Acta Odontologica Scandinavica, 2013; 71: 1000–1007

ORIGINAL PAPER

Microleakage effect on class V composite restorations with two adhesive

systems using different bleaching methods

OZDEN OZEL BEKTAS1, DIGDEM EREN1, GULSAH GOKTOLGA AKIN1,

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BILAL UTKU SAG1 & MUTLU OZCAN2,3

1
Department of Restorative Dentistry, Faculty of Dentistry, Cumhuriyet University, Sivas, Turkey, 2Clinic for Fixed and
Removable Prosthodontics and Dental Materials Science, Center for Dental and Oral Medicine, University of Zürich,
Switzerland, and 3Dental Materials Unit, Zürich, Switzerland

Abstract
Objective. The main objective of this study was to evaluate the effects of an at-home and two in-office (chemically activated
and KTP laser-activated) bleaching methods on the microleakage of composite resin restorations bonded with etch-and-rinse
and self-etch adhesive systems. Materials and methods. Class V cavity preparations were performed on 96 premolars and
teeth were divided into two groups according to the two adhesive systems (etch-and-rinse and self-etch). After cavities were
restored with an adhesive systems and composite resin, they were submitted to thermocycling procedures. Teeth were divided
into four sub-groups according to the bleaching systems (control, at-home bleaching, chemically activated office bleaching and
For personal use only.

KTP laser-activated office bleaching). After the bleaching procedure, teeth were evaluated for marginal leakage. All data were
analyzed using the Mann-Whitney U and Kruskal-Wallis tests (p < 0.05). Results. The results of the present study showed that
the control group presented lower microleakage values compared with the groups treated with bleaching agents, except for the
chemically activated in-office bleaching. When the scores of microleakage at the enamel and gingival margins of the four groups
were compared, the differences among the groups were found to be statistically significant (p < 0.05). Comparing the gingival
and enamel margins in each group, statistically significant differences were found in the at-home group (p < 0.05) and no
significant differences were seen in the other groups (p > 0.05). No significant difference was found between the adhesive
systems after treatment with the same bleaching techniques. Conclusion. Under the conditions of this study, microleakage
of composite resin restorations differs according to the bleaching methods used and no difference was found between
the adhesive systems.

Key Words: chemically activated bleaching, KTP laser-activated bleaching, at-home bleaching, adhesive resin

Introduction etching step for etch-and-rinse systems (usually char-

Contemporary restorative techniques are based on the
adhesive properties of tooth-colored resin-based
materials [1]. The field of adhesive dentistry has
made remarkable progress over the past decade.
The current adhesion strategies depend exclusively
on how dental adhesives interact with the smear layer.
One strategy involves etch-and-rinse adhesives, which
remove the smear layer, and the second strategy
involves self-etch adhesives, which make the smear
layer permeable without removing it completely [2].
The difference between the two approaches is repre-
sented by the use of a preliminary and separate
acterized by a gel of 35–37% phosphoric acid) that is
later rinsed away [3]; conversely the self-etch/primer
agent is only air-dried, thus remaining within the
modified smear layer [2].
One of the most common esthetic problems in
dentistry is tooth pigmentation or darkening, for
which tooth bleaching is a conservative treatment
[4]. The use of a variety of bleaching techniques
has attracted most interest from the dental profession
because these techniques are non-invasive and rela-
tively simple to carry out [5]. Currently, there are two
main bleaching techniques: at-home (professionally
administered) and in-office (professional) [6].

Correspondence: Özden Özel Bektas, Cumhuriyet University, Faculty of Dentistry, Department of Restorative Dentistry, Sivas, Turkey.
Tel: +90346 2191010 2791. Fax: +90346 2191237. E-mail: ozdenozel@hotmail.com

(Received 16 May 2012; accepted 24 September 2012)

ISSN 0001-6357 print/ISSN 1502-3850 online  2013 Informa Healthcare
DOI: 10.3109/00016357.2012.741703

The use of at-home bleaching is widespread and
is gaining in popularity for many reasons. It requires
less in-office time, is simple to perform, is safe, can
be self-administered by the patient, is a lower-cost
procedure compared with in-office treatment and
has few adverse effects [6,7]. Although at-home
bleaching has increased dramatically in popularity,
in-office bleaching products are still in demand and
are strongly promoted by manufacturers [8]. There are
still many advantages to in-office bleaching. These
include professional control, avoidance of the contact
of whitening agents with soft tissues and bleaching of all
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parts of teeth, such as the cervical areas and immediate
results [9].
Bleaching agents for at-home use contain low con-
centrations of carbamide peroxide (CP) and hydrogen
peroxide (HP) [10]. They range from 10% to more than
45% for carbamide peroxide and from 3% to 14% for
hydrogen peroxide. Ten per cent carbamide peroxide is
equivalent to ~ a 3.4% solution of hydrogen peroxide
[11]. However, in-office bleaching systems contain high
concentrations of both peroxides (30–38%) [12,13] and
these materials are activated either chemically or by a
light source [14]. Since the introduction of in-office
bleaching treatments, the use of curing lights (including
halogen curing lights, plasma arches, LED, LED plus
lasers and lasers) has been recommended to accelerate
For personal use only.
the action of the bleaching gel [15]. Among them,
laser-activated in-office tooth bleaching officially started
in 1996, with the approval of the argon laser (480 nm)
and the CO2 laser (10 600 nm) [16]. Today, the
Nd:YAG (1.064 nm), diode (810 and 980 nm) and
potassium-titanyl-phosphate (KTP,532 nm) lasers are
also used [7,17–19].
The KTP laser emits at 532 nm, representing a
frequency-doubled Nd:YAG laser device, which is
used to activate the potent photosensitizer rhodamine
B dye under high-pH conditions in an aqueous gel
[20,21]. Zhang et al. [17] compared the effects of a
KTP laser, a diode laser and LED and suggested
that the KTP laser was capable of producing signi-
ficantly more bleaching than the LED or diode laser.
Goharkhay et al. [19] also reported that treatments
with the KTP laser-activated bleaching showed the
strongest bleaching reactivity. The action of the KTP
laser, whose wavelength is in the visible portion of the
spectrum, is the result of an interaction between the
agent in the gel (cromophore) and the staining mole-
cules in the enamel. If the chromophore peak of
absorption is not matched exactly with the related
wavelength, there will be no benefit from adding a
laser to the treatment [18].
In addition to in-vitro studies, two case reports
[22,23], one of which was conducted on teeth with
tetracycline discoloration [23], have shown that KTP
laser bleaching resulted in a clinically significant
improvement in tooth shade. Other than an improve-
ment in whitening effects, information is lacking
Microleakage of bleached restorations 1001
about the effects of the KTP laser on tooth surfaces
and restorations during dental bleaching.
The effect of bleaching agents on the bond interface
of restorations to dental substrates is controversial.
Most of the current research shows marginal sealing
alterations [24,25] and a decrease in bond strength
after bleaching [26,27]. Previous studies have com-
pared bond quality between etch-and-rinse and self-
etch adhesives subsequent to bleaching [28–31].
Some of them have advocated the use of etch-and-
rinse adhesives over self-etching ones subsequent to
bleaching [29,31]; there is little knowledge about
the effect of post-restorative bleaching on adhesive
systems.
The main objective of the current research was to
conduct an in-vitro study to evaluate the effects of the
different bleaching methods (one at-home and two in-
office, both chemically activated and laser-activated)
on the microleakage of existing composite resin
restorations bonded with etch-and-rinse and self-
etch adhesive systems. The null hypothesis was that
using bleaching agents would not influence the micro-
leakage of existing composite resin restorations.
Materials and methods
Ninety-six carious-free human premolars with intact
enamel surfaces that had been extracted for perio-
dontal or orthodontic reasons were used. Further
conditions included these: no-to-minimal fillings,
hardly any plaque and no previous root canal treat-
ment. To avoid dehydration, the teeth were stored in
distilled water immediately after extraction.
Standardized Class V cavity preparations were per-
formed on the buccal surfaces of each tooth. The
cavities were made with a cylindrical diamond bur
(Diatech, Swiss Dental, Heerbrugg, Switzerland) in
a water-cooled, high-speed hand piece and they
were ~ 4 mm in mesiodistal length, 3 mm occluso-
gingival height and 2 mm depth. The gingival margin
of the cavity extended into the cementum 1 mm below
the cemento–enamel junction (CEJ). A new bur was
used for each of the four preparations. No bevels were
placed.
After completing the preparations, the teeth were
randomly divided into two groups according to the
adhesive systems (Clearfil SE Bond and Prime &
Bond NT). The adhesive systems used in the study
are presented in Table I and they were used in strict
accordance with the manufacturers’ instructions.
Clearfil AP-X composite, shade A2 (Kuraray Medi-
cal, Tokyo, Japan), was placed in one increment and
cured for 40 s using a quartz-tungsten-halogen light
(Hilux, Benlioglu, Ankara, Turkey). The output of
the curing unit was measured with a curing radio-
meter to ensure light intensity at a constant value of
550 mW/cm2. The same operator performed all cavity
preparations and restorations. All restorations were
 1002 Ö. Ö. Bektas et al.
Table I. Commercial names, manufacturers and application
procedures of adhesive resins.
Adhesive resin Manufacturer Application procedure
Clearfil Kuraray Medical, Apply primer for 20 s.
SE Bond Tokyo, Japan Mild air stream.
Apply bond.
Gentle air stream.
Light cure for 10 s.
Prime & Dentsply, Apply 37% phosphoric
Bond NT Konstanz, acid for 15 s.
Germany Rinse 15 s and dry.
Apply PBNT for 7 s.
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Wait 20 s and air-dry 5 s.
Light cure for 10 s.
immediately finished with finishing diamond burs and
polished with a graded series of Sof-Lex Extra Thin
disks (3M ESPE, St. Paul, MN). The restored speci-
mens were stored in distilled water at 37 C for 24 h.
The teeth were then submitted to 1000 thermocycling
procedures with temperatures between 5 C ± 2 C
and 55 C ± 2 C and with a dwelling time of 30 s.
Following thermocycling, both adhesive system
groups were divided into four groups (n = 12) accor-
ding to the bleaching systems used: control (not
bleached), at-home bleaching (Opalescence PF),
chemically activated in-office bleaching (Opalescence
For personal use only.
Boost) and KTP laser-activated in-office bleaching
(The Smartbleach).
. Group 1: Clearfil SE Bond + not bleached;
. Group 2: Prime & Bond NT + not bleached;
. Group 3: Clearfil SE Bond + Opalescence PF (10%
carbamide peroxide, Ultradent Products, South
Jordan, UT);
. Group 4: Prime & Bond NT + Opalescence PF
(10% carbamide peroxide, Ultradent Products);
. Group 5: Clearfil SE Bond + Opalescence Boost
(38% Hydrogen Peroxide, Ultradent Products);
. Group 6: Prime & Bond NT + Opalescence Boost
(38% Hydrogen Peroxide, Ultradent Products);
. Group 7: Clearfil SE Bond + The Smartbleach
(55% Hydrogen Peroxide, High Tech Laser,
Milton, QLD, Australia); and
. Group 8: Prime & Bond NT + The Smartbleach
(55% Hydrogen Peroxide, High Tech Laser).
In groups 1 and 2, restorations were not bleached.
They were stored in distilled water at 37 C. In groups
3 and 4, Opalescence PF was placed on the buccal
surfaces of teeth using a syringe. Each restoration was
treated with an at-home bleaching agent for 8 h a day
on 10 consecutive days according to manufacturers’
recommendations.
In groups 5 and 6, each restoration was treated with
a chemically activated in-office bleaching agent, Opal-
escence Boost, for 15 min. Two bleaching sessions
were performed, consisting of two applications of the
gel on 4 consecutive days. To activate the bleaching
agent, chemicals were pressed from the red syringe
to the clear syringe with thumbs and the activator
and bleaching agents were mixed. Then the gel was
applied on the buccal surfaces of teeth for 15 min. The
bleaching agent was agitated with an applicator every
5 min. Then the bleaching agent was removed and
fresh agent was re-applied again. After the second
application, the bleaching gel was removed and teeth
were rinsed with water. The teeth were stored in
distilled water for 6 h and the bleaching session
was repeated. Thereby the total procedure lasts
~ 60 min per day. The bleaching procedures were
performed on 4 consecutive days.
In groups 7 and 8, each restoration was treated with
a laser bleaching agent (Smartbleach). Two bleaching
sessions were performed, consisting of two applica-
tions of the gel on 4 consecutive days. Powder and
55% hydrogen peroxide were merged, whereby the
concentration decreased to 25%. Manufacturer’s
instruction recommended a holding time of 5 min
to allow the carbonate buffer system within the gel to
elevate the pH to ~ 9.5. The bleaching agent was
applied on the buccal surfaces of the tooth, then was
irradiated for 30 s. Irradiation occurred with a KTP
laser (DEKA Dental Laser Systems, Florence, Italy)
at 532 nm (Output power of 1 W, continuous wave
(cw) mode, energy density 13.33 J/cm2). The distance
between the instrument tip and tooth surface was kept
at 10 mm. A circular motion was employed to prevent
over-heating. The bleaching agent remained on the
tooth surface for another 7 min after irradiation.
Thereby one application of bleaching was completed.
Then the bleaching agent was removed and fresh
agent re-applied and irradiated again. After the sec-
ond application, the bleaching gel was removed and
the teeth were rinsed with water. The teeth were
stored in distilled water for 6 h and the bleaching
session was repeated.
For all groups bleaching agents were applied to the
buccal surfaces and covered the area completely,
reaching a thickness of ~ 2 mm. After the bleaching
procedure all teeth were thoroughly washed with water
and gently blotted dry. The teeth were stored in
distilled water at 37 C between bleaching treatments.
After bleaching treatments were completed, the
specimens were coated with nail varnish, leaving a
1-mm window around the cavity margins. The teeth
were then placed in a solution of 0.5% basic fuchsin
dye for 24 h at room temperature. The specimens
were then rinsed in tap water and each specimen was
sliced longitudinally using a low-speed diamond disk
(Isomet Buehler, Ltd., Lake Bluff, IL) with water
coolant and evaluated for marginal leakage. The pri-
marily stained half of the tooth was used to evaluate
the microleakage. The degree of dye penetration was
then graded at 40 original magnification with a
stereomicroscope (SMZ 800, Nikon, Tokyo, Japan)
using the following scale:
 Microleakage of bleached restorations 1003

Table II. Enamel and gingival microleakage scores of SE bond groups.

Enamel scores Gingival scores

Groups 0 1 2 3 4 0 1 2 3 4
Control 12 0 0 0 0 11 1 0 0 0
At-home 9 3 0 0 0 2 2 1 7 0
Chemically activated in-office 12 0 0 0 0 8 2 2 0 0
Laser activated in-office 7 3 0 2 0 5 2 2 3 0

. 0: No marginal leakage; Bond NT, p = 0.003). The mean microleakage values of

. 1: Basic fuchsin penetration within 1/3 of the cavity the four groups, respectively, from lower to higher, were
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wall; control, chemically activated in-office bleached, laser-

. 2: Basic fuchsin penetration within 2/3 of the cavity
wall;
. 3: Basic fuchsin penetration within the last 1/3 of
the cavity wall without reaching the axial wall; and
. 4: Basic fuchsin penetration spreading along the
axial wall.
Statistical analyses were carried out using Kruskal-
Wallis and Mann-Whitney U-tests (p < 0.05).
Results
Data showing the extent of leakage scored for the enamel
and gingival margins of the restorations are shown
For personal use only.
activated in-office bleached and at-home bleached. For
SE bond groups, the differences between control and
laser-activated in-office bleached (p = 0.029), control
and at-home bleached (p = 0.001) and chemically
activated in-office bleached and at-home bleached
(p = 0.002) were found to be statistically significant.
For Prime & Bond NT, the differences between control
and at-home bleached (p = 0.001) and chemically
activated in-office bleached and at-home bleached
(p = 0.027) were found to be statistically significant.
Comparing the gingival and enamel margins in
each group, statistically significant differences existed
in the at-home bleached groups (p < 0.05). No
significant differences were exhibited in the other

in Tables II and III. Statistical results of the Kruskal-

Wallis test for microleakage scores of the groups are
shown in Tables IV and V.
When the scores of microleakage at the enamel
margins of the four groups were compared, the differ-
ences among the groups were found to be statistically
significant (p = 0.013) for Clearfil SE Bond. The mean
microleakage values of the four groups, respectively,
from lower to higher, were control, chemically acti-
vated in-office bleached, laser-activated in-office
bleached and at-home bleached. The differences
between control and laser (p = 0.022) and office and
laser (p = 0.022) were found to be statistically signi-
ficant. However, when the scores for microleakage at
the enamel margins of the four groups were compared,
there were no statistical differences found (p = 0.234)
for Prime & Bond NT.
When the scores of microleakage at the gingival
margins of the four groups were compared, the differ-
ences among the groups were found to be statistically
significant (for SE Bond, p = 0.001; and for Prime &
groups (for SE Bond, p = 0.006; and for Prime &
Bond NT, p = 0.021).
No significant differences were found between the
SE bond and Prime & Bond adhesive systems after
being treated with the same bleaching system
(p > 0.05).
Discussion
This study assessed the post-restorative bleaching
effects on composite resin restorations bonded with
an etch-and-rinse and a self-etch adhesive system in
terms of microleakage. The results of the present
study showed that the control group presented lower
microleakage values compared with the groups
treated with bleaching agents, except for the chemi-
cally activated in-office bleaching. Thus, the null
hypothesis was rejected.
Earlier studies that compared the effect of bleaching
agents on marginal leakage showed controversial

Table III. Enamel and gingival microleakage scores of Prime & Bond NT groups.

Enamel scores Gingival scores

Groups 0 1 2 3 4 0 1 2 3 4
Control 12 0 0 0 0 11 1 0 0 0
At-home 10 1 1 0 0 3 2 3 7 0
Chemically activated in-office 12 0 0 0 0 8 2 1 1 0
Laser activated in-office 10 0 1 1 0 5 4 3 0 0
 1004 Ö. Ö. Bektas et al.

Table IV. The results of KW for SE Bond enamel and gingival No published data were available for comparison
margin scores (KW = 10.81, KW = 18.16, respectively). about the effect of laser-activated in-office bleaching
Enamel margin Gingival margin
on microleakage.
On the other hand, one of the possible side-effects
Mean SD Mean SD of bleaching products is the weakening of the enamel
Control 0.00 0.00 0.08 0.28
structure by oxidation of organic or inorganic
elements [39]. Changes in micro-hardness are related
At-home 0.25 0.43 2.08 1.24
to a loss or gain of minerals (demineralization or
Chemically activated 0.00 0.00 0.50 0.79 remineralization) of the dental structure [40]. This
in-office
can also cause enamel microleakage. Zhang et al. [17]
Laser activated 0.75 1.13 1.25 1.28 have shown that use of the KTP laser at 1.0 W for 30 s
in-office
with a 35% hydrogen peroxide gel (Hi-Lite; Shofu,
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Kyoto, Japan) yielded dramatic results, but with no

results. Two studies have reported that bleaching treat-
ments had no effect on microleakage of existing
restorations [32,33]. Crim [24,34] evaluated the
effects of bleaching on marginal leakage of resin com-
posite restorations and concluded that pre-restorative
bleaching [34] had no effect, while post-restorative
bleaching [24] adversely affected the marginal seal of
resin composites. In another in-vitro study, the effects
of pre- and post-restorative bleaching with 10% car-
bamide peroxide on marginal leakage of resin compo-
site restorations were investigated [35] and it was found
that marginal leakage of resin composite restorations
increased in both pre- and post-operatively bleached
groups. These conflicting findings could be attributed
For personal use only.
significant differences in the enamel micro-hardness.
Goharkay et al. [19] reported that prolonged uses (2 
10-min impact time with 2  30-s radiation time and
4  10-min impact time with 4  30-s radiation time)
of Smartbleach with a KTP laser caused some areas of
mild erosion on enamel surfaces. In the present study
a KTP laser was used for 2  30 s of radiation time
twice a day for 4 consecutive days.
It is also known that lasers are used to increase
the temperature of a bleaching agent applied to the tooth
surface to accelerate the bleaching process [41]. The
information regarding dental pulp temperature increase
[41], restoration microleakage [42] and dental or
restoration surface alterations following bleaching

to the different bleaching agent used in the studies. [42] indicates a rapid and effective absorption of
Microleakage occurring at the margin suggests peroxide with the increased temperature of the agent
discontinuity between the restoration and dentin fol- or tooth tissue [43]. However, Zhang et al. [17] reported
lowing bleaching. This may be due to the bleaching that maximum intra-pulpal temperature rise was 3.8 C
effects on the restoration, the tooth structure or both for photoactivation with KTP laser. It is known that
[36]. Several studies have determined that bleaching temperature increases of more than 5.5 C are poten-
results in significantly greater effects on the surface tially hazardous to pulp vitality [44]. Also, Fornaini et al.
and sub-surface structure of both tooth and restora- [18] reported that the increases in gel temperature
tions, compared to their respective controls [37,38]. following KTP laser irradiation were lower than diode
Also, previous studies suggested that bleaching effects laser irradiation. Therefore, the KTP laser has been
on microleakage depend not only on the applied reported as potentially a valid and safe tool for laser-
bleach but also on the tooth substrate and restorative assisted tooth bleaching in the clinic [17,18].
materials [24,25,32,35]. Incorrect use of laser parameters could result in an
In the current study, according to the results of increase in the tooth temperature, which could cause
microleakage scores in enamel margins, the laser- deleterious effects [7]. Therefore, the light parameters
activated in-office bleached groups presented greater for clinical applications should be carefully assessed
microleakage than other groups. This difference was [41]. In this study, impact times and laser para-
statistically significant for SE Bond-treated groups. meters were chosen on the basis of the manufacturer’s
recommendations.
Table V. The results of KW for Prime & Bond NT enamel and Another explanation for the adverse effect on micro-
gingival margin scores (KW = 4.27, KW = 13.99, respectively). leakage by laser bleaching agents is that they may
Enamel margin Gingival margin
contribute to the consistency of bleaching agents. Laser
bleaching agents (Smartbleach) come in a semi-liquid
Mean SD Mean SD form (a cross between a liquid and a gel), rather than as a
Control 0.00 0.00 0.08 0.28
gel like at-home (Opalescence PF) and in-office
(Opalescence Boost) bleaching agents. Esberard et al.
At-home 0.25 0.62 1.66 1.23
[45] reported that semi-gel agents may be more readily
Chemically activated 0.00 0.00 0.58 0.99 absorbed by dental tissues, thereby causing more
in-office
aggressive changes than gels on tooth surfaces.
Laser activated 0.41 0.99 0.83 0.82 Also, according to the results of the microleakage
in-office
scores in enamel margins, there is no statistically

significant difference among chemically activated in-
office bleached, at-home bleached and non-bleached
restorations. Information in the existing literature
supports our results, which showed that chemically
activated in-office bleaching [33] and at-home bleac-
hing [25,36] did not affect marginal leakage in enamel
margins.
In comparing microleakage in samples of gingival
margins, it was observed that all bleaching agents
tested caused greater microleakage in proportion to
occlusal margins. Our findings are also in agreement
with Crim [24], who evaluated the effect of bleaching
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on the microleakage of Class V composite resin
restorations. He concluded that post-restorative
bleaching did not affect the marginal seal of restora-
tions as much at enamel as at dentin. Also, Yu et al.
[36] found that treating Class V composite restora-
tions with bleaching gels had no effect on enamel
microleakage and they also claimed that bleaching
effects on cervical dentin microleakage depended on
the materials tested.
In other studies that evaluated the effects of bleac-
hing agents on tooth structures, it was found that
carbamide peroxide had a greater effect on dentin
than on enamel. Engle et al. [46] evaluated the
potential effects of 10% carbamide peroxide and
found that the bleaching effects on surface wear
For personal use only.
were more evident in dentin than in enamel. Also,
Esberard et al. [45] reported that 10% carbamide
peroxide caused many irregularities and pittings of
the cementum surface. The deleterious potential of
carbamide peroxide was not found at enamel margins,
which could be interpreted as a consequence of the
difference in composition of enamel and dentin. This
is in agreement with reports that hydrogen peroxide
can cause degradation of organic components, as well
as demineralization of hard tissues [47]. The cemen-
tum in close proximity to the CEJ is more organic and
thin; therefore, it is easily affected by chemicals such
as bleaching agents [48].
In the current study, gingival microleakage results
showed that at-home bleaching agents presented
more statistically significant differences than the
control and chemically activated in-office bleaching
groups in both adhesive systems.
Despite the low concentration of hydrogen pero-
xide released, at-home bleaching systems are usually
in contact with the teeth for extended periods. The
daily application of carbamide peroxide for 8 h for
10 consecutive days used in the current study simu-
lated the at-home bleaching technique. It should be
considered that demineralization is an undesirable
effect resulting from bleaching agents and it is related
to their concentration and to the time necessary to
obtain teeth whitening [49].
Mortazavi et al. [50] evaluated the effects of post-
operative bleaching on microleakage of an etch-and-
rinse and two self-etch adhesives. They reported that
Microleakage of bleached restorations 1005
the carbamide peroxide gel significantly increased the
microleakage of composite restorations in one of the
self-etch adhesive groups at dentinal walls, while no
effect was found with the other groups. They claimed
that the dental adhesives have different abilities in
microleakage prevention, so the bonded interfaces
were affected by bleaching agents differently. In the
current study no significant difference was found
between the SE bond and Prime & Bond adhesive
systems after treatment with the same bleaching
system. Previous studies have reported that Clearfil
SE bond has prevented microleakage [51,52].
The main limitation of the present study is that the
bleaching procedures were carried out in the absence
of saliva. It is known that natural saliva remineralizes
the teeth after the bleaching process [53]. Therefore,
further studies that investigate the role of natural
saliva in bleaching-induced structural changes in teeth
should be carried out.
Future clinical research is necessary to confirm the
findings regarding the efficiency of bleaching agents,
considering the alterations to the tooth surfaces and
assessment of the possible adverse effects, such as the
degree of dentinal sensitivity and gingival inflamma-
tion that have been reported for most bleaching
techniques.
Conclusion
Within the limitations of this in-vitro study, the
following conclusions can be drawn:
(1) The effect of post-restorative bleaching agents
on microleakage of composite resin restorations
differs according to the bleaching agent used.
(2) The marginal leakage of resin composite restora-
tions is increased after bleaching with laser-
activated bleaching agents.
(3) At-home bleaching causes more microleakage at
dentin margins than enamel.
(4) The SE bond and Prime & Bond adhesive systems
did not exhibit different microleakage scores after
being treated with the same bleaching system.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
References
[1] Breschi L, Mazzoni A, Ruggeri A, Cadenaro M,
Di Lenarda R, De Stefano Dorigo E. Dental adhesion review:
aging and stability of the bonded interface. Dent Mater 2008;
24:90–101.
[2] Perdigão J. New developments in dental adhesion. Dent Clin
North Am 2007;51:333–57.
[3] Tay FR, Pashley DH. Dental adhesives of the future. J Adhes
Dent 2002;4:91–103.
[4] Gursoy UK, Eren DI, Bektas OO, Hurmuzlu F, Bostanci V,
Ozdemir H. Effect of external tooth bleaching on dental
 1006 Ö. Ö. Bektas et al.
plaque accumulation and tooth discoloration. Med Oral Patol
Oral Cir Bucal 2008;13:E266–9.
[5] Sulieman MA. An overview of tooth-bleaching techniques:
chemistry, safety and efficacy. Periodontol 2000 2008;48:
148–69.
[6] Barcellos DC, Benetti P, Fernandes VV Jr, Valera MC. Effect
of carbamide peroxide bleaching gel concentration on the
bond strength of dental substrates and resin composite.
Oper Dent 2010;35:463–9.
[7] Marcondes M, Paranhos MP, Spohr AM, Mota EG,
da Silva IN, Souto AA, et al. The influence of the Nd:
YAG laser bleaching on physical and mechanical properties
of the dental enamel. J Biomed Mater Res B Appl Biomater
2009;90:388–95.
Acta Odontol Scand Downloaded from informahealthcare.com by University of Zuerich Zentrum fuer Zahn Mund und on 12/14/13
[8] Al Shethri S, Matis BA, Cochran MA, Zekonis R, Stropes M.
A clinical evaluation of two in-office bleaching products. Oper
Dent 2003;28:488–95.
[9] Gurgan S, Cakir FY, Yazici E. Different light-activated in-
office bleaching systems: a clinical evaluation. Lasers Med Sci
2010;25:817–22.
[10] Seghi RR, Denry I. Effects of external bleaching on indenta-
tion and abrasion characteristics of human enamel in vitro.
J Dent Res 1992;71:1340–4.
[11] Haywood VB, Berry TG. Natural tooth bleaching. In
Summit JB, Robbins JW, Schwartz RS, editors. Fundamentals
of operative dentistry: a contemporary approach. 2nd ed.
Chicago, IL: Quintessence; 2001. p 401–26.
[12] Berger SB, Cavalli V, Martin AA, Soares LE, Arruda MA,
Brancalion ML, et al. Effects of combined use of light irra-
diation and 35% hydrogen peroxide for dental bleaching on
human enamel mineral content. Photomed Laser Surg 2010;
28:533–8.
For personal use only.
[13] Ushigome T, Takemoto S, Hattori M, Yoshinari M,
Kawada E, Oda Y. Influence of peroxide treatment on bovine
enamel surface–cross-sectional analysis. Dent Mater J 2009;
28:315–23.
[14] Hafez R, Ahmed D, Yousry M, El Badrawy W, El-Mowafy O.
Effect of in-office bleaching on color and surface roughness of
composite restoratives. Eur J Dent 2010;4:118–27.
[15] Marson FC, Sensi LG, Vieira LC, Araújo E. Clinical eval-
uation of in-office dental bleaching treatments with and
without the use of light-activation sources. Oper Dent
2008;33:15–22.
[16] Sun G. The role of lasers in cosmetic dentistry. Dent Clin
North Am 2000;44:831–50.
[17] Zhang C, Wang X, Kinoshita J, Zhao B, Toko T,
Kimura Y, et al. Effects of KTP laser irradiation, diode laser,
and LED on tooth bleaching: a comparative study. Photomed
Laser Surg 2007;25:91–5.
[18] Fornaini C, Lagori G, Merigo E, Meleti M, Manfredi M,
Guidotti R, et al. Analysis of shade, temperature and hydrogen
peroxide concentration during dental bleaching: in vitro study
with the KTP and diode lasers. Lasers Med Sci 2011;DOI: 10.
1007/s10103-011-1037-4.
[19] Goharkhay K, Schoop U, Wernisch J, Hartl S,
De Moor R, Moritz A. Frequency doubled neodymium:
yttrium-aluminum-garnet and diode laser-activated power
bleaching–pH, environmental scanning electron micros-
copy, and colorimetric in vitro evaluations. Lasers Med
Sci 2009;24339–46.
[20] Verheyen P. Laser assisted bleaching: Smartbleach. J Oral
Laser Appl 2001;3:207–13.
[21] Overloop K, Blum R, Verheyen P. Esthetic dentistry with
Smartbleach: an overview. J Oral Laser Appl 2001;2:
129–34.
[22] Kinoshita J, Jafarzadeh H, Forghani M. Vital bleaching of
tetracycline-stained teeth by using KTP laser: a case report.
Eur J Dent 2009;3:229–32.
[23] Kuzekanani M, Walsh LJ. Quantitative analysis of KTP laser
photodynamic bleaching of tetracycline-discolored teeth.
Photomed Laser Surg 2009;27:521–5.
[24] Crim GA. Post-operative bleaching: effect on microleakage.
Am J Dent 1992;5:109–12.
[25] Owens BM, Rowland CC, Brown DM, Covington JS III.
Postoperative dental bleaching: effect of microleakage on class
V tooth colored restorative materials. J Tenn Dent Assoc
1998;78:36–40.
[26] Cavalli V, de Carvalho RM, Giannini M. Influence of carba-
mide peroxide-based bleaching agents on the bond strength of
resin-enamel/dentin interfaces. Braz Oral Res 2005;19:23–9.
[27] Khoroushi M, Aghelinejad S. Effect of postbleaching appli-
cation of an antioxidant on enamel bond strength of three
different adhesives. Med Oral Patol Oral Cir Bucal 2011;16:
990–6.
[28] Miyazaki M, Sato M, Onose H. Durability of enamel bond-
strength of simplified bonding systems. Oper Dent 2000;25:
75–80.
[29] Miyazaki M, Sato H, Sato T, Moore BK, Platt JA. Effect of a
whitening agent application on enamel bond strength of self-
etching primer systems. Am J Dent 2004;17:151–5.
[30] Breschi L, Cadenaro M, Antoniolli F, Visintini E,
Toledano M, Di Lenarda R. Extent of polymerization of
dental bonding systems on bleached enamel. Am J Dent
2007;20:275–80.
[31] Gurgan S, Alpaslan T, Kiremitci A, Cakir FY, Yazici E,
Gorucu J. Effect of different adhesive systems and laser
treatment on the shear bond strength of bleached enamel.
J Dent 2009;37:527–34.
[32] Klukowska MA, White DJ, Gibb RD, Garcia-Godoy F,
Garcia-Godoy C, Duschner H. The effects of high concen-
tration tooth whitening bleaches on microleakage of Class V
composite restorations. J Clin Dent 2008;19:14–17.
[33] White DJ, Duschner H, Pioch T. Effect of bleaching treat-
ments on microleakage of Class I restorations. J Clin Dent
2008;19:33–6.
[34] Crim GA. Prerestorative bleaching: effect on microleakage of
class V cavities. Quintessence Int 1992;23:823–5.
[35] Ulukapi H, Benderli Y, Ulukapi I. Effect of pre- and postop-
erative bleaching on marginal effect of leakage of amalgam and
composite restorations. Quintessence Int 2003;34:505–8.
[36] Yu H, Li Q, Attin T, Wang Y. Protective effect of resin coating
on the microleakage of Class V restorations following treat-
ment with carbamide peroxide in vitro. Oper Dent 2010;35:
634–40.
[37] Cehreli ZC, Yazici R, García-Godoy F. Effect of home-use
bleaching gels on fluoride releasing restorative materials. Oper
Dent 2003;28:605–9.
[38] Attin T, Vollmer D, Wiegand A, Attin R, Betke H. Subsurface
microhardness of enamel and dentin after different external
bleaching procedures. Am J Dent 2005;18:8–12.
[39] McEvoy SA. Chemical agents for removing intrinsic stains
from vital teeth. II. Current techniques and their clinical
application. Quintessence Int 1989;20:379–84.
[40] Featherstone JD, ten Cate JM, Shariati M, Arends J. Com-
parison of artificial caries-like lesions by quantitative micro-
radiography and microhardness profiles. Caries Res 1983;17:
385–91.
[41] Buchalla W, Attin T. External bleaching therapy with activa-
tion by heat, light or laser–a systematic review. Dent Mater
2007;23:586–96.
[42] Attin T, Hannig C, Wiegand A, Attin R. Effect of bleaching on
restorative materials and restorations–a systematic review.
Dent Mater 2004;20:852–61.
[43] Khoroushi M, Fardashtaki SR. Effect of light-activated
bleaching on the microleakage of Class V tooth-colored
restorations. Oper Dent 2009;34:565–70.

[44] Zach L, Cohen G. Pulp response to externally applied heat.
Oral Surg Oral Med Oral Pathol 1965;19:515–30.
[45] Esberard R, Esberard RR, Esberard RM, Consolaro A,
Pameijer CH. Effect of bleaching on the cemento-enamel
junction. Am J Dent 2007;20:245–59.
[46] Engle K, Hara AT, Matis B, Eckert GJ, Zero DT. Erosion and
abrasion of enamel and dentin associated with at-home
bleaching: an in vitro study. J Am Dent Assoc 2010;141:
546–51.
[47] Carrasco-Guerisoli LD, Schiavoni RJ, Barroso JM,
Guerisoli DM, Pécora JD, Fröner IC. Effect of different
bleaching systems on the ultrastructure of bovine dentin.
Dent Traumatol 2009;25:176–80.
[48] SchroederHE,ScherleWF.Cemento-enameljunction–revisited.
Acta Odontol Scand Downloaded from informahealthcare.com by University of Zuerich Zentrum fuer Zahn Mund und on 12/14/13
J Periodontal Res 1988;23:53–9.
For personal use only.
Microleakage of bleached restorations 1007
[49] Goldberg M, Grootveld M, Lynch E. Undesirable and adverse
effects of tooth-whitening products: a review. Clin Oral Inves-
tig 2010;14:1–10.
[50] Mortazavi V, Fathi M, Soltani F. Effect of postoperative
bleaching on microleakage of etch-and-rinse and self-etch
adhesives. Dent Res J (Isfahan) 2011;8:16–21.
[51] Yazici AR, Başeren M, Dayangaç B. The effect of current-
generation bonding systems on microleakage of resin com-
posite restorations. Quintessence Int 2002;33:763–9.
[52] Sengün A, Unlü N, Ozer F, Ozturk B. Bond strength of five
current adhesives to caries-affected dentin. J Oral Rehabil
2002;29:777–81.
[53] Miranda CB, Pagani C, Benetti AR, Matuda Fda S. Evalu-
ation of the bleached human enamel by Scanning Electron
Microscopy. J Appl Oral Sci 2005;13:204–11.