BLEACHING OF DISCOLORED

TEETH
• Introduction
• History
• Causes of tooth discoloration
• Bleaching
• Bleaching materials
– Hydrogen peroxide
– Sodium perborate
– Carbamide peroxide
• Chemistry of bleaching
• Dental bleaching mechanism
• Factors that affect bleaching
• Vital teeth bleaching
– Photo or thermobleaching-homogenous, uneven
– Nightguard vital bleaching
– Laser activated
• Bleaching pulpless teeth
– Thermocatalytic technique
– Walking bleach
– Combination bleaching
– Inside outside bleaching
• Alternatives to bleaching
• Conclusion
 INTRODUCTION

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.
Esthetic improvement of acceptably shaped
but discolored teeth by chemical means is highly
desirable because of its conservative nature. The
chemical agents & specific procedures used depend
upon a number of factors, including the type,
intensity & location of the discoloration.
 TOOTH WHITENING TIMELINE
• Unsuccessful bleaching
Middle ages
• Initial attempts at bleaching
1877 Chappel-oxalic acid
1888 Taft-Calcium hypochlorite
1884 Harlan-hydrogen dioxide
1895 Electric currents
• Non-vital bleaching initiated
1895 Garretson
1911 Rossental-Ultraviolet waves
 TOOTH WHITENING TIMELINE
• Modern bleaching techniques begin
1918 Abbot-Superoxol and heat
• Successful non-vital bleaching
1958 Pearson-intrapulpal bleach
1967 Nutting and Poe-walking bleach
• Modern techniques
1978 Superoxol heat & light
1989 Munro-out patient tooth whitening
 CAUSES OF TOOTH DISCOLORATION (Ingle)

Patient-Related Causes Dentist-Related causes

Pulp necrosis Endodontically related
Intrapulpal hemorrhage Pulp tissue remnants
Dentin hypercalcification Intracanal medicaments
Age Obturating materials
Tooth formation defects Restoration related
Developmental defects Amalgams
Drug-related defects Pins and posts
Composites
 TOOTH FORMATION DEFECTS
Defects in enamel formation (Cohen)
Amelogenesis imperfecta Endemic fluorosis
Rickets Chromosomal anomalies
Inherited diseases Lead
Thalidomide, tetracycline Childhood illness
Malnutrition Metabolic disorders
Defects in dentin formation (Cohen)
Dentinogenesis imperfecta
Erythropoetic Porphyria
Tetracycline & minocycline
Genetic anomalies
Amelogenesis imperfecta

Treatment: If the amelogenesis imperfecta is of a variety

which exhibits sufficient enamel thickness the teeth should
be aggressively treated with topical fluoride. Following this
treatment, the enamel may found to be suitable for bonding.
The more common, as well as predictable, treatment is to
provide full prosthetic coverage for the affected teeth. Any
vital bleaching technique is contraindicated.
Dentinogenesis imperfecta

Treatment: Due to thin or even nonexistent enamel,

there are no other options than to treat this condition
with full prosthetic coverage. Vital bleaching
technique is contraindicated.
Erythroblastosis foetalis
Treatment: Usually none is necessary

Porphyria
Treatment: Tooth whitening, sometimes in conjunction with
bonding.

Sickle cell anaemia & Thalassemia:

Treatment: tooth whitening, with the addition of bonding
procedures for the more intractable cases.
 Drug related defects

Tetracycline staining
The exact mechanism of tetracycline staining is not
completely understood. Two schools of thought
exist concerning the nature of the binding of
tetracycline in hard tissue.
Tetracycline staining
Mechanism

1. It is hypothesized to occur by the joining of the tetracycline

molecule with calcium through chelation process & subsequent
incorporation in to the hydroxylapatite crystal of the tooth during
the mineralization stage of development, forming a tetracycline-
calcium phosphate complex. (Epker; Albert & Rees; Finerman &
Milch)

2. A second theory maintains that the discoloration involves a

binding of the tetracycline to tooth structure by a metal organic
matrix combination of the tetracycline complex. Although some
tetracycline accumulates within the enamel, it is primarily deposited
in dentin because of the large surface area of the dentin apatite
crystals compared with enamel apatite crystals. However, enamel
hypoplasia also can result. (Milch, Rall, Tobie)
The discoloration depends on four factors
1. Age at the time of administration
Since tetracycline can cross the placental barrier, tetracycline affects
both the deciduous and permanent dentitions, making the teeth
vulnerable throughout odontogenesis. Even as short an exposure as
three days can cause discoloration of the teeth any time from four
months in utero through age nine.
Goldstein RE
Anterior primary teeth are susceptible to discoloration by systemic
tetracycline from 4 months in utero through 9 months postpartum.
Anterior permanent teeth are susceptible from 3 months postpartum
through age 7 years.
(Moffitt J M et al: prediction of tetracycline induced tooth discoloration,
J Am Dent Assoc 88: 547, 1974)
Duration of administration
The severity of staining is directly proportional to the length of the
time the medication was administered.
Dosage
The severity of the staining is directly proportional to the
administered dosage.
Type of tetracycline
Chlortetracycline: gray brown stain
Dimethylchlortetracycline: yellow stain
Oxytetracycline: yellow stain
Tetracycline: yellow stain
Doxycycline: Does not cause staining
Tetracycline staining has been classified into three groups

1. First-degree stains:
2. Second-degree stains:
3. Third-degree stains:
Treatment: The results of bleaching yellow, yellow-brown & brown
stains are more favorable than those with blue-gray stains. When
teeth show any combination of yellow, brown, blue & gray stains,
the blue & gray components may remain to some degree despite a
more favorable bleaching of the yellow & brown components. In
addition, less intense stains have better prognosis & usually bleach
more quickly. Teeth with diffuse staining generally respond better
than those with banding.
Endemic fluorosis
Black & McKay gave the first clinical description of fluorosis in 1916
Fluorosis is actually a form of enamel hypoplasia; hence the
white spotting is seen. The teeth are not discolored on eruption, but
there surface is porous & will gradually absorb colored chemicals
present in the oral cavity. Discoloration is usually bilateral, affecting
multiple teeth in both arches. It presents as various degrees of
intermittent white spotting, chalky or opaque areas, yellow or brown
discoloration, and, in severe cases, surface pitting of the enamel.
Since the discoloration is in the porous enamel, such teeth can be
bleached externally. (Ingle)
Treatment: Bleaching can be an effective treatment modality for this
type of discoloration. If staining is accompanied by pitting & other
surface defects, bleaching is best viewed as a useful adjunctive
treatment preceding bonding or veneering. If fluorosis has caused
severe loss of enamel, bleaching should not be used at all. (R E
Goldstein)
 DENTIST-RELATED CAUSES

Endodontically Related
Pulp tissue remnants.
Intracanal medicaments.
Obturating materials.

Restoration related
Amalgam.
Pins and posts.
Composites.
 BLEACHING

Bleaching is a decolorisation or whitening process that can

occur in solution or on a surface.
Bleaching techniques may be classified as to whether they
involve vital or nonvital teeth & whether the procedure is performed
in the office or with some outside the office component. Bleaching
generally has an approximate lifespan of 1 to 3 years, although the
change may be permanent in some situations.
 BLEACHING MATERIALS

• Hydrogen Peroxide

• Sodium Perborate

• Carbamide Peroxide
 CHEMISTRY OF BLEACHING

The color producing materials in solution or on a surface are

typically organic compounds that possess extended conjugated
chains of alternating single or double bonds and often include
heteroatoms, carbonyl and phenyl rings in the conjugated system
and often are called chromophore. Bleaching and decolorisation of
chromophore can occur by destroying one or more of the double
bonds in the conjugated chain, by cleaving the conjugated chain or
by the oxidation of their chemical moieties in the conjugated chain.
 HYDROGEN PEROXIDE BLEACHING

H2O2 H2O + O• WEAKER FREE

RADICAL

H + HO2 LOWER PERCENTAGE OF

STRONGER FREE
RADICAL

IONIZATION OF H2O2 AT ACIDIC pH

 HYDROGEN PEROXIDE BLEACHING

H2O2 H2O + O• WEAKER FREE

RADICAL

H + HO2 HIGHER PERCENTAGE OF

STRONGER FREE
RADICAL

IONIZATION OF H2O2 AT BUFFERED pH

 HYDROGEN PEROXIDE BLEACHING

In presence of decomposition catalysts & enzymes (oral cavity), the

hydrogen peroxide ionization occurs as follows.

2H2O2 2H2O + O2
Visible tooth changes Conversion process

Darkly pigmented carbon ring structure

Lightly pigmented unsaturated structures

Hydrophilic nonpigmented structures

SATURATION POINT
COMPLETELY BLEACHED STAINS

BREAKDOWN OF Decomposition of ENAMEL

MATRIX molecular structures

Carbon dioxide

Loss of Enamel Matrix Complete oxidation

Water
 FACTORS THAT AFFECT BLEACHING

• SURFACE CONTACT: Thorough scaling & polishing should be performed in

order to eliminate all superficial debris.
• HYDROGEN PEROXIDE CONCENTRATION: The higher the concentration,
the greater the effect of the oxidation process. The highest concentration generally
used is 35% hydrogen peroxide. When gelling agents are added to a of 35%
solution of hydrogen peroxide, the concentration of hydrogen peroxide is reduced
to 25%.
• TEMPERATURE: An increase of 10˚C doubles the rate of the chemical reaction.
Generally, if the temperature is elevated to a point at which the patient does not
feel discomfort, then the procedure is taking place at a safe range of temperature.
• PH: The optimum pH for hydrogen peroxide to have its oxidation effect is at 9.5
to 10.8. This produces a 50% greater result in the same amount of time as at a
lower pH.
• TIME: The effect of the bleach is directly related to the time of exposure. The
longer the exposure, greater the color change.
 IN-OFFICE BLEACHING OF VITAL TEETH
PHOTO OR THERMO BLEACHING
This technique basically involves application of 30 to 35% hydrogen
peroxide and heat or a combination of heat and light or ultraviolet
rays to the enamel surface. Heat is applied either by electric heating
devices or heat lamps.
Indications
• Light enamel discolorations
• Mild tetracycline discolorations
• Endemic fluorosis discolorations
• Age-related discolorations
PHOTO OR THERMO BLEACHING
Contraindications
• Severe dark discolorations
• Severe enamel loss
• Proximity of pulp horns
• Hypersensitive teeth
• Presence of caries
• Large/poor coronal restorations (Ingle)
• Latex allergy, which means a rubber dam, cannot be used.
 PREPARATION

EVALUATE TOOTH
COLOR WITH A
SHADE GUIDE
 protective cream
(oraseal) to the
surrounding gingival
tissues
 PREPARATION

Elastic ribber stops

 PREPARATION

rubber dam applied

 PREPARATION

Clean the enamel surface

with pumice and water
to remove extrinsic
stains
Bleaching with heat or light

Acid etch the darkest or

most severely
stained areas with
buffered phosphoric
acid for 10 seconds
and rinse with water
for 60 seconds
Before bleaching a fold
of 2"×2" gauge placed
over lower lip to
protect from extra
solution that may drip
down
30 to 35% hydrogen
peroxide solution
Homogenous discoloration

Single thickness 2"×2"

gauge pad saturated
with hydrogen
peroxide, swab is used
to continually apply
fresh solution
The illuminator is ideal
to use due its accuracy
in recording the
bleaching
The LED readout shows
the temperature and
time
Rinse with warm water
for one minutes and
rubber dam is
removed
 Uneven discoloration

After rinsing & drying, at the end of patient preparations, apply fresh
solution of 35% hydrogen peroxide to the stained area of enamel of
the teeth with cotton tipped applicator. Allow the solution to remain
on the teeth for 5 to 10 minutes.
finishing
 finishing

Polished with abrasive

disks, wheels and
impregnated cups
 finishing

Final result
 BLEACHING WITHOUT HEAT

Products which contain dual activated bleaching systems

lighten the teeth through chemical & light oxidation instead of heat.
The 35% H2O2 powder & liquid are combined to produce a gel. The
gel should be applied in a 1 to 2 mm thickness for 7 to 9 minutes.
Light activation, chemical activation or a combination of two can be
used & may be repeated as many as six times per visit, depending on
the type & severity of the stain. The curing light should be used for
only 3 to 4 minutes.
 Complications and Adverse Effects

Post-operativePain

Pulpal Damage

Dental Hard Tissue Damage

 NIGHTGUARD VITAL BLEACHING

Haywood & Heymann in 1989 reported Nightguard vital

bleaching, out of the office technique for lightening teeth also has
been referred to as home bleaching; matrix bleaching, mouthguard
bleaching, & dentist prescribed / home applied bleaching.
The technique involves the application of a mild bleaching
agent to the teeth through the wearing of a custom-made, vaccum-
formed appliance.
Numerous products are available, mostly containing either 1.5
to 10% hydrogen peroxide or 10 to 15% carbamide peroxide that
degrades slowly to release hydrogen peroxide
There are three basic forms of matrix bleaching, involving different
levels of dentist participation & supervision.

1. Power matrix bleaching: Dentist monitored Nightguard vital

bleaching combined with in-office bleaching.
2. Dentist monitoring of completely home based bleaching:
3. Home bleaching without dental supervision: (OTC systems-Over
the counter tooth whitening):
In cases of endemic fluorosis, a solution of anesthetic ether, hydrochloric
acid & Superoxol is used for bleaching. The solution is prepared in a
clean dappen dish, as follows;
1 part anesthetic ether 0.2 ml
5 parts hydrochloric acid (36%) 1.0 ml
5 parts hydrogen peroxide (30%) 1.0 ml

The anesthetic ether removes surface debris, the hydrochloric etches

the enamel & hydrogen peroxide bleaches the enamel. (Grossman)
 LASER-ACTIVATED BLEACHING

Recently, a technique has been introduced using lasers for extra coronal
bleaching.

Two types of lasers can be employed:

1. The argon laser that emits a visible blue light and
2. Carbon-dioxide laser that emits invisible infrared light.

Laser bleaching is a relatively new technique, and there are currently no

long-term studies regarding its benefits or adverse effects.
 NONVITAL BLEACHING

Three basic techniques have been used to bleach nonvital teeth:

• Thermocatalytic
• The intracoronal (walking)
• The combination of both techniques.
 NONVITAL BLEACHING

Indications (Ingle)
• Discolorations of pulp chamber
• Dentin discolorations
• Discolorations not amenable to extracoronal bleaching

Contraindications
• Superficial enamel discolorations
• Defective enamel formation
• Severe dentin loss
• Presence of caries
• Discolored composites
NONVITAL BLEACHING

Gingival tissue is
protected with rubber
dam
NONVITAL BLEACHING

patient's eyes are

shielded with safety
glasses
NONVITAL BLEACHING

Endodontic filling
The GP ends 2mm apical
to the CEJ
NONVITAL BLEACHING

Barrier
GIC is placed with
lentulo spiral
NONVITAL BLEACHING

Barrier showing bobsled

tunnel shape
THERMOCATALYTIC BLEACH

Placement of Superoxol
and heating unit
THERMOCATALYTIC BLEACH

Effect of superoxol is
accelerated by heat
bleaching instruments
THERMOCATALYTIC BLEACH

Heated external brushes

carry superoxol to the
buccal surface
WALKING BLEACH

Placement of bleaching
paste and cavit
WALKING BLEACH

Walking bleach of
Sodium Perborate and
water mixed to a thick
paste
WALKING BLEACH

Paste carried to the

pulp chamber with an
amalgam carrier
WALKING BLEACH

2mm of space is left

for Cavit
 Combination bleaching
Thermocatalytic & walking bleaches may be used separately
or in combination. The combination of Superoxol & heat followed
by walking bleach using a mixture of Superoxol & sodium perborate
is effective in bleaching teeth about 90% of the time.
(Ho S, Goerig AC, an in vitro comparison of different bleaching agents
in the discolored tooth J Endodontics 1989; 15:106-111)
 Barrier
The age of the patient at the time the tooth became pulpless & the lack of
a bleach barrier appear to be critically important in the cause of
external cervical root resorption.
Clinicians have no control over the age at which a tooth becomes pulp
less, but they have control over the barrier.
What is perfect barrier?
Where should it be located?
What shape should it take?
Which material is best?
EXTERNAL CERVICAL ROOT RESORPTION

External root resorption

 EXTERNAL CERVICAL ROOT RESORPTION

Mechanisms:
In 10% of all teeth, the CEJ is defective or absent,
• Passing through patent dentinal tubules or through lateral root canals
or accessory foramina.
• Bleaching agents may infiltrate between the gutta-percha & the root
canal walls.
• Heat application during treatment may invoke a resorptive process.
• 35% hydrogen peroxide mixed with sodium perborate can lower the
pH in the periodontal membrane area, which may increase the
likelihood of cervical resorption. (Ernest A Lado, bleaching of
endodontically treated teeth: an update on cervical resorption;
General Dentistry, 1988, 500-502)
 INSIDE-OUTSIDE BLEACHING

This technique is called inside-outside bleaching; it consists of

administration by the patient of the bleaching agent within & outside
the tooth simultaneously.
The bleaching takes place within the tooth & on the outside of
the tooth simultaneously, as carbamide peroxide gel injected into the
coronal orifice & into the mouthguard.
According to some authors, an advantage of this technique is
the time needed to complete the treatment. (3 to 4 days). This is
because that hydrogen peroxide & urea molecules are small enough to
pass freely through enamel & dentin. They thus can bleach parts of
tooth protected from direct contact with the solution. This technique
works quickly because the nascent oxygen released from the
carbamide peroxide can move freely inside & outside the tooth to
achieve whitening.
 ALTERNATIVES TO BLEACHING
Microabrasion

Advantages Disadvantages

 More conservative of the  Does not remove deep

tooth structure than stains
fillings & veneers
 Good esthetics, especially  Not recommended for
when combined when generalized stains
combined with tooth
whitening  Can be time consuming
 Low cost
 Conclusion

Bleaching agents & techniques are effective,

conservative approaches to the removal of unesthetic
discolorations from vital and non-vital teeth. As with all
types of therapeutic modalities, proper diagnosis and
treatment planning are essential.
THANK YOU