TOOTH WHITENING

(BLEACHING)
By
Dr. Amr A. Shabka
Professor of Operative Dentistry
Cairo University
Chairman of Dental Dept., Dar Al Fouad Hospital
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Esthetic dentistry has

become an integral part of any

thriving restorative dental
practice.

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As dental health improves, with the concurrent

drop in the provision of basic restorative care,
patients are now asking their dentists to provide
for aesthetic treatments in a more pressing way
than their demand for disease treatment.
Tooth whitening is a modality of treatment that is
gaining a wide popularity among dental patients
and is asked for very frequently.

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Unfortunately, whitening is frequently described

in consumer magazines and television shows,
driving

consumers

interest

towards

this,

apparently, benign therapy.

This

is

done

indications,

without

emphasizing

contra-indications,

complications and

on

the

limitations,

hazards of this treatment

modality, as well as for the need for efficient

professional supervision, often misleading a great
sector of the patients who ask for this therapy.
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Introduction
Tooth discoloration varies in etiology,
appearance, localization, severity, and
adherence to tooth structure. It may be
classified as intrinsic, extrinsic, and a
combination of both.
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*Extrinsic Discoloration

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Regular use of chlorhexidine rinse

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Staining can occur in tooth defects

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Brown stains resulting from pipe smoking

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Black stains from chewing betel-nuts

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Stains due to chromogenic food stuffs

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Thick brick-red stain on the cervical third

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Green stain associated with poor oral hygiene

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*Intrinsic Discoloration

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Yellow teeth caused by ingestion of iron

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Dental discoloration associated with abrasion and erosion

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Aging discoloration
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Non-vital discoloration
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Hypoplastic discoloration

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Hypocalcific discoloration
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Fluorosis discoloration

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Tetracycline discoloration. A, Moderate B. Severe

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Mild minocycline
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Gray stain as a result of an amalgam restoration

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Internalized: Extrinsic and becomes intrinsic

as nicotine stained teeth.

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Bleaching

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Full Coverage Esthetic Crowns

Veneering
Macroabrasion
Microabrasion
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Removal of surface stains
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TOOTH BLEACHING

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History of Bleaching
Bleaching of discolored, pulp less teeth was first
described in 1864.Since then, a variety of
medicaments

such

as

chloride,

sodium

hypochlorite, sodium perborate, and hydrogen

peroxide have been used, alone, in combination,
and with and without heat activation.
The "walking bleach" technique was introduced
in 1961.
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 Medicaments
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 or carbamide peroxide.
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Mechanism

O2

Bleaching

O2

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O2

O2

Whitening effect is entirely

dependent on

x
=
Peroxide conc.

Time of contact
with teeth
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Darkly pigmented
Carbon-ring
Structures
Lightly pigmented
Unsaturated
Structures
Completely
bleached
stain

Saturation
Point

Breakdown
of enamel
matrix

Carbon
Dioxide

Hydrophilic
Nonpigmented
Structures

Decomposition
Of molecular
Structures
Water

Loss of enamel
Bleaching

Complete
oxidation
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Sorted by Hue:
A1 A2 A3 A3.5 A4 B1 B2 B3 B4 C1 C2 C3 C4 D2 D3 D4
Sorted by Value:
B1 A1 B2 D2 A2 C1 C2 D4 A3 D3 B3 A3.5 B4 C3 A4 C4

Lightest to Darkest
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Behavioral History

Dealing with the patients

Esthetic Formula
It was found in a study that there
is a strong relation between color
of the skin and color of the teeth.

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Factors Affecting Color of the Tooth:

1.Lighting conditions.
2.Translusency.
3.Opacity.
4.Texture.
5.Gloss.
6.Human eye: fatigue and blindness.
7.Brain influence.
8.Physiological conditions as aging.

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Teeth with large amalgams may appear darker

after they are bleached. This is because the
internal restoration becomes more visible
through the bleached enamel.
Be aware that some teeth do not respond to
bleaching and occasionally the colors return
shortly after completion of treatment.
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Prior to bleaching it is important to note the

following for optimal results:

Perform a diagnosis, ensure

the health of the soft tissue,
restore carious teeth.

Remove calculus and external

stains from the teeth.

Take a Photograph.

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When Bleaching
May Not
Be Necessary?

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If Prophylaxis alone satisfies your patient.

Correction of discolored restorations.
Restoring the discolored carious teeth.

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When will
Bleaching be
Contraindicated?
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 Severe periodontitis
Extremely large pulps
Exposed Root surfaces
Severe loss of Enamel
The teeth with multiple fillings
Extensive

large

non-ceramic

restorations

Pregnancy and Nursing

Peroxide Allergy

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Stains Contraindicated for Successful

Tooth Bleaching
Tetracycline stains covered with porcelain or composite resin
veneers cannot be bleached successfully.
Similarly, very dark or black stains resist bleaching as do small,
deep, discolored or opaque white spots.
Fluorosis can result in superficial white, brown and yellow
spots.
These types of stains are best removed physically (enamel
micro-abrasion) or managed restoratively.
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In-office dentist
supervised

At-home patient
applied

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Methods
Non-vital

Vital
In-office

In office
Dentist supervised
Patient applied
Walk-in
Over-the-counter products
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 Non-vital Tooth
Bleaching
METHODS:
A

combination

of

sodium

perborate

and

water

hydrogen

peroxide

has

or
been

used in the "walking bleach"

technique. The medicament is
placed

in

the

pulp

chamber,

sealed, left for 37 days, and is

thereafter
until

replaced

acceptable

achieved.

regularly

lightening

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EFFICACY
The immediate results after intracoronal
bleaching with 10% carbamide peroxide were
better than those with sodium perborate in
30% hydrogen peroxide.
After 14 days and one year, there was no
difference in the shade of the teeth bleached
with

sodium

perborate in 30%

hydrogen

peroxide, sodium perborate in 3% hydrogen

peroxide, or sodium perborate in water.
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ESTHETIC RESULTS
The evaluation of the esthetic outcome of a
bleaching treatment is subjective, and the
patients opinion may differ from that of the
dental surgeon.
The results depend on the patient psychology
and his mood during the procedure.
In addition, different terms and definitions of
the outcomes have been applied which make
comparisons between studies difficult.
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ADVERSE EFFECTS
Cervical root resorption and Ankylosis:
Mechanism

for

this

effect

is

unclear, but it has been suggested

that

the

OH

free

radical

(by

product) reaches the periodontal

tissue through the dentinal tubules
and

initiates

an

inflammatory

reaction.
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Tooth crown fracture has also been

observed after intracoronal bleaching,
most probably due to extensive removal
of the intracoronal dentin.
In addition, intracoronal bleaching with
30% hydrogen peroxide has been found
to reduce the micro-hardness of dentin
and enamel and weaken the mechanical
properties of the dentin.

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Treatment
: Certain authors pretend

that

mixing

the

bleaching solution with sodium perborate

may reduce this side effect as they react with
the free radical byproducts.

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 Bleaching External
Tooth

External bleaching is appropriate for teeth

with:
Yellow discolorations associated with aging
and mild and uniform fluorosis.
Blue/gray stains and tetracycline-induced
stains, longer treatment times are required
generally.
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METHODS
Vital tooth bleaching can be performed
at home and in-office. Four different
approaches for tooth whitening have
been recognized:
Dentist-administered bleaching.
Dentist-supervised bleaching.
Dentist-provided bleaching.
Over-the-counter products.

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The difference between both systems is

only a time factor.

(Munhter 2006)

They have concluded that the in office

may be more rapid, more costly but it
might cause more tooth sensitivity and
more gum irritation.

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Dentist-Administered
Bleaching
The use of a the bleaching agent is
often

supplemented

source;

with

heat

(power bleaching) using

available lamps (Apolite Plasma Arc,

luma Arc, Optilux 501 and Diode
laser).

It

was

found

augment
tooth

the

that

the

effects

whitening.

So,

light

of

can

peroxide

they

were

pretending that the light by itself

appeared to have a bleaching effect.
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White Lie
Sources of light and heat DO NOT

INCREASE THE WHITENING EFFECT, but

rather DECREASE THE TIME AND NUMBER
OF DENTIST VISITS.

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is bleaching an optical
illusion?

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Laser Bleaching

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The increase in surface temperature readings ranged

from 0.44C (Luma arc) to 86.3C (Laser) with no
bleaching

gel

present.

Intra-pulpal

temperature

increases ranged from 0.30C to 15.96C.

The

presence

of

the

bleaching

gel

reduces

the

increase of temperature at the tooth surface and

within the pulp.

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It was found that heat application

increased the risk of development of
external cervical resorption.
Even the use of LED, thermal pulp
damage

was

not

be

absolutely

excluded. (Suliman 2005)

Finally, no beneficial whitening effects
were added by using lights.
(Hein 2003)
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White Lie
Sources of light and heat DO NOT

INCREASE THE WHITENING EFFECT, but

rather DECREASE THE TIME AND NUMBER
OF DENTIST VISITS.

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There are medications which are

considered to be photoreactive and
may cause adverse conditions in
conjunction with photocatalytic
systems.

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Generic name

Trade name

Chlorthiazide

Diupres, Aldoclor

Hydrochlorothiazide

Adoril,Capozide,
Lopressor, Orotic, Dyazide

Chlorthalidone

Tenoretic, Hygroton

Naprosyn

Naproxen

Piroxican

Feldene

Doxycycline

Vibramycin

Oxaprozin

Daypro
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Ultrasonic Tooth Bleaching

Ultrasonic Whitening:
This is a new method of bleaching
which is still undergoing trials in
Britain.
Gel containing a bleaching agent is
put in a special tray, which is fitted
over the teeth. The tray also
contains a copper element which
gives out ultrasonic vibrations.
These vibrations speed up the
oxidizing process of the bleach.

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Ozone, O3 Bleaching
Ozone, O3 is one of the most powerful
oxidising agents that occurs naturally.
The use of ozone as a bleaching agent
should provide a fast, effective and
harmless method to whiten teeth. It
should cause no damage to tooth or
supporting tissues, and should pose no
risk to the operator and support team,
or the patient.
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The HealOzone

The latest newcomers in bleaching, are

researches conducted to use a light
activated titanium oxide photocatalyst
prior to the application of the bleaching
agent, in order to boost the oxidation
process by increasing the amount of free
radicals generated, in an attempt to
achieve satisfactory bleaching results,
using lower and safer concentrations of
bleaching agents.

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Dentist-supervised
bleaching

By means of a bleaching tray loaded with

high concentrations of carbamide peroxide
(from 30 to 40%) that is placed in the
patients mouth for an average of 30 min
while the patient is in the dental office.

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Custom Tray.
A nightguard with
window design for
bleaching

of

single tooth.
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The studies clearly demonstrate that there was no statistically significant

difference between the reservoir and non-reservoir teeth. In addition, no
clinically significant oral tissue side effects .
But the lack of reservoir may have a pushing effect on the teeth which
make the patient feeling
discomfort.
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Over-the-counter
products
Strips.
Paint on.
Paint on plus.
Whitenning pens.

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They

are

peroxide

or

based

on

hydrogen

carbamide
peroxide

of

various concentrations and placed in a

pre-fabricated tray, or by the recently
introduced

strips

painting.

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or

by

patient

"In reality, brush-on whitening

is designed for the segment of
the public that is in love with
shortcuts. "

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EFFICACY AND ESTHETIC

RESULTS

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It is generally advocated that most teeth

are susceptible to bleaching, provided that
the treatment is carried out for a sufficiently
long time.

The patient's pretreatment shade was A4

(left). After 2 weeks of bleaching a shade of
B1 was achieved (right).

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LOCAL SIDE-EFFECTS
Tooth sensitivity:

Affects 66% of

the patients during the early stages of

treatment.

It is due to the glycerin -

glycerin literally sucks the moisture out

from the enamel of the teeth and it's the
primary cause of most tooth sensitivity
from whitening.

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It

is solved by adding some ACP to

the bleaching gel that crystallizes

and forms hydroxyapatite. It also
decreases

the

surface

precipitation.

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protein

Fluoride gels in the bleaching trays have been

recommended for treating tooth sensitivity. It
does not affect the whitening process.
Potassium nitrate applied either by brushing
before initiating whitening or by application via a
tray during whitening to reduce sensitivity.
Administer anti-inflammatory analgesics.

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Mucosal Irritation:
The ill fitted bleaching tray may induce tissue irritation. It is one
of the most major causes of tissue irritation.
Increase in the concentration of hydrogen peroxide may induce
chemical injury in the form of erythema or mucosal sloughing.
Increasing the time may induce inflammation or hyperplasia.

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ISOLATION
Tooth-bleaching

products

using

concentrated

H(2)O(2) should not be used without gingival protection;

that H(2)O(2) containing products should be avoided in
patients with damaged or diseased soft tissues.
For night guard vital
bleaching, minimal amounts of
low dose H(2)O(2) (including in
the form of carbamide peroxide)
are preferred, thereby avoiding
prolonged
exposures

and

concentrated

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It is recommended to advise the patient to use

waxed dental floss, as the unwaxed one will act as
wick. It absorbs the bleaching gel, leading to
continuous gingival irritation.

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Uneven Bleaching:
Some patients

will experience a temporary

mottling of the teeth, because some areas of the

teeth will whiten quicker. This always settles
down over time as treatment continues.

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Bleaching

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Alteration of enamel and dentin surface:

The enamel surface exposed to the bleaching agents
underwent slight morphologic alterations.
Hydrogen peroxide causes denaturation of proteins
in the organic component of dentin and enamel, with
an increase in organic component.
Loss of the aprismatic enamel layer.

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Use of carbamide peroxide on the enamel

surface could change the levels of the
minerals that may indicate damage to the
organic component of the matrix, especially in
dentin,

due

to

the

concentration.

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higher

organic

All glycerine-based bleaching products used

had a significant dehydrating effect on
dentin.
The application of protective varnishes prior
to bleaching treatment may reduce or even
prevent dentin dehydration. (operative 2006)

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The bond strength between enamel and resinbased fillings was reduced in the first 24 hrs
after bleaching.
Following

bleaching,

residuals

in

the

hydrogen
enamel

peroxide

inhibits

the

polymerization of resin-based materials and

thus reduces bond strength.

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Therefore, tooth-bleaching agents should not

be

used

immediately

after

restorative

treatment with resin-based materials.

After the bleaching treatment, the 10% sodium
ascorbate application was reported to be
effective in reversing bond strength.

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Hydrogen
peroxide was totally
eliminated when
the bleached teeth were
treated with catalase,
sodium ascorbate
or 70% ethanol.

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Pulp

Diffusion of peroxides into the

pulp tissue lead to oxidative
stresses
which
could
negatively affect the cell
metabolism.

The inflammatory cells might

be present in the pulp after
10% carbamide peroxide. But it
does not affect the pulp
enzymes.
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Effect of Other Components in the Bleaching Products:

These additives keep the gel contained within the
tray better and slow down the chemical reaction.

Decreases the enamel microhardness. It inhibits

hydroxyapatite crystal growth because of its high
calcium binding capacity.

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Thanks to the saliva present naturally, it has a

buffering and remineralizing capacity that is
expected to maintain the pH level of the oral
cavity and to increase or uphold the dentin
mineral content.

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Urea:
It increases the permeability.
Urea denatures proteins and causes an increase in
porosity of the outer enamel surface mainly due to
the nascent oxygen when released in the inner
structure.

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Glycerin:
It represents a slight decrease in micro
hardness for sound enamel and dentin,
similar to the effect of carbamide peroxide. It
could act as an adsorbed layer barrier to
saliva and to the remineralization effect.
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GENERAL SIDE-EFFECTS
Not yet assessed due to the big number
that should be involved in the study, to
declare is it 100% safe or not.
It is not safe for pregnant females.

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Bleaching

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Amalgam:
Amalgam:
Different
reported

types
to

of

amalgam

exhibit

alloys

different

were

oxidation

reactions when exposed to the bleaching

agents.

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Glass Ionomer:
Auto-Cure, Resin modified and Compomer:
It has been found that bleaching may increase their
solubility with complete or partial debonding of fillers
leading to increased surface roughness.

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Resin Composites:
Some reports indicate significant reduction in
micro-hardness in bleach-treated resin composites
with an increase in surface roughness.

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The suggested roughness was due to loss from the

matrix rather than the filler particles. Filler-matrix
interactions

appear

to

have

great

effect

on

increasing the resistance of the composite resin.

In-office bleaching products are not detrimental to the
surface finish of composites, compomers, giomers nor
resin-modified glass ionomer cements.
(Oper.Dent.2006)

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For the micro-filled:

Significant reduction of the surface hardness.

For the packable composites:

The surface microhardness was not affected.

For the Ormocer:

Significantly less wear than the composites
matrices, thus, it has greater surface hardness.
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N.B. It was concluded that bleaching

with 38% hydrogen peroxide and
15% carbamide peroxide did not
cause major surface texture
changes on the polished surfaces
of the restorative materials.

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The

surface

roughness

may

not

be

clinically

noticeable, but if it increases plaque accumulation, this

could lead to secondary caries. If changes in the
surface characteristics occur with bleaching it could
have a direct effect on bacterial adherence to these
surfaces.

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Ceramic Restorations
No effects on the color or
physical properties of porcelain
or other ceramic materials have
been reported
??????????????????????????
Temporary Restorations
Hydrogen peroxide and carbamide
peroxide both cause microscopic
changes to IRM restorations.
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Bleaching

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Refrain from eating, drinking, or smoking for 30

minutes. Also, avoid citrus foods and beverages to
minimize discomfort from sensitivity.
If sensitivity should occur, cease treatment, and wait 24
hours before resuming bleaching treatments. Your
dentist will be able to guide you in completing your
treatment.
Never use lemon juice for teeth whitening because
vitamin C will cause the teeth to lose calcium, damaging
teeth quicker than anything else.
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Bleaching

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Avoid enamel staining substances such as

coffee, tea and tobacco products for several
days following your bleaching appointment.
To maintain whiteness, repeat the treatment
procedure for two days every four to six
months, or as needed.
Store the syringes in your refrigerator. The
material expiration date is two years from
receipt.
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Chewing

gums

containing

sodium

hexametaphosphate decreases the induced

stain formation by 33% compared to non-gum
treatment. (Perra 2006)

Avoid the use of any mouthwash

containing

Chlorohexidine.

(Bernardi 2004)
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Use of Toothpaste That Promotes Whitening

Whitening toothpastes do not lighten the color of
tooth structure, they simply remove surface stains
with mild abrasives or special chemical or
polishing agents.

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Follow-up
Call the patient after 1-2 weeks to evaluate tissue
response and monitor compliance.
Monitor lightening, check for complications and
provide fresh bleaching agent.
If complications occur, stop treatment for a few days
and proceed with shorter wearing time or lower
concentration.
Take post operative photographs to verify changes.
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Relapse
The supporters of tooth bleaching admit that it
does not last forever. However "Many in-office
bleaching procedures tend to relapse in color
somewhat after a week, most likely due to
rehydration of the tooth structures
If the patient did not follow properly the
instructions

after

the

bleaching

visit,

chances for relapse increase dramatically.

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the

Well,
Well,there
thereare
are44KEY
KEYCOMPONENTS
COMPONENTSto
tomaking
makingsure
sureyou
you
get
getthe
thebest
bestpossible
possibletooth
toothwhitening:
whitening:
1) Immediately

before

bleaching,

brush

your

teeth

with

an

oxygenating toothpaste combined with the finest natural polishing

agents AND aloe vera to strengthen your gums & prevent any
sensitivity.
2) Use form-fitting mouth trays that are fitted to your specific bite.
Make sure they fit snugly around each tooth, and at all points they
press firmly around the sides of your teeth and gums.

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3) Use a 21% concentrated bleaching gel based on

carbamide peroxide that is formulated specifically to
reduce the sensitivity to your teeth and gums. (In other
words - No glycerin).
4) Immediately after bleaching, enhance the effect by
using an oxygenated oral rinse. Make sure not to use a
mouthwash

with

alcohol

as

this

chemically curtail the bleaching effect.

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can

actually

THE FUTURE
GC Tion: Low concentration hydrogen peroxide gels used

in conjunction with a titanium oxide photo catalyst.

Non peroxides bleachers depending mainly on
bicarbonates to prevent the mishaps of
peroxides.
Hydroxy apatites (Under investigation).

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Concluding Remarks
We advocate a more selective use of tooth
bleaching and a limitation on its use to patients for
whom such treatment could be professionally
justified.

Our concerns are based on the lack of large-scale

clinical investigations on adverse effects and the
limited toxicological data on carbamide peroxide.

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Bleaching should be more selectively undertaken

to patients for whom such treatment modality is

justified.

An accurate pre-operative examination &

assessment for patients undergoing this

procedure is a must.

A good dentist-patient communication, prior to

starting the treatment,& relating to the limitations,

possible hazards & relapses is mandatory.
Bleaching

Amr A Shabka

Patients unrealistic expectations should be

apprehended & controlled in order to prevent or

minimize dissatisfactions & deceptions.

Relapses are unavoidable & could be managed by

touch-ups.

Bonded restorations should not be performed until

two weeks after the bleaching procedures.

The most efficient type of bleaching is the in-office

+ home combination type

Bleaching

Amr A Shabka

White light units of bleaching systems do not

whiten more they simply reduce the time & number

of visits ,THIS IS A WHITE LIE.
Bleaching does not remove stains, it simply

lightens their color, so the term TOOTH

WHITENING should be better substituted with
the term COLOR LIGHTENING OF TEETH

Bleaching

Amr A Shabka

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Bleaching

Amr A Shabka