Pulpal Temperature Rise During Light-Activated Bleaching

Ayçe Unverdi Eldeniz,1 Aslihan Usumez,2 Serdar Usumez,3 Nilgun Ozturk 2

1
Department of Endodontics, School of Dentistry, Selcuk University, Konya, Turkey

2
Department of Prosthodontics, School of Dentistry, Selcuk University, Konya, Turkey

3
Department of Orthodontics, School of Dentistry, Marmara University, Istanbul, Turkey

Received 5 February 2004; revised 29 June 2004; accepted 2 July 2004

Published online 20 October 2004 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jbm.b.30144

Abstract: The purpose of this study was to measure intrapulpal temperature rise induced by
two kinds of bleaching gels when the tooth was exposed to a variety of light-curing units and
a diode laser in vitro. The root portions of 80 extracted intact human maxillary central incisors
were sectioned with a carborundum disk approximately 2 mm below the cementoenamel
junction perpendicular to the long axis of the teeth. Two bleaching agents containing heat-
enhancing colorant was applied to the labial surface. Light-curing units used were a conven-
tional halogen (40 s), a high-intensity halogen (30 s), a light-emitting diode unit (40 s), and a
diode laser (15 s). The temperature rise was measured in the pulpal chamber with a J-type
thermocouple wire that was connected to a data logger. Ten specimens were used for each
system and bleaching-agent combination. Differences between the starting temperature and
highest temperature reading were taken and the calculated temperature changes were aver-
aged to determine the mean value in temperature rise. Temperature rise values were com-
pared using two-way analysis of variance (ANOVA) at a preset ␣ of 0.05. Temperature rise
varied significantly depending on curing unit and diode laser used. The diode laser induced
significantly higher temperature increases than any other curing unit (11.7°C). The light-
emitting diode unit produced the lowest temperature changes (6.0°C); however, there were no
statistically significant differences among the curing units and there were no statistically
significant differences between bleaching agents. Light activation of bleaching materials with
diode laser caused higher temperature changes as compared to other curing units and the
temperature rise detected was viewed as critical for pulpal health. © 2004 Wiley Periodicals, Inc.
J Biomed Mater Res Part B: Appl Biomater 72B: 254 –259, 2005

Keywords: light-activated bleaching; temperature; dentin

INTRODUCTION sodium perborate, and carbamide peroxide are generally used

Aesthetics, by definition, is the science of beauty, the partic-
ular detail of an animate or inanimate object that makes it
appealing to the eye.1 Tooth discoloration is becoming a
greater concern as more emphasis is placed on esthetics. With
the growing awareness of esthetic options, there is greater
demand for solutions to such unsightly problems as food
staining, fluorosis, and tetracycline staining. Bleaching sys-
tems have been received by the public as a more conservative
and economical method of improving the appearance of the
dentition.2 Bleaching is one of the corrective measures used
to treat discolored teeth. It can be performed internally on
nonvital teeth or externally on vital teeth. Hydrogen peroxide,
Correspondence to: A. Usumez, Selcuk Universitesi, Dishekimligi Fakultesi, Pro-
tetik Dis Tedavisi Anabilim Dalı, Kampus, Konya, Turkey (e-mail:
asli_u@hotmail.com)
© 2004 Wiley Periodicals, Inc.
254
for bleaching.3,4 These materials are found effective for
bleaching teeth, but side effects are changes in tooth struc-
ture,5,6 microleakage of restorations,2 external root resorp-
tion, and pulpal irritation.7,8 The thermocatalytic, walking
bleach and mouthguard are the most popular bleaching meth-
ods.9 In the thermocatalytic method, an external heat source
is applied to activate the bleaching agent.3 The energy of the
heat source is absorbed into all intermolecular and intramo-
lecular bonds and reaches maximum vibrations.10 The hydro-
gen peroxide molecule falls apart into different, extremely
reactive ionic fragments that swiftly combine with chro-
mophilic structure of the organic molecules, altering them
and producing simpler chemical chains.10 Cohen11 reported
on the histological effects of hydrogen peroxide and heat for
vital bleaching and concluded that vital bleaching utilizing
this method is harmless to pulpal tissue.
Bleaching systems have offered easy-to-use bleaching
agents, essentially using highly concentrated hydrogen per-
 TEMPERATURE RISE DURING LIGHT-ACTIVATED BLEACHING
TABLE I. Visible Light Curing Units Studied
Brand Launch Year Type of Unit
Laser Smile 2001 Diode laser
Optilux 501 2001 High-intensity halogen
Hilux 1996 Conventional halogen
Elipar Freelight II 2003 LED
oxide mixed with thickening agents or additional buffering
agents, catalysts, or heat-enhancing colorants.12 The energy
source can be derived from halogen curing units, high-inten-
sity curing units, and diode lasers.12 Laser devices have been
used in dentistry for soft tissue surgery, root end sealing and
sterilization, and for altering enamel and dentin surfaces to
increase resistance to decay or to facilitate the bonding of
composites and bleaching.13,14
Conventional halogen usually operates at light intensities
between 400 and 800 mW/cm2. Halogen bulbs produce light
when electric energy heats a small tungsten filament to high
temperatures. Despite their common use in dentistry, halogen
bulbs have several disadvantages. The basic principle of light
conversion by this technique is claimed to be inefficient as the
light power output is less than 1% of the consumed electrical
power and as they have a limited effective lifetime of ap-
proximately 100 h due to degradation of bulb components by
the high heat generated.15
A solid-state light-emitting diode (LED) technology was
proposed in 1995 for the polymerization of light-cured dental
materials to overcome the shortcomings of halogen visible
light-curing units.16 LEDs use junctions of doped semicon-
ductors to generate light, instead of the hot filaments used in
halogen bulbs.17 LEDs have a lifetime of over 10,000 h and
undergo little degradation of output over this time. LEDs
require no filters to produce blue light, are resistant to shock
and vibration, and take little power to operate.18 LEDs’
longer life span and more consistent light output compared
with halogen bulb technology show promise for dental appli-
cations.19 Light curing with high-energy output causes sig-
nificantly higher pulp chamber temperature changes as com-
pared to conventional halogen curing light.20 The purpose of
this in vitro study was to measure the temperature rise in-
duced by selected curing units: conventional halogen (40 s),
high-intensity halogen (30 s), LED unit (40 s), and diode laser
(15 s) during activation of two different bleaching agents.
The hypothesis tested assumed that there is no difference in
temperature rise in pulpal chamber when bleaching material
was activated with these three curing units and the diode
laser.
MATERIALS AND METHODS
The three curing units evaluated were Hilux 550 (First Med-
ica, NC, USA); Optilux 501 (Kerr, Danbury, CT, USA);
255
Applied
Activation
Time (s) Manufacturer
15 Biolase, San Clemente, CA, USA
30 Kerr, Danbury, CT, USA
40 First Medica, NC, USA
40 3M Espe, St. Paul, MN, USA
Elipar FreeLight (3M Espe, St. Paul, MN, USA); and a diode
laser (Lasersmile, Biolase, San Clemente, CA, USA). Man-
ufacturers’ names and addresses, applied time and other per-
tinent information are listed in Table I.
Preparation of Teeth
Eighty maxillary central incisor teeth, extracted for periodon-
tal reasons, were selected. Each tooth was free of dental
caries or restoration. The teeth were cleaned and stored in
deionized water at room temperature immediately after ex-
traction.
The root portions of the teeth were sectioned with a
slow-speed diamond saw (Isomet, Buehler Ltd., Lake Bluff,
IL) approximately 2 mm below the cementoenamel junction
perpendicular to the long axis of the teeth, and stored in
deionized water until used. An opening was made into the
pulpal chamber from the radicular portions of the teeth so that
a thermocouple wire could be inserted. The pulpal chamber
was cleaned of remnant pulpal tissues. The root stub was then
secured to an acrylic plastic base with an autopolymerizing
resin. A hole was drilled through the acrylic plastic base to
provide entrance for thermocouple wire into the pulpal cham-
ber.
The labial surfaces of the teeth were thoroughly pumiced
for 2 min, rinsed for 2 min in distilled water, and dried with
clean, dry, compressed air. Each experimental group was
treated with one of the following 35% hydrogen-peroxide–
containing bleaching materials: Opalescence XTRA (Ultra-
dent, South Jordan, UT, USA) or Quasar Brite (Spectrum
Dental, Culver City, CA, USA). Quasar Brite was mixed
according to the manufacturer’s instructions and both of the
bleaching agents were applied with a brush to the tooth
surface, in a layer approximately 1-mm thick.
Light application time for conventional halogen light
(light intensity, 450 mW/cm2) and LED (light intensity, 380
mW/cm2) unit was 40 s. Laser irradiation was 15 s (under
bleaching mode, 10 W, continuous wave) and high-intensity
halogen (light intensity, 850 mW/cm2) application time was
30 s (under bleaching mode).
Temperature Measurement
The temperature rise was measured in the pulp. The distance
between the emitting tip of the light source and the tooth
surface was set at 10 mm. A silicone heat-transfer compound
256 ELDENIZ ET AL.
Figure 1. Schematic drawing of experimental set up showing the
temperature measurement during activation of bleaching material.
(ILC P/N 213414, Wakefield Engineering, MA, USA) was
applied in the pulp chamber. This compound facilitated the
transfer of heat from the wall of the dentin to the thermocou-
ple wire. A J-type thermocouple wire with 0.36-inch diameter
(Omega Engineering, Stamford, CT, USA) was connected to
data logger (XR440-M Pocket Logger, Pace Scientific, NC,
USA) during application of curing units and diode laser
(Figure 1).
The sampling rate of the data logger was set to one sample
every 2 s for a recording period starting with light curing for
approximately 60 –90 s until the temperature started to de-
crease. The collected data which was available in both tabular
and graphic form was monitored in real time and transferred
to a computer. Measurements were made for each combina-
Figure 2. Temperature versus time graphs of diode laser, high-intensity halogen, conventional halo-
gen, and LED during activation of Opalescence-Xtra.
tion of bleaching material and curing unit or diode laser and
difference between start and highest temperature reading was
taken. Then 10 calculated temperature changes were aver-
aged to determine the mean value in temperature rise.
The results of testing were entered into an Excel (Mi-
crosoft威, Seattle, WA, USA) spreadsheet for calculation of
descriptive statistics. Statistical analysis was performed using
two-way analysis of variance (ANOVA) and then Tukey
HSD tests (SPSS/PC, Vers.10.0, SPSS, Chicago, IL, USA)
for comparisons among groups at the 0.05 level of signifi-
cance.
RESULTS
Temperature rise values of the bleaching agents with the three
light units and diode laser tested are given in Figures 2 and 3
and Table II.
Temperature rise values with the same light source was
pooled as no statistically significant effect of bleaching agent
on temperature rise values was detected with ANOVA (p ⫽
0.647). Pooled temperature rise values with three light units
and diode laser are given in Table III.
Temperature rise varied significantly depending on the
curing unit (conventional halogen, high-intensity halogen,
LED) and diode laser used (ANOVA, p ⬍ 0.001; Table IV).
The diode laser (11.7°C ⫾ 2.1°C) induced a significantly
higher temperature increase than any other curing unit
(Tukey, p ⬍ 0.001). The LED unit produced the lowest
temperature increase (6.04°C ⫾ 1.0°C), however there were
no statistically significant differences among the curing units
tested (Tukey, p ⬍ 0.05).
 TEMPERATURE RISE DURING LIGHT-ACTIVATED BLEACHING
Figure 3. Temperature versus time graphs of diode laser, high-intensity halogen, conventional halo-
gen, and LED during activation of Quasar-Brite.
DISCUSSION
This in vitro study measured the temperature changes caused
by the heat generated by three commercially available curing
units and a diode laser. Under the conditions of the present
study, the highest temperature rise was recorded using the
diode laser for 10 s. The temperature rise during activation of
bleaching material was lower with the LED unit than the
conventional halogen, high-intensity halogen, and the diode
laser. This result is in accordance with the previous stud-
ies21,22 which concluded that LED unit produces the least
thermal insult during polymerization process.
Aqueous hydrogen peroxide has been used clinically at
30% to 35% levels to lighten teeth for many years, but the
process has required multiple visits. Heat and light have
been used empirically in attempts to catalyze hydrogen
peroxide decomposition and speed tooth lightening.12 The
current study was planned to determine comparative ther-
mal risk to the pulp induced by these three light units and
diode laser.
TABLE II. Intrapulpal Temperature Rise Values (⌬T, °C) with
Various Light Sources
Light Source Quasar Brite Opalescence Xtra
Diode laser 11.5 ⫾ 2.2 12.0 ⫾ 2.0
High-intensity halogen 7.2 ⫾ 1.9 8.5 ⫾ 1.6
Conventional halogen 6.3 ⫾ 1.4 6.4 ⫾ 2.2
LED 5.9 ⫾ 1.0 6.0 ⫾ 1.0
[Mean ⫾ standard deviation (n ⫽ 10)].
257
Light-activated, heat-enhancing colorant may increase in-
trapulpal temperature values.23 Two different bleaching
agents that contain 35% hydrogen peroxide with different
colorants [Quasar Brite (pink) and Opalescence Xtra (dark
red)] were selected for the current study. Temperature rise in
the latter was higher but there were no statistically significant
differences between groups.
When using high-energy lasers in biological vital tis-
sues, the adverse effects must be considered. Histological
reactions after laser treatment were investigated. Adrian24
found a localized pulpal response in the region that,
through dentinal tubules, had indirect contact with the
irradiation spot of an Nd:YAG laser in dentin. The rest of
the pulp was unaffected.24 This finding was confirmed by
Stelzel and colleagues,25 who found pulpal response when
irradiating deep dentin layers. The current study focused
on the intrapulpal temperature changes and no information
is given about histological evaluation.
Pulpal changes caused by bleaching agents have been
investigated by several authors. Seale and colleagues8
TABLE III. Pooled Intrapulpal Temperature Rise Values with
Light Sources
Mean ⫾ SD Tukey Grouping*
Diode laser 11.75 ⫾ 2.07 A
High-intensity halogen 7.84 ⫾ 1.93 B
Conventional halogen 6.35 ⫾ 1.80 B
LED 6.04 ⫾ 1.03 B
Mean ⫾ standard deviation.
*Groups with different letters are statistically significantly different.
258 ELDENIZ ET AL.
TABLE IV. Two-Way Analyses of Variance
Mode DF MS F P
Bleaching material 1 6.14 1.95 .16
Light source 3 133.08 42.29 .00
Bleaching material† 3 1.72 .55 .65
Light source
found that histological damage to dog teeth from hydrogen
peroxide used alone or with heat is reversible after 60
days. They reported histological evidence of disappearance
of the odontoblastic layer under the treated area and a
dense inflammatory infiltrate and area of scalloped dentin
with isolation. Robertson and Melfi7 indicated that these
pulpal alterations appear to be reversible. According to the
results of the current study, temperature rise values are
critical for pulp tissue. Reversibility in alterations in cal-
cified structures and pulp tissue needs to be evaluated
further on human teeth.
Zach and Cohen26 reported irreversible pulpal damage in
15% of rhesus monkeys for temperature elevations of 5.6°C,
60% for temperature elevations of 11°C, and 100% for tem-
perature elevations of 16.6°C. Even though their experimen-
tal setting was different from this study, their results can be
suggested as a baseline for potential histopathological
changes in pulpal tissues when the temperature rise exceeds
5.6°C. The total duration of temperature rise and storage of
harmful heat is important. Eriksson and colleagues27 stated
that 42°C was a critical temperature when maintained 1 min.
However, Reingewirtz and colleagues28 showed that energy
dissipation is rather rapid and happens within 10 s.
Kreisler and colleagues29 stated that diode laser irradiation of
root surfaces may jeopardize pulp vitality and recommended that
a power output of 1.0 W and exposure time of 10 s must not be
exceeded to ensure a safe clinical application. In the current
study a power output of 10 W and exposure time of 15 s were
applied according to the manufacturer’s instructions and diode
laser caused a temperature rise of 11.7°C, whereas an increase of
7.8°C for high-intensity halogen, 6.35°C for conventional halo-
gen, and 6.0°C for LED was recorded. Considering these values,
the maximal temperature increase detected for all curing unit
and diode laser tested in this study were viewed as critical.
However, the temperature values measured in this study cannot
be directly applied to temperature changes in vivo. The reason is
that the experimental set up of this study did not consider heat
conduction within the tooth during in situ bleaching material
activation due to the effect of blood circulation in the pulp
chamber.30
CONCLUSION
Measurements of temperature rise during activation of
bleaching material in vitro indicated that during light activa-
tion of selected bleaching materials, diode laser caused sig-
nificantly higher temperature increases as compared to high-
intensity halogen, conventional halogen, and LED curing
units. The maximal temperature increases determined were
viewed as critical for the pulpal health for any of the three
types of curing units and diode laser tested.
The authors would like to thank Ultradent for supplying “Opal-
escence” and Mr. Enver Atali for supplying Lasersmile unit.
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