flow chart

introduction
history
bleaching in children
discolouration
bleaching agents
mechanism of action of each agent
treatment plan in children last reference in office etc from article
classification of bleaching
in office bleaching
home bleaching
bleaching for non vital tooth
bleaching with micro abrassive technique
complication of bleaching
effects of bleaching on tooth
recommendation
conclusion

CHAPTER I
INTRODUCTION

Dental esthetics is an integral part of facial esthetics . 'The perfect smile' has
gained lot of interest off late including straight and light coloured teeth .
Esthetic concerns about the smile is often patients main reason other than pain
for seeking dental care . Esthetic problems in childhood and adolescence can
have a significant effect on psychosocial development and interaction with
peers. The psychological benefit of an oral esthetic improvement is hence very
important. The cosmetic impairment of tooth discolouration, especially in the
anterior region, can be treated by a number of invasive therapies such as indirect
crowns and veneers, micro abrasion, or by the placement of direct composite .
The trend for non invasive dental treatment has led to development of different
material and whitening technique that are capable of re establishing patient's
smile. The procedure of tooth whitening or bleaching can be employed as a less
invasive alternative to restoration with either ceramic or composite. Also, an
increased consciousness about appearance for social acceptance makes such an
aesthetic treatment extremely desirable.
It is estimated that more than a million people have had teeth bleached by
dentists, while perhaps millions more have tried their own hand at bleaching
with over-the-counter products. The popularity of bleaching is easily
understood. For the appropriate patient, with careful diagnosis, case selection,
treatment planning, and attention to technique, bleaching is the simplest, least
invasive, least expensive means available to lighten discolored teeth and
diminish or eliminate many stains in both vital and pulpless teeth.

Once considered the province of a few pioneering specialists in esthetic

dentistry, bleaching has now moved into the mainstream of restorative dentistry.

HISTORICAL BACKGROUND
In a somewhat barbaric treatment, the barber would whiten teeth by first filing
them down with a metal apparatus and then dousing the teeth with nitric acid, a
powerful corrosive, to whiten them. The acid made the teeth shiny white but at
the same time it caused the destruction of tooth enamel and eventually lead to
pulpy, decayed choppers. Ironically this kind of teeth whitening method did not
prevent people from the practice because the future prospect of losing all of
their teeth was a small price to pay for physical glamour. It's popularity
continued to grow until it became a status symbol for one to have his teeth
bleached white with the destructive nitric acid.
This practice continued until the ending years of 18th century Since the late
1800s, dentists have been preoccupied with aesthetic procedures, such as
bleaching and tooth recontouring, but there were different views on the success
of these procedures. Arguments against bleaching included the length of time to
achieve a lightening effect and technique sensitivity, with teeth often reverting
back to their original colour.13 By 1848, non-vital tooth bleaching with chloride
of lime was practised,15 but maccording to Kirk, Truman is often credited with
introducing the mostm effective technique for non-vital teeth at the time when
chlorine was produced from a solution of calcium hydrochlorite and acetic acid,
known as Labarraques solution.16 Many different bleaching
agents were also successfully used on non-vital teeth, including aluminium
chloride, oxalic acid, pyrozone (etherperoxide), hydrogen peroxide, sodium
peroxide, sodium hypophosphate, sulphurous acid and cyanide of
potassium.13 Apart from the reducing agent sulphurous acid, the rest were all
oxidizing agents that worked directly or indirectly on the organic portion of the
stain. By the 1860s, vital teeth were also bleached externally using oxalic acid
and later using hydrogen peroxide or pyrozone.13 This was followed in the

CHAPTER III

BLEACHING IN CHILDREN AND ADOLESCENCE

Although tooth bleaching has been performed over the years in children as
young as age 4, it is rarely done in children younger than 6. It may be indicated
for those children who report (or parents who report) that tooth discoloration is
bringing negative attention. Similarly, some researchers advocate whitening
for young permanent teeth, even when they are only partially erupted with
incomplete root formation, because even young patients can be highly
concerned over discoloration of their anterior teeth. In a 2004 study, 32% of a
group of 2,495 children were dissatisfied with their tooth color, 19% of parents
were dissatisfied with their childs tooth colour, and only 9% of dentists felt the
subjects had unsatisfactory tooth colour.
Recommendations for childrens whitening safety are essentially based on
human research findings from studies utilizing adults. Few clinical studies on
minor study subjects (especially those with primary teeth) have been performed,
partially due to ethical reasons. The findings mostly depend on case reports in
minor subjects. Hard tissue effects seen in in vitro studies of extracted primary
teeth are extrapolated to vital teeth. No evidence of lasting local or systemic
effects has been observed in short-term studies. There have been no data to
justify recommending against using whiteners in children. Caution, however,
must still be taken. No studies published in peer-reviewed dental journals have
stated that tooth bleaching is unquestionably safe for all children. Those that
recommend it state that it is considered safe without directly measured
systemic effects. Conclusions regarding safe usage in pediatric whitening
studies, therefore, are mostly based on short-term clinical observations and
measurements and studies tabulating patient complaints.
Currently, while there are dentist-dispensed and in-office tooth whiteners that
have received the ADAs Seal of Acceptance their safety and effectiveness data

were collected from adults, with no specific indication or descriptions on the

use of these whiteners for children. Long-term evaluation is needed to reveal the
consequences of repeatable use of tooth whiteners. In the majority of tooth
whiteners on the market, the peroxide concentrations range from approximately
3% to 38%. Meanwhile, peroxides in lower concentration have been studied
more extensively by researchers in general as concerns linger over potential
adverse effects . Factors for determining exposure include: (1) route; (2) dose;
(3) tissue contact; (4) duration of each application; (5) frequency of treatment;
(6) total number of applications; and (7) amounts swallowed and absorbed
through any portals of injury.
The characteristics of permanent dentin in young adolescents are closer to that
of adults than the primary dentition, but may still be thinner by comparison. The
maxillary cuspids of adolescents may not erupt until age 12 or 13, and enamel
calcification takes approximately another 2 years. Moreover, childrens teeth are
easier to bleach than adult teeth,28 because enamel permeability decreases with
age. The downside, however, is that their pulps may receive more exposure to
peroxide as .With primary teeth having thinner dentin and enamel and relatively
larger pulps than permanent teeth, increased sensitivity to peroxide would be
expected in theory. This, however, does not appear to be consistent with limited
clinical findings. One investigator reported more complaints from adolescent
subjects than 7- to 11-year-olds. The same and other reports suggested whether
a larger pulp can recover from insult more rapidly, because the apex of the tooth
is also larger. It is unclear whether the age difference itself has an effect on the
willingness to report the sensitivity among these 2 groups.

Psychological Aspects Associated with Dental Esthetics

The odd attracts society in odd manner, as is the case when a patient with
discolored teeth smiles. Because of that pediatric patients have psychological
impact.The effect of a smile is so significant that advertising experts refer to this
phenomenon as smile power.A negative self image due to discolored tooth or
teeth can have serious consequences on adolescents and could be considered as
an appropriate indication for bleaching. Brantley reported a 4 year old child
with tooth discoloration. The child reported that other children and adults were
now commenting about her dark teeth. Before pursuing whitening treatment,
parents should be made aware that their child (especially teenagers) may expect
an unrealistically fast occurring and whiter shade change.

CHAPTER II
HISTORICAL BACKGROUND

CHAPTER 1V
DISCOLOURATION OF TEETH

Most common cause for discolouration in primary and young permanent

teeth are
1)from a traumatic injury (ie, calcific metamorphosis, darkening with
devitalization),
2) irregularities in enamel coloration of a permanent tooth due to trauma
or infection of the related primary tooth, or
3)intrinsic discoloration/staining (eg, fluorosis, tetracycline staining)

chapter IV