bleaching-teeth//nubia galeano

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)