Tooth Bleaching

PatientTeaching:ToothWhitening Everybodylovesa brightwhitesmile, and thereare a varietyof productsand proceduresavailableto help you improvethe lookof yours.Manypeopleare satisfied with the sparkletheyget frombrushingtwicedaily with a fluoridecontainingtoothpaste, cleaningbetweentheir teeth oncea day and the regularcleaningsat yourdentist's office.If you decideyouwouldlike to go beyondthis to makeyoursmilelookbrighter, youshouldinvestigateall of youroptions. Youcan take severalapproachesto whitenyour smile: In-officebleaching At-homebleaching Whiteningtoothpastes Talk to YourDentist Youmaywantto start by speakingwith your dentist. He or she can tell you whether whiteningprocedureswouldbe effectivefor you. Whitenersmaynot correctall typesof discoloration.For example,yellowishhuedteethwill probablybleachwell, brownishcoloredteethmaybleachless well, and grayishhuedteethmaynot bleachwell at all. Likewise,bleachingmaynot enhanceyoursmileif you havehad bondingor toothcoloredfillingsplacedin yourfront teeth. Thewhitenerwill not effect the colorof these materials,andtheywill standout in yournewlywhitenedsmile. In thesecases,you may wantto investigateotheroptions,like porcelainveneersor dental bonding.

Youalso maywant to speakwith yourdentist shouldany sideeffectsbecome bothersome.For example,teeth can becomesensitiveduringthe periodwhenyou are usingthe bleachingsolution.In manycases,this sensitivityis temporaryand should lessenoncethe treatmentis finished.Somepeoplealsoexperiencesoft tissueirritation eitherfroma tray that doesn'tfit properlyor fromsolutionthat maycomein contact with the tissues.If you haveconcernsaboutsuchside effects, you maywantto discuss themwith yourdentist. DentalOfficeBleaching

Thereare two effectivebleachingmethodscommonlyusedby dentistsin the dental officethein-office"power"bleachingand laser bleaching.

Dentist In-Office Power Bleaching

The in-office"power"bleachingis oneof the quickestand mosteffectivewaysto whiten teethbut requiresa sessionat the dentist'soffice. The dentistisolatesandprotectsyour lips, gums,and insideliningof yourmouth.Next, a powerfulbleachingagentis applied to the teeth. Finally, a powerfullight sourceis appliedwhichcompletesthe procedure by activatingthe bleachingagent. Whilethis providesone of the best resultsof any bleachingmethods,it is moderately expensive,rangingfrom$300$600per arch or $600-$1200for all of yourteeth. (In dental termsan archis eitherthe upperset or lowerset of teeth). Laser Bleaching Laserbleachingis a relativelynewprocedureonly recentlyreceivingFDAapproval. Despiteits hightech soundingname,laser bleachingis simplya variationof the above in-officepowerbleachingmethod. The procedureis muchthe same.Gumsand lips are protectedand a bleachingagentis applied.The only differenceis that an argonlaser is usedto activatethe bleachingagent insteadof the usual light source. Inventorsof the procedureclaimthat this producesa betterwhiteningresult thanthe conventionalin-officepowerbleaching.Wemustsay that the jury is still out. This is a casewhereclinicalstudiesneedto be performedto substantiatetheseclaims.Laser bleachingdoescost morethanthe typicalin-officepowerbleaching,rangingbetween $750to $2000for a completeset of teeth. Basics of the In-Office Bleaching Thereare a numberof bleachingproceduresthat yourdentist can performin the dental office: For yourupperarchonly, the dentistcan makea custommouthpiece, use a relativelyhighconcentrationof bleachingmaterial (oftencalledPowerBleach),and haveyou wearit in the office. A singletoothor set of teethcan be bleachedusingveryhighconcentrationsof the bleachingmaterial. Yoursoft tissueis protectedduringtheseprocedures. This procedure,combinedwith take-homedentist-dispensedbleachingis effective in the treatmentof severestainingdueto traumaand exposureto certaindrugs suchas tetracycline. The insideof a toothcan be bleachedafter a root canalprocedureto lightenit to

matchthe surroundingteeth. Pros.Fast dramaticresultscan be achieved.Youcan haveimmediateresultsfor a specialevent. Specificproblemteethcan be lightenedto matchthe rest of yoursmile. Youare workingwith a professionalwhoknowshowto handlesuchingredientsand proceduresand can integratebleachinginto youroverall oral healthcareplan. Cons.Thecost is higherthanover-the-counterproducts.Minorand transienttooth sensitivitycan occurfor somepatients. ADA News Release A reportby Dr. DavidGarber,a privatecare dentist and a clinicalprofessorat the MedicalCollegeof GeorgiaSchoolof Dentistry,suggeststhat combiningin-officepower bleachingwith dentist-dispensedat homewhiteningtraysmayprovidebothimmediate toothshadelighteningand longerlastingeffects. He also pointsout that the new cosmeticlaserbleachingmayprovidea quickand longerlastingsolutionfor some. The combinationof powerbleachingand dentist-dispensedbleachingis accomplished by treatingthe teethfor 30 minuteswith a concentratedformulaof hydrogenperoxide andthenprovidingtwo weeksof treatmentfor 30 minuteseachday at home.In-office powerbleachingis characterizedby rapidlighteningusinga highconcentrationof hydrogenperoxide(usually30-35 percent)that is activatedby heat and light. Patients weara rubberdamto protecttheir soft tissuesfromthe highconcentrationof hydrogen peroxide. "Whilein-officepowerbleachingalonecan be quickand dramatic,the patientoftenmust comebackfor multipletreatmentsbecausethe originalstainsor shademayreturn," said Dr. Garber.The combinationof powerbleachingwith a 30-minuteper day, everyotherday at-homebleachingschedulecan achievethe mostrapidand predictable results, he contends. Newlaser bleachingmayalso be an optionfor somepatientswhowantdramatic whiteningeffectsquickly,Dr. Garberreports. Recentlyapprovedby the Foodand Drug Administrationfor marketingas a light source,lasershavegarnereda great deal of attentionin the consumerpress.The ADA'sCouncilon ScientificAffairsat its January 2000meetingissueda call to manufacturersfor clinicaldata provingthat laser bleachingis safe and effective. Dr. Garberpointsout that lasersusedfor lighteningteeth do not bleachteeth, they merelycreatea reactionwhenthe hydrogenperoxidecomesin contactwith the laser's beam.It is this reactionthat beginsto lightenteeth. "At this stage,thereis little researchthat provesthat any of theseapproachesare more effectivethantraditionalbleachingmethods,"he reports.

Dr. Garberpresentedhis findingsat "TheInternationalSymposiumon the NonRestorativeTreatmentof DiscoloredTeeth,"held last fall at the Schoolof Dentistryof the Universityof NorthCarolinaat ChapelHill and supportedby ColgateOral Pharmaceuticals.
Source:The Journalof the AmericanDentalAssociation(JADA).

Dentist-Supervised Take Home Bleaching Systems

Thesesystemsare becomingincreasinglypopular.Withthesesystemsthe dentist makesa moldof yourteeth. This moldis thenusedto createcustommouthpiecetrays whichsnuglyfit yourteeth. The patienttakesthe traysand bleachingagenthome.Eachnightfor threeto four weeksthe patientplacesbleachingagenton the traysandplacesthe traysin his or her mouth.A brief visit or two to the dentistensuresthat you are doingthe hometreatments correctlyand allowsthe dentistto inspectyourgumsfor irritation. Whatwe like aboutthesesystemsis that the mouthpiecetraysare custommadeto fit eachindividual'smouth.This meansthat bleachingagentis less likelyto be swallowed or less likelyto seeponto and irritategumtissue. Second,whenusingthesesystemsthe patientvisits the dentistofficeto ensurethat the procedureis proceedingsmoothly.This allowsthe dentistto makesure the custom traysare fittingproperly.Moreimportantly,it allowsthe dentist to checkfor gum irritation/ damageand allowsthe dentist to checkfor toothsensitivity. Theseare the mostcommonsideeffectsof the bleachingprocedure. Thesesystemscan cost between$250-$300per arch($500$600for all of yourteeth). For extremelyyellowteeth, an in-officepowerbleachingis performedfollowedby treatmentwith a dentistsupervisedtake homesystem.This usuallyprovidesgood results. (HomeBleaching)Background Homebleachingis a processin whichpatientsapplyperoxidebasedgels to their discoloredteeth for the purposeof lightening(i.e., whitening)them.Althoughthereare manybleachingproducts,this discussionwill coveronly thoseprescribedor dispensed by the dentistandhavingcarbamideperoxideas their activeingredient.Homebleaching first beganin 1968whenan orthodontistin Ft Smith,Arkansasnoticedthat patientswho hadbeenwearingorthodonticpositionersfilled with the oral antisepticGly-Oxidehad their teethwhitened.Later, a pedodontistin the samecity substitutedProxigel(Reed& Carnrick)for Gly-Oxidein his patientspositioners.He did so becauseProxigel(a mixtureof 10%carbamideperoxide,water, glycerine,and carbopol)wasthickerand, therefore,remainedin the positionerslonger. Clinicaltrials of the Proxigeltechniquein

1988at the Universityof NorthCarolinafoundit to be effective.An averagetreatment timeof 6 weeksusuallyproduceda lighteningof 2 Vita shades.The first commercially availablehomebleachingproduct,Whiteand BriteTM(OmniiInternational),wasmarketed in March1989. Mechanism Althoughnot fully understood,the mechanismof bleachingappearsto involvethe decompositionof unstableperoxidesinto unstablefree radicalsthat breakdown organicpigmentedmoleculesin discoloredenamelthroughoxidationreactions.The breakdownproductsare smaller, less heavilypigmentedconstituents. ProductIngredients The mainingredientsin mosthomebleachingproductsare carbamideperoxideand carbopol. Carbamide peroxide is alsoknownas ureaperoxide,hydrogenperoxidecarbamide, andperhydrolurea.It is commonlypresentin a 10 to 20%concentration;a 10% carbamideperoxideconcentrationis equivalentin bleachingeffectivenessto a 3.6% concentrationof hydrogenperoxide.Carbamideperoxidedecomposesto hydrogen peroxideand urea. The hydrogenperoxidefurtherdecomposesto waterand oxygen, while the ureabreaksdownto ammoniaandcarbondioxide. Carbopol, a highmolecularweightpolyacrylicacid polymer,is usuallypresentin a 0.5 to 1.5%concentration.It functionsas a thickeningagentand helpsto retainthe solution in the applicationtray. This reducesthe needfor frequentreplenishingof the gel. Carbopolhas alsobeenfoundto extendthe activeoxygenreleasingtimeof the bleachingsolutionby up to four times.Carbopolis foundin DentlBright(Cura Pharmaceutical),RembrandtLighten(Den-Mat), and Opalescence(Ultradent),among manyothers.Productsthat do not containcarbopolusuallyuse someotherthickening agent.Otheringredientsin homebleachingproductsincludeglycerine,sodium stannate,flavorings,and phosphoricor citric acid. Becausebleachingsolutionsare morestableat a lowerpH, phosphoricor citric acid is addedto lowertheir pH. Commonly,homebleachingproductshavea pH rangeof from5 to 7, but someproducts varyfrom3 to 8.5 due to variationsin qualitycontrol. It is importantto notethat the somewhatlow pH of bleachingproductsis quicklyneutralizedwhenthe solutioncomes into contactwith saliva. ProductUse Shelf life is approximately2 yearsand is maximizedby storingthe productsin a refrigerator.Mostof thesematerialsare appliedto the teeth by the patientusinga vacuumformedtray madeof plastic. Somemanufacturersrecommendthat reservoirs be built into the tray on the facial surfacesof the involvedteethso that a greateramount of the bleachinggel is retainedfor a longerperiodof time. Whenhomebleaching

productswerefirst introduced,the daily applicationtimesrangedfrom1 to 18 hours, with the patientreplenishingthe solutionin the tray every hourto 2 hours. Newer formulationsare effectivewith muchshorterapplicationtimes.Typically,instructions nowcall for twicedaily treatmentsof from30 minutesto 2 hours.Manyproductsgive the patientthe alternativeof usingovernightapplications.Treatmenttimesare oftenas short as two weeks,and nearlyall patientsreachtheir maximumlighteningresult by the endof six weeks.Patientscan expecta lighteningof from1 to 2 Vita shadesand results shouldbe noticeablein the first few daysof treatment.The retail cost of bleaching productsvariesgreatly, fromapproximately20 to $2.00per mL. Bleachingresultslast for varyinglengthsof timedependingon productusedand the specificcase, among otherthings.Mostoften, relapseoccurstwo or threeyearsafter treatment,however studieshavefoundthat the timemayvary from1 to 7 years. Examplesof CarbamidePeroxideContainingHomeBleachingProducts
Product NuproGold Opalescence RembrandtLighten Zaris VivaStyle Perfecta Platinum UltimateWhiteandBrite Manufacturer Dentsply/Professional Ultradent DenMat 3M ESPE IvoclarVivadent AmericanDentalHygenics ColgateOral Pharmaceuticals OmniiInternational Available Concentrations 10%,15% 15%,20% 10% 10%,16% 10%,16% 11%,16%,21% 10% 10%,16%,22%

PotentialAdverseEffects Someadversesoft tissueeffectshavebeennotedas a result of the use of bleaching products.The mostcommoneffect is an ulcerationor irritationof the gingivaand mucosa.It is usuallymild and transientand can easilybe resolvedby reducingthe daily 1 applicationperiod. Sorethroatsthat haveoccurredwith the use of bleachingagents haveapparentlybeenrelatedto the use of cinnamonflavoringin someproductsto whicha small portionof the populationis allergic. Bleachingagentsmayalso affect dental hardtissues.Themostcommonsideeffect is a transientanddoserelatedsensitivityof the teethto thermalchanges.This is believedto 2 result fromthe freelydiffusiblenatureof the solution ratherthanits low pH. Clinical observationsindicatethat homebleachingwith 10%carbamideperoxidesolutionsdoes 3 not adverselyaffect pulpal tissues. Temperaturesensitivityduringtreatmentcan be reduced/eliminatedby treatingthe involvedteethwith a desensitizer(e.g., D/Sense2 [Centrix], Seal & Protect[Dentsply/Caulk],Systemp.desensitizer[IvoclarVivadent])or a dentinbondingagent(e.g., SingleBond[3M ESPE],One-Up BondF [J. Morita], Excite [IvoclarVivadent]). Severalstudieshavebeendoneto evaluatehowhomebleachingagentsaffect enamel anddentin. Onestudyfoundthat bleachingagentswerecapableof removingthe smear

4 layerfromdentin, but producedrelativelyfew changesin the enamel. Studies evaluatingwhetheror not enamelis adverselyaffectedby homebleachingagentshave producedequivocalresults. Whileseveralhavefoundno evidenceof adverseeffects,2,5 othershaveshownthat changesoccurin the porosityand surfacemorphologyof 6-8 enamel.

Homebleachingproductscan affectthe bondstrengthof resin compositeto etched enamel.Oneinvestigationfoundthat bondstrengthwassignificantlyreducedby a 9 single,24-hourbleachingtreatmentusinga popularhomebleachingproduct. Another studyfoundthat bleachingwith 10 to 20%carbamideperoxidegels significantly decreasedbondstrengthfor up to 2 weeksafter the bleachingtreatmentwas 10 completed. An initial reductionin bondstrengthfollowingthe use of at least some productsdoesoccurand is believedto be dueto the presenceof oxygenin the tooth surface,whichinhibitsresin polymerization.It is prudentto wait severalweeksafter completionof bleachingtreatmentbeforebondingto the involvedteeth. An additionalproblemthat has beenassociatedwith homebleachingis temporomandibulardysfunction(TMD)whichcan occuras a result of changesin the occlusionsecondaryto longtermtray use. This is nowless of a problemthanit was originallywhentrayswerewornfor manyhourseachday. The problemcan also be minimizedby usinga thin (i.e., -mmthick) tray material. Thin traysnot only help reducethe possibilityof TMDproblems,but are also moreestheticallypleasingto patients.Traysshouldbe trimmedcarefully, becauseimpingementon soft tissuescan causeirritation. Effectson DentalMaterials Studiesevaluatingthe effectsof homebleachingproductson restorativematerialshave producedequivocalresults. Onestudyfoundthat a homebleachinggel significantly reducedthe hardnessof a hybridresin compositeovera four-weektreatmentperiod. 11 Scanningelectronphotomicrographsalso revealedsurfacecracking. Bleacheshave beenfoundto adverselyaffect the colorof variousrestorativematerials, with glass 12 ionomersexhibitingthe greatestcolorchange. Anotherinvestigationfoundthat the shadesof two hybridand onemicrofill compositewereunaffectedby two home 13 bleachingproducts. Still anotherreportfoundno adverseeffectsfrombleaching solutionson eitherthe surfacetextureor colorof porcelain,resin composite,amalgam, 4 or gold restorations. Someresearchersbelievethat the tendencyfor bleachingagents to adverselyaffect restorativematerialsis relatedto their pH becausegreatereffects havebeennotedfor productswith pH valuesbelow5.5. Safety As homebleachingproductsgrewin popularity, the AmericanDentalAssociations Councilon ScientificAffairsbeganto monitortheir development.Its conclusion,based on the clinical dataobtainedover the last ten years,wasthat 10%carbamideperoxide

productswith neutral pH are safe and effective.Thefollowing10%carbamideperoxide productshave,in fact, receivedthe ADASeal of Acceptance:Opalescence,Colgate Platinum,RembrandtLighten,PattersonBrandToothWhiteningGel (PattersonDental), andNite WhiteClassic(DiscusDental). It is importantto be awareof severalthings,however.Becauseperoxidesare mutagens, someresearchersandcliniciansrecommendthat bleachingproductsnot be usedin patientswhoare smokersor heavydrinkers,sincethe carcinogeniceffectsmaybe additive.Peroxidescan also delaywoundhealingwhenusedfor longperiods.In additionto the complicationsof bleachingalreadynoted(i.e, soft tissueirritation,TMD, sorethroat, toothsensitivity), nauseahas alsobeenreported. References
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. HaywoodVB, HeymannHO. Nightguardvital bleaching.QuintessenceInt 1989;20:173176. Haywood VB, Leech T, Heymann HO, Crumpler D, Bruggers K. Nightguard vital bleaching: effects on enamelsurfacetextureand diffusion.QuintessenceInt 1990;21:801804. HaywoodVB, HeymannHO. Nightguardvital bleaching:howsafe is it? QuintessenceInt 1991;22:515523. HunsakerKJ, ChristensenGJ. Toothbleachingchemicals- influenceon teeth and restorations[Abstract]. J Dent Res1990;69:303. HaywoodVB, HouckV, HeymannHO. Nightguardvital bleaching:effectsof varyingpH solutionson enamel surfacetextureandcolor change.QuintessenceInt 1991;22:775782. BenAmar A, LibermanR, Gorfil C, Bernstein Y. Effect of mouthguard bleaching on enamel surface. Am J Dent 1995;8:2932. Bitter NC. A scanningelectron microscopystudy of the long-term effect of bleachingagents on enamel: A preliminaryreport. J ProsthetDent 1992;67:852855. Bitter NC. A scanningelectronmicroscopestudy of the long-term effect of bleachingagentson the enamel surfacein vivo. GenDent1998;46:8488. GarciaGodoy F, Dodge WW, Donohue M, O'Quinn JA. Composite resin bond strength after enamel bleaching.OperDent 1993;18:144147. Cavalli V, Reis AF, Giannini M, AmbrosianoGMB. The effect of elapsedtime followingbleachingon enamel bondstrengthof resin composite.OperDent 2001;26:597-602. Bailey SJ, Swift EJ. Effects of home bleaching products on resin composites [Abstract]. J Dent Res 1991;70:570. Kao EC, Peng P, Johnston WM. Color changes of teeth and restorative materials exposed to bleaching [Abstract]. J Dent Res1991;70:570. Monaghan P, Lee E, Lautenschlager EP. At home, vital bleaching effects on composite resin color [Abstract]. J Dent Res1991;70:570.

Over-the-Counter Bleaching Systems

Overthe-counter(OTC)bleachingsystemsare take homekits whichyou can buy at the local store, orderby mail-order, or buy off the Internet.Usuallytheyare relatively inexpensivecostingfrom$29 - $175. Thesekits workin a similarfashionto the dentist-supervisedtakehomekits. A bleachingagentis appliedto a mouthtray andthe tray is insertedinto the mouthfor 2-8

hours.Treatmentlasts between2-4 weeks.We personallydo not recommendthesekits for two reasons: First, manyof thesekits containa standardmouthpiecetray for applyingbleachonto your teeth. Becausethe traysare standard(madeto fit everyone),theytendnot to fit snugly.Consequently,youmaybe ingestingbleachingagent. In addition,trayswhich are not custommadeallowbleachto seepontoand irritategumtissue. Second,dentistsdo not checkyour teethandgumswhenyou use thesesystemsto determineif the bleachingprocessis proceedingsafelyand to ensurethat you are not injuringyourteeth. Whilewe do not recommendthesesystems,if you do wantto take the risk anduse them,we wouldrecommendthat you do the followingwhenevaluatingthe widearrayof take homesystemsavailable: If possibletry to use a kit that allowsyou to customizeyourmouthtraysto some degree.Somesystemscomewith moldablemouthtrayswhichbetter fit yourmouth. Whilenot as goodas the mouthtrayscreatedby yourdentist, theyare betterthan standardmouthtraysthat comewith manykits. Try to find otherswhohaveusedthe systemyouplanto use andask themhowthe systemworkedfor them.Whilesomepeoplehavebeensatisfiedwith results, others havehad horribleexperiences. Whileusingthe system,if you ever experienceprolongedpain, changesin gumtissue color, or increasedsensitivityto hot or cold foods,see a dentist immediately. WhiteningToothpastes A commontrendhas beenthe proliferationof toothpasteswhichclaimto whitenteeth. Sometimestheseclaimsmistakenlylead consumersto thinkthat thesewhitening toothpastesare miraclecures. Thesetoothpastesare not effectiveat whiteningthe underlyingtooth. Whattheytendto do is removestainsso that the underlyingwhitenessof the toothbecomesmore apparent. Thinkof thesetoothpastesas "carwashes"for yourteeth. In the samewaythat a good car washingremovesthe dirt andgrimeon yourcar makingit sparkle,whitening toothpastesremovestainsand crudfromyourteeth. Smokerstoothpastesworkin muchthe samewayremovingtobaccoassociatedstainsfromteeth.>Beawarethat thereis great variabilityin the effectivenessof thesetoothpastes.Somemaywork extremelywell whileothersmayonly maketeethappearwhiterby one shadeor less. To obtaina moredramaticimprovement,othertechniquessuchas bleachingare often tried.

It is importantto notethat whileeffectivein removingstains,manybrandsof whitening andsmokerstoothpastescan destroytoothenamelin the process.Thesetoothpastes use harshabrasivesto removethe stains. Overlongperiodsof repeateduse, these harshabrasivesbeginto removetoothenamelmakingteethappearyellowand causing teethto becomesensitiveto cold or heat. Wesuggestusingone of the newerbreedsof whiteningtoothpasteswhichdo not containharshabrasivesbut insteaduse othermethodsfor removingstainsfromteeth.
Source:Dental Zone

www.saveyoursmile.com

Alternative Methods of Whitening Teeth

For thosewhoare disappointedwith bleachingor whowanta still brightersmile, several techniquesexist. Thesetechniques,however,tendto be moreexpensivethan bleaching. Porcelain Veneers Porcelainveneersare a popularoption.Theseare very thin piecesof porcelainwhichare shapedand placedon the front of the toothwith a resin glue(analogousto placingpanelingon a wall). The advantagesof veneersare that theyprovidefor a brilliantlywhitesmilewhichis resistantto discolorationand fadesonly very slowlyover time. Theseveneerscan be expensive,however,costingaround$250per toothveneered.

Bonding Anotheroptionis bonding.Duringbondingthe dentistappliesa whiteplasticquartz resinto the tooth. This resinis thensculptedby the dentist ontothe tooth. Costing around$150per tooth, this procedureis less expensivethanveneersbut doesnot withstanddiscolorationby foods,coffee, and smokingas well as veneersdo. Caps Capsrepresenta moredrasticmeasureandare usuallyreservedfor teethcompletely brokendown,teeth with fillings,or teethhavingundergonea root canal. The toothis totallygrounddown,an impressionmade,anda porcelainmetal cap addedto the tooth. The cost - nearly$1500$1800per tooth. Special Situations

Somepeoplehavediscoloredteethas a result of their mothershavingbeentreatedwith

tetracyclineduringpregnancyor as a result of havingthemselvesbeentreatedwith tetracyclineduringearly childhood.Thesestainscan be especiallydifficult to remove. A commonprocedureis to first bleachthe teeth and thenapplyporcelainveneersto the affectedteeth. Bleachingfadesthe stain to a point whereit will not showthroughthe veneerwhenit is applied.

Bleaching Method

Dentist-inoffice power bleaching

LaserBleaching

Takehome dentistsupervised bleaching

Over-the-counter bleaching system

Typeof System

Traditional Sameas in-office thermocatalytic. treatment Activeingredient:3035%H2O2.

10%carbamide Over-the-counter 3peroxidewith stepbleaching bleachingtray. 3% system. 6% H2O2. H2O2. Dentist makes Patientplaces custommouthpiece bleachingagenton trayswhichsnugly mouthtraysthat fit your teeth. Each comewith kit. Tray nightthe patient is placedon teeth placesbleaching overnight. agenton the trays andplacesthe trays in his / her mouth.

Procedure

Dentist isolatesand Similarto in- office protectslips, gums, powerbleaching andinsideof mouth. with the exception A bleachingagentis that a laser is used appliedto the teeth. as the light source Finally, a powerful whichactivatesthe light sourceis bleachingagent. appliedwhich completesthe procedureby activatingthe bleachingagent. Time 1-2 hours 1-2 hours Cost(per wholeset $600$1200 $750to $2000 of teeth) Advantages Producesbest results. Quickand convenient. Proponentssay producesbetter resultsthandentistin-officebleaching. Jury still out.

2-3 weeks $300to $500

2-3 weeks $40 to 300

Producesgood Inexpensive. results. Dental followups during treatmentmakesure thingsare proceedingwell with no adverseside Nevertheless producesexcellent effects. results. Quickand convenient.

Disadvantages

Relatively expensive.

Relatively expensive.

Requiressticking Not recommended. gel andtoothtray into your mouthfor Verypoorresults. two to threeweeks. Standardfit mouth tray can cause bleachingagentto seepontoand damagegums.No dental followups to ensurethat procedureis proceedingwithout side-effects. Requiressticking gel andtoothtray into your mouthfor two to threeweeks.

Safety and Effectiveness of Teeth Bleaching

Questionsaboutthe safetyand efficacyof this bleachingtechniquehavebeenraisedby patients,dentistsand recentlyby U.S. Foodand DrugAdministration.Past surveyshave providedsomeanswersto thesequestions. In onesuchsurvey,90%of the dentistswhousedthis typeof homebleachingmethod thoughtthat patientsweresatisfiedwith the technique;66%reportedside effectssuch as gingivalirritation(28%)and toothsensitivity(23%).In anotherclinicaltrial, patients using10%carbamidebleachingsolutionwerepittedagainstpatientsusinga placebo.A significantdifferencein colorchangewasfoundin patientsusingthe carbamide peroxidesolution.Anotherstudyreportedsuccessfulcolorchangeafter 5 night-time applicationsof the carbamideperoxide,but therewasan initial colorreversion. However,the reversedcolorwasstill significantlylighterthanthe initial colorand remainedlighter3 monthsafter treatment.The lastingeffect of teethbleaching, however,has not beenconfirmedby any documentedstudies,but it is generally estimatedto last 1-3 years. The instantclinicaltrial by Hayward,Leonardet al. describedbelowwasundertaken with four objectives: to determinethe effectivenessof a nightguardvital bleachingtechniquein a controlled populationof patientsover an extendedperiod; to documentany side effectsof treatmentwith two different10 percentcarbamide peroxidesolutionson gingivaltissueandteeth duringtreatment; to evaluatethe stabilityof the bleachingtreatmentover time; to determineif any sideeffectscontinuedor surfacedafter treatmentstopped.

Thirtyeight adult patientswhohad expressedconcernabouttheir discoloredteethwere selectedfor this clinicaltrial. Thesepatientsweredividedinto variouscategoriesbased uponcausesof staining,suchas tetracycline,agingor inherentdiscoloration,brown fluorosisandtrauma. The patientsweregivena six-weeksupplyof one of two 10%carbamideperoxide solutions(Proxigel, Reed& Carnrickor Gly-Oxide,MarionMerrell DowLab, Inc.) Patientswereinstructedto wearthe nightguardfor six to eight hoursat night, or to wear the guardduringthe day and changethe solutioneverytwo to six hours. The successof the trial includingthe changein colorandthe lastingchangein color weremeasuredby the patient'sperceptionsof the colorof their ownteethas compared to the untreatedlowerarchor a standardizedcolorshadetab. Theultimategoal of any teethbleachingtreatmentis patientsatisfactionwhichin turn is the result of patient's perceptionof the statusof their teeth. Conclusions Carbamideperoxidein a 10 percentsolutioneffectivelylightenedthe colorof teethin 92 percentof 38 patientsin a six-weekperiod,with an averagedaily wearingtimeof seven to eight hours.Teethstainedby aging,brownfluorosis,traumaor inherentdiscoloration werelightenedin 96.7 percentof the patients,and tetracyclinestainedteethwere lightenedin 75 percentof patients.Teethstainedby tetracyclinedid not lightenas much as teeth stainedby othermeans. A significantnumberof patients,about66 percent,experiencedtransientside effectsof gingivalirritationand/ortoothsensitivityduringtreatment.However,thesesideeffects did not prohibitcontinuationof treatment,and generallylastedfour to sevendays. The two majorside effectsreportedweretoothsensitivityand gingivalirritation.The sensitivityof the teethmaybe causedby the easypassageof the hydrogenperoxide andureathroughthe teethto the pulp, resultingin a reversiblepulpits. Furthermore,the sensitivityof the gingivalcouldhavebeencausedeitherby mechanicalirritationfromthe nightguardor chemicalirritationof the solution.With adjustmentof the guard,cessationof treatment,and/ordecreasingthe treatmenttime for severaldays, the gingivalirritationresolved.No side effectsoccurredor returnedat 13 to 25 monthsafter bleaching. Seventyfour percentof the groupnotedno noticeabledecreasein the colorof their teethafter 13 to 25 monthswith no furthertreatment.Noneof the bleachedteeththat hadreceivedno furthertreatmenthad returnedto the originalcolor. Patientswhohad retreatedtheir teeth did so after at least one year, andretreatmentrequireda much shortertimethanthe originalbleachingtreatment.Threeyearsafter treatment(31 to 42 months),62 percentof the respondentshad no perceivablelossof colorlightening,and no side effectshad occurred.

Source:HaywoodVB, LeonardRH, NelsonCF, BrunsonWD:Effectiveness,side effectsand longterm statusof nighguardvital bleaching.J Am Dent Assoc 125: 12191226, 1994.

References
1. 2. 3. 4. 5. 6. 7. 8. HaywoodVB, HeymannHO. Nightguardvital bleaching.Quintessence Int 1989;20:173176. HaywoodVB, LeechT, HeymannHO, et al. Nightguardvital bleaching:Effectson enamelsurface textureanddiffusion.Quintessence Int 1990; 21: 801-806. HaywoodVB, HeymannHO. Nightguardvital bleaching:Howsafe is it? Quintessence Int 1991;22:515523. AlbersHF. Homebleaching.ADEPT Report 1991;2(1): 9-17. HaywoodVB. History,safety, andeffectivenessof currentbleachingtechniquesandapplications of the nightguardvital bleachingtechnique.Quintessence Int 1992;23:471488. Croll TA: Toothbleachingfor childrenandteens:a protocolandexamples.Quintessence Int 25:811-817, 1994 HaywoodVB, LeonardRH, NelsonCF, BrunsonWD:Effectiveness,side effectsandlongterm statusof nighguardvital bleaching.J Am Dent Assoc 125: 12191226, 1994 GoldsteinGR, KiremikjianSchumacherL. KriserDentalCtr, 345 E 24thSt., NewYork, NY 10010. Bleaching:Is it safe andeffective?J Prosthen Dent 69(3): 325-8, 1993

Studiesby ToothBleachingSystemManufacturers The efficacyof toothbleacherswasalso studiedby dental productmanufacturers.They concludedthat their productswereeffectivein achievinglighteningeffects(1,4,5,6,9). Lighteningeffectswerevariablefromindividualto individualand alsoaccordingto whichsystemwasused.Patientsatisfactionwashighestin dentist-prescribedat home systems(5,6,8). Treatmenttimeis aboutfive to six weeksfor the prescribedin home systems. The sameresultscan be achievedin less timeby usingthe in-officeprocedure.It must be notedthat this searchyieldedno evidenceprovingthe efficacyof over-the-counter typesystems.Theywerebrandedas unsafeandineffectivedue to their lack of studies backingup their claims.Anotherquestionthat is closelyrelatedto efficacyis longevity of the achievedresults. Generally, noticeablecosmeticresultscan be achievedbut how longdo theylast?For bothin-officeand dentist-prescribed,retreatmentwasnecessary everyoneto threeyearsto maintainthe initial results(2,4). The issueof productsafetyis still in questionby the ADAand to date, no product currentlyavailableto the publicis ADAapproveddue to lack of substantialevidence provingtheir safety. But productmanufacturersof bleachingproductshaveconducted their ownstudiesprovingtheir safety. Theycite evidencedisputingbleachingagent's activeingredient(hydrogenperoxide),carcinogenicpotential (1,4,8). Theyclaimthe concentrationsof hydrogenperoxidein their productsdo no harmto gingivaltissues, pulp, enamel,and restorations.Uponconductingtheir studies,productmanufacturer's data concludedthat the onlyside effectswereunpleasanttaste, slighttoothsensitivity,

andminorgingivalirritation.All thesesymptomswerereverseduponthe cessationof treatment(3,4,9). (Thesewerestudiesdonefor dentist-prescribedin-homesystems). For productsusedin in-officesystems,the higherconcentrationof hydrogenperoxide causedreversibleplural damagewhichresultedin post treatmentsensitivity(7). Again, over-the-countersystemswerenotedas beingunsafebecauseof their acidicand abrasiveingredients.It wasalso pointedout that due to lack of dental supervisionand (4) evaluation,dissolutionof toothenamelcouldoccurif usedimproperly . Also, their potential to becomeabusedin hasteto achievea lighteningeffectswasnoted,and use of thesekindsof productscan be of moreharmthangood. Discussion As the literaturereviewprogressed,it becameevidentthat the safestand mosteffective methodswerethoseconductedunderdentalsupervision.Evaluationby a dentistis importantin determiningif bleachingwill be effective.In contrast,OTCsystemsplace the consumerin the role of decidingwhatis best for the treatmentwithouthavingany real backgroundknowledgeof the subjectandits potentialharmfulside effects. Usinga dentist-prescribedsystemensuresthat propercare and maintenancewill be givento the patient. Useof OTCdoesnot give this assurance.Often,thesesystemsare abuseddue to consumerignoranceor impatienceto reachdesiredresults. It is importantthat people consideringtoothbleachingget evaluatedandeducatedby a dentist as to the possible achievableresultsas well as to possibleadverseeffectof bleachingproducts.It would be timewell spentin askingthe dentist questionsand receivingbackgroundinformation thanto hastilypurchasea glamorousgimmickthat has not beenprovento be safe and effective. Conclusions Dentist supervisedsystemshavebeenprovensafe andeffective. The safetyand effectivenessof OTCbleachersare undetermined. Thereare someadversesideeffectsassociatedwith eachsystem. Patientsatisfactionis highestfor dentist-prescribedin homesystems.
Source:ChinEdwardA, FranssenSusan,DwanAndrew,HufundaJoe, Universityof MichiganSchoolof Dentistry.

References 1. 2. 3. 4. 5.
BerryJH. Whataboutwhitener?Safetyconcernsexplored.J Am Dent Assoc 1990Aug;121:2225.

GoldsteinGR, KiremidjianSchumacherL. Bleaching:is it safe andeffective?J Prosthet Dent 1993 Mar;69:3258. HaywoodVB. History,safety, andeffectivenessof currentbleachingtechniquesandapplicationsof nightguardvital bleaching technique.Quintessence Int 1992 Jul;23:47188. HowardWR. Patient-appliedtoothwhiteners.J Am Dent Assoc 1992 Feb;123:5760. IbsenR, OuelletD. RembrandtWhiteningSystemandQuickStart versatiletoothbleachingsystems.J Esthet Dent 1991SepOct;3:16973.

6. 7. 8.
9.

ReinhardtJW, EivinsSE, Swift EJ Jr, DenehyGE. A clinicalstudyof nightguardvital bleaching.Quin tessence Int 1993 Jun;24:37984. Shearer,AC. Externalbleachingof teeth. Dent Update 1991 Sep;18:28991. SimonJF, AllenH, WoodsonRG, EilgersAS. Efficacyof vital homebleachingJ Cal Dent Assoc 1993Jan;21:725. TamL. Vital toothbleaching:reviewandcurrentstatus. J Can Dent Assoc 1992Aug;58:65460.

Clinical Trial of Three 10 % Carbamide Peroxide Bleaching Products

by Laura Tam, DDS, M.Sc.

Abstract

Background
A profusion of commercial bleaching systems exists on the market today, but there are few clinical comparisons of these systems.

Methods
In this study, three different commercial 10% carbamide peroxide bleaching systems were used by 24 patients in an overnight protocol for two weeks. Each patient used two of the bleaching products simultaneously in a sidebyside comparison.

Results
The mean onset of tooth whitening was 2.4 1.7 days. Tooth sensitivity was the most frequent side effect, as 64% of the patients reported tooth sensitivity occurring after 4.8 4.1 days and lasting for 5.0 3.8 days. Although intrapatient differences were recorded for the three commercial 10% carbamide peroxide bleaching systems by the patients, there were no statistical differences in the time of onset of subjective tooth whitening and the onset, frequency and duration of tooth sensitivity among the three commercial bleaching systems when

compared pairwise or independently (p < 0.05).

Conclusion
Selection of which bleaching product to use should be based on the concentration of the active ingredient, the viscosity of the product and other marketing features. Further research is needed to investigate the causes of tooth sensitivity and methods to reduce its severity and frequency. Introduction Patients today have many options to achieve a more ideal tooth colour or appearance, including bleaching, veneers and crowns. Tooth bleaching is a relatively simple and conservative option. The most popular method of tooth bleaching is the home bleaching system wherein the patient wears a custommade bleaching tray containing carbamide peroxide overnight. 14 A profusion of commercial bleaching systems exists on the market today. Home bleaching systems commonly utilize carbamide peroxide to deliver a more stable form of hydrogen peroxide, the active bleaching agent. Most home bleaching systems contain 10% carbamide peroxide, but different commercial brands claim superiority based on differences in the carrier of the active ingredient, which could affect material delivery, material retention in the bleaching tray (material viscosity) or patient compliance (tooth sensitivity, material taste). Although there are a few reports that compare the different bleaching systems by listing their material marketing contents,56 clinical comparisons of different bleaching systems are rare. In this study, three commercial 10% carbamide peroxide bleaching systems were used by 24 patients in an overnight protocol maintained for two weeks to compare their subjective clinical effects.

Fig. 1: Prestudy photo of maxillary arch. Teeth were matched to the Vita shade tab A3.

Fig. 2. Post-study photo of maxillary arch. teeth were matched to the Vita shade tab A1.

Materials and Methods The bleaching treatment was performed on 24 volunteer adult dental students, staff and patients who expressed an interest in bleaching their teeth. The indications, contraindications, risks and benefits of bleaching were written into the consent form and discussed with each subject. The bleaching treatment was performed on vital teeth with no or minimal intact restorations, no or minimal dentin exposure, and no or minimal history of tooth sensitivity. The fabrication of the bleaching trays, the dispensing of the bleaching kits and the photographing the patients were personally supervised by the author. An irreversible hydrocolloid impression was taken of each patient's upper arch to fabricate stone study models. Reservoirs approximately 0.5 mm to 1.0 mm thick for the bleaching agent were built into the bleaching trays by first applying a photopolymerizable spacer material (LC

BlockOut, Ultradent) onto the labial surfaces of the teeth to be bleached. The number of teeth to be bleached depended on the patient's smile line. Generally, teeth 14 to 24 or 15 to 25 were prepared for bleaching on the study model. The spacer was kept away (approximately 0.25 mm to 0.50 mm) from the gingival margin, the interproximal contacts and the incisal and occlusal edges. A flexible 0.9mmthick ethyl vinyl acetate bleaching tray was then vacuum formed and trimmed in a scalloped fashion to avoid all soft tissue contact. The proprietary bleaching systems under investigation were Nite White Excel (peppermint cream flavour, Discus Dental), Platinum Professional Toothwhitening System (Colgate) and Opalescence Whitening Gel (regular flavour, Ultradent). For each patient, two bleaching systems were randomly selected and randomly designated "left" or "right". The patient was to use one bleaching system for the left side and another for the right side, thus using the two agents simultaneously. A preliminary trial using disclosing agents in one of the bleaching materials showed no significant crossover of bleaching material to the other side when the bleaching tray was fabricated as described. Furthermore, mild crossover of two bleaching materials was not a serious concern, because other teeth in addition to the central incisors were to be used for comparing the bleaching effect.Each patient received a daily log form, which clearly labeled which material was to be used for which side. The log was also to record the patient's smoking habits, the patient's coffee and tea intake, the presence or absence of restorations on the teeth to be bleached, and the presence or absence of subjective tooth sensitivity before bleaching. Patients were instructed how to place the bleaching agents into the bleaching trays. Each patient was to wear the tray for approximately 14 consecutive nights (after brushing and during sleep). Each patient was asked to record daily the duration of bleaching and any subjective evaluations or effects of each bleaching agent. Patients were advised that if they experienced tooth sensitivity or other side effects, they could reduce their exposure to the agents by reducing either the duration or the frequency of bleaching. The patients were free to discontinue the treatment at any time. A prestudy photograph of the teeth was taken under standardized lighting conditions using the same camera and dental operatory light, with and without a matching Vita shade guide tab of the teeth to be bleached (Fig. 1). After the bleaching treatment, a poststudy photograph of each patient was taken (Fig. 2) and the daily logs were collected. Data on the onset of tooth whitening (first patient record of subjective tooth whitening) and the onset, frequency and duration of tooth sensitivity for each bleaching agent were analyzed by ANOVA (p < 0.05). Paired ttests were also performed to compare the two bleaching agents used sidebyside on the same patient (p < 0.05).The protocol for this study was approved by the University of Toronto Office of Research Services Human Subjects Review Committee. Results Fifteen women and nine men participated. Their mean age was 28.5 years (range 17 to 51). They did not exhibit tooth sensitivity or recession in the subject teeth before the bleaching treatment. The patients bleached their teeth for 13.5 2.9 nights. Threequarters of the patients (18 of 24) complied with the daily regimen. The other patients skipped a day or more during the treatment for sensitivity reasons. The recorded time of onset of subjective tooth whitening and the onset, frequency and duration of tooth sensitivity are listed in Table 1.Side effects of the bleaching treatment presented minimal problems to the patients. Six patients (25%) reported gum tingling, tenderness or mild sensitivity for one or two days. One patient reported a scratchy throat for one day. One patient reported sleep interruption and a sore jaw for a couple of days toward the end of treatment. Another patient reported some bruxism as a response to wearing the tray. Three patients did not like the consistency of one of the bleaching products compared with the other.Intrapatient differences in whitening effect and tooth sensitivity by the two commercial bleaching systems used by each patient were occasionally reported; however, there was no clear trend for the intrapatient differences for the bleaching agents. No intrapatient differences in tooth whitening were noted between the left and right halves. There were no statistical differences in the time of onset of subjective tooth whitening and the onset, frequency and duration of tooth sensitivity among the three commercial bleaching systems when compared pairwise (paired ttest) or independently (ANOVA). Discussion

A placebo gel was not included in this study because it is well known that carbamide peroxide and hydrogen peroxide bleaching materials will lighten teeth significantly more than placebo materials.7-11 The patients were aware which bleaching agents they were using. It was thought that potential bias by the patients toward a particular agent would be minimal given that the agents had the same 10% carbamide peroxide concentration, the patients had no previous bleaching experience or affiliations with any of the agents, and no marketing or extraneous packaging materials were given to the patients.No attempt was made to quantify the degree of whitening achieved. Other studies have attempted to quantify tooth colour changes by using the Vita shade tab system or a colorimeter. The Vita shade tab system requires subjective shade matching, and the colorimeter has been criticized because of its technique sensitivity and need for a flat surface. In addition, small increments of change that could perhaps be measured by instruments such as a colorimeter would not necessarily indicate a clinically significant result. A clinically significant bleaching result necessitates a clear perception by the patient of a difference in tooth colour. In this study, therefore, a notation by the patient that the teeth became whiter was accepted as a clinically significant colour change.

Table 1. Time of Onset of Subjective Tooth Whitening and Time of Onset, Frequency and Duration of Tooth Sensitivity as Reported by Patients After Bleaching Treatment

Product Platinum Opalescence Nite White Totals

Number of 17 halves 15 halves 16 halves 24

Onset of whitening (days) 2.6 1.6 2.1 1.4 2.4 2.0 2.4 1.7

Onset of Frequency of sensitivity sensitivity (%) (days) 65 60 62 64 6.2 4.8 4.0 3.7 3.9 3.6 4.8 4.1

Duration of sensitivity (days) 4.4 3.4 6.2 4.9 4.5 3.0 5.0 3.8

Every patient reported some degree of tooth whitening. The colour changes ranged widely from very slight to dramatic. The average onset for apparent tooth colour change was 2.5 days. An early onset of bleaching effect is desirable to encourage compliance. Four patients reported the onset of tooth whitening as occurring in localized areas of their teeth, resulting in white spots. This response to bleaching has been attributed to variations in enamel structure. 12 The visibility of the white spots diminishes over time as the dentin and the rest of the enamel become whiter and perhaps as some of the early enamel whitening regresses. Patients should be advised of the likelihood of initial white spots as a result of the bleaching treatment. The advantages of overnight wear include greater patient convenience and improved material retention due to less salivation and less interference with the bleaching tray by the patient. Disadvantages are that overnight wear generally leads to longer contact times and does not allow the patient to monitor the side effects, such as tooth sensitivity. Tooth sensitivity was the most significant side effect of this study. Its frequency was relatively high compared to other reported problems. Other clinical studies using 10% carbamide peroxide for overnight wear over a period of several weeks have reported a 9% to 100% incidence of tooth sensitivity. 7,13-16 Leonard and colleagues17 suggested that the only predictors for tooth sensitivity during home bleaching were frequency of application and whether the patient had sensitive teeth before bleaching. Sex, age, day or night wear pattern, dental arch, and absence or presence of abrasion, defective restorations or gingival recession had no significant effect on the development of tooth sensitivity in their study.In the present study, most reports of sensitivity were mild, transient, sporadic or continuous over a few days, and were elicited by a cold stimulus. When specific teeth were indicated, they were usually the incisors and canines; the premolars were never indicated as specifically sensitive. Two patients reported episodes of spontaneous sensitivity. Two patients reported sensitivity to heat. Five patients reported one to three days of "acute," "very," "extreme," "high" or "severe" tooth sensitivity. The mean number of days of sensitivity was 5.0 3.8 days. All patients should be advised of the likelihood of tooth sensitivity as part of their informed consent. They should also be told that sensitivity could be severe enough

to prevent or at least delay the completion of treatment. In other studies, 2 of 17, 4 of 10 and 4 of 28 patients discontinued their bleaching treatment as a result of tooth sensitivity. 7-16 In the present study, 25% of the patients skipped at least one day of bleaching for tooth sensitivity reasons but continued to bleach their teeth thereafter. One patient stopped treatment after 12 days because of sensitivity.The patients were generally assessed within one week of the bleaching treatment. No patients reported the persistence of tooth sensitivity after the cessation of bleaching. This is in agreement with other reports, which conclude that no longterm irreversible pulpal effects are associated with these bleaching techniques. 6 Electric pulp tests have indicated no significant changes in pulp response following bleaching whether the teeth were sensitive or not.7,16 Longer exposures to bleaching agents do not appear to increase the level of tooth sensitivity. In this study, tooth sensitivity often diminished during the latter part of treatment. In one 6month clinical study, the majority of toothsensitive days occurred near the beginning of treatment and there were only zero to 20 days of total tooth sensitivity.18 Tooth sensitivity has been attributed to the permeation of the bleaching agent into the pulp. 19 Fluoride gels in the bleaching trays have been recommended for treating tooth sensitivity; 3 however, fluoride's action in desensitization is unknown. It could be beneficial in reducing exposure of the pulp to the bleaching agents by simply supplanting the use of the bleaching agent for that day. Fluoride and other desensitizing pastes could also theoretically reduce the penetration of hydrogen peroxide into the pulp by reducing the permeability of dentinal tubules at their orifices. Nonetheless, the best ways to reduce the pulpal inflammation causing tooth sensitivity are probably to reduce the time of exposure to the bleaching agent and to administer antiinflammatory analgesics. Despite some reported intrapatient differences, there were no statistically significant differences among the three commercial bleaching systems with respect to tooth sensitivity. According to information from the manufacturers, Opalescence uses glycerine and contains 20% water. Platinum has a waterbased dentifrice formulation. Nite White Excel uses a polyglycol composition and is unique because it contains no water. The water content of the bleaching agent could conceivably affect both tooth dehydration and material stability. In the present study, the different water content of the three commercial bleaching systems did not appear to affect tooth sensitivity or tooth whitening. The pH values of the three bleaching materials were measured at room temperature by a flat surface polymer body combination electrode with an Accumet 620 pH/mV meter (Fisher). For Platinum, the mean pH was 5.90 ( 0.03, standard deviation); for Opalescence, 6.40 ( 0.09); and for Nite White, 7.43 ( 0.03). Scanning electron microscope investigations have shown slight changes to enamel surface morphology after exposure to bleaching material, particularly under more acidic conditions. The clinical significance of these changes, however, is considered negligible or minimal for bleaching treatments of normal duration when the buffering and remineralization potential of the saliva are considered. Furthermore, it has been shown that the pH of a carbamide peroxide solution increases during nightguard wear as a result of urea breakdown. The pH of the material can affect peroxide radical liberation (and hence, bleaching effect) and material stability. A sufficiently lowpH material can also open exposed dentinal tubules, resulting in increased tooth sensitivity. In the present study, the different pH values of the three commercial bleaching systems did not result in clinical differences in tooth sensitivity or tooth whitening. The selection of a bleaching product should be based on the concentration of the active ingredient, the viscosity of the bleaching agent (higher material viscosity leads to greater material retention)24 and other marketing features. It is likely that higher concentrations of carbamide peroxide will not only whiten teeth more quickly and to a greater degree, but will also lead to increased sensitivity problems. Therefore, a balance between tooth sensitivity and tooth whitening needs to be struck for each individual patient. In Canada, a concentration of 10% carbamide peroxide is significant because formulations containing greater than 10% can be used only under the supervision of dental professionals. In the United States, only 10% carbamide peroxide formulations have received the American Dental Association Seal of Acceptance from

the Council on Scientific Affairs of the American Dental Association.Bleaching methods and materials appear to be growing by leaps and bounds. This study attempts to provide some independent clinical data for dental practitioners for the most common home bleaching method using an overnight wearing regimen in a clinical setting. Further research is needed to investigate the causes of tooth sensitivity and methods to reduce its severity and frequency. Dr. Tam is an assistant professor in the Department of Restorative Dentistry, Faculty of Dentistry, University of Toronto, 124 Edward St. Toronto, ON M5G I G6. The author has no declared financial interest in any company manufacturing the types of products mentioned in this article.Acknowledgments: The author thanks Mr. R. Kandola, a third-year dental student in the faculty of dentistry, University of Toronto, for his assistance in obtaining the pH measurements. Reprinted with permission. Journal of Canadian Dental Association. April 1999, Vol. 65, No. 4.

References
1. Christensen GJ. Bleaching teeth: Report of a survey, 199J Esthet Dent 1998; 10:16-20. 2. Burrell KH. ADA supports vital tooth bleaching&-;but look for the seal J Am Dent Assoc 1997; 12 8:3 S5 S. 3. Whitening products and fluorides. The Dental Advisor 1996; 13 (4):1-6.

4. Trends in dentistry. Lighter, whiter, brighter: trends in tooth whitening products and procedures. Dental Products Report 1996; July:20-7. 5. Freedman G, McLaughlin G. Whitening teeth: the demand is increasing. Dent Today 1996; 15:100, 104, 106, 108-12. 6. Tooth bleaching, state-of-art 9CRA Newsletter 1997; 21(4):1-4.

7. Gegauff AG, Rosenstiel SF, Langout KJ and Johnston WM. Evaluating tooth color change from carbamide peroxide gel. JADA 1993; 124:65-72. 8. Rosenstiel S.F., Gegauff A.G. and Johnston WM. Duration of tooth color change after bleaching. JADA 1991; 122:54-63. 9. Rosenstiel SF, Gegauff AG, McCafferty RJ and Johnston WM. In vitro tooth color change with repeated bleaching. Quintessence Int 1991; 22:7-12. 10. Matis BA, Cochran MA, Eckert G and Carlson TJ. The efficacy and safety of a 10% carbamide peroxide bleaching gel. Quintessence Int 1998; 29:555-63. 11. Ouellet D, Los S, Case H and Healy R. Double-blind whitening night guard study using ten percent carbamide peroxide. J Esthet Dent 1992; 5:79-83. 12. Haywood VB. Achieving, maintaining and recovering successful tooth bleaching. J Esthet Dent 1996; 8:31-8. 13. Haywood VB, Leonard RH, Nelson CF and Brunson WD. Effectiveness, side effects and long-term status of night guard vital bleaching. JADA 1994; 125:1219-26.

14. Reinhardt JW, Eivins SE, Swift Jr Ell and Denehy GE. A clinical study of night guard vital bleaching. Quintessence Int 1993; 24:379-84. 15. Sterrett J, Price RB and Bankey T. Effects of home bleaching on the tissues of the oral cavity. J Can Dent Assoc 1995; 61:412-20. 16. Schulte JR, Morrissette DB, Gasior EJ and Czajewski MV. The effects of bleaching application time on the dental pulp. JADA 1994; 125:1330-51. 17. Leonard RH, Phillips C and Haywood VB. Predictors for sensitivity and irritation in night guard vital bleaching. J Dent Res 1996; 75 (Abstr. no. 2894):379. 18. Haywood VB, Leonard RH and Dickinson GL. Efficacy of six months of night guard vital bleaching of tetracycline-stained teeth. J Esthet Dent 1997; 9:13-29. 19. Heymann HO. Bleaching of vital teeth. Quintessence lnt 1997; 28:420-7. 20. Bitter NC and Sanders JL. The effect of four bleaching agents on the enamel surface: A scanning electron microscopic study. Quintessence Int 1993; 24:817-24. 21. Ben-Amar A, Liberman R, Gorfil C and Bernstein Y. Effect of mouth guard bleaching on enamel surface. Am J Dent 1995; 8:29-32. 22. Leonard RH, Austin SM, Haywood VB and Bentley CD. Change in pH of plaque and 10% carbamide peroxide solution (luring night guard vital bleaching treatment. Quintessence Int 1994; 25:819-23. 23. Frysh H, Bowles WH, Baker F, Rivera-Hidalgo F and Guillen G. Effect of pH on hydrogen peroxide bleaching agents. J Esthet Dent 1995; 7:130-3. 24. Ploeger BJ, Robison RA, Robinson DF and Christensen RP. Quantitative in vivo comparison of five carbamide peroxide bleach gels. J Dent Res 1991.

CDA RESOURCE CENTRE For more information on tooth bleaching techniques, products and other related issues, contact the CDA Resource Centre. The Resource Centre has information packages and textbooks on tooth bleaching. It can also do computer searches for CDA members. Reprinted with permission.Journal of Canadian Dental Association.April 1999, Vol. 65, No. 4.

CDA Statement Concerning Teeth Whiteners

Whitening or bleaching claims are being made by a number of products containing various type of oxidizing agents as the whitening or bleaching ingredient. Most of these products are in the form of a liquid or gel that is applied (directly by the dentist or by the patient) via a mouthguard tray, and worn for several hours daily; others are toothpastes, one of which may be combined with a gel, while some utilize a multi-step process consisting of a mouth-cleaning agent, a gel, and one or more polishing creams. Some products are intended to be prescribed by dentist while others are sold over the counter.

The Committee of Community and Institutional Dentistry has written to Health Canada and expressed concern that these products fall under the regulatory category of cosmetics rather than drugs. Health Canada has indicated that these products will not be reclassified. Whitening or bleaching products may be safe and effective. However, concern has been expressed because manufacturers do not have long term safety data available. Some published scientific studies show that regular use of oxygenating agents may damage temporarily the soft tissues of the mouth, and may delay the healing of already damaged tissue. Other studies show that the use of these agents may cause varying degrees of damage to the pulp of the teeth. CDA continues to believe that such products should be used selectively and carefully. Although light to moderate aging stains may be visibly reduced by products containing oxygenating agents, the need for longer term safety studies supports the need for a cautious approach. Candid patient disclosure and adequate advice on home care are essential if clinicians choose to use or recommend these products. CDA believes that the public should only use these products after consultation with a dentist.

Approved by Resolution 97-73 CDA Board of Governors

Research Reference Guide 1. 2. Li, Y., et al., "Evaluation of A Combined InOffice and AtHome Applied Bleaching Agent," Journal of Dental Research, Volume 78, Abs. No. 312 (1999): 144. Kugel, G., et al., "Effective Tooth Bleaching in 5 Days: Using a Combined In Office and AtHome Bleaching System," Compendium (Apr 1997). The Dental Advisor Plus, Vol. 6, No. 5 (Sept.Oct. 1996). The Dental Advisor Plus, Vol. 7, No. 4 (Aug. 1995). Barghi, N., Morgan, J., "A Transitional Treatment," Dentistry Today (Jun. 1995). Godder, B., et al., "Evaluation of Two AtHome Bleaching Systems," Journal of Clinical Dentistry, Vol. V (1994): 8688. Yiming, L., "Evaluation of Cytotoxicity of Rembrandt Lighten Bleaching Gel Using the Cell Counts and MTT Tetrazolium Assay," (1993). Unpublished Data Available on Request. Reinhardt, J.W, et al., "A Clinical Study of Nightguard Vital Bleaching," Quintessence Interna- tional, Vol. 24 (1993): 379384. Ouellet, D., et al., "DoubleBlind Whitening NightGuard Study Using Ten Percent Carbamide Peroxide," Journal of Esthetic Dentistry, Vol. 4 (1992): 8083.

3. 4. 5. 6.

7.

8.

9.

10.

Furnish, G.M., et al., "Success and Longevity of Home Bleaching Using 10 % Carbamide Peroxide," American Association of Dental Research, Abs. 664 (1992). Lavelle, C.L.B., et al., "A Preliminary Clinical Evaluation of Rembrandt Lighten,"University of Manitoba (1992). Scherer, W., et al., "AtHome Bleaching System: Effect on Gingival Tissue," (1992). Unpublished Data Available on Request. Strassler, H.E., "Clinical Technique for Bleaching With the Rembrandt Whitening System and Quik Start Bleaching Gel," Journal of Esthetic Dentistry Vol. 3, No. 5 (Sept.Oct. 1991).

11.

12.

13.