Abu-ElMagd D.M. 1, El-Sayad I.I.1, Abd El-Gawad L.M.

2 ABSTRACT:

Tooth whitening and temperature rise with two bleaching activation methods

Objectives: To measure the tooth whitening and the surface and intrapulpal temperature increase in vitro on extracted upper human incisors after chemical, zoom light and diode laser activated bleaching. Materials and Methods: Thirty caries-free upper human incisors were selected. Teeth were divided into three equal groups according to the methods of activation of the bleaching agent (n=10). A whitening gel containing hydrogen peroxide was applied to the buccal surface of all teeth. Group I was bleached using chemically activated hydrogen peroxide gel, for three applications of 15 min each. Group II was bleached with high intensity advanced power zoom activation light (Zoom AP), for three applications of 15 min each. Group III was bleached with diode laser activation technique, where the teeth were irradiated with 2 watt diode laser for three applications of 30 sec each. Degree of whitening was assessed using an image analysis system, while temperature rise was recorded using a thermocouple on the external tooth surface and intrapulpal. Results: The degree of whitening increased significantly in all groups. However, the percentage of whitening was not statistically significantly different between the three groups. In addition, group II showed statistically significant higher mean rise in both surface and pulp temperatures than group I and group III. Conclusions: Chemical bleaching produces the same whitening effect as zoom AP light and laser, with no surface or pulpal temperature rise. Laser application is faster and produces less surface and pulp temperature increase than zoom AP light. Diode lasers used to activate bleaching gels are not considered dangerous to the vitality of dental pulps using power settings of 2W. KEYWORDS: Tooth whitening, temperature rise, thermal changes, zoom, diode laser.

1. INTRODUCTION:
The number of people searching for a brighter and a beautiful smile has been increasing over the past decade. A recent survey found that 80% of adults aged 18 years to 49 years said that they would like to have whiter, brighter teeth. Over the past 5 years, the demand for tooth bleaching has increased by more than 300%. This has resulted in renewed interest from the dental profession in the variety of bleaching techniques available, as they should be essentially noninvasive and simple to carry out. New materials and equipment are under development to meet that demand, currently there are several whitening techniques available for clinical and home use (1, 2).Tooth bleaching today is based upon hydrogen peroxide as the active agent. Hydrogen peroxide may be applied directly, or produced in a chemical reaction from sodium perborate (3) or carbamide peroxide (4). Broad ranges of peroxide-based treatments are currently available including those that are professionally administered (in-office) and self-directed (over the counter) (5). In-office (Power bleaching) technique bleaches teeth in a single visit with or without an auxiliary as light or heat (6). It seems to be a suitable alternative to home-bleaching especially in the case of very severe discolorations, discolorations of a single tooth, lack of patient compliance or if rapid treatment is desired. To enhance or fasten the whitening process, heat activation of the bleaching agent could be done by light, heat or laser (7). When hydrogen peroxide decomposes oxygen free radicals are liberated, which are very reactive unstable ions, possessing in its structure an unpaired electron. To become stable, the oxygen ion captures an electron from surrounding molecules, as the pigments present in enamel surface. This process can result in a break up of the complex chain of pigments, making them clearer (8). The activation of hydrogen peroxide for bleaching can be fastened by light or heat, which increases the hydrogen peroxide temperature, speeds up oxygen ion liberation and, consequently, the whitening effect (9, 10). The aim of light is not directly to whiten teeth, but to activate the peroxide by absorbing light by the photosensitive agent (a dye) and transferring the absorbed energy to the peroxide (11, 12). The efficiency and safety of light-activated bleaching have received attention, as there are concerns about maintaining pulp vitality and avoiding thermal heating at tooth surface and pulp chamber (13), which may lead to sensitivity and, ultimately, pulp damage (14). The aim of power bleaching is to whiten teeth efficiently with controlled temperature rise and without morphological or chemical changes of enamel (15-19).
1. Department of Operative Dentistry, Faculty of Oral and Dental Medicine, Cairo University, Cairo Egypt. 2. National Institute of Laser Enhanced Sciences (NILES), Cairo University, Cairo Egypt.
Lasers in Dentistry XV, edited by Peter Rechmann, Daniel Fried, Proc. of SPIE Vol. 7162, 71620J 2009 SPIE CCC code: 1605-7422/09/$18 doi: 10.1117/12.808844

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For years photo-polymerization devices made of filtered halogen lamps, which emit light in the blue spectral region, have been used for activation of hydrogen peroxide in whitening gels. Although these devices achieve high power, they produce high amounts of heat and degrade the filter by the lamps infrared emission (20). Also, the light-induced bleaching needs longer exposure to light, so high temperature rise may result causing pulpal damage. Contemporary approaches have used also plasma arc lamps, lasers and light emitting diodes (21, 22). For some light sources, there was significant increase in surface and pulpal temperature during bleaching (23, 24). With improvements in laser technology, semiconductor (diode) lasers have shown to be highly reliable, effective, cheaper and occupy less space in the clinic (25). Recently, diode lasers in the near infrared, with appropriate energy density, are being used to desensitize the bleached teeth (23). Studies showed that near-infrared laser could improve the inflammatory response of pulp tissues, reduce pulp damage and relieve pain after the whitening process. Several case studies showed the efficacy of light activated bleaching systems (26- 30). However, the clinical and in vitro literature evidence for the effect of light on tooth bleaching versus a suitable non-light control is limited and controversial. Therefore, the aim of this in vitro study was to evaluate the effect of chemical bleaching without activation versus zoom light and diode laser activated bleaching on tooth whitening and on surface and intrapulpal temperature rise.

2. MATERIALS AND METHODS: 2.1 Preparation and grouping of teeth:

Thirty extracted sound human maxillary central incisors were selected. After polishing teeth with pumice to remove surface debris or contaminants, they were stored in de-ionized water until their use. Roots of teeth were cut 2 mm apical to the cementoenamel junction (CEJ), and the apical orifice of the root canal was enlarged. The remaining pulp tissue was removed, and the empty pulp chamber was filled with heat sink compound (American Oil and Supply Co., Newark, NJ, USA) which replaced the pulp tissue as a heat conducting medium. Teeth were randomly divided into three groups of ten teeth each, according to different bleaching regimes. Approximately 0.5 ml of the bleaching gel was applied to cover labial surfaces of teeth with a uniform layer of about 2 mm thick. After each application, the bleaching gel was removed and the surface temperature was allowed to return to room temperature, this was checked by reference to the thermocouple readings.

2.2 Bleaching regimes:

Group I: Chemical bleaching (control). The Opalescence Xtra Boost system comes pre-packed as two components mixed at the time of application. In this group the gel was not activated, it was applied for three separate times 15 min each with a total bleaching time of 45 min. Group II: Zoom advanced power (Zoom AP). Zoom AP teeth whitening system has a new proprietary bulb technology and a new custom Sodium- Free Short Arc bulb, which emits optimal bleaching spectrum at the highest power output. The Zoom unit has an infrared filter to minimize the heat generated during bleaching. The zoom bleaching gel was applied three separate times for 15 min each with a total bleaching time of 45 min. Group III: Diode laser. In Opalescence Xtra Boost teeth whitening system the activation of the bleaching gel during bleaching is optional. Thus it was activated in group III using diode laser applied perpendicular to the labial surface in a circular motion. Again the bleaching regime was to apply the gel three separate times, for 30 s each, with a total bleaching time of 1.5 min.
Table 1: Composition of the bleaching agents

Agent Oplescence Xtra Boost teeth whitening system Zoom teeth whitening system Light source Zoom AP light unit Diode laser

Manufacturer Ultradent Products, Inc. UT 84095, USA Discus Dental, Inc. USA

Active ingredient 38% hydrogen peroxide concentration pH 7 25% hydrogen peroxide concentration pH 7-9 Wavelength (nanometers) 340-600 (violet color) 980 Power 25 watt 2 watt

Table 2: Light sources used for tooth whitening

Manufacturer Discus Dental, Inc. USA L.M.2500, Premier Laser systems

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2.3 Color change measurements:

The teeth color of the three groups was assessed at baseline and after treatment, so that each tooth was considered the control of itself to eliminate color variability of different teeth. Each group was subjected to computer image analysis (CIA) system using the image analysis software (Image J, 1.41, NIH, USA) to measure color before and after treatment. A tooth image was captured under controlled lighting conditions by a digital camera with suitable calibration standards and analyzed via the computer software, which converts the digital photo (32 bit) into (8 bit) photo (black and white) for the color to be measured with a gray scale from 0 (black) to 255(white), and in between the gray colors were present.

2.4 Surface and intrapulpal temperature rise measurements:

A digital thermocouple (52 K/J digital thermometer Fluke USA) was used to measure temperature changes. All teeth had been sectioned 2 mm below (CEJ) to allow easy access of the thermocouple, which was held in place using red wax. Measurements were made on the tooth surface and inside the pulp chamber, at room temperature before and after application of the bleaching gel on the tooth surface. Intrapulpal measurements were made by placing the thermocouple at the most coronal level of the pulp chamber and its position was checked using radiography.

2.5 Statistical analysis:

Data were presented as means and standard deviation values. Analysis of Variance (ANOVA) was used to compare between means of the three groups. Tukeys post-hoc test was used to determine significant differences between means when ANOVA was significant. Students t test was run to compare between means of two groups and Paired t-test was used to compare color changes before and after bleaching. The significance level was set at P 0.05. Statistical analysis was performed with SPSS 15 (SPSS, Inc., Chicago, IL, USA) (Statistical Package for Scientific Studies) for Windows.

3. RESULTS: 3.1 Color measurements:

The means, standard deviations and results of ANOVA test for the comparison between mean color measurements and percentage changes in color of the three groups are shown in table 3 and figure 1. The degree of whitening increased significantly in all groups. However, the percentage of whitening was not statistically different between the three groups.
Table 3: Means, standard deviations and results of ANOVA and paired t-tests for comparing mean and percentage change in color:

Group Bleaching Before After P-value Difference % Difference

*: Significant at P 0.05
M e a n g ra y s c a le 200 180 160 140 120 100 80 60 40 20
0

Control Mean SD 135.9 4.1 181.4 9.4 <0.001* 45.5 5.3 33.4 2.9

Zoom AP Mean SD 132.5 3.7 174.4 7.5 <0.001* 41.9 7.1 31.7 5.5

Laser Mean SD 128.8 7.1 174.3 13.7 <0.001* 45.5 11.5 35.4 8.7

P-value 0.374 0.755 0.866 0.780

The percentage difference was calculated as: Color (after) Color (before) X 100 Color (before)
C o n tro l Zoom AP Laser

B e fo re b le a c h in g

A fte r b le a c h in g D iffe re n c e

Fig. 1: Comparison between mean color measurements of the three groups

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3.2 Surface and intrapulpal temperature rise measurements:

Temperature rise measurements of the three groups took place in three different days, the percentage changes in temperature were calculated to avoid variability in room temperature. The means, standard deviation values and results of student's t-test for comparing between mean percentage changes in surface and intrapulpal temperature rise are shown in table 4 and figure 2. Chemical bleaching didn't produce any rise in temperature, thus it was removed from table 4. For surface temperature, at first application, zoom AP showed statistically higher mean percentage change than diode laser (P<0.02). While at second and third applications, there was no statistically significant difference between the two groups. For intrapulpal temperature, at all applications Zoom AP showed statistically higher mean percentage change than diode laser (P<0.001). Means, standard deviation values and results of ANOVA and Tukey's test for comparing between mean percentage changes in temperature rise between different applications are shown in table 5 and figure 3. For surface temperature, both Zoom AP and laser third bleaching application had the highest mean percentage change, which was statistically significant than first and second applications. No statistical significant difference was found between first and second applications. For intrapulpal temperature, both Zoom AP and laser third application had the highest mean percentage change, that was statistically significant. There was a statistical significant difference between first and second applications, as the latter had statistically higher mean percentage change than the first application but statistically lower than the third application.
Table 4: Means, standard deviations and results of students t-test for comparison between mean percentage changes in temperature.

Temperature Surface temperature

Group application First Second Third First

Zoom AP Mean SD 10.2 6.9 17.6 10.6 15.5 22.1 3.1 2.2 4.6 2.7 3.6 3.8

Laser Mean SD 4.1 4.5 13.4 2.9 8.6 14.5 1.7 1.6 3.7 1.1 2.6 3.7

P-value 0.021* 0.471 0.112 <0.001* <0.001* <0.001*

intrapulpal temperature
*: Significant at P 0.05

Second Third

Percentage change = Surface/intrapulpal temperature Room temperature x100 Room temperature

Table 5: Means, standard deviations and results of ANOVA and Tukeys tests for comparing between mean percentage changes in temperature of different applications :

Temperature Surface temperature

Group application First Second Third P-value First

Zoom AP Mean SD 10.2 b 6.9 b 17.6 10.6 15.5

a

Laser Mean SD 4.1 b 4.5 b 13.4

a

3.1 2.2 4.6 2.7 3.6 3.8

1.7 1.6 3.7 1.1 2.6 3.7

<0.001*
c b

<0.001* 2.9 c 8.6

b

Intrapulpal temperature P-value

Second Third

22.1 a

14.5 a

<0.001*

<0.001*

*: Significant at P 0.05, Means with different letters are statistically significantly different according to Tukeys test

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Mean % rise in temperature

25 20 15 10 5 0 First session

Zoom AP

Laser

Second Third session First session Second Third session session session intrapulpal temperature

Surface temperature

Fig. 2: Comparison between means percentage changes in temperature with both activation methods
Mean % rise in temperature
25 20 15 10 5 0

First session

Second session

Third session

Zoom AP

Laser

Zoom AP

Laser

Surface temperature

Intrapulpal temperature

Fig. 3: Comparison between mean percentage changes in temperature with different applications

4. DISCUSSION:
With in-office bleaching, discolored vital teeth can be successfully whitened by using highly concentrated bleaching regimens. The current bleaching mechanism is based on the ability of hydrogen peroxide to penetrate tooth structure and produce free radicals that oxidize organic stains within teeth (31). Color is the most important parameter in assessment of bleaching regimens. Therefore, the change in color is the measure of efficacy of any tested system. In general, natural tooth color has a significant tendency to change with age of the subject, to become darker and more yellow (32). The perception of tooth color is a complex phenomenon and can be influenced by the type of incident light, the reflection and absorption of light by the tooth, the adaptation state of the observer and the context in which the tooth is viewed. While reflection and absorption of light by the tooth can be influenced by specular transmission of light through the tooth, specular reflection at the surface, diffuse light reflection at the surface, absorption and scattering of light within dental tissues, enamel mineral content, enamel thickness, dentine color, and presence of extrinsic and intrinsic stains (33, 34). Several methods are used to assess color changes including visual method, computer analysis of digital images, colorimeters and spectrophotometers. The use of computer image analysis system to assess the efficacy of bleaching regimens relies upon the precise and accurate colorimetric measurements and an appropriate whiteness scale or index (35).

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To accelerate the bleaching process, the bleaching agent can be heat-activated. The use of high intensity light, for raising hydrogen peroxide temperature to accelerate the rate of chemical bleaching of teeth was reported in 1918 by Abbot (36). When light is projected onto a bleaching gel, a small fraction is absorbed and its energy is converted into heat. Most likely this is the main mechanism of action of all light-activated bleaching procedures. Under photochemically initiated reactions using light or lasers, the formation of hydroxyl radicals from hydrogen peroxide has been shown to increase (37). Due to the increased release of hydroxyl-radicals (thermocatalysis), an increase in efficacy is conceivable. However, this study showed no significant increase in the whitening efficacy of the bleaching agent following Zoom AP or laser activation, as the three bleaching mechanisms are based on the ability of hydrogen peroxide to penetrate tooth structure and produce free radicals to oxidize organic stains within teeth (31). In addition, the efficacy of power bleaching without activation using high concentrated hydrogen peroxide as the primary active ingredient, was proven by several in vitro and in vivo studies (32, 38-40). Although the rate of chemical reaction can be increased by increasing the temperature, where a 10C can double the rate of reaction (39), the useful range of temperature increase is limited as it should not exceed the threshold value (5.5C) because of possible pulpal damage which could interfere with the ability of this activation mode to increase the efficacy of bleaching gel (7). The results of this study were in accordance with Jones et al and Perdigao et al (38, 42) who found that when a chemical catalyst was added to hydrogen peroxide immediately prior to bleaching, the oxygen was released rapidly, inducing the whitening effect, light or laser application did not significantly affect the degree of hydrogen peroxide decomposition, as the whitening results of chemical and light activated bleaching were very similar. In contradiction, Tavares et al and Luk et al (43, 44) reported the application of light significantly improved the whitening efficacy of bleaching agents. They concluded that light augments peroxide tooth bleaching. The results of this study showed no increase in surface or intrapulpal temperature of chemically bleached teeth, while teeth bleached with Zoom AP showed statistically higher mean percentage change in surface temperature than laser in the first application only but not in the other two applications, which could be attributed to the mixing of some products used in the light activated bleaching with ingredients claimed to aid the energy transfer from light to peroxide gel which are often colored materials e.g. carotene. The orange-red color of carotene increases blue light absorption. In order to increase the absorption of red and infrared light, small silica particles may be added, which give a bluish appearance and may contribute to the increase of surface temperature in Zoom AP group in the first application (21,22,30,44). While for all applications Zoom AP showed statistically higher mean percentage increase in intrapulpal temperature than laser, this may be due to the fact that lasers emit a well defined monochromatic light at a single wavelength only, in contrast, metal halide lamps emit a wide wavelength range, from ultraviolet (UV) to infrared (IR). Usually the lamps have UV and IR filters to exclude these radiations, to narrow the emitted wavelength range to 400-580 nm, and to reduce the side effects on living cells. Unfortunately, optical filters can not suppress 100% of the radiation within a specific range. Therefore, a fraction of IR is still emitted which adds to absorption and heat conversion of the emitted visible light and may lead to further intrapulpal temperature rise. Also the intrapulpal temperature rise may be due to the addition of light activated heat enhancing colorant, as the more the output profile of the light matched the spectral absorbance needs of the colorant, the greater the potential for light absorption and the resulting heat increase (23). Moreover, within the visible spectrum, the violet Zoom AP light is more readily absorbed in biological tissues than the red light due to its higher scattering coefficient. It is the absorption that is the important factor for temperature rise within the bleaching product and dental hard and soft tissues, this may explain the higher surface and intrapulpal temperature rise with Zoom AP light (7). In this study selective diode laser radiation showed statistically significantly less surface and intrapulpal temperature rise (less than 5.5C) than Zoom AP, as laser systems can create very high power densities within a very short time. This narrow spectral output of laser compared to the more broad banded output of other lights can minimize thermal damage and decrease bleaching time (46, 47). In addition, this could be due to the use of bleaching gel able to offer a protective insulating layer against surface and intrapulpalal temperature rise that accompany the use of diode laser for bleaching (48). As the gel has large amounts of hydrogen peroxide (38%) and water, evaporation of both of these components could potentially produce a cooling effect transmitted to the thermocouple on tooth surface (49). Also power settings of 1-2 watt are within the safety parameters for using this device to activate the bleaching agent (48). Although, the surface temperature increase with Zoom AP was below 5.5C nowadays regarded as the threshold value which should not be exceeded (6,49), the highest intrapulpal temperature rise was 8C which exceeded the 5.5C limit determined by Zach and Cohen to cause irreversible pulpitis in 15% of monkey teeth subjected to such levels (19). This result could be due to subjecting the teeth to repeated temperature rise over a 15 min period during each of the three

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applications of the bleaching session. Baldissara et al found that intrapulpal temperature rise between 8.9C- 14.7C in humans did not produce overt pulp pathosis (50). Also absence of an intact pulpal blood flow, which acts as an efficient heat sink, with the pulpal circulation being able to dissipate some of the applied heat before pulpal cells are damaged may account for this increase in intrapulpal temperature with Zoom AP (48). The results of this study showed that the third application of Zoom AP or laser bleaching showed the highest percentage rise in surface and intrapulpal temperature which could indicate a cumulative effect of temperature on dental tissues and may cause a cumulative insult, effects of which need further studies (23,51).

5. CONCLUSIONS:
Under the limitations of this investigation, the following conclusions could be drawn: 1-Chemical bleaching produces the same whitening effect as zoom AP light and laser, with no surface or pulpal temperature rise. 2- Laser application is faster and produces less surface and pulp temperature increase than zoom AP light. . 3-Diode lasers used to activate bleaching gels are not dangerous to the vitality of dental pulps using power settings of 2W.

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