ORIGINAL ARTICLE / ORIGINALNI RAD

Serbian Dental Journal, vol. 57, No 4, 2010

UDC: 616.314-083:615.242

DOI: 10.2298/SGS1004193S

The Effect of Bleaching Agents on Human Enamel

Microhardness
Tatjana Savi-Stankovi, Branislav Karadi
Department of Restorative Dentistry and Endodontics, School of Dentistry, University of Belgrade, Belgrade, Serbia
SUMMARY

Introduction Bleaching agents can cause alteration of hard tissues of the tooth. The aim of this study was to evaluate
the effect of two different concentrations of carbamide peroxide (10% and 35%) on human enamel microhardness.
Material and Methods The study was conducted on ten extracted teeth divided into two groups. The teeth were
sectioned in mesiodistal direction using the diamond disc in order to obtain experimental and control samples. First
group was exposed to the concentration of 10% carbamide peroxide (Opalescence gel, Ultradent. Pro, US) at the
time intervals that corresponded to home night bleaching technique of vital teeth. Second group was exposed to
high concentration of 35% carbamide peroxide (Opalescence Quick, Ultradent. Pro, US) at the time intervals that
corresponded to the professional bleaching technique of vital teeth. Control samples were exposed to artificial saliva
for the same time intervals as the samples from experimental group. Knoops test for enamel microhardness was
performed at the beginning, after the first phase of therapy, after the therapy was completed and after three weeks
of exposure to artificial saliva. The results were statistically analyzed using analysis of variance (ANOVA) and Student
t-test.
Results The microhardness values of enamel samples treated with 10% carbamide peroxide decreased after 8 hours
(261 khn) and three weeks of treatment (222 khn) but increased after three weeks of exposure to artificial saliva (263
khn). The decrease of enamel microhardness of the samples treated with 10% carbamide peroxide was not statistically significant. The microhardness values of enamel samples treated with 35% carbamide peroxide were reduced
after 1 hour (235 khn) and 3 hours (190 khn) and increased after three weeks of exposure to artificial saliva (241 khn).
Microhardness of enamel treated with 35% carbamide peroxide was significantly decreased in experimental samples
compared to controls.
Conclusion Carbamide peroxide in concentration of 35% leads to the significant decrease in enamel microhardness
compared to 10% carbamide peroxide.
Keywords: urea peroxide; teeth bleaching; enamel microhardness

INTRODUCTION
For a long time, white teeth have been considered as an
indicator of health as well as an important factor of youth
and beauty. Looking for the conservative, the least aggres
sive and economically acceptable treatment, bleaching
teeth has become an important part of dental practice.
The first publication regarding vital teeth bleaching tech
niques by Haywood and Heymann [1] in 1989 has intro
duced a new approach in bleaching teeth. Nowadays,
the most frequently used bleaching agents are based on
hydrogen peroxide or carbamide peroxide. Carbamide
peroxide in concentration of 10-22% is the major agent
for bleaching vital teeth by home night technique, while
the concentration of 35% is used for professional bleach
ing of vital teeth in dental office. Carbamide peroxide in
situ decomposes into urea, ammonia, carbon dioxide,
water and hydrogen peroxide where the latter is the active
bleaching substance [2].
Bleaching agents have effect on chemical / physical and
morphological structure of enamel that must be taken
into account when this therapy is used. Several studies

have shown correlation between changes on the surface

of enamel (microhardness, structural changes) and the
concentration of bleaching agent [3, 4].
Past research concerning the effect of carbamide perox
ide on dental enamel during teeth bleaching has shown
significant contradictions [5-8]. Some studies claim that
changes in enamel structure are minor and return to the
original level after bleaching is completed while others
declare the opposite. Ferreira et al. [9] found that contact
between bleaching gel (pH 5.5) and enamel in a short
period of time (not longer than 30 minutes) does not lead
to changes in enamel microhardness. On the contrary, the
studies of Rotstein et al. [4], Leonard et al. [10], Attin et al.
[11] and many others reported a significant reduction in
microhardness of enamel even after the period of remin
eralization. Recent study of Basting et al. [12] showed a
significant decrease in microhardness of enamel after
application of 10% carbamide peroxide for 8 hours per
day during 42 days. The value of microhardness returned
to the initial level after remineralization period of 7 days.
Research done by Araujo et al. [13] indicated significant
reduction of enamel microhardness after application of

Address for correspondence: Tatjana SAVI-STANKOVI, Department for Restorative Dentistry and Endodontics,
School of Dentistry, 4 Rankeova St., 11000 Belgrade, Serbia; tanjeze@gmail.com

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Savi-Stankovi T. and Karadi B. The Effect of Bleaching Agents on Human Enamel Microhardness

10% carbamide peroxide for 1 hour or 7 hours per day

during three weeks in both cases. Smidt et al. found lesser
reduction of enamel microhardness after exposure to 10%
carbamide peroxide gels (6 hours per day during 16 days)
with a pH range from 4.3 to 5.5 [14].
The effect of bleaching products based on high concen
trations of carbamide peroxide (35%) and hydrogen perox
ide (30 to 38%) used in dental office (power bleaching)
on biomechanical characteristics of enamel was also eval
uated. These concentrations are normally used either as a
separate technique or in combination with at home night
bleaching technique. Carbamide peroxide in the concen
tration of 35% is the highest concentration available at the
market and it corresponds to 11.4% of hydrogen perox
ide solution. The research performed by Sulieman et al.
[15] did not observe a significant change in microhard
ness of enamel after application of 35% carbamide perox
ide for 30 minutes. The studies done by Attin et al. [11]
and Lewinstein et al. [16] indicated a significant reduc
tion of enamel microhardness after the treatment with
35% of hydrogen peroxide or 35% of carbamide perox
ide fully recovered after the application of 0.05% fluo
ride solution. Numerous studies reported different levels
of enamel microhardness reduction after application of
35% carbamide peroxide [3, 17-20].
The aim of this study was to examine the effect of carb
amide peroxide products in two different concentrations
on enamel microhardness.
MATERIAL AND METHODS
Ten intact, noncarious premolars and third molars extracted
for orthodontic indications were used in the study. The
teeth were divided into two groups of 5 teeth. After extrac
tion, the teeth of both groups were immersed in distilled
and deionized water at 37C in order to prevent dehydra
tion. The teeth were cleaned in an ultrasonic bath 3 times
for 15 minutes. Prior to experiment the teeth were stored
in artificial saliva in a water bath at the temperature of
37C for 24 hours. Using a low speed diamond disc the
root was cut 2-3 mm from the enamel-cement junction
in apical direction. The teeth were sectioned in mesio
distal direction using a diamond disc (Brasseler Gebr. &
COMET, Germany) at low speed giving the two halves, one
was experimental and one was control sample. Each half
was embedded into autopolymerizing acrylate (Simgal-R,
Galenika) using a cylindrical plastic mold with the diame
ter of 3 cm. The vestibular side (the enamel) was exposed.
Outer surface of enamel was flattened using water-cooling
discs (Minnesota Mining & MFG.Co.3M) of 180, 320 and
600 micron fineness. This procedure provided the parallel
area of about 9 mm2 to measure microhardness by Knoops
test. For the teeth halves from the first group which were
subjected to 10% carbamide peroxide, ten individual trays
were made before the treatment in order to simulate the
situation in the mouth. A tray was made of flexible ethyl
vinyl acetate polymer having 0.9 mm thickness (Soft-Tray,
Ultradent Product. Inc). For each tooth the tray was made
separately using a Vacuum former (Ultradent. Pro, US).

Experimental halves from the first group were

subjected to 10% carbamide peroxide solution (pH 6.5)
(Opalescence gel, Ultradent. Pro, US) for the time inter
vals that corresponded to the clinical application of homenight vital teeth bleaching technique (manufacturers
recommendation). Their corresponding control halves
were exposed to the artificial saliva for the same time
intervals. All samples were immersed in tested bleaching
agent and artificial saliva (experimental and control) for 8
hours during three weeks. Each half was covered with the
tray and placed in a covered container containing artifi
cial saliva (pH 7.0) at 37C. After 8 hours, the halves were
removed and rinsed with distilled unionized water for 5
seconds. During the remaining 16 hours (during the day),
the fragments were immersed in separate closed contain
ers with artificial saliva (pH 7.0) at 37C. Artificial saliva in
the containers was changed every third day. After comple
tion of the treatment (21 days), experimental and control
halves were stored in artificial saliva only, for three weeks.
Knoops microhardness test for experimental and control
halves was done at the beginning of the experiment, after
8 hours, after three weeks of the treatment (21 days) and
after three weeks of storage in artificial saliva, respectively.
Experimental halves from the second group were treated
with 35% carbamide peroxide (pH 6.0) (Opalescence
Quick, Ultradent. Pro, US) at intervals corresponding to
the clinical application for vital teeth bleaching method
in dental office while the control halves were subjected
to artificial saliva for the same time intervals. The teeth
halves were exposed to the tested bleaching agent and
artificial saliva (experimental and control) for 60 minutes
every second day (three times a week). For the remaining
time, they were stored in containers with artificial saliva
(pH 7.0) at 37C. Knoops microhardness test was evalu
ated at the beginning, after 60 minutes of the treatment,
following the series of three times of 60 minutes (at the
end of the treatment) and after three weeks of storage in
artificial saliva.
Three measurements in the middle third of the crown
with a load of 50 grams during 30 seconds were performed
for all samples from the first and the second group using
the device Leitz Wetzlar 7569 (Germany). Statistical anal
ysis was done using the analysis of variance (ANOVA) and
Student t-test for independent samples.
RESULTS
The mean value of microhardness for the experimen
tal samples exposed to 10% carbamide peroxide at the
beginning of measurements was 273.08 khn, after 8h of
exposure 261.06 khn, after three weeks of the treatment
microhardness decreased to 222.15 khn. After the period
of three weeks of exposure to artificial saliva, microhard
ness of enamel increased to 262.53 khn (Table 1). Changes
in microhardness for the experimental samples were not
statistically significant (F=0.670; p>0.05).
The average values of microhardness for the control
samples were fairly consistent during the experiment. The
difference in microhardness values between the experi

Stomatoloki glasnik Srbije. 2010;57(4):193-200

Table 1. The average values of microhardness of experimental (E) and control (C) samples exposed to 10% carbamide peroxide
Tabela 1. Srednje vrednosti mikrotvrdoe eksperimentalnih (E) i kontrolnih (K) uzoraka izlaganih karbamid-peroksidu u koncentraciji od 10%
Value
Vrednost
X
SE
SD
Variance
Varijansa

Beginning
Poetak
E
273.08
33.56
75.04

C/K
285.34
25.07
56.07

After 8 hours of therapy

Posle osam sati terapije
E
C/K
261.06
280.85
30.46
24.69
68.12
55.20

5631.35

3143.54

4640.31

3047.54

After three weeks of therapy

Posle tri nedelje terapije
E
C/K
222.15
282.87
18.97
24.31
42.41
54.35
1798.63

2953.73

Remineralization
Remineralizacija
E
C/K
262.53
281.88
23.84
22.80
53.30
50.99
2841.06

2599.52

ANOVA: F=0.660; p>0.05

X average value; SE standard error; SD standard deviation
X srednja vrednost; SE standardna greka; SD standardna devijacija

Table 2. The average values of mic rohardness of experimental (E) and control (C) samples exposed to 35% carbamide peroxide
Tabela 2. Srednje vrednosti mikrotvrdoe eksperimentalnih (E) i kontrolnih (K) uzoraka izlaganih karbamid-peroksidu u koncentraciji od 35%

E
261.00
6.00
13.42

C/K
262.60
10.47
23.41

E
234.60
6.90
15.42

C/K
261.80
8.62
19.28

After 3 times per

60 minutes of therapy
Posle tri puta po
60 minuta terapije
E
C/K
190.00
262.60
5.83
10.47
13.04
23.41

180.00

547.80

237.80

371.70

170.00

Beginning
Poetak

Value
Vrednost
X
SE
SD
Variance
Varijansa

After 1 hour of therapy

Posle jednog sata terapije

547.80

Remineralization
Remineralizacija
E
241.20
4.00
8.96

C/K
260.80
9.83
21.98

80.20

483.20

t=5.139; p<0.05
ANOVA (E:C/K): F=4.434; p<0.05

mental and the control samples was not statistically signif

icant (F=0.660; p>0.05).
The mean value of microhardness for the experimen
tal samples exposed to 35% carbamide peroxide at the
beginning of the experiment was 261.00 khn, after 1 hour
of exposure to the bleaching gel decreased to 234.60 khn
while after three hours it was 190.00 khn. After three
weeks of storage in the artificial saliva, microhardness of
the samples increased to 241.20 khn (Table 2). The great
est difference in microhardness values was found between
the initial values and the values of microhardness after 3
hours of the treatment (t=5.139; p<0.05).
The average values of microhardness for the control
samples were approximately the same during the experi
ment. The difference in microhardness of the experimen
tal and the control samples after the treatment using 35%
carbamide peroxide was statistically significant (F=4.434;
p<0.05).
The difference in the microhardness of the experimen
tal and the control samples after a period of remineraliza
tion was not statistically significant.
DISCUSSION
Hardness of solid substances can be determined by static,
dynamic and special methods. Static methods by Knoop
and Vickers are used to measure microhardness of hard
dental tissues. The force exerted on a test indenter gradu
ally increases to the maximum value [21]. Knoops test for
microhardness has been adopted as one of the main exper
imental methods for the analysis of changes in enamel and
dentin physical properties after exposure to various agents.
That was the reason for its use in current study [3, 5, 6].

The most valid results for the detection of enamel phys

ical properties alteration caused by different bleaching
agents can be obtained from in vivo research. Buffering
potential of saliva can not be ignored as well as its specific
remineralization effect. The composition of saliva is vari
able during the day making difficult to simulate physio
logical conditions in the experimental setup [11].
During the process of bleaching, hydrogen peroxide
diffuses through the organic matrix of enamel. Hydrogen
peroxide is oxidative agent and has ability to produce
highly reactive peroxide and superoxide ions. Although
bleaching is a complex process, the main reaction is oxida
tion [22]. Molecular changes occur within the organic
matter of hard tissues [4]. As a result of oxidation of the
enamel organic and inorganic substance, the enamel
matrix is dissolved and various side effects come out. The
side effects appear as decrease in enamel microhardness
and change of enamel morphological characteristics [23].
The effect of bleaching is directly dependent on exposure
time and concentration of bleaching agent. Longer the
period of exposure and the concentration of bleaching
agent, a color change will be more pronounced. However,
longer the oxidation process causes greater effects on hard
tissue [19, 20, 21]. The impact of bleaching agents on
possible side effects depends also on pH of the agent as
well as on the quality of dental hard tissues [24].
The current study found changes in microhardness of
the treated enamel surface after application of carbamide
peroxide in higher concentrations. Observed difference in
enamel microhardness values is most probably result of
different concentrations of bleaching agents and exposure
times. The load (force), the diameter of diamond indenter
and the indentation time were strictly controlled and stan
dardized. In addition, bleaching agents used in this study

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Savi-Stankovi T. and Karadi B. The Effect of Bleaching Agents on Human Enamel Microhardness

had pH values above the critical for the demineralization

of enamel. The results of this study also showed that there
was no statistically significant reduction of microhardness
after treatment with 10% carbamide peroxide. This can be
explained by the fact that it is very low concentration of
carbamide peroxide which breaks down onto 7% urea and
3% hydrogen peroxide after contact with the saliva and
oral fluid. Hydrogen peroxide further breaks onto water
and nascent free oxygen [1]. After keeping samples in arti
ficial saliva, there was an increase in microhardness which
can be associated to remineralization effect of saliva [25].
Results of the current study are consistent to the results
of Murchison, Nathoo, Seghi, Unlu et al. [5-8], who
reported that microhardness of enamel remained the same
after applying 10% carbamide peroxide. Results from our
study are partially consistent to the study of Basting et al.
who reported a significant reduction of enamel micro
hardness after application of 10% carbamide peroxide but
also upturn of the value after remineralization period of 7
days [22]. The reason for inconsistent results could be the
fact that in their study the treatment lasted much longer
(42 days).
In the current study, the effect of 35% carbamide perox
ide on microhardness of enamel was significantly reduced
after completion of the treatment (after 3 hours). A signif
icant reduction in microhardness after completion of the
treatment can be explained by the fact that 35% carb
amide peroxide corresponds to 11.4% solution of hydro
gen peroxide (the rest is urea) and it is still much higher
concentration compared to 3% of hydrogen peroxide.
Enamel microhardness values of the experimental samples
returned to its original value after three weeks storage in
artificial saliva. Since there was no significant difference
between the control and the experimental samples and the
values of microhardness returned after a period of remin
eralization it was an indication that enamel was completely
recovered. Reaching the initial values of microhardness
can be explained by remineralization effect of the saliva.
Our results are also consistent to the results of Attin et al.
[11] and Lewinstein et al. [16], who showed a significant
decrease in microhardness of enamel after the treatment
with 35% carbamide peroxide. The results of the current
study are partially in agreement with the results of Attin et
al. [19] and Oltu et al. [26] since they reported a significant
reduction of enamel microhardness after the treatment
completion which was not returned to the initial level
after the period of remineralization. Their findings were
explained by the fact that the samples were kept briefly in
artificial saliva (5 days) after the treatment completion.
Inconsistent data obtained from different studies
regarding the effect of bleaching agents on enamel micro
hardness is the consequence of different methodologies
used in research. This is especially true for the study of
Attin et al. [19], who used enamel from bovine teeth. It is
known that bovine enamel has three times faster progres
sion of the lesions compared to human enamel. Oltu et al.
[26] also showed a significant decrease of enamel micro
hardness value after exposure to 35% carbamide peroxide
which did not reach the initial level after expected period
of remineralization. Given that previous studies reported

the contradictory data regarding the effect of different

concentrations of carbamide peroxide on the mechan
ical properties of enamel, further research is required.
CONCLUSION
Based on the results from the current study it can be
concluded that carbamide peroxide in the concentra
tion of 10% does not affect the microhardness of enamel,
while the concentration of 35% significantly reduces the
enamel microhardness.
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Received: 04/08/2010 Accepted: 05/11/2010

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Savi-Stankovi T. and Karadi B. The Effect of Bleaching Agents on Human Enamel Microhardness

Uticaj preparata za izbeljivanje zuba na mikrotvrdou glei

Tatjana Savi-Stankovi, Branislav Karadi
Klinika za bolesti zuba i endodonciju, Stomatoloki fakultet, Univerzitet u Beogradu, Beograd, Srbija

KRATAK SADRAJ

Uvod Sredstva koja se koriste za izbeljivanje zuba mogu da dovedu do promena na tvrdim zubnim tkivima. Cilj ovog rada je bio da
se ispita efekat dve koncentracije (10% i 35%) karbamid-peroksida, sredstva za izbeljivanje zuba, na mikrotvrdou glei.
Materijal i metode rada Istraivanje je obavljeno na 10 ekstrahovanih zuba podeljenih u dve grupe. Svi zubi su preseeni dija
mantskim diskom u meziodistalnom pravcu, kako bi se dobili eksperimentalni i kontrolni uzorci. Prva grupa je izlagana koncen
traciji od 10% karbamid-peroksida (Opalescence gel, Ultradent. Pro, US) u vremenskim intervalima koji odgovaraju primeni tzv.
kuno-none tehnike beljenja vitalnih zuba. Druga grupa je izlagana koncentraciji od 35% karbamid-peroksida (Opalescence Qu
ick, Ultradent. Pro, US) u vremenskim intervalima koji odgovaraju primeni ambulantne tehnike beljenja vitalnih zuba. Kontrolni
uzorci su izlagani vetakoj pljuvaki u istim vremenskim intervalima kao i eksperimentalne polovine. Knopov (Knoop) test mere
nja mikrotvrdoe glei primenjen je na poetku, posle prve faze terapije, na kraju terapije i posle tri nedelje izloenosti vetakoj
pljuvaki. Rezultati su statistiki obraeni primenom analize varijanse (ANOVA) i Studentovog t-testa.
Rezultati Vrednosti mikrotvrdoe glei eksperimentalnih uzoraka tretiranih desetoprocentnim rastvorom karbamid-peroksida
se smanjuju nakon osam sati (261 khn) i nakon tri nedelje tretmana (222 khn), a poveavaju posle tri nedelje izloenosti vetakoj
pljuvaki (263 khn). Izmereno smanjenje vrednosti mikrotvrdoe za gle koja je tretirana ovom koncentracijom karbamid-perok
sida nije bilo statistiki znaajno. Vrednosti mikrotvrdoe glei eksperimentalnih uzoraka tretiranih tridesetpetoprocentnim ras
tvorom karbamid-peroksida se smanjuju nakon jednog sata (235 khn) i tri sata (190 khn), a poveavaju posle tri nedelje izloenosti
vetakoj pljuvaki (241 khn). Smanjenje vrednosti mikrotvrdoe za gle koja je tretirana ovom koncentracijom karbamid-perok
sida bilo je statistiki znaajno i u okviru grupe eksperimentalnih uzoraka i u odnosu na kontrolne uzorke.
Zakljuak Karbamid-peroksid u koncentraciji od 35% dovodi do znaajnog smanjenja mikrotvrdoe glei u odnosu na efekat de
setoprocentnog rastvora karbamid-peroksida.
Kljune rei: karbamid-peroksid; beljenje zuba; mikrotvrdoa glei

UVOD
Boja ili belina zuba, kao svojevrsni indikator zdravlja, ujedno
je i veoma vaan faktor mladosti i lepote. U potrazi za to kon
zervativnijim, najmanje agresivnim i ekonomski prihvatljivim
tretmanom, beljenje zuba je postalo jedna od vanih opcija u
stomatolokoj praksi. Prvi opis tehnike izbeljivanja vitalnih zu
ba, koji su 1989. godine objavili Hejvud (Haywood) i Hejman
(Heymann) [1], otvorio je novo poglavlje u pristupu tretmana
diskolorisanih zuba. Danas se na tritu uglavnom nalaze ma
terijali za izbeljivanje zuba iju aktivnu supstancu ini vodonikperoksid ili karbamid-peroksid. Karbamid-peroksid u koncen
traciji od 10% do 22% osnovni je agens u primeni tzv. kunonone tehnike izbeljivanja vitalnih zuba, dok se u koncentraciji
od 35% primenjuje za ambulantno izbeljivanje. Karbamid-pe
roksid se in situ razlae na ureu, amonijak, ugljen-dioksid, vo
du i vodonik-peroksid, koji je aktivna supstanca [2].
Sredstva za izbeljivanje zuba stvaraju i promene u hemijskofizikoj i morfolokoj strukturi glei, pa se i to mora uzeti u ob
zir prilikom ovog terapijskog postupka. Istraivanja pokazuju
da postoji bliska veza izmeu promena na povrini glei (pro
mene mikrotvrdoe, strukturne promene povrine) i koncen
tracije sredstava za izbeljivanje [3, 4].
Dosadanja istraivanja uticaja karbamid-peroksida na gle
tokom izbeljivanja zuba pokazuju znaajne kontradiktornosti [58]. Rezultati ukazuju na to da su eventualne promene neznatne
i da se vraaju na prvobitni nivo nakon prestanka terapije, dok
drugi nalazi govore suprotno. Fereira (Ferreira) i saradnici [9]
su u svom istraivanju pokazali da kontakt glei sa gelom za
izbeljivanje (pH 5,5) u kratkom vremenskom periodu (ne du
em od 30 minuta) ne dovodi do promena u mikrotvrdoi. S

druge strane, istraivanja Rottajna (Rotstein) i saradnika [4],

Leonarda (Leonard) i saradnika [10], Atina (Attin) i saradnika
[11] i drugih autora ukazuju na to da postoji znaajno smanje
nje mikrotvrdoe glei zuba i nakon perioda remineralizacije.
Novija istraivanja Bastingove (Basting) i saradnika [12] takoe
ukazuju na znaajno smanjenje mikrotvrdoe glei nakon pri
mene desetoprocentnog rastvora karbamid-peroksida u traja
nju od osam sati dnevno tokom 42 dana. Ove vrednosti se po
sle perioda remineralizacije od sedam dana vraaju na poetni
nivo. Istraivanja Arauha (Araujo) i saradnika [13] su ukaza
la na znaajno smanjenje mikrotvrdoe glei nakon primene
desetoprocentnog rastvora karbamid-peroksida u trajanju od
jednog sata ili sedam sati dnevno tokom tri nedelje u oba slu
aja. mit (Smidt) i saradnici [14] su pokazali da je smanjenje
mikrotvrdoe glei manje nakon izlaganja zuba karbamid-pe
roksidu u koncentraciji od 10% (est sati dnevno tokom 16 da
na) gelovima iji je pH u opsegu od 4,3 do 5,5.
Efekat visokih koncentracija preparata na bazi karbamidperoksida (35%) i vodonik-peroksida (30-38%), koje se kori
ste u ambulantnim uslovima beljenja zuba (engl. power bleac
hing), takoe je proveravan u funkciji promene biomehanikih
osobina glei. Ove koncentracije se inae koriste ili kao zaseb
na tehnika, ili u kombinaciji sa kuno-nonom tehnikom izbe
ljivanja. Koncentracija od 35% karbamid-peroksida je najvea
na tritu, a odgovara koncentraciji od 11,4% rastvora vodonikperoksida. U istraivanju Sulimana (Sulieman) i saradnika [15]
nije naena znaajna promena mikrotvrdoe glei nakon pri
mene tridesetpetoprocentnog rastvora karbamid-peroksida to
kom 30 minuta. Istraivanja Atina i saradnika [11] i Levintaj
na (Lewinstein) i saradnika [16] ukazuju na znaajno smanje
nje mikrotvrdoe glei nakon tretmana koncentracijom od 35%

Stomatoloki glasnik Srbije. 2010;57(4):193-200

vodonik-peroksida ili karbamid-peroksida, koja se potpuno vra

a nakon tretmana sa 0,05% rastvora fluorida [11, 16]. Postoji
veliki broj studija koje ukazuju na razliite vrednosti smanje
nja mikrotvrdoe glei posle primene tridesetpetoprocentnog
rastvora karbamid-peroksida [3, 17-20].
Cilj ovog rada je bio da se ispita efekat dve razliite koncentra
cije preparata karbamid-peroksida na mikrotvrdou glei zuba.
MATERIJAL I METODE RADA
U eksperimentu je korieno deset izniklih intaktnih nekarije
snih premolara i treih molara izvaenih iz ortodontskih razlo
ga. Zubi su svrstani u dve grupe od po pet zuba. Ekstrahovani
zubi prve i druge grupe su, radi spreavanja dehidratacije, po
sle vaenja potapani u destilovanu i dejonizovanu vodu na 37C.
Potom su premeteni u ultrazvuno kupatilo i ieni tri puta po
15 minuta. Neposredno pre izvoenja eksperimenta uvani su u
vetakoj pljuvaki u vodenom kupatilu na temperaturi od 37C
24 asa. Dijamantskim diskom i niskoturanim motorom sa sva
kog zuba je uklonjen koren 2-3 mm apikalno od gleno-cement
ne granice. Zubi su potom iseeni u meziodistalnom pravcu di
jamantskim diskom (Gebr. Brasseler & KOMET, Germany) i ni
skoturanim motorom ime su dobijena dva dela od kojih je je
dan bio eksperimentalni a drugi kontrolni. Svaki deo je zatim
uloen u autopolimerizujui akrilat (Simgal-R, Galenika), u ci
lindrine plastine kalupe prenika od 3 cm, tako da je vestibu
larna strana (gle) bila slobodna. Spoljanja povrina zubne gle
i je poravnata vodeno-hlaenim diskovima (Minnesota Mining
& MFG.Co.3M) finoe od 180, 320 i 600 m. Ovaj postupak je
obezbedio paralelne povrine od oko 9 mm2 za merenje mikro
tvrdoe Knopovim (Knoop) testom. Za delove zuba prve grupe,
koji su izlagani desetoprocentnom rastvoru karbamid-peroksi
da, pre poetka tretmana napravljeno je deset pojedinanih tre
jeva, kako bi se simulirala situacija u ustima. Trej je bio napra
vljen od fleksibilnog etil-vinil acetatnog polimera debljine 0,9
mm (Soft-Tray, Ultradent Product. Inc) za svaki zub pojedina
no u vakuum-formeru (Ultradent. Pro, US).
Eksperimentalni delovi zuba prve grupe izlagani su karba
mid-peroksidu (pH 6,5) u koncentraciji od 10% (Opalescence
gel, Ultradent. Pro, US) u intervalima koji odgovaraju klinikoj
primeni kuno-none tehnike izbeljivanja vitalnih zuba (pre
poruka proizvoaa). Njihove odgovarajue kontrolne polovi
ne su u istim vremenskim intervalima izlagane vetakoj plju
vaki. Svi uzorci zuba su potapani u sredstvo i vetaku plju
vaku u trajanju od osam sati tokom tri nedelje, tako to je sva
ki deo prekriven trejem i postavljen u zatvorenu posudu s ve
takom pljuvakom (pH 7,0) na 37C. Posle osam sati vaeni
su iz posudica i ispirani destilovanom nejonizovanom vodom
pet sekundi. Za vreme preostalih 16 sati (tokom dana) uzorci
su potapani u zasebne zatvorene posude s vetakom pljuva
kom (pH 7,0) na 37C. Vetaka pljuvaka u kontejnerima je
menjana svakog treeg dana. Po zavretku tretmana (21 dan)
uzorci obe grupe su uvani samo u vetakoj pljuvaki tri nede
lje. Knopov test mikrotvrdoe i eksperimentalnih i kontrolnih
uzoraka je primenjen na poetku eksperimenta, nakon osam
sati i posle tri nedelje tretmana, odnosno posle tri nedelje sta
janja u vetakoj pljuvaki.
Eksperimentalni delovi zuba druge grupe tretirani su karba
mid-peroksidom (pH 6,0) u koncentraciji od 35% (Opalescence

Quick, Ultradent. Pro, US) u vremenskim intervalima koji odgo

varaju klinikoj primeni ambulantnog izbeljivanja vitalnih zu
ba, a kontrolne polovine u istim vremenskim intervalima izla
gane su vetakoj pljuvaki. Svi uzorci su izlagani agensu i ve
takoj pljuvaki tokom 60 minuta svaka dva dana (tri puta ne
deljno). Preostalo vreme su skladiteni u posude s vetakom
pljuvakom (pH 7,0) na 37C. Knopovim testom je proverava
na mikrotvrdoa: na poetku, nakon 60 minuta tretmana, po
sle serije od tri puta po 60 minuta (kraj terapije) i posle tri ne
delje stajanja u vetakoj pljuvaki.
Za sve uzorke obe grupe vrena su tri merenja u srednjoj tre
ini krunice zuba s optereenjem na svakom delu zuba od 50 g
30 sekundi na aparatu Leitz Wetzlar 7569 (Germany). Za stati
stiku obradu podataka primenjeni su analiza varijanse (ANO
VA) i Studentov t-test za nezavisne uzorke.
REZULTATI
Srednja vrednost mikrotvrdoe eksperimentalnih uzoraka izla
ganih desetoprocentnom rastvoru karbamid-peroksida na po
etku merenja bila je 273,08 khn, nakon osam sati 261,06 khn,
da bi se posle tri nedelje tretmana smanjila na 222,15 khn, dok
se posle perioda izlaganja vetakoj pljuvaki u trajanju od tri
nedelje poveala na 262,53 khn (Tabela 1). Promene mikrotvr
doe eksperimentalnih uzoraka nisu bile statistiki znaajne
(F=0,670; p>0,05).
Srednje vrednosti mikrotvrdoe kontrolnih uzoraka bile su
prilino ujednaene tokom eksperimenta. Razlike u vrednosti
ma mikrotvrdoe izmeu eksperimentalnih i kontrolnih uzora
ka nisu bile statistiki znaajne (F=0,660; p>0,05).
Srednja vrednost mikrotvrdoe eksperimentalnih uzoraka
izlaganih tridesetpetoprocentnom rastvoru karbamid-perok
sida na poetku eksperimenta bila je 261,00 khn, nakon jed
nog sata izlaganja gelu smanjila se na 234,60 khn, a posle tri sa
ta na 190,00 khn, da bi se posle tri nedelje stajanja u vetakoj
pljuvaki poveala na 241,20 khn (Tabela 2). Najvea razlika u
vrednostima mikrotvrdoe uoena je izmeu poetnih i vred
nosti posle tri sata tretmana (t=5,139; p<0,05).
Srednje vrednosti mikrotvrdoe kontrolnih uzoraka su i ov
de bile priblino istih vrednosti tokom trajanja eksperimenta.
Razlike u vrednostima mikrotvrdoe eksperimentalnih i kon
trolnih uzoraka posle tretmana karbamid-peroksidom u kon
centraciji od 35% bile su statistiki znaajne (F=4,434; p<0,05).
Razlike u vrednostima mikrotvrdoe eksperimentalnih i
kontrolnih uzoraka nakon perioda remineralizacije nisu bile
statistiki znaajne.
DISKUSIJA
Tvrdoa vrstih supstanci moe se odrediti statikim, dinami
kim i specijalnim metodama. Statike metode po Knopu i Vi
kersu (Vickers) koriste se za merenje mikrotvrdoe vrstih zub
nih tkiva, a sila ispitivanja koja deluje na utiskiva postepeno
se poveava do maksimalne vrednosti [21]. Knopov test tvrdo
e je usvojen kao jedan od osnovnih eksperimentalnih metoda
za analizu fizikih promena glei i dentina nakon dejstva raz
liitih agensa, to je bio i glavni razlog da se primeni u ovom
istraivanju [3, 5, 6].

199

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Savi-Stankovi T. and Karadi B. The Effect of Bleaching Agents on Human Enamel Microhardness

Najvalidniji rezultati fizikih promena glei pod dejstvom

razliitih agensa za izbeljivanje mogu se dobiti istraivanjem u
uslovima in vivo. Puferski potencijal pljuvake se ne moe zane
mariti, a pogotovo ne njen remineralizacioni efekat. Sastav plju
vake se esto menja u toku samo jednog dana, to znatno otea
va simulaciju fiziolokih uslova u eksperimentalnoj sredini [11].
Tokom procesa izbeljivanja zuba vodonik-peroksid difundu
je kroz organski matriks glei. Vodonik-peroksid je oksidacio
ni agens i ima sposobnost da proizvodi slobodne radikale per
hidroksilni i superoksidni jon, koji su veoma reaktivni. Iako je
izbeljivanje zuba sloen proces, glavna reakcija je reakcija ok
sidacije [22]. Tokom ovog procesa dolazi do molekularnih pro
mena u okviru organske strukture tvrdih zubnih tkiva [4]. Kao
posledica oksidacije organskog i neorganskog sastava glei ras
tvara se gleni matriks i javljaju se sporedni efekti. Oni se ogle
daju u promeni mikrotvrdoe glei i njenih morfolokih osobi
na [23]. Efekat izbeljivanja direktno zavisi od vremena izlaga
nja sredstvu za beljenje i njegove koncentracije. to je dui pe
riod izlaganja i koncentracija sredstva za izbeljivanje vea, to je
promena boje izrazitija, ali je i proces oksidacije dui, pa tako
i njegov efekat na tvrda zubna tkiva [19, 20, 21]. Dejstvo mate
rijala za izbeljivanje (u smislu pojave sporednih efekata) tako
e zavisi od pH vrednosti sredstva za beljenje, ali i od kvaliteta
tvrdih zubnih tkiva [24].
Rezultati ovog istraivanja su pokazali promene u mikro
tvrdoi tretirane glei nakon primene vee koncentracije kar
bamid-peroksida. Uoene razlike u vrednostima mikrotvrdo
e glei verovatno su posledica razliitih koncentracija agensa
za izbeljivanje, odnosno trajanja njihove primene, budui da su
optereenje (sila), prenik dijamantnog utiskivaa i vreme uti
skivanja bili strogo kontrolisani i standardizovani. Osim toga,
preparati koji su korieni u ovom istraivanju imaju pH vred
nosti koje su iznad kritinih za demineralizaciju glei. Rezulta
ti su takoe pokazali da nije dolo do statistiki znaajnog sma
njenja mikrotvrdoe posle primene desetoprocentnog rastvo
ra karbamid-peroksida. Ovo se moe objasniti injenicom da je
re o veoma niskoj koncentraciji karbamid-peroksida, koja se
u kontaktu s pljuvakom i tenostima u ustima razlae na sed
moprocentnu ureu i troprocentni vodonik-peroksid, a dalje na
vodu i slobodni nascentni kiseonik [1]. Posle uvanja uzora
ka u vetakoj pljuvaki mikrotvrdoa glei se poveala, to se
dovodi u vezu s remineralizacionim dejstvom pljuvake [25].
Dobijeni nalazi su u skladu s rezultatima istraivanja Mar
isona (Murchison) i saradnika [5], Natoa (Nathoo) i saradni
ka [6], Senjija (Seghi) i Denrija (Denry) [7] i Unlua (Unlu) i sa
radnika [8], koji takoe nisu uoili promene mikrotvrdoe gle
i nakon primene desetoprocentnog rastvora karbamid-perok
sida. Ovi rezultati su delimino u skladu i sa istraivanjem Ba
stingove (Basting) i saradnika [22], koji su ustanovili znaajno

smanjenje mikrotvrdoe glei posle primene ove koncentraci

je karbamid-peroksida, ali i vraanje ovih vrednosti posle re
mineralizacije od samo sedam dana. Razlog za ove razlike u re
zultatima mogao bi da lei u injenici da je tretman trajao znat
no due 42 dana.
Analiza dejstva karbamid-peroksida u koncentraciji od 35%
na mikrotvrdou glei u ovom istraivanju ukazuje na njeno
znaajno smanjenje po zavretku tretmana (posle tri sata). Ovo
smanjenje se moe objasniti injenicom da karbamid-peroksid
u ovoj koncentraciji odgovara rastvoru vodonik-peroksida od
11,4% (ostatak ini urea), to je ipak via koncentracija vodo
nik-peroksida u odnosu na troprocentni rastvor. Vrednosti mi
krotvrdoe glei eksperimentalnih uzoraka su se posle tri nede
lje stajanja u vetakoj pljuvaki vratile na poetne. S obzirom
na to da nije zabeleena znaajna razlika izmeu kontrolnih i
eksperimentalnih uzoraka, te da su se vrednosti mikrotvrdoe
glei nakon perioda remineralizacije vratile na poetne, moe
se rei da se gle potpuno oporavila. Dostizanje vrednosti mi
krotvrdoa do poetnog nivoa moe se objasniti remineraliza
cionim efektom pljuvake. Dobijeni nalazi su u skladu s rezul
tatima istraivanja Atina i saradnika [11] i Levintajna i sarad
nika [16], a delimino i u saglasnosti s rezultatima druge stu
dije Atina [19] i istraivanja Oltua (Oltu) i saradnika [26], ko
ji su uoili znaajno smanjenje mikrotvrdoe glei nakon pre
stanka tretmana, koja se nakon perioda oekivane reminerali
zacije nije vratila na poetni nivo. Oni ovo tumae injenicom
da su uzorci po zavretku tretmana kratko uvani u vetakoj
pljuvaki (pet dana).
Razliiti podaci o promeni mikrotvrdoe glei posle prime
ne sredstava za izbeljivanje dobijeni u drugim studijama posle
dica su primene razliitih metodologija istraivanja. Ovo se po
sebno odnosi na studiju Atina i saradnika [19] koja je izvedena
na goveoj glei, za koju se zna da ima tri puta bru progresiju
lezija u odnosu na gle kod ljudi. Oltu i saradnici [26] su tako
e ukazali na znaajno smanjenje mikrotvrdoe posle dejstva
karbamid-peroksida u koncentraciji od 35%, koje, i posle pe
rioda oekivane remineralizacije, nije dostigla poetni nivo. S
obzirom na to da su nalazi dosadanjih studija dejstva razliitih
koncentracija karbamid-peroksida na mehanika svojstva gle
i zuba oprena, neophodna su dalja istraivanja u ovoj obla
sti stomatologije.
ZAKLJUAK
Na osnovu dobijenih rezultata moe se zakljuiti da karba
mid-peroksid u koncentraciji od 10% ne utie na mikrotvrdo
u glei, dok koncentracija od 35% dovodi do njenog znaaj
nog smanjenja.