1. Vital Bleaching
Dr. Ignatius Lee

3. Potential Results
Before
After

4. 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

5. 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

6. 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

7. Over the Counter Bleaching
6% to 14% hydrogen peroxide
Strips, wraps, paint on products
Least expensive
Results least predictable

8. Vital Bleaching Advantages
Low cost
High success rate
No tooth alternation

9. Vital Bleaching Disadvantages
Unpredictable results
Need Re-treatment
Possible side effects

10. Contraindications
When the extrinsic stain can be removed by a thorough prophylaxis
Dental caries
Discolored restoration
Restoration showing through

11. Vital Bleaching Mechanism
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

12. 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

13. 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

14. 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

15. Prognosis Brown fluorosis discoloration White spot Tetracyclin stain
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

16. Prognosis Uneven pulp size Initial color relapse
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

17. 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)

18. 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

19. 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

20. Effects on Restorations
Defective 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

21. 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).

22. 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

23. 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.

24. 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

25. 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

26. 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

27. Safety Issues Carcinogenic effect Ingestion Allergy
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

28. Excessive free radicals
Safety Issues
Excessive 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

29. JADA 135:319
6.6% HCl + silicon carbide microparticles
(Opalustre)

30. JADA 134:1066
18% HCl (PREMA)

31. Clinical Case 16 y.o. male Discoloration due to fluorosis
Opalustra (6.6% HCl + silicon carbide microparticles) - 4 x 60 sec
Followed by
Opalesence Xtra Boost (38% hydrogen peroxide) - 2 x 20 min

32. First session
Before
After

33. Second Session
Before
After

35. 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)

36. 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

37. 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

38. 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)

39. Nightguard Bleaching (Laboratory Procedure for Tray)
Make tray using vacuum former

40. 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

41. Nightguard Bleaching Clinical Protocol
Try-in Tray
Placed material in tray

42. Nightguard Bleaching Clinical Protocol
Seat in loaded tray
Removed excess
material

43. Nightguard Bleaching
Opalescence - sustained release

44. 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)