Vital Bleaching

Dr. TOM DIENYA

Definition

 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.

(Sturdevent. C.M)
WHAT DOES BLEACHING REALLY
ENTAIL?

Degradation of high molecular

weight complex organic molecules
that reflect specific wave length of
light responsible for the color of the
stain into lower molecular weight
and less complex molecules that
reflect less light is called lightning.
Potential Results
HISTORY

Bleaching was unsuccessfully used in

the middle ages
Modern bleaching technique began in
1918.Abbot used the combination of
superoxol and heat.
1958—Prarson—intra pulpal bleach
1967--Nutting and Por—walking bleach
History cont…

1978—superoxol +heat + light

1989—Haywood .& Hayman (night
guard vital bleaching,10% carbimide
peroxide)
1996—laser tooth whitening officially
started with the approval of ion laser
technology Argon and CO2 lasers to
be used with a potential system of
chemicals
 CONTRAINDICATIONS FOR
BLEACHING

•Poor Case Selection

–Patient having emotional or psychological
problems are not right choice for bleaching.
–In case selection, if clinician has opinion that
bleaching is not in patient’s best interest, he should
decline doing that.
 CONTRAINDICATIONS FOR
BLEACHING
•Dentin Hypersensitivity
Hypersensitive teeth need extra protection before going
for bleach

•Teeth with Hypoplastic Marks and Cracks

–Application of bleaching agents increase the
contrast between white opaque spots and normal
tooth structure:
–In these cases, bleaching can be done in
conjunction with:
–Microabrasion
–Selected ameloplasty
–Composite resin bonding
 CONTRAINDICATIONS FOR
BLEACHING

•Extensively Restored Teeth

–These teeth are not good candidate for
bleaching because:
–They do not have enough enamel to
respond properly to bleaching.
–Teeth heavily restored with visible, tooth
colored restorations are poor candidates as
composite restorations do not lighten, infact
they become more evident after bleaching
 An extensively restored and discoloured tooth
unsuitable for bleaching. A new restoration (core) and crown
would be more appropriate
Vital Bleaching

 Today there are 3 major methods for vital

bleaching
» In office or power bleaching
» At home or tray bleaching
» Over the counter
Cont…

 In-office bleaching technique (25%-35%

hydrogen peroxide)
 Dentist prescribed home applied technique
(10%-22% carbamide peroxide once or twice
daily)
 Over the Counter Bleaching Strips (3%-6%
once for 15mins or twice for 30 mins)
Types of Staining

Extrinsic staining is multi-factorial:

 Tooth Surface Morphology

 Diet
 Smoking
 Oral Hygiene
 Foods such as tea,coffee, red wine
Types of Staining

Intrinsic Stains:
 Food molecules
 Change in structural composition of dental hard
tissues
 Trauma
 Pulp Necrosis
 Pulp obliteration
 Previous endodontic treatment
 CONSTITUENTS OF BLEACHING
GELS
•Carbamide peroxide
•Hydrogen peroxide and sodium hydroxide
•Sodium perborate
•Thickening agent-carbopol or carboxy
polymethylene
•Urea
•Surfactant and pigment dispersants
•Preservatives
•Vehicle-glycerine and dentifrice
•Flavors
•Fluoride and 3 percent potassium nitrate.
 CONSTITUENTS OF BLEACHING
GELS
•Carbamide Peroxide (CH6N2O3)
–It is a bifunctional derivative of carbonic acid. It is
available as:
–Home bleaching
–5 percent carbamide peroxide
–10 percent carbamide peroxide
–15 percent carbamide peroxide
–20 percent carbamide peroxide.
–In office bleaching
–35 percent solution or gel of carbamide peroxide.
 CONSTITUENTS OF BLEACHING
GELS

•Hydrogen Peroxide (H2O2)

–H2O2 breaks down to water and nascent oxygen.
–It also forms free radical perhydroxyl (HO2)
which is responsible for bleaching action
 CONSTITUENTS OF BLEACHING
GELS

•Sodium Perborate
–It comes as monohydrate, trihydrate
or tetrahydrate.
–It contains 95 percent perborate,
providing 10 percent available oxygen
 CONSTITUENTS OF BLEACHING
GELS

•Thickening Agents
–Carbopol (Carboxy polymethylene): Addition of
carbopol in bleaching gels causes:
–Slow release of oxygen
– Increased viscosity of bleaching material, which
further helps in longer retention of material in tray and
need of less material
–Delayed effervescence–thicker products stay on the teeth
for longer time to provide necessary time for the carbamide
peroxide to diffuse into the tooth
–The slow diffusion into enamel may also allow tooth to be
bleached more effectively.
 CONSTITUENTS OF BLEACHING
GELS

•Urea
–It is added in bleaching solutions to:
–Stabilize the H2O2
–Elevate the pH of solution
–Anticariogenic effects.
 CONSTITUENTS OF BLEACHING
GELS

•Surfactants
–Surfactant acts as surface wetting agent which
allows the hydrogen peroxide to pass across gel
tooth boundary
 FACTORS AFFECTING BLEACHING

•Amount of time,
–the bleach is in contact with the teeth:
–Increase in contact time, increases the bleaching
effect
•Cleanliness of tooth surface:
–Cleaner the enamel surface, better is the effect of
bleaching
•Concentration of solution:
–Increase in peroxide concentration, increases the
effect of bleaching
 FACTORS AFFECTING BLEACHING

•Location and depth of discoloration

•Temperature:
–Increase in temperature increases the release of oxygen
free radicals which increases bleaching effect
•Rate of oxygen free radical release:
–More is the oxygen free radical release, better is the effect
of bleaching
•Viscosity of solution:
–Addition of agents like glycerine, glycol to increase the
viscosity of bleaching solution decrease the efficacy of
bleaching agent
 FACTORS AFFECTING BLEACHING

•Age of patient
•Original shade and location of discoloration.
•Frequency with which bleaching solution is
changed
•Degradation rate of bleaching agent
that is rate of oxygen release
Material

Oxidising Agents:

Hydrogen Peroxide (25%-35%, 5.3%, 6%)

Carbamide Peroxide (10%, 22%)

Mechanism of Action

 Oxidation of organic pigments in the tooth.

 Carbamide peroxide is broken down to

hydrogen peroxide and urea by salivary
enzymes.

 Therefore it is hydrogen peroxide that works.

Mechanism of Action

 Hydrogen peroxide breaks down into free

radicals.
 Free radicals then work by breaking the
carbon : carbon double bonds found in the
double bonded organic stains in the teeth
 Breaking these bonds leads to lightening of
the molecules until they lose their color.
IN OFFICE VITAL TOOTH
BLEACHING

Vital tooth bleaching

is one of the least
invasive, most
conservative and most
effective procedure to
dramatically improve
the esthetic
appearance of patient
smile and self-
confidence.
 Indications

Light enamel discolorations

Mild tetracycline
discolorations
Endemic fluorosis
discolorations
Age related discolorations
 Contraindications

Severe dark discoloration

Severe enamel loss
Hypersensitive teeth
Presence of caries
Large/poor coronal restoration
 In-office Bleaching

•Thermocatalytic Vital Tooth Bleaching

–Equipment needed for in-office bleaching are:
–Power bleach material
–Tissue protector
–Energizing/activating source
–Protective clothing and eye wear
–Mechanical timer
 In-office Bleaching

•Light Sources Used for In-office Bleach

–Various available light sources are:
–Conventional bleaching light
–Tungsten halogen curing light
–Xenon plasma arc light
–Argon and CO2 lasers
–Diode laser light.
 In-office Bleaching
•Xenon Plasma Arc Light
–High intensity light, so more heat is
liberated during bleaching
–Application requires 3 seconds per tooth
–Faster bleaching
–Action is thermal and stimulates the
catalyst in chemicals
–Greater potential for thermal trauma to pulp
and surrounding soft tissues.
 Xenon
Plasma Arc
Light
 Procedural steps
Familiarize the patient with
– Probable cause of discoloration
– Procedure to be followed
– Expected out come
– Possibility of future re-discoloration
Take radiographs
– Detect all carious lesions
– Defective restorations and proximity of
pulp horns
Evaluate tooth
color
– With shade guide
– Take clinical
photographs
before and
through out
treatment.
Apply a
protective cream
to the
surrounding
gingival tissues
and isolate the
tooth with a
rubber dam and
waxed dental
floss ligature.
Do not inject
local anesthetic.
APPLICATION OF 40%
hydrogen
PEROXIDE(opalescense
boost) ON THE TOOTH
SURFACE

MATERIAL IS ALLOWED
TO STAY FOR 5-10
MINUTES. The cycle is
repeated three times until
desirable color is achieved
PRE AND POST OPERATIVE

BEFORE AFTER

BEFORE AFTER
NIGHT GUARD BLEACHING/ HOME
BLEACHING TECHENIQUE

Introduced by
Haywood and
Haymann in 1989
Dentist prescribed
home bleach
technique.
Bleaching tray ,/
material prepared and
dispensed along with
follow up appointment
for check up.
Cont..

• Indications for Use

– Mild generalized staining
– Age related discolorations
– Mild tetracycline staining
– Mild fluorosis
– Acquired superficial staining
– Stains from smoking tobacco
– Color changes related to pulpal trauma
or necrosis.
Contraindications

– Teeth with insufficient enamel for bleaching

– Teeth with deep and surface cracks and fracture lines
– Teeth with inadequate or defective restorations
– Discolorations in the adolescent patients with large pulp
chamber
– Severe fluorosis and pitting hypoplasia
– Noncompliant patients
– Pregnant or lactating patients
– Teeth with large anterior restorations
Contraindications cont….

– Severe tetracycline staining

– Fractured or malaligned teeth
– Teeth exhibiting extreme sensitivity to
heat, cold or sweets
– Teeth with opaque white spots
– Suspected or confirmed bulimia nervosa
 Advantages of Home Bleaching
Technique

•Simple method for patients to use

•Simple for dentists to monitor
•Less chair time and cost effective
•Patient can bleach their teeth at their
convenience.
 Side Effects of Home Bleaching

•Gingival irritation—Painful gums after a few

days of wearing trays
•Soft tissue irritation—From excessive wearing
of the trays or applying too much bleach
to the trays
•Altered taste sensation—Metallic
taste immediately after removing trays
•Tooth sensitivity—Most common sid effect.
MATERIALS USED
Tray :step by step

Alginate impression
of the arch to be
taken.
Model prepared
Block resin applied on
the labial surface of
the teeth to be
bleached to form a
small reservoir for the
bleaching agent.
 BIOSTAR MODEL AND TRAY
MATERIAL IN POSITION

MOULDED TRAY BLEACHING TRAY \ MATRIX

 BRUSHING FLOSSING

APPLICATION OF BLEACHING INSERTION STORAGE

MATERIAL
Familiarize the patient
with the use of
bleaching agent and
wearing the guard,
instruct the patient
that this procedure
should be performed
3-4 hours per day or
over night.

Recall the patient

every 2 weeks to
monitor stain
lightening.10%
carbamide peroxide
is used for this
technique ,this can be
later increased to
16%,or up to 20% as
per the case
reqirements.
BEFORE AFTER

BEFORE AFTER
 Vivastyle paint on
THE PROFESSIONAL VARNISH SYSTEM
FOR WHITENING TEETH
 Why use a varnish system ?
Vivastyle paint on is insoluable in water. Consequently,
the varnish is not prematurely washed off the teeth by
saliva.

Vivastyle paint on contains 6% carbamide peroxide

when applied. This component releases oxygen , which
gently lightens stains. Once it has dried, its
concentration is about five times higher.
 STEPS OF APPLICATION

Available as standing tube with brush and

dispensing dish for single use
Brushing and flossing of teeth before application of
varnish
DRYING WITH BLOTTING APPLYING PROTECTIVE
PAPER GEL
Vivastyle paint on is applied directly to the teeth
with a brush and allowed to dry for 30 seconds
 The dried varnish remains on the teeth for 20
minutes and is subsequently removed with a
toothbrush.
 APPLICATION OPTIONS

Once daily for 20 min. over a period of 14 days.

Twice daily for 20 min. over a period of 7 days
 CLINICAL RESULTS

-Noticeable whitening of teeth after just a few days

-Less irritation
Significant whitening of teeth after treatment with Vivastyle Paint on
 Advantages

professional tooth whitening without a tray,

as
– Patients find tray application uncomfortable
– Patients are looking for a more cost-effective
alternative
– smooth integration into daily schedule
gentle application

touching up of previously whitened teeth

Bleaching

 No one technique is supreme as at the end

of the day the mechanism of action is the
same. The only difference is that some may
produce results faster.
 However a combination of techniques such
as in-office with dentist prescribed has seen
to have better results.
 Microabrasion

•Contraindications
–Age related staining
–Deep enamel hypoplastic lesions
–Areas of deep enamel and dentin stains
–Amelogenesis imperfecta and dentinogenesis
imperfecta cases
–Tetracycline staining
–Carious lesions underlying regions of
decalcification
 Microabrasion

•Indications
–Developmental intrinsic stains and discolorations
limited to superficial enamel only
–Enamel discolorations as a result of hypominera-
lization or hypermineralization
–Decalcification lesions from stasis of plaque and
from orthodontic bands
–Areas of enamel fluorosis
–Multicolored superficial stains and some irregular
surface texture
 Microabrasion

•Advantages
–Minimum discomfort to patient
–Can be easily done in less time by operator
–Useful in removing superficial stains
–The surface of treated tooth is shiny and
smooth in nature
 Microabrasion

•Disadvantages
–Not effective for deeper stains
–Removes enamel layer
–Yellow discoloration of teeth has been reported
in some cases after treatment.
MICRO ABRASION:

 It is a technique for removing about

25m of the enamel surface. It is
particularly useful for eliminating white or
brown spots or surface roughness.
 Original protocol used 18% HCl and
pumice. A proprietary compound consists
of water soluble gel containing a dilute
conc. of HCl and an abrasive.
 The gel is applied to the enamel surface with
special rubber cups in a contra angle hand
piece for about 10sec / tooth and teeth must be
well rinsed with water.

 Assessment is made of color change and

degree of tooth removal and the process is
repeated as required. When the desired result
has been achieved, teeth are rinsed thoroughly
with water and the residual solution is
neutralized with sodium bicarbonate. The teeth
are rinsed again with water, dried, and polished
with a fine, fluoride containing prophy paste.
The McInnis micro abrasion
technique:

 A solution of 5 parts 30% H2O2, 5 parts

36% hydrochloric acid, and 1 part diethyl
ether is applied directly to the discolored
areas for 1-2min. Fine cuttle discs are
used over the enamel surface for 15 sec
to removes the softened enamel surface.
 How it works
 This technique is used to remove localized,
superficial white spots and other surface stains
or defects.
 It uses 12-fluted composite finishing bur and
fine grit finishing diamond in a high speed
hand piece to remove the defect.
 Care must be taken to use light, intermittent
pressure and carefully monitor removal of
tooth structure to avoid irreversible damage to
the tooth.
 Airwater sprays is used as coolant and
maintain the tooth in hydrated state to facilitate
assessment of defect removal.
Cont….

 After removal of the defect, a 30-fluted

composite finishing bur is used to remove
any facets or striations created by the
previous instruments.
 Final polishing is accomplished with an
abrasive rubber point.
Diamonds are forever, Skyce
is just for cosmetics.
 MEDICAL EXPERTISE ON COSMETIC
PROCEDURES
Dentists of today are finding that more and more
people who consult them are no longer really patients.
They are individuals who desire perfectly aligned,
sparking white teeth, and who may even ask for tooth
jewellery. These cosmetic procedures have to be
accomplished by professionals with professionals
products.

Vivadent has developed the skyce system of tooth

jewellery, which enables dentists to satisfy this cosmetic
demand according to dental requirements.
 STUNNING JEWELLERY ON HEALTHY
TEETH
Patients want a sparking smile and dentists want teeth
to be healthy. Dentists are committed to maintaining
the health of teeth at all costs.
The dental jewellery is bonded onto the tooth in the
same way as an orthodontic bracket.
 SLIGHT ETCHING; STRONG BOND

Retentive pattern is produced on the enamel using

37% phosphoric acid.
Placement of flowable composite, the right consistency
Lifting the skyce using a probe tip with bonding agent
Skyce bonded to the tooth with flowable composite
 Skyce
Flowable Composite
Tooth

Skyce is bonded to the tooth with the transparent Flowable

composite

Skyce must be encircled by a little Flowable composite to

ensure micromechanical retention.
 TWO COLOURS; TWO SIZES

Skyce is made of crystal glass.

It is available in two different colours and sizes: “crystal” and

sapphire blue”, 1.8 mm or 2.5 mm in diameter.
Thank You!