d e n t a l m a t e r i a l s x x x ( 2 0 0 6 ) xxx–xxx

available at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/dema

External bleaching therapy with activation by heat,

light or laser—A systematic review

Wolfgang Buchalla a,b , Thomas Attin a,b,∗

a Department of Preventive Dentistry, Periodontology and Cariology, University of Zürich, Plattenstrasse 11, CH-8032 Zürich, Switzerland
b Department of Operative Dentistry, Preventive Dentistry and Periodontology, Georg-August-University Göttingen, Göttingen, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Objective. External bleaching procedures utilizing highly concentrated 30–35% hydrogen per-
Received 17 October 2005 oxide solutions or hydrogen peroxide releasing agents can be used for tooth whitening. To
Received in revised form 4 March enhance or accelerate the whitening process, heat-activation of the bleaching agent by light,
2006 heat or laser is described in the literature. The aim of the present review article was to sum-
Accepted 9 March 2006 marize and discuss the available information concerning the efficacy, effects and side effects
of activated bleaching procedures.
Sources. Information from all original scientific full papers or reviews listed in PubMed or ISI
Keywords: Web of Science (search term: (bleaching OR brightening OR whitening OR colour) AND (light
Peroxide OR laser OR heat OR activation)) were included in the review.
Bleaching Data. Existing literature reveals that activation of bleaching agents by heat, light or laser
Activation may have an adverse effect on pulpal tissue due to an increase of intra-pulpal temperature
Heat exceeding the critical value of 5.5 ◦ C. Available studies do not allow for a final judgment
Laser whether tooth whitening can either be increased or accelerated by additional activation.
Light Conclusion. Therefore, application of activated bleaching procedures should be critically
assessed considering the physical, physiological and patho-physiological implications.
© 2006 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

1. Introduction [1,2]. It should be noted that a single application of in-office-

1.1. In-office-bleaching therapies
With in-office applied bleaching therapies, discolored, vital
teeth can be successfully whitened mostly by using highly
concentrated bleaching regimens. In-office-bleaching pro-
cedures seem to be an appropriate alternative to home-
bleaching applications with trays, foils or gels, especially in
the case of very severe discolorations, discolorations of sin-
gle teeth, lack of patient compliance or if a rapid treatment is
desired. In-office-bleaching could also be applied as a kind of
boost therapy, thereby initiating the bleaching process, which
might be continued afterwards by home-bleaching procedures
bleaching is usually not sufficient to achieve optimal bleaching
results [3]. This means that the in-office-bleaching procedure
has to be repeated several times during an appointment or
that even multiple appointments are needed to obtain opti-
mal results. In-office-bleaching is usually performed using
bleaching agents with high concentrations (30–35%) of H2 O2 .
Due to the high peroxide concentration, the gingiva should
be protected by rubber dam or alternatives, such as specially
designed light-curing isolating pastes [4].
Most descriptions in the literature of successful appli-
cations of in-office-bleaching therapies are case reports or
studies, in which no comparisons to well-approved meth-
ods, such as home-bleaching-procedures have been done

∗
Corresponding author. Tel.: +41 44 634 3271; fax: +41 44 634 4308.
E-mail address: thomas.attin@zzmk.unizh.ch (T. Attin).
0109-5641/$ – see front matter © 2006 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.dental.2006.03.018

DENTAL-964; No. of Pages 11

2 d e n t a l m a t e r i a l s x x x ( 2 0 0 6 ) xxx–xxx
[3,5–8]. However, in a randomized clinical study Auschill et al.
[9] were able to show that both home-bleaching procedures
(10% carbamide peroxide gel tray application or 5.3%-H2 O2 -
impregnated strips) and in-office-bleaching with 35% H2 O2
without heat-activation may be used to brighten teeth six
shades on the vita color scale. With the in-office-procedure the
desired six grades were achieved after only 3.1 ± 0.5 applica-
tions of 15 min each, whereas 31.8 ± 6.6 applications of 30 min
each were needed with the strip and 7.1 ± 1.9 applications for
8 h each were necessary when using the carbamide peroxide
gel. Frequency and severity of side effects, such as tooth hyper-
sensitivity or gingival irritation, were similar for the three
approaches as reported by the study participants. However,
subjective acceptance of the procedure was slightly higher for
subjects treated with the carbamide peroxide agent as com-
pared to the two remaining groups. Scanning electron micro-
scopic pictures (2000×-magnification) of the bleached tooth
surfaces did not show any alterations, which might have been
attributed to the bleaching procedures in any of the treatment
groups. This finding corroborated the results of a previous
in vitro-study in which the same bleaching agents had been
applied [10]. In contrast to the results of the study performed
by Auschill et al. [9], a recent study showed lower brighten-
ing of teeth treated by in-office-bleaching (35% H2 O2 , no heat
application) as compared to a 14-day application of 10% car-
bamide peroxide in a tray [11]. In this study, the two bleach-
ing techniques were directly compared in the same patient
using an intriguing split-mouth-design. This design allowed
for treatment of three anterior teeth each with either the car-
bamide peroxide agent or the in-office-application, which was
adopted for six periods of 10 min each on 2 different days.
1.2. Heat-activated bleaching therapies
To accelerate the bleaching process, the bleaching agent can
be additionally heat-activated. This idea of power bleaching
dates back to 1918, when Abbot [12] reported the use of high-
intensity light to increase the temperature of hydrogen per-
oxide. Mostly, application of heat, light or lasers is used to
increase the temperature of a bleaching agent applied to the
tooth surface. The application of a heated spatula (30–55 ◦ C) or
of an extraorally heated bleaching gel is also described [13,14].
The effectiveness of these methods as applied with vital teeth
has been described in several clinical reports, animal stud-
ies and reviews without showing evidence of irreversible side
effects [14–34]. In the study by Nathanson and Parra [34], the
majority of patients (70%) reported post-operative discomfort
in the form of a mild sensitivity that did not last more than
24 h. Interestingly, the authors did not find differences in the
discomfort levels among young, 12-year-old subjects and older
patients included in their study. It should be noted that in the
reports mentioned above the duration of heat activation was
mostly limited to short periods as recommended by manufac-
turers of bleaching agents or heat-generating devices. Despite
the non-existent incidence of reported irreversible side-effects
due to external bleaching, it should be noted that Glickman et
al. [35] published a case report of a patient who suffered an
acute flare-up of sensitivity in a tooth following vital bleach-
ing. This case emphasizes the importance of assessing pul-
pal status before initiation of an external bleaching therapy.
With respect to internal bleaching of non-vital, endodontically
treated teeth, it is well-known that heat application increases
the risk of development of external, cervical resorption
[36,37].
1.3. Background of the present review
Surveying the scientific literature, it becomes evident that only
few randomized, controlled clinical studies exist, which deal
with the application of activated procedures for whitening
of vital teeth. The present review is based on a systematic
literature search in PubMed or ISI Web of Science with the fol-
lowing search term: (bleaching OR brightening OR whitening
OR colour) AND (light OR laser OR heat OR activation). All origi-
nal scientific full papers or reviews fulfilling the search criteria
were included in the review, abstracts dealing with the topic
were not taken into consideration. To allow for estimation of
the benefit of the activation, special attention was given to
studies in which activated bleaching procedures were com-
pared to non-activated.
Firstly, an overview about the principles of bleaching acti-
vation with light, heat or laser is provided.
2. Principles of activation in external
bleaching
From a scientific point of view, data on mechanisms of action
and efficacy of laser, light and heat-activated dental bleach-
ing are still limited. In this chapter, the basic principles and
possible mechanism of action of these bleaching procedures
will be discussed. An overview of light sources for activation
of bleaching procedures described in the literature and avail-
able on the market is presented in Table 1. It is common to
all described light-activated bleaching procedures, that light is
used in addition to the application of a bleaching product (such
as a bleaching gel) rather than on its own. It is the effect the
light or heat has on the chemical bleaching product (gel) rather
than on the tooth substance itself and the chromophores it
contains that may lead to an increased bleaching effect.
2.1. Thermocatalysis
The release of hydroxyl-radicals from peroxide is accelerated
by a rise in temperature according to the following equa-
tion: H2 O2 + 211 kJ/mol → 2HO• . This is in accordance with
an increase in speed of decomposition of a factor of 2.2 for
each temperature rise of 10 ◦ C. Due to the increased release
of hydroxyl-radicals (thermocatalysis), an increase in effi-
cacy is conceivable. However, the useful range in temperature
increase is limited because of possible damage to the dental
pulp as described below in greater detail.
If light is projected onto a bleaching product, such as a
bleaching gel, a small fraction is absorbed and its energy is
converted into heat. Most likely, this is the main mechanism
of action of all light-activated bleaching procedures. In order
to increase light absorption and, as a result, heat conversion,
some bleaching products are mixed with specific colorants,
e.g. carotene. The orange-red color of carotene increases the
absorption of blue light. In order to increase the absorption of
Table 1 – Overview of light sources
Light source
QTH lamp
(quartz–tungsten–halogen
lamp) and derivatives (e.g.
with xenon gas filling)
Plasma arc lamp (xenon
discharge lamp) and
derivatives (e.g. mercury
added)
Metal halide lamps (discharge
lamps filled with metal
halides, mercury and
argon)
LED (light emitting diode)
Main source of light Wavelength after Power output at exit Power at tooth surface Properties and risks when used for
emission filtering (typical) window (typical) (mW/cm2 ) (typical) (from Hein et al. light-activated bleaching
(nm) [41]) (mW/cm2 )
Incandescent light: heated 380–520 (violet-blue) 400–3000 Resin curing lights: >100; Filtered broad band light source;
d e n t a l m a t e r i a l s x x x ( 2 0 0 6 ) xxx–xxx
tungsten filament bleaching lamps: <80 readily absorbed by carotene (red
color); thermal damage cannot be
excluded with high-power lamps
or long irradiation duration
Luminescent light: light 380–580 (near UV- 600–2000 Filtered broad band light source;
emission by recombination violet-blue-green) readily absorbed by carotene (red
of electrons with ionized color); thermal damage cannot be
xenon atoms excluded with high-power lamps
or long irradiation duration
Luminescent light: light Bleaching lamps: <80
emission by recombination
of electrons with ionized
metal atoms
430–490 (blue) 200–2000 ? Narrow band light source, not
filtered; readily absorbed by
carotene (red color); thermal
damage cannot be excluded with
high-power lamps or long
irradiation duration
3
 4
Table 1 (Continued )
Laser Wavelength (typical) Power output at exit window Properties and risks when used for light-activated
(nm) (typical) (mW/cm2 ) bleaching

Argon-ion laser (continuous wave or pulsed) 488 (blue) e.g. 1100 Limited penetration depth into dental hard tissue; readily
absorbed by carotene (red color); risk of thermal damage rel-
atively low

Argon-ion laser (continuous wave or pulsed) 514 (blue-green) ?a Low absorption in water and tooth mineral; absorption in
hemoglobin; risk of thermal damage relatively low

KTP laser (kalium-titanyl-phosphate crystal fre- 532 (green) e.g. 3000 Relatively low absorption in water and tooth mineral; high
quency doubled Nd:YAG laser, pulsed) absorption in hemoglobin; medium penetration depth into

d e n t a l m a t e r i a l s x x x ( 2 0 0 6 ) xxx–xxx
dental hard tissue

He–Ne laser (continuous wave) 632 (red) ?a Relatively low absorption in water and tooth mineral;
absorption in pigments and hemoglobin; deeper penetration
depth into dental hard tissue

Nd:YAG laser (neodynium: yttrium aluminum garnet, 1064 (IR-A, NIR) ?a Low absorption in water and tooth mineral; absorption
pulsed) in dark pigments; deep penetration into dental hard
tissue—pulp damage due to temperature rise

Diode laser (continuous wave or pulsed)
Er,Cr:YSGG laser (erbium chromium: yttrium scan-
dium gallium garnet, pulsed)
810, 830, 980 (IR-A, NIR) ?a Low absorption in water and tooth mineral; absorption in
pigments; deep penetration into dental hard tissue—pulp
damage due to temperature rise
2790 (IR-B, SWIR) ?a Very high absorption in water and high absorption in tooth
mineral (OH− ); low penetration depth into dental hard
tissue—relatively low risk of direct pulp damage

Er:YAG laser (erbium: yttrium aluminum garnet, 2940 (IR-B, SWIR) ?a Highest absorption in water and high absorption in tooth
pulsed) mineral (OH− ); low penetration depth into dental hard
tissue—relatively low risk of direct pulp damage

CO2 laser (continuous wave or pulsed) 9400, 10600 (IR-C, LWIR) ?a High absorption in water and highest absorption in tooth
mineral (phosphate); low penetration depth into dental
hard tissue—relatively low risk of direct pulp damage using
pulsed mode

Abbreviations: IR, infrared; IR-A, infrared A (DIN, 700–1400 nm); IR-B, infrared B (1400–3000 nm), IR-C, infrared C (3000–15,000 nm); NIR, near infrared (700–1400 nm); SWIR, short wave infrared
(3000–8000 nm); LWIR, long wave infrared (8000–15,000 nm).
a
No data is available on light intensity at the exit window of the laser hand-piece. Usually, power input or power output of the laser itself is quoted, but light transmission through fiber, hollow fiber
or mirrors, in combination with a hand-piece that expands the laser beam, significantly reduces the power.
 d e n t a l m a t e r i a l s x x x ( 2 0 0 6 ) xxx–xxx
red and infrared light, small silica particles in the nm- or lower
␮m scale may be added, which gives these products a bluish
appearance.
2.2. Photolysis
A release of hydroxyl-radicals from H2 O2 is also possible
through direct excitation by light (photolysis). Following the
equation H2 O2 + h
→ 2HO• (with h = Planck’s constant) light of
a specific frequency
is absorbed, resulting in bond fission of
H2 O2 into two hydroxyl-radicals. The required energy can only
be provided by high frequency light, corresponding to a wave-
length of 248 nm and lower (UV C) which makes its use in the
oral cavity difficult if not impossible.
For an appraisal of the safety of light-activated bleaching
procedures, the light source used is an important factor. A vari-
ety of light sources that greatly differ in their properties are
available to date to be used for light activation of bleaching
products.
2.3. Light sources
Incandescence lamps like quartz–tungsten–halogen (QTH)
lamps, plasma arc lamps (used synonymously for xenon
gas discharge or xenon short arc lamps) and laser sources
(laser = light amplification by stimulated emission of radia-
tion) of a variety of different wavelengths as well as light
emitting diodes (LED) have been proposed for light activation
of bleaching products. Metal halide lamps work in a similar
way to xenon discharge lamps, except that metal ions are the
source of light emission rather than ionized xenon gas. The
light emission properties of metal halide lamps are similar
to those of xenon discharge lamps. A fundamental difference
between these light sources is that lasers emit a well-defined
monochromatic light at a single wavelength only (with some
exceptions where two or three single wavelengths are emit-
ted at the same time). In contrast, QTH and plasma arc lamps
emit a wide wavelength range from ultraviolet (UV, wave-
length  < 380 nm), across the entire visible spectrum (VIS,
 = 380–750 nm) deep into the infrared (IR,  > 750 nm). Usually,
QTH and plasma arc lamps are equipped with UV- and IR-
filters to exclude UV and IR-radiation and narrow the emitted
wavelength range to, e.g. 400–580 nm, in order to reduce the
risk of possible side effects of IR and UV radiation on living
cells. It is in the nature of optical filters that they are not able
to suppress 100% of the incoming radiation within a specific
range. Therefore, the suppression of IR by an IR-filter in QTH
and plasma arc lamps is not complete and a fraction of IR is
still emitted. Using QTH and plasma arc lamps the directly
emitted IR radiation adds to the absorption and heat conver-
sion of the emitted visible light and may lead to an additional
pulpal temperature rise [38].
Most lamp systems marketed for use with light-activated
bleaching are resin curing lights that in some cases have an
extra setting for bleaching (bleaching mode). Light systems
that are specifically designed for bleaching procedures have
a light output such that multiple teeth, e.g. the whole dental
arch, can be illuminated.
The mechanism of action of laser systems offered for
bleaching purposes depends on the wavelength, power of the
5
radiation and, if applicable, the pump mode. Laser based sys-
tems are usually marketed for a whole range of dental appli-
cations with bleaching being one of them. Laser systems
for bleaching applications usually employ a handpiece that
expands the laser beam such that the laser is not used in point
focus. By expanding the laser beam, the laser light spreads
over the surface of a few teeth. Consequently, some laser typi-
cal properties are lost, but the risk of tissue damage is reduced.
The power per unit area at the surface of the gel (or tooth) may
be in the range of conventional QTH lamps or plasma arc lamp
systems or even lower.
The knowledge of some absorption properties of light in
tooth tissue is helpful in assessing the risks associated with
laser and light-activated bleaching. Wavelengths with a high
absorption coefficient in water and in tooth mineral are read-
ily absorbed at the tooth surface, where heat conversion takes
place. These wavelengths, i.e. around 3000 nm at the border
between IR-B and IR-C, hardly penetrate deeper into dental
hard tissue and therefore, hardly pose a threat to the liv-
ing pulp. Light in the red and near infrared spectral range
(NIR, IR-A) behaves completely differently, because this wave-
length range penetrates biological tissue more easily. Light
within this spectral range can penetrate deeper into dental
hard tissue as well, which makes thermal damage to pulpal
tissue more likely. Within the visible spectrum, violet light is
more readily absorbed in biological tissue than red light due to
higher scattering. The penetration depth of visible light into
dental hard tissue increases in the order of violet, blue, green,
yellow, orange and red due to decreasing scattering coeffi-
cients.
It is worth noting that conversion of visible light into heat is
only possible in the event of absorption of the respective pho-
tons. It is the absorption (which depends on the wavelength
and substance) that is the important factor for a temperature
rise (whether intended or not) within the bleaching product
(gel), dental hard tissue or pulpal tissue.
The pulse modus of laser systems is another important
factor for efficacy and safety. Pulsed laser systems (Hz and
kHz-range) can create very high power densities within a very
short time (milliseconds and less). Thermal tissue damage can
be minimized by appropriate choice of pulse duration and rep-
etition rate, allowing for a sufficient “cool down” period in
between pulses. Pulsed laser systems can be used in a more
tissue friendly manner compared to continuous wave lasers
with comparative energy output [39,40].
The LED-systems available for light-activated bleaching
usually consist of a multitude of LED’s mounted side by side.
LED’s emit light that is distributed across a band of 20–80 nm
bandwidth and more. Therefore, LED’s hold a position in
between monochromatic lasers and broad band light sources,
e.g. QTH and plasma arc lamps. The emission of LED’s used
with systems available for light-activated bleaching is within
the blue range and does not extend as far into the IR spectral
range as QTH or plasma arc lamps do. Therefore, LED-systems
available for light-activated bleaching are not equipped with
an additional IR filter. A remaining concern is that there is still
a portion of IR emission that inevitably also comes with LED’s,
because the so called “wings” of the emission spectra of the
LED’s used extend into the IR region. Thermal pulp damage
from LED-systems cannot be absolutely excluded and has to
6 d e n t a l m a t e r i a l s x x x ( 2 0 0 6 ) xxx–xxx
be taken into consideration, especially when high power LED’s
are used for a longer time period.
3. Efficacy of light–bleaching gel interaction
The potential increase in efficacy of bleaching gels by light
activation is still not well documented. However, more recent
publications indicate that the benefit of the additional use
of light is limited. The direct effect on the bleaching gel was
evaluated by measuring the decomposition rate of H2 O2 in a
laboratory set-up [41]. Neither the application of light, nor the
application of heat increased the decomposition rate of H2 O2 .
Although, the temperature of a bleaching gel with reddish
appearance containing carotene increased considerably, the
temperature increase was not high enough to accelerate per-
oxide decomposition significantly. An important result of this
study was, however, that a chemical activation that is done
by mixing two components of the respective bleaching gels,
where one comprises peroxide, can indeed increase peroxide
decomposition. The gel component that contains H2 O2 has
an acidic pH in most cases, because peroxide-decomposition
is reduced in an acidic environment, which makes this com-
ponent stable for storage. It appeared that the main function
of the activating gel component (synonymously referred to as
“catalyst” or “booster”) is to increase the pH of the mixed gel,
thereby increasing the decomposition rate of peroxide and the
formation of bleaching active radicals.
4. Critical assessment of the clinical
performance of activated bleaching procedures
4.1. Effect of temperature increase in the pulp chamber
Generally, it should be noted that all bleaching activation
modes mentioned may be accompanied by a temperature
increase at the tooth surface, but also in the pulpal cham-
ber. However, the bleaching gel usually applied may act as an
isolator reducing intra-pulpal temperature increase as com-
pared to activated bleaching performed without gel applica-
tion. This means that laser activation (diode laser, 30 s, 3 W,
830 nm) without the use of bleaching gel results in an intra-
pulpal temperature increase of about 16 ◦ C, whereas only an
8.7 ◦ C temperature increase was recorded when a gel was
applied during activation [42]. Temperature increase may also
depend on amount and type of color pigments included in
the gels [43]. Since the 1960s, when Nyborg and Brännström
[44] performed their classical experiment, it is known that
a distinct intra-pulpal temperature increase leads to patho-
logical alterations of the pulp. They applied heated instru-
ments (150 ◦ C) for 30 s in freshly prepared class V cavities
of premolars and extracted the teeth and the contralateral
non-heated controls 4 weeks later. Although the patients
did not feel discomfort in the clinical examinations per-
formed 1 month after treatment, the histological assessment
yielded localized pulpal necrosis in some of the heat-treated
cases.
Moreover, in an animal study it was proved that an intra-
pulpal increase in temperature of 5.5 ◦ C leads to irreversible
pulp damage in 15% of the test animals (Macaca rhesus mon-
key). Even 60% of the animals showed irreversible pulp alter-
ations in the treated teeth when the intra-pulpal temperature
increase amounted to 11.1 ◦ C, and in all examined teeth an
irreversible necrotic response was observed when intra-pulpal
temperature was elevated 16.6 ◦ C above normal level [45]. Due
to the results of these studies an intra-pulpal temperature
increase of 5.5 ◦ C is nowadays regarded as the threshold value,
which should not be exceeded to avoid irreversible pulp dam-
age [42]. However, it was also discussed that the injury and the
alterations of the dentin after application of heat are probably
the main causes of post-operative inflammation or necrosis of
the pulp. This hypothesis was postulated by Baldissara et al.
[46] who observed a low susceptibility of pulpal cells to heat
(8.9–14.7 ◦ C) in histological assessments of molars and premo-
lars being extracted 60–91 days after application of the heat.
The thermal impulse applied in the study resembled the tem-
perature rise during preparation of a tooth for fabrication of
direct provisional crowns with exothermal resins. They sug-
gested that, at least in the short term, heat does not appear to
be a major factor in pulp pathologies during the post-operative
period of dental treatment and prosthodontic treatment in
particular.
4.2. Effect of activation of bleaching agents on
peroxide penetration
Heating of the bleaching agent not only leads to an increase
in intra-pulpal temperature, but also to a distinctly increased
penetration of peroxide from the bleaching material into
the pulp [47,48]. It was shown that color change in exter-
nally bleached teeth is highly influenced by color change
in subsurface dentin [49]. The fact that heated bleaching
agents penetrate into dental hard tissue more rapidly may
explain the whitening effect of heat-activated bleaching meth-
ods, also when applied for short periods. It should, how-
ever, be noted that diffusion of peroxide into the pulp
leads to oxidative stress which could negatively affect cell
metabolism. Although, small amounts of diffused peroxide,
as observed after application of a 10% carbamide peroxide
gel, are responded to by coronal odontoblasts and endothe-
lial cells with increasing synthesis of heme oxygenase-1, this
mechanism might represent a component of an initial defense
response in the pulp that precedes classical inflammatory
pathways probably rendering the penetrated peroxide harm-
less [50]. This observation was made in an ex vivo investiga-
tion using immunohistological methods. In contrast to this
finding, it was shown that the amount of peroxide, which
diffuses through a 0.5 mm thick dentin disc in less than 1 h,
is able to inhibit enzyme activity (succinyl dehydrogenase)
of pulp fibroblasts, as evaluated in a cell culture test [51].
A recently published study confirmed the observation that
peroxide released from bleaching agents applied on intact
tooth surfaces is able to diffuse to the pulp chamber. How-
ever, the authors calculated that the level of peroxide reached
in the pulp chamber is not expected to adversely affect pulpal
enzymes [52]. When H2 O2 is heated to 50 ◦ C, enzyme activi-
ties in extracts of calf dental pulps are significantly reduced.
Thereby, reduction in activity of different enzymes to the
heated peroxide differs ranging from 20% (aldolase) to 95%
 d e n t a l m a t e r i a l s x x x ( 2 0 0 6 ) xxx–xxx
(glucose-6-phosphate-dehydrogenase) as shown in the study
by Bowles and Thompson [53]. Despite the findings mentioned
above, additional safety studies are still needed to allow for
final assessment of the influence of peroxide diffusion into
the pulp in the clinical situation.
Clinically, patients treated with heat-activated bleaching
therapies often complain of tooth hypersensitivity even up
to 48 h after completion of bleaching [54]. However, bleaching
treatments adopted without application of light or heat may
also lead to post-operative tooth hypersensitivity as shown
in numerous studies [55–60]. As yet, there is no clear evi-
dence, whether application of heat increases the frequency
and severity of post-operative tooth hypersensitivity, since
randomized controlled clinical studies addressing this ques-
tion are still lacking. This is also true for the question
whether heat-activation of bleaching agents may induce or
increase micromorphological changes of bleached enamel or
dentin. In the study by Lewinstein et al. [61], 30% hydro-
gen peroxide was heated to either 37 or 50 ◦ C and applied
onto enamel and dentin samples. They found a microhard-
ness reduction in the treated samples as compared to con-
trols treated with distilled water and samples treated with
heated sodium perborate/peroxide-mixtures. Unfortunately,
no unheated 30% hydrogen peroxide control was used, so
that the study does not allow for estimation of the heating
effect.
Table 2 – Survey of studies, in which heat-activated, external bleaching procedures were compared with other bleaching
techniques
7
4.3. Influence of type of bleaching agent on
heat-activated tooth whitening
The degree of tooth brightening achieved with activated
bleaching methods depends on the mode and type of acti-
vation, but also on the composition of the applied bleaching
substance. Luk et al. [62] proved that using the bleaching
gel Opalescence Xtra (35% H2 O2 ) application of halogen light
resulted in the highest difference when compared to the
non-activated application mode. However, when using the
bleaching gel QuickWhite (35% H2 O2 ), infrared (and not the
halogen) light was most effective. It should also be noted
that the infrared light and the additionally tested CO2 -laser
(with emission in the long wave IR spectral range) caused
the highest tooth temperature increase in this study. Due to
this finding, selection of a specific combination of bleach-
ing agent and light that demonstrates good color change
and little temperature elevation for in-office-bleaching is
recommended.
4.4. Survey of studies comparing activated and
non-activated bleaching regimes
In Table 2 all studies, which compare activated and
non-activated external bleaching therapies and which are
presently listed in PUBMED, are summarized.
8 d e n t a l m a t e r i a l s x x x ( 2 0 0 6 ) xxx–xxx
Table 2 (Continued )
For critical judgment of animal (e.g. dogs) studies, it is
important to notice that differences in morphology of dog
teeth compared to human teeth exist. In dog canine teeth, the
combined average thickness of enamel and dentin amounted
to 1.7 mm, whereas human premolars, as used in the ex vivo
studies mentioned in the tables, have an average thickness
of about 3.8 mm. This means that the dental hard tissues of
dog teeth may provide less pulpal protection as compared to
human teeth.
The studies in the tables give evidence, that heat acti-
vation might be accompanied by an intra-pulpal tempera-
ture increase, which in some cases may exceed the critical
elevation in temperature of 5.5 ◦ C [38,42]. Additionally, heat
application resulted in an increased peroxide penetration into
the pulp [47]. Histological assessments of extracted teeth in
humans [63] or dogs [64] showed that the applied heat might
cause mild inflammatory responses in single cases, which
could, however, also have been provoked by application of
 dental materials
Table 2 (Continued )
35% peroxide alone. The animal study performed by Seale and
Wilson [65] showed that severity of pulp response and non-
reversibility of pulp damages are associated with the length
of the heat-activated bleaching procedure. However, it should
be noted that adverse effects, such as signs of pulp inflam-
mation or others, are not reported in all investigations [54].
It is interesting to remark that the presently available studies
do not allow for a concluding judgment whether the degree
of tooth whitening could either be increased or accelerated
by the additional application of heat. There are studies, in
which a better bleaching effect due to heat application was
observed, even though the effects depended on the mode of
activation and were not perceptible or measurable in all cases
under examination [62,66–69]. From these studies, only the
investigation by Tavares et al. [66] was performed in vivo. In
contrast to these studies, other investigations did not show an
increased whitening effect, when applying either laser [70] or
light activation [41,67] in comparison to non-activated treat-
ment modalities. The latter mentioned investigations [41,67]
were split-mouth designed in-vivo studies and allowed for
evaluation of the effect of activation in the same patient.
When assessing the color of bleached teeth it should also be
borne in mind that teeth might be mildly dehydrated during
the bleaching therapy with bleaching gels. The dehydration
is probably greater when bleaching is conducted with addi-
tional heat and rubber dam isolation is used, which might in
turn increase the brightening effect temporarily. This positive
effect on tooth lightness is reversed due to the rehydration
of the teeth in the following period. This means that both
dentists and patients should not be over enthusiastic with
the result of an in-office-bleaching therapy immediately after
completion of the treatment.
5. Recommendations
Heat- and light-activated bleaching techniques may poten-
tially cause pulp irritation. As yet, it is still debatable,
whether the activation results in superior tooth brightening
as compared to non-activated bleaching therapies. Therefore,
application of heat- and light-activated bleaching proce-
xxx ( 2 0 0 6 ) xxx–xxx 9
dures should be critically weighed up, keeping in mind the
physical, physiological and patho-physiological implications
mentioned above. If heat or light-activation is applied, it is
strongly advised to follow manufacturers’ recommendations
with limited duration of heat-activation to a short period of
time, in order to avoid undesired pulpal responses.
references
[1] Perdigão J, Baratieri LN, Arcari GM. Contemporary trends
and techniques in tooth whitening: a review. Pract Proced
Aesthet Dent 2004;16:185–92.
[2] Barghi N. Making a clinical decision for vital tooth
bleaching: at-home or in-office? Compend Contin Educ
Dent 1998;19:831–8.
[3] Al Shethri S, Matis BA, Cochran MA, Zekonis R, Stropes M.
A clinical evaluation of two in-office-bleaching products.
Oper Dent 2003;28:488–95.
[4] Powell LV, Bales DJ. Tooth bleaching—its effect on
oral-tissues. J Am Dent Assoc 1991;122:50–4.
[5] Lu AC, Margiotta A, Nathoo SA. In-office tooth whitening:
current procedures. Compend Contin Educ Dent
2001;22:798–805.
[6] Fiedler RS, Reichl RB. Combined professional and home
care nightguard bleaching of tetracycline-stained teeth.
Gen Dent 2000;48:257–61.
[7] Deliperi S, Bardwell DN, Papathanasiou A. Clinical
evaluation of a combined in-office and take-home
bleaching system. J Am Dent Assoc 2004;135:
628–34.
[8] Gallagher A, Maggio B, Bowman J, Borden L, Mason S, Felix
H. Clinical study to compare two in-office (chairside)
whitening systems. J Clin Dent 2002;13:219–24.
[9] Auschill TM, Hellwig E, Schmidale S, Sculean A, Arweiler
NB. Efficacy, side-effects and patients’ acceptance of
different bleaching techniques (OTC, in-office, at-home).
Oper Dent 2005;30:156–63.
[10] Auschill TM, Hellwig E, Schmidale S, Hannig M, Arweiler
NB. Effectiveness of various whitening techniques and
their effects on the enamel surface. Schweiz Monatsschr
Zahnmed 2002;112:894–900.
[11] Zekonis R, Matis BA, Cochran MA, Al Shetri SE, Eckert GJ,
Carlson TJ. Clinical evaluation of in-office and at-home
bleaching treatments. Oper Dent 2003;28:114–21.
10 dental materials
[12] Abbot CH. Bleaching discolored teeth by means of 30%
perhydrol and the electric light rays. J Allied Dent Soc
1918;13:259.
[13] Shearer AC. External bleaching of teeth. Dent Update
1991;18:289–91.
[14] Weinberg SP, Reingold AL. Heated bleaching: a safe and
rewarding method. Dent Today 1997;16(4):58, 60, 62–65.
[15] Berger A, Gutknecht N, Lampert F. In-Office-Bleaching
unter Verwendung einer Plasmalampe. Fallbeispiele zur
Aufhellung vitaler und avitaler Zähne. Quintessenz
2003;54:765–72.
[16] Seale NS, Thrash WJ. Systematic assessment of color
removal following vital bleaching of intrinsically stained
teeth. J Dent Res 1985;64:457–61.
[17] Reyto R. Laser tooth whitening. Dent Clin North Am
1998;42:755–62.
[18] Garber DA. Dentist-monitored bleaching: a discussion of
combination and laser bleaching. J Am Dent Assoc
1997;128(Suppl.):26S–30S.
[19] Sulieman M. An overview of bleaching techniques: 3.
In-surgery or power bleaching. Dent Update 2005;32:101–8.
[20] Walsh LJ, Liu JY, Verheyen P. State of the art: tooth
discoloration and its treatment using KTP laser-assisted
tooth whitening. J Oral Laser Appl 2004;4:7–20.
[21] Walsh LJ. Laser whitening “down under”. J Oral Laser Appl
2004;4:65–6.
[22] Walsh LJ. The current status of laser applications in
dentistry. Aust Dent J 2003;48:146–55.
[23] Stabholz A, Zeltser R, Sela M, Peretz B, Moshonov J,
Ziskind D, et al. The use of lasers in dentistry: principles
of operation and clinical applications. Compend Contin
Educ Dent 2003;24:935–48.
[24] Nash RW. In-office bleaching system for quick esthetic
change. Compend Contin Educ Dent 1999;20:986–90.
[25] Smigel I. Laser tooth whitening. Dent Today 1996;15:32–6.
[26] Ward DH. An innovative, heat-accelerated, in-office
whitening technique for nonvital teeth. Dent Today
2003;22:56–9.
[27] Weinberg SP. Bleaching tetracycline-stained teeth a
combined approach. Dent Today 1997;16(8):56, 58–59.
[28] Weinberg SP, Rethnam S. A combination technique for
nonvital bleaching. Dent Today 1997;16(5):82, 84–85.
[29] Hanosh FN, Hanosh GS. Vital bleaching: a new
light-activated hydrogen peroxide system. J Esthet Dent
1992;4:90–5.
[30] Sun G. The role of lasers in cosmetic dentistry. Dent Clin
North Am 2000;44:831–50.
[31] Cohen S, Parkins FM. Bleaching tetracycline-stained vital
teeth. Oral Surg Oral Med Oral Pathol 1970;29:465–71.
[32] Wilson CF, Seale NS. Color change following vital bleaching
of tetracycline-stained teeth. Pediatr Dent 1985;7:205–8.
[33] Myers DL, O’Dell NL, Lake FT, Bell RA, Barenie JT. The
effectiveness of bleaching for the removal of tetracycline
from rat incisors. J Pedod 1980;4:227–35.
[34] Nathanson D, Parra C. Bleaching vital teeth: a review and
clinical study. Compend Contin Educ Dent 1987;8:490–7.
[35] Glickman GN, Frysh H, Baker FL. Adverse response to vital
bleaching. J Endod 1992;18:351–4.
[36] Attin T, Paque F, Ajam F, Lennon ÁM. Review of the
current status of tooth whitening with the walking bleach
technique. Int Endod J 2003;36:313–29.
[37] Friedman S, Rotstein I, Libfeld H, Stabholz A, Heling I.
Incidence of external root resorption and esthetic results
in 58 bleached pulpless teeth. Endod Dent Traumatol
1988;4:23–6.
[38] Baik JW, Rueggeberg FA, Liewehr FR. Effect of
light-enhanced bleaching on in vitro surface and
intrapulpal temperature rise. J Esthet Restor Dent
2001;13:370–8.
xxx ( 2 0 0 6 ) xxx–xxx
[39] Miserendino LJ, Neiburger EJ, Walia H, Luebke N, Brantley
W. Thermal effects of continuous wave CO2 laser exposure
on human teeth: an in vitro study. J Endod 1989;15:
302–5.
[40] Miserendino LJ, Abt E, Wigdor H, Miserendino CA.
Evaluation of thermal cooling mechanisms for laser
application to teeth. Lasers Surg Med 1993;13:83–8.
[41] Hein DK, Ploeger BJ, Hartup JK, Wagstaff RS, Palmer TM,
Hansen LD. In-office vital tooth bleaching—what do lights
add? Compend Contin Educ Dent 2003;24:340–52.
[42] Sulieman M, Addy M, Rees JS. Surface and intra-pulpal
temperature rises during tooth bleaching: an in vitro
study. Br Dent J 2005;199:37–40.
[43] Eldeniz AU, Usumez A, Usumez S, Ozturk N. Pulpal
temperature rise during light-activated bleaching. J
Biomed Mater Res B Appl Biomater 2005;72:254–9.
[44] Nyborg H, Brännström M. Pulp reaction to heat. J Prosthet
Dent 1968;19:605–12.
[45] Zach L, Cohen G. Pulp response to externally applied heat.
Oral Surg Oral Med Oral Pathol 1965;19:515–30.
[46] Baldissara P, Catapano S, Scotti R. Clinical and histological
evaluation of thermal injury thresholds in human teeth: a
preliminary study. J Oral Rehabil 1997;24:791–801.
[47] Bowles WH, Ugwuneri Z. Pulp chamber penetration by
hydrogen peroxide following vital bleaching procedures. J
Endod 1987;13:375–7.
[48] Wetter NU, Walverde D, Kato IT, Eduardo CP. Bleaching
efficacy of whitening agents activated by xenon lamp and
960-nm diode radiation. Photomed Laser Surg
2004;22:489–93.
[49] Wiegand A, Vollmer D, Foitzik M, Attin R, Attin T. Efficacy
of different whitening modalities on bovine enamel and
dentin. Clin Oral Investig 2005;9:91–7.
[50] Anderson DG, Chiego Jr DJ, Glickman GN, McCauley LK. A
clinical assessment of the effects of 10% carbamide
peroxide gel on human pulp tissue. J Endod
1999;25:247–50.
[51] Hanks CT, Fat JC, Wataha JC, Corcoran JF. Cytotoxicity and
dentin permeability of carbamide peroxide and
hydrogen-peroxide vital bleaching materials, in vitro. J
Dent Res 1993;72:931–8.
[52] Pugh Jr G, Zaidel L, Lin N, Stranick M, Bagley D. High
levels of hydrogen peroxide in overnight tooth-whitening
formulas: effects on enamel and pulp. J Esthet Restor Dent
2005;17:40–5.
[53] Bowles WH, Thompson LR. Vital bleaching: the effects of
heat and hydrogen peroxide on pulpal enzymes. J Endod
1986;12:108–12.
[54] Cohen SC. Human pulpal response to bleaching
procedures on vital teeth. J Endod 1979;5:134–8.
[55] Gerlach RW, Barker ML, Sagel PA. Comparative efficacy and
tolerability of two direct-to-consumer tooth whitening
systems. Am J Dent 2001;14:267–72.
[56] Karpinia K, Magnusson I, Barker ML, Gerlach RW. Clinical
comparison of two self-directed bleaching systems. J
Prosthodont 2003;12:242–8.
[57] Haywood VB. History, safety, and effectiveness of current
bleaching techniques and applications of the nightguard
vital bleaching technique. Quintessence Int 1992;23:471–88.
[58] Haywood VB, Leonard RH, Nelson CF, Brunson WD.
Effectiveness, side effects and long-term status of
nightguard vital bleaching. J Am Dent Assoc
1994;125:1219–26.
[59] Jorgensen MG, Carroll WB. Incidence of tooth sensitivity
after home whitening treatment. J Am Dent Assoc
2002;133:1076–82.
[60] Pohjola RM, Browning WD, Hackman ST, Myers ML,
Downey MC. Sensitivity and tooth whitening agents. J
Esthet Restor Dent 2002;14:85–91.
 dental materials
[61] Lewinstein I, Hirschfeld Z, Stabholz A, Rotstein I. Effect of
hydrogen-peroxide and sodium perborate on the
microhardness of human enamel and dentin. J Endod
1994;20:61–3.
[62] Luk K, Tam L, Hubert M. Effect of light energy on peroxide
tooth bleaching. J Am Dent Assoc 2004;135:194–201.
[63] Robertson WD, Melfi RC. Pulpal response to vital bleaching
procedures. J Endod 1980;6:645–9.
[64] Seale NS, McIntosh JE, Taylor AN. Pulpal reaction to
bleaching of teeth in dogs. J Dent Res 1981;60:948–53.
[65] Seale NS, Wilson CF. Pulpal response to bleaching of teeth
in dogs. Pediatr Dent 1985;7:209–14.
[66] Tavares M, Stultz J, Newman M, Smith V, Kent R, Carpino
E, et al. Light augments tooth whitening with peroxide. J
Am Dent Assoc 2003;134:167–75.
xxx ( 2 0 0 6 ) xxx–xxx 11
[67] Papathanasiou A, Kastali S, Perry RD, Kugel G. Clinical
evaluation of a 35% hydrogen peroxide in-office whitening
system. Compend Contin Educ Dent 2002;23:334–5.
[68] Wetter NU, Barroso MC, Pelino JE. Dental bleaching
efficacy with diode laser and LED irradiation: an in vitro
study. Lasers Surg Med 2004;35:254–8.
[69] Dostalova T, Jelinkova H, Housova D, Sulc J, Nemec M,
Miyagi M, et al. Diode laser-activated bleaching. Braz Dent
J 2004;15(Special Issue):SI3–8.
[70] Jones AH, Diaz-Arnold AM, Vargas MA, Cobb DS.
Colorimetric assessment of laser and home bleaching
techniques. J Esthet Dent 1999;11:87–94.
[71] Sydney GB, Barletta FB, Sydney RB. In vitro analysis of
effect of heat used in dental bleaching on human dental
enamel. Braz Dent J 2002;13:166–9.