Periodontology 2000, Vol.

48, 2008, 148169

Printed in Singapore. All rights reserved

 2008 The Author.

Journal compilation  2008 Blackwell Munksgaard

PERIODONTOLOGY 2000

An overview of tooth-bleaching
techniques: chemistry, safety and
efficacy
M U N T H E R A.M. S U L I E M A N

Tooth discolouration results from varied and complex causes that are usually classified as being either
intrinsic or extrinsic in nature. Extrinsic discoloration
arises when external chromogens are deposited on
the tooth surface or within the pellicle layer. Intrinsic
discoloration occurs when the chromogens are
deposited within the bulk of the tooth (usually in the
dentine) and are often of systemic or pulpal origin (1,
150). A third category of stain internalization has
been described to include those circumstances where
extrinsic stain enters the tooth through defects in the
tooth structure (1).
Tooth discoloration creates a wide range of cosmetic problems, and, as the dental profession and
the public strive for a more esthetically pleasing
appearance, considerable amounts of time and
money are being invested in attempts to improve the
appearance of discolored teeth. A study assessing the
impact of teeth on personal esthetic satisfaction
found that dental variables (including tooth color)
were more important than orthodontic variables,
suggesting that the appearance of the teeth was a
greater contributing factor to an esthetic smile than
their position within the arch (101). In another study,
of 254 patients, it was found that the appearance of
the dentition was more important to women than to
men and that the esthetics of the dentition was more
important to younger patients (147).
The methods available to manage discolored teeth
range from the removal of surface stain, bleaching or
tooth-whitening techniques and surgical techniques
to camouflage of the underlying discoloration, using
veneers and crowns.
The use of a variety of bleaching techniques has
attracted most interest from the dental profession
because these techniques are noninvasive and relatively simple to carry out. Contemporary bleaching

148

systems are based primarily on hydrogen peroxide or

one of its precursors, notably carbamide peroxide,
and are often used in combination with an activating
agent such as heat or light. Bleaching agents can be
applied externally to the teeth (vital bleaching), or
internally within the pulp chamber (nonvital
bleaching) (41, 54). Both techniques aim to bleach
the chromogens within the dentine, thereby changing
the body color of the tooth.

Tooth discoloration
Natural color of teeth
Teeth are made up of many colors, with a natural
gradation from the darker gingival third to the lighter
incisal third of the tooth. This variation is affected by
the thickness and translucency of enamel and dentine, as well as by the reflectance of different colors.
Typically, canine teeth are naturally darker than
central and lateral incisors and teeth become darker
with age, whereas lighter teeth are common in
younger people, especially in the primary dentition.
The color of teeth is primarily determined by the
dentine but is influenced by the color, translucency
and varying degrees of calcification of enamel as well
as its thickness, which is notably greatest at the
occlusal or incisal edge. The normal color of teeth is
determined by the blue, green and pink tints of
enamel and is reinforced by the yellow through to
brown shades of the dentine beneath.

Classification of tooth discoloration

The appearance of teeth depends on their absorptive
or reflective properties of light and is influenced by

An overview of tooth-bleaching techniques

Table 1. Colours produced by various causes of tooth

discolouration
Types of discolouration

Colour produced

Extrinsic (direct stains)

Tea, coffee and other foods
Cigarettes cigars
Plaque poor oral hygiene

Brown to black
Yellow brown to black
Yellow brown

Extrinsic (indirect stains)

Polyvalent metal salts and
cationic antiseptics
(e.g. chlorhexidine)
Intrinsic
Metabolic causes
(e.g. congenital
erythropoietic porphyria)
Inherited causes
(e.g. amelo
dentinogenisis)
Iatrogenic causes
Tetracycline
Fluorosis
Traumatic causes
Enamel hypoplasia
Pulpal haemorrhage
products
Root resorption
Ageing causes
Internalized
Caries
Restorations

Black and brown

Purple brown
Brown or black

Metabolic causes of discoloration

A number of metabolic disorders, such as alkaptonuria, congenital erthropoietic porphyria and
congenital hyperbilirubinemia, cause tooth discoloration. Alkaptonuria is an inborn error of metabolism that results in a brown discoloration of the
permanent dentition (79), whereas congenital
erythropoietic porphyria, a rare, recessive, autosomal metabolic disorder, gives a red purplebrown
discoloration of teeth (37). Congenital hyperbilirubinemia is characterized by yellowgreen discoloration caused by the deposition of bile pigments in
calcifying dental hard tissues, particularly at the
neonatal line, as a result of massive hemolysis in
rhesus incompatibility.

Banding appearance
Classically yellow, brown,
blue, black or grey
White, yellow, grey or black
Brown
Grey black
Pink spot
Yellow

Orange to brown
Brown, grey, black

all the structures that make up the tooth, including

the enamel, dentine and pulp. Any changes to these
structures during formation or throughout development and post-eruption (3 months in utero to 20
years) can cause a change in the light-transmission
properties and hence discoloration.
Table 1 shows the types of tooth discoloration and
the typical tooth colors they produce.

Intrinsic discoloration
Intrinsic discoloration occurs following a change to
the structural composition or thickness of the dentinal hard tissues during tooth development.
This classification can be further subdivided into
the following categories:
metabolic causes.
inherited causes.
iatrogenic causes.
traumatic causes.
idiopathic causes.
ageing causes.

Inherited causes of discoloration

Amelogenesis imperfecta is a hereditary condition
in which the mineralization or matrix of enamel
formation is disturbed. There are currently 14 different subtypes based on clinical appearance, with
the majority inherited as an autosomal-dominant or
X-linked trait with varying degrees of expressivity
(139, 158, 160). The appearance can be badly
affected with hypoplastic thin enamel that is yellow
to yellowbrown in color or the enamel can be quite
mildly hypomineralized (snow-capped), depending
on the type of amelogenesis imperfecta present.
The color of the teeth is presumed to reflect the
degree of hypomineralization of the enamel: the
darker the color the more severe the degree of
hypomineralization (18).
Dentine defects can either be inherited or caused
by environmental factors (120). Genetically determined defects may occur in isolation or may be
associated with a systemic disorder.
Dentinogenesis imperfecta is an inherited disorder
of dentine, which may or may not be associated
with osteogenesis imperfecta (18). Dentinogenesis
imperfecta type I is associated with osteogenesis
imperfecta (mixed connective tissue disorder of type
I collagen) and is characterized by opalescent primary teeth, especially when the condition is the
result of a dominant inheritance pattern. Dentinogenesis imperfecta type II or hereditary opalescent
dentine may be more severe in the primary than in
the secondary dentition, the pulp chambers often
become obliterated and the dentine undergoes rapid
wear once the enamel has chipped away. Clinically,
the appearance is an amber, grey to purpleblue
discoloration or opalescence, thought to be a result

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of the absorption of chromogens into the porous

dentine after exposure of the dentine. This condition
is clearly demonstrated by opalescence on transillumination.
Unlike dentinogenesis imperfecta type II, dentinogenesis imperfecta type I shows enamel that is
much less prone to fracture and the dentine seldom
obliterates pulp chambers; hence, radiographic
examination can differentiate between the two types.
A third type of dentinogenesis imperfecta has been
described (157) that is similar in appearance to
dentinogenesis imperfecta types I and II but with the
radiographic appearance of shell teeth with multiple
pulpal exposures in the primary dentition.
There is some controversy as to whether dentinal
dysplasias are a separate entity from dentinogenesis
imperfecta (18). The primary and secondary dentitions in type I dentinal dysplasia are of normal
shape and form but have an amber translucency.
The pulp chambers in the primary dentition are
frequently obliterated while only crescentic pulpal
remnants are found parallel to the cementoenamel
junction of the secondary dentition. Type II dentinal
dysplasias are thought to involve thistle-shaped pulp
chambers and pulp stones with a brown tooth discoloration (126).

Iatrogenic causes of discoloration

Tetracycline staining results from systemic administration of the drug and its subsequent chelation to
form complexes with calcium ions on the surface of
hydroxylapatite crystals primarily within dentine, although enamel is also affected (140). Tetracycline
should be avoided in expectant and breast-feeding
mothers, and in children up to the age of 12 years, to
avoid discoloration of the developing teeth. The discoloration produced depends on the type of tetracycline used, the dosage and the period of time for
which it is taken, as well as the age of the patient at
the time of administration. Generally, the affected
teeth tend to be yellow or browngrey in color and
the appearance is worse on eruption and diminishes
with time. This is because once erupted the teeth are
susceptible to color changes by photo-oxidation
(exposure to light), causing lightening of the intrinsic
stain. Various analogues of tetracycline produce different color changes, for example, chlorotetracycline
produces a slate-grey color, and a creamy discoloration is produced by oxytetracycline (10, 94).
Tetracycline staining has also been classified
according to the extent, degree and location of the
tetracycline involvement (64).

150

degree I: there is minimal expression of tetracycline stain, which is uniformly confined to the
incisal three-quarters of the crown and is light
yellow in color.
degree II: there is more variability in staining,
ranging from a highly uniform deep yellow to a
grey-banded discoloration in which a distinctive
difference in discoloration is noted between the
cervical region and the incisal four-fifths of the
crown.
degree III: there is very dark blue or grey uniform
discoloration.
Post-eruptive staining with minocycline used for the
treatment of acne in adolescents and adults has been
described as a result of chelation with iron to form
insoluble complexes (14) or by the formation of
complexes of the drug with secondary dentine (117).
Fluorosis may be the result of the natural occurrence
of fluoride in water supplies or from fluoride in
mouthrinses, tablets or toothpastes. This type of
staining is most often confined to the enamel, varying
from areas of flecking to diffuse opaque mottling
superimposed onto a chalky white or dark brown
black background. The dark discoloration is thought to
be post-eruptive by a process of internalization of
extrinsic stain into the porous enamel (151). The
severity of the discoloration is related to the age and
dose administered and can affect both the primary and
secondary dentitions in endemic cases of fluorosis.

Traumatic causes of discoloration

One of the most common causes of tooth discoloration seen in everyday general practice is that caused
by pulpal hemorrhagic products following trauma.
The major cause of the discoloration is thought to be
the accumulation of the hemoglobin molecule or
hematin molecules in the traumatized tooth, and
their penetration into the dentine determines the
severity of the discoloration.
Root resorption following trauma often presents as
a pink spot lesion at the cementoenamel junction in
an otherwise symptomless tooth. The resorption always begins at the root surface but may be internal
(of pulpal origin) or external (of periodontal origin).
Enamel hypoplasia in permanent teeth may be the
result of disturbance of the developing tooth germ
following trauma or infection of the deciduous tooth,
giving rise to a localized enamel defect. Pitting or
grooving may predispose to later internalization of
external chromogens. Generalized hypoplasia may
result from any disturbance of the developing tooth
germ by many different fetal or maternal conditions,

An overview of tooth-bleaching techniques

such as rubella infection or even drug intake during

pregnancy. The defect is usually directly related to
the degree of the systemic upset and can be chronologically traced back to the time of the upset.
Dentine hypercalcification may result following
trauma temporarily disturbing the blood supply of a
tooth and affecting the odontoblasts, giving rise to
excessive irregular dentine deposition in the pulp
chamber and canal walls. The tooth gradually
decreases in translucency and becomes yellow or
yellowbrown in color but is still vital (113).

Idiopathic causes of discoloration

Molar incisor hypomineralization is a condition of
unknown etiology that is characterized by severely
hypomineralized enamel affecting the incisors and
permanent first molars (154). The appearance of the
hypomineralized enamel is asymmetrical, affecting
one molar severely while leaving the contralateral
molar relatively unaffected or only with minor subsurface defects (152). The incisors also show asymmetry but not usually with loss of enamel substance.
The enamel defects can vary from white to yellow or
brownish areas, but they always show a sharp demarcation between sound and affected enamel (153).
The enamel is porous and brittle, breaking down
shortly after eruption under masticatory forces, and
often resembles enamel hypoplasia but is distinguished by having irregular borders with normal enamel as opposed to smooth borders with hypoplastic
lesions (153).
The suggestions of possible etiologies for molar
incisor hypomineralization include environmental
changes during a limited time period, infections
during early childhood, dioxin in breast milk and
genetic factors.

Ageing causes of discoloration

The natural darkening and yellowing of teeth with age,
and the change in their light-transmission properties,
is the result of a combination of factors involving both
enamel and dentine. The enamel undergoes both
thinning and textural changes (96), while the deposition of secondary and tertiary dentine and pulp stones
all contribute to the darkening process of ageing.

Extrinsic discoloration
External staining may be divided into two main categories: direct staining by compounds incorporated

into the pellicle layer and producing a stain as a result

of the basic color of the chromogens; and indirect
staining where there is chemical interaction at the
tooth surface with another compound that produces
the stain.

Direct staining
Direct-staining chromogens derived from dietary
sources such as tea and coffee are taken up into the
pellicle and their natural color imparts the stain onto
the tooth surface. Smoking or chewing tobacco,
medicines, spices, vegetables and red wine are also
known to cause direct staining. It is the polyphenolic
compounds found in food that are thought to give
rise to the color of the stain (105). The actual mechanism of staining is not fully understood but certainly
involves pellicle constituents. Naked enamel does not
take up chromogens easily and pellicle proteins are
often cited as reacting with chromogens, but how
specific this reaction is has not been clarified and
some degree of nonspecificity is probable; the chromogen is merely incorporated within the pellicle
layer much as a sponge can soak up and hold fluids.
Dentine chromogens may be absorbed into the tissue
itself as dentine is more porous than enamel, both in
respect of intertubular dentine and the tubules
themselves (125).
Traditionally, extrinsic tooth discoloration has
been classified according to its origin and whether it
is metallic or nonmetallic (47).
Nonmetallic extrinsic stains caused by beverages,
tobacco, mouthrinses and other medicines are adsorbed on to the tooth surface by incorporation into
the plaque or the acquired pellicle. Chromogenic
bacteria have also been implicated in extrinsic
staining in children who have poor oral hygiene
(causing green and orange stains) and in those who
have good oral hygiene (causing blackbrown stains)
but the mechanism involved has not been established (150).

Indirect staining
Indirect dental stains are associated with cationic
antiseptics and metal salts that are either colorless or
a different color from the stain produced as a result of
a chemical interaction with another compound.
Polyvalent metal salts are known to be associated
with extrinsic staining, such as the black discoloration seen in people using iron supplements and in
iron foundry workers exposed occupationally to these
metal salts. Other examples include the green dis-

151

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coloration resulting from use of mouthrinses containing copper salts or the violetblack color resulting
from the use of potassium permanganate-containing
mouthrinses (149).
Cationic antiseptics, such as chlorhexidine, hexetidine, cetylpyridinium chloride and others mouthrinses, also cause staining after prolonged use.
Chlorhexidine, for example, produces the brown
black discoloration seen around the labial and lingual
surfaces of anterior teeth after only about 710 days
of use.
The mechanism of staining by metal salts, and
particularly by cationic antiseptics, has attracted
much interest from the dental profession and has
been much debated (1, 150). The majority of the data
drawn from randomized controlled laboratory and
clinical studies support a dietary etiology. Thus,
staining is thought to be a result of the precipitation
of anionic dietary chromogens, such as polyphenols,
onto adsorbed cationic antiseptics or polyvalent
metal salts on the tooth surface (1, 150).

silver points in root canals give a grey or pink

appearance to a root-treated tooth.

Development of night guard vital

bleaching
A successful home bleaching technique using
hydrogen peroxide was first described by Klusmier in
1968 (52) when it was noticed that teeth became
whiter after treatment of a mouth injury with Glyoxide (hydrogen peroxide mouthwash) in an orthodontic retainer. The results were lighter teeth in
addition to healing of the injury. However, this
technique received worldwide acceptance when described in 1989 by Haywood & Heyman (53), who
employed 10% carbamide peroxide in a custommade tray worn at night: the night guard vital
bleaching technique (53).

Development of power bleaching

Internalized discoloration
Extrinsic stains are taken up into the enamel or
dentine via a developmental or acquired defect. The
incorporation of extrinsic stain into the porous tooth
structure of developmental defects has already been
discussed under the intrinsic staining section above.
Acquired defects of teeth resulting from function
and parafunction, dentinal caries and restorative
materials can all lead to tooth discoloration, directly
or indirectly.
tooth wear and gingival recession: the loss of enamel and dentine by erosion, abrasion and attrition
can result in the exposure of dentine to extrinsic
chromogens. The exposure of dentine, or the loss
of enamel, gives rise to darker looking teeth as
more of the yellow color of dentine is apparent.
Cracks as a result of trauma to the enamel, or
gingival recession and exposure of dentine, predispose the teeth to extrinsic stain internalization.
dentinal caries: the progression of the carious lesion is usually associated with changes in color,
ranging from the initial white spot lesion to the
black arrested lesion that picks up stain from an
extrinsic source (145).
restorative materials: the classic greyblack discoloration seen around old amalgam restorations
is thought to be caused by the migration of tin into
the dentinal tubules (155). Eugenol-containing
medictions cause an orangeyellow stain, and

152

In-surgery bleaching techniques used since the early

1900s were further modified in 1991 with the introduction of 30% hydrogen peroxide gels activated by
conventional light-curing units rather than a heat
source. This technique is often referred to as power
bleaching. Although these power gels could be controlled easily compared with the liquids used previously, full-mouth isolation was still needed to protect
the gums and the surrounding soft tissues. Power
bleaching was frequently combined with home-use
tray systems to maximize the bleaching effect and
give a kick start to the whitening procedure before the
patient continued with night guard vital bleaching at
home.
A further modification to the power bleaching
system was the use of an argon laser as an activating
light source to replace conventional curing lights
(110). The present-day systems are activated by a
variety of light sources: plasma arc lamps, Xenonhalogen, light emitting diode (LED) light and diode
lasers. However, light sources are not essential and
there are systems that require chemical activation
only and are merely painted onto the teeth with the
usual use of gingival and mucosal isolation (22).

Current bleaching materials

The home bleaching materials currently available are
a combination of different concentrations and fla-

An overview of tooth-bleaching techniques

vours of both carbamide peroxide or hydrogen peroxide used in either custom-made trays or one size
fits all type trays. In addition to these are the relatively new hydrogen peroxide gels on polyethylene
strips (Whitestrips; Procter & Gamble, Cincinnati,
OH, USA), which are applied like medical plasters
onto the surface of the labial tooth and lap over the
incisal edges of the teeth. Other over-the-counter
bleaching agents include paint-on carbamide peroxide preparations of various concentrations used in a
similar way to the bleaching strips. Disposable trays
that are prefilled with 9% hydrogen peroxide with
inbuilt gingival protection have recently been introduced (Ultradent Products Inc., South Jordan, UT,
USA).
Glycerine-based home bleaching solutions have
now been largely replaced because they dehydrate
the tooth, increasing the risk of thermal sensitivity.
Less viscous solutions of both hydrogen peroxide and
carbamide peroxide are now available that are applied for shorter time periods, but their low viscosity
may lead to leakage onto the gingivae, increasing the
potential gingival irritation (76).
The deep bleaching technique has recently become popular among the profession, with its proclaimed predictability of shade B1 (Vita, Zahnfabrik,
Germany) results for every patient. This technique
involves night guard vital bleaching for 14 nights
using 16% carbamide peroxide in specially made
trays that is followed, on the 15th day, by a 1-h insurgery power bleaching session using 9% hydrogen
peroxide in the same trays. The manufacturers
claim that the home bleaching conditions the teeth
by increasing their permeability so that the in-surgery procedure is a lot more effective. The trays are
made by first taking impressions in metal trays
using a medium-bodied silicone for greater accuracy. The reservoirs on the trays are made by adding
a colored stone to the cast models instead of the
resin usually used in this procedure. This, coupled
with the use of a greater force pressure in the
vacuum moulding machine, gives rise to a better
seal to the bleaching tray about 1 mm below the
gingival margin. It is this better sealing of the tray,
enabling the bleaching agent to be active all night,
which is believed to be key to the procedure. In
addition, the patient must continue with the home
bleaching for 14 consecutive days and, to reduce the
inevitable sensitivity, the patient is given a desensitizing agent containing benzalkonium chloride and
fluoride. There is no scientific evidence yet available
to support the claims made regarding this technique.

Bleaching chemistry
Hydrogen peroxide acts as a strong oxidizing agent
through the formation of free radicals, reactive oxygen molecules and hydrogen peroxide anions (32).
These reduce or cleave pigment molecule double
bonds to either break down pigments to small enough molecules that diffuse out of the tooth or to
those that absorb less light and hence appear lighter.
Such pigmented molecules tend to be organic, although inorganic molecules can be affected by these
reactions.
Hydrogen peroxide forms a loose association with
urea to produce urea peroxide (carbamide peroxide),
which is easily broken down in the presence of water
to release free radicals that penetrate through the
enamel pores and into the dentine to produce the
bleaching effect. The urea can theoretically be further
decomposed to carbon dioxide and ammonia, which
elevates the pH to facilitate the bleaching procedure
further (138). This can be explained by the fact that,
in a basic solution, lower activation energy is required for the formation of free radicals from
hydrogen peroxide, and the reaction rate is higher,
resulting in an improved yield compared with an
acidic environment (27).
The breakdown of hydrogen peroxide into free
radicals is summarized in Fig. 1.
Stains caused by inorganic substances locked into
the crystal lattice of the enamel structure, or held
superficially by salivary protein interactions, require
the oxidation of the sulphide or thiolate bonds via
suitable catalysts, such as Fe(II), before they are
receptive to bleaching agents. Often these catalysts
are either unavailable or in short supply, causing the
degradation of hydrogen peroxide to proceed very

H2O2

2HO

HO + H2 O2
HO2

H2O + HO2

H + O2
+

2 H2O2

2H2O + 2{O}

2H2O + O2

H2O2

H + HOO

Fig. 1. Hydrogen peroxide forms free radicals like hydroxyl

and perhydroxyl radicals and superoxide anions (A),
reactive oxygen molecules that are unstable and transformed to oxygen (B), and hydrogen peroxide anions (C).

153

Sulieman

slowly, and therefore extended treatment times are

usually required for these stains (103).
The perhydroxyl (HO2) free radical is thought to be
the most reactive species in tooth bleaching, the
formation of which is favoured by high pH, but this is
rarely the situation as the product shelf life is
adversely affected under these conditions. Although
the perhydroxyl free radical is a very reactive species,
it does need metal trace elements in the mouth to
catalyse its action.
With use of both carbamide peroxide and hydrogen
peroxide the teeth should ideally be dry and free of
debris because enzymes and proteins found in saliva
are capable of catalyzing the nonbleaching breakdown of peroxides to water and oxygen.
In addition to their use in nonvital bleaching
techniques, perborates in gel form, very much like
carbamide peroxide, have been used for tray-applied
vital bleaching. However, when dispatched in powder
form, perborates can be incorporated into a paste
after mixing with water, saline or hydrogen peroxide
and placed in the pulp chambers of nonvital teeth.
Sodium perborate is stable when in the form of a dry
powder but in the presence of acid, moist air or water
it decomposes to form metaborate, hydrogen peroxide and nascent oxygen (Fig. 2). Hydrogen peroxide
mixed with sodium perborate potentiates its effect
and is believed to produce a better bleaching effect
(103, 114), although no evidence to support this is
available. These compounds have also been shown to
remove chlorhexidine-induced extrinsic stain both
in vitro and in vivo (2). Other products marketed as
peroxide-free bleaching agents employ an oxygen
complex made up of a mixture of sodium perborate,
sodium chlorite and oxygen.

Bleaching safety
A number of authors have investigated the safety of
bleaching procedures (1113, 22, 28, 60, 61, 6669, 73,
89, 90, 97, 118, 122, 123, 131, 162) but have tended to
concentrate mainly on the use of carbamide peroxide
used in at home bleaching systems (11, 13, 28, 60, 66
69, 89, 90, 97, 118, 122, 123, 162). The evidence on
safety published to date on the whole tend to suggest
that bleaching is a relatively safe procedure (28, 60,
61, 6769, 73, 90, 97, 122, 131, 162) but some workers
have voiced concerns about potential structural
changes that may occur as a result of bleaching (11
Na2[B2(O2)2 (OH)4 ] + 2H2O

2Na BO3+ 2H2O2

Fig. 2. The formation of hydrogen peroxide from sodium

perborate.

154

13, 89, 123). Adverse effects reported by frequency for

all home bleaching products show that 27% of patients suffer an unpleasant taste and a further 27%
complain of a burning palate sensation. Other adverse effects included burning throat or gingival tissues, gingival ulceration and tooth sensitivity (60). All
such ill effects usually resolve on cessation of treatment.
A number of studies have reported an increase in
gingival health following bleaching procedures (109)
and two reasons have been put forward for this. The
first is that the bleaching solution is toxic to the
bacteria within the gingival crevice (8) and the second is that patients undergoing bleaching might take
more interest in their teeth and as a result may
improve their oral hygiene during the treatment.

Tooth sensitivity
The sensitivity of teeth in some individuals during
bleaching is a problem that has attracted little research attention, even though two-thirds of patients
generally experience sensitivity during home
bleaching, which usually lasts between 1 and 4 days
(67, 99, 112, 119). However, a number of studies have
assessed the occurrence of the sensitivity relative to
its time of onset and duration of the symptoms. The
incidence of sensitivity ranges from 11 to 93% of
patients using 10% carbamide peroxide (32, 71, 73,
79) and the average first report of sensitivity was after
4.8 days (4.1 days), usually lasting for 5 days (3.8
days) (142).
Tooth sensitivity is believed not to relate to exposed root surface or dentine or caries, but instead is
explained by the easy passage of the hydrogen peroxide molecules through the enamel and dentine into
the pulp (50). This results in pulpal inflammation
affecting the pulpal sensory nerves that trigger in
response to stimuli, such as cold drinks, until the
inflammation subsides. However, dentine exposure
may be a factor in tooth sensitivity as it is often
misdiagnosed as not being present clinically (9). In
fact, other workers (65) have correlated the incidence
and severity of thermal sensitivity with gingival
recession and the frequency, not actual duration, of
the treatment (76).
Risk factors for the development of tooth sensitivity
and gingival irritation that are associated with night
guard vital bleaching were reported by Leonard et al.
(74). No statistical relationship existed between age,
gender or tooth characteristics, with the dental arch
bleached and the development of side effects. Initially, a statistically significant association existed

An overview of tooth-bleaching techniques

between the side effects and the whitening solution

used. However, when the analysis was controlled for
usage pattern, this relationship disappeared. Patients
who changed the whitening solution more than once
a day reported more statistically significant side
effects than did those who did not change the
whitening solution during their usage time.
Schulte et al. (119) reported on a clinical study
involving the use of 10% carbamide peroxide on 28
people. Four subjects discontinued bleaching because
of thermal sensitivity, whereas the remainder showed
no change in pulpal readings recorded before the start
of the treatment and at any time during the study.
Sterrett et al. (129) found that all the individuals
experienced mild, transient sensitivity during a 3week trial. However, the consensus view from other
trials was that two-thirds of patients experienced
mild, transient thermal sensitivity, which disappeared on the cessation of bleaching (67, 99, 112,
119). The penetration into the pulp of various commercially available 10% carbamide peroxide bleaching products has been shown to differ significantly
and may therefore account for the varying levels of
sensitivity reported (144).
Although there is a widely held belief that higher
concentrations of bleaching agents produce a greater
prevalence of tooth sensitivity, studies reported
disprove this theory (68, 86).
Cohen & Parkins (24) monitored vital bleaching for
six children with tetracycline-stained teeth involving
heat and hydrogen peroxide application for eight
consecutive 30-min sessions at 1-week intervals. Pretreatment and post-treatment vitality tests were
performed on test and control teeth, and no changes
in vitality were found throughout the study.
Cohen (23) also attempted to relate the prevalence
of tooth sensitivity in vital bleaching with possible
histological pulpal changes. The study involved 19
patients in whom 51 premolars were bleached with
35% hydrogen peroxide and heat in 30-min sessions.
All test and control teeth were extracted for orthodontic reasons and subsequently histologically
examined. Of the patients treated, 78% experienced
some form of sensitivity, lasting for 24 h, from
bleaching; in one individual the discomfort lasted for
48 h. Histological findings from the study showed
that all pulps were normal except for moderate
vasodilation and aspiration of odontoblast nuclei into
the dental tubules, which was found to occur with
equal frequency in both test and control teeth. Cohen
(23) concluded that sensitivity and discomfort during
and after bleaching procedures are caused by heat
application increasing the intrapulpal pressure that

leads to the sensation of pain. Histological changes to

the pulp after night guard vital bleaching with 10%
carbamide peroxide have recently been reported to
be minor; they did not affect the overall health of the
pulp tissue and were reversible within 2 weeks posttreatment (40). In a previous study in which the pulps
were evaluated after overnight bleaching with 10%
carbamide peroxide for either 4 or 14 days, mild
inflammatory changes were demonstrated in four out
of 12 teeth, irrespective of treatment duration (46).
However, in those teeth treated for 14 days, followed
by a rest period of 14 days, no inflammation was
detected.
In a clinical study monitoring post-operative discomfort associated with vital bleaching, Nathonson &
Parra (99) found that 30% of patients had no sensitivity, whereas the majority of the others only experienced mild symptoms lasting less than 24 h, with
patient age having no effect on the degree of sensitivity experienced. This was contrary to the widely
held view that younger patients with wider pulp
horns would develop more sensitivity.
The efficacy of desensitizing agents used in patients who experience tooth sensitivity during tooth
whitening has been reported in a study of such patients who had pre-existing symptoms prior to the
start of the whitening procedure (76). This study
suggested that the use of a 3% potassium nitrate and
0.11% fluoride desensitizing agent for 30 min prior
to whitening may decrease tooth sensitivity when
compared with a placebo gel.

Effects on the pulp

A study of the penetration of hydrogen peroxide reported that the compound enters readily through the
enamel and dentine to reach the pulp chamber of
extracted teeth (16). Bowles & Thompson (15) have
shown that hydrogen peroxide concentrations as low
as 5% can dramatically inhibit pulpal enzyme activity.
These enzymes were quite sensitive to the combination of hydrogen peroxide and heat, but the quantities
required to produce this inhibitory effect were in the
region of 50 mg. A follow-up study then went on to
show that although dental hard tissues exhibited
substantial permeability to hydrogen peroxide, especially with the application of heat, the quantities that
diffuse into the pulp chamber were in the order of only
micrograms: too low to produce inhibitory effects on
enzymes and therefore unable to cause permanent
pulpal damage (16). The effects of carbamide peroxide
penetration were also studied and it was found that
for the same effective concentration, there was less

155

Sulieman

penetration of the pulp from carbamide peroxide than

from free hydrogen peroxide (26).
The effects of light-enhanced bleaching on the
in vitro surface and on intrapulpal temperature rise
have been reported (4, 134, 137). Baik et al. (4) investigated the effect of the presence, absence and ageing
of heat-enhancing colorant added to the bleaching gel
on the temperature rise of the gel itself, as well as on
the temperature rise within the pulp chamber, when a
tooth was exposed to a variety of lights. The results
showed that the freshness of this bleaching agent
influences the temperature rise of the bleaching gel
and may also increase the intrapulpal temperature.
Use of the lights elevated the bleach temperature,
which resulted in an increased intrapulpal temperature that may further impact on patient sensitivity and
pulpal health. A variety of different bleaching lights,
including a diode laser, were investigated by Sulieman
et al. (134, 137) who found that these lights did not
increase the intrapulpal temperature above the critical
5.5 C (161) as long as they were used within the
manufacturers guidelines.

Root resorption
Cervical resorption is seen occasionally in bleached,
root-filled teeth and has been attributed to a combination of trauma and bleaching with high-concentration hydrogen peroxide (30%) and heat (39).
Heithersay et al. (57, 58) studied the radiographs and
records of 204 teeth from 158 patients who had received tooth-bleaching treatment in a specialist endodontic practice in the past 119 years. Seventy-eight
per cent of these teeth had prior incidents of traumatic injury. All teeth were bleached using a combination of thermocatalytic or heat-activated 30%
hydrogen peroxide and walking bleach techniques.
Only four of these teeth (2%) had developed invasive
cervical resorption during the review period, which
might have been a result of the original trauma.

Effects on physical properties

Scanning electron microscopy of enamel bleached
with carbamide peroxide showed little or no change in
morphology (55), whereas other work showed areas of
shallow erosions (54) or more substantial changes in
enamel structure (11, 12, 123). Surface hardness and
wear resistance has also been investigated with results
showing a lack of agreement on the overall effect of
bleaching. The results range from no effect on toothwear (70, 73, 156) to a significant decrease in the

156

hardness and fracture resistance of enamel (13, 89).

Bleaching does not cause any perceptible etching of
the teeth, and morphological changes in the outer 25
lm of the enamel are clinically insignificant (90, 146).
Abrasion, erosion, surface hardness and morphological changes of enamel and dentine following power
bleaching using 35% hydrogen peroxide were investigated (131). There were no significant changes
following the bleaching procedure as the high concentration of hydrogen peroxide did not affect the
abrasion, erosion or hardness of both enamel and
dentine. One possible reason for the reported deleterious effect on enamel and or dentine of bleaches is
not the bleach itself but the pH of the formulation
used. The pH of various commercially available toothwhitening agents was analysed in a study by Price et
al. (108) who found the range was from highly acidic
(pH 3.67) to highly basic (pH 11.13), with the over-thecounter preparations having a significantly different
pH to both the at-home and in-surgery bleaching
materials. The over-the-counter bleaching agents
have been found to have very acidic pH values, which
may cause erosion of the enamel, and the toothpastes
supplied with them can be quite abrasive (62).
There may be a loss of organic components from
bleached enamel and dentine surfaces. The calcium:phosphate ratio of dentine was found to be
significantly reduced by bleaching with 30% hydrogen peroxide and 10% carbamide peroxide in a study
by Rotstein et al. (115). In another study, by
McCraken & Haywood (90), teeth exposed to 6 h of
bleaching using carbamide peroxide lost an average
of 1.06 lg mm2 of calcium, which was found to be
similar to the amount lost from the enamel after a
2-min exposure to carbonated cola, orange juice or
carbonated diet cola (48). The potential for remineralization in vivo could counteract these effects but to
date this has not been investigated.
Bleaching has no effect on the erosion and
demineralization of enamel (17, 80, 106, 123), but the
methods of assessment have been debated as microhardness has often been the sole method of
measurement. The argument is that measuring only
the softened portion of the lesion is unable to
quantify the bulk loss of tissue, which would require
assessment methods such as profilometry.

Effects on enamel dentine

bonding
Bonds to enamel dentine may be altered following
bleaching because of the presence of hydrogen

An overview of tooth-bleaching techniques

peroxide. Resin tags in bleached enamel are less

numerous, less well defined and shorter than those
in unbleached enamel (100). Bonding to dentine
may be altered after bleaching (33) and the smear
layer may be removed (61). Bonding between glass
ionomer and dentine may also be affected by the
possible precipitation of hydrogen peroxide and
collagen that forms on the cut dentine surface after
tooth bleaching (100).
The residual oxygen in the tooth surface also
inhibits the polymerization of the composite resin
and disrupts the surface (62, 93). However, bond
strength improves if the procedure is delayed for 2
weeks post-bleaching.

Effects on restorative materials

The effects of bleaching agents on composite resins
are conflicting, ranging from no effect (7, 67, 83) to
alteration of surface hardness (5, 42), surface roughening etching (127) and changes in tensile strength
(31). However, these effects were very small and
considered unlikely to be clinically significant (140).
Prolonged bleaching treatment may cause microstructural changes in amalgam surfaces and this may
increase exposure to the patient of toxic by-products
(115). Existing amalgams may change in color from
black to silver, but not all combinations of amalgam
and bleaching agents result in higher mercury levels.
Little effect is reported on gold or porcelain restorations; however, the glass ionomer matrix may show
alteration in its matrix (63). Provisional crowns made
of methyl methacrylate may discolor to become
orange, but other materials are not affected (111).

Toxic effects
Carbamide peroxide administered as a home
bleaching agent breaks down to produce hydrogen
peroxide and urea in the mouth. The toxicology of
hydrogen peroxide has been reviewed by the European Centre for Ecotoxicology and Toxicology of
Chemicals (36), and others (77), who reported that
hydrogen peroxide is found to occur naturally in
many vegetables and is produced in humans during
normal metabolism of aerobic cells. In addition to
this, phagocytic cells, such as neutrophils and macrophages, provide an important source of endogenous hydrogen peroxide and play an essential role in
defence against various pathological microorganisms
(148). However, free radical oxidative reactions with

proteins, lipids and nucleic acids have a number of

potential pathological consequences (38). To prevent
these potential dangers, the body has a number of
defense mechanisms at the tissue and cellular level
that work to repair any damage sustained. Enzymes
such as catalase, peroxidase and superoxide dimutase are commonly found in body fluids, tissues and
organs to metabolize hydrogen peroxide (37, 57).
Salivary peroxidase has been suggested to be the
bodys most important and effective defence against
potential adverse effects (19). The hydrogen peroxide
exposure dose has been estimated to be approximately 3.5 mg for a treatment of both arches using
10% carbamide peroxide (77), while the oral cavity is
capable of decomposing more than 29 mg of hydrogen peroxide per minute (84).
The dermal toxicity of hydrogen peroxide is low,
with concentrations of up to 35% not considered as
being irritant to rabbit skin; however, concentrations
of greater than 50% are corrosive. Various mouth
rinses and oral antiseptics (10 and 15% carbamide
peroxide, and hydrogen peroxide up to a concentration of 3%) have been used for some time with no
detectable ill effect on humans and have been approved by the US Food and Drug Administration
since 1979. On the contrary, reports are of beneficial
effects on gingival irritation and plaque accumulation, and an anticariogenic action (124).
Hydrogen peroxide has been found not to be carcinogenic, mutagenic or teratogenic (37, 78, 159), and
concerns of toxicity or serious damage to soft tissues
appear to be unfounded (49). Initially, concerns were
raised about the role of hydrogen peroxide in mutagenesis on the basis of some in vitro tests that were
not reproduced in vivo (67). In fact, the frequency of
genetic mutation induced by 10% carbamide peroxide is not significantly different from that of a physiological saline control (159). The only side effect
reported from ingesting large quantities of a carbamide peroxide home bleaching product was a
laxative effect from the presence of glycerine found
within the gel (3).

Evidence of efficacy of
tooth-whitening techniques
A variety of case reports and small clinical studies
have shown that a 10% carbamide peroxide gel used
in night guard vital bleaching techniques produces
predictable results (66, 69, 74, 75, 85, 88, 104, 109,
116) as do hydrogen peroxide strips (44). Similarly,
power bleaching using 35% hydrogen peroxide, with

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Sulieman

or without light and or heat activation, has also been

shown to be effective (60, 130, 131, 133).
Heyman et al. (59) reported a mean change of 7
units on the Vita shade guide after bleaching with a
10% carbamide peroxide gel over 7 days. However,
there was a wide range of responses, ranging from 3
to 13 units, which highlights the unpredictable nature
of teeth. Papathanasiou et al. (104) reported a mean
change of 8 Vita units when using a 15% in-office
hydrogen peroxide system, whereas Gerlach & Zhou
(44) reported a mean change of 5.5 units when using
a whitening strip, but 25% of their sample had a
shade change in excess of 8 units.
Clinical and laboratory studies have also reported
tooth-whitening changes using the L*a*b* system of
measurement (25). For example, an in vitro study on
dentine by White et al. (156) reported an improvement of DL* of 7 units when a 10.5% carbamide
peroxide gel was used for 30 h. Similarly, Gerlach &
Zhou (44) reported an improvement of DL* of 2 units
with a whitening strip product.
Various workers have compared two or more night
guard vital bleaching agents clinically; very similar
results were obtained, usually in the magnitude of
about 7 shade guide units improvement (82). Rosenstiel et al. (112) reported on a single power
bleaching session in a group of 20 young adults,
which produced an average whitening effect of 6.2 L*
units (as measured using a colorimeter) that was still
detectable 6 months post-treatment. In-surgery
bleaching has been compared with night guard vital
bleaching using 10% carbamide peroxide in a 3month single blinded clinical study (163). Comparisons were made of the color change, color relapse as
well as tooth and gum sensitivity. A 14-day home
treatment was compared with 60 min of in-surgery
bleaching consisting of two clinical bleaching sessions of three 10-min applications. The at-home
bleaching produced significantly lighter teeth, but
significantly higher cervical sensitivity. Colour
relapse for both bleaching techniques stabilized by 6
weeks.
Long-term results of bleaching efficacy were reported by Leonard (72), with at least 43% shade
retention without retreatment at 10 years.
The effect of the lights used for in-surgery bleaching techniques have been the subject of various debates as to their efficacy in improving the bleaching
process (6, 70, 81). Hein et al. (56) reported that the
three lights used in their study (halogen curing light,
Xe-halogen light and metal halide light) did not
lighten teeth more than their bleach gels alone and
concluded that output from any of the lights used

158

resulted in heat or light that catalysed breakdown of

the gels. They also concluded that proprietary
chemicals added to the gels caused them to perform
differently from the 35% aqueous hydrogen peroxide
liquid controls used in the laboratory tests. Furthermore, these chemicals were also probably responsible for the reduced time required to bleach with the
Xe-halogen light. Contrary to these results, Luk et al.
(81) reported that color and temperature changes
were significantly affected by an interaction of the
bleach and light variables. The application of lights
significantly improved the whitening efficacy of some
bleaching materials but it caused a significant temperature increase in the outer and inner tooth surfaces. Other workers have also reported a study on
the use of lights for in-surgery bleaching and concluded that the use of lights with the peroxide gel
significantly lightened teeth more than peroxide or
light treatment alone (143). The results of this study
must be interpreted with caution as the reported
shade improvement with light-only application was
4.9 shade guide units, which was probably the result
of a great deal of tooth dehydration. In another
in vitro study, it was found that an activating light
source did improve the whitening effect but the
freshness of the hydrogen peroxide was probably
more of a contributing factor (135).
Researchers at Procter & Gamble have reported on
many trials using a whitening strip and various concentrations of carbamide peroxide (44). In general,
the magnitude of the whitening response decreased
with age and, on average, for every 10 years of aging,
individuals should expect approximately 0.3 units
less whitening benefit. Baseline color also affected
the response, with the greatest average whitening
seen in individuals with more yellow teeth. For both
strip and tray systems used, increasing the peroxide
concentration was observed to improve the whitening response (47, 48, 141). When treatment time was
doubled to 28 days using these whitening strips, an
additional 29% whitening effect was achieved compared with the normal treatment duration of 14 days
(34, 50). Pre-brushing teeth prior to the application of
whitening strips was also found to yield a significantly more efficacious whitening result (50), although no explanation for this was offered.
After the introduction of a new higher-concentration whitening strip (14% hydrogen peroxide), which
was thinner and incorporated a smaller volume of
bleaching gel, various comparative trials were reported in a pooled report (43). Efficacy results for
these strips were significantly better than placebo or
pooled positive controls evaluated in clinical trials

An overview of tooth-bleaching techniques

assessing tooth shade. The reported irritation and

patient tolerability were similar to those reported
with previous lower-concentration strips and other
marketed positive bleaching controls.
Hydrogen peroxide (8.7%), carbamide peroxide
(18%) and sodium percarbonate (19%) paint-onbleaching agents have been introduced directly to the
public as over-the-counter preparations. The shade
improvements with these agents were reported to be
about 4 shade guide units from baseline (41) with a
reduction in yellowness (Delta b*) of about )0.95
units (43).
Long-term efficacy has been reported by Leonard
(72), with shade retention without retreatment in at
least 43% of subjects at 10 years post-treatment. The
initial efficacy of the night guard vital bleaching
technique was 98% for nontetracycline-stained teeth,
and, with extended treatment times for tetracyclinestained teeth, 86% of these teeth were lightened.
Laboratory studies have reported on the efficacy of
different concentrations of carbamide peroxide. Although higher concentrations of 10 and 16%
produced a quicker 2-shade shift than a 5% concentration, the eventual result on whitening was the
same for all concentrations (75). Other studies that
compared various concentrations of carbamide peroxide and hydrogen peroxide also found that the
eventual result was the same, but the time taken to
reach that end point was quicker with high concentrations of bleaching agents (130, 136). In a similar
clinical study on patients with tetracycline-stained
teeth, more rapid bleaching effects were achieved
with a higher concentration of carbamide peroxide
(15 and 20%) but the end results were the same as
those for a lower concentration of carbamide peroxide (10%) (87). In a separate study comparing the
clinical effect of 10 and 15% carbamide peroxide
using three different shade-assessment methods, results at 2 weeks showed a significantly better shade
improvement for the higher-concentration product.
However, by 6 weeks there were no statistical significant differences between the two concentrations
(86).
To establish the efficacy of both 20% carbamide
peroxide and the equivalent concentration of 7.5%
hydrogen peroxide used in an in vivo study of daytime use of bleaching agents, it was found that there
were no significant differences between the two
products in terms of tooth lightness, and gingival and
tooth sensitivities (95).
The mechanism of tooth color change during
bleaching is poorly understood. Many workers suggest that tooth color is primarily determined by the

dentine, which can be changed by bleaching techniques (121, ten Bosch and Coops, 1995). Some
studies, using 35% hydrogen peroxide, have reported
color changes in both enamel and dentine (3, 52, 91,
92, 98, 132). Others dispute the idea of color change
in dentine and believe that this occurs in enamel
only, thereby masking the unchanged dentine (21).
However, the successful bleaching of tetracyclinestained teeth, and those with dentinogenesis imperfecta (30, 61), add weight to the argument that the
color change takes place primarily within dentine.
McCaslin et al. [1999] reported on a study using 10%
carbamide peroxide and its effect on dentine color
changes, and found that the color change in dentine
occurred at a uniform rate.
A study by Carrillo et al. (20), of inside outside
bleaching of nonvital teeth and the surrounding vital
teeth, reported an average Vita shade change of 15
and 6 for the nonvital and vital teeth respectively.
Friedman (39) also reported very favourable shade
changes for nonvital bleaching, but was cautious over
long-term results (15 years) with 50% shade relapse
observed.

Indications and contraindications

for bleaching
Nearly every patient can have their teeth bleached,
but not every case is guaranteed to have a successful
outcome or be enough to satisfy the esthetic needs of
the patient. The indications for bleaching are basically the same for both in-surgery and home
bleaching but the clinician must decide which
method is best suited to the patients needs.

Indications
generalized staining.
ageing.
smoking and dietary stains such as those of tea and
coffee.
fluorosis.
tetracycline staining.
traumatic pulpal changes.
pre-restorative and post-restorative treatments.
Very severe tetracycline staining may not be amenable to bleaching alone and therefore combination
treatments, such as bleaching and veneers, may be
considered. Prior bleaching reduces the amount of
tooth substance removed in preparation for the veneers, which would otherwise have been necessary in
order to mask the stain and allow for porcelain build

159

Sulieman

up. Fluorosis with multiple spots of varying colors

may require a combination of bleaching and microabrasion using hydrochloric acid and abrasives polishes (29). Bleaching is also indicated prior
to extensive restorative cosmetic work in the anterior
region of the mouth in order to allow general
improvement of the shade of the teeth, which are
then matched with the new restorative restorations.
Bleaching can also be used post-restoratively when
patients present with incorrectly made restorations
whose shades are lighter than the natural dentition.
As mentioned above, bleaching can be undertaken
in most cases but some contraindications are worthy
of mention. Patients with high expectations may
never be satisfied and should be identified by asking a
simple question as to what they hope to achieve with
the bleaching procedure. Patients who reply dazzling
white or words to that effect should be treated
cautiously, while more reasonable replies may be a
freshening look to the teeth or a little lighter. Decay,
peri-apical lesions and sensitivity does not preclude
those patients from bleaching, but these conditions
have to be resolved prior to bleaching.

Contraindications

patients high expectations.

decay and peri-apical lesions.
pregnancy.
sensitivity, cracks and exposed dentine.
existing crowns or large restorations in the smile
zone.
elderly patients with visible recession and yellow
roots.
Existing crowns or restorations that need to be
changed following bleaching may be considered as a
contraindication for patients who do not want or
cannot afford this extra financial burden. It is not
always necessary to change composites following
bleaching because some types of composites display
a chameleon effect, taking on the shade of the surrounding tooth and blending in well, if not quite
perfectly. The other contraindications mentioned
above can be rectified before embarking on a
bleaching course of treatment. For instance, in the
case of decay, a restoration can be preformed and
resurfaced for the correct bleached shade about 2
weeks post-bleaching once the end shade has stabilized and to allow for the dissipation of the residual
oxygen that may inhibit the composite bond to
enamel dentine. Similarly, apical lesions should be
treated and the root canal filling sealed effectively
using a glass ionomer material prior to bleaching.

160

The sensitive patient can have fluoride-desensitizing

gels applied to teeth in the bleaching trays for a
period of a few weeks prior to bleaching. Elderly patients with yellow receded roots present a problem in
that the roots do not bleach as readily compared with
the crowns, leaving an obvious mismatch that requires to be corrected by restorative dentistry. If the
patients are aware of this and are willing to undergo
restorative work to address this issue, then it cannot
be considered as a contraindication.

Who best to bleach?

Although it is difficult to predict the result of
bleaching teeth for every individual, there are some
guidelines gained from various studies, reports and
personal experience. For instance, the effect of
bleaching in older patients who have teeth with small
pulps and various accumulated dietary stains, as well
as the aging discoloration caused by secondary dentine deposition, is relatively predictable. In the authors experience, teenagers with yellow teeth or with
basically white teeth except for the yellow canines
tend to respond well to bleaching. Browns stains are
more difficult to bleach but generally respond to
longer bleaching regimens than stains caused by
nicotine (51). White fluorosis spots tend not to bleach
but will become less obvious as a result of the lightening of the surrounding tooth area (51).
Severe tetracycline staining may be very difficult to
bleach but mild-to-moderate tetracycline staining
tends to respond to extended bleaching regimes of 3
to 6 months (51). Different brands of tetracycline
present with different colored tooth banding, which
is especially difficult to treat as not all respond well to
bleaching, leaving the possible need to use restorations to cover the nonresponsive band (51). Figure 3
shows an example of fluorosis brown stain removed
using 10% carbamide peroxide.

Bleaching protocol
Diagnosis of the cause of the discoloration should be
made and recorded in the patients notes. The options for treatment can be extrinsic stain removal,
bleaching or both. Other options, such as veneers and
crowns, should also be discussed with the patient and
recorded in the notes.
The teeth that are to be bleached should be identified and checked for the following:
vitality.
caries.

An overview of tooth-bleaching techniques

pre-operative photograph with the shade tab in situ

should always be taken under standardized lighting
conditions without using the dental operating light,
which would result in washout of the shade. After all
the relevant explanations, options, limitations and
prognosis have been discussed with the patient, a
consent form should be signed and the patient
referred for a hygiene session about 710 days prior
to the bleaching procedure.

Home bleaching
Bleaching material regimen

Fig. 3. The use of 10% carbamide peroxide to remove a

brown flourotic stain from a maxillary right central
incisor.

cracks.
recession, exposed dentine.
developmental defects such as white spots.
In addition, the presence of composite fillings, veneers, crowns or highly translucent teeth should be
noted. Patients must be warned that these will not
change shade but their margins may merely be
cleaned up by the bleaching agent acting on the
surrounding tooth structure. Hence, they may need
replacement following the bleaching treatment.
Highly translucent teeth do not bleach well and
sometimes appear greyer rather than whiter (45).
Patients need to be aware of all these points and the
information again needs to be recorded in the notes.
Some authors advocate the use of full-mouth periapical radiographs to document the size and vitality
of pulps to predict sensitivity levels or check for periapical pathology (51). In view of the current ionization radiation regulations and the unnecessary
exposure of the patient to high levels of radiation,
other forms of vitality testing, such as ethyl chloride
or electric pulp testers, are advised instead. Any teeth
that require root canal therapy should have this carried out prior to the bleaching procedure. Following
the assessment of the teeth, the shade should be
agreed with the patient and recorded in the notes. A

Nearly all the bleaching materials on the market have

been shown to work to a comparable extent (82).
Generally, the higher-concentration, thicker, more
viscous materials produce a lightening effect more
quickly than lower-concentration, less viscous
materials. However, higher concentrations tend to
produce more cases of thermal sensitivity (107).
The choice of material to use depends on a number
of factors, including the type of discoloration present
and how dark the teeth are initially. However, the
most important consideration has to be the patient,
their lifestyle, the time available for bleaching
and whether there are existing problems with tooth
sensitivity.
The bleaching regimen is therefore determined by
the patients lifestyle, preference and schedule. If the
patient is happy and able to wear trays overnight,
then 10% carbamide peroxide worn for 8 h overnight
is the treatment of choice (Fig. 4). However, if time is
at a premium, this regimen is not recommended as
bleaching will take about 4 weeks in total as the top
and the bottom teeth are bleached separately. In the
authors experience, some patients are able to wear
both upper and lower trays simultaneously overnight,

Fig. 4. Loaded tray inserted into the patients mouth before

removal of excess bleaching agent.

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Sulieman

thereby reducing the bleaching period to 2 weeks, but

many patients cannot cope with this regimen. Higher
concentrations of carbamide peroxide, such as 15 or
20%, can be selectively used to treat darker teeth
within an arch such as canines while still using 10%
carbamide peroxide to bleach the lighter teeth within
the arch at the same time.
Some patients are unable to wear trays overnight
and prefer daily use, which has the advantage of more
frequent replenishment of the bleaching gel for
maximum bleaching effect, but both occlusal pressure
and increased salivary flow may dilute the gel (35).

ucts; they are aimed at reducing the concentration

and amount of bleaching gel used, or the bleaching
time. The trays are trimmed back, if necessary, and
less gel is used in the trays with the excess thoroughly
removed. The patients can be instructed to apply the
bleaching materials only on alternate nights, or even
every third night, to reduce the problems of sensitivity. This can delay the treatment time but ensures
that the patient is comfortable with the bleaching
regime.

Nonvital bleaching techniques

Home bleaching side effects
Some patients experience problems with gingival or
soft tissue irritation during home bleaching, but the
vast majority of problems are those of tooth sensitivity, which have been reported to affect about twothirds of patients (61, 99). Painful gums may be the
result of incorrectly fitting trays impinging on them
or the use of excess material in the trays. The trays
can be easily trimmed back and polished, while the
patient can be instructed to use less material if other
areas of mucosa or soft tissues are irritated. Some
patients who bleach teeth overnight report a metallic
taste sensation immediately following tray removal,
but this usually disappears after about 2 h (42).
Thermal tooth sensitivity is a common side effect
noticed by patients as early as the third day of
bleaching following the removal of trays and may
persist for 34 h afterwards. Patients who experience
severe sensitivity should be advised to stop bleaching
and the sensitivity should be treated. Treatment can
take the form of fluoride-containing toothpastes or
neutral sodium fluoride gels in the bleaching trays
worn overnight. Desensitizing potassium nitrate, or
potassium nitrate and fluoride-containing gels, are
also available for use in trays for about 2 h before or
after the bleaching procedure. Potassium nitrate in
toothpastes takes about 3 weeks to reduce sensitivity
measurably, but when put in a tray for 1030 min,
relief is almost immediate. Lower degrees of sensitivity
can be treated with desensitizing toothpaste rubbed or
brushed onto the cervical necks of the affected teeth.
Fluoride acts primarily as a blocker of dentinal
tubules, which acts to slow down the dentinal fluid
flow that causes sensitivity, while potassium nitrate
acts like an anesthetic by preventing the nerve from
repolarizing after it has depolarized in the pain cycle
(51).
Other forms of treating sensitivity are passive in
terms of not involving specific desensitizing prod-

162

There are a number of nonvital bleaching techniques

available, which include walking bleach and modified walking bleach, nonvital power bleaching, also
known as thermo photo bleaching, and inside
outside bleaching.

Walking bleach technique

First described by Spasser (128), the walking bleach
technique involved sealing into the tooth a mixture of
sodium perborate with water by introducing it into
the pulp chamber. After 1 week the patient would
return and the procedure would be repeated until the
desired whitening had occurred. The technique was
modified using a combination of 30% hydrogen
peroxide and sodium perborate sealed into the pulp
chamber for 1 week modified or combination walking bleach technique (102, 103). Sodium perborate is
stable when in the form of a dry powder, but in the
presence of acid, warm air or water it decomposes to
form metaborate, hydrogen peroxide and nascent
oxygen. Hydrogen peroxide mixed with sodium perborate potentiates its effect and produces a better
bleaching effect (114).
Prior to any bleaching procedure the nonvital tooth
must be radiographed to assess the quality of the root
canal obturation and the apical tissues. Any deficiencies must be rectified before bleaching.
The combination bleach technique differs from
the above only in that sodium perobrate is mixed
with 30% hydrogen peroxide (or lower concentrations), instead of water, to form a thick paste that is
sealed into the cavity. The procedure is quicker acting
and hence can produce results after 1 week. The
current walking bleach technique involves sealing in
10% carbamide peroxide instead of sodium perborate without needing to mix the product, simply
syringing the gel into the cavity and reviewing the
patient in 3 days.

An overview of tooth-bleaching techniques

Internal nonvital power bleaching

This technique is the least favoured because of its use
of high temperatures and the probable increased risk
of internal resorption. Hydrogen peroxide gel at a
concentration of 3035% is applied into the pulp
chamber and activated either by light or heat. The
temperature is usually between 50 and 60 C and
maintained for 5 min before the tooth is allowed to
cool down for a further 5 min before the gel is removed by washing with water for a further minute
(114). The tooth is dried and the walking bleach
technique is used between visits until the tooth is
reviewed 2 weeks later to assess if further treatment is
necessary.
A variation of this technique uses 35% hydrogen
peroxide gel applied both internally to the pulp
chamber and externally to the labial surface of the
tooth, with light activation internally and externally.
High temperatures are not involved and the same
preparation protection techniques are used on the
tooth. Light activation both internally and externally
can be in the form of a conventional halogen-curing
light, plasma arc lamp or a diode laser. Following this
procedure, the tooth is washed and dried before being
sealed with a temporary restoration. The patient is
reviewed 2 weeks later when the shade would have
stabilized and the tooth is ready for a definitive restoration to be placed or is bleached further if required.

Inside outside bleaching

This technique is a combination of internal bleaching
of nonvital teeth using the home bleaching technique. The preparation of the nonvital tooth is exactly
the same as for the walking bleach technique in that
a protective barrier is placed over the root canal
system using glass ionomer material and the access
cavity is completely cleaned in readiness for the
bleaching procedure.
The advantage of this technique for bleaching
nonvital teeth is that it utilizes both an internal and
an external approach for the bleaching agent. The use
of a lower concentration of bleach, usually 10% carbamide peroxide, is thought to reduce the risk of
external resorption. There is no need for frequent
changes in temporary dressings, as experienced with
the walking bleach when the oxygen build up within
the pulp chamber dislodged the dressing. Additionally, the technique achieves the lightening effects
within a matter of days compared with weeks.
The main disadvantages of this technique are the
need for patient compliance and a little degree of

Fig. 5. Bleaching of a nonvital upper left central incisor

using the inside outside technique.

manual dexterity to place the bleaching agent into

the cavity. Coupled to the ease with which overuse
can lead to overbleaching the tooth, and with the
potential for external resorption still existing, although reduced, this technique is by no means
without its risks.
As with the modified bleaching technique, the inside outside bleaching technique has been modified
by use of varying concentrations of carbamide peroxide, such as 5, 16, 22 or 35%, as used in the waiting
room technique. Figure 5 shows a typical example of
the results achieved using this technique.

Power bleaching
The power bleaching technique is used on those
patients who do not have the necessary time available for home bleaching, who have a problem with
wearing trays that may cause them to gag or who
even find the taste of the home bleaching gel not to
their liking. Another advantage is that the immediate
results produced in power bleaching can be used to
motivate the patient to continue with home bleaching top-up treatment. It must be emphasized that
although there is an immediate result with power
bleaching, it is by no means necessarily the end point

163

Sulieman

in terms of tooth whiteness and further bleaching

sessions may be necessary. It can be likened to the
home bleaching procedure that produces results
within the first 4 days for most people but over the
next couple of weeks this is further enhanced until it
reaches a terminal end point where the tooth shade
does not improve any further.
The increased surgery time required for in-surgery
bleaching is obviously a disadvantage, as it makes the
procedure more expensive for the patient. Some reports also highlight that power bleaching causes
dehydration of the teeth, thereby giving a falsely
lighter shade immediately post-treatment (6). This
causes further problems, with patients perceiving
that there is color regression or rebound following
rehydration of the teeth. Some manufacturers have
addressed this problem by producing gels that contain 1020% water, which rehydrates the teeth
throughout the bleaching procedure, while others
have tackled the problem by using lower concentrations of hydrogen peroxide (15%), which is a waterbased solution, thereby increasing the water content
by 20%. However, by far the biggest disadvantage of
the power bleaching procedure is the caustic nature
of the 3550% hydrogen peroxide used. The need for
a meticulous protocol in handling, applying, removal
and disposal of these materials is essential. The risk
of tissue burns to the lips, cheeks, gingiva, the rest of
the face or eyes makes isolation and protection
techniques mandatory (Fig. 6).
The main safety issue concerning the activating
lights used in power bleaching is heat generation and
its effect on the pulp. Recent research showed that
the increase in the intrapulpal temperature with most
bleaching lamps was below the critical threshold
of a 5.5 C increase thought to produce irreversible
damage. The only lamp that produced an intrapulpal
temperature increase above this threshold was the
laser-based lamp, and this was also found to be be-

Fig. 6. Isolation of teeth and gums typically used in a

power bleaching procedure.

164

low the critical temperature once the power output

was reduced from 3 to 2 W (137).
There are many different materials available, but
broadly speaking they are either based on 35% carbamide peroxide or hydrogen peroxide of the same or
higher concentration. Hydrogen peroxide is more
widely used as the power bleaching agent, but the
range of concentrations in current use varies from
about 1750% and the bleaching time for which they
are used also varies. Thirty-five per cent carbamide
peroxide yields approximately 10% hydrogen peroxide and is used in certain bleaching systems, sometimes known as waiting room bleach, because the
patient wears the custom-made trays full of the
material and waits in the waiting room of the surgery.
Thirty-five per cent hydrogen peroxide is available
in a powderliquid combination mixed together to
produce a gel, or in a ready-made gel to which liquid
is added. There are many different combinations
available depending on the system or activation
method used.

Light activation
Various types of curing lights are used to activate the
bleaching gel or expedite the whitening effect. Initially, conventional curing lights were used but these
were quickly joined by lasers and plasma arc lamps.
In addition, some systems are activated by a chemical reaction upon mixing two gels, while others utilize
a dual-activation system.
Halogen curing lights can be used with a number of
different systems and generally activation is via the
lights bleach mode for 30 s per tooth and the application involves three 10-min passes. Plasma arc
lamps are also used in a similar way to halogen curing lights but, with the aid of a full smile illuminator,
they can act in the same way as Xenonhalogen lights,
irradiating both arches at the same time, which is
generally three 10-min passes. Similarly, metal halide
lamps are used with a two-part 25% hydrogen peroxide gel in a dual-arch technique employing three
20-min passes followed by the application of sodium
fluoride gel.
Diode lasers of 830 and 980 nm wavelengths can be
used for tooth bleaching in combination with 35
50% hydrogen peroxide gel. The gel is produced by
mixing the hydrogen peroxide liquid with a powder
containing mainly fumed silica and a blue dye. The
blue dye absorbs the laser wavelength and heats up
to cause the controlled breakdown of the hydrogen
peroxide to oxidizing perhydroxyl free radicals.

An overview of tooth-bleaching techniques

Waiting room bleach technique

Thirty-five per cent carbamide peroxide is activated
by holding the syringe under hot running water for a
few minutes prior to use. The gel is transferred into
the custom-made tray and the excess material removed from the patients mouth before asking the
patient to sit in the waiting room for about 3060
min. After this time has elapsed the patient returns
and the gel is suctioned and rinsed off the teeth. The
procedure can be repeated two or three times more
in the one session.
Power bleaching may frequently require more than
one visit to produce an optimal result. However, for
many patients a single visit is enough to satisfy their
esthetic needs and no further treatment is required.
Power bleaching should be used in cases where time
is at a premium with patients requiring faster results
and in cases where it is felt that the patient needs a
kick start before continuing with home bleaching. It
can also be used on teeth with different stain etiologies, but must be carried out with meticulous care
and attention as a result of the caustic nature of the
35% hydrogen peroxide used.
The goal of modern dentistry is maximum preservation of tooth substance with excellent esthetics.
Bleaching alone, or in combination with minimally
invasive adhesive dentistry, very often fulfils this goal
without the need to progress to the much more
destructive techniques of veneers, crowns and
bridges.

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