dr. kekere-ekun bleaching &aesthetics

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Nothing to Smile About

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Introduction

• Aesthetic options for tooth discoloration– Composite Resin Restoration– Veneers– Crowns– Tooth Whitening (Bleaching)

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Bleaching Option• Non-invasive, most conservative method

for lightening dark or discolored teeth• Simple, convenient, easily accomplished • Relatively painless• Relatively inexpensive• Good aesthetic result• Safe esp. when supervised• Wider acceptance

Objective• To remove stains, discolorations• Improve patient smile• Provide positive change in patient’s self-

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Active Agent: Mechanism of Action

• Hydrogen peroxide diffuses through the organic matrix of enamel and dentin.

• Hydrogen peroxide decomposes to form free radicals (reactive oxygen species with unpaired electron)

• The free radicals released penetrate enamel and dentin, changing stained molecules in the dentin to clear ones. The free radicals oxidize stains in the teeth.

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Indications• Extrinsic stains

– Food, colored drinks (tea, coffee, red wine) – Tobacco smoking and chewing, cigarette

smoking– Yellowish brown discolorations associated with

aging

• Intrinsic stains– Dental fluorosis– Tetracycline-induced– Pulp necrosis– Intrapulpal haemorrhage– Endodontic treatment: Pulp tissue remnants,

intracanal medicaments, obturating materials7

Contraindications

• During pregnancy or lactation• Generally in children under 12yrs• Known allergy to hydrogen peroxide or

other ingredients of the products• Extrinsic stains which can easily be

removed by professional tooth cleaning• Dental caries• Discolored restoration

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Types of Tooth Bleaching

• Vital Tooth Bleaching [External Bleaching]

• Non-Vital Tooth Bleaching [Internal Bleaching]

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Vital Tooth Bleaching Systems

• In-office or power bleaching [Professionally-administered]

• At-home (Tray & Trayless bleaching) [Professionally-dispensed]

• Over-the-counter [Self-administered]

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In-Office/Power Bleaching• 25% to 38% hydrogen peroxide

• Involves chair time; thus increased cost to the patient

• Results most predictable; good compliance

• May require 1+ office visits (30-60 min)

• Good for non-compliant or unwilling patients; also for patients demanding instant result

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Barrier placed with light cured resin to protect gingival tissues during high concentration

hydrogen peroxide in-office bleaching

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In-office bleaching: Two visits of in-office, one-hour light-enhanced bleaching (Sapphire

Professional Whitening, Den-Mat)

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In-office bleaching

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In-office light-activated bleaching

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At-Home Tray Bleaching

• 10% to 22% carbamide peroxide; 6% to 10% H2O2

• This technique allows the patient to use a custom-fitted tray device at home, while the results and concentrations are monitored by a dental professional

• Applied for a period of 2-6 weeks

• Could be worn overnight or during the day for 2-3 hrs

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At-Home Tray Bleaching: Laboratory Procedures for Tray

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Scalloped and Non-Scalloped Trays for At-Home Bleaching

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At-Home Tray Bleaching: Clinical Protocol

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At-Home Tray Bleaching: Clinical Protocol

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Pre-Bleaching

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Same patient after whitening maxillary dentition with 10%

Carbamide Peroxide

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Same patient after whitening the mandibular arch

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Pre-Bleaching Post-Bleaching

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At-home tray bleaching: 6 weeks of bleaching with 10% carbamide peroxide

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6 weeks of tray bleaching

Tetracycline Stain: Tooth whitening after 6 months of at-home tray whitening with a 10% carbamide peroxide

system

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At-Home Trayless Bleaching Strips

• Use of whitening strips [Introduced mid-year 2000]

• Uses a flexible polyethylene strip to deliver a hydrogen peroxide bleaching gel to the anterior dentition.

• Worn only for 30 minutes, twice a day• Effects comparable to at-home tray

bleaching products

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At-Home Trayless Bleaching Systems

• 6.5% hydrogen peroxide (Crest Professional Whitestrips™)

• 14% hydrogen peroxide (Crest® Whitestrips ® Supreme)

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Maxillary (top) and mandibular (bottom) strips

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Fitting the strip

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Fitting the strip

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2 Weeks Application of Whitening Strips, 30 Minutes Twice a Day: Slightly Whiter Dentition

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Over-the-Counter Bleaching Systems

• 6% to 14% hydrogen peroxide

• Unsupervised at-home bleaching; no diagnosis of the condition for which the patient is bleaching

• Least expensive; results least predictable

• Some of these products can be dangerous to oral tissues, since they are not supervised by dentists

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Over-the-Counter Bleaching Systems

• Crest Whitestrips™ (5.3% Hydrogen peroxide)

• Colgate Simply White (18% carbamide peroxide) [paint-on]

• Crest Night Effects (19% sodium percarbonate) [paint-on]

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Prognosis of Bleaching

Patient Selection:• Select patients with conditions that have the

best prognosis for success with bleaching

Efficacy of Bleaching• Dose dependent (concentration of bleaching

agent)• Time dependent (contact time with hard

tissue)• Type of tooth discoloration• Rate of diffusion below tooth surface• Patient’s age

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Prognosis of Bleaching

Tooth discoloration with the best prognosis:

• Yellowing of the teeth without any systemic or developmental cause:– Food– Smoking– Aging– Staining

• Mild fluorosis staining• Mild tooth darkening due to trauma• Mild tetracycline staining

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Prognosis of Bleaching

• Dark gray, blue, black and dark blue-gray stains are more tenacious

• Successful lightening of darkly-stained teeth (e.g. moderate to severe tetracycline discoloration) has been reported with prolonged bleaching periods (six months to one year)

• Poor Prognosis: Consider other comprehensive aesthetic or restorative care

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Bleaching Relapse

• With in-office bleaching, CRA reported relapse of 41% at 1 year.

• For tray bleaching, Haywood reports 26% at 18 months.

• Others have reported varying degrees of bleaching relapse over time.

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Minimizing Bleaching Relapse

• Using a whitening toothpaste to remove surface stains.

• Rinsing immediately after consuming stain-causing beverages or foods.

• Using straw to drink beverages that stain, such as coffee, tea, colas, etc.

• Checking with your dentist whether you need a touch up

• Depending on the whitening method used, one may need a touch up in 6 months or after a year or two.

• If you smoke or drink a lot of coffee, you may need a touch up more often.

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Common Side Effects of Bleaching

Tooth Sensitivity to Temperature Changes

• Primary side effect associated with vital bleaching

• Generally associated with previous history of sensitive teeth

• Related to frequency of application per day• Related to use of higher concentrations• Related to the pH of the bleaching gel• Typically begins early in the bleaching process

(1st or 2nd day)• Usually mild and transient in nature; may not

interfere with bleaching process47

Tooth Sensitivity to Temperature Changes – Remedy

• Reduce wear time or frequency of application

• Utilize a lower concentration of peroxide

• Utilize a product that contains desensitizing agent

• Use of desensitizing agent before, during and after

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Common Side Effects of Bleaching

Irritation of Mucosa and Gingiva• Oral soft tissues have two primary

mechanisms for dissipating peroxide and preventing gingival irritation –salivary dilution and degradation.

Presentation:• Gum, lip and tongue soreness • Throat irritation

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Irritation of Mucosa and Gingiva

Remedy:• Stop bleaching for 2-3 days

• Reduction of wearing time

• Utilize a lower concentration of peroxide

• Remake tray

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Non-Vital Bleaching

• Intra-coronal bleaching of discolored root-filled teeth

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Non-Vital Bleaching

• The “Walking Bleach” technique• Use of Superoxol (30% hydrogen peroxide)

and sodium perborate• The Superoxol and sodium perborate

mixture on a cotton pellet is placed inside the access opening

• The Superoxol and sodium perborate mixture can be left inside of the access opening and sealed with a temporary filling

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Non-Vital Bleaching

• Evaluate patient 1-2wks later and if the desired results are not achieved, the procedure can be repeated

• Once the tooth is lightened and color is satisfactory, the superoxol and sodium perborate are removed, canal irrigated thoroughly

• Acid-etch, rinse, dry and treat with bonding agent

• Restore with composite

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Intense discoloration of a pulpless maxillary central

incisor, and successful bleaching with Superoxol (30% H2O2)

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Post-traumatic discoloration of a maxillary left central incisor. A mixture of perborate and distilled water, placed in the chamber 2 times over 3 weeks, achieved the lightening of the tooth to its natural color.

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Traumatic pulp necrosis and dentin discoloration of a maxillary central incisor: Esthetic results following one treatment of “walking bleach” with sodium perborate mixed with Superoxol

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Non-Vital bleaching of discolored upper left central incisor

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References1. Martin P. Modern Trends & Techniques in Tooth Whitening. Supervised Self-

Study Courses from Benco Dental.2. Farmer DS, Burcham P, Marin PD. The ability of thiourea to scavenge

hydrogen peroxide and hydroxyl radicals during the intra-coronal bleaching of bloodstained root-filled teeth. Australian Dental Journal 2006;51:(2):146-152.

3. Haywood VB. Nightguard Vital Bleaching: Indications and Limitations. U S Dentistry 2006.

4. Randa A, Azza A. Effect of Bleaching gel preparations on the color change of unstained and stained compomer and composite resin restorative materials. Cairo Dental Journal, 14 (3) : 329 – 337.

5. Home-Use Bleaching Agents. J Am Dent Assoc 2001;132;1292-1293.6. Settembrini L, Gultz J, Kaim J, Scherer W. A technique for bleaching nonvital

teeth: inside/outside bleaching. J Am Dent Assoc 1997;128;1283-1284.7. Matis BA, Gaiao U, Blackman D, et al. In vivo degradation of bleaching gel

used in whitening teeth. J Am Dent Assoc. 130:227–235, 1999.8. Haywood VB. Dentine hypersensitivity: bleaching and restorative

considerations for successful management. International Dental Journal (2002) 52, 376–384.

9. Matis BA, Wang Y, Eckert GJ, Cochran MA, Jiang T. Extended Bleaching of Tetracycline-stained Teeth: A 5-Year Study. Operative Dentistry, 2006, 31-6, 643-651.

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References10. Strassler HE. Vital Tooth Bleaching: An Update. Continuing Education The

Baltimore College of Dental Surgery University of Maryland Dental School.11. Haywood VB. Nightguard vital bleaching: Current concepts and research. J

Am Dent Assoc 128:19s–25s, 1997.12. Li Y. Toxilogical considerations of tooth bleaching using peroxide

containing agents. J Am Dent Assoc 128: 31s–36s, 1997.13. Haywood VB, Leonard RH, et al. Effectiveness, side effects and long-term

status of nightguard vital bleaching. J Am Dent Assoc 125: 1219–1226, 1994.

14. Taher NM. The Effect of Bleaching Agents on the Surface Hardness of Tooth Colored Restorative Materials. The Journal of Contemporary Dental Practice, Volume 6, No. 2, May 15, 2005.

15. Ellias E, Sajjan G. Effect of bleaching on microleakage of resin composite restorations in non-vital teeth: An in-vitro study. Endodontology, Vol. 14, 2002.

16. Perdigao J, Baratieri LN, Arcari GM. Contemporary Trends and Techniques in Tooth Whitening: A Review. Practical Procedures & Aesthetic Dentistry 2004; 16(3): 185-192.

17. Boksman L. Current Status of Tooth Whitening, Literature Review. September 2006 Dentistry Today.

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References20. Geriach RW, Zhou X. Vital Bleaching with Whitening Strips:

Summary of Clinical Research on Effectiveness and Tolerability. The Journal of Contemporary Dental Practice, Volume 2, No. 3, Summer Issue, 2001.

21. Geriach RW, Barker ML. Professional Vital Bleaching Using a Thin and Concentrated Peroxide Gel on Whitening Strips: An Integrated Clinical Summary. The Journal of Contemporary Dental Practice, Volume 5, No. 1, February 15, 2004.

22. John I. Ingle and Leif K. Bakland. Endodontics. Ontario: BC Decker Inc, 5th ed., 2002.

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Something to Smile About

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