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Dental Materials 11
Dr. Alaa Omar

‫مدير األكاديمية عمر الحريبات‬

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 "Tooth Whitening"

 This process was called bleaching.

 Tooth whitening can be done on both, vital
and non-vital teeth, it depends on the case,
different materials with different strength,
concentrations and agents can be used to
lighten and whiten the teeth that were
discolored\became dark for several reasons
color of the tooth.

 When to restore and not whiten teeth?

 If discoloration is too severe, tooth whitening may not work, we refer to
restorative options, like :
1. Crowns and Veneers.
2. Whitening followed by restorations, restorations must by delayed as any remaining
part of the whitening agents \whitened enamel can produce weak bond with
composite and the color might darken a little after bleaching before it became
stable.
 Tooth whitening is a more conservative option compared to crowns\Veneers.
 Success depends on:
 Type or cause of discoloration & Intensity.
 Whitening agent used, strength, length of exposure, technique used.
 Tooth vitality (patients might complain sensitivity, so they wait until the pain
subsides to continue the treatment).
 Presence of restoration.
 For non-vital teeth:
- We refer to it as walking bleach because  For vital teeth we have three types:
you place the whitening agent in the 1. Home bleaching.
RCTed tooth(non-vital),then the patient 2. In-office (done by the dentist).
walk out for 7-10 days then he came back 3. Whitening strips(done by the patient).
to access the progress of the whitening
procedure.
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 Types of discoloration:

1. Non vital teeth:

a. Teeth with necrotic pulp.

b. Teeth that have
undergone endodontic
treatment.

 The discoloration is
usually dark in color; it
could be either from
a. The necrotic pulp.
b. GP remnants at the coronal part of the tooth.
c. The decomposition of HB in RBCs in the diseased pulp.

2. Vital teeth:

 Teeth become more yellowish with aging because of the extra production of tertiary
dentin.

3. Staining: the main problem that can cause discoloration, it can be:

a. Extrinsic stains can be removed partially by tooth paste, scaling and polishing,
tooth whitening.
b. Post-eruptive: amalgam (cannot be properly removed by whitening), caries,
endodontic treatment.

c. Pre-eruptive: during formation or calcification.

 Tetracyclin: bonds chemically with hydroxyapatite appear brown or gray.
 Fluorosis: ranges from white shadows on enamel to brown spots and pitting.
 Dentinogenesis and Amelogenesis Imperfecta (no success).

 The above Pre-eruptive stains are very hard to be treated by bleaching.

 You should always tell the patient what to expect from treatment and advice him to
keep up with natural shades and avoid very white shades.
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 How does a whitening agent work?

 The whitening agent oxidizes the pigments, breaks

them down, it whitens them and makes them soluble,
so they dissolve and the color or the shape of the
tooth becomes white (oxidizing action).

 This action is enhanced by low intensity heat or high

intensity light (blue light), so the process becomes
quicker but it may cause more sensitivity to the
patient.
 Always lighten the color of the teeth one shade
lighter than what the patient wants, so that when he
finishes the treatment and the color stabilizes, it will be just like what he wants.
 Smokers have to stop or reduce the amount of smoking to avoid relapse.

Whitening agents:

1. Hydrogen peroxide:

 The main whitening agent available to use, it can be

used in a variety of concentrations depending on the
severity of the case and the technique you will use.

 Hydrogen peroxide (H2O2): it is an oxidizing agent that breaks up into water and
oxygen.
 Free radicals of oxygen are highly reactive and cause whitening.

 It can cause reversible pulpitis, the patient will feel sensitivity temporarily, once the
patient stops using the product, the pain is going to subside, and therefore you
need to give instructions and precautions to the patient.

 Concentration (5-35%) gel or liquid, the gel is easier to use as it will not flow
everywhere.
 Many factors can affect what agent we use for bleaching.

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2. Carbamide peroxide:

 Usually used with home bleaching techniques, because it is a weaker product

compared to hydrogen peroxide so it’s less irritant (safer).
 Breaks up into: Urea & Hydrogen peroxide.
 Carbopol is incorporated in the product, it is easier to apply and it increases
adhesion to tooth surface, and it is also a thickening material (like a gel).
 Available in different concentrations: 10-20% or higher, depending on the severity
or the patient (if you have sensitive teeth, you can use lower concentrations).
 10% carbamide peroxide gives off 3% hydrogen peroxide so it is weaker than the
pure hydrogen peroxide.

 Examples:
a. Opalescence: very popular, based on hydrogen peroxide.
b. Poladay(day use) and Polanight(night use):everyone has its own instructions ,and
patients may come back with TMJ pain but they will get used to it.

3. Sodium peporate:

 Used specifically for non-vital teeth.

 Weak oxidizing agent that’s why we use it for walking bleach.
 It is a powder that can be mixed with water or usually
hydrogen peroxide into a paste, we put it in the tooth access
cavity after removing the filling and placing a liner to protect
the GP, then we close it up with TF and sent the patient home
for 7 days, at the next visit, when the shade of the tooth is fine,
we remove it and restore the tooth.
 If it needs more whitening, we can refresh the material.

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 Whitening technique:

Non-vital teeth

1. Power whitening:

 In these cases the bleaching product is activated either by

light or heat, to make the treatment more intense and
therefore faster results.
 Power whitening can be done for vital teeth also.
 The laser, light, or heat activated material is placed on the
coronal surface of the tooth then activated after applying
resin dam. Then after 7-14 days the tooth is restored.
 Remember when applying any type of whitening treatment (vital or non vital) to
protect the gingiva and the mucosa to prevent irritation from bleaching agents by
applying Vaseline on the gingiva, lips and mucosa and isolate teeth by rubber dam.
 There is another type of dams which are resin dams, they are injected all around,
and so only the coronal part of the tooth is exposed.

2. Walking bleach:

 Notice the discoloration of the tooth in the

picture, this happened either because of the
necrotic pulp or after RCT, so here the dentist
is going to open up the access cavity and fill it
with the bleaching agent, then place a
temporary filling then the shade of the tooth
becomes lighter, after that the TF and the
bleaching material which is the sodium
perborate are going to be removed, then a permanent restoration is placed.

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 Sodium perborate is mixed with 35% hydrogen
peroxide then applied in pulp chamber for 3-7
days.
 One of its disadvantages, is that it can cause
external root resorption if not used properly,
especially if there is overcutting in the tooth
surface while dong the access cavity, and no
enough support for enamel ,so the hydrogen
peroxide going through the dentinal tubules towards the cementum.

Vital teeth whitening

 Professionally applied, in-office.

 Assisted by Laser, in order to make it more intense (more dangerous to the tooth).
 Supervised patient applied:
 Hydrogen peroxide
 Carbamide peroxide
 Professional whitening and Stain removing swabs.
Here the patient comes to the clinic, you take an impression to make a special
tray so that he can put the bleaching agent in it and you take the initial shade
and he will come back for assessment.

 Un-supervised patient applied.

 Crest white strips
 Whitening dentifrices
 Additional products
 Some whitening gums

The products that are not supervised by the dentist and used by the patient have
low concentration of the whitening agent.

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 a. In office whitening:

 Power whitening, to make it more intense.

 In some cases, single visit can achieve very good results, if the patient wants extra
whitening, he can continue with home products.
 Gel 15-35% hydrogen peroxide H2O2.
 Patient protection, rubber, or paint on resin dam (Vaseline).
 Light or heat activated method.
 May contain chemical or light activators.
 We should not use local anesthesia, because the sensation gives you an indication
whether your treatment is going well or not, for example if the patient feels great
pain, you have to stop the treatment.
 Retreatment may be needed as early as 6 months or every 2 years usually, depends
on the patient and how far can he maintain the shade of his teeth.

 Activation method effectiveness is questionable,

what really works is the oxidizing agent itself
(hydrogen peroxide),but if might faster the process
 We put glasses on the patient's eyes to protect him
from the blue light.

 Resin dam application after putting

Vaseline, we do that to protect the
gingiva and the surrounding soft tissues
from the irritant agent.

 Hydrogen peroxide application.

 This is all for protection, we

should be careful where we
inject the bleaching agent.

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b. Laser whitening (single session):

 It is very powerful and fast, so a single session should be enough.

 Laser (argon, carbon dioxide) activates the whitening agent.
 Laser also interacts with the stain to neutralize it, but neutralization becomes less
active as the tooth becomes whiter.
 Very fast technique.
 Extra caution is needed.
 Can increase intra-pulpal temperature (over heating of the pulp).
 Should never be used in full power for vital teeth in
order to avoid any damage to the pulp.
 Pre-bleaching procedure using whitening enhancement
swabs are used (mentioned later).

c. Patient applied, professionally supervised (home

bleaching):

 Depends on length of treatment and strength of the whitening agent, this will
affect the results.
 Also depends on the compliance and the cooperation of the patient.

 Materials used:

i. Hydrogen peroxide:

 2-10% gel
 You take an impression for the patient and make a
custom tray.
 Worn for 30 min for multiple sessions (depends on
product and instructions).
 Professionally supervised white strips from Crest (3-
14% concentration).
 Worn 30 minutes twice daily for 30 days.
 Unsupervised strips are available but have lower % of bleach.

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  Example : Opalescence

 6, 10, 15% hydrogen peroxide.

 Patient applied tray (Loaded in the tray).
 Snugly fits and contains whitening gel, it should
fit well around the teeth so that the gel is
contained in the tray and does not flow all over
the gingiva or the lips.
 Duration to be worn depends on concentration.
 If sensitivity occurs, discontinue the treatment.
 The patient can use desensitizing agent based on
fluoride or potassium nitrate in order to minimize the sensitivity, so that he can
use the product, or he can change the product.

ii. Carbamide peroxide:

 Weaker than hydrogen peroxide.

 Chemical used 10-22% carbamide peroxide at a near
neutral pH in a viscous gel.
 Custom-made trays(alginate impression).
 To be worn during the day or at night.
 Poladay: used during the day for 30-45 min.
 Polanight: used at night, might be annoying.

 So, you need to take a photo for the patient

and the shade before the treatment, and you
need to take an impression.
 The gel is available in syringes, it is injected
into the tray where each tooth is, and then
the patient can put the appliance in.
 The treatment can take 2-3 weeks until he is
satisfied with the shade.
 It might cause irritation so desensitizing
agents are used.

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 iii. Professional whitening and stain removing
swabs:

 Power swabs were introduced as pre-bleaching

products (mentioned previously).
 Used before home bleaching or in office bleaching.
 Pre-bleaching procedure using whitening enhancement
swabs to clean the external surface of the tooth and
hydrate it before the whitening procedure, used in
combination with the whitening agent.
 Contains solvents, chelators, saponifiers, surfactants.

d. Over the counter products, unsupervised:

 Crest whitening strips (3-7% Hydrogen peroxide),

low concentration, not effective.
 Whitening dentifrices (tooth paste): the effect is
mainly achieved by mechanical removal of stains by
abrasives.
 They might contain whitening products and they
also contain some abrasives:
 Hydrated silica.
 Precipitated calcium carbonate.
 Dicalcium phosphate dehydrate
 Some contain peroxides (H2O2, sodium percarbonate, calcium
peroxide).

e. Additional products (used by the

patient):

 Mouth rinses
 Floss
 Chewing gum
 Whitening pens

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 Side effects of bleaching:

o Sensitivity (from tray pressure or whitening agent).

o Irritation of the gingiva.
o Soreness of the muscles of mastication from wearing night guards overnight.
o Roughness of composite restoration surfaces.
o Keep in mind that the composite doesn’t bleach like the teeth, so the patient might
need to change the restoration after doing the whitening procedure.
o Enamel breakdown (staining, pitting).

 Potassium nitrate tooth paste maybe used for 2 weeks before and during
treatment to protect from sensitivity.

Contraindications for tooth whitening:

 Allergy to bleaching agent.

 Patients with very sensitive teeth
 Patients with multiple composites who do not wish to replace them.
 Cracked or hypoplastic enamel.
 Carious lesions
 Radiation therapy, chemotherapy (no light activated products).
 If patient is diagnosed with melanoma (no light activated products).
 Using photosensitive drugs
 If non vital tooth is heavily restored
 Amalgam stains will not be removed by non vital whitening.

So you need to take detailed history from the patient.

What to consider during tray whitening?

 Patients should be given instruction on how to manage tooth sensitivity, gingival

irritation.
 Reversible pulpitis may occur and may require discontinuation of treatment if it
continues.
 Vitamin E oil may help to smooth the tissue when power whitening.
 The patients should be advised to use over the counter products with ADA seal.

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 Restorative considerations:

 Before bleaching:
A. Carious teeth should be restored.
B. Leaky restorations replaced.

 After bleaching:
A. Esthetic restorations may need to be replaced.
B. 2 weeks period is needed for teeth color to stabilize and to replace composites
or veneers, so the shade of the teeth will slightly change (become darker) after
you finish the treatment, so once the color stabilizes you can go ahead with the
restoration.
C. Keep in mind that you cannot restore the tooth immediately after bleaching
because this might interfere with the bonding or adhesion of composite.

The End

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