After reading this article the reader will be able to:
List the different types of vital tooth bleaching systems that are professionally dispensed;
List the esthetic conditions that can be treated with vital tooth bleaching;
Describe the adverse reactions that have been associated with vital tooth bleaching;
Describe at least three different ways to manage bleaching related tooth hypersensitivity;
Describe how to manage bleaching relapse.
The patients coming into dental offices today are better educated than in the past. Our patients to understand what dentistry has to offer because television and the print media have had news stories, reality shows and articles that have provided our patients with insights on the latest advances and research in dentistry including periodontal disease and its implications with heart disease, lasers, CAD-CAM, implants, white fillings, porcelain veneers and tooth whitening among others. Also, the internet provides patients with access to information on the advances in dental treatment.
Esthetic dentistry is a major area that our patients are requesting more information about. The types of dental treatments that enhance personal appearances have increased over recent years. With the increase in patient awareness of the ability to improve their smiles as presented on national television, in advertisements and articles patients have accepted and like the concept that they can change the appearance of their smiles with only a few visits to the dentist. Esthetic dentistry is elective. Patients no longer need to be dissatisfied with the appearance of their smiles. Esthetic restorative dentistry includes many treatment modalities to change the appearance of teeth. These treatments range from the routine placement of composite resin res- torations, porcelain veneers, tooth whitening, all-ceramic full and partial coverage restorations, porcelain-metal restorations, implants, and removable prosthetic restorations. With the increased knowledge and interest by patients in having the appearance of their teeth changed with esthetic dentistry, the more conservative technique of tooth whitening with vital bleaching has gained wider acceptance.
Tooth whitening refers to any procedure that changes the shade and appearance of teeth without the use of restorative materials. Tooth whitening can include professionally dispensed products and over-the-counter (OTC) patient purchased products. To patients tooth whitening includes whitening toothpastes, OTC bleaching products, routine dental prophylaxis, professionally dispensed vital bleaching products, non-vital tooth bleaching and even denture cleaners. Bleaching can be used as a treatment for teeth that are discolored due to intrinsic and extrinsic staining. Examples of intrinsic staining are endodontic staining, tetracycline induced discoloration. Extrinsic staining of the enamel include fluorosis, yellowing due to aging, hypoplastic enamel, caries demineralization, and staining of teeth due to smoking, ingested food and beverages Caries can be both intrinsic and extrinsic staining of tooth structure.
Professionally dispensed vital tooth bleaching refers to the materials, techniques and devices used for vital bleaching that are dispensed in the dental office. In recent years patients have had increased interest in the use of bleaching for treatment of discolored teeth. Bleaching, especially at-home bleaching, has been of interest to dentist and patient alike because it is the most conservative, non-invasive treatment modality currently available to the dental clinician to change the appearance of teeth. Bleaching is usually used to lighten the shade of teeth that are darkened due to intrinsic and extrinsic discolorations. These techniques can include a variety of concentrations of hydrogen and carbamide peroxide, in-office techniques with and without light or heat enhancement, professionally dispensed whitening strips, and tray bleaching. This article will review the different types of systems, indications and contraindications for vital tooth bleaching and some of the reported adverse effects.
The first reports of tooth bleaching were as early as 1877.1 The acceptance of tooth bleaching as a non-invasive, conservative treatment for discolored teeth has only gained increasing acceptance of the past 30 years using heated, high concentrations of hydrogen peroxide. 2,3 The clinical reports using in most cases, special heat lamps mounted at chairside with the application of the dental dam as a barrier to protect the gingival tissues from the high concentration, heated hydrogen peroxide required the need for multiple office visits (five to seven) and chairtime (at least one hour per visit) to attain an acceptable tooth whitening result. Among the adverse reactions reported were tooth hypersensitivity and soft tissue irritation due to the high concentration of hydrogen peroxide seeping under the dental dam.
The desire to have less complex tooth bleaching procedures led to investigations into other types of delivery systems and chemistries to achieve vital bleaching. In 1989, a technique using an athome mouthguard (tray) with an OTC 10% carbamide peroxide that was used for the treatment of gingivitis was described as successfully whitening teeth. 3 This initial report was followed by the introduction of technique specific carbamide peroxide gels for vital tooth whitening for use in mouthguards. As with any new procedure presented to the dental profession, there were concerns about the safety, efficacy and longevity of these bleaching techniques with peroxide materials. Both the the United States Food and Drug Administration and the dental profession raised these issues. 4-6
Research to answer many of the concerns expressed about professionally dispensed bleaching peroxides have adequately addressed these concerns and have demonstrated safety and effectiveness of tooth whitening with peroxide products. 7-10 By 1995, a survey of 8,143 dentists reported that 91% provided vital tooth bleaching in their dental practices. 11 Seventynine percent of these dentists reported success with tooth whitening. Among the side effects reported by the respondents were the following: 62.2% noted tooth sensitivity 10.7% of the time; 45.9% reported soft tissue irritation 5.6% of the time, 2.1% noted systemic effects 0.2% of the time, and 18.8% reported no side effects.
Vital tooth bleaching has become a well accepted and successful procedure in dental practices. Vital bleaching with peroxides using a tray is the most pop- ular. In recent years a number of manufacturers have introduced light-enhanced tooth bleaching products with devices to provide for this light enhancement combined with higher concentration peroxides for in-office use. The availability of OTC tooth whitening products to our patients has also increased significantly in the past decade.
During the early introduction of tray (mouthguard) vital bleaching with carbamide and hydrogen peroxide bleaching agents, studies have demonstrated efficacy and safety with these agents. In all cases, the agents evaluated lightened the color of the teeth safely and effectively with minimal, transient adverse reactions reported. When the bleaching procedure was completed, these adverse reactions that were reported during treatment were no longer present. These adverse reactions will be covered later in this article.
With the increased acceptance by the dental profession of vital tooth bleaching and tooth whitening with other products, the American Dental Association issued a report in 1994 and revised in 1998 on the guidelines for safety and efficacy criteria for peroxide containing products to include their use for tooth bleaching. Any product that meets these criteria could receive the American Dental Association Seal of Acceptance. To receive the seal, a company would have to submit safety studies and two clinical trials that demonstrate at least two value oriented shade increments of change when the bleaching recommendations are followed. To date the majority of bleaching products to obtain the seal are 10% carbamide peroxide gels to be used with a tray delivery.
The original concept of professional vital bleaching started with well fitted custom made trays from patient impressions and casts as vehicles to hold a 10% carbamide peroxide gel. Today the clinician has many choices for providing patients with at-home tooth bleaching materials and techniques. These include a variety of different types of tray and trayless systems that provide for the delivery of either hydrogen or carbamide peroxide in a wide range of concentrations. When comparing the chemical concentration of hydrogen peroxide to carbamide peroxide an approximate formula ratio to use is that 3% hydrogen peroxide is approximately equivalent to 10% carbamide peroxide.
In the past decade a number of different peroxide bleaching products have been introduced for professional dispensing. There have been modifications in the chemistry to make the available peroxide longer lasting for overnight tray bleaching. The addition of a carbopol to carbamide peroxide vital tooth bleaching gels extend the bleaching potential of the gel over as long as eight hours. This allows the clinician to make the recommendation to patients that a tray with a carbamide bleaching gel can be worn overnight.
This is not true of hydrogen peroxide based vital tooth bleaching products. Hydrogen peroxide will lose more than 50% of its bleaching potential within 30 minutes. This chemical degradation over 30 minutes is responsible for the recommendation of trayless strip technology, e. g., Crest Whitestrips, that a strip be worn for only 30 minutes at a time. Also, most manufacturers have made available a range of higher concentrations of peroxides both carbamide peroxide and hydrogen peroxide to decrease the wear time of the tray and/or decrease the time necessary to achieve the final whitening result. Higher concentration hydrogen peroxides (25%-35%) are used for in-office bleaching with and without light and heat enhancement.
In recent years, manufacturers have developed novel, trayless methods using plastic strips that release stored hydrogen peroxide for bleaching teeth. The first product introduced professionally was Crest Whitestrips (Procter and Gamble) for in-office dispensing. Later Whitestrips were made available over-the-counter. Strips for whitening teeth usually extend from canine to canine the maxillary and mandibular arches. They also work best when the teeth are well-aligned. Professionally dispensed Whitestrips are a higher concentration than OTC Whitestrips. There are many OTC products for whitening teeth. This article will be limited to in-office treatment.
PATIENT SELECTION FOR VITAL TOOTH BLEACHING
When treatment planning for successful esthetic treatment for tooth discolorations it is important to select patients with conditions that have the best prognosis for success with bleaching. Key factors that have an effect on the final result after bleaching include concentration of the bleaching agent, duration of use of the bleaching agent, type of tooth discoloration, color of the teeth and patient's age. It has been report- ed that tooth discolorations with the best prognosis for whitening are yellowing of the teeth without any systemic or developmental cause (food, smoking, aging staining); mild flourosis staining; mild tooth darkening due to trauma; mild tetracycline staining. 16,17
It has been reported that moderate to severe tetracycline discoloration can be lightened in shade with overnight use of a vital mouthguard bleaching over a period of six months. 22
Many dentists are using vital tooth bleaching as an adjunct to their esthetic bonding procedures. For patients dissatisfied with tooth malposition and shape combined with discolorations, lightening the shade of teeth first with bleaching makes masking tooth discolorations less difficult. It is important that before any bonding procedure that bleaching be discontinued for at least one week before the restorative treatment to prevent interference with bonding adhesion and material setting. 23-26
AT-HOME TRAY BLEACHING
When professional vital tooth bleaching using trays for at-home use was first introduced to the profession, there were concerns over adverse reactions and patient complaints. The adverse reactions and patient complaints included taste of bleaching gel, gingival irritation, uneven tooth bleaching, a splotchy appearance of the teeth during the initial stages of bleaching and tooth hypersensitivity while bleaching. These issues have been investigated and research has provided a better understanding. In response, manufacturers of tooth bleaching products have made changes in technique recommendations and product components to address these issues. Clinician and patient complaints concerning issues of taste have been addressed with an expanded selection of better flavors for improved patient acceptance.
Gingival irritation has been seen with trays that were poorly fabricated either due to inaccuracy of casts or due to the need for scalloping the tray for higher concentrations of hydrogen and carbamide peroxide bleaching gels. 27 During the initial bleaching, especially with higher concentrations of tray bleaching gels, patients have reported a splotchy appearance of the teeth during the first week. 27 This uneven coloration of the teeth being bleached disappears after the first week of bleaching.
Tooth sensitivity during bleaching has been the highest reported adverse reaction. In clinical research studies tooth sensitivity during bleaching, either with at-home tray delivery and in-office procedures has been reported in a range of 18%-78% of patients. 28-30 The sensitivity due to tooth bleaching in clinical observations suggest that it is transient with no long term effects. 31 Some clinicians believed that this transient sensitivity was due to gingival recession. It has been shown that gingival recession is not a factor in the occurrence of tooth hypersensitivity when bleaching. 32 There was no significant difference in reported sensitivity while bleaching based upon the presence or absence of gingival recession.
To minimize tooth sensitivity during vital tooth bleaching, the clinician can recommend the patient decrease time the tray is worn the first week to no more than an hour a day for carbamide peroxide products or for higher concentration hydrogen peroxides as little as 15 minutes a day or use lower concentrations of peroxide.
A 5% potassium nitrate (KNO3) formulation has been shown to be an effective desensitizer in toothpastes. 33,34 Noting this a number of manufacturers have added a 5% KNO3 desensitizing agents to their bleaching gels. The addition of KNO3 to a bleaching gel fails to account for the fact that the desensitizing effect of KNO3 is use to extended use. 28,35 Two effect strategies using a KNO3 desensitizing toothpaste that have been clini- cally evaluated are brushing with the desensitizing toothpaste for two weeks prior to initiating bleaching 23 and having the patient place a sensitivity toothpaste containing a 5% KNO3 one week prior to the initiation of bleaching in the tray that will be used for bleaching for 30 minutes a day. 36
Both of these strategies take into account the mechanism for desensitizing that KNO3 provides. Another strategy is to have a patient use a professionally dispensed desensitizing gel with 5% KNO3 for use with bleaching. 37 Amorphous calcium phosphate (ACP) has been shown to be an effective desensitizer. 38,39 Recent research has shown that a paste (Prospec MI Paste, GC America) containing Recaldent®, a casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), has been effective in reducing tooth sensitivity due to bleaching. 36,40 One manufacturer, Discus Dental, has introduced bleaching products that contain ACP. A research study evaluating these ACP containing bleaching gels demonstrated that ACP could be added to a 16 percent carbamide peroxide bleaching gel with significant reduction in clinical measures of dentinal hypersensitivity both during and after treatment. 41
Over the years there has been controversy about what tray is best. When tray bleaching was introduced, the trays were fabricated from thin and thick flexible vacuum forming materials and thin rigid plastic materials. Some manufacturers created a foam lined tray believing it would hold the bleach on the teeth more effectively. From the current research that has evaluated a wide variety of tray configurations and types, and duration of wearing the tray, one can conclude the following:
• Thin flexible vacuum formed materials are the standard;
• The use of spacers on the stone model to create reservoirs is not necessary but the use of reservoirs will lead to the patient swallowing less of the bleaching gel;42,43
• Scalloping the tray to follow the gingival contours is not necessary when using a 10% carbamide peroxide but should be done for higher concentrations of carbamide peroxide or hydrogen peroxide equivalents.
Over-trimming the tray leaving a portion of the tooth uncovered is not a problem because the bleach will penetrate beyond the tray;
• Custom fitted trays provide improved bleaching gel-tooth contact;
• Most companies provide bleaching gel for a two week time of application;
• Higher concentrations of carbamide peroxide bleach worn in a tray show faster initial improvements, but over a six week period of time comparing 10% carbamide peroxide to higher concentrations there is no difference in the final result;
• The concept of teeth lightening to a final certain level has been termed as the "inherent lightness potential" of a tooth; there is an endpoint to how much lighter teeth will get;
• In most cases moderate and dark tetracycline staining can be treated with bleaching over an extended time of 3-6 months;
• Concern over the effectiveness of the bleaching potential with overnight wearing of a tray has
been addressed; wearing a tray overnight with a bleaching gel has demonstrated a degradation in peroxide concentration over time but that the bleaching agent is still effective. Hydrogen peroxide has a greater than 50% degradation within 30 minutes while carbamide peroxide bleaching gels can be used overnight;
• 10% at-home carbamide peroxide bleaching gels are clinically safe when exposed to enamel, dentin, root surfaces, ceramics, cast metal and composite resins; there is one case report of greening of amalgam during bleaching.
At-home tray bleaching requires a number of steps for success to include accurate study casts that need to be trimmed to allow for a vacuum down thin flexible mouthguard to be fabricated. When doing tray bleaching it is important that the casts be inspected to be certain there were no irregularities, bubbles, or distortions. For tray fabrication, stone casts should be trimmed leaving a minimal base to assure an accurate adaptation of the thin, soft vinyl mouthguard/ tray material.
Using a vacuum unit, the bleaching tray can be fabricated using 0.040 inch thick, 5" x 5" clear ethyl vinyl acetate sheets. One excellent vacuum unit is the Sta-Vac II unit from Buffalo Dental. It is a workhorse vacuum unit to fabricate bleaching trays, athletic mouthguards, templates for implants, orthodontic retainers among others. Once the tray is vacuumed on the cast, it can be easily trimmed on the cast using a Tray Magic (Premier Dental Products) electric, soft tray trimmer to leave a scalloped tray that follows the free margin of the gingival on both the facial and lingual surfaces leaving all the gingival tissues uncovered by the tray (Fig. 1).
By trimming the tray on the cast, there is less concern about distortion that occurs when trimming with a scissor. The trays should be free of loose plastic tags. Scalloping of the tray is especially important with any of the higher concentration bleaching gels. The bleaching tray when using concentrations of 10% carbamide peroxide can be trimmed leaving a 0.5-1mm extension from the free gingival margin (Fig. 2) .
The patient should be instructed on the how to place the bleaching gel in the trays and how to remove any excess gel after insertion. Although there are variations in the duration for wearing the tray, for most patients two weeks at least one hour a day will provide up to 90% of the whitening effect (Fig. 3). Research has shown that a bleaching endpoint will be reached at 6 weeks independent of the concentration and type of peroxide used (Fig. 4). Table 1 has a partial listing of at-home professionally dispensed bleaching products.
IN-OFFICE ONE HOUR WHITENING
The first bleaching of teeth to change color was an in-office procedure. Currently the most popular systems for in-office bleaching use high concentration hydrogen peroxides and are often referred to as "one-hour bleaching." These high concentration hydrogen peroxides range from 25%-35%. In-office bleaching can be provided to patients as either a one-visit 1 -1 1/2 hour treatment or a multiple visit procedure. One can use one of the light enhanced bleaching techniques, a laser activated bleach or merely a paint-on bleaching gel or solution.
For the in-office light enhanced systems, usually the light can only be used for bleaching (BriteSmile, Discus Dental; LumaArch, LumiLite; Zoom 2, Discus Dental). One light system is based upon a plasma arc high intensity photopolymerization device (Sapphire PAC Light, Den-Mat) that can be used for in-office whitening and for resin photopolymerization.
In-office professional whitening can be a perfect complement to the at-home whitening system you are using. There are many patients that cannot find the time to apply trays or strips in their busy lives. In-office whitening offers them the convenience of whitening their teeth in one or more dental appointments.
How effective is in-office bleaching? Studies have been done to compare in-office bleaching to at-home tray bleaching. 53,54 At-home tray bleaching usually gives the best final result. The results of in-office bleaching with light enhancements have been controversial. Within the dental literature there are conflicting studies as to whether or not high concentration hydrogen peroxide bleaching compounds are effective. 55,56
Some studies have shown that the use of a light-activated/enhanced bleaching product provides better whitening 49,50,57 while other studies demonstrate that there is no benefit to using an accessory light. 58-60 There are a variety of one-hour whitening systems and products available. The techniques for one hour whitening vary from product to product. In most cases the in-office vital tooth bleaching products are 25-35% hydrogen peroxide gels. The use of high concentration hydrogen peroxide gels intraorally require that specific safety protocols be used. First, the patient and patient must be wearing eye protection and the gingival soft tissues adjacent to the procedure must have a barrier placed (Fig. 5). Some lights generate heat and or UV rays, so a rubber dam napkin can be used to shield the face from the light source.
In some cases the manufacturers provide moisturizers for the lips or sun screen as protection from the UV rays. While a dental dam would be ideal, as was seen with earlier bleaching techniques, the placement of a dental dam will inhibit the bleaching of the cervical areas of the teeth which patients will be dissatisfied with. Patients want their entire visible tooth surface to get whiter. The manufacturers have responded by providing barrier protection in the form of a light cured resin (similar to flowable composite resin) that is painted over the gingival tissues and light cured. See Table 2 for a partial listing of one-hour bleaching systems.
Concerns have been expressed that use one-hour whitening with light enhancement is not different from whitening without the light, multiple visits are needed, one week at-home tray whitening is recommended after the in-office procedure and that there is sensitivity during this chairside procedure. If this is the case, why use a light? The use of a light to enhance vital tooth bleaching is important in the dental practice because the patient expects to see the light.
Our patients do not live in closets with no contact with the outside world. Our patients have seen articles in the newspapers and magazines, watched the extreme make-over television shows where the light is being used. Even though the research is not definitive to the use of light enhanced bleaching, the patient expects its use. Without using the light the patient will wonder if they are getting the proper care. There is no harm to using the light and many look upon light enhanced bleaching to be important for patient satisfaction and marketing.
A 25-year-old patient desired tooth whitening. She had just completed orthodontic treatment and felt that her teeth had got- ten darker (Fig. 6). After a complete oral examination and evaluation, this patient was a good candidate for vital tooth bleaching. The patient was presented with different treatment options including tray whitening and inoffice vital bleaching.
For this patient, the use of athome tray bleaching did not fit her busy schedule. While there are many options for one-hour tooth whitening for this case it was decided to use a new inoffice bleaching agent TiON (GC America) which uses the photocatalyst "V-CAT" to enhance bleaching effectiveness. 40 V-CAT is a nitrogen doped titanium dioxide that was developed by Toyota Central R&D Laboratories that is more effective than standard titanium dioxide photo-catalysts used in the past. V-CAT has a high photo-catalytic activity under both UV and visible light irradiation.
When TiON is used according to the manufacturer's directions, the V-CAT technology produces color changes (whitening) of the teeth when the bleaching agent is exposed to a dental curing light or a bleaching light system. When TiON with the V-CAT chemistry is activated by UV and visible light irradiation, the hydrogen peroxide contained in the whitening gel is rapidly converted to OH and O radicals by the V-CAT.
The TiON system involves seven steps. Cleaning the teeth with the TiON prophy paste, apply a lip balm to the patient's lips, isolate with cotton rolls or use a lip retractor then create a gingival mask with the Gingival Protector, dispense the Reactor in a dispensing dish, apply the Reactor to the tooth surfaces, connect the Whitening Gel syringe to the Whitening Liquid Syringe and mix the two together, apply the Whitening Gel to the teeth, irradiate the teeth, and remove the Bleaching Gel.
Before starting treatment, all extrinsic stain was removed from the teeth with a dental oral prophylaxis using the non-fluoridated prophylaxis paste provided in the TiON kit (Fig. 7). The teeth were rinsed and dried. A lip balm was applied to the patient's lips. To protect the gingival during the tooth whitening procedure, the Gingival Protector (GC Dental), a light activated flowable resin, was applied from second premolar to second premolar on both the maxillary and mandibular arches and light cured (Fig. 8 ). For ease of application, no more than two teeth were isolated at a time and light cured until all the teeth being bleached were isolated at the attached gingival tissues before initiating the bleaching procedure.
The teeth were now ready for the bleaching procedure. Five drops of Reactor were applied to the dispensing dish. Reactor is the innovative photo-catalyst VCAT that provides enhanced whitening power to the TiON bleaching system. Each tooth was painted with a thin layer of the Reactor with a disposable brush (Fig. 9). Using dried forced air from an air syringe, all excess Reactor agent was removed from the tooth surfaces (Fig. 10). The Whitening Gel syringe and Whitening Liquid syringe from the kit were screwed together using their bayonet mount and connected together (Fig. 11). The two reagents were mixed together by inject all the gel into the liquid syringe. Then to mix the two reagents the liquid was injected into the gel syringe and the mixing process was repeated 20 times for a thorough mixing of the bleaching agents.
At the final mix all the bleaching agent was in the gel syringe. When mixing was complete the special syringe tip was placed onto the Whitening Gel syringe. Using the special tip the Whitening Gel was applied onto the teeth to be whitened to a thickness of 0.5-1.0mm (Fig. 12). Light activation can be done with either a curing light (LED, halogen, Plasma Arc) or a bleaching light (metal halide). Place the light source as close to the tooth/ teeth as possible and irradiate the teeth with a curing light for one minute per tooth or a bleaching light for twenty minutes for both arches simultaneously. For this treatment, the Bleaching Gel was activated with a halogen curing light, one minute for each tooth (Fig. 13). After light activation, the bleaching gel was removed from the teeth by wiping the gel from the teeth from cervical area to incisal edge (Fig. 14).
As part of the procedure and to assure no tooth sensitivity due to the whitening process, Prospec MI Paste, a casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) was applied to the teeth using a gloved finger and rubbed into the facial tooth enamel surfaces (Fig. 15). Prospec MI Paste can also be applied with a prophylaxis cup or using a tray. The MI Paste was left on the teeth for five minutes and then rinsed off.
Recent research35 has shown that the use of Prospec MI Paste almost eliminates tooth sensitivity and there is evidence that it will minimize shade relapse after whitening. After completion of the TiON treatment, it was noted that the patient had lightened her teeth by six shades. She was happy with her new smile (Fig. 16). For this patient since she is wearing a clear, hard custom made orthodontic tray-retainer, it was decided to continue whitening with the GC TiON Whitening System Take Home kit using her orthodontic retainer.
The TiON in-office bleaching process can be repeated at the same appointment or during another appointment using the mixed bleaching gel if desired. For darker discolored teeth, a dentist may desire repeating the procedure for up to three times in a single visit. If the procedure will be repeated during another dental visit, the bleaching gel should be stored in a refrigerator between uses.
From all clinical and research accounts, tooth whitening with the latest generation of vital bleaching products is effective and safe12-18,20,49,50,58,59,63,64 also relatively long lasting. Bleaching relapse has been reported. With in-office bleaching, CRA reported relapse of 41% at one year. 59 For tray bleaching Haywood reports 26% at 18 months. 65 Others have reported varying degrees of bleaching relapse over time. 66-68 To prevent bleaching relapse a patient would have better success with a power toothbrush with a whitening toothpaste over manual toothbrushing. 66
Bleaching can be maintained through the use of whitening toothpastes and bleaching toothpastes with yearly touch-up bleaching using a peroxide bleaching agent in the patient's custom fitted tray.
Vital tooth bleaching is an effective treatment modality that can change the appearance of teeth. Patient satisfaction has been demonstrated after use of both professionally dispensed bleaching treatments and OTC products. Based upon the clinical results reported with professional vital tooth bleaching, it is a viable, esthetic treatment for the discolored dentition. 67 Its conservative nature and little if any risk make it an important part of an esthetic dentistry treatment plan.
Howard E. Strassler, DMD, is Professor and Director of Operative Dentistry, Department of Endodon- tics, Prosthodontics and Operative Dentistry, University of Maryland Dental School Baltimore, MD. firstname.lastname@example.org
Luis Sensi, DDS, MS, PhD, assistant Professor, department of Endodontics, Prosthodontics and Operative Dentistry, University of Maryland Dental School, Baltimore, MD.
Oral Health welcomes this original article.
1. Feinman RA, Goldstein RE, Garber DA. Bleaching teeth. Chicago: Quintessence Books, 1987, p. 10.
2. Cohen S, Parkins FM. Bleaching tetracycline-stained vital teeth. Oral Surg 29:465-471, 1970.
3. Haywood VB, Heymann HO. Nightguard vital bleaching. Quintessence Int 20:173-176, 1989.
4. Berry J. FDA says whiteners are drugs. ADA News, 22(18): 1,6,7, 1991. American Dental Association, Council on Scientific Affairs. Acceptance program guidelines for home-use tooth whitening products. Chicago: American Dental Association, 1998.
5. Haywood VB. The Food and Drug Administration and its influence on home bleaching. Curr Opin Cosmetic Dent: p. 12-18. 1993.
6. Burrell KH. ADA supports vital tooth bleaching -but look for the seal. J Am Dent Assoc 128: 3s-5s, 1997.
7. Haywood VB. Nightguard vital bleaching: current concept and research. J Am Dent Assoc 128: 19s-25s, 1997.
8. Li Y. Toxilogical considerations of tooth bleaching using peroxide containing agents. J Am Dent Assoc 128: 31s-36s, 1997.
9. Haywood VB, Heymann HO. Nightguard vital bleaching: how safe is it? Quintessence Int, 22:515-523, 1991.
10. Christensen GJ, Christensen RP. Home use bleaching survey -1995. CRA Newsletter 19(10):1, 1995.
11. Howard WR. Patient applied tooth whiteners. J Am Dent Assoc 123:57-60, 1992.
12. Gegauff AG, Rosenstiel SF, Langhout KJ, Johnson WM. Evaluating tooth color change from carbamide peroxide gel. J Am Dent Assoc, 124: 65-72, 1993.
13. Rosenstiel SF, Gegauff AG, Johnston WM. Randomized clinical trial of efficacy and safety of a home bleaching procedure. Quintessence Int 27:383-388, 1996.
14. Godder B, Kaim JM, et al. Evaluation of two at-home bleaching systems. J of Clin Dent 5: 86-88, 1994.
15. Reinhart JW, Eivins SE, et al. A clinical study of nighguard vital bleaching. Quintessence Int 24:379-384, 1993.
16. Russell CM, Dickinson GL, et al. Dentist supervised home bleaching with ten percent carbamide peroxide gel: a six month study. J Esthet Dent 8: 177-182, 1996.
17. Haywood VB, Leonard RH, et al. Effectiveness, side effects and long-term status of nightguard vital bleaching. J Am Dent Assoc 125: 1219-1226, 1994.
18. Fasanaro TS. Bleaching teeth: history, chemicals and methods used for common tooth discolorations. J of Esthet Dent 4:71-78, 1992.
19. Haywood V. Nightguard vital bleaching: current information and research. Esthet Dent Update 1(2) :20-23, 1990.
20. Matis BA, Gaiao U, Blackman D et al. In vivo degradation of bleaching gel used in whitening teeth. J Am Dent Assoc. 130:227-235, 1999.
21. Haywood VB, Heymann HO. Response of normal and tetracycline-stained teeth with pulp size variation to nightguard vital bleaching. J Esthet Dent 6: 109-114, 1994.
22. Godwin JM, Barghi N, Berry TG, et al. Time duration for dissipation of bleaching effects before enamel bonding. J Dent Res; 71: 179 (Abstr 590), 1992.
23. Cvitko E, Denehy GE, Swift Jr EJ, et al. Bond strength of composite resin to enamel bleached with carbamid peroxide. J Esthet Dent 1991; 3: 100-102.
24. Machida S, Anderson MH, Bales DJ. Effect of a home bleaching agent on adhesion to enamel. J Dent Res; 71:282 (Abstr. 1408), 1992.
25. Basting RT, Rodrigues JA, Serra MC, Pimenta LAF. Shear bond strength of enamel treated with seven carbamide peroxide bleaching agents. J Esthet Restor Dent 16:250-260, 2004.
26. Strassler HE, Symer SE, and Hendrix J. Update of vital tooth bleaching. California Dental Institute for Continuing Education 63:11-23. 1997
27. Haywood VB, Cordero R, Wright K, Gendreau L, Rupp R, Kotler M, Littlejohn S, Fabyanski J, Smith S. Brushing with a potassium nitrate dentifrice to reduce bleaching sensitivity. J Clin Dent 16: 17-22, 2005.
28. Tredwin CJ, Naik S, Lewis NJ, Scully C. Hydrogen peroxide tooth whitening (bleaching) products: review of adverse effects and safety issues. Br Dent J 200:371-6, 2006.
29. Jorgensen MG, Carroll WB. Incidence of tooth sensitivity after home whitening treatment. J Am Dent Assoc 133:1076-1082, 2002.
30. Swift EJ Jr., AT-home bleaching: pulpal effects and tooth sensitivity issues, part ii. J Esthet Restor Dent 18:301-4, 2006.
31. Gerlach RW, Barker ML, Anastasia MK, Bsoul S, Terezhalm GT. Gingival recession and clinical response with extended whitening strip use. J Dent Res 84 (Special Issue A): Abstract no. 2124, 2005.
32. Hodosh M. A superior desensitizer-potassium nitrate. J Am Dent Assoc 88: 831-2, 1974.
33. Poulsen S, Errboe M, Hovgaard O, et al. Potassium nitrate toothpaste for dentine hypersensitivity. Cochrane Database Syst Rev. 2001;2:CD001476.
34. Blalock J, Callan RS, Brackett MG, Frazier K, Browning WD. Clinical evaluation of sensitivity of 10% carbamide peroxide tooth-whitening gels. J Dent Res 85 (Special Issue A): Abstract no. 1382, 2006.
35. Strassler HE. Tooth whitening-now and in the future: Part 2. Contemp Esthet Restor Pract. 8(9):50-55, 2004.
36. Leonard, Jr. RH, Smith LR, Garland GE, Caplan DJ. Desensitizing agent efficacy during whitening in an atris population. J Esthet Restor Dent 16: 49-56, 2004.
37. Tung MS, Eichmiller FC. Dental applications of amorphous calcium phosphates. J Clin Dent. 10(1 Spec no):1-6. 1999.
38. Yates R, Owens J, Jackson R, Newcombe RG, Addy
M. A split-mouth placebo-controlled study to determine the effect of amorphous calcium phosphate in the treatment of dentine hypersensitivity. J Clin Periodontol 25:687-92, 1998.
39. Dunn J, Wilson AC, Arambula M, et al. Effects of TiON gel applications on in-office tooth whitening. J Dent Res 85 (Special Issue A): Abstract no. 1369, 2006.
40. Giniger M, MacDonald J, Siemba S, Felix H. The clinical performance of professionally dispensed bleaching gel with added amorphous calcium phosphate. J Amer Dent Assoc 136:383-392, 2005.
41. Matis BA, Hamdan YS, Cochran MA, Eckert GJ. A clinical evaluation of a bleaching agent used with and without reservoirs. Oper Dent 27:5-11, 2002.
42. Haywood VB. Nightguard vital bleaching; current concept and research. J Am Dent Assoc. 128: 21S-25S, 1997
43. Oliver TL, Haywood VB. Efficacy of nightguard vital bleaching technique beyond the borders of a shortene tray. J Esthet Dent 11: 95-102, 1999.
44. Leonard RH, Sharma A, Haywood VB. Use of different concentrations of carbamide peroxide for bleaching teeth: an in vitro study. Quintessence Int 29:503-507, 1998.
45. Matis BA, Mousa HN, Cochran MA, Eckert GJ. Clinical evaluation of bleaching agents of different concentrations. Quintessence Int 31:303-310, 2000. 46. Leonard RH, Haywood VB, Eagle JC, Garland GE, et al. Nightguard vital bleaching of tetracycline-stained teeth: 54 months post treatment. J Esthet Dent 11:265-277, 1999.
47. Matis BA, Wang Y, Jiang T, Eckert GJ. Extended athome bleaching of tetracycline-stained teeth with different concentrations of carbamide peroxide. Quintessence Int 33:645-655, 2002.
48. Li Y. et al. Effect of Light Application on an In-Office Bleaching Gel. J Dent Res 82 (Special Issue, AADR Abstracts): #895. 2003.
49. Luk K, Tam L, Hubert M. Effect of light energy on peroxid tooth bleaching J Am Dent Assoc. 135(2): 194- 2004.
50. de Silva Gottardi M, Brackett MG, Haywood VB. Number of in-office light activated bleaching treatments needed to achieve patient satisfaction. Quintessence Int 37:115-20, 2006.
51. Tavares M, Stultz J, Newman M, Smith V, Kent R, Carpino E, Goodson JM. Light augments tooth whitening with peroxide. J Am Dent Assoc 134:167-75, 2003.
52. Dietshi D, Rossier S, Krejci I. In vitro colorimetric evaluation of the efficacy of various bleaching methods and products. Quintessence Int 37:515-26, 2006.
53. Zekonis R, Matix BA, Cochran MA, Al Shetri SE, Eckert GJ, Carlson TJ. Clinical evaluation of in-office and at-home bleaching. Oper Dent 28:114-21, 2003.
54. Buchalla W, Attin T, External bleaching therapy with activation by heat, light, or laser -A systematic review. Dent Mater 30: epub ahead of print, 2006.
55. Joiner A. The bleaching of teeth: a review of the literature J Dent 34: 412-9, 2006.
56. Li Y, Lee SS, Zheng M, Forde CA, Carino CM. Effect of light treatment on in vitro tooth bleaching efficacy. J Dent Res 85 (Special Issue A): Abstract no. 275, 2006.
57. Papathanasiou A, Kastali S, Perry RD, Kugel G. . Clinical evaluation of a 35% hydrogen peroxide inoffice whitening system. Comp Cont Dent Educ 23:335-346, 2002.
58. Clinical Research Associates, In-office vital tooth bleaching an update, 28(6):1-2, 2004
59. Sulieman M, MacDonald E, Rees JS, Addy M. Comparison of three in-office bleaching systems based on 35% hydrogen peroxide with different light activators. Am J Dent 18: 194-7, 2005.
60. Kugel G, Papathanasiou A, William 3rd AJ, Anderson C, Ferreira S. Clinical evaluation of chemical and lightactivated tooth whitening systems. Compend Contin Educ Dent 27:54-62, 2006.
61. Kugel G, Ferreira S, Sharma S, Barker ML, Gerlach RW. Clinical trial assessing light enhancement of inoffice tooth whitening. J Dent Res 84 (Special Issue A): Abstract no. 287, 2005.
62. Hunsaker KJ, Christensen GJ, Christensen RP. Tooth bleaching chemicals. Influence on teeth and restorations. J Dent Res; 69; 303 (Abstr. 1558), 1990.
63. Haywood VB, Houck VM, Heymann HO. Nightguard vital bleaching: effects of various solutions on enamel surface texture and color. Quintessence Int; 22:775-782, 1991.
64. Haywood VB. Achieving, maintaining and recovering successful tooth bleaching. J Esthet Dent 8:31-38, 1996.
65. Kugel G, Aboushala A, Sharma S, Ferreira S, Anderson C. Maintenance of whitening with a power toothbrush after bleaching treatment. Compend Contin Educ Dent 25:119-131, 2004.
66. Leonard Jr RH. Efficacy, longevity, side effects and patient perceptions of nightguard vital bleaching. Compend Contin Educ Dent 19:766-774, 1998.
67. Haywood VB. Current status of nightguard vital bleaching. Compend Contin Educ Dent Suppl 21:S10-17, 2000.
68. Ritter AV, Leonard RH Jr, St Georges AJ, Caplan DJ, Haywood VB. Safety and stability of nightguard vital bleaching: 9-12 years post-treatment. J Esthet Restor Dent 14:275-285, 2002.
Esthetic dentistry is a major area that our patients are requesting more information about
Tooth whitening refers to any procedure that changes the shade and appearance of teeth without the use of restorative materials
Among the adverse reactions reported were tooth hypersensitivity and soft tissue irritation
MAINTAINING WHITENED TEETH -- MINIMIZING BLEACHING RELAPSE
Use a whitening toothpaste to remove surface stains and prevent yellowing with a power toothbrush
Brush or rinse immediately after consuming stain-causing beverages or foods
Use a straw to drink beverages that stain, such as coffee, tea, colas and red wine
For woman wear a bright shade of lipstick-blue or pink based. It will make your teeth appear whiter. Avoid orange or brown shades
Check whether you need a touch up. Depending upon the whitening method you used, you may need a touch up in six months or after a year or two. If you smoke or drink a lot of coffee, you may need a touch up more often
Higher concentration hydrogen peroxides (25%-35%) are used for in-office bleaching with and without light and heat enhancement
patient complaints concerning issues of taste have been addressed with an expanded selection of better flavors
the tray on the cast, there is less concern about distortion that occurs when trimming with a scissor
a high photo-catalytic activity under both UV and visible light irradiation
The two reagents were mixed together by inject all the gel into the liquid syringe
treatment, the Bleaching Gel was activated with a halogen
curing light, one minute for
bleaching relapse a patient would have better success with a power toothbrush with a whitening toothpaste over manual toothbrushing