Professional Documents
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Attractive teeth have always been the typical patient’s primary concern.
Today with the advent of new materials and techniques dentist can meet the or even exceed the
expectation of the patients for beautiful smile with brighter and whiter teeth.
Bleaching has now become the most common esthetic treatment for the patients. Earlier bleaching
techniques and services were provided by special esthetic dentist. But now with the increase in demand,
bleaching has become integral component of every clinic.
Bleaching is simplest, least invasive, least expensive means available to lighten discolored teeth
and diminish or eliminate many stains in both vital and non-vital teeth.
Tooth discoloration affects both primary and permanent teeth with etiology being multifactorial.
Bleaching is an inexact science, deals with numerous factors, dentist skills, and type of discoloration age
of the patient.
Nicotine / smoke/cigar/bidi/pipe
forces, hydration forces,
hydrophobic interaction
Tobacco chewing
and hydrogen bonds.
Red wine
Feinmen 1987
Trauma- Dark pinkish immediately after trauma dark brown/ pinkish brown
few days later.
Hemin
Hematin
Hematoidin
Hematoporphymis
Hemocidemrin
Hemoglobin+hydrogen Sulphide(bacteria)—
iron sulphide(black)
Congenital Syphilis
Hereditary hypoplasia
Vitamin C deficiency
-ledermix pastes
Nitrate (eugenol-orange yellow stain)
Amalgam-amalgam hue
D. AGING
- Amalgam hue
Chromogen build to the tooth surface and cause discoloration. The color of dental stain is same
as color of chromogen (Ex-tea coffee wine)
The chromogen change colour after binding. (Food stain when darker with age)
(iv) Metallic----Nonmetallic
(v)pre-eruptive---Post-eruptive
Grey stains
First degree: mild tetracycline staining: yellow to grey, uniformly spread, no banding
Fluorosis
(2)-opaque fluorosis
Fluorosis
Range
Range
Chalky-lustre
Grossman’s cement
N2
Tubuliseal
AH26---grey
BLEACHING
BLEACHING
----May be defined as the lightening of the colour of tooth through the application of a chemical agent to
oxidize the organic pigmentation in the tooth- GROSSMAN
----The treatment ,usually involiving an oxidative chemical that alters the light absorbing and / or light
reflecting nature of the material structure , thereby increasing its value(whiteners)-ADA
3rd phase-> acceptable treatment but provided by specialist dentist(phase of tetracycline staining ,
fluorosis)
History
1799
Labarraque’s solution
1877
Chapple
1889
1918
Abbot – used high intensity light that produce rapid temperature rise in
H2O2 to accelerate chemical bleaching.
1958
Pearson
1961
SPASSER
1965
STEWART
Thermocatalytic technique
Pellet saturated with H2O2 inserted into pulp and heated with hot instrument.
1966
McInnes
1968
KLUSMIER
1979
1982
Abou-Rass
1987
1988
White & brite( 30% H2O2) first commercial product-> results of Munro findings
1989
1991
1996
Settembrini et al
Inside/outside bleaching
Advantages of Bleaching
Improved esthetics
Low cost
Minimal invasiveness
Disadvantages of Bleaching
-Effects the enamel bond strength- due to residual oxygen or peroxide that inhibit setting of bonding
resin
CHEMISTRY OF BLEACHING
Weakly acidic
MOA: OXIDATION
Transforms an organic substance into chemical intermediates that are lighter in colour.
REDOX REACTION
9.5-10.8
H2O2
Acidic pH Alkaline pH
HO2°< O° HO2°>O°
Reactions
Per hydroxyl
Radicals(unstable/ electrophilic)
Xanthopterin
Highly pigmented
Attack organic molecules C=C (yellow)
carbon ring
White Pigments compounds
Converted into hydroxyl
groups(alcohol)
(eucopterin Break double bonds
Convert to chains
Colourless
Single bonds
SATURATION POINT
Properties of H2O2
Clear liquid
Colourless/odourless
Stored in refrigerators
Organic inorganic
[]- 3-45%
Provide alkaline
environment pH 8 (CH4N2O) urea +6.65% ammonia+Carbon dioxide+3.35% Hydrogen Peroxide
30% carbomide peroxide -> 10% H2O2
(C ) SODIUM PERBORATE
3 forms-> monohydrates
Trihydrates
Tetrahydrate
MOA
+
Oxygen complexes
(3) Urea
(6) Preservatives
(7) Flavouring agents
Actions
(+) thickens products stay on the teeth to provide necessary time for agent to diffuse into tooth.
polyx
composition undisclosed
(3) UREA
Anticariogenic
wound healing
(4) VEHCLE Glycol (Anhydrous glycerine)
(6)PRESERVATIVES
citroxain
Phosphoric acid
Citric acid
Sodium stannate.
(+) sequestrate metal ions (Cu1Mg1Fe) that increase break down of H2O2.
Bleaching gel
Acid Rinse
Trayless system
Over use
Patient may have existing pulpal exposure that may become exaggerated.
Posses both
Reduce caries
plaque removal
Uses
-tartar control
Surface phenomenon
H2O2
Calcium peroxide
Sodium percarbonate
CPS
-used by dentist
Chemical abrasive
(5)Toothpaste containing sodium bicarbonate
-be well controlled by the dentist to customize the treatment to the patient’s needs.
(2) [ ] of agent : α
(7) Sealed environment : H2O2 sealed in the across cavity maintain the required [ ] for active
bleaching.
dentifrice
Type of stain
This changes the optical qualities of the tooth to appear more opaque.
(2) Previously oxidized substance may become chemically reduced and cause the tooth to
reflect old discolouration.
(3) Enamel may become remineralized with the staining molecule of original stain.
(-) resin tags in bleached enamel are less in no, less defined and shorter than in
unbleached enamel
Increased sensitivity.
roughness
Chemical burn
Soreness
Irritation/ ulceration
Sore throat
Unpleasant taste
Burning palate
Gastric irritation :laxative effect
Contraindication of bleaching
Extremely large pulp
Exposed root surface
Ortho trt
Severe loss of enamel.
Presence of extensive restoration
Nursing lactating mother
Patient allergic to peroxides
In house bleaching -> incase of latex allergy, use latex-free rubber Dan
Indication of Bleaching
Fairly light stain -> yellowinnate colour or due to aging
Brown
Time :
Photoflood lamp
13-30 cm distance from Illuminator – rheostat controlled solid state heating device with special
tooth. metal tips shaped to provide heating-> flat/ wand type
Chemical +light
No Heat
Blue green paste can be applied 6 times /contains ferrous sulphate ->
chemical activation
Oxidation
White contains
Managanese sulphate
Brite smile
Paste
Thermocatalytic method
+ damage to Odontoblast
Reversible pulpits
Emits heat-
Illuminator
(3) Using heated bleaching gels: gel heated by placing in warm water for 2-3 mins.
Rembrandt products -> 35% CPS heated to 80°C and applied to tooth
directly
Hot air
More expensive
Technique
Miara(2000)
35% H2O in bleaching tray, seal the edges of tray with light use resin
Laser bleaching
Argon + CO2
488 nm 10600 nm
KPT
(LASER)
Disadvantages :- costly
Time consuming
materials
Alternate technique
Better dissociation of O2
Blue light
Yellow brown
colour easily
removed
Tooth whitens
CO2 laser
Diode Laser
980 nm
Semiconductor laser
not photothermal X
produce more reactive per hydroxyl ions used in bleaching tetracycline stains
1st action
Photoxidation of quinine
KTP 532 nm
Colourless
Thermal energy
(2) Pearlinbrite laser whitening system with energy transfer crystal (ETC)
Recent Advancement
Cold plasma
Matrix bleaching
At home bleaching
Haywood & Heymann coined the term night guard vital bleaching in 1989
Because patients bleached the teeth at night while they slept with trays in mouth.
Home bleaching is a simple technique whereby after an initial consultation with the dentist, a
mouth guard or a tray is made for the patients to bleach the teeth at home.
D
Low cost
I
Inexpensive + simple
S
Effective
A
Fast
D
Allow dentist to monitor
V
A Lab fee inexpensive
T Results 2 weeks
N (-)open to abuse
indications
Mild generalizing staining
Age yellow discolouration ,
Acquired superficial stain
Mild fluorosis
Pulpal trauma
Patient with low expectation
Young patient with inherited grey or yellow hue
Single tooth
Trauma
Mild tetracycline staining
Contraindication
Severe tetracycline
Pitting hypoplasia
Fluorosis stain
Adolescent with large pulp
Patient with unrealistic expectation
Patient with inadequate /defective restoration
Pitted / thin/ eroded enamel
Abrasion / attrition / erosion of enamel
Deep surface cracks
# lines
Large anterior restoration
Teeth with periapical radiolucency
# ed /maligned teeth
DMBA
Lack of compliance
known
Smokers
carcinogen
Lactating/ nursing mothers/pregnant
elevated in
Sensitive teeth
presence of
Cervical abrasion
oxygenating
agent
Treatment
(1)
Maxillary arch should be bleached first
Better retention of upper tray
Effect of gravity
Reduced effect of salivary flow
(2)Mandibular arch acts as control (3)
2 trays -> together cause TMJ occlusion problem
(4)Max arch unsuccessful no waste of cost and time
Tray Designs
What is reservoir?
- Bioinert material
- Easy to clean,rinse
Sheet
Occlusal stabilization
(1)
Instruction: minor sensitivity common
(2)
Later even
(3)
INTRACORONAL BLEACHING
AAE 1998 -> Intracoronal bleaching of non –vital teeth involves the use of chemical agents within the
coronal portion of an endodontically treated tooth to remove tooth discolouration.
NUTTING & POE-1967 – sodium perborate + H 2O2 1 weeks ( modified walking bleach)
When fresh +
-LA
Barrier – GIC
-RMGIC
ZnP
Zn polycarboxylate
IRM
Cavit
✔✔This technique allows the patient to see their teeth in different light during their
daily activities.
indications
- Pulp degeneration
GROSSMAN
(RBS) (Bacteria)
extensive restoration.
Inflammatory reaction
PREVENTION
(1) Proper Barrier Technique -> also called assurance sealing plug
“bobbled tunnel”
Proximal view
Three periodontal probing are made with a custom transfer periodontal probe)
Labial
Distal edge.
The internal bevel of barrier will be placed 1 mm incisal to external probing of epithelial
attachment
-
(2)[ why an endodontic plunger should not be used with free liquid bleach in
pulp chamber??]
-NaOCl
-catalase
-Sodium ascorbate
-> all cases of resorption occurs if tooth become pulpless before age of 25 and with use of H 2O2
+heat
Other disadvantage
Chemical burns
Damage to Restoration
COMBINATION BLEACHING TECHNIQUE
- Motivates patient
Bleaching
+ home bleach
Barrier placed
Ortho + bleaching
Repositioning appliances to move teeth into more appropriate position (+) the matrix holds the
bleaching agents.
ABRASIVE TECHNIQUE
Erodesd and abraded with a special compound leaving a perfectly intact enamel surface behind
MICROABRASION AGENT
Hydrochloric acid -> less than 200 micron enamel removed ~ 22-27micron
HCl + pumice
Yellow/brown
Enamel fluorosis
contraindication
Tetracycline staining
Amelogenesis imperfecta
Dentinogenesis imperfecta
10% HCl + fine grit silicon Carbide particle in water soluble paste applied
manually or handpiece.
Red: [ ] HCl
Opalustre : purple syringes containing HCl + silicon carbide micro particle in water soluble
paste.
Easy to perform
Conservative. Caustic
Minimal maintenance
MACROABRASION + ADJUNCT
Rinse with water after eating -> Remove stain easily residual food
removed.
H2O2 mouthwash
Fruits-> strawberries
Milk yogurt
Baking soda-> water+ salt -> paste -> brushing for 1 min.