Vital Bleaching Dr. Ignatius Lee

Potential Results Before After

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 Bleaching Advantages Low cost High success rate No tooth alternation

Vital Bleaching Disadvantages 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 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

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 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

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

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 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

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 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

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

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

JADA 134:1066 18% HCl (PREMA)

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

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 Bleaching Clinical Protocol Try-in Tray Placed material in tray

Nightguard Bleaching Clinical Protocol Seat in loaded tray Removed excess material

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)