the results in as
fe& as C or < days'
b) nderson Ta)eo Hara* and @''G'
"unenta B2333) Bsuggested by
?(assier) used a techni#ue &here
sodium (erborate and &ater &as used
as a &al)ing bleach techni#ue instead
of HD+D to (revent cervical resor(tion'
?odium (erborate bro)e do&n to
sodium metaborate and HD+D' T&o year
results &ere satisfactory &ith this
techni#ue'
Clinical !ea"ure!ent of tooth 0hitening
number of methods are available
for measuring the colour of teeth and the
colour changes undergone during tooth
&hitening (rocedures' +ne of the most
common methods is the simultaneous
com(arison of the tooth &ith a standard
shade guide' This has been used in a large
number of tooth &hitening studies &here
longitudinal changes in tooth colour have
been measured' It is a sub/ective method
and a number of factors can influence this
(rocess' Gor e.am(les*lighting conditions*
e.(erience* age* fatigue of the human eye*
ma)e-u(* room decor and colour blindness'
Therefore* caremust be ta)en to standardise
and control these factors'
Colourimeters are instruments
designed to measure the colour of ob/ects'
The colour is often e.(ressed in terms of the
Commission Internationale de l9!O clairage
BCI!) @ab colour s(ace' The CI! @ab colour
s(ace re(resents a uniform colour s(ace*
&ith e#ual distances corres(onding to e#ual
(erceived colour differences' In this three-
dimensional colour s(ace the three a.es are
@P* aP and bP' The @P value is a measure of
the lightness of an ob/ect and is #uantified
on a scale such that a (erfect blac) has an
@P value of 0ero and a (erfect reflecting
diffuser an @P value of 288' The aP value is a
measure of redness B(ositive aP) or
greenness Bnegative aP)' The bP value is a
measure of yello&ness B(ositive bP) or
blueness Bnegative bP)' The aP and bP co-
15
ordinates a((roach 0ero for neutral colours
B&hite* greys) and increase in magnitude for
more saturated or intense colours' The use
of a colourimeter to measure tooth colour in
vivo re#uires the fabrication of a custom
(ositioning /ig to ensure re(roducible intra-
oral (ositioning of the instrument9s a(erture
onto the tooth surface'
nother a((roach for measuring tooth colour
is by using non-contact camera-based digital
imaging and analysis systems' Ty(ically* an
image of the anterior teeth is ca(tured under
controlled lighting conditions by a digital
camera together &ith suitable calibration
tiles or standards and then subse#uently
analysed via com(uter soft&are to
determine the colour of the individual teeth*
often e.(ressing them in terms of CI! @ab
values' Gor e.am(le* after 2< days use of a
28: carbamide (ero.ide tray-based system*
the mean change from baseline in @P and bP
&ere D'86 and Q2'76* res(ectively'
+actor" influencing tooth 0hiteninng
T(e of %leach
The ma/ority of contem(orary tooth
&hitening studies involve the use of either
hydrogen (ero.ide or carbamide (ero.ide'
In general* the efficacy of hydrogen (ero.ide
containing (roducts are a((ro.imately the
same &hen com(ared &ith carbamide
(ero.ide containing (roducts &ith e#uivalent
or similar hydrogen (ero.ide content and
delivered using similar format and
formulations*
n alternative source of hydrogen (ero.ide
is sodium (ercarbonate and this has been
used in a silicone (olymer containing
(roduct that is (ainted onto the teeth forming
a durable film for overnight bleaching
(rocedures'
tooth bleaching system based on
sodium chlorite a((lied to the tooth surface
and activated under acidic conditions has
been described in the literature* ?imilarly*
other (otential vital tooth bleaching systems
have been outlined in the literature &ith
limited su((orting evidence for their efficacy'
These include sodium (erborate*
(ero.ymonosul(hate* (ero.ide (lus metal
catalysts and o.ireductase en0ymes' The
long-term acce(tability and relative efficacy
of these alternative tooth bleaching systems
re#uires significant further research'
Concentration and ti!e
T&o of the )ey factors in
determining overall tooth &hitening efficacy
from (ero.ide containing (roducts are the
concentration of the (ero.ide and duration of
a((lication' ?ulieman et al' com(ared the in
vitro tooth bleaching efficacy of gels
containing =HC=: hydrogen (ero.ide and
found that the higher the concentration* the
lo&er the number of gel a((lications
re#uired to (roduce uniform bleaching'

Heat and light
The rate of chemical reactions can
be increased by increasing the tem(erature*
&here a 28
0
C rise can double the rate of
reaction' The use of high-intensity light* for
raising the tem(erature of the hydrogen
(ero.ide and accelerating the rate of
chemical bleaching of teeth &as re(orted in
2325 by bbot'
"omplications of internal #leacing
2' Cervical
resor(tion
"ossible mechanism is that HD+D
(ercolates from the access cavity
to the root surface through the acid
treated (atent dentinal tubules'
This stimulates an inflammatory
res(onse tending to dentin
resor(tion'
lternative theory H bacteria that
have lea)ed into the (ul( chamber
from the gingival crevice via the
dentinal tubules or directly from the
16
access cavity may cause
resor(tion'
%oot resor(tion can be arrested by
(lacing Ca+H in the chamber'
D' ?(illage
of bleaching agents
+.idi0ing agents are more safe to
handle as a (aste than a solution'
((ly rubber dam'
ny s(illage must be diluted
immediately &ith co(ious volumes
of &ater'
C' Gailure
to bleach
Commonest is discolouration by metal
ions in silver amalgam'
Incom(lete removal of com(osite resin
or AIC &hich (revents the bleaching
agents to (enetrate into dentinal
tubules'
HD+D &hich has (assed its e.(iry date
or im(ro(erly stored'
+ver bleaching
%ecommended since it may dar)en &ith
time an assume desired shade'
Im(ortant not to over bleach therefore
as) the (atient to monitor and return in
case of over bleaching'
<' Brittlene
ss of tooth cro&n
- Bleachin
g causes the coronal tooth structure to
be brittle' This may be caused due to
removing all the discoloured dentin
rather than using the bleaching agents
to discolour the dentin'
c) @aser assisted bleaching
- +ne
com(any uses the argon laser
&avelength of <55nm for C8 second to
accelerate the activity of its bleaching
gel' fter the laser energy is a((lied*
the gel is left in (lace for C-< minutes
then removed' This (rocedure is
re(eated <-7 times'
- nother
(roduct uses Ion @aser Technology'
The argon laser is used as (reviously
described' Then the C+D laser is
em(loyed &ith another (ero.ide
solution to (romote (enetration of the
bleaching agent into the tooth to (rovide
bleaching belo& the surface'
- rgon
laser energy is in the form of a blue light
and is absorbed by the dar) colour' It
seems to be the ideal instrument to be
used in tooth &hitening &hen used &ith
=8: HD+D and a (atented catalyst' The
affinity to dar) stains ensures that the
yello&-bro&n colours can be easily
removed'
- The C+D
laser has no colour re#uirement' It is
unrelated to the colour of the tooth and
the energy is emitted* in the form of
heat' It is invisible and (enetrates only
8'2mm into &ater and HD+D* &here it is
absorbed' This energy can enhance the
effect of &hitening after the initial argon
laser (rocess'
?) RE+ERENCES
2' ,Bleaching teeth- %onald Geinman*
%onald Aoldstein and David
Aarber* Ruintessence "ublishing
Co' Inc'* 2356'
D' ,History safety and effectiveness of
current bleaching techni#ues and
17
a((lications of the night guard vital
bleaching techni#ue-' Hay&ood
Van B'* Ruintessence Int'* 233D1 DC
F <62-<55'
C' ,n atomic force microsco(y study
on the effect of bleaching agents on
the enamel surface-' C' Hegedus et
al* I' Dent'* D6 F 2333* =83-=2='
<' ,!stimation of dissolution of
calcium by +ld McInnes and Ne&
McInnes solution-'Nages&ar %ao
%' and Nangrani V'* Ind' !nd' I'*
23351 =8-=C'
=' ,Bleaching teeth F Ne& materials H
ne& role-' %onald !' Aoldstein*
I''D''* 23561 <C-=D'
7' ,Historical develo(ment of
JhitenersF Clinical safety and
efficacy-' Van B' Hay&ood* Dental
>(date* 2336 (ril'
6' , techni#ue for bleaching non-vital
teeth-' @eonard ?ettembrim et al*
I''D''* 2336 ?e(tember* 2D5C-='
5' ,Non-vital tooth bleaching F D
year case re(ort-' 'T' Hara* @''G'
"imenta* Ruintessence Int'* 23331
C8 F 6<5-=<'
3' ,@aser assisted bleaching F n
u(date-' ID* Vol' 2D3* +ct' 35
"g' 2<5<-2<56'
28' ,The effectiveness of a modified
hydrochloric acid #uart0-(umice
abrasion techni#ue on fluorosis
stainsF case re(ort- Aam0e
!rdogan* Ruint' Int'* 23351 D3 F
223-2DD'
22' ,!namel microabrasion F The
techni#ue-' Croll T'B'* Ruint' Int'*
23531 D8 F C3=-<88'
18