Vital Bleaching
Dr. Ignatius Lee
Potential Results
Vital Bleaching
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Modern era of vital bleaching began with
Haywood and Heymann’s 1989 article on
nightguard vital bleaching - using a custom fitted
plastic mouthguard to apply a 10% carbamide
peroxide gel.
Today there are 3 major methods for vital
bleaching
» In office or power bleaching
» At home or tray bleaching
» Over the counter
In-office/Power Bleaching
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25% to 38% hydrogen peroxide
Involve chair time; thus most expensive
Results most predictable
Good for non-compliant or unwilling patients,
also for patients demanding instant result
At Home or Tray Bleaching
10% to 22% carbamide peroxide
(10%=3.6% hydrogen peroxide); 6% to
10% hydrogen peroxide
 Typically will attain optimal results in 2-6
weeks
 Results are dose/time dependent

Over the Counter Bleaching
6% to 14% hydrogen peroxide
 Strips, wraps, paint on products
 Least expensive
 Results least predictable
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Vital Bleaching
Advantages
Low cost
 High success rate
 No tooth alternation

Vital Bleaching
Disadvantages
Unpredictable results
 Need Re-treatment
 Possible side effects

Contraindications
When the extrinsic stain can be removed
by a thorough prophylaxis
 Dental caries
 Discolored restoration
 Restoration showing through

Vital Bleaching
Mechanism
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The active ingredient is hydrogen peroxide, an
oxidizing agent
It diffuses through the organic matrix of enamel
and dentin
Produces free radicals, which are responsible
for the bleaching process (oxidation)
These free radicals open the highly pigmented
carbon rings and converting them into chains,
which are lighter in color
Etiology of Tooth
Discoloration

Extrinsic Stain
» superficial changes
» secondary to colored food,
drinks (tea, coffee, cola),
tobacco products,
smokeless tobacco
» more of a problem if there
are microcracks

Aged Related Color
Change
» thinned enamel
» darkened dentin due to
deposition of secondary
dentin, more yellowish
Etiology of Tooth
Discoloration

Intrinsic Stain
» medication given
systemically, e.g.
tetracyclin, minocyclin
» fluorosis
» systemic conditions, e.g.
jaundice, erythroblastosis
fetalis, porphyria
» dental caries
» old restorations showing
through, e.g. amalgam
» trauma
» heredity
Prognosis
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Discoloration due to aging, inherited
discoloration, smoking, chromogenic materials,
trauma (evenly distributed discoloration) EXCELLENT PROGNOSIS
Works better in removing yellow, orange and
light musky brown color
Dark blue-gray stain do not response as well
Prognosis

Brown fluorosis
discoloration
» good prognosis, may need
micro-abrasion and at home
bleaching
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White spot
» not removed, only get lighter
during treatment
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Tetracyclin stain
» do not typically response well
» may need multiple in-office
application, extended take
home application (2 to 6
months) or combination
Prognosis

Uneven pulp size
» uneven results; smaller pulp slower to lighten or do
not lighten as much
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Initial color relapse
» due to oxygen trapped in tooth diffuses out of tooth
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Longevity of color change
» one to three years, individual variations
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Non-responsive teeth
» extend treatment time or use in-office bleaching as a
booster
Effects on Restorative Materials
Composite
» minimal changes in color, surface roughness and
physical properties
» may increase microleakage at CEJ with earilier
generation of dentin bonding system
» effect unknown on the current generation of bonding
system
Amalgam
» in one invitro study, the amount of mercury released
into the peroxide solution was significantly higher
than released into saline solution (4-30x)
Effects on Restorative Materials
Ceramic
» no effects on the color or physical properties
Luting cements
» an intro study showed that glass ionomer, and
particularly zinc phoshpate dissolved readily in 10%
carbamide peroxide
» clinical significance not known
Effects on Restorative Materials
Temporary restorations
» causes microscropic surface change in IRM
(Intermediate Restorative Material, a eugenol based
temporary material) in both hydrogen peroxide and
carbamide peroxide
» macroscropically, IRM appears cracked and swollen
when exposed to hydrogen peroxide but not carbamide
peroxide
» metharcylate discolored when exposed to carbamide
peroxide
» causes no color change in polycarbonate crown and
composite-type temporary
Effects on Restorations
Defective restoration
» should consider repairing defects before bleaching to
prevent unwanted penetration of the bleaching agent
through open margin
» should consider temporary repair instead of
replacing the restoration because of color match
concern
Composite / Bonding
» delay any bonding or composite procedure for at
least one week following bleaching
» rationale: lower bond strength and allow for better
color match due to regression of bleaching result
Effects on Pulp
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Application of peroxide gel resulted in rapid
penetration of peroxide to the pulp chamber.
Minor irritation of the pulp tissue did occur, but
that it was resolved within 2 weeks after cessation
of treatment.
No differences between whitened and unwhitened
teeth on their responses to electric or cold pulp
tests (up to 12 years following bleaching).
No evidence of irreversible pulpitis even in
extended treatment regimen (more than 6 months).
Effects on Enamel
Lower enamel microhardness (3% to 7%)
immediately after treatment
 Slight increase in surface porosity as
observed under SEM.
 More surface dissolution by phosphoric acid
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Safety Issues
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Sensitivity to Temperature Change
» Primary side effect associated with vital bleaching.
» Typically begins early in the bleaching process (1st or
2nd day); increased during the course of the treatment.
» Usually mild and transient in nature.
» Adding potassium nitrate and sodium fluoride to the
formulation results in significant reduction in sensitivity
as reported by the patients.
Safety Issues

Sensitivity to Temperature Change
» Reported incidence of sensitivity from 7% to as high as
75%
» Of those who experienced sensitivity; over 70% are
labeled as mild and less than 10% are labeled as severe.
» Up to 20% of placebo group experienced sensitivity
(due to tray or glycerin)
» Predictors of sensitivity: history of tooth sensitivity and
treatment frequency (more 1x/day) and dose
(concentration and time)
» Non-predictors: age, gender, exposed dentin/cementum,
cracks, pulp size, caries
Safety Issues

Sensitivity to Temperature Change Remedy
» Reduce wear time or frequency of application
» Utilize a lower concentration of peroxide
» Immediate removal (in-office) or refrain from
using for a couple days
» Utilize a product that contain fluoride and or
sodium nitrate
Safety Issues
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Irritation of gingiva
» due to improper isolation (leaking rubber dam) or
excess bleaching agent (patient sensitive to bleaching
agent or poor fitting nightguard)
» poor fitting or improperly trimmed nightguard
» immediate removal (in-office) or for 2-3 days
» reduction of wearing time, remake nightguard

Not recommended for pregnant or lactating
woman
Safety Issues
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Carcinogenic effect
» potentiate the effect of a known carcinogen associate
with tobacco products (DMBA)
» special warning for smokers; refrain

Ingestion
» not a major problem
» taste and laxative effect from the glycerine base
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Allergy
» peroxide, nightguard material
Safety Issues
Excessive free radicals
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Low level: may contribute to aging.
Moderate level: oxidation damage to DNA
occurs, thus possibly leading to mutations and
possible carcinogenic.
High level: death
JADA 135:319
6.6% HCl + silicon carbide microparticles
(Opalustre)
JADA 134:1066
18% HCl (PREMA)
Clinical Case
16 y.o. male
Discoloration due
to fluorosis
Opalustra (6.6% HCl + silicon carbide microparticles) - 4
x 60 sec
Followed by
Opalesence Xtra Boost (38% hydrogen peroxide) - 2 x
20 min
First session
Before
After
Second Session
Before
After
In-office Bleaching
(Clinical Protocol)
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Clean teeth with pumics
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Record pre-op shade
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Isolate teeth as close to
the gingival margin as
possible with rubber dam
(no tears, leakage, fully
inverted)
In-office Bleaching
(Clinical Protocol)
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Mix the thickening agent
(Cab-o-Sil) with 35%
hydrogen peroxide to a
non-slumping
consistency.
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Place the gel material on
the teeth for 30 min
In-office Bleaching
(Clinical Protocol)
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May need to “refresh”
with hydrogen peroxide
liquid if the gel appear
too dry
Rinse and clean; remove
rubber dam and record
post-op shade
Nightguard Bleaching
(Laboratory Procedure for Tray)

Trim cast to ideal
thickness for use in
vacuum former
» base of cast parallel to
occulsal plane, and 45mm from gingival
margin (result in good
adaptation of tray
material)
Nightguard Bleaching
(Laboratory Procedure for Tray)
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Make tray using vacuum
former
Nightguard Bleaching
(Laboratory Procedure for Tray)
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Trim tray using #25
Bard-Parker blade
» trim to gingival margin;
scallop around interdental
papilla
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Smooth edges using
alcohol torch
Nightguard Bleaching
Clinical Protocol
Nightguard Bleaching
Clinical Protocol
Nightguard Bleaching
Opalescence - sustained release
How to deal with patient’s
expectation
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Bleaching is an inexact science
Results depends on dentist’s skill, individual
variation in the teeth, and the patient’s
continuing habits , diet and hygiene care
Difficult to guarantee results
Keys to avoid problem
» ensure that patient understand the limitations and
what is involved in keeping the enhanced look for as
long as possible
» document patient’s appearance before treatment
(intraoral camera, photo, shade guide, reference pt)