Vital Bleaching
Nubia Galeano DDS
Potential Results
Vital Bleaching
Modern era of vital bleaching began with Haywood and Heymann’s 1989 article on nightguard vital bleaching - using a custom fitted plastic mouthguard to apply a 10% carbamide peroxide gel.
Today there are 3 major methods for vital bleaching» In office or power bleaching» At home or tray bleaching» Over the counter
In-office/Power Bleaching
25% to 38% hydrogen peroxide Involve chair time; thus most
expensive Results most predictable
Good for non-compliant or unwilling patients, also for
patients demanding instant result
At Home or Tray Bleaching
10% to 22% carbamide peroxide (10%=3.6% hydrogen peroxide); 6% to 10% hydrogen peroxide
Typically will attain optimal results in 2-6 weeks
Results are dose/time dependent
Over the Counter Bleaching
6% to 14% hydrogen peroxide Strips, wraps, paint on products
Least expensive Results least predictable
Vital BleachingAdvantages
Low cost High success rate No tooth alternation
Vital BleachingDisadvantages
Unpredictable results Need Re-treatment Possible side effects
Contraindications
When the extrinsic stain can be removed by a thorough prophylaxis
Dental caries Discolored restoration Restoration showing through
Vital BleachingMechanism
The active ingredient is hydrogen peroxide, an oxidizing agent
It diffuses through the organic matrix of enamel and dentin
Produces free radicals, which are responsible for the bleaching process (oxidation)
These free radicals open the highly pigmented carbon rings and converting them into chains, which are lighter in color
Etiology of Tooth Discoloration
Extrinsic Stain» superficial changes» secondary to colored food, drinks (tea, coffee, cola), tobacco products, smokeless tobacco
» more of a problem if there are microcracks
Aged Related Color Change» thinned enamel» darkened dentin due to deposition of secondary dentin, more yellowish
Etiology of Tooth Discoloration
Intrinsic Stain» medication given systemically, e.g. tetracyclin, minocyclin
» fluorosis» systemic conditions, e.g. jaundice, erythroblastosis fetalis, porphyria
» dental caries» old restorations showing through, e.g. amalgam
» trauma» heredity
Prognosis
Discoloration due to aging, inherited discoloration, smoking, chromogenic materials, trauma (evenly distributed discoloration) - EXCELLENT PROGNOSIS
Works better in removing yellow, orange and light musky brown color
Dark blue-gray stain do not response as well
Prognosis Brown fluorosis discoloration» good prognosis, may need micro-abrasion and at home bleaching
White spot» not removed, only get lighter during treatment
Tetracyclin stain» do not typically response well
» may need multiple in-office application, extended take home application (2 to 6 months) or combination
Prognosis
Uneven pulp size » uneven results; smaller pulp slower to lighten or do not lighten as much
Initial color relapse » due to oxygen trapped in tooth diffuses out of tooth
Longevity of color change » one to three years, individual variations
Non-responsive teeth » extend treatment time or use in-office bleaching as a booster
Effects on Restorative Materials
Composite» minimal changes in color, surface roughness and physical properties
» may increase microleakage at CEJ with earilier generation of dentin bonding system
» effect unknown on the current generation of bonding system
Amalgam» in one invitro study, the amount of mercury released into the peroxide solution was significantly higher than released into saline solution (4-30x)
Effects on Restorative Materials
Ceramic» no effects on the color or physical properties
Luting cements» an intro study showed that glass ionomer, and particularly zinc phoshpate dissolved readily in 10% carbamide peroxide
» clinical significance not known
Effects on Restorative Materials
Temporary restorations» causes microscropic surface change in IRM (Intermediate Restorative Material, a eugenol based temporary material) in both hydrogen peroxide and carbamide peroxide
» macroscropically, IRM appears cracked and swollen when exposed to hydrogen peroxide but not carbamide peroxide
» metharcylate discolored when exposed to carbamide peroxide
» causes no color change in polycarbonate crown and composite-type temporary
Effects on RestorationsDefective restoration
» should consider repairing defects before bleaching to prevent unwanted penetration of the bleaching agent through open margin
» should consider temporary repair instead of replacing the restoration because of color match concern
Composite / Bonding» delay any bonding or composite procedure for at least one week following bleaching
» rationale: lower bond strength and allow for better color match due to regression of bleaching result
Effects on Pulp
Application of peroxide gel resulted in rapid penetration of peroxide to the pulp chamber.
Minor irritation of the pulp tissue did occur, but that it was resolved within 2 weeks after cessation of treatment.
No differences between whitened and unwhitened teeth on their responses to electric or cold pulp tests (up to 12 years following bleaching).
No evidence of irreversible pulpitis even in extended treatment regimen (more than 6 months).
Effects on Enamel
Lower enamel microhardness (3% to 7%) immediately after treatment
Slight increase in surface porosity as observed under SEM.
More surface dissolution by phosphoric acid
Safety Issues
Sensitivity to Temperature Change» Primary side effect associated with vital bleaching.
» Typically begins early in the bleaching process (1st or 2nd day); increased during the course of the treatment.
» Usually mild and transient in nature.» Adding potassium nitrate and sodium fluoride to the formulation results in significant reduction in sensitivity as reported by the patients.
Safety Issues
Sensitivity to Temperature Change» Reported incidence of sensitivity from 7% to as high as 75%
» Of those who experienced sensitivity; over 70% are labeled as mild and less than 10% are labeled as severe.
» Up to 20% of placebo group experienced sensitivity (due to tray or glycerin)
» Predictors of sensitivity: history of tooth sensitivity and treatment frequency (more 1x/day) and dose (concentration and time)
» Non-predictors: age, gender, exposed dentin/cementum, cracks, pulp size, caries
Safety Issues
Sensitivity to Temperature Change - Remedy» Reduce wear time or frequency of application
» Utilize a lower concentration of peroxide
» Immediate removal (in-office) or refrain from using for a couple days
» Utilize a product that contain fluoride and or sodium nitrate
Safety Issues Irritation of gingiva
» due to improper isolation (leaking rubber dam) or excess bleaching agent (patient sensitive to bleaching agent or poor fitting nightguard)
» poor fitting or improperly trimmed nightguard» immediate removal (in-office) or for 2-3 days» reduction of wearing time, remake nightguard
Not recommended for pregnant or lactating woman
Safety Issues Carcinogenic effect
» potentiate the effect of a known carcinogen associate with tobacco products (DMBA)
» special warning for smokers; refrain Ingestion
» not a major problem» taste and laxative effect from the glycerine base
Allergy» peroxide, nightguard material
Safety IssuesExcessive free radicals
Low level: may contribute to aging.
Moderate level: oxidation damage to DNA occurs, thus possibly leading to mutations and possible carcinogenic.
High level: death
JADA 135:319
6.6% HCl + silicon carbide microparticles (Opalustre)
JADA 134:1066
18% HCl (PREMA)
Clinical Case
Opalustra (6.6% HCl + silicon carbide microparticles) - 4 x 60 sec
Followed by
Opalesence Xtra Boost (38% hydrogen peroxide) - 2 x 20 min
16 y.o. maleDiscoloration due to fluorosis
First session
Before
After
Second Session
Before
After
In-office Bleaching(Clinical Protocol)
Clean teeth with pumics
Record pre-op shade
Isolate teeth as close to the gingival margin as possible with rubber dam (no tears, leakage, fully inverted)
In-office Bleaching(Clinical Protocol)
Mix the thickening agent (Cab-o-Sil) with 35% hydrogen peroxide to a non-slumping consistency.
Place the gel material on the teeth for 30 min
In-office Bleaching(Clinical Protocol)
May need to “refresh” with hydrogen peroxide liquid if the gel appear too dry
Rinse and clean; remove rubber dam and record post-op shade
Nightguard Bleaching(Laboratory Procedure for
Tray)
Trim cast to ideal thickness for use in vacuum former» base of cast parallel to occulsal plane, and 4-5mm from gingival margin (result in good adaptation of tray material)
Nightguard Bleaching(Laboratory Procedure for
Tray)
Make tray using vacuum former
Nightguard Bleaching(Laboratory Procedure for
Tray)
Trim tray using #25 Bard-Parker blade» trim to gingival margin; scallop around interdental papilla
Smooth edges using alcohol torch
Nightguard BleachingClinical Protocol
Nightguard BleachingClinical Protocol
Nightguard Bleaching
Opalescence - sustained release
How to deal with patient’s expectation
Bleaching is an inexact science Results depends on dentist’s skill, individual variation in the teeth, and the patient’s continuing habits , diet and hygiene care
Difficult to guarantee results Keys to avoid problem
» ensure that patient understand the limitations and what is involved in keeping the enhanced look for as long as possible
» document patient’s appearance before treatment (intraoral camera, photo, shade guide, reference pt)