BLEACHING

Presented by:
Suman Waiba Tamang
Roll no.31
BDS final Year

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CONTENT
 Tooth discoloration
 Classification of tooth discoloration
 Bleaching
 Classification of bleaching treatments
 Mechanism of bleaching
 Vital and Non-vital bleaching techniques
 Bleaching of tetracycline stained teeth
 Micro-abrasion and Macro-abrasion
 Conclusion
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 References
TOOTH DISCOLORATION

 Tooth discoloration is defined as “ any change in the

hue, color, or translucency of a tooth due to any cause;
restorative filling materials, drugs (both topical and
systemic), pulpal necrosis, or hemorrhage may be
responsible.”
- Ingle 6th edition

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CLASSIFICATION OF TOOTH DISCOLORATION

 Can be classified on basis of several factors. For

example location, etiology, no. of teeth involved, etc.

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BASED ON CAUSE:- INGLE

Dentist related cause Patient related cause

ENDODONTICALLY
RELATED 1. Pulp necrosis
Pulp tissue remnants 2. Intarpulpal
Intracanal medicaments haemorrhage
Obturating materials 3. Dentin
hypocalcification
4. Tooth formation
defects
RESTORATION 5. Developmental
RELATED defects
Amalgams 6. Drug-related defects
Pins and posts 5
Composites
BASED ON LOCATION OF DISCOLORATION
 Given by Dayan et al 1983, Hayes et al 1989
EXTRINSIC STAINS INTRINSIC STAINS
Located on outer surfaces of the teeth Located on internal surfaces of teeth

Causes: Causes:
1. Remnants of Nasmyth 1. Hereditary disorders
membrane 2. Medications
2. Poor oral hygiene 3. Excess fluoride
3. Existing restoration 4. High fevers associated with
4. Plaque and calculus formation early childhood illness, and
5. Eating habits: tea, coffee stains other types of trauma.
6. Tobacco chewing habit 5. Staining may be located in
7. Chromogenic bacteria enamel or dentin
8. Mouthwashes: chlorhexidine
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BASED ON SURFACE AREA OR NUMBER OF
TEETH INVOLVED
LOCALISED GENERALISED
1. Non-vital 1. Tetracycline staining.
2. Amalgam blues 2. Fluorosis
3. Turner’s hypoplasia 3. Tobacco stains
Due to trauma, high fever during the 4. Because of ageing,
stage of development generalized yellowish
4. Localized area of dys-mineralization or the discoloration
failure of the enamel to calcify properly can 5. Tea or coffee stains
result in hypo-calcified white spot
5. After eruption, poor oral hygiene during
orthodontic treatment frequently results in
decalcified defects

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CLASSIFICATION BY NATHOO AND GAFFAR

 Based on chemistry of discoloration

 Classified extrinsic stains as:

I. N1 type or direct dental stain: The colored materials

(chromogens) bind to the tooth surface and cause
discoloration. The color of the dental stain is same as the
color of the chromogen. E.g. Bacterial adhesion to pellicle,
tea, coffee, metals and wine

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CLASSIFICATION BY NATHOO AND GAFFAR

II. N2 type or direct dental stain: The chromogen changes

color after binding to the tooth. E.g. Food that has aged

III. N3 type or indirect dental stain: Colorless material or a

pre-chromogen binds to the tooth and undergoes
chemical reaction to cause a stain. E.g. Browning of foods
that are high in carbohydrate and sugar, cooking oils,
baked products and fruit.

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BASED ON ETIOLOGY
PRE-ERUPTIVE POST-ERUPTIVE
1. Amelogenesis imperfecta 1. Age
2. Dentinogenesis 2. Dental materials
imperfecta 3. Food, beverages and
3. Endemic fluorosis habits such as smoking
4. Erythroblastosis fetalis 4. Idiopathic pulpal
5. Porphyria recession
6. Sickle cell anaemia 5. Traumatic injuries
7. Thalassemia 6. Internal resorption
8. Medications: tetracycline
staining

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MANAGEMENT/ TREATMENT
 Prevention
 Scaling: Most of the surface stains can be removed by
routine prophylactic procedures.
 Micro-abrasion
 Macro-abrasion
 Veneers:
 Direct veneers
 Indirect veneers
 Ceramic crowns
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 Bleaching: • Non-vital bleaching • Vital tooth bleaching
BLEACHING

 The lightening of the color of a tooth through

the application of a chemical agent to oxidize
the organic pigmentation in the tooth is
referred to as bleaching.
-Sturdevant

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HISTORY

 Bleaching of non vital teeth was reported in 1848

 Inoffice bleaching of vital teeth was 1st reported in
1868.
 By early 1900s, in-office vital bleaching had evolved to
include the use of heat and light for activation of the
process.

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BLEACHING AGENTS

 The most commonly employed bleaching agents are as

follows:
A. Hydrogen peroxide
B. Sodium perborate
C. Carbamide peroxide
D. Over-the-counter (OTC) agents

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A. HYDROGEN PEROXIDE
 They are strong oxidizers
 Concentration between 5 and 40%.
 In office: 25-38%, at home 3-7.5%
or even 14%
 Mechanism of Action
 H2O2 has a low molecular
weight and hence can penetrate
dentin and release oxygen that
breaks down the double bond of
inorganic and organic 17

compounds inside the tubule.

PROPERTIES:
 Itis a clear, colorless, odorless liquid, stored in lightproof
amber bottles.
 Itis unstable and should be kept away from heat, which
could cause it to explode.
 Itshould be stored in sealed refrigerated containers, as it
decomposes readily in an open container and in the
presence of organic debris.
 It has ischemic effect on skin and mucous membrane causing
a chemical burn. It is especially painful if it comes in contact
with the nail bed or the soft tissue under the fingernail.
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 Because the amount needed for a bleaching operation is
about 1–2 mL, the solution can be dispensed into a clean
dappen dish.
 Once treatment has been completed, any remaining
solution should be discarded.
 H2O2 can be used alone or mixed with sodium perborate
into a paste for use in the “walking bleach technique.”

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B. SODIUM PERBORATE
 Stable,white powder, normally supplied in a granular
form that has to be ground into a powder before using.
 Types: Vary in their oxygen content:
 Sodium perborate monohydrate
 Sodium perborate trihydrate
 Sodium perborate tetrahydrate

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MECHANISM OF ACTION
 Thepowder is water-soluble. When mixed into a paste with
superoxol, this paste decomposes into sodium metaborate,
water, and oxygen.
 Sodium perborate → Sodium metaborate + Hydrogen
peroxide + O2
 When sealed into the pulp chamber, sodium perborate
oxidizes and discolors the stain slowly, continuing its activity
over a longer period of time. This procedure is called the
walking bleach technique.

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C. CARBAMIDE PEROXIDE
 Also known as urea hydrogen peroxide.
 Concentration ranges from 3 to 45% depending on at-home and
in-office bleach.
 The most popular commercial preparations have a
concentration of 10% carbamide peroxide.

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Mechanism of Action

 Carbamide peroxide → Urea + Ammonia + Carbon dioxide + 3.5%

hydrogen peroxide
 Additives in gel preparation include glycerine or propylene glycol,
sodium stannate, phosphoric or citric acid, and flavoring agents.
 Some preparations contain carbopol, a water-soluble polyacrylic acid
polymer, which is added as a thickening agent. It prolongs the release
of active peroxide and improves the shelf life.

Making a paste by mixing two spoonful of powder with 1 drop of glycerol 23

to a firm consistency then placing the mixture into the pulp chamber.
D. OVER-THE-COUNTER (OTC) BLEACHING
AGENTS
 Include tray systems, tray-less
systems, chewing gums, tooth pastes,
bleaching strips, and paint-on
products.
 The scientific rationales behind such
systems are not justified because the
cause of tooth discoloration is diverse.
 These products primarily work by
removing extrinsic surface stain only. 24
MECHANISM (REDOX REACTION)
Tooth + Bleaching agent
(Reducing agent takes up electron) (Oxidizing agent gives fee
electrons)

Free reactive radicals react with the unsaturated bonds

Larger stain molecules are converted into smaller one

Simpler molecules are formed

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Reflects less light or becomes colorless

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 The degree of shade change depends on:
 The concentration of hydrogen peroxide (greater
concentration = greater shade change)
 The time it is in contact with the teeth to be
bleached.

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 Chemical Reason for inclusion
Hydrogen peroxide Active ingredient
Carbamide peroxide Source of hydrogen peroxide
Sodium perborate Source of hydrogen peroxide
Urea Stabilizer, and increases the pH, which is less irritant to
soft tissue
Increased antibacterial effect
Glycerine Increases viscosity, so that the product is retained in the
bleaching tray
Carbopol (polyacrylic acid polymer) Increases viscosity, decreases breakdown in saliva and
slows release of oxygen

Alcohol ethoxylates or sodium xylene sulphonate Surfactant – promotes wetting by lowering surface tension

Amorphous calcium phosphate (ACP) Decreases sensitivity by occluding the dentinal tubules
with calcium phosphate

Improves enamel smoothness

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and restores luster
 Potassium nitrate Decreases sensitivity by altering nerve conduction

Fluoride (e.g. sodium fluoride) Decreases sensitivity by occluding the dentinal tubules

Promotes remineralization

Provides caries resistance

Neutralizers Alkaline substances to create neutral pH

Flavorings Increases patient acceptability

Carotene Converts light energy to heat so increasing the activation

of hydrogen peroxide by speeding up its dissolution into
free radicals in products intended to be exposed to light
energy

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CLASSIFICATION OF BLEACHING
TREATMENTS

1. Non vital bleaching procedures:

1. In-office nonvital bleaching technique
2. Walking bleach technique

2. Vital bleaching procedures:

1. In-office vital bleaching techniques
2. Dentist-prescribed, home applied technique

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A. INTRACORONAL BLEACHING (BLEACHING OF AN
ENDODONTICALLY TREATED TOOTH/NONVITAL BLEACHING)

1. Walking Bleach Technique:

 An in-office bleaching procedure that does not require
the use of heat and employs Sodium perborate as
bleaching agent.
 Process is slower and continues till the patients reports
back for the subsequent appointment for assessment
and cessation of the treatment. So called walking bleach

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INDICATIONS AND CONTRAINDICATIONS OF
WALKING BLEACH TECHNIQUE
Indications Contraindications
• Discoloration of pulp • Superficial enamel
chamber discoloration
• Dentin discoloration • Defective enamel
formation
• Discolorations not • Severe dentin loss
amenable to extra coronal • Presence of caries
bleaching • Discolored composites

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PREPARATION
 The crowns should be relatively intact. Crowns weakened by an
access preparation and with large or multiple restorations or large
carious lesions are not recommendable for bleaching.
 These teeth should be restored with a post and core and a full-
veneer porcelain crown for the best functional and esthetic result.
 The root canal filling should be well condensed, radiopaque, with
no voids, and well adapted to the root canal walls to prevent
percolation of the bleaching solution into the periradicular tissues.
 Ifthe canal is obturated with a silver cone, the cone should be
replaced with a well-condensed gutta-percha filling, before
bleaching is attempted.
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CLINICAL PROCEDURE: WALKING BLEACH
TECHNIQUE
 Step 1: Isolation and access refinement:
 Prepare the tooth for bleaching by polishing the enamel
surface with a prophylaxis paste to remove any gross
surface debris or discolorations.
 Apply petroleum jelly to the gingival tissues around the
tooth to be bleached for protection against tissue
irritation.
 Adapt the rubber dam, invert it, ligate it with wax dental
floss, and hold it securely in place with a clamp on the
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tooth to be bleached.
 Re-establish the access cavity.
 Remove any gutta-percha root canal filling that extends
into the pulp chamber with a hot finger plugger or Gates-
Glidden drill to the level of the crest of the alveolar bone.
 The remaining root canal filling should be vertically
condensed with finger pluggers to 1 mm apical to the
cementoenamel junction.
 This can be confirmed with the help of a periodontal
probe placed in the pulp cavity and reproducing the same
probing depth in the gingival sulcus.
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STEP 2: CORONAL SEALING CEMENT
 Seal the orifice of the root canal with at least 1 mm
intracoronal barrier over the gutta-percha to prevent
percolation of the bleaching agent into the apical area.
 Materials used as barriers:
 Glass ionomer cement, resin-modified glass ionomer
cement (RMGI), Cavit, or mineral trioxide aggregate
 Of these, MTA has been shown to be superior.
 Itis important to confine the bleaching agents to the crown
of the tooth above the level of the bone. Since cervical root
resorption has been reported following bleaching.
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STEP 3: SODIUM PERBORATE BLEACHING
 Protect the exposed areas of the patient’s face by draping it
and cover the patient’s eyes with glasses. The patient’s
clothing should be covered with a plastic apron. The
operator should wear gloves to protect his hands.
 Mix sodium perborate powder with distilled water. In case
of severe stains, 3% hydrogen peroxide can be used to form
a thick paste in a clean dappen dish.
 Carry the thick paste into the pulp chamber with a plastic
instrument or amalgam carrier. Make sure the entire facial
surface of the pulp chamber is covered with the paste.
 Place a small cotton pellet, slightly moistened with H2 O2,
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over the bleaching paste

STEP 4: TEMPORARY SEAL
 Seal the access cavity to a thickness of 3 mm using an adhesive
material. This ensures a tight seal around the margins and prevents
the leaching of bleaching material.
 If materials like intermediate restorative materials are used then
apply pressure with the gloved finger against the tooth until the
filling has set. This is to ensure that the temporary filling is not
displaced with the liberation of oxygen.
 The area should remain isolated for approx. 5 min after closure to
evaluate the adequacy of the seal of temporary restoration.
 Ifbubbles appear around the margins, it indicates leakage so
temporary restoration must be replaced.
 Ifno bubbles, remove the rubber dam and check the occlusion for38

any abnormal contacts

STEP 5: INTERAPPOINTMENT SCHEDULE:
 The sodium perborate is changed weekly.
 Ifthe shade is too dark, additional bleaching is necessary. If
the shade is too light, the tooth should be permanently
restored.
 On successful bleaching of the tooth, the chamber is rinsed
and filled to within 2mm of the cavosurface margin with a
paste consisting of Ca(OH)2 powder in a sterile saline. The
walls and margins are kept clean and free of Ca(OH)2 paste.
 This reduces the possibility of the resorption.
 The access cavity is resealed with a temporary restoration
to allow the Ca(OH)2 to remain in the pulp for 2 weeks 39
STEP 6: FINAL CORONAL RESTORATION

 Temporary filling is removed and Ca(OH)2 is rinsed

away and the chamber is dried.
 Tooth is restored with light cure composite.

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 Internalstaining of the dentin caused by the remnants
of obturating materials in the pulp chamber, as well as
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by materials and tissue debris in the pulp horns.

 Coronal restoration is removed completely, access preparation
is improved, and gutta-percha is removed apically to just below
the cervical margin. Next, the pulp horns are cleaned with a
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round bur.
 A protective cement base is placed over the
gutta-percha, not extending above the cervical
margin. After removal of sealer remnants and
materials from the chamber with solvents, a
paste composed of sodium perborate and
water (mixed to the consistency of wet sand)
is placed. The incisal area is undercut to retain
the temporary restoration.

Materials used as barriers:

- Glass ionomer cement, resin-modified glass ionomer cement (RMGI), Cavit,
or mineral trioxide aggregate 43
 A temporary filling seals the access.

44
 At a subsequent appointment, when the desired shade has been reached, a
permanent restoration is placed. Acid-etched composite restores lingual
access and extends into the pulp horns for retention and to support the
45

incisal edge.
Before and After Opalescence Endo Non-Vital Whitening Gel 40% H2O2
(Photo courtesy of Dr. Rich Tuttle) 46
CLINICAL CONSIDERATION:
 The maximum bleaching effect is attained about 24 hours after
the treatment.
 Teeththat are bleached a shade too light seem to revert to their
former color shortly after bleaching.
 This phenomenon may be associated with the ingress of
pigmenting substances from the saliva into the dentin by way of
the enamel, whose permeability may have been increased by the
bleaching process.
 Generally, two treatments, performed about a week apart, are
necessary to attain the desired shade, although in some cases a
single treatment is sufficient 47

 Slight potential (1%) exists for external root resorption.

2. BLEACHING OF ENDODONTICALLY TREATED TEETH IN
OFFICE (HEAT-AND-LIGHT/ THERMOCATALYTIC BLEACHING)

 Involvesa thermocatalytic technique consisting of the

placement of the 35% H2O2 liquid into the debrided
pulp chamber and acceleration of the oxidation process
by placement of heating instrument into the pulp
chamber.
 Current technique uses 30-35% H2O2 pastes or gels
that requires no heat. This is frequently the preferred
technique for in-office bleaching technique. 48
PROCEDURE:
 Afterpreparation of the tooth as previously described, a loose
mat of cotton is placed on the labial surface and another is
placed in the pulp chamber of the tooth to be bleached.
 The loose cotton mats are saturated with 30% H2O2 .
 Thesolution is activated by exposing it to light and heat from a
powerful light.
 The tooth is subjected to several, usually 5- to 6-minute
exposures and the bleaching solution is replenished at frequent
intervals.
 On completion of the bleaching process, a pellet of cotton
moistened with H2O2 , or H2O2 and sodium perborate, is sealed
49

in the pulp chamber until the following appointment.

 An alternative to activate the H2O2 is the application
of a thermostatically controlled electric heating
instrument or a stainless steel instrument heated
over a flame.
 Heat and light from a photoflood light aimed directly
on the tooth from a distance of 2 feet or more also
activate H2O2 .

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EXTERNAL CERVICAL ROOT RESORPTION
WITH BLEACHING

 On average, 10% of the cases of internally bleached teeth

showed external cervical resorption as a consequence.
 Onset in 1-7 years.

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 The hydrogen peroxide liberated

Presents wide permeability in the dentine and gets out through the
dentine gaps in the amelodentinal junction.

Its tissue toxicity induces inflammation in the adjacent connective

Dissolution of the extracellular matrix.

The exposed dentine will be recognized as antigenic and then

macrophages and clasts in the area cause resorption52
Pre-bleaching Postbleaching radiograph at 14 Postbleaching radiograph at 26
radiograph of a 15 months. The crown presented months demonstrating rapid and
year old female with discoloration and extensive extensive external cervical root
horizontal fractures resorption
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MANAGEMENT OF EXTERNAL CERVICAL
ROOT RESORPTION
 Walking bleach technique or an in-office technique that does not
require the use of heat is preferred.
 Immediately after bleaching, paste of Ca(OH)2 and sterile water is
placed in the pulp chamber.
 Sodium perborate alone rather than in conjunction with H2O2
should be used. Although sodium perborate bleach more slowly,
it is safer and less aggressive to the teeth.
 Periodic radiographs should be obtained for cervical resorption
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 The placement of a base over the gutta-percha to prevent
penetration of caustic bleaching agents into the cervical
periodontium.
 This is also recommended in canals obturated with silver
cones which cannot be removed and resealed with gutta-
percha.
 Montgomery suggested leaving the gutta-percha filling at a
more coronal level so that the bleaching agents are
completely restricted to the pulp chamber.

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 The treatment consists of the removal of all granulation
tissue present in the resorped region and restoration of
the resorption with materials such as glass ionomer,
composite resin, amalgam or Mineral Trioxide
Aggregate (MTA).
 MTA will be washed out by saliva if it the resorption is
in contact with oral environment. GIC will be better
option.

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INHIBITION OF RESIN POLYMERISATION

 Residual oxygen following bleaching adversely effects

the bonding and polymerization of composite resins.
 Sodium ascorbate which is a buffered form of Vitamin C
that contains 90% ascorbic acid bound to 10% sodium-
a powerful antioxidant is used in eliminating residual
oxygen following bleaching

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B. EXTRACORONAL BLEACHING (VITAL
TOOTH BLEACHING)
1. Bleaching of Vital Teeth in Office:
 Uses 35% H2O2 solution that is directly placed on the teeth.
 The bleaching agent is commercially available in the form of
gel which prevents running of the material on application.
 This may involve the application of heat and/or light to
activate the bleaching agent, hence called thermocatalytic
bleaching.
 With this technique, patient compliance is not a major factor
since effective results can be obtained in two to three visits.
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INDICATIONS AND CONTRAINDICATIONS OF
IN-OFFICE VITAL BLEACHING TECHNIQUE
• Indications • Contraindications
• Discolored teeth as a result of • Superficial stains that can be
mild fluorosis, and tetracycline removed with rubber cup and
stains prophylaxis paste
• In severe discolorations, • Carious tooth structure or dark-
bleaching could be performed colored resin restoration
to lighten the tooth color before
restoration with bonded resin or
porcelain veneers or crowns

• In order to match the existing • Hypersensitive teeth

color of the crown that is lighter • Children with large pulp
than the natural teeth chamber
• Pregnant and lactating women
• Exposed root surfaces 59
PROCEDURE:

 Take a radiograph to detect the presence of caries,

defective restorations, and proximity to pulp horns.
Well-sealed small restorations and minimal amounts of
exposed incisal dentin are not usually a contraindication
for bleaching.
 Evaluate the tooth color with a shade guide and take
clinical photographs before and throughout the
procedure.
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STEP 1: RUBBER DAM ISOLATION

 Protect the gingival tissues with orabase or Vaseline or

cocoa butter before application of rubber dam to protect
the soft tissues from any advertent exposure to the
bleaching agent.
 Anterior teeth are isolated with a heavy rubber dam to
provide maximum retraction of tissue and an optimal
seal around teeth.
A good seal is ensured by ligation of the dam with waxed
dental tape or the use of a sealing putty or varnish.
61
STEP 2: 30-35% H2O2 BLEACHING
 Place protective sunglasses over the patient’s and the
operator’s eyes.
 Clean the enamel surface with pumice and water.
 Apply 30–35% hydrogen peroxide liquid on the labial
surface of the teeth using a small cotton pellet or a piece
of gauze. A bleaching gel containing hydrogen peroxide
may be used instead of the aqueous solution.
 Apply heat with a heating device or a light source to
accelerate the oxidation reaction. The temperature
should be maintained between 125 and 140°F (52–60°C). 62
 PAC lights and high-output quartz lights are commonly
used
 However, this causes a greater level of tooth
dehydration. This effect not only can increase tooth
sensitivity but also results in an immediate apparent
whitening of tooth owing to dehydration that makes
actual whitening result more difficult to access.

63
STEP 3: DURATION OF TREATMENT

 The treatment time should not exceed 30 minutes even

if the result is not satisfactory. Remove the heat source
and allow the teeth to cool down for at least 5 minutes.
 Generally rendered weekly for two to six treatments.

64
STEP 4: POSTOPERATIVE CONSIDERATIONS

 Pumice is used on the teeth to remove the residual

exposed gel from the enamel surface.
 Remove the bleaching agent and irrigate thoroughly.
 Dry the teeth and gently polish them with a composite
resin polishing cup. Apply neutral sodium fluoride gel
for 3–5 minutes.
 Instruct the patient to use a fluoride rinse daily for 2
weeks.
65
 Documentation with photographs and shade tab. It is
often difficult to ascertain tooth shade when
hypoplastic bands are present. In these situations, the
cervical tooth color is recorded. 66
 Perform oral prophylaxis and clean the enamel surface
using pumice slurry to remove surface debris.
67
 Application of gingival liquid dam to prevent
chemical burn. 68
 Bleaching gel (35% H2O2) applied on the labial surfaces
of teeth and activated using laser light to catalyze the
bleaching reaction. 69
 Immediate post-bleaching appearance.
Apply neutral sodium fluoride gel for 3–5 minutes.
Instruct the patient to use a fluoride rinse daily for 2 weeks.
70
 One week after in-office bleaching procedure and post-
bleaching care using CPP-ACP. Note the change of tooth
71

color indicated by the shade tab.

ADVANTAGES AND DISADVANTAGES OF IN-
OFFICE VITAL BLEACHING TECHNIQUE:
Advantages Disadvantages
• Totally under dentist’s • Cost of the treatment
control and soft tissue can
be generally protected
from the process.

• Has potential for bleaching • Unknown duration of the

teeth more rapidly treatment
• Unpredictable outcome
72
2. BLEACHING OF VITAL TEETH AT HOME

 Much less labor intensive.

 Requires substantially less in-office time.

73
INDICATIONS AND CONTRAINDICATIONS OF
BLEACHING OF VITAL TEETH AT HOME:
Indications Contraindications
• Superficial enamel • Severe enamel loss
discolorations

• Mild yellow discolorations • Hypersensitive teeth

• Brown fluorosis • Bruxism
discolorations
• Age-related discolorations • Presence of caries
• Defective coronal
restorations
• Allergy to bleaching gels
74
PROCEDURE:
1. FABRICATION OF VINYL CUSTOM NIGHTGUARD:

1. Impression of arch to be treated

2. Cast is poured
3. Night guard is formed on the cast with the use of a
heated vacuum-forming machine

75
 Upper and lower casts trimmed to maintain a base
height of 10–12 mm.
76
 Reservoirs are formed on the labial surfaces of the teeth. The
margins of the reservoir should end 1 mm short of the free gingival
margin. 77
The cast is duplicated using irreversible hydrocolloid
impression material.
78
 The cast is placed on the vacuum-forming machine. Note that the plastic
tray material is warmed from a coil above. The plastic tray material sags
(25mm) as it is softened. Vacuum is created at the base of the machine and
adapts the tray material on the cast. 79

 The free gingival margin is marked and trimmed accordingly.

 Bleaching tray has to be tried in the patient’s mouth
and necessary adjustment should be made before
delivering the tray.
80
STEP 2: EVALUATION OF THE CUSTOM
NIGHTGUARD
Insert the night guard into
the patient’s mouth

Evaluate adaptation, Further shortening by

round edges or blanching trimming in problematic
of tissues. area.

Evaluate occlusion in
maximum intercuspation. 81
If Premature posterior contacts prevent
comfortable occlusion

Trim nightguard to exclude terminal

posterior tooth coverage

82
STEP 3: CARBAMIDE PEROXIDE BLEACHING

 10-15% carbamide peroxide bleaching material as clear

gel or white pastes is used.
 Carbamide peroxide degrades into 3.5% H2O2 (active
ingredient) and 6.5% urea.
 Material containing Carbopol is recommended as it
thickens the bleaching agent and extends oxidation
process.

83
STEP 4: CLINICAL USE OF NIGHTGUARD
BLEACHING
A thin bead of material is extruded into the night guard along
the facial aspects of tooth to be bleached.
 Usually only anterior 6-8 teeth are bleached.
 After inserting the night guard, wipe excess material from the
soft tissue along the edge with a soft bristled toothbrush.
 The tray should be worn for a time period of 4 hours for every
session.
 Do not drink liquids or rinse during treatment and remove
nightguard for meals and oral hygiene. 84
 Ifthe nightguard is worn at night, single application of
bleaching material at bedtime is indicated.
 Inthe morning, remove the night guard, clean it under
running water with toothbrush and store it in container
provided.
 Total treatment time using an overnight approach is
usually 1-2 weeks.

85
 Reduce or discontinue the treatment immediately and
contact dentist in case of:
 Sensitivity
 Irritated gingiva
 Desensitizing agents may be prescribed in case of
sensitivity.
 Bleach one arch at a time beginning with maxillary arch.
This allows the untreated mandibular arch to serve as a
constant standard for comparison.
86
 In case of uneven distribution of discoloration of teeth
(e.g., fluorosis, where discoloration is not uniform), the
tray can be loaded in areas corresponding to teeth that
require further bleaching.
 Ifthe patient is wearing ceramic crown or crowns, then
the tray is cut in that area and that particular tooth is
eliminated from bleaching. Bleaching agents are known
to cause etching and weakening of ceramic prosthesis.
87
ADVANTAGES AND DISADVANTAGES OF IN-
HOME BLEACHING TECHNIQUE:
Advantages Disadvantages
• The use of lower • Reliance on patient
concentration of peroxide. compliance.

• Ease of application • Longer treatment time

• Minimal side effects. • Potential for soft tissue
• Lower cost because of changes with excessively
reduced chair time. extended use
88
 ADVERSE EFFECTS OF EXTRACORONAL
BLEACHING:
1. Tooth sensitivity:
 Occurs due to permeation of the bleaching agent into the tooth
structure through the enamel microcracks, resulting in transient pulpal
hyperemia.
 Directly related to the concentration of hydrogen peroxide.

 Management:
 Do not to perform bleaching in teeth exposed due to caries or
defective restorative margins.
 Postoperativecare using fluoridated mouth rinse or amorphous
calcium phosphate in casein phosphopeptide (ACP-CPP) is used to89

promote remineralization of the enamel surface.

ADVERSE EFFECTS OF EXTRACORONAL
BLEACHING: CONTD..
2. Enamel damage:
 Bleaching action on the enamel may result in erosive
areas and increased porosity.
 Caustic nature of hydrogen peroxide causes reduction
in the enamel microhardness.
 Peroxides can cause changes in the organic–inorganic
ratio rendering the enamel weak.
 Management:
90

 Follow up with the enamel remineralization protocol.

 ADVERSE EFFECTS OF EXTRACORONAL
BLEACHING: CONTD..
3. Gingival irritation:
 Most often seen following in-office bleaching technique due
to the use of highly caustic bleaching agent coming in contact
with the unprotected gingival tissue.
 The margins of the ill-fitting tray can cause gingival irritation.
 Management:
 Proper fitting tray should be used
 Treated by copious rinsing with water.
 More severe chemical burns can be treated with topical
application of anesthetic gels combined with good oral 91

hygiene.
ADVERSE EFFECTS OF EXTRACORONAL
BLEACHING: CONTD..
4. Mercury release from amalgam restoration:
 This has been reported with extracoronal bleaching.
 Prevention:
 Itis not advisable to perform extracoronal bleaching
for teeth with extensive amalgam restoration.

92
TETRACYCLINE-STAINED TEETH

 Much more resistant to bleaching.

 Requires prolonged duration of several months before
any results are observed.
 Minocycline has the ability to affect permanent
dentition even in adults due to its ability to form
complexes with the calcium in dentin (chelate). It is
usually seen with long-term use for the treatment of
acne.
93
 Chlortetracycline (Aureomycin): Gray-brown
 Dimethylchlortetracycline (Ledermycin): Yellow
 Doxycycline (Vibramycin): Does not cause staining
 Oxytetracycline (Terramycin): Yellow Under fluorescent
light

94
TETRACYCLINE DISCOLORATION CLASSIFICATION
(JORDON AND BOSKMAN, 1984)
I. First degree: Light yellow to light
gray staining without banding
II. Second degree: Darker and more
extensive yellow or gray staining
without banding
III. Third degree: Severe staining
characterized by dark gray or blue
discoloration with banding
 De-staining of the yellow color is
most successful, whereas brownish
teeth are least successfully bleached.
95
 The use of 30% hydrogen peroxide and a
thermostatically controlled heat source for bleaching
tetracycline-stained teeth has been described.
 Unfortunately, the decoloration is only superficial
because the chemical cannot reach the real cause of
the discoloration, which is the incorporation of
tetracycline into the dentin.

96
 Another method, the pulps of the teeth are
intentionally extirpated, the root canals are cleaned,
shaped, and obturated, and the teeth are internally
bleached as previously described.
 Labial veneers with composite resins or even porcelain-
veneer full-crown restorations are indicated instead of
intentional devitalization of a tooth with a normal pulp.

97
MICRO-ABRASION AND MACRO-ABRASION

 Conservative alternatives for the reduction or

elimination of superficial discolorations.
 Stained areas or defects are abraded away.

98
MICRO-ABRASION
A number of micro-abrasion techniques to improve the
appearance of fluorotic teeth have been described.
 In1984, McCloskey reported the use of 18% HCl swabbed
on teeth for the removal of superficial fluorosis stains.
 In 1986, Croll and Cavanaugh modified the technique to
include the use of pumice with 18% HCl to form a paste
applied with a tongue blade.
This technique is called micro-abrasion and involves the
surface dissolution of the enamel by acid along with
abrasives of the pumice to remove the superficial stains or
defects. 99
MICRO-ABRASION CONTD..

 Croll further modified:

 Reduced the concentration of HCl to 11%
 Increased the abrasiveness of the paste using silicon
carbide particles instead of pumice.
 Marketed as Prema compound or Opalustre

100
McINNES SOLUTION VS MODIFIED McINNES
SOLUTION

McInnes Solution Modified McInnes Solution

• 1 part of anesthetic • Comprises 20% sodium
ether (0.2%): removes hydroxide instead of 36%
surface debris hydrochloric acid.
• 5 parts of hydrochloric • Since sodium hydroxide is highly
acid (36%): etches the alkaline in nature, it dissolves
enamel calcium of the enamel at a
• 5 parts of hydrogen slower rate.
peroxide (30%): • Hence, modified McInnes
bleaches the enamel solution is considered to be a
slower but safer alternative to
McInness solution.
101
INDICATIONS AND CONTRAINDICATIONS
Indications Contraindications
1. Developmental intrinsic stains and 1. Age-related staining
discolorations 2. Tetracycline staining
2. Superficial surface enamel stains 3. Deep enamel hypoplastic lesions
and opacities 4. Some concentric areas of
3. Yellow–brown stains hypocalcification that extend to
4. Multicolored stains (brown, gray, the dentin
or yellow) 5. Most amelogenesis imperfecta
5. Superficial hypoplastic enamel lesions
6. Areas of enamel fluorosis 6. Most Dentinogenesis lesions
7. White patches and white spot 7. Carious lesions underlying regions
8. Decalcification lesions from stasis of decalcification
of plaque and from orthodontic 8. Areas of deep enamel and dentin
bands stains
9. Some irregular surface textures
102
CLINICAL PROCEDURES

Micro-abrasion.
A, Patient with unesthetic fluorosis stains on central
incisors. B, Rubber dam isolation with protective glasses
103
MICRO-ABRASION CLINICAL PROCEDURE

C, Prema compound D, Hand applicator for

applied with special applying Prema
rubber cup compound. 104
MICRO-ABRASION CLINICAL PROCEDURE

E, Stain removed from Treated enamel surfaces

the left central incisor polished with
after micro-abrasion. prophylactic 105

paste.
G, Topical fluoride applied H, Final esthetic result.
to treated enamel surfaces
106
MACRO-ABRASION

 Alternative technique for removal of localized,

superficial white spots (not subject to conservative,
remineralization therapy) and other surface stains or
defects is called macro-abrasion

107
CLINICAL PROCEDURE:
A 12- or 16-fluted composite finishing bur
or a fine grit finishing diamond in high
speed is used to remove the surface
defect.
 Light intermittent
pressure is used to avoid
unnecessary removal of the tooth
structure.
 Air–water spray is recommended, not only
as a coolant but also to maintain the teeth
in a hydrated state. 108
CLINICAL PROCEDURE CONTD..

 On removal of the defect, a 30-fluted composite finishing

bur is used to remove any striations on the surface.
 The surface is finally polished with abrasive rubber points.
 Thistechnique works well when employed in conjunction
with micro-abrasion where the former removes gross
defect and the latter is used for final treatment.

109
MACRO-ABRASION

A, Outer surfaces of
maxillary anterior teeth are B, Removal of discoloration
unesthetic because of by abrasive surfacing.
supericial enamel defects. 110
MACRO-ABRASION

C, a 30-fluted composite D, Completed treatment

finishing bur is used to revealing conservative
remove any striations on the esthetic outcome. 111

surface.
112
CONCLUSION

 Conservative estheticprocedures help dentists to restore

a wide range of esthetic challenges ranging from surface
malformations to discolorations of varying complexities.
 The inherent advantages and limitations of each of these
procedures are to be taken into consideration in order to
realize their optimal clinical performance.

113
REFERENCES:

 Grossman’s ENDODONTIC PRACTICE 14TH Edition.

 Sturdevant’s Art and Science of Operative Dentistry 2nd South Asia Edition.
 Ingle’s ENDODONTICS6
 Internet sources

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THANK YOU!
115