RESEARCH

Effect of 10% carbamide peroxide bleaching gel on marginal

Integrity of tooth colored restorative materials : An invitro
microleakage study
Indiresha. H. Narayana,1 Meena. N.,2 B.V. Sreenivasa Murthy3

ABSTRACT
Aims
and
objectives: To
evaluate
the
effect
of
10% carbamide peroxide bleaching gel on marginal integrity of
tooth colored restorative materials.
Materials and Methods: Forty five human premolar teeth
extracted for orthodontic reason with good enamel integrity were
selected for the study and divided into three groups of 15 teeth
each. Class-V cavities were prepared on the buccal surfaces of the
teeth. The cavities were restored with composite resin, resin
modified glassionomer, and conventional glass ionomer in the
respective groups. 10 teeth in each group were subjected
to thermocycling. After thermocycling the teeth were exposed to
the bleaching agent. The remaining teeth were kept aside as
control. After bleaching, all the teeth, including the control groups
were subjected to microleakage analysis.
Results: Statistical significant differences(P<0.001) were seen
between the control groups and the experimental groups. The
marginal integrity of the resin modified glass ionomer was less
affected while exposing to bleaching, when compared to
composite resin and conventional glass ionomer.
Conclusion: The results suggest that resin modified
glass ionomer performed better at both enamel and dentin
margins when compared to the other two experimental groups.
Keywords:
carbamide peroxide,
restorative resins, glass ionomer.

Introduction

bleaching,

microleakage,

remained unanswered2. There are studies that have

evaluated microhardness, microstructure, and mineral
content
of
enamel
after
bleaching
with carbamide peroxide3. Some studies have evaluated
subsurface hardness and morphology of bleached
enamel and have reported some changes4,5. Other
studies have stated that, the bond strength of resin
composites to bleached enamel decreases immediately
after the bleaching procedure6.
However little is known about the effect of bleaching
gel on the marginal integrity of tooth colored
restorative materials. Some authors have reported
detrimental effects on resin-tooth bond as well as an
increase in micro leakage for teeth restored after
bleaching procedure due to the presence of active
chemicals in the enamel which may affect the resin
enamel bond7, 8. But,very few studies are available
which have evaluated the effect of post
operative carbamide peroxide application on marginal
leakage of existing tooth colored bonded restorations
both at enamel and dentin/cementum margins9,10,11.
The aim of the present study was to
evaluate microleakage in class-V restoration at enamel
and dentin/cementum margins using commonly used
tooth colored restorative materials such as, composite
resin, resin modified glass ionomer and conventional
glass ionomer after being exposed to bleaching cycles
by a commercially available 10%carbamide peroxide
bleaching gel.

Vital bleaching has become the most frequently used

Materials and methods
treatment
modality for improving the
esthetic
2 Yoshaskam
3 S.Balagopal
4
Patri,
Agnihotri,
appearance of teeth. Christensen has said, It is perhaps
Forty five freshly extracted caries free human premolars
the most behaviour-changing procedure in dentistry1.
were used in this invitro study. After mechanical
Various techniques for bleaching vital teeth have been
debridement, all teeth were cleaned with pumice-water
developed, and amongst the techniques night guard
slurry. The integrity of enamel was evaluated using a
vital bleaching is very popular. The majority of products
magnifying lens. The teeth were stored in distilled
in the market for night guard vital bleaching use
water at 37 C till use. Class-V cavities were prepared
10% carbamide peroxide1.
with a no. 330 tungsten carbide bur(SS White, USA)
Since 1989, when Haywood and Heymann formally
under copious water, on the buccal surface of each
introduced carbamide peroxide for at-home bleaching
tooth with the occlusal margin of the prepared cavity
technique, it has become popular and is widely
on enamel and gingival margin on the root surface. The
accepted by the dental profession. Nevertheless, some
approximate dimension of the cavity was 3mm wide,
concerns about at home bleaching have always
2.5mm in height and 1.5mm in depth. Bur was replaced
remained unanswered2. There are studies IJCD
that have
DECEMBER,
2011every
2(6) fifth cavity preparation. The teeth were
after
37
2011
Int. Journal of Contemporary Dentistry
evaluated
microhardness, microstructure, and
mineral
randomly divided into three groups with each group
content
of
enamel
after
bleaching

RESEARCH
2.5mm in height and 1.5mm in depth. Bur was replaced
after every fifth cavity preparation. The teeth were
randomly divided into three groups with each group
comprising of fifteen teeth and fifteen restorations
each. The restored teeth were stored in distilled water
at 37C for five days before subjecting them to
bleaching treatment. This will prevent dehydration of
the teeth and also mimick the mouth temperature6.
Each group was restored with the following restorative
materials,
Group
1was
restored
with
microhybrid flowable composite resin, EsthetX flow (Dentsply
,USA).
The
prepared
cavity
was
etched
with Scotchbond multipurpose etchant(3M ESPE, USA)
for 10 seconds, rinsed thoroughly with water for 30
seconds and dried with gentle blow of air .The bonding
agent, prime & bond NT(Dentsply,USA) was then
applied as per the manufacturers instructions and was
cured for 20 seconds. The composite was placed with a
two-step procedure. The first increment was placed in
the gingival part of the prepared cavity, flowed with a
syringe tip provided by the manufacturer to avoid air
entrapment and cured for 40 seconds. The second
increment was flowed into the rest of the cavity and
cured.
Restorations were finished and polished with coarse,
medium, fine, and ultra-fine polishing discs (Soflex-3M,
USA).
Group 2 - was restored with resin modified
glass ionomer cement,Fuji II LC(GC corporation, Japan).
The prepared cavities were conditioned with dentin
conditioner (GC corporation, Japan) and the restorative
material was placed and cured as per the
manufacturers instructions. The restoration was
finished and polished and a protective varnish (GC
corporation, Japan) coating was applied to the restored
surfaces.
Group 3 - was restored with conventional
glass ionomer cement, Fuji II (GC corporation, Japan).
The prepared cavities were conditioned and the
restorative material was placed as per the
manufacturers instructions. The restoration was
finished and polished and a protective varnish (GC
Corporation, Japan) coating was applied to the restored
surfaces.
Ten teeth in each group were randomly selected
and thermocycled for 300 cycles at 5C and 55C with a
dwell time of 60 seconds each. Five teeth in each group
were treated as control groups and these teeth were
neither subjected to thermocycling nor the bleaching
procedure. Thermocycling has been used invitro as a
means to simulate the aging effects that the
restorative materials are subjected to in the mouth22.
Following thermocycling all teeth were exposed to
commercially available 10% carbamide peroxide gel,
Platinum-Overnight (Colgate Palmolive,USA) for eight
hour period per day for 14 days. The bleaching agent

was renewed daily; fresh bleaching agent was placed

for every exposure cycle. The teeth were stored in
distilled water at 37C when they were not subjected to
bleaching procedure. Following bleaching procedure all
the teeth including control groups were sealed with
sticky wax (DPI,India) 1mm short of the restoration
margin. The teeth were again coated with nail varnish
(Revlon red, Revlon USA) on the sticky wax seal 1mm
short of the restoration margin.
The teeth were then immersed in 1% solution
of methylene blue dye for 24 hours. At the end of 24
hours the teeth were thoroughly rinsed in running tap
water. Each tooth was then mounted in cold cure acrylic
resin block (DPI,India) and sectioned buccolingually through the center of the restoration using a
diamond disc (Horico,Germany). The specimens were
examined
under
a
stereo-microscope(Leica
microsystems,Germany) at 20X magnification by two
observers for dye penetration along the tooth
restoration interphase and also the depth of
penetration was scored.
Microleakage scores were given according to the
following criteria:
*Microleakage scoring criteria :
Score:
Description :
0 ------------No dye penetration
1 -------------Dye penetration not more than half of
the occlusal or gingival wall.
2 -------------Dye penetration more than half of
the occlusal or gingival wall.
3 -------------Dye penetration along axial wall.
The results were evaluated using Analysis of Variance of
ranks and Kruscal Wallis test.
At Enamel Margins
+Control groups showed no dye penetration (5 teeth in
each group).
Analysis of variance on ranks: Groups 1, 2 and 3;
H=5.482; p =0.064
Kruscal Wallis test was also used to test the
difference between groups : Control with Groups 1, 2
and 3; H=18.76; p <0.001
At Dentin Margins
+Control groups showed no dye penetration (5 teeth in
each group).
Analysis of variance on ranks: Groups 1, 2 and 3;
F=2.547; p=0.097
Kruskal Wallis test was also used to test the difference
between groups: Control with Groups 1, 2 and 3;
H=29.083; p <0.001
Note: Due to no Significant difference of data by
ANOVA, pairwise comparison was done between data of
the different instruments. By Dunns test there is a
significant difference between control and groups 1, 2 &
3.

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38

RESEARCH
Table 1 shows the scores of microleakage analysis for each group at enamel margin as given below

Score 0

Score 1

Score 2

Score 3

Group 1 (10 teeth)

Group 2 (10 teeth)

Group 3 (10 teeth)

Table 2 shows the scores of microleakage analysis for each group at dentin/cementum margins as given below

Score 0

Score 1

Score 2

Score 3

Group 1 (10 teeth)

Group 2 (10 teeth)

Group 3 (10 teeth)

Fig.1 Micro Leakage Assessment under Stereo Microscope in micro-hybrid flowable composite resin (Group 1)

Dentin Margin

39

Enamel Margin

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2011 Int. Journal of Contemporary Dentistry

RESEARCH
Fig.2 Micro Leakage Assessment under Stereo Microscope in resin modified glass ionomer cement (Group 2)

Enamel Margin

Dentin Margin

Fig.3 Micro Leakage Assessment under Stereo Microscope in conventional glass ionomer cement (Group 3)
Enamel Margin

Dentin Margin

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2011 Int. Journal of Contemporary Dentistry

40

RESEARCH
Results
Sigmastat (Version
3.1, Systat software
Inc, San
Jose, CA) was used for the analysis of data. The analysis
indicates that at enamel margin (P=0.064), there is no
significant statistical difference between the different
restorations. Table 1 shows the microleakage at the
enamel between control and groups 1, 2 & 3 (P<0.001)
there is significant statistical difference between the
control and group 3 (restored with conventional
glass ionomer cement). The analysis at the dentin
margin (Table 2) indicates that between groups
(P=0.097) there is no significant statistical difference.
But, between control and groups 1, 2 & 3 (P<0.001)
there is an indication of significant statistical difference
between control and all the three groups. Fig.1-3 shows
the Micro Leakage Assessment under Stereo
Microscope in group 1-3.

Discussion
The results of this study shows the detrimental effects
of bleaching on the marginal integrity of already
restored cervical cavities with three different
restorative materials. Adverse effect on the marginal
seal of a tooth colored restorative material leads to
marginal gap which in turn leads to microleakage, which
may be responsible for secondary caries, marginal
discoloration, pulpal inflammation and hypersensitivity8,
9, 10, 16,25,26
.
The purpose of the present invitro study was to
evaluate the effect of 10% carbamide peroxide
bleaching gel on marginal integrity of widely used tooth
colored restorative materials. The effect of bleaching
agents on restorative materials have been evaluated by
a number of studies2,6,7,8,9,10,12. Some studies showed
that bleaching class-V composite resin restorations
increases microleakage at dentin/ cementum margins2,
6
.
Several authors have reported that carbamide peroxide
bleaching agents adversely affected the marginal seal of
resin composite restoration6, 8, 9, 10, 20. Also, it has been
shown that teeth exposed to 10% carbamide peroxide
lost calcium, but this amount was similar to that lost
during 2.5 minutes exposure to a cola beverage5. The
carbamide peroxide material used in the above study
was in an acidic base. The low pH may have been
responsible for the calcium loss. Today most of
the carbamide peroxide bleaching agents are available
in a neutral base24.
In our study all the materials were used to restore
standardized class V cavity prepared in a human
premolar tooth with occlusal margins in enamel and
gingival margin in dentin or cementum. The restorative
materials under investigation exhibited a certain
amount of micro leakage in enamel and
dentin/cementum margins after exposure to bleaching
with 10% carbamide peroxide gel.

41

In enamel margins, Composite resin and Resin modified

glass ionomers performed better when compared to
conventional
glass ionomers after
bleaching
cycles. Where as in dentin or cementum margins resin
modified glass ionomers performed
better
than
composite resin and conventional glass ionomer.
There was significant increase in micro leakage in the
conventional glass ionomer group in both enamel and
dentin margin when compared with the other two
groups.
Microleakage is the undetectable passage of bacterial
fluids, molecules or ions between a cavity wall and the
restorative
material
applied
to
it
(Kidd
1976)22.Microleakage pattern at enamel or dentin in a
restoration is complex. Investigators visualize the
location of the infiltrated tracers by taking a single
section from the center of the restoration as the
assessment of the restoration as a whole is difficult. The
use of organic dyes as tracers in one of the oldest and
most common methods of detecting leakage
invitro22. The same was followed in this study and
micro leakage was evaluated by taking a single section
from the center of the restoration.
It is known that carbamide peroxide breaks down in to
urea peroxide and hydrogen peroxide9. Hydrogen
peroxide is responsible for the bleaching effect9. In the
present
study,
these
residual
substances
possibly played a role in the increased marginal
leakage of the restorative materials. Another
consideration is the presence of dentin tubules that
may enhance the rate of penetration of the bleaching
agents and residual oxygen diffusion through the more
porous dentin margins than on enamel margins, there
by increasing micro leakage.
Thus, within the scope of this study,we infer that
caution should be exercised while suggesting night
guard vital bleaching technique to patients with
multiple tooth colored restorations especially if the
restorations have one of the margins at
dentin/cementum. A thorough follow-up to check for
any post-operative symptoms is mandatory.

Conclusion
It is reported that marginal integrity of tooth colored
restorations when exposed to postoperative bleaching
cycles are detrimentally affected9. Our invitro
microleakage study concurs to some extent to the
previous findings. Invivo, the majority of the scientific
evidence supports to fact that bleaching is safe to both
patients and the restorations

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About the Authors
1.

Dr. Indiresha. H. Narayana

MDS

Associate professor.
Dept of Conservative Dentistry & Endodontics,
M.S.Ramaiah Dental College & Hospital,
Bangalore.

2.

Dr. Meena. N.

3.

Dr. B.V. Sreenivasa Murthy.

MDS

Professor.
Dept of Conservative Dentistry & Endodontics,
V.S. Dental College & Hospital, Bangalore.
MDS

Professor & Head.

Dept of Conservative Dentistry & Endodontics,
M.S.Ramaiah Dental College & Hospital,
Bangalore.

Correspondence Address
Dr. Indiresha.H.N
#80, 8th Main, BSK-3rd stage,
Avalahalli Extension, Bangalore 560085.
E-mail: indiresha.hn@gmail.com
Ph nos, 0-9342854675 / 0-9900001103

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2011 Int. Journal of Contemporary Dentistry

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