Basic Research—Technology
Effect of Intracoronal Bleaching Agents on
Dentin Microhardness
Daniel Pinto de Oliveira, DDS, MSc,*‡ Erica Cappelletto Nogueira Teixeira, DDS, MSc,†
Caio Cezar Randi Ferraz, DDS, MSc, PhD,‡ and Fabricio B. Teixeira, DDS, MSc, PhD*
Abstract
The purpose of this in vitro study was to compare the
effect of intracoronal bleaching agents associated or
unassociated with chlorhexidine gel on dentin micro-
hardness. Sixty human maxillary incisor crowns were
divided into six groups, and bleaching agents were
sealed into the pulp chambers as follows: sodium per-
borate ⫹ water (SPW), sodium perborate ⫹ 2% chlor-
hexidine gel (SP ⫹ CHX), sodium perborate ⫹ 30%
hydrogen peroxide solution (SP ⫹ HP), 37% carbamide
peroxide gel (CP), 37% carbamide peroxide gel ⫹ 2%
chlorhexidine gel (CP⫹CHX), and water (W). After the
bleaching procedure, microhardness testing was carried
out on the dentin surface at three different levels: inner,
middle, and outer dentin. The greatest reduction in
microhardness was observed for the SP ⫹ HP group. No
differences were observed between the SPW and SP ⫹
CHX group. The 2% chlorhexidine gel did not adversely
affect dentin microhardness when associated with the
tested bleaching agents. CHX might be considered as
an antimicrobial vehicle during intracoronal bleaching.
(J Endod 2007;33:460 – 462)
Key Words
Chlorhexidine, dentin microhardness, intracoronal
bleaching
From the *Department of Endodontics and the †Depart-
ment of Diagnostic Sciences & General Dentistry, School of
Dentistry, University of North Carolina at Chapel Hill, Chapel
Hill, North Carolina; ‡Department of Endodontics, Piracicaba
School of Dentistry, State University of Campinas, Piracicaba,
SP, Brazil.
Address requests for reprints to Dr. Fabricio B. Teixeira,
Department of Endodontics, School of Dentistry, University of
North Carolina at Chapel Hill, 05 Brauer Hall Campus Box
7450, Chapel Hill, NC 27599-7450. E-mail address: teixeirf@
dentistry.unc.edu.
0099-2399/$0 - see front matter
Copyright © 2007 by the American Association of
Endodontists.
doi:10.1016/j.joen.2006.08.008
460 Oliveira et al.
I ntracoronal bleaching is an established, simple, cost-effective, and conservative
method of improving the shade of discolored anterior teeth that have received root
canal treatment (1). In the walking bleach technique, the most commonly used bleach-
ing agents are hydrogen peroxide and sodium perborate, either alone or in combination
(2). The successful use of 37% carbamide peroxide gel during the walking bleach
technique has also been reported in the literature (3– 6).
Recently, a gel base containing 2% chlorhexidine (CHX) was introduced as an
alternative to water or hydrogen peroxide as a sodium perborate vehicle. Usually, the
bleaching agents are applied for 3 to 6 weeks in the walking bleach technique, during
which time the treated tooth can be subject to contamination of oral fluids and bacteria
through the temporary sealing (7). Because of its good antimicrobial activity and
substantivity, CHX might help to eliminate any bacteria that leak by the coronal sealing
during the walking bleach technique (8). The 2% CHX gel would act as an antimicrobial
vehicle in those cases.
Despite the well-known antimicrobial properties of CHX, there are no data related
to its effect on dentin structure when associated with intracoronal bleaching agents. The
effects of at-home bleaching agents on the tooth structure and morphology have been
extensively studied. However, few studies have focused on the adverse effects that these
new combinations of intracoronal bleaching materials have on the dentin microhard-
ness. It is assumed that hardness reduction of the treated dental hard tissues might
indicate their dissolution and degradation, increasing dentin permeability and also
possibly presenting a problem for upcoming restorative procedures (9 –11).
The aim of this in vitro study was to determine the effect of 37% carbamide
peroxide gel combined with or without 2% CHX gel and the effect of sodium perborate
in combination with three different vehicles (water, 30% hydrogen peroxide solution,
and 2% CHX gel) on the microhardness of human dentin following the walking bleach
technique.
Materials and Methods
Sixty intact human maxillary incisors had their roots sectioned at 2 mm below the
CEJ using a double-sided diamond disc (Brasseler USA, Savannah, GA). Endodontic
access cavities were prepared using a #6 round carbide bur (Midwest, Wichita Falls,
TX), and the pulp was removed with a spoon excavator. According to Perez et al. (12),
the teeth were immersed in an ultrasonic bath for 10 minutes in 5.25% NaOCl followed
by 10 minutes in a 17% EDTA bath to eliminate the smear layer produced during the
initial preparation. The apical orifice was sealed with 2 mm of a temporary material
(Cavit–3M Espe, Seefeld, Germany).
The crowns were randomly divided into six groups of 10 specimens each, as
described in Table 1. The pulp chamber was filled with the bleaching agent, and the
access cavity of the tooth was sealed with Cavit. After 7 days, the temporary restoration
was removed, the original bleaching agent was washed out with water, and a fresh
portion of the bleaching agent was placed into the access cavity. This procedure was
repeated every 7 days for 3 weeks, according to the walking bleach technique. The
bleaching agent was appropriately combined with the designated vehicle(s) for each
group to maintain a 2:1 ratio in solution (about 0.1 g bleaching agent and 0.05 ml
vehicle). In group 6 (control group), a cotton pellet soaked with distilled water was
placed into the pulp chamber and replaced every 7 days. The teeth were wrapped in
JOE — Volume 33, Number 4, April 2007

gauze, soaked with distilled water, and kept in an incubator at 37°C
throughout the experiment.
After the bleaching procedure, the teeth were sectioned longitudi-
nally using a low-speed diamond saw (Buehler, Lake Bluff, IL). One-half
of each tooth was embedded individually in rings with polyester resin
(Buehler). The samples were flattened and polished through a wet
grinding using 400, 600, and 1200-grit SiC abrasive papers (Buehler).
A Knoop indentor was used, keeping the long axis of the diamond
parallel to the dentin surface in a microhardness testing machine (Mi-
cromet 2100 Microhardness Tester, Buehler). For each specimen,
three indentations were made at different dentin levels (the inner, mid-
dle, and outer dentin) using a load of 25 g for 15 seconds. The inden-
tation on the inner dentin was made approximately 50 ␮m from the
pulp chamber; the indentation on the outer dentin was made approxi-
mately 1,000 ␮m from the indentation on the inner dentin; and the
indentation on the middle dentin was made midway between the two
indentations. Using the three different measurements obtained for each
depth in the same specimen, a mean was calculated.
Analysis of variance and Tukey’s test were used to check significant
differences between groups. Statistical analyses were performed at the
0.05 level of significance.
Results
Mean and standard deviation (SD) values for dentin microhard-
ness of the tested groups at each depth are shown in Table 2. For all six
groups, the mean Knoop microhardness (KHN) was the highest for
outer dentin, followed by middle and inner dentin (Table 2). There
were statistically significant differences between mean KHN for speci-
mens in treatment groups and those in the control group (water), which
demonstrated the highest KHN at all dentin levels. The association SP ⫹
HP revealed the lowest microhardness values, regardless of the dentin
level evaluated. In all three dentin levels there were no differences
between the SP ⫹ CHX and the SPW groups. The least reduction in
microhardness when compared with the control group was demon-
strated by the CP ⫹ CHX group, followed by the CP group.
Discussion
A reduction in the hardness of treated dentin indicates its dissolu-
tion and degradation (13). However, the exact mechanism by which
bleaching agents may affect dentin is not fully elucidated. Some studies
have indicated that hydrogen peroxide can cause dissolution of inor-
ganic material, a reduction in the calcium-phosphorus ratio, and a reduc-
tion in the organic components of dentin by protein oxidation (10, 14).
The pH of the bleaching agents, the buffering capacity of dentin, and the
increase in diameter and density of the dentinal tubules as the pulp is
approached are factors that can influence dentin microhardness (15).
A change in pressure within the pulp chamber may influence the
effect of bleaching agents on dentin (11). Oxygen is released when
hydrogen peroxide, sodium perborate, and carbamide peroxide de-
TABLE 1. Bleaching agents evaluated
Groups Bleaching Agents
1 SP (Proderma, Piracicaba, Brazil) ⫹ water ⫺ 2g:1 ml
2 SP ⫹ 2% CHX gel (Proderma, Piracicaba, Brazil) ⫺
2g:1 ml
3 SP ⫹ 30% HP (Proderma, Piracicaba, Brazil) ⫺
2g:1 ml
4 37% CP (Super Endo; Whiteness, Porto Alegre,
Brazil)
5 37% CP ⫹ 2% CHX gel (2:1)
6 Water
SP, Sodium Perborate; HP, Hydrogen Peroxide; CHX, Chlorhexidine; CP, Carbamide Peroxide.
JOE — Volume 33, Number 4, April 2007
Basic Research—Technology
TABLE 2. Means and standard deviation (KHN ⫾ SD) microhardness values
of inner, middle, and outer dentin
Bleaching Inner Middle Outer
Agent Dentin Dentin Dentin
SPW 54.5b ⫾ 5.4 59.2b ⫾ 4.8 72.8b ⫾ 5.4
SP ⫹ CHX 53.9b ⫾ 4.8 60.4b ⫾ 4.5 73.1b ⫾ 5.0
SP ⫹ HP 45.8a ⫾ 5.2 57.9a ⫾ 5.5 66.6a ⫾ 6.1
CP 60.9c ⫾ 6.0 66.1c ⫾ 5.8 73.8b ⫾ 4.3
CP ⫹ CHX 63.5c ⫾ 5.0 69.2c ⫾ 4.7 74.3b ⫾ 5.2
Water 68.2d ⫾ 5.8 77.4d ⫾ 7.2 82.0c ⫾ 6.8
Means with same superscript letter in columns are not significantly different (p ⱖ 0.05).
compose (5). This may lead to an increase in pressure within the pulp
chamber, forcing the bleaching agents through the dentinal tubules. The
effect of the bleaching agent is likely to be most pronounced in the inner
dentin. This fact is related to the great diameter and density of dentinal
tubules close to the pulp (11). The dentin microhardness values ob-
tained for inner and outer dentin of the control group in this study are
similar to those reported in previous studies (13, 16). In all dentin
levels evaluated, group 3 (SP ⫹ HP) showed the greatest values in the
dentin microhardness reduction. This study also found that group 5
(CP ⫹ CHX) in all dentin levels showed the least alteration in dentin
microhardness. In all dentin levels tested, group 1 (SPW) exhibited
higher microhardness values than those of group 3 (SP ⫹ HP).
The literature related to the vehicle used in the SP paste is very
controversial. Some authors have stated that the undesirable effects on
human dentin structure are influenced by the vehicle (14, 17); whereas
other authors have shown that the vehicle does not influence the alter-
ations to dentin caused by the walking bleach technique (11). The
bleaching ability of SP pastes using different vehicles is also controver-
sial. Some studies have demonstrated better bleaching results when SP
is associated to HP than when combined with distilled water (18, 19).
Other studies have shown similar bleaching ability for both associations
(20 –22). Oliveira et al. (8) showed that a gel base containing 2% CHX
can be an effective SP vehicle during the walking bleach technique. In
that study, after 3 weeks of evaluation the bleaching efficacy of the SP ⫹
2% CHX gel paste was similar to that of sodium perborate with either
water or 30% hydrogen peroxide.
The CHX in gel form has already been suggested as a root canal
dressing (23) and as an auxiliary during root canal irrigation, showing
good performance (24, 25). The gel base used in the present study was
a natrosol gel (hydroxyethyl cellulose) that is a nonionic, inert, and
water-soluble agent (26). The properties of CHX gel, such as broad
spectrum of antimicrobial activity, substantivity, low toxicity, and water-
solubility, have increased the interest in its use during the root canal
treatment (25). In this study, the association of CHX to either SP or CP
(groups 2 and 5) affected the dentin microhardness to the same level as
that of the groups without CHX (groups 1 and 4), regardless of the
dentin areas tested. Based on the results of this study, previous results,
and the antimicrobial properties of the CHX gel, its use could be con-
sidered during intracoronal bleaching as an antimicrobial vehicle with-
out adversely affecting dentin microhardness.
Acknowledgments
This study was supported by the UNC-Endodontic Foundation
and CAPES (BEX: 0173/05-3).
References
1. Amato M, Serena Scaravilli M, Farella M, Riccitiello F. Bleaching teeth treated end-
odontically: long-term evaluation of a case series. J Endod 2006;32:376 – 8.
2. Nutting EB, Poe GS. A new combination for bleaching teeth. J South California Dent
Assoc 1963;31:289 –91.
Intracoronal Bleaching Agents on Dentin Microhardness 461
Basic Research—Technology
3. Liebenberg WH. Intracoronal lightening of discolored pulpless teeth: a modified
walking bleach technique. Quintessence Int 1997;28:771–7.
4. Marin PD, Heithersay GS, Bridges TE. A quantitative comparison of traditional and
non-peroxide bleaching agents. Endod Dent Traumatol 1998;14:64 –7.
5. Vachon C, Vanek P, Friedman S. Internal bleaching with 10% carbamide peroxide
in vitro. Pract Periodont Aesthet Dent 1998;10:1145– 8, 1150 –2.
6. Teixeira EC, Hara AT, Serra MC. Use of 37% carbamide peroxide in the walking
bleach technique: a case report. Quintessence Int 2004;35:97–102.
7. Hosoya N, Cox CF, Arai T, Nakamura J. The walking bleach procedure: an in vitro
study to measure microleakage of five temporary sealing agents. J Endod 2000;
26:716 – 8.
8. Oliveira DP, Gomes BPFA, Zaia AA, Souza-Filho FJ, Ferraz CCR. In vitro assessment of
a gel base containing 2% chlorhexidine as a sodium perborate’s vehicle for intra-
coronal bleaching of discolored teeth. J Endod 2006;32:672– 4.
9. Heling I, Parson A, Rotstein I. Effect of bleaching agents on dentin permeability to
Streptococcus faecalis. J Endod 1995;21:540 –2.
10. Rotstein I, Dankner E, Goldman A, Heling I, Stabholz A, Zalkind M. Histochemical
analysis of dental hard tissues following bleaching. J Endod 1996;22:23– 6.
11. Chng HK, Palamara JEA, Messer HH. Effect of hydrogen peroxide and sodium per-
borate on biomechanical properties of human dentin. J Endod 2002;28:62–7.
12. Perez F, Calas P, Falguerolles A, Maurette A. Migration of a Streptococcus sanguis
strain through root dental tubules. J Endod 1993;19:297–301.
13. Saleh AA, Ettman WM. Effect of endodontic irrigation solutions on microhardness of
root canal dentine. J Dent 1999;27:43– 6.
14. Rotstein I, Lehr Z, Gedalia I. Effect of bleaching agents on inorganic components of
human dentin and cementum. J Endod 1992;18:290 –3.
462 Oliveira et al.
15. Pashley D, Okabe A, Parham P. The relationship between dentin microhardness and
tubule density. Endod Dent Traumatol 1985;1:176 –9.
16. Craig RG, Gehring PE, Peyton FA. Relation of structure to the microhardness of human
dentin. J Dent Res 1959;38:624 –30.
17. Kawamoto K, Tsujimoto Y. Effects of the hydroxyl radical and hydrogen peroxide on
tooth bleaching. J Endod 2004;30:45–50.
18. Ho S, Goerig AC. An in vitro comparison of different bleaching agents in the discol-
ored tooth. J Endod 1989;15:106 –11.
19. Warren MA, Wong M, Ingram TA 3rd. In vitro comparison of bleaching agents on the
crowns and roots of discolored teeth. J Endod 1990;16:463–7.
20. Ari H, Ungor M. In vitro comparison of different types of sodium perborate used for
intracoronal bleaching of discoloured teeth. Int Endod J 2002;35:433– 6.
21. Rotstein I, Mor C, Friedman S. Prognosis of intracoronal bleaching with sodium
perborate preparation in vitro: 1-year study. J Endod 1993;19:10 –2.
22. Weiger R, Kuhn A, Lost C. In vitro comparison of various types of sodium perborate
used for intracoronal bleaching of discolored teeth. J Endod 1994;20:338 – 41.
23. Siqueira JF Jr., de Uzeda M. Intracanal medicaments: evaluation of the antibacterial
effects of chlorhexidine, metronidazole, and calcium hydroxide associated with three
vehicles. J Endod 1997;23:167–9.
24. Ferraz CC, Figueiredo de Almeida Gomes BP, Zaia AA, Teixeira FB, de Souza-Filho FJ.
In vitro assessment of the antimicrobial action and the mechanical ability of chlor-
hexidine gel as an endodontic irrigant. J Endod 2001;27:452–5.
25. Gomes BP, Souza SF, Ferraz CC, et al. Effectiveness of 2% chlorhexidine gel and
calcium hydroxide against Enterococcus faecalis in bovine root dentine in vitro. Int
Endod J 2003;36:267–75.
26. Miyamoto T, Takahashi S, Ito H, Inagaki H, Noishiki Y. Tissue biocompatibility of
cellulose and its derivatives. J Biomed Mater Res 1989;23:125–33.
JOE — Volume 33, Number 4, April 2007