Vital Bleaching

Dr. Ignatius Lee

Potential Results
 Vital Bleaching
 Modern era of vital bleaching began
with Haywood and Heymann’s 1989
article on nightguard vital bleaching
- using a custom fitted plastic
mouthguard to apply a 10% carbamide
peroxide gel.
 Today there are 3 major methods for
vital bleaching
» In office or power bleaching
» At home or tray bleaching
» Over the counter
 In-office/Power Bleaching

 25% to 38% hydrogen peroxide

 Involve chair time; thus most
expensive
 Results most predictable
 Good for non-compliant or
unwilling patients, also for
patients demanding instant result
 At Home or Tray Bleaching

 10% to 22% carbamide peroxide

(10%=3.6% hydrogen peroxide);
6% to 10% hydrogen peroxide
 Typically will attain optimal
results in 2-6 weeks
 Results are dose/time
dependent
 Over the Counter Bleaching

 6% to 14% hydrogen peroxide

 Strips, wraps, paint on
products
 Least expensive
 Results least predictable
 Vital Bleaching
Advantages

 Low cost
 High success rate
 No tooth alternation
 Vital Bleaching
Disadvantages

 Unpredictable results
 Need Re-treatment
 Possible side effects
 Contraindications

 When the extrinsic stain can

be removed by a thorough
prophylaxis
 Dental caries
 Discolored restoration
 Restoration showing through
 Vital Bleaching
Mechanism
 The active ingredient is hydrogen
peroxide, an oxidizing agent
 It diffuses through the organic matrix
of enamel and dentin
 Produces free radicals, which are
responsible for the bleaching process
(oxidation)
 These free radicals open the highly
pigmented carbon rings and converting
them into chains, which are lighter in
color
 Etiology of Tooth
Discoloration
 Extrinsic Stain
» superficial changes
» secondary to colored
food, drinks (tea,
coffee, cola), tobacco
products, smokeless
tobacco
» more of a problem if
there are microcracks
 Aged Related Color
Change
» thinned enamel
» darkened dentin due to
deposition of secondary
dentin, more yellowish
 Etiology of Tooth
Discoloration
 Intrinsic Stain
» medication given
systemically, e.g.
tetracyclin, minocyclin
» fluorosis
» systemic conditions,
e.g. jaundice,
erythroblastosis
fetalis, porphyria
» dental caries
» old restorations
showing through, e.g.
amalgam
» trauma
» heredity
 Prognosis
 Discoloration due to aging,
inherited discoloration, smoking,
chromogenic materials, trauma
(evenly distributed discoloration)
- EXCELLENT PROGNOSIS
 Works better in removing yellow,
orange and light musky brown color
 Dark blue-gray stain do not
response as well
 Prognosis
 Brown fluorosis
discoloration
» good prognosis, may
need micro-abrasion and
at home bleaching
 White spot
» not removed, only get
lighter during
treatment
 Tetracyclin stain
» do not typically
response well
» may need multiple in-
office application,
extended take home
application (2 to 6
months) or combination
 Prognosis
 Uneven pulp size
» uneven results; smaller pulp slower to lighten
or do not lighten as much
 Initial color relapse
» due to oxygen trapped in tooth diffuses out of
tooth
 Longevity of color change
» one to three years, individual variations
 Non-responsive teeth
» extend treatment time or use in-office
bleaching as a booster
Effects on Restorative Materials
Composite
» minimal changes in color, surface roughness and
physical properties
» may increase microleakage at CEJ with earilier
generation of dentin bonding system
» effect unknown on the current generation of
bonding system
Amalgam
» in one invitro study, the amount of mercury
released into the peroxide solution was
significantly higher than released into saline
solution (4-30x)
Effects on Restorative Materials

Ceramic
» no effects on the color or physical
properties

Luting cements
» an intro study showed that glass ionomer,
and particularly zinc phoshpate dissolved
readily in 10% carbamide peroxide
» clinical significance not known
Effects on Restorative Materials

Temporary restorations
» causes microscropic surface change in IRM
(Intermediate Restorative Material, a
eugenol based temporary material) in both
hydrogen peroxide and carbamide peroxide
» macroscropically, IRM appears cracked and
swollen when exposed to hydrogen peroxide
but not carbamide peroxide
» metharcylate discolored when exposed to
carbamide peroxide
» causes no color change in polycarbonate
crown and composite-type temporary
 Effects on Restorations
Defective restoration
» should consider repairing defects before bleaching
to prevent unwanted penetration of the bleaching
agent through open margin
» should consider temporary repair instead of
replacing the restoration because of color match
concern
Composite / Bonding
» delay any bonding or composite procedure for at
least one week following bleaching
» rationale: lower bond strength and allow for better
color match due to regression of bleaching result
 Effects on Pulp
 Application of peroxide gel resulted in rapid
penetration of peroxide to the pulp chamber.
 Minor irritation of the pulp tissue did
occur, but that it was resolved within 2
weeks after cessation of treatment.
 No differences between whitened and
unwhitened teeth on their responses to
electric or cold pulp tests (up to 12 years
following bleaching).
 No evidence of irreversible pulpitis even in
extended treatment regimen (more than 6
months).
 Effects on Enamel

 Lower enamel microhardness (3%

to 7%) immediately after
treatment
 Slight increase in surface
porosity as observed under
SEM.
 More surface dissolution by
phosphoric acid
 Safety Issues
 Sensitivity to Temperature Change
» Primary side effect associated with vital
bleaching.
» Typically begins early in the bleaching
process (1st or 2nd day); increased during
the course of the treatment.
» Usually mild and transient in nature.
» Adding potassium nitrate and sodium
fluoride to the formulation results in
significant reduction in sensitivity as
reported by the patients.
 Safety Issues
 Sensitivity to Temperature Change
» Reported incidence of sensitivity from 7% to
as high as 75%
» Of those who experienced sensitivity; over
70% are labeled as mild and less than 10% are
labeled as severe.
» Up to 20% of placebo group experienced
sensitivity (due to tray or glycerin)
» Predictors of sensitivity: history of tooth
sensitivity and treatment frequency (more
1x/day) and dose (concentration and time)
» Non-predictors: age, gender, exposed
dentin/cementum, cracks, pulp size, caries
 Safety Issues
 Sensitivity to Temperature Change -
Remedy
» Reduce wear time or frequency of
application
» Utilize a lower concentration of
peroxide
» Immediate removal (in-office) or
refrain from using for a couple days
» Utilize a product that contain
fluoride and or sodium nitrate
 Safety Issues
 Irritation of gingiva
» due to improper isolation (leaking rubber
dam) or excess bleaching agent (patient
sensitive to bleaching agent or poor fitting
nightguard)
» poor fitting or improperly trimmed nightguard
» immediate removal (in-office) or for 2-3 days
» reduction of wearing time, remake nightguard

 Not recommended for pregnant or lactating

woman
 Safety Issues
 Carcinogenic effect
» potentiate the effect of a known carcinogen
associate with tobacco products (DMBA)
» special warning for smokers; refrain
 Ingestion
» not a major problem
» taste and laxative effect from the
glycerine base
 Allergy
» peroxide, nightguard material
 Safety Issues
Excessive free radicals
 Low level: may contribute to
aging.
 Moderate level: oxidation damage
to DNA occurs, thus possibly
leading to mutations and possible
carcinogenic.
 High level: death
JADA 135:319

6.6% HCl + silicon carbide microparticles

(Opalustre)
JADA 134:1066

18% HCl (PREMA)

 Clinical Case

16 y.o. male
Discoloration due
to fluorosis

Opalustra (6.6% HCl + silicon carbide microparticles) -

4 x 60 sec
Followed by

Opalesence Xtra Boost (38% hydrogen peroxide) - 2 x

20 min
First session

Before

After
 Second Session

Before

After
 In-office Bleaching
(Clinical Protocol)
 Clean teeth with
pumics

 Record pre-op shade

 Isolate teeth as
close to the gingival
margin as possible
with rubber dam (no
tears, leakage, fully
inverted)
 In-office Bleaching
(Clinical Protocol)
 Mix the thickening
agent (Cab-o-Sil)
with 35% hydrogen
peroxide to a non-
slumping
consistency.

 Place the gel

material on the
teeth for 30 min
 In-office Bleaching
(Clinical Protocol)
 May need to
“refresh” with
hydrogen peroxide
liquid if the gel
appear too dry
 Rinse and clean;
remove rubber dam
and record post-op
shade
 Nightguard Bleaching
(Laboratory Procedure for Tray)

 Trim cast to ideal

thickness for use
in vacuum former
» base of cast
parallel to
occulsal plane, and
4-5mm from gingival
margin (result in
good adaptation of
tray material)
 Nightguard Bleaching
(Laboratory Procedure for Tray)

 Make tray using

vacuum former
 Nightguard Bleaching
(Laboratory Procedure for Tray)

 Trim tray using

#25 Bard-Parker
blade
» trim to gingival
margin; scallop
around interdental
papilla
 Smooth edges using
alcohol torch
Nightguard Bleaching
Clinical Protocol
Nightguard Bleaching
Clinical Protocol
Nightguard Bleaching

Opalescence - sustained release

 How to deal with patient’s
expectation
 Bleaching is an inexact science
 Results depends on dentist’s skill, individual
variation in the teeth, and the patient’s
continuing habits , diet and hygiene care
 Difficult to guarantee results
 Keys to avoid problem
» ensure that patient understand the limitations and
what is involved in keeping the enhanced look for
as long as possible
» document patient’s appearance before treatment
(intraoral camera, photo, shade guide, reference
pt)