BLEACHING OF DISCOLORED TEETH

Contents Introduction History Causes of Tooth Discolouration Bleaching Materials Bleaching Techniques Non-vital bleaching Vital bleaching Conclusion References

INTRODUCTION
Discoloration of anterior teeth is a cosmetic problems that is often the patients primary concern. Although restorative procedures are available, discoloration can often be corrected totally or partially by a more conservative approach i.e. bleaching, which is relatively simple to perform and less expensive.

BLEACHING
Defined : as the whitening of a tooth through the application of chemical agent to oxidise/reduce the organic pigmentation in the tooth. Advantage Safe procedure Painless to adults No tooth reduction required No anesthesia necessary Least expensive to treatment altenatives

Disadvantage

Normal tooth colour may be restored Bleaching can caused discomfort in children because of their large pulps. Extended treatment time may be necessary.

INDICATIONS

Discoloured teeth due to either extrinsic or intrinsic stains.

Contra-indications to bleaching

Patient selection Patients with emotional or psychologic problem or those with unrealistic goals do not make good candidates for bleaching.

Dentinal hypersensitivity These symptoms may be associated with severe cases of attrision,erosion,abrasion or abfraction .

Suspected or confirmed bulimia Application of bleaching agent in such cases may result in acute pulpitis. Bulimia patients may require a comprehensive course of restorative treatment involving veneers and crowns.

Generalized dental caries and leaking restoration Use of bleaching agents for such patients who fall in this category may lead to severe, generalized hypersensitivity

Heavily restored teeth Teeth with visible,tooth colored restorations respond poorly to bleaching because the composite restorations do not lighten and become more evident after bleaching.

Teeth with opaque white spots Teeth slated for bonded restorations or orthodontic bracketing. Oxygen produced during bleaching remains in the enamel or dentin oxygen interferses with the bonding agent and induses bonding failure.

HISTORY
A professional response to the unrelenting quest for white teeth dates back at least 2000 years.

First century Roman physicians maintained that brushing teeth with urine, particularly Portuguese urine, whitened teeth. In the 1300s, after abrading the enamel with coarse metal files, aquafortis, a nitric acid solution was applied to whiten the teeth.

Guy de Chauliac, in 14th century recommended a tooth whitening procedure in which teeth were gently cleaned with a mixture of honey and burnt salt to which some vinegar was added, which was considered authoritative for nearly 300 years.

The introduction of clinical procedure of vital tooth bleaching was done by Chapple in 1877, who used oxalic acid as the bleaching agent. The first mention of peroxide as a bleaching agent was in 1884 by Harlan, which he called hydrogen dioxide. In 1888, Taft and Atkinson suggested calcium hypochlorite to be an effective tooth whitening solution. In 1916, Kane proposed the use of 18% HCl to the brown fluoride stain. Although not regarded as the bleaching agent, it is capable of removing the stains as it dissolves the surface of teeth. In 1918, Abbot found that the bleaching action of hydrogen peroxide could be greatly enhanced by the addition of heat and light.

In 1937, Ames proposed the combination of 5 parts of 100% H2O2 with 1part of ether activated by heat as the treatment for the stains caused by fluoride. In 1939, Younger proposed the use of 30% H2O2, ether and heat for the stains caused by fluoride.

In 1966, the use of HCl combined with H2O2 was advocated by McInnes for the stains caused by fluoride. Non-vital bleaching was introduced by Garretson in 1895 who applied chloride to the tooth surface but could not achieve very good results. In 1958, Pearson reported the use of superoxol sealed within the pulp chamber. He found that within 3 days, the oxygen releasing capacity of the solution had whitened the experimental teeth to some extent. In 1967, Nutting and Poe refined this method and termed as walking bleach where they packed a mixture of 30% H2O2 and sodium perborate in the pulp chamber for 1 week.

In 1989, Haywood and Heymann introduced a technique for bleaching vital teeth which they called Night guard vital bleaching. In this technique, the use of Carbamyl peroxide was introduced which was placed in a molded tray, which the patient places over his teeth for hours at a time.

In 1992, Rembrandt introduced whitening tooth pastes and enzyme based dentifrices.

In 1994, Light activation of the bleaching agents was introduced which further led to activation of bleaching agents by argon laser, CO2 laser and plasma arc. In 1999, Diode laser was introduced as a vector in tooth whitening. From 1995 till date a variety of concentrations of bleaching gels containing remineralising agents, fluoride and peroxide free chemicals have been available.

Etiology of Tooth Discolouration The etiology of tooth discolouration may be extrinsic or intrinsic or both. Extrinsic stains Diet related Bacterial strains Medications Habits

Pipe smoking

Mouth wash

Bacterial products

Tobacco stains

Mouth wash

Intrinsic stains 1. Pre-eruptive Alkaptonuria Amelogenesis imperfecta Fluorosis Erythroblastosis foetalis Porphyria Tetracycline staining Jaundice 2. Post eruptive Age Pulpal necrosis Intrapulpal haemorrhage Dentin hypercalcification Iatrogenic discoloration Remnants of pulpal tissues Intra canal medicaments Obturating materials Restorations

Enamel hypoplasia

Trauma

Mild fluorosis

Severe flourosis

Tetracycline staining

Mild tetracycline stains

Dentinogenesis imperfecta

Amelogenesis imperfecta

Pulpal heamorrhagic product

Extrinsic Stains: These are caused by the daily intake of substances such as food and beverages or the use of tobacco products. These substances tend to adhere to the enamels hydroxyapetite structure and here by discolour the teeth or reduce the whiteness of teeth. Over a period they may penetrate the enamel layer and gradually give rise to intrinsic discolorations.

Nathoos Classification(for extrinsic dental stain)

N1 type dental stain or direct dental stain: Coloured material(chromogen) binds to the tooths surface and causes discoloration. The color of chromogen is similar to that of dental stain. N2 type dental stain or direct dental stain: Colored material(chromogen) changes color after binding to the tooth. N3 type dental stain or indirect dental stain: Colourless material or a pre-chromogen binds to the tooth and undergoes a chemical reaction to cause a stain.

CAUSES OF EXTRINSIC STAINS: 1. Diet: These stains affects multiple teeth and appears as yellow or brown stains of varying intensities. Consumption of strong tea or coffee immediately after orange or grape juice is a common cause of external discoloration.

Black current juice or cola drinks act by both etching and staining the tooth simultaneously.

2. Bacterial Strains:

Chromophilic bacteria frequently seen in the deciduous or mixed dentition can cause a dotted or black-line stain.
It has been documented that this type of bacteria is associated with lower-than normal caries rates and the removal may result in recolonization of the oral cavity by a more cariogenic flora.

3. Medication: Chlorhexidine acts in reducing plaque formation by disturbing the pellicle matrix formation, which attracts more extrinsic strains not readily removed by tooth brushing. 4. Habits: Smoking marijuana may produce characteristic linear, green circumferential rings at the cervical margins.

Smoking tobacco causes a yellow-brown discolouration especially on the lingual aspects of the teeth. Chewing tobacco causes a black-brown stain that is most noticeable on the buccal surfaces of the mandibular posterior teeth.

5) Gingival Hemorrhage Chronic gingivitis may induce staining from the breakdown of blood in the gingival sulcus.

Intrinsic Stains
These are stains which are incorprated within the matrix of enamel and dentin and are caused by the deposition or incorporation of substances within these structures. These stains may be caused during the developmental stage i.e., pre-eruptively or after the eruption into the oral cavity.
1.

Pre-eruptive discolorations:
Alkaptonuria:Also known as phenylketonuria or ochronosis. It is a recessive genetic disorder resulting in dark brown pigmentation of the permanent teeth.

Amelogenesis imperfecta:- It affects both primary and permanent dentition and can be further subdivided into

Hypomaturtion: where the enamel is chipped off from the underlying dentin Hypo calcification: where the thickness of enamel is normal but is soft in consistency and completely abrades soon after eruption, which results in a tooth with crown that ranges in appearance from a dull opaque white to a dark brown. In addition, these teeth are usually rough and pitted. Hypo plastic: where the enamel is quiet thin, smooth, hard and yellow in appearance, with occasionally pitting.

Dentinogenesis Imperfecta:
is a hereditary developmental disturbance of dentin that may be seen alone or in conjuction with systemic disorder of bone (osteogenesis imperfecta). This disorder is autosomal dominant . WITKOP outlined three descriptive classification of this disorder 1.Dentinogenesis imferfecta 2.Heriditary with opalescent dentine 3.Brandy white isolate.

Usually affects the primary teeth more seriously than the permanent dentition. The clinical crowns appear reddish-brown to grey opalescent.

Fluorosis
Black and McKay first reported this condition in 1916. The optimum concentration of fluoride in the drinking water for the dental development is 1ppm.

When the intake approaches 2ppm, noticeable white spots occur in the enamel.
when it approaches 3ppm, patchy brown discolouration of the enamel occurs. Higher concentrations than this can result in pitting and anomalies in the enamel formation. The high concentration of fluoride is believed to cause a metabolic alteration in the ameloblasts which results in a defective matrix and improper calcification. The teeth can be affected by fluorosis from the second trimester in utero through age 9.

Erythroblastosis fetalis:- This is a blood disorder of the

neonate which might discolour the teeth .This disease in the fetus or new born results from Rh incompatibility which leads to massive lysis of erythrocytes.

The discolouration ranges from brown to greenish-blue. This condition is usually self-treating and the staining resolves as the child matures.

Porphyria:- is a metabolic disease.

In this condition, the haematoporphyrin pigment creates a characteristic reddish-brown discolouration of the teeth known as Erythrodontia. More commonly seen in the primary dentition than the permanent dentition. The colouration is dispersed throughout the enamel, dentin and cementum and fluoresces red under ultraviolet light.

Tetracycline staining

The tooth discolouration caused by incorporation of systemic tetracycline was first reported in 1956 by Schwashman and Schuster. Since, it crosses the placental barrier it can affect both the primary and permanent dentition. Though the exact mechanism of staining is not fully understood, it is believed that the tetracycline molecule binds to the calcium of the tooth forming tetracycline orthophosphate.

The clinical appearance of tetracycline-stained teeth ranges from light yellow to dark grey bands.
Usually the darker shades are confined to the gingival 1/3rd of the teeth and the lighter shades will often be located exclusively in the incisal 1/3rd.

When the tetracycline stained teeth are exposed to sunlight, they gradually turn to shades of dark grey or brown. Cohen and Parkins: suggest this as the reason why labial surfaces of the incisors darken while the molars remain yellow for a longer period of time. Studies have shown that further exposure of such teeth to various light sources such as sunlight, incandescent or ultraviolet lights produces a subsequent lightening of the tetracycline stain. It has been postulated that tetracycline incorporated into hydroxyapetite, when oxidized by light produces the red quinone product 4, 12 anhydro-4-oxo-4-dedimethylamino tetracycline (AODTC).

Tetracycline is a bacteriostatic antimicrobial,which was commomly given for treatment of

Chronic middle ear infection in children Long term therapy for acne valgarius. Cystic fibrosis Rocky mountain spotted fever.

The severity of tooth discolouration depends on four factors associated with tetracycline administration.

Age at the time of administration: Anterior primary teeth are susceptible to discolouration by systemic tetracycline from 4 months in utero through 9 months post partum. Anterior permanent teeth are susceptible from 3 months post partum to 8 years. Duration of administration: Severity is directly proportional to the length of time the medication was administered. Dosage: Severity is directly proportional to the administered dosage.

Type of Tetracycline:

Chlortetracycline (Aureomycin): Gray-brown

Dimethylchlortetracycline (Ledermycin): Yellow stain Doxycycline (Vibramycin): Does not cause stain

Oxytetracycline (Terramycin): Yellow stain

Tetracycline (Achromycin): Yellow stain

Jordan and Boksman has classified the tetracycline staining as follows

Primary staining: Light yellow or light grey, slight but uniformly distributed without banding. Secondary staining: Darker or more extensive yellow or grey staining without banding. Tertiary staining: Severe staining characterized by dark grey or blue discoloration, usually with banding.

First degree tetracycline stains

Second degree tetracycline stains

Third degree tetracycline stains

Minocycline Staining: It is found that Minocycline, a semisynthetic derivative of tetracycline .unlike tetracycline it is poorly absorbed in gastroinstestinal track.

Minocycline, although combines poorly with calcium, has the ability to chelate with iron and form insoluble complexes,forming a yellow grey discolouration .
Minocycline stains may be responsive to bleaching while others with severe banding may require veneers.

Jaundice: Bluish green or brown staining of primary teeth is seen in children who suffered severe jaundice during infancy.

These stains are the result of postnatal staining of the dentin by bilirubin or biliverdin.

2. Post-eruptive discolorations:
a)

Age In older patients, colour changes in the crown occur physiologically as a result of extensive secondary dentin formation, thinning and optical changes of the enamel. Food and beverages also have a cumulative discolouring effect because of the inevitable crack, crazing and incisal wear of the enamel and underlying dentin.

In addition, amalgam and other coronal restorations that degrade over time cause further discoloration.

2) Pulpal Necrosis: Bacterial, mechanical or chemical irritation to the pulp may result in tissue necrosis. Tissue disintegration by products are then released that may penetrate tubules and discolour the surrounding dentin. The degree of discolouration is directly related to how long the pulp has been necrotic. The longer the discolouration products are present in the pulp chamber, the greater the discolouration.

c) Intrapulpal haemorrhage: It is the most common result of traumatic injury to a tooth, which results in disrupted coronal blood vessels, haemorrhage and lysis of erythrocytes.

Blood disintegration products, presumably as iron sulfides permeate dentinal tubules to stain the surrounding dentin, which tends to increase with time. If the pulp becomes necrotic, the discoloration usually remains.
If the pulp survives, the discolouration may resolve and the tooth reverts to its original shade. Sometimes, mainly in young individuals the tooth remains discoloured even if the pulp responds to vitality.

d) Dentin hypercalcifiation/calcific metamorphosis It is the extensive formation of tertiary or irregular secondary dentin in the pulp chamber or on canal walls, which may occur following certain traumatic injuries which did not result in pulpal necrosis.

In such cases, temporary disruption of blood supply occurs followed by partial destruction of odontoblasts. These are replaced by undifferentiated mesenchymal cells that rapidly form irregular dentin on the walls of the pulp lumen. As a result, the translucency of the crowns of such teeth gradually decreases, giving rise to a yellowish or yellow-brown discoloration.

e) Iatrogenic Discolouration Remnants of pulpal tissues: Pulp fragments remaining in the crown, usually in the pulp horns, may cause gradual discoloration. The pulp horns must be opened up and exposed during access to ensure removal of pulpal remnants and to prevent retention of sealer at a later stage.

2. Intracanal medicaments

Several intracanal medicaments are liable to cause internal staining of the dentin.
Phenolics or iodoform based medicaments sealed in the root canal and chamber are in direct contact with dentin sometimes for longer periods, allowing penetration and oxidization.

These compounds have a tendency to discolour the dentin gradually.

Idoform induced discolourations tend to be more severe.

3. Obturating materials: It is a frequent and severe cause of single tooth discolouration. Incomplete removal of obturating materials and sealer remnants in the pulp chamber, mainly those containing metallic components, often results in dark discoloration. Such discolouration can be prevented by removing all the obturating material to a level just cervical to the gingival margins.

4. Coronal Restorations: Amalgam Silver alloys have severe effects on dentin because of the dark coloured metallic components that can turn the dentin dark grey. When used to restore lingual access preparations or a developmental groove in anterior teeth as well as in premolars, amalgam may discolour the crown. such discolorations are difficult to bleach and tend to rediscolour with time. Replacing the amalgam restoration with an esthetic restoration usually corrects the problem.

b) Pins and Posts:

Metal pins and prefabricated posts are sometimes used to reinforce a composite restoration in the anterior teeth. Discolorations from inappropriately placed pins and posts is caused by a metal seen through the composite or tooth structure.

In such cases, coverage of the pins with a white cement or removal of the metal and replacement of the composite restoration is indicated.

c) Composites: Microleakage around composite restoration causes staining. Open margins may allow chemicals to enter between the restoration and the tooth structure and discolour the underling dentin. In addition, composites may become discoloured with time, affecting the shade of the crown, which needs to be replaced with a new well sealed restoration.

Bleaching Materials:
The most commonly used bleaching agents in dentistry are Hydrogen peroxide Sodium perborate Carbamide peroxide.

Hydrogen Peroxide:
It is a clear, colourless and odourless liquid. Higher concentrations of these solutions must be handled with care as they are thermodynamically unstable and may explode unless refrigerated and kept in a dark container. Because of its ischemical effect on skin and mucous membrane it resembles a chemical burn. It is especially painful if it comes in contact with the nail bed or the soft tissue under the finger nail. It can be used for both intra and extra-coronal bleaching.

Chemistry of bleaching:

Bleaching is a chemical process, which occurs mostly by the oxidation during which the organic materials are eventually converted into carbondioxide and water.
The most commonly used bleaching agent is hydrogen peroxide which requires the least time for the desirable action. In the bleaching process, the oxidizing agent i.e. the bleaching agent has free radicals with unpaired electrons which it gives up and becomes oxidized, whereas the reducing agent i.e., the substance being bleached accepts the electrons and becomes reduced.

Hydrogen peroxide bleaching:

H2O2 has the ability to produce free radicals i.e., H2O (perhydroxyl-stronger free radical) and O. (nasant oxygen-weaker free radical). In pure aqueous form, hydrogen peroxide acid reduced breakdown extended shelf life.

Ionization:H2O2 H2O + O (Higher percentage of the weaker free radical)

H + HO2 (Lower percentage of stronger free radical)

The perhydroxyl is the more potent free radical in the bleaching process. In order to promote the formation of perhydroxyl, the hydrogen peroxide needs to be made alkaline.
Optimum pH 9.5 to 1.8 at which ionization takes place. H2O2 H2O + O (Lower percentage of weaker free radical)

H + HO2

(Higher percentage of stronger free radical)

This reaction results in greater bleaching efficacy in the same time as at other pH levels. Thus, H2O2 is most effective between pH of 9.5 10.8. In the presence of decomposition catalysts and enzymes the H2O2 ionises as follows. 2H2O2 2H2O + O2 Where no free radicals are produced and the bleaching is ineffective. Some of these enzymes may be present in the mouth. Therefore, it is important to make the teeth free of debris and dry when applying the bleaching agent.

Mode of Supply:

Hydrogen peroxide:Solution: Various concentrations of hydrogen peroxides are available, but 30% to 35% stabilized solutions are the most commonly used. They can be used either alone or mixed with sodium perborate. Gel: Also available in the form of Silicon dioxide gels containing various concentrations of hydrogen peroxide (6 to 38%). Recently introduced is the Opalescence xtra boost which contains 38% hydrogen peroxide for quicker results and which does not even require light activation (Syringes).

These gels are also available in preloaded disposable whitening tray where the concentration of hydrogen peroxide is about 9%. It is available as crest white from ultradent which consists of a delivery tray (outer tray with handle) and a disposable adaptive tray (inner tray without handle). The inner tray consists of a gingival barrier gel on the border of the tray and 9% H2O2 gel inside the tray. Both the trays are centered on the arch and lightly pressed into place, the outer tray is then removed and the inner tray is adjusted. It is advised to wear 30 to 60 min/7-10 days.

Teeth whitening strips:

These are flexible pieces of plastic or polyethylene that have been coated on one side with a thin film of hydrogen peroxide gel.

The idea of the teeth whitening strips was to reduce the thickness of the peroxide gel. The thickness of the bleaching gels on the whitening strips is about 0.2mm while that of a paper is 0.1mm. It is to 1/5th quantity compared to the tray bleaching.

The concentration of the hydrogen peroxide gels on the whitening strips varies from 6% to 10%. The teeth whitening strip kit consists of half the strips designed to adapt the upper arch and half the lower arch. It is advised to use these strips for 30 min twice a day. 6% gel strips for 14 days and 10% gel strips for 7 days. Disadvantage:- The length of the strips is small so that they adapt only to the anterior teeth. Adverse effects: Gingival irritation: As there is no barrier to restrict these gels. Sensitivity

Hydrogen peroxide toxicity

Cervical root resorption after internal (non vital) tooth bleaching. Increased sensitivity after external(vital) tooth bleaching.

For resorption to occur ,there must be a combination of

Deficiency in the cementum(exposing the dentin) Injury to the periodontal ligament Infection(sustaining the inflammation).

HYDROGEN PEROXIDE TOOTH-WHITENING (BLEACHING)PRODUCT:REVIEW OF ADVERSE EFFECTS AND SAFETY . BDJ vol 2000 no 7 apr 2006

Hydrogen peroxide in the form of carbamide peroxide is widely used for tooth whitening (bleaching),both in professionally and in self administered product. Cervical root resoption is a possible consequense of internal bleaching and is more frequently observed in teeth treated with the thermo-cataytic procedure. Direct contact with H2O2 induces genotoxic effects . Several carcinogenesis studies indicated H202 might act like a promotor.

Effect of bleaching on the structure of enamel

Surface alteration in enamel topography follow vital bleaching using hydrogen peroxide.

High concentration of hydrogen peroxide damage enamel surface intergrity.

Effect of tooth bleaching on tooth restoration

Bleaching with hydrogen peroxide increase the solubility of glass ionomer and other cements and reduce the bond strength between enamel and resin based filling in the first 24 hour.

Hydrogen peroxide residues in the enamel may inhibit the polymerisation of resin based material and reduce bond strength.
So ,hydrogen peroxide should not be used prior to treatment with resin based material

Sodium Perborate: It is supplied in a granular form, that has to be ground into a powder before using.

It is either mixed with water or hydrogen peroxide to form a thick paste and is packed into the pulp chamber.
When fresh ,it contains 95% perborate .

Sodium perborate is stable when dry,but in the presence of acid,warm air,or water it decompses to form sodium metaborate,hydrogen peroxide and nascent oxygen.

Various forms of sodium perborate monohydrate trihydrate tetrahydrate They differ in there oxygen content which determines the bleaching efficacy.

Commonly used sodium perborate are alkaline and there pH depends on the amount of hydrogen peroxide released and residual sodium metaborate.

Chemistry of bleaching

Sodium perborate:Sodium perborate when mixed with water decomposes to form sodium metaborate and hydrogen peroxide releasing O2. When mixed with superoxol it decomposes to form sodium metaborate and water releasing O2. The oxidation is slow and is active over a long period of time

Advantage of sodium perborate

Carbamade peroxide:Also known as urea peroxide, cabramyl peroxide, perhydrol urea, perhydelure, carbamide urea, urea H2O2 and H2O2 carbamide. It is a clear, colourless odourless liquid. When used as a bleaching agent it breakdowns to hydrogen peroxide. Previously used only for extracoroanl bleaching. Lee et al (2004), found that carbamide peroxide had very low levels of extraradicular diffusion of peroxide in the presence of cemental defects. Therefore, it could be an alternative to the other intracoronal bleaching agents. 35% carbamide and 35% H2O2 were more effective than Na perborate after 7 days.

Bleaching preparations containing carbamide peroxide usually include glycerine or propylene glycol, sodium stannate, phosphoric or citric acid and flavour additives. Some preparations contain carbapol, a water soluble polyacrylic acid polymer as a thickening agent which prolongs the release of active peroxide and improves shelf-life.

Carbamide peroxide: The most common mode of supply is in the form of gels, which are supplied in syringes. It is available in various concentrations ranging from 3 to 45%. However, popular commercial preparation contain about 10% carbamide peroxide with a mean pH of 5 to 6.5. Leonard et al. studied the use of different concentrations of carbamide peroxide for bleaching teeth and found that lower concentrations of carbamide peroxide take longer time to whiten teeth but eventually achieve the same result as higher concentrations, which may cause increased sensitivity.

Enzymes:There are certain enzymes which are found to have a considerable bleaching efficiency on both extrinsic and intrinsic stains. These enzymes are obtained either from plants or microorganisms. These enzymes are effective either without peroxides or with very little % of peroxides (0 to 1%). Laccases act on the molecular oxygen and yield hydrogen peroxide without any need for hydrogen peroxide. They are obtained from fungi E.g. Mycelipthora thermophila. These enzymes are found to be effective against intrinsic stains.

Oxidases act on the molecular oxygen and yield hydrogen peroxide. E.g. L-amino acid oxidase Trichoderma harzianum, glucose-oxidase Aspergillus species, Xylitol oxidase Streptomyces species. They are found to be effective against extrinsic stains. Peroxidase:- Act on hydrogen peroxide and yield water. These enzymes require very little % of hydrogen peroxide for their action. They are obtained from plants e.g. Horse radish peroxidase or from microorganisms. E.g. Haloperoxidase from Curvularia species. They are found to be effective against both extrinsic and intrinsic stains along with Laccases

Enzymes:These enzymes either alone or in combination with peroxides are added to the mouth washes or tooth pastes. Their concentration ranges from 0 to 20% with 0 to 1% of peroxides if used.

Sodium perborate:Sodium perborate when mixed with water decomposes to form sodium metaborate and hydrogen peroxide releasing O2. When mixed with superoxol it decomposes to form sodium metaborate and water releasing O2. The oxidation is slow and is active over a long period of time

Carbamide peroxide chemistry: Carbamide peroxide used as bleaching agent breaks down into H2O2. 10% carbamide peroxide produces 3.6% H2O2. CH2 N2O H2O2 NH3 H2O2

CO2 Then, the ionization of H2O2 is the same.

BLEACHING TECHNIQUES: Before carrying out the bleaching process, it is important to assess the type of stain. Certain extrinsic stains can be removed by regular intense mechanical brushing with cleaning agents containing abrasives or surfactants.

Basically bleaching techniques are:Non-vital

Walking bleach Thermocatalytic UV light photooxidation In-office Night guard Over the counter

Vital

1. Non-vital bleaching: These procedures are carried out for endodontically treated teeth. Indications: Discolouration of pulp chamber Dentin discolouration Discolourations not amenable to extracoronal bleaching Contraindications: Superficial enamel discolourations Defective enamel formation Severe dentin loss Presence of caries Discoloured composites Extensive restorations

In any of the non-vital bleaching techniques, there are certain steps which are common. Radiographic assessment of the status of the periapical tissues and the quality of endodontic obturation. If the obturation is inadequate, the tooth should be retreated prior to bleaching. If there are any leaking or discoloured restorations, they have to be replaced. Evaluate the tooth colour with a shade tab by taking photographs at every appointment. Orabase or vaseline should be applied to the gingival tissues, followed by isolation with rubber dam which should fit tightly at the cervical margin of the tooth to prevent possible leakage of the bleaching agent onto the gingival tissues. Opal dam can also be used.

Remove all restorative material from the access cavity, expose the dentin and refine the access. Verify that the pulp horns and other areas containing pulp tissue are clean. Remove the obturation material to just below labial gingival margin. Orange solvent, chloroform or xylene on a cotton pellet may be used to dissolve sealer remnants. Next is the application of the barrier material. This is one of the most important step as the improper location, material and the shape of the barrier material could lead to external cervical resorption.

Walking Bleach:
In this technique, a mixture of sodium perborate and inert liquid such as water, saline or anaesthetic solution or even H2O2 can be used but preferably lower concentrations are placed in the pulp chamber. Studies have shown more number of external cervical resorption cases with the combination of sodium perborate and 30% hydrogen peroxide. Studies with different types of sodium perborae, water and H2O2 have shown that the combination of sodium tetraborate with water was quiet effective. Timpavat et al. found the bond strength to be better with Naperborate + H2O. Excess liquid from sodium perborate should be removed by tamping with a cotton pellet.

Excess bleaching paste from the undercuts in the pulp horns should be removed and the access cavity should be sealed with a temporary filling (Preferably IRM) which should be at least 3mm. Rubber dam should e removed and the patient should be informed that bleaching agents work slowly and significant lightening may not be evident for several days. Patient should be evaluated after 2 weeks and the procedure should be repeated if necessary.

Thermocatalytic: This technique involves placement of the oxidizing agent, generally 30% to 35% H2O2 in the pulp chamber followed by heat application either by electric heating devices or specially designed photoflood lamps for 5min. this process should be continued until the desirable results are achieved. Should not be repeated for more than 5-6 times. Care should be taken that the temperature of the heating device does not exceed 114F. Lamp unit should be 13 inches away from patient. Metal clamps should not be used. Recall the patient in a week to assess the colour after rehydration. Repeat the procedure, if necessary.

Photo-oxidation: In this technique, 30% to 35% of H2O2 solution is placed in the pulp chamber on a cotton pellet followed by exposure to the curing light for 20-30 sec. For plasma arc or laser 3-5 seconds of exposure time is sufficient. If the bleaching gels are used they have to be expressed into the access cavity and onto the labial surface of the tooth and should be exposed to the curing light from both the sides.

Adverse effects:

External cervical root resorption:- It is one of the most commonly noticed complication with intracoronal bleaching using hydrogen peroxide. It is asymptomatic and is generally noticed during routine examination. The exact cause of this response is not fully understood, although a number of mechanisms have been postulated.

In 10% of all teeth, the cemento-enamel junction is defective or absent, resulting in a portion of the tooth being devoid of cementum coverage. 35% H2O2 may denature the dentin, involving a foreign body response by elements in the approximating gingival tissue causing cervical resorption.

Internally applied 35% H2O2 may directly contact periodontal membrane may passing through patent dentinal tubules or lateral canals or accessory foramina. Bleaching agents may infiltrate between the guttapercha and root canal walls. They could then communicate with the periodontal ligament through dentinal tubules, lateral canals or apex which can cause resorption anywhere along the length of the canal. Heat application while using high concentrations of H2O2 may enhance external cervical root resorption. 35% H2O2 mixed with sodium perborate can lower the pH in the periodontal membrane, which may increase the likelihood of cervical resorption.

Chemical burns:- 35% H2O2 is caustic and may cause chemical burns and sloughing of the gingiva. Therefore, when using such solutions the soft tissues should always be protected with Vaseline or orabase and rubber dam or with opal dam. Coronal fracture:- Increased brittleness of the coronal tooth structure, particularly when hat is applied, is also thought to result from bleaching. This may be due to dessication of the dentin and enamel. This was noticed clinically but has not yet proven conclusively.

Suggestions for safer bleaching: Verification of adequate endodontic obturatiion This provides an additional barrier against damage by oxidizers to the periodontal ligament and periapical tissues. Protect the oral mucosa by Vaseline or orabase. Effective isolation by opaldam or rubber dam. Use of interproximal wedges and ligatures may provide a better seal. Use of protective barriers In most of the clinical reports of the post bleaching cervical root resorption protective barrier was not used. The barrier of adequate thickness should protect the dentinal tubules and confirm to the external epithelial attachment.

Acid etching should be avoided as it does not enhance the bleaching process, but causes undesirable periodontal ligament irritation. Avoid strong oxidizers. Avoid heat. Recall the patient periodically and examine clinically and radiographically.

Post bleaching tooth restoration: Permanent restoration of the tooth is essential for long-term successful bleaching. Coronal microleakage especially that of lingual access restoration and a leaking restoration may lead to rediscolouration. Therefore, a composite restoration is advised as early as possible. This should be planned 1 or 2 weeks after complete removal of the bleaching materials. This time period is for the elimination of residual peroxides. The use of catalase for 3 min has been proposed for the removal of residual peroxides where adequate bonding can be acquired.

In case of thermocatalytic or photooxiation bleaching, it has been advised to pack Ca(OH)2 paste in the pulp chamber for a few weeks prior to placement of final restoration to counteract acidity caused by bleaching agents and to prevent root resorption.

Vital bleaching techniques: There are various techniques for bleaching vital teeth depending on the degree of staining. In-office or Power Mouth guard or Night guard or At-home Over-the counter

1. In-office: Indications: Light enamel discoloration Mild tetracycline discoloration Endemic fluorosis discoloration Age related discoloration Contraindications: Severe dark discolorations Severe enamel loss Proximity of pulp horns Hypersensitive teeth Presence of caries Large/ poor coronal restorations

Techniques:Familiarize the patient about causes of discoloration, procedure to be followed and the treatment outcome. Make radiographs to detect the presence of caries, defective restorations and proximity to pulp horns. Evaluate tooth colour with shade tabs by taking photographs at all the appointments. Apply Vaseline or oraseal and then isolate with rubber dam by using waxed dental floss or wedgets for additional sealing. Avoid using metal clamps, as they are subjected to heat.

Do not inject a local anesthetic. Position protective sunglasses over the patients and operators eyes. Clean the enamel surface with pumice and water. For the darkest or most severely stained areas acid etch with 35% phosphoric acid for 5 to 10 seconds and rinse with water for 60 seconds. Place a small amount of 30 to 35% H2O2 solution into a dappen dish. Apply the H2O2 liquid on the labial surface of the teeth using a small cotton pellet or a piece of gauze. Bleaching gel can also be used instead of solution which can be better controlled.

Apply heat with a heating device or light source. The temperature should be controlled that the patient does not feel any discomfort, usually between 125F and 140F (52C to 60C). Rewet the enamel surface with H2O2 as necessary. If the tooth becomes too sensitive, discontinue the bleaching procedure immediately. Do not exceed 30 min even if satisfactory results are not obtained. Heating can be carried out by thermostatically controlled electric heating device or a stainless steel instrument such as Woodson No.2 heated over flame. There are different light sources available for photo-oxidation conventional bleaching light. This supplies energy to enhance the bleaching action of H2O2 by adding heat. The heat causes more vigorous release of oxygen and facilitates the dissolution of pigments. It is slow and often uncomfortable for the patient.

Tungsten-Halogen curing light: These curing light provides heat and stimulates the initiation of the chemical reaction by activating the light sensitive chemicals in the bleaching agent. This is a time consuming process (i.e., 40 to 60 sec per application per tooth).

Argon laser: It emits a visible blue light. The action it is to stimulate the catalyst in the chemical. There is no thermal effect with this. It is easy to use and is best for removal of initial dark stains, such as those caused by tetracycline. However, it becomes less effective as the teeth whitens and when there are fewer stain molecules.

Carbon dioxide laser: It emits invisible infra red light. They interacts directly with the catalyst-peroxide combination. It removes the stains regardless of the tooth colour. It emits heat and can enhance the bleaching effect initiated by the argon laser.

Xenon plasma arc light:It is a non-laser, high intensity light which produces a great deal of heat; therefore, it can be applied only for a brief 3 sec period. The action is thermal and stimulates the catalyst in the chemical. Although it is very fast, there is a greater potential for thermal trauma to the pulp and surrounding soft tissues than with other light sources.

Diode laser light: It is a true laser light produced from solid-state source. It is ultra fast taking 3 to 5 sec to activate the bleaching agent. This does not produce heat. Remove the heat source and allow the teeth to cool down for at least 5 min. Then wash with warm water for 1 minute and then remove the rubber dam. Do not rinse with cold water since the sudden change in temperature may damage the pulp or can be painful to the patient. Dry the teeth and gently polish them with a composite resin polishing cup. Treat all the etched and bleached surfaces with 1.1% neutral sodium fluoride gel for 3 to 5 min.

Inform the patient that cold sensitivity is common, especially during the first 24 hrs and advise to use a fluoride rinse daily for 2 weeks. Recall the patient after 2 weeks and evaluate the effectiveness of bleaching by sing the same shade tab used pre-operative assessment. Repeat the procedure if necessary.

Adverse effects:1. Post operative pain: A common immediate postoperative problem is pulpalgia characterized by intermittent shooting pain. It may occur during and after the bleaching session and usually persists for between 24 and 48 hrs. The intensity of pulpalgia is related to the duration and temperature of the bleaching procedure. Therefore, shorter bleaching periods are recommended. If long term sensitivity to cold develops, topical fluoride treatments and desensitizing tooth pastes should be used to alleviate these systems.

. Pulpal damage:Extra coronal bleaching with hydrogen peroxide and heat has been associated with some pulpal damage. Although no significant irreversible effects on the pulp have been found, these procedure should be carried out with caution and not in the presence of caries, areas of exposed dentin or in close proximity to pulp horns. Defective restorations must be replaced prior to bleaching.

Dental hard tissue damage: Hydrogen peroxide causes morphologic and structural changes in enamel, dentin and cementum and reduces the micro-hardness of these structures. These changes may cause dental hard tissues to be more susceptible to degradation and to secondary caries formation. Therefore, teeth should be well polished after the bleaching procedure.

Mucosal damage: Ulceration and sloughing of the mucosa may be caused when the highly concentrated peroxide substances come in contact with the mucosa. Generally, the mucosa appears white but does not become necrotic or leave scar tissue. The associated burning sensation is extremely uncomfortable for the patient and can be treated by extensive water rinses until the whiteness is reduced. In more severe cases, a topical anesthetic, limited movements and good oral hygiene aid healing. Application of protective cream or catalase can prevent mot of these complications. Vitamin E oil can also be applied immediately after contact.

Night guard vital bleaching: Indications: Superficial enamel discolorations Mild yellow discolorations Brown fluorosis discolorations Age-related discolorations Contraindications: Severe enamel loss Hypersensitive teeth Presence of caries Defective coronal restorations Allergy to bleaching gels Bruxism Pregnant and lactating 8. Smoking

Technique: This technique has been widely advocated as a home bleaching technique with a wide variety of materials. Numerous products are available, mostly containing 1.5 to 10% hydrogen peroxide or 10 to 15% carbamide peroxide, that degrade slowly to release hydrogen peroxide. Carbamide peroxide products are the more commonly used at home bleaching agents. Familiarize the patient with the probable causes of discolouration, procedure to be followed and the expected outcome. Carry out thorough oral prophylaxis Assess the colour of the teeth with a shade tab by taking photographs at all the appointments.

Make alginate impressions of both the arches. Cast the impression by taking care not to incorporate voids or drags in the impression. Apply approximately 0.5mm thickness of block out material to the desired labial surfaces to provide reservoir spaces in the tray. It should be 1 to 15mm short of the gingival margin and should not extend onto the incisal edges and occlusal surfaces. Extending the block-out material onto the incisal edges or occlusal surfaces can cause the margins of the tray to open upon occluding or the tray to impinge on the soft tissues.

1.

Cure the block-out material on each tooth for 20 to 40 seconds. Now heat the tray material on the vacuum former unit until it sags approximately 2 inches, then adapt it to the cast and allow it to cool. It is then trimmed with a scalpel or elastic knife approximately 0.25 to 0.3mm occlusally from the gingival margin facially and lingually in a scalloped manner. The tray is then placed on the cast and the extensions are checked. Now gently flame polish the edges one quadrant at a time with a torch. While still warm, hold the periphery of each segment firmly against the model for 3 sec with a water-moistened finger. Otherwise, after trimming the tray with scalpel a rubber wheel in a micromotor can be used to smoothen the rough edges.

Insert the mouth guard to ensure proper fit. Remove and apply the bleaching agent in the space of each tooth to be bleached. Reinsert the mouth guard over the teeth and remove excess bleaching agent. Familiarize the patient with the use of bleaching agent and wearing the mouth guard. The procedure is usually performed 3 to 4 hrs a day and the bleaching agent is replenished every 30 to 60 min. Some clinicians recommend wearing the guard during sleep for better long-term esthetic results. The duration of wearing the mouth guard and replenishing the bleaching agent depends on the severity of staining, concentration of the bleaching agent and the manufacturers instructions.

Instruct the patient to brush and rinse their teeth after meals. The guard should not be worn eating. Inform the patient about thermal sensitivity and minor irritation of soft tissues and to discontinue use of the guard if uncomfortable. Treatment may be carried out for 4 to 24 weeks. Recall the patient every 2 weeks to monitor stain lightening. Check for tissue irritation, oral lesions, enamel etching and leaky restorations. If complications occur, stop the treatment and reevaluate the feasibility of continuation at a later date. Rediscoloration with this technique is not more frequent than the other technique.

Adverse effects: Systemic effects: Controlled mouth guard bleaching is considered relatively safe. However, accidental ingestion of large amounts of these gels may be toxic and cause irritation to the gastric and respirator mucosa. Bleaching gels containing carbopol are usually more toxic. Therefore, it is advisable to pay specific attention to any adverse systemic effects and to discontinue treatment immediately if they occur. Dental hard tissue damage:- In vitro studies indicate morphologic and chemical changes in enamel, dentin and cementum associated with some agents used for mouth guard bleaching.

Tooth sensitivity: Transient tooth sensitivity to cold may occur during or after mouth guard bleaching. In most cases, it is mild and ceases on termination of treatment. Treatment for sensitivity consist of discontinue the use of mouth guard for few days or the reduction of wearing or the use of desensitizing agents. Mucosal damage:- Minor irritations or ulcerations of the oral mucosa have been reported to occur during the initial course of treatment. Possible causes are mechanical interference by the mouth guard, chemical irritation by the bleaching agent and allergic reactions to gel components. In most cases, readjustment and smoothing the borders of the guard will suffice. However, if tissue irritation persists, treatment should be discontinued.

Damage to restorations: Some in vitro studies suggest that damage of bleaching gels to composite resins may be caused by softening and cracking of the resin matrix. However, there are few other studies which did not find any significant adverse effects on either surface texture or colour of restorations. Generally, if composite restorations are present in esthetically critical areas, they may need replacement to improve colour matching following successful bleaching.

It has also been reported that both 10% carbamide peroxide and 10% hydrogen peroxide may enhance the liberation of mercury and silver from amalgam restorations and may increase exposure of patients to toxic byproducts. Coverage of the amalgam restorations with a protective layer of dental varnish prior to the bleaching gel application may prevent such hazards. Unpolished restorations corrode more.

Occlusal disturbances:- Typcially, occlusal problems related to the mouth guard may be mechanical or physiologic. From a mechanical point of view, the patient may occlude only on the posterior teeth rather than on all teeth simultaneously. Removing posterior teeth from the guard until all of the teeth are in contact rectifies the problem. From a physiologic point of view, if the patient experiences TMJ pain, the posterior teeth can be removed from the guard until only the anterior guidance remains. In such cases, wearing time should be reduced.

Studies have found that At-home bleaching for 2 weeks is more effective than in-office bleaching 3 times at 3 different appointments. Leonard et al. studied the desensitizing agent efficacy during whitening in an at-risk population and suggests that the use of an active 3% KNO3 and 0.11% F desensitizing agent for 30 min prior to whitening may decrease tooth sensitivity when compared with placebo in a population at risk for tooth sensitivity.

Gamze (2003) had suggested that 10 gm of Carbamide peroxide/ day can be considered as a safe dose for the prevention of systemic effects in a person / day can be considered as a safe dose for the prevention of systemic effects in a person of 70 kg wt.

Alternative Techniques: 1. Acid-pumice technique:

In this technique, 18% HCl is mixed with fine flour of pumice to make a thick paste. This paste is applied to the enamel surface with a piece of wooden tongue blade or crushed orange wood stick. Exerting firm pressure, the paste is worked into the enamel surface with a swirling motion for 5 seconds. The enamel surface is then rinsed for 10 seconds with water. The paste is re-applied until the desired lightening is achieved.

The thick paste of sodium bicarbonate and water are applied to neutralize the surface. Polish with a fine fluoride prophylaxis paste and superfine aluminium oxide composite resin polishing discs. Apply 1.1% neutral sodium fluoride gel for 4 min.

This technique can be used in combination with the night guard bleaching using lower concentration bleaching agents.

2. McInnes technique:This technique uses a combination of 5 parts of 30% H2O2, 5 parts of 36% HCl and 1 part of diethyl ether. The solution is applied directly to the stained areas for 1 to 2 minutes with cotton applicators. While the surface is wet, a fine cuttle disc is run over the stained surfaces for 15 seconds. This process is repeated until the desirable results are achieved, during subsequent appointments.

Macro abrasion: This technique can be combined with night guard vital bleaching to achieve better results. In this technique the severely dark stains are removed with diamond points, followed by finishing with carbide burs and polishing by using the composite polishing disc. Further lightening is achieved by night guard bleaching.

Over-the-counter: Many home bleaching products are available over the counter or through mail order, radio and television advertisements. This approach is not recommended as overuse and abuse are a concern. These systems include Tooth pastes AP-24, Rembrandt Mouth rinses Crest Tooth brushes Spine brush pro whitening Dental floss Super smile Teeth whitening strips Crest Chewing gums Brits smile, Happy dent Pain on varnish Vivastyle Brite smile stick or pen

Tooth brushes: Certain powered tooth brushes are available which are said to remove the extrinsic stains mechanically. E.g. Spin brush prowhitening. Paint on varnish:Applied with a brush. On application it contains 6% carbamide peroxide. Once, it is dried the concentration increases. Insoluble in saliva and remains on teeth for 20 min. subsequently removed with a tooth brush. Advantages:Can be applied exactly wherever it is needed. Contains D-panthenol Provitamin Noticeable after 7 days

Chewing gums: Brite smile, Happy dent Supersmile whitening floss: It is the worlds first floss treated with Calprox (not waxed) to safely whiten between teeth and baking soda for fresher breath. Removes stubborn stains and odour causing plaque under the gum. Calprox is a clinically proven whitening agent which gently dissolves the protein pellicle, removing stains and plaque in the process.

Boil and Bite:Boil a pot of water and then submerge the mouthpiece into it for 5 to 15 sec. Mouthpiece begin to wilt. Place the mouthpiece into the mouth and press against the front of your teeth with your fingers an the back of your teeth with your tongue. Let it cool. Remove the mouthpiece from the mouth and cut the handle. Squeeze whitening gel and place it for 1-3 hrs.

Tooth pastes: They contain enzymes that are thought to help to break down the organic protein components of the stains. E.g.Rembrandt whitening contaisn citroxain, derived from papaya Janina ultrawhite opal contains Bromelain, which is derived from Pineapple.

Tooth brush: It is clinically proven that it whitens the teeth in 14 days. Removes up to 88% of surface stains tobacco, wine, tea and coffee after 14 days of use. Increased bristle density, concave polishing strips and new cup shaped pattern designed to enhance the retention of dentifrice at the brush-tooth surface interface.