Endodontology, Vol.

15, 2003

Effect of various night guard vital bleaching agents on surface morphology of enamel - A SEM study
*Dildeep Kaur ** Vishwanath ***Jayalakshmi KB

ABSTRACT
Discoloration of anterior teeth is an esthetic problem, which requires effective treatment. Bleaching as a treatment modality is the simplest and least invasive. For night guard bleaching various commercially available products containing 10-15% carbamide peroxide are available. Hence an in vitro study was done to evaluate the effect of various night guard bleaching agents containing 10% carbamide peroxide on the surface texture of 40 freshly extracted premolars. The photomicrographs obtained from SEM were categorized as mild, moderate and severe enamel alteration and it was concluded that different bleaching agents containing 10% carbamide peroxide cause different effects on enamel surface Key words : Vital bleaching, carbamide peroxide, night gaurd bleaching, enamel surface.

Introduction
With the increasing concern for esthetics, dentist are working hard to give their patient what is called the perfect smile. Discoloration of anterior teeth is an esthetic problem, which requires effective treatment. Currently, many treatment modalities are available such as laminate veneers, jacket crowns, micro abrasion and bleaching. Among these, bleaching is the simplest, most common, least invasive and least expensive means for diminishing or eliminating stains in vital teeth. For the treatment of discolored vital teeth, a choice between In office bleaching and Night Guard bleaching is available. Various
* Post Graduate Student ** Professor *** Professor and Head, Dept. of Conservative Dentistry and Endodontics, Bapuji Dental College and Hospital, Davangere 577 004 Karnataka

commercial products containing 10 15% carbamide peroxide are being dispensed over the counter. Night Guard bleaching is preferred over In office bleaching due to its ease of application, minimal side effects and fewer clinical visits. Studies have been conducted to investigate the effect of commercially available 10% carbamide peroxide products on the surface of enamel with indefinite results. Because carbamide peroxide containing bleaching agents are utilized over prolonged periods and certain amount of enamel matrix may be degraded, this in-vitro laboratory study was undertaken to determine their effects on the enamel surface morphology, using scanning electron microscopy. The objectives of the study were : 1. To determine the surface morphological changes on enamel following treatment with 10% carbamide peroxide containing bleaching agents. 2

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2. To assess if different commercially available 10% carbamide peroxide agents cause different alterations of the surface morphology. 3. To determine whether the pH of the solution affects the enamel surface morphology.

The control group was just treated with water soaked cotton wool. After bleaching treatment for 21 days, the samples were washed under tap water and dried. The teeth were slowly removed from the cast by holding the neck of the teeth with a tweezer. Care was taken not to disturb the surface morphology of the bleached teeth. The labial tooth surface was sliced mesio distally using a diamond disc, washed and dried. The samples were then gold coated and observed under vacuum chamber of scanning electron microscope (Model JOEL ISM IOA) and were photographed at x3000 magnification.

Materials and Methods

The present in vitro study was conducted at Bapuji Dental College and Hospital, Davangere, and evaluated under SEM at the Indian Institute of Sciences, Bangalore. The following bleaching agents were used : 1. Opalescence (Ultradent Co.) containing 10% Carbamide Peroxide 2. Nitewhite Excel 2 -10% carbamide peroxide 3. Platinum tooth whitening system (Colgate Palmolive) 10% Carbamide Peroxide Forty intact freshly extracted human premolars (for orthodontic purpose) were selected for the study. The teeth were then dried and randomly divided into 4 experimental groups of 10 teeth each. Group I Control Group : Distilled water Opalescence bleaching gel Platinum Tooth Whitening System Nite White Excel Group II Group III Group IV -

Results
The photomicrographs obtained from the scanning electron microscope after treatment with bleaching agents were examined for mild, moderate and severe alterations. They were graded as follows: A Mild alterations, No loss of enamel prisms. B Moderate alterations, loss of enamel prisms. C Severe alterations, deep irregularities with loss of prisms Group I (The control group) The photomicrographs obtained showed unaffected surface. The samples showed the typical perikymata and imbrication lines characterized by an undulating or hill and valley appearance. Few samples also showed scratch lines. Group II (Treated with Opalescence) Photomicrographs showed no exposure of prism or prism core. Mild surface alterations were seen but were quite similar to the control group. Some debris was seen. Only one of the 10 test samples showed moderate alternations. 3

Teeth in each group were mounted on a cast and a vacuum tray was fabricated. Each experimental group was incubated at 370C for 8 hours daily with the adapted trays loaded with the respective bleaching agents. Then the teeth were washed with water and the trays were replaced with water soaked cotton wool for another 16 hours in the incubator. This procedure was repeated for 21 days.

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Group III (Treated with Platinum whitening system) The photomicrographs showed no exposure of prism core. The enamel surface was covered with an amorphous layer obscuring the characteristic perikymata and imbrication lines. The surface layer was quite dense and enamel prism terminations were not appreciated. 2 samples showed moderate porosities with exposure of enamel core. Group IV (Treated with Nite White excel 2) The photomicrographs showed significant amount of irregular porosities, exposure of underlying prism structure of enamel and preferential loss of prism cores. Other enamel areas showed an amorphous surface, as though the mineral, mobilized from the prism cores, was deposited on to it, masking the characteristic perikymata. Results of SEM photographs indicated that there were surface morphological changes seen in Group II, III and IV (Table 1). Statistical analysis using chi square test and Fishers exact probability test was done. The camparison of enamel surface changes is shown in Table 2. Fishers test signified that morphological changes between Group II and Group III were similar and were statistically not significant. But between Group II and Group IV and Table-1. Surface alterations with different bleaching agents Groups Group II (Opalescence) Group III (Colgate Platinum) Group IV (Nite White) A - Mild alterations B - Moderate alterations C - Severe alterations 4 A 9 8 0 B 1 2 6 C 0 0 4

Table 2. Comparison of enamel surface between experimental groups. Groups II II Vs III Vs IV p value 0.39 0.001 0.0004

III Vs. IV

between Group III and Group IV, the changes were statistically significant. The results also showed that the pH of the bleaching agent was not a determinant of surface morphological changes.

Discussion
Many dental procedures, including bleaching, are performed empirically and without thorough knowledge of what their biological effects may be. This lack of understanding may give rise to unpredictable results. Bleaching is known to cause deleterious effects. Despite the advantages of night guard vital bleaching, it is known to have disadvantages like occasional sensitivity, pulpal irritation and surface morphological alterations. Different authors have reported that following bleaching with 10% carbamide peroxide, there has been an increase in up to 30% fracture susceptibility of the tooth, failure of bond with resin 1 , decrease in microhardness and pulpal irritation.2 The results of this study showed that following bleaching, the enamel surface showed morphological alterations ranging from mild, moderate to severe, which is in accordance with the studies conducted by Ben et al1 and Bitter and Norman2. Inspite of the fact that all the three bleaching agents used in this study contained the same active ingredient, i.e. 10% carbamide peroxide, yet the surface morphology varied. This may be attributed to

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the presence of other ingredients in the agents, which are commercial secrets. Group II specimens, which were treated with Opalescence showed mild alterations. This could be because of the presence of Carbopol, i.e. carboxypolymethylen polymer, a thickening agent in Opalescence gel, while it is absent in the other two agents. The presence and absence of this ingredient could have contributed to the variations in the surface texture alterations between the experimental groups7. Carbopol helps in time sustained release of the active agent throughout the treatment, which avoids the immediate breakdown of carbamide peroxide into its by products and hence limits its immediate violent action. It has also been stated that the thicker the agent, slower is the oxygen release. Among the 3 agents, group II i.e. Opalescence was the thickest followed by Platinum whitening system and Nite White, hence less was the immediate violent action of hydrogen peroxide, and less was the enamel surface alterations. Secondly, presence of water is very essential to avoid dehydration of the tooth during treatment. Material used in group II i.e. Opalescence, is rich in water and hence does not cause drying of the tooth, thus causing minimal surface alteration5. Thirdly, presence of sodium hydroxide as an ingredient in the bleaching agents plays a

very critical role in determining the action of the agent. It was suggested that a combination of sodium hydroxide and hydrogen peroxide is more effective in bleaching than only hydrogen peroxide and the action is faster and more violent4. Sodium hydroxide is absent in Opalescence, hence it showed mild alterations. Group III specimens, which were treated with Platinum Whitening system showed mild to moderate alterations, including frequent loss of enamel core. This is in accordance with a study done by Flaitz and Hicks3. Platinum Whitening System is unique in that it contains a remineralizing agent dicalcium phosphate dehydrate, which requires an increased length of time for whitening to occur. Also Platinum Whitening System is a water based agent, hence it does not cause any dehydrating effect on the tooth. The thickening agent added to this product i.e. Polyox (a polymer used in denture adhesive) and a detergent i.e. sodium lauryl sulfate are other ingredients which might attribute to the difference in surface morphological changes in contrast to group II and group IV5. Lastly, Platinum Whitening System also lacks sodium hydroxide, and hence causes mild surface alterations. The specimens treated in group IV i.e. Nite white showed surface alterations ranging from moderate to severe, showing irregular surface

Fig. 1. Group II (Opalescence) Showing mild alterations

Fig. 2. Group III (Colgate Platinum) Showing mild - moderate alterations

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it can be stated that inspite of the fact that Nightguard vital bleaching causes surface morphological alterations, they are clinically insignificant6. The changes in the surface morphology due to carbamide peroxide agents may undergo repair over time by precipitation of mineral phase derived from saliva into the surface porosities (remineralization).

Conclusion
Fig. 3. Group IV (Nite White) Showing severe alterations

This in vitro study conclude that: 10% Carbamide peroxide containing bleaching agents do cause surface morphological alterations in enamel but they are clinically not significant. This study also concluded that different commercially available 10% Carbamide peroxide containing bleaching agents cause different effects The pH of the bleaching agent is not a determinant of the degree of surface alterations caused.

with considerable porosities. This result is in accordance with the study done by Flaitz and Hicks3. Nite white is an anhydrous whitening agent i.e. sodium hydroxide is an ingredient of Nite white gel, which is absent in the other two agents. Moreover, Nite white is a less viscous agent compared to others. Hence, there might be a very immediate action of hydrogen peroxide causing morphological alterations. The presence of debris seen in few samples could be due to precipitation of fluoride from the bleaching agents. According to this present study, the pH of the bleaching agents does not seem to the surface alterations. The influence pH of Opalescence is 6.5, Colgate Platinum is between 5-6 and Nite White is 6.9. One explanation for this finding lie in the breakdown products of urea from carbamide peroxide. Ammonia and carbon dioxide released on degradation of urea appear to have an effect of elevating the pH of the solution. Hence carbamide peroxide due to its effect of raising the pH, also acts as a bacteriostatic agent in caries control3 It has been reported that a possible effect on the surface of enamel from bleaching may be considered negligible compared to surface enamel loss in prophylaxis (5 - 10m), mere etching (25 50m) or microabrasion (26m loss with every 5 seconds application). Hence 6

References
1. Ben AA Liberman R., Gorfile et al: Effect of mouthguard bleaching on enamel surface. Am. J. Dent. 1995; 8 : 29-32. 2. Bitter C., Norman : A scanning electron microscopy study of the effect of bleaching agent on enamel : a preliminary report. J. Prosthe. Dent. 1992; 67: 852- 55. 3. Flaitz CM, Hicks MJ : Effects of carbamide peroxide whitening agents on enamel surface and caries like lesion formation A SEM and polarized light microscopic in vitro study. J. Dent. Child; 1996; 249-56. 4. Goldstein E, Ronald initials , Garber AD : Complete dental bleaching. Quintessence, publishing Comp. Ic. 1995. 5. Van HB : Consideration and variations of dentists prescribed home applied vital tooth bleaching techniques. Compend. Cont. Educ. Dent. Suppl. 1994; 17: 616-621. 6. Van HB: History, safety and effectiveness of current bleaching technique and application of the night guard vital bleaching technique. Quint. Int. 1992; 23 : 477- 488. 7. Waraporn T., Satamonont P,Vongsavan N: In vitro penetration of the pulp chamber by three brands of carbamide peroxide. J. Esth. Dent. 1999; 11 : 259 264.