I) INTRODUCTION

Bleaching is an age old treatment whose time has finally come. The
technique has been performed for over a century. It is one of the most
documented clinical techniques in dentistry and yet for reasons unknown, it
has escaped the acceptance that it deserves.
The current trend toward cosmetic dentistry has generated more
interest in bleaching as patients are asking for whiter and more beautiful
teeth. Our society tends to dislike yellowing of teeth that comes with age or
the various intrinsic stains that occur developmentally.
Products to whiten! teeth are plentiful in the market place.
Bleaching alone can significantly change the appearance of teeth,
sometimes in only one office visit and almost less invasively and less
e"pensively than procedures such as crowning, bonding or veneering.
There is now little reason to accept discoloured teeth when bleaching, in
con#unction with other cosmetic dental technique is now readily available.
II) HISTORY
Bleaching as yet another means to achieve that da$$ling smile is not
new% the first reported cases date in the &'
th
century, but it is less well
known and less understood than bonding and veneers.
&
History of bleaching vital teeth
- (.). Torres *arago$a has reported e"tensively about bleaching of vital
teeth. +is report shows the earliest efforts at bleaching were focused on
the search for an effective bleaching agent.
- The first publication of bleaching was in &,-- by .happle, the agent of
his choice was o"alic acid.
- Taft and /tkinson suggested the use of chlorine for bleaching.
- In late &'012s, home bleaching using &13 carbamide pero"ide was
discovered by 4lusimer.
- In &,,5, +arlan published first reports of pero"ide used in bleaching.
+e called it hydrogen dio"ide.
- In &,'6, various practitioners began to e"periment with electric current
to speed the process of bleaching.
- 7ossental suggested the use of 8( waves to help bleaching in &'&&.
- By &'&,, /bbot had introduced the forerunner of the combination used
today% 9upero"ol and an accelerated reaction by heat and light.
The technique of nightguard vital bleaching went technically
unnoticed until +eywood and +eymann described the technique in )arch
:
&',' and a similar product was introdced by a manufacturing company in
the same month. The night guard vital bleaching and over the counter kits
have kindled a resurgence of interest in tooth bleaching.
History of bleaching non-vital teeth
- /s early as &,5,, non;vital tooth bleaching with chloride of lime was
practiced.
- Truman is credited for introducing well before &,05, the most effective
method of bleaching non;vital teeth, which used chlorine from a
solution of calcium hydrochlorite and acetic acid. The commercial
derivative of this, known as <abarrque2s solution, was a liquid chloride
of soda.
- In &,'6, =arretson published the first report of bleaching non;vital
teeth..
- 9upero"ol >?13 +
:
O
:
@ was introduced by a manufacturing company
early in the &'112s.
- In &'61, Pearson left the solution of 9upero"ol for :;? days in the pulp
chamber.
- Pyro$on >ether;pero"ide@ was used effectively for non;vital teeth in the
late &'612s and early &'01s.
?
- Autting and Poe carried out the approach of walking bleach! in &'0-.
They elected to use B9upero"ol2 instead of BPyro$one2, for safety and
combined it with sodium perborate to achieve synergistic effect. They
recommended the use of sodium pero"yborate monohydrate because it
released more o"ygen than sodium perborate. They also advised that
guttapercha be sealed before the treatment is initiated and sealed the
solution in the pulp chamber for & week.
III) CAUSS O! DISCO"OURATION O! TTH AND
INDICATIONS
#$ %trinsic &iscolo'ration
- Occurs when some agent literally stains or damages the enamel surfaces
of the teeth. They are found on the outer surface of teeth and are usually
of local origin which can be removed by oral prophyla"is.
- .igarettes, cigars and pipes will produce a yellowish brown to black
discolouration, usually in the cervical portion of the teeth and primarily
on the lingual surfaces.
- .hewing tobacco stains frequently penetrate the enamel producing a
deeper stain.
5
- .offee and tea cause severe tenacious discolourations, usually brown to
black stains.
($ Intrinsic &iscolo'ration
These are stains within the enamel and dentin caused by the
deposition or incorporation of substances within these structures, such as
tetracycline stains, dentinogenesis imperfect, a fluorosis by products
released into the dentinal tubules during illness >e.g., bilirabin involved
with #aundice@ trauma >primarily the breakdown of haemoglobin@, or
pigmentation escaped from the medicaments and materials used in
restorative dentistry.
1) Tetracycline staining
Tetracycline staining was first reported in mid;&'61s, less than a
decade after widespread use of this antibiotic.
- Teeth are most susceptible to tetracycline discolouration during their
formation i.e. during the second trimerster in utero to roughly , years
after birth.
- The tetracycline molecules appears to chelate with calcium and
becomes incorporated into the hydro"yapatite crystals.
- The tetracycline involves predominantly the dentin.
6
- 9everity of the stains depends on the time and duration and the dosage
of the drug administration, so also the type of tetracycline.
.ategories of tetracycline discolouration
According to Jordan and Boksman
Cirst degree tetracycline stainingD
- is a light yellow, brown or gray staining.
- uniformly distributed throughout the crown.
- no evidence of banding or locali$ed concentration.
7esponds well to bleaching in two or three sessions.
9econd degree tetracycline staining.
- dark or gray staining.
- e"tensive than first degree with no banding.
7esponds well to bleaching in 5 to 0 sessions.
Third degree tetracycline stainingD
- dark gray or blue with marked banding.
7esponds to bleaching but bands usually evident following even
e"tensive treatment. It may be removed with some veneering technique.
0
Courth degree tetracycline stainingD
- .reated to include those stains that are too dark to attempt vital
bleaching.
2) Fluorosis staining
- )ottled enamel that occurs when children ingest e"cessive fluoride
during development of enamel and dentin.
- Eamage occurs during development usually during third month of
gestation through eighth year of life.
- +igh concentration of fluoride in e"cess of &ppm >more than 5ppm F
moderate to severe discolouration@ is believed to cause a metabolic
alteration in the ameloblasts resulting in defective matri" and improper
calcification.
- Prevalence F premolars, :
nd
molars, ma"illary incisors, canines, &
st
molars and mandibular incisors.
- There are two types of damagesD
&. Eiscolouration.
:. 9urface defects.
-
Types D
&. 9imple fluorosis staining appears as brown pigmentation on a smooth
enamel surface.
- 7esponds well to bleaching.
:. Opaque fluorosis appears as flat gray or white fleeks on enamel surface.
- 7esponds poorly to bleaching because tooth cannot be bought to
lightness in the affected area.
?. Cluoride staining with pitting has dark pigmentation with surface
defects, necessitates bleaching followed by composite resin bonding.
3) Discolouration from pulp necrosis
a@ Trauma;related discolouration
- Trauma can cause haemorrhage as blood vessels rupture in the pulp
chamber.
- Blood is hydraulically driven into the dentinal tubules, where the 7B.
undergo hemolysis emitting haemoglobin. +aemoglobin is degraded
releasing iron than forms a black compound by combining with
hydrogen sulfide to become iron sulfide.
,
- Immediately after in#ury, crown remains pink as blood breaks down.
The tooth becomes orange, then blue, then brown or black.
b@ Pulp degeneration without haemorrhage
- Aecrotic tissue contains various protein degradation products which
create a grayish brown discolouration of the crown.
- This responds well to non;vital bleaching technique.
4) Iatrogenic Discolouration
.onsidered intrinsic because it effects inner structure of the tooth.
a@ Trauma during pulp e"tirpation +aemorrhage.
b@ Cailure to remove all pulpal remnants. 7esponds well to non;vital
bleaching technique.
c@ )edications and materials used in dental restorations if they leak.
d@ )etal amalgams;reflect as a discolouration through the enamel.
e@ Breakdown of restorations such as acrylics, silicate cements or
composite resins can cause the tooth to look grayer and discoloured.
f@ 9ilver nitrates F cause black or bluish black discolourations.
g@ (olatile oils F cause yellowish brown stains.
'
h@ Iodine;creates brown, yellow or orange stains.
i@ 7oot canal sealers containing silver causes black stains.
#@ Pins cause blue grayish stains.
5) Discolouration as a symptom of systemic condition
- Grythroblastic fetalis >7h incompatibility between mother and foetus@
characteri$ed by breakdown of an e"cessive number of erythrocytes F
degradation of these blood cells causes intrinsic staining of dentin of
developing teeth.
- Haundice results in staining of dentin bluish green or brown primary
teeth by bitrubin or biliverdin.
- Porphyria >rare condition@ F e"cessive pigment production infuses
dentin and makes primary and permanent teeth purplish brown.
- =enetic conditions such as amelogenesis imperfecta interfering with
normal enamel matri" formation.
- /cquired illnesses such as cerebral palsy, serious renal damage and
severe allergies. Brain, neurologic and other traumatic in#uries can
interfere with the normal development of the enamel.
&1
- Gnamel hypoplasia caused by deficiencies of vitamins /, ., E and
calcium and phosphorous during the formative period.
If these conditions cause tooth deformity or white spots, they
respond poorly to bleaching.
6) Discolouration due to eredity and dental istory
- 9ome people are genetically programmed to have lighter or darker
teeth.
- Eental caries may be seen as an opaque halo or as a gray
discolouration. Bleaching not effective until the cause of discolouration
is removed.
- Eeeper pigmentation as a result of bacterial degradation of food debris
in areas of tooth decay or decomposition. If breakdown is repaired,
bleaching may not be necessary.
!) Discolouration due to aging
&. )ore stains of coffee and food.
:. Eue to wearing away of enamel.
&&
/dvantage in older patients pulp recession makes aging a boon in
terms of bleaching, since, it makes the patient less sensitive to the
bleaching compound.
I)) CONTRAINDICATIONS O! *"ACHIN+ TOOTH
Bleaching should not be advised when the pertinent tooth hasD
&. .racks and hypoplastic or severely undermined enamel.
:. G"tensive silicate, acrylic or composite restorations.
- these teeth may not have enough enamel to respond properly to
bleaching.
?. Eiscolouration by metallic salts, particularly silver amalgam, the
dentinal tubules can become virtually saturated by these alloys causing
stains that no amount of bleaching can significantly improve.
5. Gnlargement of the pulp or other disease that makes the tooth sensitive
to bleaching solutions or may require special care and desensiti$ation.
)) ,CHANIS, O! ACTION
Ho- &oes bleaching -or./
The mechanisms of bleaching are not completely understood and
may be somewhat different for different types of stains.
&:
- Cor stains in which pellicle or other organic substances appear on the
surface or subsurface of the tooth, the bleaching agent may o"idi$e
these substances.
- The reason why etching sometimes enhances the effects of bleaching
may well be that, this procedure removes surface organic material and
penetrates the enamel slightly, possibly e"posing slightly deeper areas
of enamel to bleach.
- Ie know that substances can penetrate the enamel and dentin, even
into the pulp and it is probably this mechanism that allows the
bleaching agents to do their work.
- The use of high intensity lighting and longer e"posure times for the
bleaching agent may work to increase this permeation.
- The mechanism by which bleaching works on the interior of teeth may
be a process of o"idation in which the molecules causing the
discolouration are released. The theories of photoo"idation or ion
e"change are both claimed to be viable reactions.
- Cor non;vital teeth, the pulp chamber can be packed with a bleaching
agent. /lthough some researchers have presented evidence that
hydrogen pero"ide can penetrate pulp chamber e"ternally to facilitate
&?
o"idation of the staining agents, it is not known whether it should affect
the products of haemolysis or degraded substances.
- +ydrogen pero"ide, in various concentrations, is the primary material
currently used by the profession in the bleaching process. .urrent in
office techniques for vital teeth and the walking bleach! technique
typically use ?1;?63 concentration of +
:
O
:
. +
:
O
:
naturally occurs in
the body even in the eyes, in low concentrations. It is manufactured and
regulated by the body and often involved in wound healing. In higher
concentrations, it is bacteriostatic and in very high concentrations is
mutagenic, possibly by disrupting the EA/ strand. +owever, the body
has mechanisms for immediate repair of natural damage, low
concentrations of +
:
O
:
do not cause serious problems. The carcinogenic
capabilities of +
:
O
:
are more often caused by other pero"ide derivatives
and the body uses the pero"idases and other mechanisms for regulating
+
:
O
:
.
- The mechanisms of action of +
:
O
:
in tooth bleaching is considered to
be o"idation, although the process is not well understood. It is felt that
the o"idi$ers remove some unattached organic matter from the tooth
without dissolving the enamel matri" but also may change the
discoloured portion to a colourless state. There is some concern that
continued long term treatment will result in dissolution of the enamel
&5
matri", but reports to date on nightguard vital bleaching techniques
have not supported this theory.
- Tetracycline stains are more resistant to o"idation because the molecule
is tightly bound to the mineral in the enamel prism matri" during
formation and hence is less accessible to immediate action. Teeth
stained with tetracycline therefore require prolonged treatment times
before any results are demonstrated and often are unresponsive to the
procedure.
- The ma#ority of products currently on the market for the nightguard
vital bleaching technique use a &13 carbamide pero"ide solution. /
&13 carbamide pero"ide degrades into ?3 +
:
O
:
and -3 urea and
hydrogen pero"ide can be considered its active ingredient. The urea
may provide some beneficial side effects because it tends to raise the
hydrogen ion concentration >p+@ of the solution.
- Cor non;vital teeth, the pulp chamber can be packed with a bleaching
agent. /lthough some researchers have presented evidence that +
:
O
:
can penetrate pulp chamber e"ternally to facilitate o"idation of the
staining agents, it is not known whether, it would affect the products of
haemolysis or degraded substances.
&6
- In the walking bleach technique for non;vital teeth, sodium perborate
was used with hydrogen pero"ide. 9odium perborate is a white powder
which decomposes into sodium metaborate and hydrogen pero"ide
releasing o"ygen. Ihen mi"ed into a paste with +
:
O
:
, this paste
decomposes into sodium metaborate, water and o"ygen. Ihen sealed
into the pulp chamber, it o"idi$es and discolours the stain slowly,
continuing its activity over a longer period.
Teeth that have been discoloured as a result of ingestion of high
amount of fluoride such as 6ppm in natural water do not respond well to
ordinary techniques of bleaching. In cases of endemic fluorosis, )cInnes
solution containing ?13 +
:
O
:
, ?03 +.l acid and 1.:3 anaesthetic ethers
in the ratio of 6D6D& is used. The anaesthetic ether removes surface debris,
the hydrochloric acid etches the enamel and the +
:
O
:
bleaches the enamel.
The +
:
O
:
as described earlier bleaches the enamel by the process of
o"idation. The hydrochloric acid present in the solution increases the
penetration of the solution and helps in faster action. But +.l acid has
various deleterious effects such as loss of contour, irritation to gingiva and
sensitivity of teeth.
.hen, Ju and 9hing >&''?@ replaced +.l by :13 AaO+ which also helps
in decomposition of +
:
O
:
and enhances the bleaching effect. AaO+ is
highly alkaline in nature and therefore dissolves calcium at a slower rate.
&0
The results suggests that &D& mi"ture of +
:
O
:
with :13 sodium hydro"ide
is a effective as old )c Innes solution and the calcium dissolved is much
less with the new )cInnes solution.
/ study by Er. Aangrani showed that use of Old )cInnes solution
resulted in loss of contour of the teeth. The time taken by Aew )cInnes
solution was double than that of Old )cInnes solution but it did not show
loss of contour of the teeth.
Er. 9hadwala studied the amount of calcium dissolution with Opalescence
night guard vital bleaching solution and Old )cInnes solution and found
out that Old )cInnes solution caused less calcium dissolunts as compared
to Aight guard vital bleaching technique. The possible reason for this could
be attributed to the fact that night guard vital bleaching technique uses
bleaching action whch lasts for 0 hours for : weeks whereas )cInnes
solution has to be used for only about :1 minutes >?;5, 6 min application@.
)I) HISTO"O+IC !!CTS O! *"ACHIN+
- 9ince &'6&, it has been shown that the bleaching procedures have
potentially damaging effects on the pulp and that substances can pass
through enamel and dentin and into the pulp.
- &'--, =riffin and =rower reported that Old )cInnes solution kept from
:;&6 minutes on the teeth showed lack of penetration into the pulp
&-
chambers. This lack of penetration may be due to the short e"posure
time tested.
- In &'61, Iainwright and <emoine showed that the low molecular
weight of +
:
O
:
and its capability to denature proteins increases the
movement of ions through teeth.
This study was further corroborated in &''' by .. +egedus et al
who stated that pero"ides affect not only the surface but also the inner
structure of enamel as a result of its molecular weight. They affect the
organic phase of enamel. This inner o"idative effects are more likely to
occur in the subsurface enamel which has more organic material.
- .ohen and .hase >&'-'@ reported effects of +
:
O
:
and heat for vital
bleaching. Their conclusion was using this technique for vital bleaching
may be considered harmless to pulpal tissues. The ne"t year in a similar
study, 7obertson and )elfi found mild superficial inflammation in a
signifiacnt number of pulps.
)II) TRAT,NT 0"ANNIN+
Gsthetic dentistry is especially the appearance of the mouth as a
whole and not simply one or more problem teeth. Bleaching may correct
the problem or facilitate other restorative techniques to correct the
problem. Bleaching is therefore the first step in any treatment plan. The
&,
e"act shade of the bleached teeth cannot be predicted. By bleaching first,
the advantage is that unnecessary tooth reduction need not be done and
anatomic shape and form is preserved. Bleaching may need to be repeated
every &;? years to maintain brightness of teeth.
0re1aration for bleaching
&@ 7ecord keeping and photographs F 7ecord keeping should begin at the
treatment planning stage. 7ecords should document decision for
treatment and alternative. It is absolutely essential to take adequate
photographs of a patients preoperative condition. Ao amount of
description can e"actly depict, how the patient looked before treatment.
In addition, photographs are more reliable than memory in documenting
the progress of treatment.
:@ .areful diagnosis, using radiographs and transilluminating techniques D
In this, the possibilities of any periapical abnormalities can be ruled out.
.aries and decalcified or hypocalcified areas will be disclosed. The si$e
and vitality of the pulp can be determined and the opacity, depth and
layers of stains can be defined. /lso, hypersensitivity of the teeth
should be ruled out.
?@ Oral prophyla"is and polishing with sodium bicarbonate D to rid teeth of
all surface stains, plaque and calculus. The patient should be protected
&'
with heavy plastic wrap and safety glasses. In most cases, anaesthetic
must not be used. 7ather, then patient should be able to tell the dentist
if leakage occurs as the heat becomes too intense. /ll members of the
dental team should wear protective eye wear, surgical rubber gloves
and masks.
5@ Preparation of teeth to be bleached . Isolation withD
a@ 7ubber dam.
b@ Protective paste;Orabase or (aseline applied to soft tissues.
c@ =au$e saturated with cold water placed under rubber dam.
d@ Pumice used to remove e"cess stain or protective paste.
e@ Closs is ligated interdentally to prevent seepage of the bleaching
solution into the gums.
Instr'2ents
- Garly approach used metal instruments and delivered direct heat to the
teeth. Patterson developed one such instrument. /dvantage is when
bleaching individual tooth as in non;vital teeth.
- / later development was the use of intense light to activate the
bleaching solution. Intense light has the advantage of supplying
uniform heat to at least ten teeth.
:1
)III) *"ACHIN+ O! )ITA" TTH
There are at least three ways of bleaching vital teeth.
&@ In office bleaching or power bleaching techniquesD
a@ Thermocatalytic method ; <ight
; +eat
b@ )cInnes solution ; Old
; Aew
:@ Aight guard vital bleaching.
?@ Over the counter preparation.
#$ In office bleaching 3 0o-er bleaching
; Cirst vital bleaching technique.
; /E/ products /E/ accepted
9upero"ol >9ultan .hemists@
9tarbrite in office bleaching.
a@ Cor tetracycline stains
; Teeth are covered with gau$e saturated with ?63 +
:
O
:
.
; The pero"ide solution may be activated by heat or light.
; Bleaching light positioned &? inches from the teeth with the light
shining directly on them. / rheostat setting of 6 usually used.
:&
; Ihere heat is used a temperature setting of 50;01K. for vital teeth.
; The gau$e should be kept wet by dispensing fresh bleaching
solution with a cotton swab.
; The bleaching agent should be kept in contact and lightLheat applied
to the teeth for ?1 minutes.
; G"cess solution rinsed off with copious amounts of warm water.
Brush and then polish.
; /t one time, it was considered to etch the teeth with phosphoric acid
before bleaching, supposedly to enhance the effect. +owever,
etching is not actually necessary.
; Tetracycline stains generally requires 6;&1 visits. Best scheduled
every :;5 weeks.
b@ Cor fluorosis stains
; Because fluorosis stains causes much more heterogenous pattern of
staining, the bleaching method is more selective.
::
; Bleaching agent F Old L Aew )cInnes solution
4Aci&ic 2e&i'2) Al.aline 2e&i'2)
Ol& ,cInnes Ratio Ne- ,cInnes Ratio
Bleaching
enamel
a@ ?13 +
:
O
:
6 parts ?13 +
:
O
:
& part
Gtches
enamel
b@ ?03 +.l 6 parts
7emoves
surface
debris
1.:3 ether & part :13 AaO+ & part
; /fter pretreatment procedures are carried out cotton applicators
carrying fresh bleaching agent applied for 6 minutes and repeated
after an interval of & minute.
; /pplication was repeated till the desired bleaching effect was
observed.
; Iith Old )cInnes solution the solution was neutrali$ed with baking
soda.
; Iarm water is flushed on the enamel before rubber dam is removed.
; Polishing is done to achieve a high enamel luster.
EisadvantagesD
&@ 7epeated isolation is a problem.
:@ Power bleach only can be applied on anterior teeth.
:?
?@ ?63 +
:
O
:
is caustic and should avoid burning
themselves or patient.
5@ Eiscomfort during and sensitivity for a week after
treatment.
6@ Ao reliable way of predicting success.
() Night g'ar& bleaching 4N+)*5 &entist 1rescribe& ho2e a11lie&
techni6'e5 &entist ho2e bleaching or 2atri% bleaching)$
; Introduced by +aywood and +eymann in &','.
; .ustom fitted prosthesis filled with &13 carbamide pero"ide is
worn for few hours each day for a few weeks.
; .arbamide pero"ide composed of appro"imately ?3 +
:
O
:
and -3
urea. +
:
O
:
degrades into +
:
O
:
and O
:
while urea degrades into
ammonia and .O
:
. /ll these materials occur naturally in the body
and are easily managed. 8sually &13 carbamide pero"ide solution
was used.
; <esser concentration of carbamide pero"ide >63 instead of &1 and
&03@ can also be used. They take longer time but may lead to less
sensitivity as compared to the higher concentration solutions.
:5
; .arbopol >B.C. =oodrich@ is added to this solution to make it
stickier, and prolong the o"ygen release. This type of material
favours overnight wear.
; Cor patients who find it uncomfortable to wear it overnight, they are
advised to place it :;5 hours before sleeping. Eisadvantage is that
the treatment time is prolonged.
ADA acce1te& bleaching 1ro&'cts for N+)*
; .olgate Platinum Overnight Professional Tooth Ihitening system.
; Aite Ihite classic.
; Opalescence whitening gel.
; Patterson Brand tooth whitening gel.
; 7embrandt <ighter bleaching gel.
7) Over the co'nter bleaching syste2s >egD perfect 9mile 9ystem@
; 9hortly after the dentist home systems were introduced, several
systems were sold directly to the consumers.
; /lso called Bhome bleaching2 systems but are more appropriately
referred as OT. home bleaching systems.
; 9ome of the earlier systems have a ?;step procedure.
an acidic pre;rinse.
:6
application of a lower strength pero"ide material
without a prosthesis.
a final application.
; <ater developed were home systems which use same strength of
bleaching solution as the dentist home system but apply the material
with a boil and form! mouthguard.
na2el ,icroabrasion Techni6'e
One of the relatively new techniques for removal of stains in
endemic fluorosis cases is the use of enamel microabrasion technique.
In &'&0, Er. Ialter 4ane, of .olorado 9prings, used &,3
hydrochloric acid with a warm instrument to successfully remove stains
associated with endemic fluorosis. 9ince &'&0, numerous investigators
have used hydrochloric acid alone on fluorosis stains. In &',5. )c .loskey
described 4anes work and demonstrated successful cases of his own. +e
found that brown fluorosis stains can permanently be removed by rubbing
the enamel with an &,3 +.l acid soaked cotton pellet wrapped around and
amalgam condenser.
Two years later .roll and .avananaugh developed a similar
technique that involves pressure application of &,3 +.l with pumice to
:0
achieve colour modification. This was called the enamel microabrasion
technique. The chief mechanism of stain removal would be limited to
enamel abrasion, rather than enamel dissolution by the acid. Er. .roll
believed that the acid abrasive action of the compound gives the enamel
surfaces, a super fine polishing as a microscopic layer of enamel is
removed. The freshly polished surface then develops a shiny glass like
te"ture, resembling a highly polished microfilled composite resin
restoration, as the tooth subsequently reminerali$ed.
Hacobsson;+unt >&',,@ reported ?1;second applications of the acid
abrasive compound using a mandrel and gear reduction handpiece on
e"tracted human teeth results in a enamel loss of less than :11Mm. In &','
4endell reported that 6 second application of +.l acid pumice mi"ture
removes 50Mm of enamel which should be considerably tolerated.
/n important concern about the safety of the hydrochloric acid
pumice abrasion procedure is the low viscosity and high concentration of
&,3 +.l. To eliminate this problem and ensure safety of this technique,
the viscosity of the acidic solution is increased by mi"ing &,3 +.l acid
with quart$ particles so that the solution takes on a water soluble gel like
form. This came to be known as the modified &,3 +.l acid quart$;pumice
abrasion technique.
:-
The procedure is as followsD
&. The gingiva was protected by a layer of
petroleum #elly.
:. The involved teeth were isolated with rubber
dam.
?. /fter the teeth were dried with air, the paste
which consisted of &,3 +.l acid quart$;pumice particles, was
applied with a cotton tip applicator to the stained areas of
enamel.
5. The paste was allowed to remain 6 seconds and
then for &1 seconds, the enamel microabrasion was effectuated
with a cotton swab pressure.
6. /fter &1 seconds, a marked degree of success
was obtained and the stain was removed.
0. /fter &6 seconds of treatment, the enamel of
the teeth turned to a normal shade.
-. /t the end of the treatment, the teeth were
washed and dried before removal of rubber dam was neutrali$ed
with a neutral sodium gel.
:,
In this procedure, the quart$ particles convert the acid into a gel
form and functions as an additional abrasive agent. 9i" months following
this treatment on several patients showed that the ob#ectives of the
treatment was achieved.
The advantage of this technique is that it is relatively economical,
involving no laboratory costs, making this technique readily acceptable to
children.
I8) *"ACHIN+ O! NON-)ITA" TTH
Preparation of the affected non;vital teethD
&@ In office bleaching.
:@ Out of office bleaching >walking bleach technique@.
?@ Other bleaching techniques.
; Isolation is done with a rubber dam.
; The tooth is meticulously cleaned internally.
; Gstablish a lingual opening of sufficient si$e to provide access to the
pulp chamber and orifice of the root canal.
; / slowly rotating bur is used to remove debris and a surface layer of
dentin within the pulp chamber.
:'
; In endodontically treated teeth, root canal filling material should be
removed to a depth of :;?mm apical to the cervical line.
; *inc polycarbo"ylate cement, cavit or $inc o"yphosphate cement
can be used to refill, &;:mm coronally to the .GH.
Bleaching should never be attempted on any tooth that does not
have a complete seal in the root canal. The agent could escape through a
porous root canal filling and cause the patient e"treme discomfort as well
as probably loss of tooth.
; 9urface stains visible on the inside of the preparation are removed,
the entire preparation is swabbed with chloroform or acetone to
dissolve any fatty material and facilitate the purification of the
bleaching agent into the tubules.
#) In-office bleaching 4Ther2ocatalytic techni6'es)
; The pulp chamber is filled loosely with cotton fibres and the labial
surface is covered with a few strands of cotton fibre to form a matri"
for retaining the bleaching solution.
; This is saturated with ?63 +
:
O
:
using a glass syringe fitted with a
stainless steel needle. The solution should be discharged slowly to
?1
saturate the cotton inside the pulp chamber and on the labial surface
e"cess should be wiped immediately.
; / thin tapered tip from a single tooth bleaching instrument can be
inserted into the pulp chamber. The heated tip is e"posed for 6
minutes, in a sequence of & minute on &6 seconds off.
; It has been established by .aldwell that a non;vital tooth can be
treated to a temperature of -?K. without causing the patient
discomfort.
; /n alternative to activate the +
:
O
:
is the use of light and heat from a
heat and light bleaching powerful light. The tooth is sub#ected to 0,
6 minute e"posures and one replenishes the bleaching agent at
frequent intervals.
; The heating instrument and cotton can then be removed. 7epeat the
above process 5;0 times or for :1;?1 minutes each time placing new
cotton fibres.
; This technique can be used alone or in combination with walking
bleach.
?&
() O't Office bleaching 49al.ing bleach)
; Cirst described by Autting and Poe in &'0?.
; This procedure consists of filling the prepared chamber >as
described previously@ with a paste consisting of ?63 +
:
O
:
and
sodium perborate. >their effect is thought to be synergistic@.
; 9odium perborate is a white powder which decompose into
sodium metaborate and +
:
O
:
releasing O
:
. Ihen mi"ed into a
paste with 9upero"ol, this paste decomposes into sodium
metaborate, water and o"ygen.
; Ihen sealed into the pulp chamber, it o"idi$es and discoloures
the stain slowly, continuing its activity over a longer period.
; / small pledget of cotton wool is placed on the paste and the
cavity is sealed with polycarbo"ylate cement kept under pressure
till the cement sets.
; The ma"imum bleaching is attained :5 hours after treatment.
; The patient should return in ?;- days.
; If shade ; dark then repeat procedure
; light then permanent restoration with silicate or =I..
?:
; =enerally two treatment sessions although in some cases one
treatment is sufficient.
7) Other 2etho&s of non-vital bleaching
a@ Inside;outside bleaching ><eonard and 9tettembrim et al &''-@
; Cabrication of a study model.
; <ight cured composite is placed on the model of the tooth or teeth to
be treated. This acts as a reservoir to be created in a vacuum
processed mouthguard whose thickness usually varies from 1.:1 and
1.?1 inch.
; )outhguard trimmed at the cervical margins on the labial and
lingual portions and tried in the patients mouth.
; The =P is the root canal is sealed off from the pulp chamber with
=I. or resin modified =I..
; Patient is taught how to in#ect &13 carbamide pero"ide into the
canal orifice and into the mouthguard with a syringe.
; G"cess .P gel can be removed by brushing or using a paper tissue.
??
; The patient may either sleep with the gel or remove the mouthguard
after & or : hours. If the patient prefers the latter, it will take a few
days longer.
; /t the end of the daily treatment, patient rinses his or her mouth and
then places a cotton pellet to prevent food from getting into the
opening.
; /n e"plorer can be used by the patient to remove the cotton pellet
before the ne"t procedure.
; The total treatment proceeds and rapidly concludes with the results
in as few as ? or 5 days.
b@ /nderson Takeo +ara, and <./.C. Punenta >&'''@ >suggested by
9passier@ used a technique where sodium perborate and water was used
as a walking bleach technique instead of +
:
O
:
to prevent cervical
resorption. 9odium perborate broke down to sodium metaborate and
+
:
O
:
. Two year results were satisfactory with this technique.
"omplications of internal #leacing
&. .ervical resorption
; Possible mechanism is that +
:
O
:
percolates from the access cavity
to the root surface through the acid treated patent dentinal tubules.
?5
; This stimulates an inflammatory response tending to dentin
resorption.
; /lternative theory F bacteria that have leaked into the pulp chamber
from the gingival crevice via the dentinal tubules or directly from
the access cavity may cause resorption.
; 7oot resorption can be arrested by placing .aO+ in the chamber.
:. 9pillage of bleaching agents
; O"idi$ing agents are more safe to handle as a paste than a solution.
; /pply rubber dam.
; /ny spillage must be diluted immediately with copious volumes of
water.
?. Cailure to bleach
; .ommonest is discolouration by metal ions in silver amalgam.
; Incomplete removal of composite resin or =I. which prevents the
bleaching agents to penetrate into dentinal tubules.
; +
:
O
:
which has passed its e"piry date or improperly stored.
?6
5. Over bleaching
; 7ecommended since it may darken with time
an assume desired shade.
; Important not to over bleach therefore ask the
patient to monitor and return in case of over bleaching.
6. Brittleness of tooth crown
; Bleaching causes the coronal tooth structure to
be brittle. This may be caused due to removing all the discoloured
dentin rather than using the bleaching agents to discolour the dentin.
c@ <aser assisted bleaching
; One company uses the argon laser wavelength
of 5,,nm for ?1 second to accelerate the activity of its bleaching gel.
/fter the laser energy is applied, the gel is left in place for ?;5 minutes
then removed. This procedure is repeated 5;0 times.
; /nother product uses Ion <aser Technology.
The argon laser is used as previously described. Then the .O
:
laser is
employed with another pero"ide solution to promote penetration of the
bleaching agent into the tooth to provide bleaching below the surface.
?0
; /rgon laser energy is in the form of a blue light
and is absorbed by the dark colour. It seems to be the ideal instrument
to be used in tooth whitening when used with 613 +
:
O
:
and a patented
catalyst. The affinity to dark stains ensures that the yellow;brown
colours can be easily removed.
; The .O
:
laser has no colour requirement. It is
unrelated to the colour of the tooth and the energy is emitted, in the
form of heat. It is invisible and penetrates only 1.&mm into water and
+
:
O
:
, where it is absorbed. This energy can enhance the effect of
whitening after the initial argon laser process.
?-
8) R!RNCS
&. Bleaching teeth! 7onald Ceinman, 7onald =oldstein and Eavid
=arber, Nuintessence Publishing .o. Inc., &',-.
Journals
&. +istory safety and effectiveness of current bleaching techniques
and applications of the night guard vital bleaching technique!.
+aywood (an B., Nuintessence Int., &'':% :? D 5-&;5,,.
:. /n atomic force microscopy study on the effect of bleaching
agents on the enamel surface!. .. +egedus et al, H. Eent., :- D &''',
61';6&6.
?. Gstimation of dissolution of calcium by Old )cInnes and Aew
)cInnes solution!.Aageswar 7ao 7. and Aangrani (., Ind. Gnd. H.,
&'',% 61;6?.
5. Bleaching teeth D Aew materials F new role!. 7onald G. =oldstein,
H./.E./., &',-% 5?;6:.
6. +istorical development of IhitenersD .linical safety and efficacy!.
(an B. +aywood, Eental 8pdate, &''- /pril.
?,
0. / technique for bleaching non;vital teeth!. <eonard 9ettembrim et
al, H./.E./., &''- 9eptember, &:,?;6.
-. Aon;vital tooth bleaching D / : year case report!. /.T. +ara,
<./.C. Pimenta, Nuintessence Int., &'''% ?1 D -5,;65.
,. <aser assisted bleaching D /n update!. H/E/, (ol. &:', Oct. ',
Pg. &5,5;&5,-.
'. The effectiveness of a modified hydrochloric acid quart$;pumice
abrasion technique on fluorosis stainsD / case report! =am$e
Grdogan, Nuint. Int., &'',% :' D &&';&::.
&1. Gnamel microabrasion D The technique!. .roll T.B., Nuint. Int.,
&','% :1 D ?'6;511.
?'
CONTNTS
I@ Introduction
II@ +istory
a@ (ital bleaching
b@ Aon;vital bleaching
III@ .auses of Eiscolouration and Indications
I(@ .ontraindications of Bleaching Teeth
(@ )echanism of /ction
(I@ +istologic Gffects of Bleaching
(II@ Treatment Planning
(III@ Techniques for (ital Bleaching
IJ@ Techniques for Aon;vital Bleaching
J@ 7eferences
51