overview of in-office bleaching of vital teeth

Hegde Mithra N et al. IRJP 2012, 3 (11)
INTERNATIONAL RESEARCH JOURNAL OF PHARMACY
www.irjponline.com
ISSN 2230 – 8407
Review Article
OVERVIEW OF IN-OFFICE BLEACHING OF VITAL TEETH
Hegde Mithra N.*, Shetty Krishna R., Shetty Shishir
Department Of Conservative Dentistry and Endodontics, A.B. Shetty Memorial Institute of Dental Sciences, Nitte University,
Deralakatte, Mangalore – 575018, Karnataka, India
Article Received on: 04/09/12 Revised on: 09/10/12 Approved for publication: 08/11/12
*Email: mithra_hegde@yahoo.com
ABSTRACT
The importance of tooth whitening for patients has shown a dramatic increase in the number of products and procedures over recent years. Vital tooth
bleaching refers to chair-side clinical application of a chemical solution to a tooth surface in order to achieve whitening effect of the teeth. Vital bleaching
have found to be very effective but they also have their the drawbacks. The current article gives knowledge of vital tooth whitening with respect to external
bleaching methods. the external bleaching of vital teeth focuses on patient selection, mechanisms, bleaching procedure and various in-office bleaching
systems and techniques and their disadvantages
Keywords: Halogen light, Plasma arc light, Laser bleaching, Chemical Bleaching
INTRODUCTION
Tooth plays a major role in the beauty and personality of an
individual. Tooth whitening has become increasingly popular
and the desire for whither teeth has become global. With the
advantage of new materials and techniques, dentists can often
meet or even exceed the expectations of the patients. Color of
the tooth is of particular importance to the patient because of
social and psychological concern.
Chairside bleaching technique has always been a challenge as
the treatments results were uncomfortable for the patients due
to the lengthy time required for the process and also because
its effectiveness is not long term1. Yet, patients seek for
immediate results.
The benefit of chairside whitening procedures for the dental
office is that they can be implemented by auxiliary staff and
the average color change per appointment has been reported
to be 2.1 to 3.7 units on a 16-scale VITA Classic shade guide
(Vident)1,2. The demand for tooth whitening procedures is
high enough that, for most dentists, tooth whitening
procedures are a “must have” in their dental clinic.
DETERMINING
THE
ETIOLOGY
OF
DISCOLOURATION
Most discoloration falls primarily into one of three
categories. The most common staining is
• Extrinsic stains are superficial, resulting from excessive use
of food substances such as coffee, tea, highly colored food or
tobacco3.
• Intrinsic stains are discolorations of the tooth structure that
may occur due to ingestion of certain drugs, excessive
exposure to fluids, or exposure to dental restorative
materials4.
• Age related discoloration usually results from a
combination of extrinsic staining thinned enamel and
darkened dentin4.
Colours produced by various causes of tooth discoloration
T ypes of di scol orat i on
Extrinsic stains
Plaque/poor oral hygiene
Tea, coffee and other foods
Chlorhexidine Mouthwash
Cigarettes/cigars
Intrinsic Stains
Fluorosis
Tetracycline medication
Amelogenisis and Dentinogenesis imperfecta
Stains due to trauma
Pulpal haemorrhage products
Aging
Internalized Caries
Restorations
PATIENT SELECTION
Di a gn osi s of t h e et i ol og y of t oot h di scol or a t i on
pl a ys a m a jor r ol e i n th e succe ss of a n y t oot h
bl ea ch in g. It a l so d epen ds on t h e c on di t i on s of
t h e t eet h l i ke
·
Decay, Size and vitality of the pulp to predict sensitivity
levels and even presence of any periapical pathology5 and
personal factors like
· The
in di vi dua l
pa t i ent ’s
desi r es
and
expe ct a t i on s a bout t h e est h et i c out c om e
Color produced
Yellow/ brown
Brown to black
Black and brown
Yellow/ brown to black
White, yellow, grey or black
Brown and black banding appearance
Brown and black
Pink spot
Yellow
Orange to brown
Grey and black
· Wi l l in gn ess t o sp en d t i m e in th e den t al cha ir
a n d or t o co- op er a t e a t h om e; an d
· Ac cept a n ce of r esp on si bi l i t y t o m odi fy
beh a vi or th a t ca n a ffect t oot h col or a t i on 6 .
THE BLEACHING MATERIALS
T h er e h a ve be en n um er ous ch a n ges t o m a t er i a ls
si n ce h om e bl ea ch in g m a t er i a l s wer e i ntr oduc ed.
Fi r st gen er a t i on m a t er i al s wer e i n li qui d for m .
T h ese m a t er ia l s di d n ot r em a in in tr a ys for a l ong
t i m e. E g. Gl yoxi de 7 .
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Hegde Mithra N et al. IRJP 2012, 3 (11)
Se c on d gen era t i on m at er i al s ar e curr ent ly
a va i l a bl e wh i ch a r e m or e vi s c ous a n d in gel
for m . Th i s i s t o st op m a t er i a l s l ea ch in g out of
t ra y a n d ca usi n g soft t i ssu e i r r it a ti on E g.
Pr ox yg el 7 .
T hir d gen era t i on di ffer s i n t h eir veh i cl e a nd
c ol or .
Consti t ue nt s of B l e ac hi ng 8 , 9
· Ca r ba m i de per oxi de -10% - 35%
· Hydr og en per oxi de a n d sodi um h ydr oxi de – 10
– 50%
· Non - h ydr og en per oxi de con t a i nin g m a t er i a l s
i . e. sodi um per bor a t e
· T hi cken in g a gent ca r bop ol or pol yx- h el ps i n
sl ow r el ea s e of ox yg en m ol ecul e s fr om gel s
a n d pr ol on gs t h e a ct i on of t h e bl ea ch i n g
m a t eri a l.
· Ur ea -i t s us ed t o st a bi l i z e h ydr og en per oxi de
a n d el eva t e t h e ph of s ol ut i on
· Veh i cl e(
gl yc er i n,
den t i fr i ce,
gl yc ol )en han ces vi sc osi t y of t h e bl ea ch i n g gel
· Sur fa ct a n t - enh an ce wet t i n g a bi l i t y a n d
pen et r at i on of h ydr ogen per oxi de i n t o th e
t oot h
· Pr eser va t i ves- gi ve s bl ea ch in g m a t eri a l bet t er
st a bi l i t y a n d dura bi l i t y
· Fl a vor i ngs- t o enh an ce pa t i en t a ccept a bi l i t y
r ecen t
pr oduct s
to
r educ e
· Fl uor i de(i n
sen si t i vi t y)
MECHANISM OF BLEACHING
Mechanism of whitening by oxidizing agents is not actually
understood. Th e t ech ni que wor ks by l i gh t enin g t he
en a m el t o gi ve t h e a ppear an ce of wh i t en ess.
On e t h eor y st a t es t h a t th e l ar ge c ol or ed or ga n ic
m ol e cul es r esp on si bl e for t h e st a i n s ar e r educe d
t o sm a l l er , l ess n ot i cea bl e m ol e cul es by t h e
oxi da t i on pr oce ss. T h e h ydr ogen per oxi d e a ct s
bot h a s an ox yg en a t or a s wel l a s oxi da n t 1 0 , 1 1 .
An ot h er th eor y i s t h a t th e per oxi de pen et r a t es
i nt o en a m el an d den t in e a n d oxi di z es t oot h
di sc ol or a t i on s. Th e pa ssa ge of n a sc en t ox yge n
i nt o t h e t oot h st r uct ur e oc cur s fi r st i n en am el and
t h en in den tin e 1 1 , 1 2 .
B LEACH ING PRO CEDURE
· Pa t i en t
is
a ssess ed
cl i n i ca l l y
and
r a di ogr a ph i ca l l y
· Shade assessment with the teeth being wet and dry
· Pr oposed t r ea t m en t pl annin g i s don e
· Pr e oper a t i ve ph ot ogr a ph s of t e et h ar e ta ken
· Isolation: there are many forms of isolation that can be
used, depending on the type of bleaching procedure used,
or the dentist's particular preference.
- Rubber dam is a good method of isolation . Ligation
of the teeth are done with waxed dental floss to prevent
seepage of the fizzing hydrogen peroxide solution through
to the underlying tissues
- Opal dam (Ultradent Products, South Jordan, Utah,
USA). These are light cured resin barrier materials that
are painted on to the gingiva around and in between the
teeth to be bleached.
· Soft tissue retraction:
-Cheek and lip retractors are placed to pull these
tissues away from the teeth and bleaching gel.
-NOLA Full Arch isolation (NOLA Full Arch
isolation, Orthocare-UK) within built suction facility
· Tongue guard to prevent the forward movementof the
tongue on to the teeth and bleaching gel.
· Gauze and cotton wool rolls placed inside the lips and
cheeks to keep them away from the gel
· T eet h ar e cl ea n ed wi t h pum i ce pr oph yl a xi s
pa st e
· Bl ea ch in g m at er ia l i s n ow a ppl i ed t o t h e t e et h .
2–3 mm layer of freshly mixed gel should be applied to
all the labial surfaces of teeth in the smile zone and lipped
over to cover the incisal edge, smile zone varies from
patient to patients but is commonly from the first or
second premolar
· Activation with or without a light source depends on the
bleaching system used
-If Light is used they are applied close to the teeth
- If laser is used Gel is placed at a thickness of 1-2 mm on to
the buccal surface of the teeth to be bleached laser light is
applied for 30 seconds about 1-2 cm from the buccal surface
of each tooth. Laser light is applied slowly for 30 seconds
and moved from right to left over the tooth’s surface.
-If pl a sm a ar c l i ght i s used, th e l i gh t i s a ppl i ed
6-7 m m a wa y fr om t h e gel . It em i t s 3 s e c on ds
bur st s of l i gh t, wh i ch i s a ppli ed on t o ea ch t oot h
i n t urn . Th i s i s gen er a ll y c on t in ued for a per i od
of t hr ee, 3-m in ut e in t er va l (depen di n g on
i n str uct i on s) or 10-15 m i n ut es, a n d th e bl ea ch i s
r em oved fr om th e t eet h vi a th e h i gh vol um e
a spi ra t or .
· The gel is left in place for a length of time dependent on
the system and concentration of hydrogen peroxide used,
usually about 10 minutes, but can range from 3–20
minutes at a time10.
· T eet h ar e th en wa sh ed, an d th e bl ea ch i s
r ea ppl i ed for a fur th er 10 m in ut es a n d th e
pr oce ss i s r epea t ed for 45 m in ut es t o 1 h our .
· T eet h a r e pol i sh ed wi t h di a m on d pol i sh in g
pa st e or a l umin um oxi de di sc s.
· Da m i s t h en r em oved. M out h i s r i n sed a n d
sh a de of t h e t eet h i s n ow a ss es sed. A
post op er a t i ve ph ot ogr a ph can be t a ken .
· Application of a neutral colourless fluoride gel may help
in cases where there was sensitivity experienced during
the procedure7,13.
· Pa t i en t i s ca l l ed 3-6 week s l a t er an d th i s
pr oce ss ca n be r epea t ed i n 6 we eks i n cr em en t
un ti l th e desi r ed sh a de i s a ch i eved.
· Patients should be given postoperative instructions:
Use of a fluoride gel or potassium nitrate containing
toothpaste in cases that experience thermal sensitivity.
Dietary advice to avoid acidic drinks, fruits, tea, coffee and
smoking for 48 hours. It is thought that the oxidizing free
radicals are still active within the teeth for a further 48 hours
post bleaching
Shade regression of about half a shade unit tends to occur
about a week to ten days post bleaching. Patients should be
made aware of this to avoid disappointment.
· Top up home bleaching kits should be given to those
cases that require further bleaching.
CHAIRSIDE BLEACHING SYSTEMS
Curing Lights
Different types of curing lights are used for the activation of
the bleaching gel. Initially, it was the conventional curing
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Hegde Mithra N et al. IRJP 2012, 3 (11)
lights but then these were quickly joined by lasers and plasma
arc lamps. In addition others utilize a dual activation system.
H al oge n Li ght
Curing lights system has been widely used in dentistry for
bleaching. This in-office bleaching system is a xenonhalogen bleaching light that launch a blue-green coloration.
Halogen light bleaching system uses 35% Hydrogen
Peroxide that contains carotene that converts light energy to
heat and therefore increases the activation of the hydrogen
peroxide based bleaching compound with a pH of 5.535.
Each bleaching session in-office is broken down into three
individual applications, with the duration of each application
being 8 minutes. It means that the cumulative exposure to the
gel is 24 minutes to delivers 2 - 4 shades 14,15,,35.
Metal Halide Lamp
Metal halide light produced from fired up mercury atoms to
activate and boost the teeth whitening solution. It is
incorporated with an IR (infra-red) filter and emits
insignificant amounts of UV(ultra-violet) emissions to
minimize heat at the surface of the tooth. Its makes use of
specific peroxide-based gel and it is provided an activator34.
These two resources are combined together during the
whitening procedure creating whitening gel that is very basic
(features a pH range that's usually somewhere between 7.5
and 8.5) and is 25% hydrogen peroxide. This technique
employs three 20-minute passes followed by the application
of sodium fluoride gel15,22.
Plasma Arc Lamp
Plasma is the fourth state of matter, Pl a sm a ar c l amp
wa s i n tr oduc ed i n 1993; it consists of charged particles,
radicals, and a strong electric field. Plasma has potential
biomedical applications because it is non thermal and
nontoxic and can be realized in a simple hand-held device .
Furthermore, it also generates energetic ions, free electrons,
and hydroxyl radicals (.OH) that contribute significantly to
tooth bleaching, so that plasma might have a synergic effect
on tooth bleaching by H2O216.
Tooth bleaching method with plasma that we can be
complementary to the conventional method because it
provides effective bleaching without thermal damage
Gas Plasma Light
Gas plasma light system which consists of a lamp filtered to
emit light in the blue-green region of the spectrum
(approximately 400-500 nanometers) and a patented delivery
device, which illuminates all smile teeth at once 15,17.
The Gas Plasma Light is used in combination with a patented
peroxide gel, which has been optimized to obtain a maximal
whitening effect and to ensure patient safety 10,17.
The patented chemistry consists of a 15% hydrogen peroxide
gel buffered at an approximately neutral pH that is
compatible with tooth enamel. The gel also contains other
ingredients such as glycerine and highly purified water to
prevent tooth dehydration and to further ensure safety. The
gel also contains a patented photo-initiator, which assists in
chromophore destruction at the tooth's surface17,18. The
plasma light technique consists of two 20 mins cycle.
A study by the prestigious Forsyth Institute also confirmed
the 9+ shades average improvement achieved using the
BriteSmile process17.
Plasma Arc Light Source
The plasma arc light employs a hydrogen peroxide-based
bleaching gel and has a 25% Hydrogen Peroxide, a pH of 8.5.
The higher doses of peroxide make the mix stronger, and
better able to remove stuck-on stains, like coffee, tea or
cigarettes19,22. The plasma arc light system consists of one 30
mins cycle, after the 1st cycle within results are evaluated and
it is determined if 2nd 30 mins cycle is necessary.
Che mi c al Ac ti vate d B le ac hi ng
Chemically-activated in office bleaching agent. Its based on
38% hydrogen peroxide two part gel system21.
It consists of one syringe, containing hydrogen peroxide,
which is mixed with the second syringe and is chemically
activated, activation is due to a unique proprietary activator
that increases the pH to 7 for maximum activation. When
mixed together, the bleaching agent is supercharged that does
not require light or laser activation22,35.
Teeth typically become at least 6 - 10 shades whiter.
Chemically-activated in office bleaching technique consists
of 3 cycles of 10-15 mins each.
Lase r B l e ac hi ng Tec hni q ue
T h e wor d “l a ser ” i s an a cr on ym for l i ght
a m pl i fi ca t i on
by
st i m ul a t ed
em i ssi on
of
r a di a t i on.
La ser bl ea ch i n g offi ci a l l y st a r t ed in 1996 wi t h
t h e a ppr ova l of Ion La ser T ech n ol og y’s a r gon
a n d car bon di oxi de l a ser s by t h e FDA. T h er e i s
l i t t l e dat a t o pr ove t h a t l a ser s ar e m or e effe ct i ve
t han th e tra di t i ona l bl ea ch in g m et h ods.
· Ca r bon di oxi de (10600 nm )
· Nd: YAG
· E r cr : YSGG
· Ar gon (515 n m )
· Di od e (980 nm )
· KT P (532 n m )
· Com bi n a ti on s
These units create output that lies in the near-infrared portion
of the spectrum (In comparison, most bleaching units
primarily emit visible light).The use of one these lasers is that
their output (a specific wavelength) "activates" a catalyst
within the whitener that, in turn, increases its effectivenes20.
Laser Whitening Gel is a unique mix of laser activated
Crystals integrated into a gel of highly processed Fumed
Silica and 35% Hydrogen Peroxide20,36.
This translucent, semi-viscous bleaching gel is applied to the
teeth and a high intensity light source (laser light) is used to
activate the Crystals to absorb the thermal energy from the
light and allowing better disassociation of the oxygen to
better penetrate the enamel matrix and increase the lightening
effect on the teeth20.
In this system Gel is laser-activated in 15-second intervals
and repeated as necessary. The laser can be exposed to a few
teeth at a time.
The effect of shade change of chemical oxidation, Light
Activation and Laser technique are the same but the
bleaching time required for Laser system is comparatively
lesser compared to the other two systems and there is no
effect on the longevity of the process of bleaching35.
BLEACHING TECHNIQUES
Wai ti ng Room B l e ac hi ng Tec hni que
In th i s t echn i que 35% car ba m i de per oxi de ( wh i ch
br ea ks down t o 10% h ydr ogen per oxi de) i s use d
a s a bl ea ch i n g a gen t. Th e t eet h ar e pol i sh ed wi t h
pr oph yl a xi s pa st e. T h e 35% ca r ba m i de per oxi de
i s h ea t ed gen t l y by h ol di n g th e s yr i n ge un der h ot
r unn in g wa t er for 2-3 m i n ut es. Hea t of t h e
s yr i n ge a ccel er a t es t h e a ct i vi t y of t h e m a t er ial
be for e i t i s l oa ded i n t o t h e m out h gua r d. The
35% ca r ba m i de per oxi de i s pl a c ed i n t o a cu st om
m a de bl ea ch i n g tr a y 6 .
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Hegde Mithra N et al. IRJP 2012, 3 (11)
Aft er exc ess m a t er i a l i s r em oved, t h e pa t i en t is
sea t ed i n th e wa i t i n g r oom for a per i od of a bou t
30 m in ut es wi t h th e bl ea ch i n g tra y i n th e m out h.
Aft er 30 min ut es, bl ea ch i s suct i on ed off t h e
t eet h be for e r i n sin g 6 .
Th i s pr ocedur e ca n be
r epea t ed 2-3 in a sin gl e sessi on .
Compr e s si ve B l e ac hi ng Te c hni que
Mi a ra (2000) suggest ed t h a t th e power bl ea ch i ng
t ech n i que coul d be m a de m or e e ffe ct i ve by
c om pr essi n g th e bl ea ch i n g ma t eri a l on th e t oot h .
In th i s t echn i que n a cen t ox yg en m ust be gui de d
un der pr essur e for per m ea t i on of t h e oxi di z ing
i on s t hr ough th e en am el . It s r ecom m en ds t o u s e
35% h ydr og en Per oxi de i n a bl ea ch i n g tr a y,
sea l i n g th e tra y edge s wi t h li gh t cur ed r esi n to
pr even t da m a ge t o th e soft t i ssu es 2 0 . Th e gel i s
ei t h er a ct i va t ed by h a l ogen l i gh t or pla sm a a rc
l i gh t .
T hi s i s a r el a ti vel y n e w t e ch n i que an d is
un der goin g cl i n i ca l eva l ua t i on . On e of t h e m a j or
c on cer n s a bout t h i s t ech n i que i s probable penetration
of hydrogen peroxide into the pulp chamber after only 15–20
minutes24.
D ual Ac ti vate d Te c hni q ue
T h e in -offi c e bl ea ch i n g syst em i s a ct i va t i on by
c om bi n a t i on of
bot h
l i gh t an d ch em i cal
a ct i va t i on . It con si st s of fer r ous sul ph a t e, wh i ch
ser ves a s a ch em i ca l a ct i va t or th at com pl et es t h e
bl ea ch in g pr oces s i n 7-9 m in ut es 2 5 . In a ddi t i on,
the
for m ul at i on
a l so
i n cl udes
m a n gan es e
sul ph a t e, wh i ch i s l i gh t a ct i va t ed a n d ca n
a cc el er a t e t h e bl ea ch i n g pr oc ess t o a s l i t t l e a s 24 m in ut es. Thi s t echn i que uses h ydr oge n
per oxi de i n a str on g con cen t ra t i on of 19-35% 2 5 .
Act i va t i on t im e
Ch em i ca l a ct i va t i on : a ppr ox. 15-20 m in s
Li gh t a ct i va t i on : 8-10 m in s
DISADVANTAGE OF VITAL TOOTH BLEACHING
- Because of the causative nature of the bleaching agent
isolation is necessary.
- Dehydration of the teeth causes a falsified lighter shade
immediately post bleaching procedure26.
- The bleaching procedure is can work out expensive for the
patient.
EFFECTS OF BLEACHING AGENT
Dental tissue and Oral mucosa
Whitening effects of hydrogen peroxide on teeth and oral
mucosa have been documented. Number of cases show
undesirable effects such as hypersensitivity (2.62–3.38%) and
gingival irritation (0.23–0.85%) have been reported27.
Changes are also seen in enamel microhardness,
micromorphological defects due to demineralization, and
effects on restorative materials have also been reported 28,29,30.
Tooth se n si ti vi ty
T oot h sen si t i vi t y i s a com m on si de-e ffe ct of
ext er n al t oot h bl ea ch in g. Dat a fr om va r i ous
st udi es of 10% ca r ba m i de per oxi de i n di ca t e t hat
fr om 15 t o 65% of t h e pa t i en t s r epor t ed i n cr ea sed
t oot h sen si t i vi t y 3 1 .
Hi gh er i n ci den ce of t oot h sen si t i vi t y ( fr om 67 t o
78%) wa s r epor t ed a ft er in -offi c e bl ea ch i n g wi t h
h ydr og en per oxi de i n c om bi n a t i on wi th h ea t.
T oot h sen si t i vi t y n or m a l l y p er si st s for up t o 4
da ys a ft er th e ces sa t i on of bl ea ch in g tr ea tm en t,
but a l on ger dur a ti on of up t o 39 da ys h a s bee n
r epor t ed 3 2 , 3 3 .
T oot h sen si t i vi t y wa s a l s o a c om m on s ym pt om i n
pa t i en t s wh o ha d n ot bl ea ch ed t h ei r t eet h , and
t h eir s ym pt om wa s c or r el at ed wi t h gi ngi val
r e c e ssi on 3 4 . Pa t i en t s wi t h a pr evi ous h i st or y of
t oot h sen si t i vi t y m a y t h us h a ve a h i gh er r i sk for
such a n a dver se e ffect fr om ext er n al t oot h
bl ea ch in g, an d th i s sh oul d be t a k en in t o a cc oun t
be for e t r ea tm en t begi n s.
CO NCLUSIO N
In office bleaching techniques are used in patient who seek
immediate results and do not wish to spend more time on
achieving results from home bleaching systems. Owing to the
caustic nature of the 35% hydrogen peroxide meticulous care
should be on performing bleaching.
For better effect of bleaching more than one visit would be
required, the results vary from patient to patient for many one
visit would be enough to satisfy the aesthetic needs of the
patients and a second visit wouldn’t be necessary
In office techniques with easier and simpler isolation
methods and improved bleaching gels and improved
whitening lights have made bleaching results very efficient
.Improved bleaching materials and technique, as described
above, result in less sensitivity and better.
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Source of support: Nil, Conflict of interest: None Declared
IRJP is an official publication of Moksha Publishing House. Website: www.mokshaph.com. All rights reserved.
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