Tooth Whitening An Evidence Based Perspe

Jorge Perdigão
Editor
Tooth Whitening
An Evidence-Based
Perspective
123
Tooth Whitening
Jorge Perdigão
Editor
Tooth Whitening
An Evidence-Based Perspective
Editor
Jorge Perdigão
University of Minnesota
Minneapolis
USA
ISBN 978-3-319-38847-2 ISBN 978-3-319-38849-6 (eBook)

DOI 10.1007/978-3-319-38849-6
Library of Congress Control Number: 2016948412
© Springer International Publishing Switzerland 2016

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Preface
Our team started working on this project immediately after I finished editing and
writing the book Restoration of Root Canal-Treated Teeth: An Adhesive Dentistry
Perspective (Springer, 2016). As with the previous book, this new book project
made me feel truly blessed to have known so many talented colleagues from differ-
ent parts of the world. The countries represented in this book include Brazil,
Germany, Portugal, Spain, and the United States of America.
More interestingly, the coauthors of this book represent different generations of
dental professionals. We will not mention here how old the oldest authors are, but
the two youngest authors were born in 1987 and 1989. Dentistry is indeed an out-
standing global and beautiful vocation.
The driving force behind the current book was the need for a compilation of
independent evidence-based information on dental whitening. We have all fielded
questions from patients inquiring about different whitening methods, including
over-the-counter bleaching, as-seen-on-TV laser bleaching, shopping-mall bleach-
ing, and jump-start bleaching, just to mention a few. As a dental professional, I have
been asked about bleaching techniques that I had never heard before, mostly anec-
dotal, yet the patients had read all the details about these supposedly cutting-edge
methods online.
My ultimate goal is to contribute to a better understanding of dental whitening
and how we can improve its outcome based on the available evidence.
Thank you for reading.
Minneapolis, MN, USA Jorge Perdigão
v
Acknowledgments
My gratitude extends to all my current and former students, mentors, and teachers.
I am also fortunate to have worked in clinical and research projects with so many
gifted coworkers in so many countries. And I am extremely appreciative of my fam-
ily for their patience and support. We never quit.
Jorge Perdigão
vii
Contents
Part I Tooth Whitening with Peroxides
1 Introduction to Tooth Whitening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

So Ran Kwon
2 Tooth Whitening: How Does It Work . . . . . . . . . . . . . . . . . . . . . . . . . . 21
So Ran Kwon
3 Overall Safety of Peroxides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Yiming Li
4 Complications from the Use of Peroxides . . . . . . . . . . . . . . . . . . . . . . . 45
André Luiz Fraga Briso, Vanessa Rahal, Marjorie Oliveira
Gallinari, Diana Gabriela Soares, and Carlos Alberto de Souza Costa
5 Human Pulpal Responses to Peroxides . . . . . . . . . . . . . . . . . . . . . . . . . 81
Diana Gabriela Soares, Josimeri Hebling,
and Carlos Alberto de Souza Costa
Part II Current Techniques for Dental Whitening with Peroxides:

Evidence Supporting Their Clinical Use
6 At-Home Tooth Whitening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Jorge Perdigão, Alessandro D. Loguércio, Alessandra Reis,
and Edson Araújo
7 In-Office Whitening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Alessandro D. Loguercio, Leandro M. Martins, Luciana M. da Silva,
and Alessandra Reis
8 Intracoronal Whitening of Endodontically Treated Teeth . . . . . . . . . 169
Jorge Perdigão, Andressa Ballarin, George Gomes,
António Ginjeira, Filipa Oliveira, and Guilherme C. Lopes
ix
x Contents
Part III Enamel Etching Techniques for Improvement of Tooth Color
9 Enamel Microabrasion for Removal of Superficial Coloration

and Surface Texture Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Kevin J. Donly and Theodore P. Croll
10 Resin Infiltration After Enamel Etching . . . . . . . . . . . . . . . . . . . . . . . 211
Sebastian Paris and Hendrik Meyer-Lueckel
Part IV Clinical Application of Combined Techniques
11 Internal Whitening and At-Home Tray Whitening . . . . . . . . . . . . . . . 225

Andressa Ballarin, Guilherme C. Lopes, and Jorge Perdigão
12 At-Home Tray Whitening and Enamel Microabrasion . . . . . . . . . . . . . 233
Jorge Perdigão, Jennifer M. Homer, and Carmen Real
13 At-Home Tray Whitening and Resin Infiltration After
Acid Etching with HCl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
George Gomes, Filipa Oliveira, and Jorge Perdigão
14 At-Home Tray Whitening and Direct Resin-Based
Composite Restorations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
15 Restorative Options for Discolored Teeth . . . . . . . . . . . . . . . . . . . . . . . 257
Edson Araújo and Jorge Perdigão
Contributors
Edson Araújo Department of Dentistry, Federal University of Santa Catarina,

Campus Universitário, Florianópolis, SC, Brazil
Andressa Ballarin Private Practice, Florianópolis, SC, Brazil
André Luiz Fraga Briso Department of Restorative Dentistry, Araçatuba School
of Dentistry, Univ. Estadual Paulista (UNESP), Araçatuba, SP, Brazil
Theodore P. Croll Department of Developmental Dentistry, University of
Texas Health Science Center at San Antonio (School of Dentistry), San Antonio,
TX, USA
Private Practice, Pediatric Dentistry, Doylestown, PA, USA
Department of Pediatric Dentistry, University of Washington School of Dentistry,
Seattle, WA, USA
Luciana M. da Silva Department of Restorative Dentistry, Federal University of
Amazonas, Manaus, AM, Brazil
Carlos A. de Souza Costa Department of Physiology and Pathology, Araraquara
School of Dentistry, Univ. Estadual Paulista (UNESP), Araraquara, SP, Brazil
Kevin J. Donly Department of Developmental Dentistry, The University of
Texas Health Science Center at San Antonio (School of Dentistry), San Antonio,
TX, USA
Marjorie Oliveira Gallinari Department of Restorative Dentistry, Araçatuba
School of Dentistry, Univ. Estadual Paulista (UNESP), Araçatuba, SP, Brazil
António Ginjeira Department of Endodontics, University of Lisbon School of
Dentistry, Cidade Universitária, Lisbon, Portugal
George Gomes Post-Graduate Program is Esthetic Dentistry, Rey Juan Carlos
University, Madrid, Spain
Josimeri Hebling Department of Orthodontics and Pediatric Dentistry, Araquarara
Jennifer M. Homer Private Practice, Menomonee Falls, WI, USA
xi
xii Contributors
So Ran Kwon Center for Dental Research, Loma Linda University School of
Dentistry, Loma Linda, CA, USA
Yiming Li Center for Dental Research, Microbiology and Molecular Genetics,
Loma Linda University School of Dentistry, Loma Linda, CA, USA
Microbiology and Molecular Genetics, Loma Linda University School of Dentistry,
Loma Linda, CA, USA
Alessandro D. Loguércio Department of Dental Materials, State University of
Ponta Grossa, Ponta Grossa, PR, Brazil
Guilherme C. Lopes Department of Dentistry, Federal University of Santa
Catarina, Campus Universitário, Florianópolis, SC, Brazil
Leandro M. Martins Department of Restorative Dentistry, Federal University of
Amazonas, Manaus, AM, Brazil
Hendrik Meyer-Lueckel Department of Operative Dentistry, Periodontology and
Preventive Dentistry, RWTH Aachen University, Aachen, Germany
Filipa Oliveira Private Practice, Lisbon, Portugal
Sebastian Paris Department of Operative Dentistry and Preventive Dentistry, Center
of Dentistry, Oral Medicine and Maxillofacial Surgery, Charité - Universitätsmedizin
Berlin, Berlin, Germany
Jorge Perdigão Division of Operative Dentistry, Department of Restorative
Sciences, University of Minnesota, Minneapolis, MN, USA
Vanessa Rahal Department of Restorative Dentistry, Araçatuba School of
Dentistry, Univ. Estadual Paulista (UNESP), Araçatuba, SP, Brazil
Carmen Real Division of Comprehensive Care, Department of Primary Dental
Care, University of Minnesota, Minneapolis, MN, USA
Alessandra Reis Department of Dental Materials, State University of Ponta
Grossa, Ponta Grossa, PR, Brazil
Diana Gabriela Soares Department of Physiology and Pathology, Araraquara
Part I
Tooth Whitening with Peroxides
Introduction to Tooth Whitening
1
So Ran Kwon
Abstract
Few dental treatments have been more successful and conservative in nature than
tooth whitening. Therefore, it is noteworthy to mention the efforts of pioneers in
our dental profession who continuously attempted to search for the most effec-
tive and safest whitening agent. This quest has extended to determine the best
whitening technique to meet our patients’ desires and expectations about the
aesthetic outcome. Here, a short history of tooth whitening agents developed and
employed based on the type of discoloration is summarized, as is our current
knowledge on the relative efficacy and safety of various types of tooth whitening
regimens available. The information on proper diagnosis and treatment planning
will guide the clinician in establishing a step-by-step protocol for determining
the etiology of the discoloration, selecting the best whitening technique, and
monitoring tooth color until the desired outcome has been achieved.
1.1 History of Tooth Whitening
Tooth whitening is a conservative and effective method to lighten discolored teeth

and has been practiced in dentistry for many centuries. During the course of devel-
opment, careful observation and research on various materials and techniques
enabled the dental profession to introduce effective, safe, and predictable methods
of whitening.
In the mid-1800s, crowns were commonly used for the treatment of discolored
teeth (Kirk 1906). However, early pioneers were concerned with the aggressive
S.R. Kwon, DDS, MS, PhD, MS

Center for Dental Research, Loma Linda University School of Dentistry,
11175 Campus Street CSP A1010, Loma Linda, CA 92354, USA
e-mail: sorankwon@llu.edu
© Springer International Publishing Switzerland 2016 3

J. Perdigão (ed.), Tooth Whitening, DOI 10.1007/978-3-319-38849-6_1
4 S.R. Kwon
removal of tooth structure using this technique and found tooth whitening to be a
promising alternative (Kirk 1906). Despite the great plea for preservation of tooth
structure and less invasive dentistry, the majority of practitioners opposed tooth
whitening and argued that it was technique sensitive, the duration of treatment was
too long, and the relapse of color to the original shade was too frequent (Kirk 1889).
Nevertheless, the quest for the ideal whitening material continued and resulted in
numerous experimental whitening agents, which were either direct or indirect oxi-
dizers employed mostly for the treatment of nonvital teeth (Kirk 1889). A variety of
whitening agents were used, reflecting the diverse nature of discoloration. For
example, oxalic acid removed iron stains associated with pulp necrosis and hemor-
rhage (Atkinson 1862), chlorine was indicated for silver and copper stains encoun-
tered with amalgam restorations (Kirk 1889), and ammonia readily removed iodine
stains caused by root canal therapy (Stellwagen 1870). The most resistant stain,
originating from metallic salts of metallic restorations, was removed using cyanide
of potassium, although due to toxicity, its use was not recommended.
While most of the early dental literature focused on nonvital bleaching, as early
as 1868, whitening of vital teeth was being attempted with oxalic acid (Latimer
1868). Hydrogen peroxide, currently the most widely used whitening material, was
reportedly used in 1884, and was called hydrogen dioxide by Harlan (Harlan 1884).
At the time, chemical manufacturing companies were relatively unrestricted, as
were dentists, who were at liberty to mix their own solutions in their office (Haywood
1992). Early work also experimented with a variety of ways to speed the bleaching
process, including electric current (Westlake 1895), ultraviolet rays (Rosenthal
1911), and other heating instruments and lights (Abbot 1918; Fisher 1911).
Manufacturing companies introduced bleaching products in the early 1900s, a tran-
sition that limited the choice of materials available to the dental profession (Haywood
1992). The product Superoxol was introduced by a manufacturing company, and
developed into the bleaching agent used by the majority of dentists because of its
efficacy and safety (Haywood 1992).
The introduction of easy and safe to use bleaching agents eventually gave rise to
over-the-counter (OTC) products that could be used at home.
The innovative technique of home whitening can be traced back to the ortho-
dontist, Bill Klusmier, in the late 1960s in Fort Smith, Arkansas (Haywood 1991).
While treating a patient during the orthodontic retention phase, he recommended
placing Gly-oxide, an oral antiseptic containing 10 % carbamide peroxide (Marion
Merrel Dow, Inc.) into the orthodontic positioner at night to facilitate tissue healing
(Haywood 1991). He noticed a significant improvement in tissue health and an
additional benefit of lightening of tooth color. Further investigation using 10 %
carbamide peroxide in a custom-made tray worn at night led to the first publication
on “Nightguard Vital Bleaching” in 1989 (Haywood and Heymann 1989). This
technique caused a major shift from the in-office use of highly concentrated hydro-
gen peroxide with activating lights, to home whitening using lower concentrations
of carbamide peroxide. In addition, this technique had fewer side effects and could
be offered to a larger section of the general patient population at a lower cost
(Haywood 1992).
1 Introduction to Tooth Whitening 5
Since the introduction of Nightguard Vital home whitening, the formula has been
continually improved. Carbopol was added to increase the gel viscosity, so it would
stay in the tray longer. This also enabled slow release of the active ingredient,
increasing the duration of its effectiveness (Matis et al. 1999). Since some were
concerned that whitening gels might cause enamel erosion, various forms of fluo-
ride were added to the formulation. Tooth sensitivity was one of the most common
reason patients gave for stopping the whitening process before the desired endpoint,
so desensitizers were added, such as potassium nitrate, sodium fluoride, and amor-
phous calcium phosphate. These additions effectively reduced the incidence and
severity of tooth sensitivity (Browning et al. 2008; Gallo et al. 2009; Maghaireh
et al. 2014; Navarra et al. 2014; Wang et al. 2015).
As demand for white teeth increased, manufacturers began supplying over-the-
counter products (OTC). The early OTC products were introduced in 1990, and
involved a three-step system: an acid prerinse, a lower strength peroxide material,
and a final toothpaste. Most often, these systems were inappropriately used, causing
damage to the enamel (Cubbon and Ore 1991). Strip technology, which involved
placing a clear strip of tape with 6.5 % hydrogen peroxide onto the tooth (Crest
White Strips, Proctor and Gamble), was an innovative advance for home-whitening
systems (Gerlach 2000).
The evolution of techniques for tooth whitening is summarized in Table 1.1 and
reflects the efforts of the dental profession’s efforts to preserve tooth structure and
simultaneously enhance the restoration and aesthetics of smiles. The future will
likely bring about even more innovations.
1.2 Current Tooth Whitening Techniques
Tooth whitening is now the most common elective dental procedure (Dutra et al.
2004), and has proven to be safe and effective when supervised by the dentist
(American Dental Association Council on Scientific Affairs 2009). More than 1
million Americans whiten their teeth annually, resulting in nearly $600 million in
revenues for dental offices (Dutra et al. 2004). Considering the numerous over-the-
counter whitening products available and the heightened consumer interest in whiter
teeth, it is the responsibility of the dental profession to educate the public about the
efficacy and adverse effects of different tooth whitening modalities, suggest or pro-
vide appropriate options based on patient’s needs and preference, and establish reli-
able and valid monitoring tools for the whitening process.
The variety of methods and products available reflects the high demand for
whiter teeth. Traditionally tooth whitening could be classified into three categories:
(1) professionally applied in-office whitening with high-concentration materials
(Fig. 1.1a); (2) dentist-dispensed patient-applied home-whitening with custom fab-
ricated trays (Fig. 1.1b); and (3) over-the-counter products (Fig. 1.1c) like strips,
paint-on gels, or brush-on adhesive liquids (Kwon and Li 2013). With the increased
demand and a quest for less expensive options, protocols for do-it-yourself (DIY)
whitening (Fig. 1.1d) are now found on the Internet, using natural ingredients such
6
Table 1.1 History of tooth whitening

Date Name Material used Discoloration
1799 Macintosh (Dwinelle 1850) Invented chloride of lime (called bleaching powder)
1848 Dwinelle (1850) Chloride of lime Nonvital teeth
1860 Truman (1889) Chloride and acetic acid, Labarraque’s solution (liquid chloride of soda) Nonvital teeth
1861 Woodnut (1861) Advised placing the bleaching medicament and changing it at subsequent appointments
1868 Latimer (1868) Oxalic acid Vital teeth
1877 Chapple (1877) Hydrochloric acid, oxalic acid All discolorations
1878 Taft (Haywood 1992) Oxalic acid and calcium hypochlorite
1884 Harlan (1884) Used the first hydrogen peroxide (called hydrogen dioxide) All discolorations
1893 Atkinson (1862) 3–25 % pyrozone used as a mouthwash, which also lightened teeth
1895 Garretson (Haywood 1992) Applied chlorine to the tooth surface Nonvital teeth
1910 Prins (Haywood 1992) Applied 30 % hydrogen peroxide to teeth Nonvital and vital
1916 Kaine (Haywood 1992) 18 % hydrochloric acid (muriatic acid) and heat lamp Fluorosed teeth
1911 Fisher (1911) Reported on the use of hydrogen peroxide with a heating instrument or a light source Vital teeth
1924 Prinz (1924) First recorded use of a solution of perborate in hydrogen peroxide activated by a light Vital teeth
source
1942 Younger (Haywood 1992) 5 parts of 30 % hydrogen peroxide heat lamp, anesthetic
1958 Pearson (1958) Used 35 % hydrogen peroxide inside tooth and also suggested 25 % hydrogen peroxide Nonvital teeth
and 75 % ether, which was activated by a lamp producing light and heat to release
solvent qualities of ether
1961 Spasser (1961) Walking bleach technique; sodium perborate and water is sealed into the pulp chamber Nonvital teeth
1965 Bouschor (1965) 5 parts 30 % hydrogen peroxide, 5 parts 36 % hydrochloric acid, 1 part diethyl ether Orange colored
fluorosis stains
1965 Stewart (1965) Thermocatalytic technique; pellet saturated with superoxol is inserted into the pulp Nonvital teeth
chamber and heated with a hot instrument
1966 Colon and McInnes (1980) Repeats Bouschor’s technique using controlled hydrochloric acid-pumice abrasion
1967 Nutting and Poe (1967) Combination walking bleach technique, Superoxol in pulp chamber Nonvital teeth
(30 % hydrogen peroxide)
1968 Klusmier (Haywood 1991) Home bleaching concept started as an incidental finding; Gly-oxide which contains Vital teeth
10 % carbamide peroxide is placed in custom-fitted orthodontic positioner
S.R. Kwon
1
1970 Cohen and Parkins (1970) 35 % hydrogen peroxide and a heating instrument Tetracycline stains
1972 Klusmier (Haywood 1991) Used the same technique with Proxigel as it was thicker and stayed in the tray longer Vital teeth
1975 Chandra and Chawla (1975) 30 % hydrogen peroxide 18 % hydrochloric acid flour of Paris Fluorosis stains
1977 Falkenstein (Haywood 1992) 1-min etch with 30 % hydrogen peroxide 10 % hydrochloric acid 100 W (104 °F) light Tetracycline stains
gun
1979 Compton (Haywood 1992) 30 % hydrogen peroxide heat element (130–145 °F) Tetracycline stains
1979 Harrington and Natkin (1979) Reported on external resorption associated with bleaching pulpless teeth Nonvital teeth
1982 Abou-Rass (1982) Recommended intentional endodontic treatment with internal bleaching Tetracycline stains
1984 Zaragoza (1984) 70 % hydrogen peroxide and heat for both arches Vital teeth
1986 Munro (Haywood 1992) Used Gly-oxide to control bacterial growth after periodontal root planning. Noticed Vital teeth
tooth lightening
1987 Feinman (1987) In-office bleaching using 30 % hydrogen peroxide and heat from bleaching light Vital teeth
Introduction to Tooth Whitening
1988 Coastal Dental Study Club Mouth guard bleaching technique Vital teeth
(Haywood 1992)
1988 Munro (Darnell and Moore 1990) Presented findings to manufacturer, resulting in first commercial bleaching product: Vital teeth
White + Brite (Omnii Int)
1989 Croll (1989) Microabrasion technique 10 % hydrochloric acid and pumice in a paste Vital teeth,
superficial
discoloration,
hypocalcification
1989 Haywood and Heymann (1989) Nightguard vital bleaching, 10 % carbamide peroxide in a tray All stains, vital and
nonvital teeth
1990 Introduction of commercial, over-the-counter bleaching vital teeth products Vital teeth
1991 Bleaching materials were investigated while the FDA called for all safety studies and
data. After 6 months the ban was lifted
1991 Numerous authors Power bleaching, 30 % hydrogen peroxide using a light to activate bleach All stains, vital
teeth
1991 Garber and Goldstein (1991) Combination of bleaching power and home bleaching Vital teeth
1991 Hall (1991) Recommended no etching teeth before vital bleaching procedure Vital teeth
1994 American Dental Association Safety and efficacy established for tooth bleaching agents under the ADA seal of
(Engel 2011) approval
7
(continued)
8
Table 1.1 (continued)

Date Name Material used Discoloration
1996 FDA (http://google2.fda.gov/searc FDA approved ion laser technology: argon and CO2 laser for tooth whitening with
h?q=ion+laser+technology+for+bl patented chemicals
eaching+teeth&client=FDAgov&s
ite=FDAgov&lr=&proxystylesheet
=FDAgov&requiredfields=−
archive%3AYes&output=xml:no_
dtd&getfields=*)
1996 Reyto (1998) Laser tooth whitening Vital teeth
1997 Settembrini et al (1997) Inside/outside bleaching Nonvital and vital
teeth
1998 Carrillo et al (1998) Open pulp chamber, 10 % carbamide peroxide in custom tray Vital
2000 Miara (2000) Compressed bleaching technique in patient’s own bleaching tray Vital teeth
2000 Gerlach (2000) 5–10 % hydrogen peroxide OTC tooth whitening strips Vital teeth
2001 Kurthy (2001) Deep bleaching technique Vital teeth
2005 Lynch (2004) Ozone whitening using ozone machine Vital teeth
2006 Kwon (2007) Sealed bleaching: prevents evaporation of active agent by placing a wrap onto the Vital teeth
power whitening gel
2006 Various whitening applications; use of brush applications, pens, and varnish Vital teeth
2011 ISO 28399 (2011) International Standard Organization: Dentistry: Products for External Tooth Bleaching Vital Teeth
Present Plasma arc, halogen, UV, LED and light-activated bleaching techniques; reduction in Vital teeth
time with power gels for in-office bleaching; Laser-activated bleaching; home
bleaching available in different concentrations and with new desensitizers
Adapted and updated from data in Haywood (1992), with permission from Taylor & Francis Group, LLC
S.R. Kwon
a b
c d
Fig. 1.1 (a) In-office whitening procedure with light activation. (b) At-home whitening with cus-
tom fabricated trays. (c) Over-the-counter whitening with strips. (d) Do-it-yourself whitening with
strawberry puree
as lemons, apples, and strawberries (Kwon and Li 2013; Natural Teeth Whitening
Solutions). The availability of OTC products and various DIY methods has pro-
vided the general population better access to whitening, but use without the supervi-
sion of a dentist has raised several potential concerns. Tooth discoloration can be the
secondary effect of an undiagnosed illness, overuse of whitening materials can dam-
age the enamel surface, and the at-home process might go unmonitored (Hammel
1998; Kwon and Li 2013; Natural Teeth Whitening Solutions). Therefore, the
supervision of a dentist or use of custom fabricated trays should be the treatment
modality of choice. The patient’s final decision, however, will most likely depend
on preference. Although at-home whitening with 10 % carbamide peroxide is safe
and effective under a dentist’s supervision (American Dental Association Council
on Scientific Affairs 2009), in-office whitening has its merits, especially in elderly
patients who may prefer the convenience and in young children who may require
full supervision during the entire procedure. Also, patients who cannot tolerate
wearing trays and those who desire an immediate effect might also prefer an in-
office treatment.
Several studies have compared the efficacy, side effects, and patient acceptance
of in-office, at-home, or over-the-counter whitening. Patient opinion was found to
depend on the whitening product, study design, application time, and methods of
color assessment. One study evaluated the time required to achieve a six-tab differ-
ence on a Vita Classical shade guide, and found this occurred the fastest with
10 S.R. Kwon
Table 1.2 Summary of current vital tooth whitening techniques

At-home
In-office whitening whitening OTC DIY
Supervision Yes Yes No No
Active ingredient HP HP/CP HP/misc Natural ingredients
Concentration ~up to 40 % ~7–35 % CP ~up to 12 % HP N/A
Activators Chemical, LED, Chemical Chemical, light N/A
Laser
Efficacy Good Good Mod-good Questionable
Safety Good Good Mod-good Questionable
Costs High Mod Low Lowest
Mod Moderate, HP Hydrogen peroxide, CP Carbamide peroxide
in-office whitening, followed by at-home whitening, with over-the-counter whiten-

ing requiring the most time (Auschill et al. 2005). The various techniques caused
similar levels of gingival or tooth sensitivity, and patients tended to prefer at-home
whitening, as previously reported (Bizhang et al. 2009; Da Costa et al. 2010;
Giachetti et al. 2010; Serraglio et al. 2016). In vitro studies comparing all four whit-
ening techniques showed in-office, at-home, and over-the-counter whitening pro-
duced good results, whereas do-it-yourself whitening with strawberry puree was
ineffective (Kwon et al. 2015a, b). Despite the equivalencies in endpoint whiteness,
a concern remains that DIY whitening could reduce tooth microhardness values
(Kwon et al. 2015a). A complete summary, including a comparison of the character-
istics of current vital tooth whitening technologies, is listed in Table 1.2. It must be
noted that this presents an overall comparison and may vary based on the specific
material employed.
1.3 Diagnosis and Treatment Planning
If a patient desires whiter teeth or would benefit from tooth whitening in conjunc-
tion with restorative or orthodontic treatment, their prognosis depends on the nature
of the discoloration and the expectations of the patient. Discoloration due to extrin-
sic origins respond better to whitening but even discoloration due to intrinsic origin
(e.g., tetracycline staining) can respond to whitening if the treatment time is suffi-
cient (Haywood 1991). The absolute contraindications to tooth whitening are few,
but unrealistic expectations, an unwillingness to comply with treatment, pregnancy,
allergy to components in the whitening material, and severe sensitivity should be
carefully considered before starting treatment.
1.3.1 Check List During Examination
Like any dental examination, the proper steps for diagnosis include obtaining medi-
cal and dental history and radiographs and conducting a thorough clinical
examination.
Active dental caries that may be close to the pulp should be given special atten-
tion. Carious lesions can be temporarily treated prior to the whitening treatment and
finalized once the color is stabilized.
A single dark tooth is a red flag and might be associated with a previous trau-
matic injury or even a periapical pathosis (Kwon 2011). Radiographs and pulp vital-
ity testing can guide the treatment (Chap. 6).
Crack lines are not an absolute contraindication but the patient should be aware
they may exacerbate sensitivity or become even more visible after tooth whitening
(Kwon et al. 2009).
Localized decalcification areas and white spots should be carefully examined as
they might blend in with the lighter tooth color or could become more noticeable
(AlShehri and Kwon 2016). In these instances, other conjunctive treatments such as
microabrasion or resin infiltration and restorative treatment may be indicated
(Chaps. 6, 9, 10, 12, 13, and 15).
Translucent areas often observed on incisal edges will remain translucent upon
whitening treatment and may end up looking grayish, continuing to be a concern for
some patients. In severe cases, a resin composite restoration to mask the translu-
cency may be needed.
Existing tooth-colored restorations in the aesthetic zone should be carefully
examined since there may be a need for retreatment that should be explained in
advance, to allow the patient to make the necessary financial commitment.
The symmetry in gingival contour should be observed and possibly resolved
prior to whitening, in order to enhance the aesthetic outcome.
Severe abrasion, attrition, and recessions should also be observed and explained
to the patient, as root exposures will not respond to whitening (Hilton et al. 2013;
Pashley 1989).
Preexisting tooth sensitivity needs to be addressed prior to the treatment, since it
may become severe upon treatment compromising the outcome of the treatment.
1.3.2 New Challenges in Tooth Whitening
1.3.2.1 Failed Attempts of Tooth Whitening

With the increased interest in tooth whitening, patients currently consult a dental
professional about this technique after several failed attempts of trying it on their
own (Fig. 1.2). Many have used over-the-counter products in various forms with
unsatisfactory results, yet exhibit teeth that are already quite light, making the treat-
ment more challenging. Therefore, it is prudent to establish the expectation of the
patient and discuss the feasibility of reaching this goal. A very realistic and natural
outcome is to reference the white of the eye (Mrazek 2004). However, patients often
want teeth that are even whiter, at which point the dentist should carefully discuss
the patient’s treatment goal, in detail.
1.3.2.2 Erosion
As lifestyles have changed throughout the decades, the consumption of soft drinks
has increased in the United States by 300 % in 20 years (Calvadini et al. 2000; Lussi
12 S.R. Kwon
Fig. 1.2 Patient complained about

previous failed attempts of tooth
whitening. A thorough examination of
existing restorations, recessions,
abfractions, and gingival asymmetry was
followed by a comprehensive treatment
plan to satisfy patient’s desire for an
aesthetic outcome
Fig. 1.3 Generalized

erosion of teeth can
contribute to a more
chromatic appearance of
teeth
et al. 2006). At the same time, the incidence of dental erosion is growing steadily
(Lussi et al. 2006). Initially, erosion is limited to the enamel, but in advanced cases
dentin becomes exposed and causes functional and aesthetic concerns that require
treatment. Generally, the tooth becomes more chromatic with the loss of enamel,
and one of the first distinct visual changes patients complain about is tooth color
(Fig. 1.3). The treatment plan may vary depending on the severity and location of
dental erosion. Restorative options, including direct resin composite and indirect
porcelain restorations, are suggested for the rehabilitation of a severe loss of tooth
structure. While dental erosion is considered to be a contraindication to tooth whit-
ening (Lussi et al. 2006), it may be beneficial in the early stages if the patient desires
a whiter smile. Indeed, since the prevalence of dental erosion is steadily increasing,
the topic merits continued research.
1.3.2.3 Tooth Whitening in Children

Another emerging topic is the age deemed appropriate for tooth whitening (Fig. 1.4a,
b). The American Academy on Pediatric Dentistry Council on Clinical Affairs recog-
nized the increased desire for whiter teeth in pediatric and adolescent patients and
advised the judicious use of whitening for vital and nonvital teeth, as well as consulta-
tion with the dentist to determine the appropriate method and timing for treatment
(American Academy on Pediatric Dentistry Council on Clinical Affairs 2015). A single
clinical study is currently registered to evaluate the efficacy and tooth sensitivity in an
adolescent population (patients ranging from 12 to 20 years) (Pinto et al. 2014).
a b
Fig. 1.4 (a) The best time for initiating whitening in children should be carefully discussed with
the parents. This 12-year-old child complained about his dark teeth as well as the localized white
areas on the upper anterior teeth. (b) Treatment options include at-home whitening with custom
fabricated trays when the child is compliant or in-office whitening where the whole procedure is
performed in the clinic
Fig. 1.5 Patient

complained about her
upper four anterior teeth
which had been restored
with porcelain laminate
veneers. Over time, she
noticed a slight darkening
of her restored teeth. In
this case, whitening from
the lingual may reduce the
chromacity of her restored
teeth
1.3.2.4 Tooth Whitening on Teeth with Veneers and Orthodontic

Braces
Lastly, with the increased interest in cosmetic dentistry more patients have existing
anterior composite resin or porcelain veneers. Over time, teeth become more chro-
matic, which can shine through existing veneer restorations (Fig. 1.5). To brighten
teeth, yet preserve the existing restoration, 10 % carbamide peroxide on the lingual
surface can be applied with custom trays (Barghi and Morgan 1997; Haywood and
Parker 1999). However, the efficacy of whitening through the lingual surface is
mainly based on a few clinical cases and evidence is limited. With the increased
awareness for a brighter smile, we face new situations. For example, increasingly
patients are requesting tooth whitening while orthodontic braces are in place. A few
studies showed tooth whitening with custom fabricated trays over brackets could
whiten teeth evenly (Jadad et al. 2011). Nevertheless, more research is needed to
address these special and challenging situations to help clinicians in the decision-
making process.
14 S.R. Kwon
1.3.3 Monitoring the Progress of Tooth Whitening
The success of tooth whitening is mainly determined by changes in tooth color and
is subjective to each patient; however, evaluating tooth color is extremely difficult
because of the complex optical characteristics of the tooth, which include gloss,
opacity, transparency, translucency, and optical phenomena such as metamerism,
opalescence, and fluorescence (Hunter 1987). Patients commonly inquire about the
expected final shade after tooth whitening. So first recording the baseline tooth
color will help determine the prognosis, and is invaluable in monitoring progress.
The prognosis of whitening is significantly enhanced with shades in the yellow-
orange range, whereas gray and bluish discolorations are more stubborn (Leonard
2003). Additionally, rather than promising a specific shade, it is prudent to suggest
a reliable reference point, such as the white of an eye, so the patient can perceive the
difference (Mrazek 2004). Commonly the white of the eye is whiter than the base-
line tooth color, providing a good reference point for the progress being made dur-
ing treatment. One of the best ways to demonstrate the efficacy and progress of
whitening is to compare the color difference of the upper, treated arch versus the
lower, untreated arch. This difference is very helpful in encouraging compliance
and also for some who cannot discern color changes well. Many times it is also
important to have color change validated by friends or family, and photographs can
be an essential monitoring tool (Kwon and Li 2013).
The Vitapan Classical (VITA Zahnfabrik, Bad Sackingen, Germany) shade
guide, with values oriented according from the lightest to the darkest tab, is com-
monly used for visual shade matching. Nevertheless, the lack of logical order, uni-
form color distribution, and light shade tabs has been pointed out as drawbacks of
the Vitapan Classical (Ontiveros and Paravina 2009). To facilitate the monitoring of
tooth whitening, a shade guide was developed, the VITA Bleachedguide 3D Master
(VITA Zahnfabrik, Bad Sackingen, Germany), composed of 15 tabs that exhibit a
wider color range and more consistent color distribution, compared to the Vitapan
Classical. The VITA Bleachedguide 3D Master was also evaluated to be the easiest
to arrange, the most harmoniously arranged and most preferred for the monitoring
of tooth whitening (Paravina 2008). The initial color tab, selected during baseline
color measurements, can be easily placed along whitened teeth, leading to the antic-
ipation of the whitening progress. The effect of tooth whitening can be easily moni-
tored by selecting the closest shade tab before and after whitening and counting the
difference in tab numbers, expressed as a difference in shade guide units (ΔSGU)
(Kwon et al. 2015b).
Methods using specialized instruments to determine tooth shade have become
available with advancements in technology. These methods have the advantage of
being uninfluenced by the human eye, environment, and light source, and generate
reproducible results (Chu 2003). Additionally, methods using instruments provide
objective shade data and allow different image-analysis options, such as basic shade
analysis, smile analysis, and synchronization, to produce a split image of pre- vs.
postwhitening. These images (Fig. 1.6a, b) can be printed immediately and are
Fig. 1.6 (a) Smile analysis before whitening. (b) Smile analysis after whitening
16 S.R. Kwon
Fig. 1.6 continued

effective tools to show objective results on the progress of tooth whitening. They
also provide motivation to initiate and continue treatment. This technique is cur-
rently used more often in research, because it is as yet expensive and time consum-
ing for use in clinical dentistry.
Acknowledgment Special thanks to Taylor & Francis for granting permission to use and update
Table 2.1 in Bleaching Techniques in Restorative Dentistry Edn 1 by Linda Greenwall.
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Tooth Whitening: How Does It Work
2
So Ran Kwon
Abstract
Tooth discoloration is classified as extrinsic or intrinsic, with extrinsic stains
arising from accumulation of residue on the surface of the tooth, and intrinsic
discoloration from stains within the enamel or dentin. For both types of stains,
tooth whitening with hydrogen peroxide is a common treatment. Hydrogen per-
oxide likely exerts its effects by interacting with chromophores within the tooth
structure, acting via what is known as the “chromophore effect.” Despite having
the desired cosmetic effect, however, hydrogen peroxide treatment also may
likely affect sound tooth tissue; and the unknowns surrounding unwanted side
effects remain a concern. Here, the etiology of extrinsic and intrinsic stains is
summarized, as is our current understanding of hydrogen peroxide treatment and
mechanisms of action. This information might guide further research and devel-
opment efforts to create new technology for the treatment of tooth
discoloration.
2.1 Etiology of Discolorations
The human tooth is composed of three dental hard tissues: enamel, dentin, and the
cementum, which are each distinct in their mineral composition and function. Of
the three tissues, dental enamel is the most mineralized and is the hardest tissue of
the body. Enamel is ~96 % mineral, 3 % water, and 1 % organic matter by weight,
whereas dentin is 70 % mineral, 20 % organic matrix, and 10 % water by weight
(Nanci 2013). Unlike bone tissue, which remodels itself continuously through
S.R. Kwon, DDS, MS, PhD, MS

11175 Campus Street CSP A1010, Loma Linda, CA 92354, USA
e-mail: sorankwon@llu.edu

22 S.R. Kwon
balanced bone resorption and formation, the dental hard tissue does not turn over.
Nonetheless, the enamel interface undergoes continuous, dynamic ion exchange
with the oral biofilm, with calcium phosphate apatite crystals moving in both direc-
tions to maintain proper mineral balance (Peters 2010). Indeed, enamel and dentin
form a semipermeable membrane that allows small molecules to pass into the tooth
structure. This property largely accounts for tooth discoloration from extrinsic
sources. The key properties that cause enamel and dentin to bind to and retain stain-
ing molecules, however, are still not well understood.
2.1.1 Extrinsic Stains
Tooth discoloration is broadly classified as extrinsic or intrinsic, depending on the

origin of the stain (Watts and Addy 2001). Extrinsic stains arise due to the accumu-
lation of residue on the enamel surface and can be accentuated by pitting or irregu-
larities of the enamel, salivary composition, salivary flow rates, and poor oral
hygiene (Hattab et al. 1999). The affinity of material to the tooth surface plays a
critical role in the deposition of extrinsic stains (Plotino et al. 2008). Stains might
adhere to the tooth via several types of attractive forces including long-range inter-
actions such as electrostatic and van der Waals forces, and short-range interactions
such as hydration forces, hydrophobic interactions, dipole-dipole forces, and hydro-
gen bonds (Nathoo 1997). Extrinsic stains take on a variety of colors, which reflect
the nature of the stain.
Brown stain is a thin and bacteria-free pellicle commonly found on the buccal
surface of the maxillary molars and on the lingual surface of the mandibular incisors
(Leung 1950). It is commonly associated with poor oral hygiene and likely results
from the deposition of tannins found in tea, coffee, and other beverages (Hattab
et al. 1999). Tobacco stains present as a tenacious dark-brown discoloration primar-
ily on the cervical one-third to one-half of teeth. The severity of discoloration is
influenced by characteristics of the tooth surface rather than the amount of tobacco
consumed (Manly 1973).
Black stain is a continuous narrow black line along the gingival margin of the
enamel and encircles the tooth (Faunce 1983). It is usually associated with a muci-
nous plaque that is infiltrated with chromogenic bacteria, primarily Actinomyces
(Slots 1974). The black stain is ferric sulfide and is formed by the reaction between
hydrogen sulfide, a metabolic by-product of bacteria, and iron from the saliva and
gingival exudate (Reid et al. 1977). It is more common in females and may occur in
individuals with excellent oral hygiene (Goldstein and Garber 1995).
Green stains on the labial surface at the gingival third of the maxillary anterior
teeth are attributed to the infiltration and growth of fluorescent bacteria and fungi,
such as Penicillum and Aspergillus (Bartels 1939). It is common in children, affect-
ing boys more frequently than girls (Leung 1950).
Orange stain appears as a yellow, orange, or a reddish-orange line in the cervical
third of the incisors (Faunce 1983). The stain is associated with chromogenic bacte-
ria, such as Serratia marcescens and Flavobacterium lutescens (Carranza and
Newman 1996).
2 Tooth Whitening: How Does It Work 23
Metallic stains are common in industrial workers exposed to metal-containing

dust or in individuals who have received certain orally administered drugs or locally
applied therapeutic agents (Hattab et al. 1999). The metal that combines with the
acquired pellicle at the tooth surface varies the stain color: dust composed of mer-
cury and lead are gray, copper and nickel stains are green to blue-green, and chro-
mic acid fumes produce a deep orange color in the enamel. The use of iodine
solution and stannous fluoride produces a brown discoloration, while silver nitrate
results in a black discoloration (Hattab et al. 1999). Antiseptic stain has been
observed after prolonged use of chlorhexidine mouth rinses and is characterized by
a brown, diffuse discoloration of the teeth (Linden et al. 1986). Despite the fact that
extrinsic discolorations may vary in color, severity, and location, all stains can be
easily removed by dental prophylaxis.
2.1.2 Intrinsic Stains
In contrast to the superficial nature of extrinsic stains, intrinsic discolorations are

incorporated during tooth formation or after eruption, and are attributable to the
presence of stain molecules within the enamel and dentin (Dahl and Pallesen 2003).
Preeruptive stains arise due to dental fluorosis, tetracycline staining, hematologic
disorders, and inherited developmental defects of enamel or dentin without sys-
temic features (Hattab et al. 1999).
2.1.2.1 Dental Fluorosis

Because it is widely available from multiple sources, dental fluorosis is the most
common cause of intrinsic discoloration and manifests as a subsurface hypominer-
alization of tooth enamel caused by chronic ingestion of fluoride during odontogen-
esis (Burt 1992). The nature and severity of dental fluorosis depends on the dosage,
duration of exposure, stage of ameloblast activity, and susceptibility of the individ-
ual (Driscoll et al. 1983). Initially, tooth discoloration may not be evident upon
eruption, but becomes more evident as the exposed porous surface gradually absorbs
chromogenic substances in the oral cavity (Steinberg et al. 1999). Clinically, signs
of mild fluorosis range from delicate accentuation of the perikymata pattern to white
opaque spots or lines. In severe cases, brown pitting patches or localized loss of
external enamel may occur (Hattab et al. 1999).
2.1.2.2 Tetracycline Staining

Tetracycline staining was first reported in the late 1950s after its introduction and
widespread use as a broad-spectrum bacteriostatic antibiotic (Shwachman et al.
1958–1959). Tetracycline exposure between the second trimester in utero to approx-
imately 8 years of age can affect the teeth, skeleton, and fingernails (Bevelander
1964). The tetracycline molecule chelates with calcium in hydroxyapatite crystals,
predominantly in dentin, forming a tetracycline-calcium orthophosphate complex
(Mello 1967). The color of tetracycline-stained teeth becomes more intense upon
chronic exposure to sun and artificial light because of the photooxidation of this
complex (McEvoy 1989). The severity of stains depends on the type of tetracycline
24 S.R. Kwon
consumed and the time, duration, and amount of drug intake (Dayan et al. 1983).
Proper diagnosis is imperative as tetracycline staining is considered one of the most
difficult stains to remove. Diagnosis is established by acquiring patient history, and
assessing clinical appearance and fluorescence under ultraviolet light (Hattab et al.
1999).
2.1.2.3 Developmental Defects and Others

Developmental defects of enamel or dentin are associated with amelogenesis imper-
fecta, dentinogenesis imperfecta, and enamel hypoplasia. Discolorations due to
developmental defects often become worse over time as the rough surfaces allow
stains to accumulate more easily. Numerous other factors can also adversely affect
the ameloblast and cause enamel hypoplasia, including nutritional deficiencies,
viral exanthematous diseases, trauma to developing teeth, birth trauma, metabolic
diseases, hemolytic diseases in newborns, local infection, ingestion of chemicals,
and other genetic factors (Hattab et al. 1999).
Intrinsic stains can also be acquired after eruption resulting in local discolor-
ation. The severity of the discoloration varies depending on the cause, and may
appear mild yellow-orange to very dark brown or black. Dental caries are a major
cause of local discoloration and often start as an opaque, white halo, ultimately
developing into an unsightly brown or black area due to the reaction of bacterial
by-products with decalcified dentin (Eriksen and Nordbo 1978). Restorative materi-
als that leak around the margins may allow debris or chemicals to enter, resulting in
discoloration of the underlying dentin (Steinberg et al. 1999). Amalgam pigmenta-
tion is very common and can result in greenish-black pigmentation caused by the
products of tin oxidation (Goldstein and Garber 1995). Endodontic materials and
sealers also have various staining potentials that, over time, cause intrinsic discolor-
ation of a tooth with a filled root canal (van der Burgt and Plasschaert 1985).
The success of tooth whitening depends upon proper diagnosis of the initial
cause of discoloration. Although stains are categorized as extrinsic or intrinsic, in
most cases the etiology is multifactorial. Further, extrinsic stains often become
internalized over time as the enamel and dentin are permeable to organic and inor-
ganic substances. Therefore, careful examination and history taking is required to
properly determine all components that contributed to the discoloration.
2.2 Mechanism of Peroxide Action
The importance of appearance in our society has increased the demand for instant
tooth whitening, resulting in a prolific and diverse array of products and tech-
niques. To keep pace with this trend, dental professionals have invested a great
amount of effort to elucidate the mechanisms through which peroxides promote
tooth whitening. The “chromophore theory” is based on the interaction of hydro-
gen peroxide (H2O2) with organic chromophores within the tooth structure and has
traditionally been accepted as the mechanism by which peroxide exerts its whiten-
ing effects. Organic chromophores have electron-rich areas, and when reactive
oxygen species such as hydrogen peroxide encounter stain molecules, they convert
the chromophore chains into simpler structures or alter their optical properties and
diminish the appearance of the stain (Albers 1991). Although the chromophore
theory is widely adopted, it is not fully understood and many fundamental ques-
tions remain: How do organic chromophores diffuse into the tooth? How do they
interact with tooth structure? Where do they accumulate? What is the composition
and fate of the breakdown products of any oxidation process? These questions
merit further investigation.
To facilitate understanding of tooth whitening, the process must be evaluated in
three distinct phases: (1) the movement of the whitening agent applied from the
outer surface into the enamel and dentin; (2) the interaction of stain molecules with
hydrogen peroxide upon its penetration into the tooth structure; and (3) the micro-
morphologic changes induced by peroxide-based materials on tooth surface and
structure that may lead to optical changes. The outcome of these three phases results
in the final color change of the tooth after whitening. Ideally, whitening agents will
maximize lightening while minimizing concurrent damage to the tooth structure
(Kwon and Wertz 2016). Investigating the effects of peroxide during each phase
will increase our understanding of the whitening process and optimize whitening
approaches.
2.2.1 Phase One: Diffusion
Extrinsic stains that are limited to the external surface of the tooth can be readily
removed with tooth brushing or dental prophylaxis. However, once the stain
becomes internalized within the enamel and dentin, hydrogen peroxide must pene-
trate these layers in order to interact with organic chromophores. Although peroxide-
based tooth whitening was introduced in the 1800s, the quantification of hydrogen
peroxide penetration into the pulp cavity was not quantified until 1987 by Bowles
and Ugwuneri (Bowles and Ugwuneri 1987). This in vitro study used leucocrystal
violet and horseradish peroxidase to spectrophotometrically measure hydrogen per-
oxide at submicrogram levels and is a well-established, accurate, selective, and sen-
sitive analytical method that is still used today (Mottola et al. 1970).
Studies evaluating the diffusion phase found that peroxide penetration was
enhanced by the following: higher hydrogen peroxide concentrations (Bowles and
Ugwuneri 1987; Gökay et al. 2004; Hanks et al. 1993; Palo et al. 2010); prolonged
application (Hanks et al. 1993; Kwon et al. 2012b; Rotstein et al. 1991); increased
temperature (Bowles and Ugwuneri 1987; Rotstein et al. 1991); the large size of
dentinal tubules in young teeth (Camps et al. 2007); variations in tooth structure due
to location, acid etching or restorations (Benetti et al. 2004; Camargo et al. 2007;
Camps et al. 2010; Palo et al. 2012; Patri et al. 2013); and light activation (Camargo
et al. 2009). Penetration was also improved by specific formulations and delivery
systems (Bharti and Wadhwani 2013; Cooper et al. 1992; Gökay et al. 2005; Park
et al. 2016; Pignoly et al. 2012; Thitinanthapan et al. 1999). The results of all
reviewed studies are in accordance with Fick’s second law of diffusion, which states
26 S.R. Kwon
that the diffusion of a molecule is proportional to the surface area, diffusion coeffi-
cient, and concentration, and that it is inversely proportional to the diffusion dis-
tance (Brotherton Boron 1994).
Additionally, studies were performed to determine the path of diffusion into the
tooth by whitening agents. Since peroxide-based materials are water soluble, it was
speculated that the diffusion of these molecules was similar to the flow of fluids that
occur in the enamel interprismatic spaces and dentinal tubules (Ake-Linden 1968;
Kwon et al. 2012a; Pashley 1996). In a study utilizing confocal laser scanning
microscopy, the diffusion pathway of hydrogen peroxide was correlated to
Rhodamine B. This demonstrated diffusion of the dye into interprismatic spaces and
accumulation along the dentin-enamel junction, followed by uptake into the termi-
nal branch of the dentinal tubules where it could directly access the predentin and
pulp cavity (Kwon et al. 2012a). However, this is not simply passive diffusion of
these molecules, but requires a concentration gradient that is determined by the
chemical affinity for each dental tissue (Ubaldini et al. 2013). Thus, as chemical
composition can affect the outcome of treatment, it is important to identify the opti-
mal whitening concentration and application times so that concurrent tooth struc-
ture damage may be minimized without compromising whitening efficacy.
2.2.2 Phase Two: Interaction
Although a wide variety of whitening products are available, most contain hydrogen
peroxide as the active agent (Dahl and Pallesen 2003). Hydrogen peroxide may be
applied directly, or produced in a chemical reaction from sodium perborate or carb-
amide peroxide (Budavari et al. 1989). Hydrogen peroxide (H2O2) is slightly more
viscous than water with a molar mass of 34.0147 g/mol and acts as a strong oxidiz-
ing agent (Hess 1995). The rate of decomposition and the type of active oxygen
formed depends on the temperature and concentration of peroxide, as well as the pH
and presence of cocatalysts and metallic reaction partners (Goldstein and Garber
1995).
Homolytic cleavage, the splitting of shared, bonding electrons resulting in an
unshared electron:
HOOH → H • + • OOH or HO• + • OH

This type of cleavage is favored by light and heat and forms free radicals.
Heterolytic cleavage, which is a deprotonation reaction leaving an electron pair:
HOOH → H + + • OOH −

This deprotonation occurs at increased pH and generates perhydroxyl anions
(Feinman et al. 1991).
A third pathway is derived by a combination of homolytic and heterolytic cleav-
age and generates active oxygen that is both an anion and a free radical:

HOO• + OH − → O •− 2 + H 2 O ( basic condition ) and HOO • → O•− 2 + H − ( acidic condition )
Active oxygen is attracted to electron-rich areas of stain molecules and cleaves dou-
ble bond to reduce color or remove the compound (Albers 1991).
Despite the well-known chemistry of hydrogen peroxide and its application to
establish the chromophore theory, many issues remain unsolved. Studies using
Fourier Transform Infra-Red (FTIR) and Raman spectroscopies failed to detect
chromophores or their breakdown products in the enamel, and are inconsistent with
the chromophore theory (Darchuk et al. 2008; Eimar et al. 2012; Fattibene et al.
2005). Thus, continued investigation is required to fully understand the mechanisms
of hydrogen peroxide in eliminating stains.
Ideally, as hydrogen peroxide moves from the external tooth surface into the
enamel and dentin, its oxidizing action should be limited to organic chromophores
until it reaches a certain saturation point, or whitening threshold. Oxidizing action
beyond the whitening threshold—characterized by the depletion of chromophores—
has been cautioned against as it might compromise tooth structure. Indeed, review
of the literature suggests hydrogen peroxide has significant interactions with the
organic and inorganic components of enamel and dentin well before the saturation
point. This may account for alterations in the physical properties of the tooth sub-
strate after the whitening treatment (Attin et al. 2005).
Extensive studies using ion-selective electrode probes, FT-Raman spectroscopy,
and a combination of scanning electron microscopy (SEM) and energy-dispersive
X-ray spectrometer and microcomputerized tomography suggest that hydrogen per-
oxide interacts with the tooth structure, and changes the chemical composition of
enamel and dentin (Kwon and Wertz 2016). While evidence exists that peroxide-
based materials do not irreversibly influence the chemistry of enamel and dentin
beyond clinical relevance (Arcari et al. 2005; Cavalli et al. 2011; Goo et al. 2004;
Lee et al. 2006; Mc Cracken and Haywood 1996; Rodrigues et al. 2007), several
studies have demonstrated significant changes in the calcium/phosphate ratio, indic-
ative of alterations in the inorganic components of hydroxyapatite (Al-Saleni et al.
2007; Berger et al. 2010; Bizhang et al. 2006; de Freitas et al. 2004; Efeoglu et al.
2005; Efeoglu et al. 2007; Rotstein et al. 1996; Rotstein et al. 1992).
Microcomputerized tomography studies of enamel treated with 10 % or 35 % carb-
amide peroxide demonstrated a demineralization depth of 50 μm and 250 μm,
respectively (Efeoglu et al. 2005; Efeoglu et al. 2007). Furthermore, infrared spec-
troscopic analysis showed changes in the enamel that was both concentration and
time dependent.
It is worth noting that changes in the organic component of enamel and dentin
are likely due to the oxidizing ability of hydrogen peroxide, while changes in the
mineral component are mainly attributed to its acidity (Jiang et al. 2007). Several
studies provide evidence supporting that the organic matrix of enamel and dentin is
oxidized by hydrogen peroxide. X-ray diffraction analysis of hydroxyapatite sug-
gests hydrogen peroxide influences the organic tissue, and Nuclear Magnetic
Resonance-based measurements indicate that proline and alanine may be more sus-
ceptible to an attack by the hydroxyl radical (Kawamoto and Tsujimoto 2004; Sato
et al. 2013; Toledano et al. 2011). Other studies assessing morphological changes in
the enamel and dentin used atomic force microscopy (AFM) and FTIR to show that
the tooth enamel matrix protein or organic matrix of dentin had partially lysed,
28 S.R. Kwon
causing these effects (Abouassi et al. 2011; Chng et al. 2005; Hegedüs et al. 1999;
Mahringer et al. 2009; Sato et al. 2013; Ubaldini et al. 2013). Moreover, other stud-
ies have implicated that proteolysis by dentin metalloproteinases and cathepsin B
might also compromise the organic component of dentin (Sato et al. 2013; Toledano
et al. 2011).
Collectively, these studies demonstrate that hydrogen peroxide indeed interacts
with all components of dentin and enamel. Thus, it may not only target chromo-
phore stains, but also whiten by modifying the organic substances within the tooth.
Future studies must identify the clinical significance of interactions between hydro-
gen peroxide and each tooth layer.
2.2.3 Phase Three: Surface Change and Color
The anticipated final outcome of tooth whitening is to increase color lightness and
reduce chroma in the yellow-blue and red-green spectrum based on the CIE Lab
system (Commission Internationale de l’Eclairage 1995). The separate contribu-
tions of enamel and dentin on tooth color have been evaluated, with some studies
placing more emphasis on the role of dentin (Kwon et al. 2013; Wiegand et al. 2005;
Kugel et al. 2007). Nevertheless, enamel characteristics also play a key role in the
optical properties of the tooth. Enamel contributes to the overall tooth color by
decreasing the translucency of the tooth, masking the color of the underlying dentin
(Kawamoto and Tsujimoto 2004; Ma et al. 2009, 2011). Changes in the enamel
have been attributed to micromorphological alterations through deproteinization,
demineralization, and oxidation of the most superficial enamel layer (Eimar et al.
2011; Ma et al. 2009, 2011). This changes the density of enamel making the distri-
bution of enamel crystals less compact and potentially increasing its refractive index
(Li et al. 2010; Ma et al. 2011).
Determining how subtle enamel surface changes affect the tooth has been an area
of interest. Studies have found that rough surfaces create a more diffuse reflection,
turning the object brighter, whereas a smooth surface leads to more specular reflec-
tion. Additionally, an increase in back scattering of short wavelengths, reflected as
bluish-white, plays a considerable role in the light scattering of teeth (Joiner 2004).
This is most easily demonstrated by the whitish color change in early caries lesions
due to the increased opacity of the tooth enamel (Ma et al. 2009, 2011; Vieira et al.
2008). Further, some studies suggest tooth color change that is associated with tooth
whitening is mainly due to mineral loss rather than the breakdown of chromophores
(Jiang et al. 2007; Kwon et al. 2002; Lee et al. 2006; Mc Cracken and Haywood
1996). The subsequent uptake of minerals after tooth whitening and the reversal of
the treatment substantially support this suggestion (Li et al. 2010).
Because of the impact of surface changes on the appearance of tooth color,
changes in surface topography have been extensively investigated. SEM and AFM
studies showed increased roughness and surface irregularities upon whitening treat-
ment (Ben-Amar et al. 1995; Bitter and Sanders 1993; Hosoya et al. 2003; McGuckin
et al. 1992; Pedreira De Freitas et al. 2010; Pinto et al. 2004; Shannon et al. 1993;
Yeh et al. 2005; Zalkind et al. 1996). Notably, most of these changes have not been
seen in studies where a remineralizing agent or saliva was used as a storage medium
(Duschner et al. 2006; Haywood et al. 1991; Joiner et al. 2004; Scherer et al. 1991;
Turkun et al. 2002; White et al. 2003). Thus, continued research on the effects of
whitening treatments on surface and tooth color changes are necessary to order to
prescribe treatments that will have long-lasting effects with minimal changes to the
overall structure of the tooth.
This up-to-date review of the literature illustrates that tooth whitening occurs in
three distinct phases, challenging the validity of the widely accepted “chromophore
effect” as the dominant mechanism of hydrogen peroxide. As such, this theory must
be modified to reflect the true complexity of the mechanisms that drive whitening.
Indeed, stains are not determined by the properties of the organic staining molecules
alone but are also affected by micromorphologic alterations on the tooth surface and
within the tooth structure; thus, whitening likely affects intact enamel and dentin
microstructures, an underrecognized concern (Kwon and Wertz 2016). In future
studies, an appreciation of the complexity of the tooth whitening process will spear-
head innovation toward materials and techniques that meet the ever-growing inter-
est in safely obtaining a brighter smile.
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Endod Dent Traumatol 12:82–88
Overall Safety of Peroxides
3
Yiming Li
Abstract
Current tooth whiteners contain peroxides as active ingredients, which release
hydrogen peroxide (H2O2) in the process of application. The primary source of
safety concerns with the peroxide-based tooth whiteners is the capability of H2O2
to produce oxidative free radicals or reactive oxygen species (ROS), which have
been associated with various pathological consequences including carcinogene-
sis and degenerative diseases. This chapter will review and discuss toxicology of
H2O2, its presence in the human body, and its potential systemic effects, genotox-
icity, and carcinogenicity on the basis of evidence available in the literature.
3.1 Background
Safety concerns with peroxide-based tooth whiteners are primarily originated from
their content of peroxide compounds (Li 1996, 1997, 2011; Li and Greewall 2013).
Carbamide peroxide (CH6N2O3) and hydrogen peroxide (H2O2) are the most com-
monly used peroxide compounds as the active ingredient in current extracoronal
tooth-whitening products, while sodium perborate (NaBO3) is primary for intra-
coronal bleaching procedures (Rotstein and Li 2008). Carbamide peroxide, or urea
hydrogen peroxide, is a white crystal or a crystallized powder. Chemically, carb-
amide peroxide is composed of approximately 3.5 parts of H2O2 and 6.5 parts of
urea; a tooth whitener of 10 % carbamide peroxide thus contains approximately
Y. Li, DDS, MSD, PhD

11175 Campus Street, Loma Linda, CA 92350, USA
Microbiology and Molecular Genetics, Loma Linda University School of Dentistry,
Loma Linda, CA, USA
e-mail: yli@llu.edu

36 Y. Li
3.5 % H2O2. Sodium perborate is also a white powder available either as monohy-
drate, trihydrate, or tetrahydrate. The monohydrate and tetrahydrate forms are com-
monly used for intracoronal bleaching, with H2O2 content theoretically around 34 %
and 22 %, respectively. In an aqueous medium, both carbamide peroxide and sodium
perborate decompose to release H2O2, which, therefore, is the true active ingredient
of the peroxide-based tooth-whitening products.
3.2 Toxicology of Hydrogen Peroxide
H2O2 as a chemical was first identified in 1818, and the well-known Fenton reaction
was proposed in 1894. Two enzymes, peroxidase and catalase, found in 1898 and
1901, respectively, were quickly recognized to play important roles in H2O2 metab-
olism in humans. Shortly after the discovery of another important enzyme, superox-
ide dismutase (SOD), in 1969, research efforts on biological properties of H2O2
have significantly increased (Li 1996).
The toxicology of H2O2 has been investigated extensively, and there are a number
of comprehensive reviews on the topic available in the literature (IARC 1985;
ECETOX 1993; Li 1996; SCCP 2005; CEU 2011). A key characteristic of H2O2 is
its capability of producing reactive oxygen species (ROS), which are known to
induce various toxicities, including hydroxyl free radicals that have been implicated
in various stages of carcinogenesis (Floyd 1990; Li 1996). Oxidative reactions of
ROS with proteins, lipids, and nucleic acids are believed to be involved in a number
of potential pathological consequences; the damage by oxidative free radicals may
be associated with aging, stroke, and other degenerative diseases (Harman 1981;
Floyd et al. 1988; Lutz 1990; Li 1996).
The major mechanism responsible for the observed toxicity of H2O2 is believed
to be the oxidative reactions and subsequent damage in cells by ROS. In cell culture
studies, H2O2 is highly cytotoxic at concentrations ranging from 1.7 to 19.7 μg/mL
or 0.05 to 0.58 mmol/L (Rubin and Farber 1984; Bates et al. 1985; Ramp et al.
1987; Tse et al. 1991; Hanks et al. 1993; Li 1996, 2003). Hepatocytes were less
sensitive to the cytotoxicity of H2O2 than fibroblasts and endothelial cells (Sacks
et al. 1978; Simon et al. 1981; Rubin and Farber 1984), while human gingival fibro-
blasts derived from primary cultures and L929 mouse fibroblasts (ATCC CCL 1;
Manassas, VA) were found to respond similarly to the cytotoxicity of H2O2 (Li
1996).
On the other hand, the human body is equipped with various defensive mecha-
nisms available at cellular and tissue levels to prevent potential damage of H2O2 to
cells during oxidative reactions and to repair any damages sustained. A number of
enzymes, such as catalase, SOD, peroxidase, and selenium-dependent glutathione
peroxidase, exist widely in body fluids, tissues, and organs, to effectively metabolize
H2O2 (Floyd 1990; Li 1996). Simply adding iron chelators and antioxidants or increas-
ing serum concentration in culture media effectively reduces or eliminates the cyto-
toxicity of H2O2 (Sacks et al. 1978; Rubin and Farber 1984). In a cell culture study,
20 mM H2O2 was undetectable after 30 min in the culture media alone and after
15 min in the media with bone tissues, indicating decomposition and inactivation of
3 Overall Safety of Peroxides 37
hydrogen peroxide in cell culture systems (Ramp et al. 1987). These enzymes also
exist in human saliva; in fact, salivary peroxidase has been suggested to be the body’s
most important and effective defense against the potential adverse effects of H2O2
(Carlsson 1987). Marshall and coworkers (2001) found that the human oral cavity,
including that of adults, juveniles, infants, and adults with impaired salivary flow, was
capable of eliminating 30 mg H2O2 in less than one and a half minutes.
3.3 Peroxides in the Human Body
The detection of H2O2 in human respiration was first reported in 1880; however, it
was not until 1969 when SOD was discovered H2O2 was recognized as an important
by-product in oxygen metabolism of humans (Li 1996, 2011). H2O2 is now known
as a normal intermediate metabolite in humans. It exists in human serum, and it is
present in human breath at levels ranging from 0.34 to 1.0 μg/L (Sies 1981; Williams
et al. 1982). The daily production of H2O2 in human liver is approximately 6.48 g in
a period of 24 h (FDA 1983). An important source of endogenous H2O2 is from
phagocytic cells, such as neutrophils and macrophages, which play an essential role
in defense against various pathological microorganisms.
3.4 Systemic Effects
Systemic effects of H2O2 have been investigated for both acute and chronic expo-
sures. A unique characteristic of H2O2 in inducing systemic toxicity is its concentra-
tion in addition to the dosage.
The reported acute systemic toxic effects of H2O2 in animals vary widely, accord-
ing to the H2O2 concentration as well as the application mode. In rats, the intrave-
nous 50 % lethal dose (LD50) of H2O2 was found to be 21 mg/kg (Spector 1956).
Using the up-and-down method, in which the dosing is adjusted up or down accord-
ing to the outcome (death or survival) of the animal that received the previous dos-
age, the oral LD50 of 4 % H2O2 solution in male and female rats was estimated at 780
and 600 mg/kg, respectively (Li 1996). The LD50 for percutaneous application of
H2O2 is much higher at >7,500 mg/kg (FDA 1983). The values of LD50 are inversely
related to the concentrations of H2O2, and they vary markedly between different
animal species and strains (IARC 1985; FDA 1983; ECETOX 1993; Li 1996).
Tissue responses to topical application of H2O2 are also related to the H2O2 concen-
tration, but they are usually minimal at low concentrations of ≤3 %.
Acute toxicity, including fatalities, has been reported in humans who acciden-
tally ingested large amounts of concentrated H2O2 solutions (Spector 1956; Giusti
1973; Giberson et al. 1989; Humberston et al. 1990; Rackoff and Merton 1990;
Christensen et al. 1992; Cina et al. 1994; Sherman et al. 1994; Asanza et al. 1995;
Ijichi et al. 1997; Rider et al. 2008; Byrne et al. 2014). A retrospective survey of a
regional poison control center found that over a 36-month period, 325 cases were
caused by H2O2 poisoning, which accounted for 0.34 % of all the reported causes
(Dickson and Caravati 1994); however, the majority of the 325 cases (71 %) was
38 Y. Li
pediatric population (age <18 years), with ingestion of H2O2 solution being the most
common route of exposure (83 % of cases). One major factor associated with the
toxicity of H2O2 is its concentration. Ingestion of H2O2 solutions of less than 10 %
usually produces no significant adverse effects, although it may cause mild irritation
to mucous membranes, which results in spontaneous emesis or mild abdominal
bloating (Humberston et al. 1990; Dickson and Caravati 1994). Exposure to H2O2
concentrations higher than 10 %, however, can result in severe tissue burns and sig-
nificant systemic toxicity. In addition to the tissue damage caused by oxidative reac-
tions, gas embolism is responsible for various pathological consequences of H2O2
ingestion (Rackoff and Merton 1990). Each milliliter of 1 % H2O2 releases 3.3 mL
oxygen; therefore, 10 mL of 30 % H2O2 can produce 1 liter oxygen (Giberson et al.
1989; Humberston et al. 1990). Common symptoms observed in acute toxicity of
H2O2 include stomach and chest pain, retention of breath, foaming at the mouth,
loss of consciousness, motor and sensory disorders, fever, gastric hemorrhage, and
liver damage. Although rare, death can occur.
Several animal studies have been conducted on acute systemic toxicity of tooth
whiteners containing carbamide peroxide. Oral gavage of 5 g/kg tooth whiteners
containing 10 and 22 % carbamide peroxide produced no evidence of acute sys-
temic toxicity in rats (Cherry et al. 1993; Adam-Rodwell et al. 1994). One study
reported unusually low LD50 (87.18–143.83 mg/kg) of two products containing
10 % carbamide peroxide in female Swiss mice (Woolverton et al. 1993). The rea-
sons for the low LD50 values are unclear but may be attributed to differences in
animal species, materials, and method. Using the up-and-down method, the LD50 of
a tooth-whitening gel with 10 % carbamide peroxide was estimated at 23.02 g/kg in
female rats (Li et al. 1996).
Chronic systemic toxicity of H2O2 has been investigated using animal models.
No visible abnormalities were detected in mice drinking 0.15 % H2O2 (about
150 mg/kg/day) ad libitum for 35 weeks, and their growth was also normal (FDA
1983). Necropsy results, however, showed changes in the liver, kidney, stomach,
and small intestine. Solutions of >1 % H2O2 (>1 g/kg/day) caused pronounced
weight loss and death of mice within two weeks. A rat study by Ito et al. (1976)
found that when administered by an oral gastric catheter 6 days weekly for 90 days,
the dose of 506 mg/kg suppressed body weight gain, decreased food consumption,
and caused changes in hematology, blood chemistry, and organ weights. The princi-
pal tissue affected was gastric mucosa, and the effects were local. The no-observed-
effect level (NOEL) of H2O2 was 56.2 mg/kg/day. Another rat study found that the
NOEL of H2O2 was 30 mg/kg/day when animals were treated by oral gastric cath-
eter daily for 100 days (Kawasaki et al. 1969). The same study showed no adverse
effects in rats receiving the diet containing 6 mg H2O2 in 20 g of food.
3.5 Genotoxicity
The genotoxic potential of H2O2 has been investigated extensively using microbes,
plants, insects, cultured mammalian cells, and animals (IARC 1985; ECETOX
1993; Li 1996; SCCP 2005). In a number of bacterial systems, H2O2 induced
point mutations or single-strand breaks in DNA. Positive mutagenicity of H2O2

has also been detected in some newer tester strains of the Ames Salmonella
mutagenicity test; however, effects are eliminated when tested with S9 activa-
tion. S9 is a rat liver microsomal preparation that contains various enzymes. It
has been found to increase the sensitivity and overall performance of the Ames
Salmonella mutagenicity test, and therefore, experiments both with and without
S9 are required for the Ames Salmonella mutagenicity test (Maron and Ames
1983). The results obtained from mammalian cells are similar to those from the
Ames Salmonella mutagenicity test; that is, the genotoxic effects of H2O2 are
detected only in test systems without S9 activation. The effect of S9 on H2O2-
induced DNA or chromosomal changes in mammalian cells in vitro is believed
to originate from the H2O2-degrading enzymes in the S9, which is the same as
that observed in the Ames Salmonella mutagenicity test.
The genotoxicity of H2O2 has also been examined using in vivo systems, and
results indicate that H2O2 is not genotoxic in various animal models (IARC 1985;
ECETOX 1993; Li 1996; SCCP 2005). The overall data available so far show that
H2O2 is genotoxic only in in vitro systems without enzymatic activation. When
enzymatic activation is incorporated into in vitro systems or when tested in animals,
H2O2 is nongenotoxic.
3.6 Carcinogenicity
The carcinogenicity of H2O2 was the subject of a number of critical reviews (IARC
1985; ECETOX 1993; Li 1996, 1998, 2000, 2011). Several investigators found no
evidence of carcinogenicity of H2O2 or carbamide peroxide. Repeated subcutaneous
injections of 0.5 % H2O2 for up to 332 days did not induce tumors in a mouse study
(Nakahara and Fukuoka 1959). Another 56-week study showed that 5 % carbamide
peroxide and 3 % H2O2 were inactive as tumor promoters (Bock et al. 1975). Klein-
Szanto and Slaga in 1982 reported that twice-weekly application of 15 and 30 %
H2O2 on mouse dorsal skin for 50 weeks did not induce any squamous cell carcino-
mas, and they thus concluded that H2O2 at 15 and 30 % was not a complete carcino-
gen. The same study also found that at 15 and 30 % concentrations, H2O2 was not a
tumor initiator but exhibited extremely weak tumor-promoting activity after 25
weeks of twice-weekly application following previous application of the carcinogen
DMBA as the initiator. At concentrations <15 %, H2O2 did not cause tumor promo-
tion. In contrast, Nagata and coworkers (1973) reported that a single subcutaneous
injection of 0.6 % H2O2 was not carcinogenic, and in fact, repeated applications of
0.6 % H2O2 on mouse skin significantly inhibited tumor development induced by the
potent carcinogen benzo(α)pyrene.
The studies that reported carcinogenicity of H2O2 and subsequently generated
safety concerns about the use of H2O2 or peroxide-containing tooth whiteners were
conducted by Ito’s group (1981, 1982, 1984) and Weitzman and coworkers (1986).
In the 1981 study by Ito and coworkers, male and female C57Bl/6 J mice received
0.1 % or 0.4 % H2O2 in drinking water for up to 100 weeks, with distilled water as
the negative control. An increased incidence of duodenal carcinoma was observed
40 Y. Li
in females only in the 0.4 % H2O2 group (4 of 50 mice), and one carcinoma was
observed in one male mouse in each of the 0.1 and 0.4 % groups. However, results
showed no dose-related incidence of duodenal adenomas. Using standard methods
for data analysis in which sexes are analyzed separately, no significant increase in
carcinoma incidence was noted in males or females. Statistical significance was
achieved only when the data from males and females were combined.
In the second study by Ito’s group (1982), three strains of mice, including the
C57Bl/6 N strain that was used in the initial study, received 0.1 % or 0.4 % H2O2
solution in drinking water for up to 740 days. Duodenal cancer (pathologically not
defined as benign, malignant, carcinoma, or adenoma) was observed only in
C57Bl/6 J mice between 420 and 740 days, with an incidence of 1 and 5 % for the
0.1 and 0.4 % H2O2 groups, respectively. However, temporary cessation of H2O2 and
replacement with distilled water for 10, 20, or 30 days decreased the incidence of
lesions in both the stomach and duodenum.
The third study by Ito’s group (1984) investigated four strains of mice that
received 0.4 % H2O2 solution in drinking water for 7 months (C57Bl/6 N mice) and
6 months (other three strains). The incidence of duodenal lesions was highly strain-
dependent and inversely related to duodenal, liver, and blood catalase activity.
C57Bl/6 N mice had low catalase activity, and the number of tumors was 41 times
that observed in mice with high catalase activity, and about ten times higher than
that for the strain with normal catalase activity. Of particular interest is the observa-
tion that another strain of catalase-deficient mice had a lower duodenal tumor inci-
dence, both in total number of tumors and number of tumors per mouse, than that of
the C57Bl/6 N mice.
Because of the potential significance of the results reported by Ito’s team, these
studies were reviewed and carefully evaluated for study design, experimental con-
duct, and data presentation (FDA 1983; IARC 1985; FDA 1988; ECETOX 1993).
Major limitations of the research include unverified H2O2 concentration and stabil-
ity in drinking water, inadequate control and documentation of tumor pathology,
and lack of information on food consumption and survival. In addition, these studies
did not measure individual animal water intake, which is relevant because reduced
water intake may contribute to the development of lesions. When water consump-
tion is decreased, the texture of the stomach contents changes, which may increase
the likelihood of tissue injury when coarse materials transverse the duodenum,
resulting in an increased rate of cell proliferation, or regenerative hyperplasia
(Bertram 1991). From a 14-day study in C57Bl/6 N mice, water consumption was
found to decrease with increasing H2O2 content (Weiner et al. 2000). Therefore, in
the same strain of mice it is appropriate to assume that the decrease in water intake
also occurred during H2O2 exposure in Ito’s studies. As a consequence, gastrointes-
tinal irritation occurred. As observed in Ito studies, changes to the epithelia were
primarily localized to the duodenum, indicating that the lesions are not chemically
induced but indicative of mechanical irritation. On the other hand, as demonstrated
by Ito and coworkers, the C57Bl/6 N mouse strain used in their studies has a low
level of duodenal catalase activity and a high spontaneous incidence of premalig-
nant duodenal lesions. The difference in catalase activity among animal strains
likely is one of the reasons that other studies that used a similar experimental design
to the study of Ito’s group, have not found carcinogenicity of H2O2. As such, after
evaluating the Ito studies, the Cancer Assessment Committee (CAC) of the US Food
and Drug Administration (FDA) concluded that Ito’s studies did not provide suffi-
cient evidence that H2O2 was a duodenal carcinogen.
The study by Weitzman et al. (1986) examined effects of topical application of
H2O2 on the cheek porch mucosa of male Syrian golden hamsters. Animals were
treated twice weekly with DMBA, a carcinogen, in combination with 3 or 30 %
H2O2 for 19 or 22 weeks. Groups receiving DMBA or 30 % H2O2 alone were also
included. Results showed that 30 % H2O2 alone did not induce any tumors at either
of the two time periods. At 19 weeks, no tumors were observed in animals receiv-
ing the DMBA and 3 % H2O2, and 30 % H2O2 had no tumor-enhancing effect. After
22 weeks, there was no tumor-enhancing effect with 3 % H2O2. The incidence of
carcinomas was higher in animals receiving a combination of 30 % H2O2 and
DMBA (5/5 animals) compared to those treated with DMBA alone (3/7 animals),
but the significance level was marginal (p = 0.054). The significance of the observed
increase in incidence of carcinoma associated with 30 % H2O2 at 22 weeks has
been questioned because of the small number of animals used and the marginal
statistical significance observed (Li 1996; Marshall et al. 1996). It is also difficult
to explain the marked differences in results between the two time periods, an inter-
val of only 3 weeks. In addition, repetitive treatment with H2O2 solutions greater
than 15 % was considered too irritating to tissues to enable detection of tumor-
promoting activity, because cells would not survive the toxic effects of high con-
centrations of H2O2 (Klein-Szanto and Slaga 1982). Marshall and colleagues
(1996), using the similar experiment design to the Weitzman study, found that
H2O2 up to 3 % was not carcinogenic or cocarcinogenic. The studies by Weitzman
et al. (1986) and Marshall et al. (1996) are particularly significant in that they do
not demonstrate a synergistic effect between H2O2 and the polycyclic aromatic
hydrocarbon DMBA during coadministration. Tumor promotion studies (Bock
et al. 1975; Klein-Szanto and Slaga 1982) provide additional evidence for a lack of
interaction between chemical carcinogens and H2O2. The study by Marshall et al.
(1996) found a reduction in tumor incidence following H2O2 administration, and
such an effect was observed with 3 % H2O2 and baking soda in the hamster cheek
pouch model.
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Complications from the Use of Peroxides
4
André Luiz Fraga Briso, Vanessa Rahal,
Marjorie Oliveira Gallinari, Diana Gabriela Soares, and
Carlos Alberto de Souza Costa
Abstract
While dental whitening or dental bleaching is one of the most popular aesthetic
procedures, dentists should base their decision to prescribe peroxide-based whiten-
ing agents on evidence-based techniques and regimens. The contact of bleaching
products with the mucosa, dental tissues, and preexisting restorations may trigger a
series of adverse effects both on soft and hard tissues. This chapter details the pre-
cautions that must be taken prior to prescribing different bleaching therapies with
the goal of improving the patient’s smile, without damaging oral tissues.Additionally,
this chapter will discuss tooth sensitivity, which is the most common side effect of
any bleaching treatment. The prevention of tooth sensitivity is of upmost impor-
tance to avoid discomfort to patients and increase patient’s compliance.
4.1 Introduction
Tooth bleaching (or tooth whitening) is a cosmetic procedure widely used owing to
its technical simplicity, proven clinical efficacy, and noninvasiveness, as it does not
remove tooth structure. Tooth bleaching is based on the oxidative potential of hydro-
gen peroxide (HP), the main active component of bleaching agents, as this molecule
is able to diffuse through the tooth enamel and promote the breakdown of organic
A.L.F. Briso (*) • V. Rahal • M.O. Gallinari

Department of Restorative Dentistry, Araçatuba School of Dentistry,
Univ. Estadual Paulista (UNESP), Araçatuba, SP, Brazil
e-mail: alfbriso@foa.unesp.br
D.G. Soares • C.A. de S. Costa
Department of Physiology and Pathology, Araraquara School of Dentistry,
Univ. Estadual Paulista (UNESP), Araraquara, SP, Brazil

46 A.L.F. Briso et al.
pigments in dentin. The two bleaching techniques traditionally used under the
supervision of a dental professional are the at-home (Chap. 6) and the in-office
(Chap. 7) bleaching techniques. Dentist-supervised at-home whitening is consid-
ered the safest for the patient, as a result of the low concentration of carbamide
peroxide (CP) or hydrogen peroxide (HP) used. Although the dental professional
supervises the at-home bleaching technique, the patient applies the product at home.
This bleaching procedure has raised questions concerning the risk of systemic tox-
icity in addition to the indiscriminate and/or inappropriate use of bleaching products
by patients, which may increase the risk of adverse effects on oral tissues.
In-office techniques traditionally involve the use of HP-based gels in high
concentrations (30–40 %). The procedure is performed in the dental office under
full control of the dentist. However, the use of HP in high concentrations results
in the diffusion of the molecule into the pulp chamber in toxic levels, resulting in
important changes in the pulp connective tissue that have been linked to high
levels of postbleaching sensitivity (Costa et al. 2010; de Almeida et al. 2015b;
Simões et al. 2015). Additionally, extreme caution must be taken to protect oral
soft tissues and prevent swallowing of bleaching product, as contact of this prod-
uct with oral mucosa can cause chemical burns resulting in severe discomfort for
the patient.
In clinical practice, tooth sensitivity and gingival tissue irritation are the most
frequently reported adverse effects by patients who undergo different bleaching
treatments (Almeida et al. 2012; Simões et al. 2015). However, in addition to its
adverse effects on soft tissues, tooth bleaching has been scientifically proven to
cause changes in mineralized tissues and in existing restorations, the extent of which
depends on the technique used (Hayacibara et al. 2004; Cavalli et al. 2004; Sasaki
et al. 2009; Mourouzis et al. 2013; AlQahtani 2013; Soares et al. 2013b; Torabi
et al. 2014b). Thus, in this chapter, we will discuss changes in soft tissues, mineral-
ized tissues, and adhesive restorations caused by the different bleaching techniques
currently available and the clinical aspects related to postbleaching tooth
sensitivity.
4.2 Effect on Oral Soft Tissues
The literature has shown that HP causes major changes in various cell types (Zhu
et al. 2012). Therefore, the contact of the molecule with biological tissues such as
gingival tissue, periodontal ligament, and pulp tissue during bleaching is not desir-
able. As bleaching products with different HP concentrations, presentation forms,
and application protocols are available for clinical or home use, distinct cellular
responses are expected depending on the regimen used. Thus, the dentist should be
aware of the possible adverse effects of each therapy in order to use the best clinical
alternative for each particular clinical situation. In this chapter, greater emphasis
will be given to the effects of the different bleaching modalities on gingival and
periodontal tissues. The effect of these techniques on the pulp tissue will be
described in detail in Chap. 5.
4 Complications from the Use of Peroxides 47
Direct contact of the bleaching gel with oral soft tissues may cause chemical
burns due to the caustic potential of HP, resulting in the development of gingival
ulcers and erosions (Powell and Bales 1991; Haywood et al. 1997; Oda et al. 2001).
HP may also cause changes in the periodontal tissue that can lead to gingival reces-
sion. The magnitude of these effects is proportional to the contact time and concen-
tration of HP in the bleaching product (Powell and Bales 1991; Haywood et al.
1997; da Costa Filho et al. 2002). These negative effects can be prevented in the
in-office technique by carefully applying a gingival barrier, which effectively pre-
cludes the contact of the whitening gel with gingival tissue and periodontal liga-
ment. For the unsupervised at-home technique, the fabrication of a suitable tray
with clear instructions for use is indispensable to prevent irritation of oral tissues.
However, many over-the-counter (OTC) products (Chap. 6) are available for use
without dentist supervision and are applied in trays with poor adaptation to dental
arches, which can increase the risk of product contact with the periodontal tissues,
especially in patients with dental misalignment. In addition, bleaching strips with
various HP concentrations, which do not require the use of trays, have gained popu-
larity mainly because of their low cost compared to that of dental professional-
supervised bleaching. However, these OTC products result in direct contact of the
gingival papilla with the bleaching strip, as they are not customized to fit the indi-
vidual dental arches of patients. With this in mind, the biological effects of different
types of bleaching techniques on soft oral tissues are discussed in the following
sections based on scientific evidence available in the current literature.
4.2.1 At-Home Bleaching
The supervised at-home bleaching technique is based on the use of bleaching gels
containing 10–22 % CP or 4–10 % HP. However, only 10 % CP has received the
American Dental Association (ADA) seal of acceptance, as seen in Chap. 6.
Therefore, at-home bleaching that involves the use of a 10 % CP gel has been con-
sidered the safest treatment modality. In this regard, the recent literature provides
long-term reports on the aesthetic and biological effects up to 17 years post treat-
ment (Boushell et al. 2012).
CP is a product of the weak link between HP and urea, which is easily broken in
the presence of water, releasing about 3.3–3.5 % HP in the process (Kwon et al.
2002; Sulieman 2008). Thus, the mechanism of CP home bleaching gels is the slow
and gradual release of low HP concentrations onto the tooth structure. For this rea-
son, the product should be applied daily for 1–8 h, over relatively long periods
(1–4 weeks) in order to achieve the desired aesthetic result.
Gingival irritation associated with supervised home bleaching is related to two
key factors, namely (1) mechanical trauma due to the tray and (2) the toxic effect of
the gel on the oral mucosa. The first step to prevent trauma to gingival tissues during
at-home bleaching is to use custom-fitted trays by dentists in a patient’s stone model.
Prefabricated trays do not provide good adaptation and may expose the oral mucosa
to contact with the peroxide bleaching product. Still, the tray may cause trauma due
a b
Fig. 4.1 Traditional tray showing (a) the evident possibility of direct contact of the bleaching gel
(arrow) with soft tissue and (b) the scalloped tray, 0.5 mm short of the gingival tissue line, that
allows keeping the bleaching gel in contact exclusively with enamel
to defects in the stone model or improper trimming of the tray. To prevent this
adverse event, during tray try-in the practitioner must identify potential compres-
sion areas that can produce traumatic ulcerative lesions, which may result in severe
discomfort for the patients (Matis 2003).
Once the possibility of mechanical trauma to gingival tissue caused by the tray is
ruled out, efforts should be directed to retain the gel inside the tray throughout its
use, reducing the possibility of leakage of the product and its consequent contact
with adjacent soft tissues. In vitro studies have determined that low HP concentra-
tions (3 %) exert a cytotoxic effect on gingival fibroblasts and negatively affect pro-
liferative capacity, fibronectin expression, and Type I collagen (Tipton et al. 1995;
Oda et al. 2001). Animal studies have shown that the topical application of 10 % CP
in rat tongue for 20 min once a week, for 3 weeks, promoted epithelial changes
characterized by increased cell proliferation of the basal layer, which was transient
and reversible 10 days after the procedure (De Castro Albuquerque et al. 2002).
This demonstrates that even low HP concentrations can have a toxic potential when
in direct contact with oral mucosa cells.
Several alternatives have been discussed in relation to the design of the tray that
can prevent leakage of the bleaching gel to soft tissue regions. Scalloping the tray at
the gingival level has proven to be an effective measure to prevent the outflow of
product to regions beyond the cervical tooth region (Matis 2003). It is, therefore,
suggested that the tray does not extend to the gingival tissue or should be ≈0.5 mm
short of the gingival tissue line, preventing its compression while minimizing the
possibility of direct contact of the bleaching product with soft tissue. After the appro-
priate volume of the bleaching gel is applied into the tray, the excess gel must be
removed using a toothbrush or a cotton swab immediately after the patient adapts the
tray in the mouth. As discussed in Chap. 6, the use of tray reservoirs does not improve
bleaching effectiveness (Matis 2003). Additionally, the inclusion of reservoirs results
in a greater amount of HP detectable in saliva (Matis et al. 2002). Thus, reservoirs are
not indicated. This will result in better adaptation of the tray to the teeth to be
bleached and less leakage of the bleaching gel, preventing tissue damage. Figure 4.1a
shows the overlapping of extended scalloped trays with the gingival tissue in com-
parison trays that are trimmed to avoid overlapping with the tissue (Fig. 4.1b).
In a clinical study conducted by Leonard et al. (2001), a 10 % CP gel applied

daily (6–8 h) for 14 days using scalloped trays resulted in minimal adverse effects
on oral soft tissues. The authors conducted an analysis of the marginal (gingival
index) and nonmarginal gingiva (nonmarginal gingival index), and the possible
changes in non-gingival soft tissues (non-gingival oral mucosal index) after 7 and
14 days of treatment. They did not observe any significant differences in all the
parameters tested between the bleached and nonbleached groups. Only 8 % of the
patients reported gingival irritation during the treatment course, and none of them
reported gingival irritation during 3, 6, and 47 months posttreatment. Similar results
were found in the study by Almeida et al. (2015) where the application (2 h daily)
of bleaching gels containing 10 and 16 % CP in scalloped trays for 21 days did not
cause genotoxicity in the adjacent gingival tissue to the teeth subjected to bleaching.
In pre- and postbleaching analyses, Firat et al. (2011) observed that the application
of 35 % CP gel at home in trays with gingival trimming for 15 days (30 min/day)
caused no changes in clinical parameters for the gingival tissue and periodontium,
but increased levels of proinflammatory cytokines in crevicular fluid. A number of
clinical studies reported that contact of at-home bleaching gels with oral tissues
resulted in inflammation and erosion of the marginal gingiva, as well as cervical
resorption and gingival recession, with the contact of the products with the marginal
gingiva for long periods being contraindicated (Powell and Bales 1991; Haywood
et al. 1997). Costa-Filho et al. (2002) performed a gingival tissue biopsy for smok-
ers and nonsmokers who underwent treatment with a gel containing 10 % CP,
applied for 8 h/day for a period of 5 weeks. Biopsies performed immediately after
the bleaching treatment revealed an increase in epithelial thickness and cell prolif-
eration to basal and parabasal layers, resulting in morphometric changes of the gin-
gival tissue, when compared with biopsies performed 15 days before the bleaching
treatment. The results were similar between the smokers and nonsmokers. In the
abovementioned clinical studies, bleaching trays without gingival trimming and res-
ervoir in the vestibular region were used.
More recent studies reported that the immediate efficacy of bleaching does not
appear to be affected by the smoking habit (de Geus et al. 2015a, b, c).
Additionally, tray whitening did not induce DNA damage to soft tissues during
the treatment (de Geus et al. 2015c) or even increase the risk of tooth sensitivity
(de Geus et al. 2015a).
The possibility of daily contact of bleaching agents rich in HP with oral tissues
remains controversial. Several studies showed that HP in high concentrations might
promote cancer in the duodenum and jejunum of rats treated concomitantly with
carcinogens. However, HP administration alone did not lead to the development of
lesions in these tissues (Naik et al. 2006; Minoux and Serfaty 2008; Paula et al.
2015). However, according to the results reported by Hannig et al. (2003), only
1.25 % HP present in the gel with 10 % CP was detected in saliva from patients who
underwent bleaching in conventional individualized trays with a 1.5-mm reservoir,
which was the highest release observed within the first 5 min. Thus, the systemic
effects of HP derived from at-home bleaching are still considered quite controver-
sial (Naik et al. 2006; Minoux and Serfaty 2008). It is noteworthy that a
cocarcinogen agent does not start mutations alone but requires a neoplastic initiator
in the oral cavity (Naik et al. 2006). The possibility of the correlation between a
cocarcinogen agent and an initiator is a contraindication for carrying out aesthetic
treatment.
Treatment supervision by a qualified dental professional is extremely impor-

tant to diagnose early changes in hard and soft tissues. The indiscriminate
online access to home bleaching materials and the use of OTC products from
online retailers and conventional drugstores may increase the safety risks of
tooth whitening.
While there are an abundant number of studies on CP-based gels for at-home
application, few studies are available related to the effects of HP-based home gels
on soft tissues. Several studies showed that the amount of HP in saliva is propor-
tional to the HP concentration in bleaching gels and that the use of CP-based gels
results in lesser amount of HP in saliva than products containing pure HP (Hannig
et al. 2003, 2005). The decomposition of 10 % CP into HP has been demonstrated
to occur primarily in the first hour after bleaching, and this degradation occurs
primarily in the region of product contact with the tooth surface (Matis et al. 1999).
However, current clinical evidence shows that a better bleaching outcome is
obtained when 10 % CP is applied for 8–10 h (Matis et al. 2009; Cardoso et al.
2010), as seen in Chap. 6.
Thus, the application of a sufficient amount of bleaching gel (enough to cover the
tooth surface) in a custom-fitted scalloped tray without reservoirs promotes effective
tooth bleaching with minimal damage to oral soft and/or pulp tissue. Furthermore, in
order to prevent inadvertent swallowing of bleaching product residues, home bleach-
ing with the use of gels with 10 % CP applied using a scalloped tray model slightly
short of the free gingival margin (≈0.5 mm) has been recommended.
The direct contact of bleaching gels with gingival and periodontal tissues
should be avoided in order to eliminate the possibility of tissue damage medi-
ated by HP.
4.2.2 OTC Products
Currently, another type of tooth bleaching treatment, which involves the use of OTC
products, has become popular (see Chap. 6). OTC products can be purchased in
supermarkets, drugstores, or even on the Internet, and are used without dentist
supervision. These products emerged in the United States about 15 years ago as an
alternative treatment of stained teeth with lower cost than traditional supervised
treatment (Demarco et al. 2009). The active component is the same as that in
Fig. 4.2 Gingival tissue in

contact with
bleaching strips
traditional bleaching agents, that is, either CP (10–18 %) or HP (1.5–14 %), which
is available in various forms such as bleaching strips, varnishes, gels, paint-on liq-
uids, mouthwashes, and toothpastes. However, these products offer no protection to
soft tissue adjacent to the teeth subjected to bleaching. As such, their indiscriminate
use without professional guidance raises concerns about the possible adverse effects
(Demarco et al. 2009).
Also available online are bleaching gels to use with universal trays, even those
administered with lights and electrodes. Poor adaptation of the tray results in the
flow of the material to the oral cavity, causing contact of a large amount of product
with the oral mucosa and possible swallowing of high concentrations of toxic com-
ponents. An OTC product was applied in areas of gingival recession (Ghalili et al.
2014), a procedure contraindicated especially when using prefabricated trays.
Studies that used varnishes and paint-on liquids showed that these products do not
promote effective bleaching of the tooth surface (Kishta-Derani et al. 2007; Lo et al.
2007). Furthermore, clinical evidence suggests that both at-home bleaching and in-
office bleaching are equally efficient for bleaching teeth and are found to be supe-
rior to Whitestrips (Bizhang et al. 2009). We therefore consider that these materials,
apart from having poor aesthetic effectiveness, may also cause some risk to the
health of consumers (Fig. 4.2).
Among the OTC bleaching products, bleaching strips are the most popular prod-
ucts owing to their aesthetic result, making them superior to other products of the
same category available in the market (Xu et al. 2007; Yudhira et al. 2007; Kwon
et al. 2013). These products were created to use without trays, with a thin layer of
HP added to the adhesive surface that is released in relatively short periods
(5–60 min). A systematic literature review demonstrated that there are differences
in aesthetic effectiveness between the products due to the levels of active ingredi-
ents and that the whitening strips and products with high concentrations of HP
caused more adverse effects (Hasson et al. 2006).
Bleaching gels with 10 % CP for at-home use contain 3.3–3.5 % HP in its com-
position, about half of the HP concentration found in the less-concentrated strips.
Clinical studies have demonstrated that the HP concentration in the saliva of patients
who underwent bleaching with strips (5.3 % HP) is about two to four times higher
than the concentration in saliva observed for 10 % and 15 % CP gels applied in cus-
tom trays (Hannig et al. 2003, 2005).
As the bleaching strips have a predefined shape, contact of the HP-rich surface
with the gingival papilla occurs during treatment. As discussed previously, adverse
effects on gingival and periodontal tissues are expected, and the extent thereof may
lead to the development of problems in patients, especially because the products are
applied without dentist supervision, which may lead to its indiscriminate use.
The main concern regarding the safety of these bleaching strips is related to
the absence of protection of the gingival tissues.
In an interesting study by Auschill et al. (2012), the bleaching efficacy and biological
effects on soft tissues provided by bleaching agents with similar HP concentrations were
evaluated. However, the products were applied according to the supervised at-home
technique or by using a bleaching strip. Patients were instructed to use a home bleaching
gel containing 5% HP in a scalloped tray with a 1.0-mm reservoir or to apply a bleach-
ing strip containing 5.3% HP, without any method of protection of soft tissues, as rec-
ommended by the manufacturers. Both products were applied twice daily for 30 min
during the 14-day period. The bleaching efficacy during, at the end, and 18 months after
the treatment was statistically similar for both products. However, 40% of the patients
who used the bleaching strip reported soft tissue irritation, while only 20% of patients
who underwent bleaching with a tray reported the development of this adverse effect.
Tooth sensitivity was also more prevalent in the patients who used a bleaching strip
(60%) than in those who used a gel in the tray (47%). In both groups of patients, the
adverse effects were considered mild and transient. Taking into account both biological
factors (soft tissue irritation and tooth sensitivity), the incidence of discomfort during
bleaching was higher for the patients who underwent bleaching with bleaching strips.
Other clinical studies showed that the percentage of tooth sensitivity and soft
tissue irritation are proportional to the concentration of HP in bleaching strips, the
contact time with tooth and soft tissues, and the total treatment time (Kugel et al.
2011; Donly et al. 2010). According to the data reported by Swift et al. (2009),
about 80 % of soft tissue irritation cases occurred after long treatment periods in
patients who used bleaching strips. Lucier et al. (2013) evaluated the toxic effect of
bleaching strips containing 6–14 % HP on the gingival epithelium in vitro in a three-
dimensional culture model. The authors observed that the application of the bleach-
ing strips for 30 min resulted in changes in tissue morphology that were associated
with the apoptotic death of cells in all epithelial layers, inducing keratinocyte pro-
liferation and increased expression levels of proinflammatory cytokines. These
effects were proportional to the HP concentration.
The presence of cracks, enamel craze lines, exposed dentin, caries lesions,
wear facets, noncarious cervical lesions, restorations with marginal gaps, gin-
gival recession, gingivitis, and periodontal disease can influence the extent of
the harmful effects of bleaching products on oral and pulpal tissues.
However, the negative effects caused by bleaching agents used in these specific
clinical situations have been rarely studied. By contrast, a number of studies have
evaluated the aesthetic effectiveness of bleaching products and techniques. Thus,
the dentist should carry out a careful clinical exam prior to starting the bleaching
treatment in order to determine the ideal treatment for each particular case. As
discussed above, the use of products containing HP for tooth bleaching without
professional supervision represents a health risk to the population generally
unaware of the factors involved with the use of such products and the conditions
of their oral health. Regulatory bodies in Brazil (ANVISA 2015) and in the
European Union (European Commission Scientific Committee on Consumer
Products 2007; European Commission Scientific Committee on Consumer Safety
2010) have already restricted the commercialization of sodium perborate and
hydrogen peroxide-based bleaching products in order to protect the population
from the risks of using bleaching agents without professional supervision.
However, in several countries, including the United States, such products are still
accessible over-the-counter to the general population and have great economic
impact owing to the strong aesthetic appeal involved (Demarco et al. 2009).
Nevertheless, according to the Food and Drug Administration (2003), hydrogen
peroxide is safe at concentrations of up to 3%, but there are insufficient data avail-
able to permit final classification of its effectiveness at 1.5–3 % concentrations for
long-term OTC use in the mouth.
4.2.3 In-Office Bleaching
It is well established that once the in-office technique is decided upon, all oral soft
tissues, as well as the face and eyes of patients, must be protected from accidental
contact with the bleaching products. Clinical studies in which qualified practitio-
ners performed the entire bleaching procedure reported a percentage of 0–4 % of
patients with mild to moderate soft tissue irritation, irrespective of the HP concen-
tration used (Marson et al. 2008; Ward and Felix 2012). This result is expected, as
the placement of a suitable gingival barrier with flowable light-cured resin effec-
tively prevents the contact of the bleaching gel with the gingival and periodontal
tissues. However, the gingival barrier must be created carefully, and it must extend
not only to the cervical region of the teeth to be bleached but also to the adjacent
soft tissues in order to prevent inadvertent contact with the bleaching product
(please refer to video “In-Office Whitening”). Lip retractors and labial and lingual
protectors should also be used with constant suction. Figure 4.3 demonstrates the
correct use of gingival barriers and intraoral protective equipment in the in-office
bleaching. This equipment will prevent the contact of the bleaching agent with
other oral tissues caused by inadvertent movements of the patient. At the end of
the application period, the gel must be carefully aspirated from the tooth surface,
followed by washing with simultaneous suction, in order to prevent the flow of
highly concentrated product to the oral cavity and the swallowing of product resi-
due by the patient (Fig. 4.3).
a b
c d
Fig. 4.3 (a) Correct use of the gingival barrier, carefully positioned in the cervical region of the
enamel, covering interdental regions and a considerable portion of the marginal gingiva. (b)
Application of bleaching gel in ideal conditions, minimizing the possibility of accidents with the
product. (c) Incorrect application of the gingival barrier, which does not adequately extend to the
tooth surface, only extending slightly into the soft tissue (arrow) and gingival papillae. (d) A typi-
cal accident during the bleaching procedure – the bleaching gel contacts the gingival tissue (arrow).
This is a placebo gel without HP, just for illustration purposes
However, quite often, gingival barriers are positioned inappropriately or are

moved during the procedure, allowing direct contact of highly concentrated and
thus toxic peroxides with the adjacent gingival tissue. When such accidents occur,
the mucosa becomes temporarily whitened and is likely to return to clinical normal-
ity after the application of a neutralizing agent and rehydration. These effects may
be observed in Figs. 4.4 and 4.5.
Figure 4.6 depicts a clinical case in which the gingival papillae retracted and
became erythematous after the at-home part of a “jump start” technique procedure
(described in Chap. 6). During prolonged contact with the oral mucosa, signifi-
cant epithelial alteration associated with acute inflammation of the underlying
connective tissue may occur. These pathological changes generated by incorrectly
performing the bleaching procedure may cause discomfort of the patient. The
severity of the damage to the buccal mucosa can be directly related to the
Fig. 4.5 (a) Mandibular incisors submitted to in-office bleaching treatment with 38 % HP. (b)
Either the application of the gingival barrier in an excessively humid operative field or the extended
time that the gel was in contact with the teeth may have caused alterations in the gel’s thixotropic
characteristics and lead to a leakage of gel, causing extensive damage to the soft tissue. (c)
Application of neutralizing product based on sodium bicarbonate. (d) Clinical aspect 45 min after
the incident
a b
c d
Fig. 4.4 (a) Seepage of 35 % HP bleaching gel to the region that is not protected with the gingival
barrier. (b) Clinical characteristic of the gingival tissue immediately after contact with the bleach-
ing gel. (c) Application of a 10 % sodium bicarbonate neutralizing agent. (d) Clinical characteristic
of the gingival tissue 7 days after the incident
a b
c d
a b
Fig. 4.6 Effect of 10 % CP on the gingival papilla region after the at-home component of a “jump
start” technique procedure. An allergic reaction to a component of the bleaching product may have
occurred since no tray compression was observed in the papilla region. (a) Pretreatment view. (b)
After removing the bleaching agent and gingival barrier, retraction in the gingival papilla associ-
ated with an erythematous surface is observed in the region between teeth #6 (13) and #9 (21). (c)
Clinical aspect after 7 days
concentration of HP present and/or released by the bleaching product, its pH, and
the time of contact of the gel with the tissue. In an ongoing in vivo study by our
research group, the oral mucosa of rats is exposed to the application of different
bleaching gels for 30 min. Then, biopsy samples of damaged tissues treated or
untreated with a neutralizing agent (such as sodium bicarbonate) are obtained and
processed for microscopic analysis of tissue response. Preliminary analysis of
histological sections stained with hematoxylin and eosin revealed that the extent
of tissue changes varied according to the bleaching product and that treating the
damaged mucosa with a neutralizing agent reduces the extent of damage caused
by the bleaching gels, particularly those with HP concentrations greater than 15 %
(Fig. 4.7).
4.3 Effect on Oral Hard Tissues
4.3.1 Change in Color of Tooth Structure
Tooth bleaching has been the first choice of treatment of intrinsic pigmentation of
tooth structure (Williams et al. 1992; Perdigão 2010). The bleaching process is
believed to occur via the action of the low-molecular-weight HP, which easily diffuses
through the enamel and dentin, releasing reactive oxygen species that effectively pro-
mote the oxidation of the organic substrate present in the tooth structure. As a result,
dental pigmentation molecules become simpler or are eliminated. Although the tradi-
tional in-office bleaching technique (30–40 % HP, applied for 30–60 min) provides
highly satisfactory cosmetic results in a short period, the biological effects are cur-
rently controversial because of the scientific evidence proving that this therapy can
cause irreversible damage to the pulp-dentin complex.
The intense tooth sensitivity in patients treated with in-office bleaching causes
great discomfort to patients, which has led researchers to reassess the con-
cepts used in the last decades.
a b
Fig. 4.7 Bleaching gels are applied to the buccal mucosa of rats for 30 min, and then the injured
tissue is treated or untreated with a neutralizing agent (sodium bicarbonate). The mucosa exposed
to 10 % CP gel does not show any noticeable change in the epithelium and underlying connective
tissue (a, d). However, the epithelium treated with gels containing 15% (b, e) or 35 % (c, f) HP
shows numerous fingerlike papillae, acanthosis, and large areas of cell vacuolation. Intense inflam-
mation associated with cell hydropic degeneration and extensive areas of edema can be observed
in the underlying connective tissue. However, these tissue changes appeared less intense when the
mucosa of the animals exposed to these gels with high HP concentrations were subsequently
treated with a neutralizing agent
c d
e f
Fig. 4.7 (continued)

Our research group has evaluated some parameters for the application of at-home
and in-office bleaching techniques, with the aim of finding more effective and more
biocompatible bleaching techniques. These parameters include the following: (1)
the need to irradiate the in-office bleaching product with a light source; (2) HP con-
centration in bleaching gels; (3) the contact time of the product with the dental
surface; (4) the need for reapplication of the product on the tooth surface during the
same clinical session; (5) the composition of the bleaching gel (CP or HP); (6) com-
bined use of at-home and in-office bleaching techniques; and (7) acid etching of the
enamel prior to bleaching.
The irradiation of in-office bleaching agents with light sources has had a strong
commercial appeal in recent decades. It has been widely used in dental offices to
(supposedly) accelerate the bleaching procedure, a technique known as power
bleaching. The action mechanism proposed for irradiation with light is based on
thermocatalysis, resulting in a twofold increase in HP decomposition with a tem-
perature increase of 10 °C (Buchalla and Attin 2007). However, the real benefits of
light-activating bleaching products remain controversial in the literature. According
to in vivo and in vitro studies conducted by our group, irradiation of the 35 % HP
bleaching gel with halogen lamps (20–40 s/application), and LED (60 s/application)
or LED/laser sources (3 min/application), did not promote a significant increase in
the bleaching effect after the first bleaching session to 1–6 months after bleaching.
Patients who underwent bleaching with light irradiation reported a longer duration
and greater intensity of tooth sensitivity (Almeida et al. 2012; Simões et al. 2015).
Based on these findings, the use of traditional in-office gels in combination

with light sources should be eliminated from everyday practice.
In relation to the HP concentration used in the in-office technique, in vitro stud-

ies that used ultraviolet reflection spectrophotometers showed that the color change
was saturated after three or four sessions when 35 % HP gels were used, with about
50–60 % of the total color change obtained after the first bleaching session (Briso
et al. 2010b; Soares et al. 2014a; de Almeida et al. 2015b). By using nonstained
specimens with external pigments, previous authors have observed that a 20 % HP
gel resulted in the same bleaching outcome as a gel with 35 % HP; this means that
about 60 % of the color change occurred after the first bleaching session, based on
the similar color change pattern observed after the second and third sessions (de
Almeida et al. 2015b). When specimens stained with black tea (yellow pigment)
were used, a 17.5 % HP gel promoted a gradual color change in the tooth structure.
While a more concentrated gel (35 % HP) caused 50 % of the color change after the
first session, a 17.5 % HP gel promoted about 36.5 % color change, with the bleach-
ing effect being intensified gradually throughout the sessions so that no difference
with the traditional 35 % HP protocol was observed at the end of four sessions
(Soares et al. 2014a). It is noteworthy that these results obtained for both 35 % HP
gel and for 17.5 % HP gel were measured for the same duration of contact with the
tooth structure (45 min).
The advantage of using in-office bleaching materials of lower concentration is

based on the fact that these products minimize HP diffusion over the tooth
structure by about 60 %, which has a positive biological effect on pulp cells
and confers less risk to the oral mucosa.
Our data is in agreement with the results of Sulieman et al. (2004). These authors
observed that the bleaching efficacy was proportional to the concentration of the
bleaching agent applied on teeth discolored with black tea. It took 2, 4, 7, and 12
applications for the gels containing 25 %, 15 %, 10 %, and 5 % HP, respectively, to
reach the same bleaching effect observed after a single application of the gel con-
taining 35 % HP. Thus, gels with reduced HP concentration can reach the same
bleaching standard attained with more commonly used higher HP concentrations.
However, the effects of lower HP concentrations are more gradual and depend on
intensity of the stains.
Similar results were obtained for the at-home bleaching technique. After treat-
ment, gels with 16 % and 20 % CP were observed to have the same bleaching poten-
tial as a 10 % CP gel, with the latter resulting in lower tooth sensitivity and lower
incidence of soft tissue irritation (Meireles et al. 2010; Basting et al. 2012).
Regarding the presentation form, we observed that home bleaching gels with 10 %
CP have the same bleaching potential as gels with 6 % HP when applied using the
same treatment regimen (1.5 h daily for 3 weeks). However, the HP-based gel
resulted in HP diffusion into the tooth structure at about 50 % greater intensity.
Furthermore, the application of the product with 10 % CP for 1.5–3 h resulted in the
same aesthetic effect after 7, 14, and 21 days of treatment; and the shorter the con-
tact time, the lower the HP trans-amelo-dentinal diffusion (de Almeida et al. 2015a).
Home treatment with gels containing 10 % CP, applied for 3–4 h a day for 3 weeks
in a custom-fitted tray, had the same bleaching potential as traditional in-office
bleaching (Briso et al. 2010b; Almeida et al. 2012; Basting et al. 2012).
Figure 4.8 is a graph developed from data observed in our laboratory and clinical
trials. The at-home bleaching technique using either 10–16 % CP or 3–7 % HP in a
custom-fitted tray versus the in-office technique (20–40 % HP) most often provides
similar results at the end of the third week of treatment, reaching the chromatic satu-
ration in most of the cases within this period. We have also found that the combina-
tion of at-home and in-office techniques (jump start) provides a faster color change
at the beginning of treatment, which makes this an interesting option to accelerate
the aesthetic result. The association of in-office bleaching sessions with low HP
concentrations (15–20 %), with daily applications of bleaching gels with 10 % CP
over a short period (1.5 h daily), following the supervised home bleaching tech-
nique (scalloped custom-fitted tray with no reservoirs), presents itself as an
7
CP 10 %, 3 h
CP 10 %, 1.5 h
6
HP 6 %, 1.5 h
HP 6 %, 45 min
5
HP 35 %, 3 × 15 min
HP 35 %, 45 min
4
HP 20 %, 45 min
0
7 Days 14 Days 21 Days (end of treatment) 28 Days
Fig. 4.8 Color change (Delta E), according to bleaching posology employed and treatment time
attractive alternative to accelerate the aesthetic result using more biologically com-
patible bleaching techniques. However, practitioners should be aware that the indi-
cation of the at-home technique should be based on a detailed initial clinical
examination to avoid the application of the material in areas that may increase the
toxic potential of this therapy to the oral tissues. These precautions will be discussed
later in this chapter.
The need for successive reapplication of the bleaching product during the same
clinical session has also been questioned. In a recent study conducted by our group, we
observed that bleaching gels with 35–38% HP retain about 86% of the initial concen-
tration of HP after 45 min of contact with the tooth structure (Marson et al. 2015).
These results demonstrate that reapplication of the bleaching product during

in-office bleaching is not necessary.
In the study of de Almeida et al. (2015b), a 35 % HP gel resulted in the same

bleaching outcome when applied once for 45 min or three times for 15 min each.
Similarly, Soares et al. (2014a) found that the continuous application of a 17.5 % HP
gel for 15 min or reapplication of the product three times for 5 min each resulted in
the same aesthetic effects after six whitening sessions. The application of the in-
office bleaching product on the tooth structure over reduced periods of time pro-
motes gradual and effective bleaching when 35 % HP bleaching gels were tested
(Soares et al. 2014a). However, application of gels with low HP concentrations on
the tooth structure over short periods (5–15 min) resulted in a limited lightening
effect, even after six bleaching sessions (Soares et al. 2014a).
Finally, acid etching of the tooth structure prior to in-office bleaching has been
indicated in order to increase the effectiveness of this clinical procedure. In an
experiment conducted recently by our research group, etching the enamel with 37 %
phosphoric acid for 20 s immediately prior to application of 35 % HP bleaching gel
(three applications of 15 min each) did not result in a significant increase in bleach-
ing effectiveness and did not interfere with HP diffusion over the tooth structure.
Thus, as enamel acid etching with phosphoric acid changes the mineral structure of
the enamel and removes hydroxyapatite without benefiting the bleaching outcome,
it should not be used with in-office whitening.
4.3.2 Microabrasion and Tooth Bleaching
In some cases, stains can still be observed on the enamel after completion of the
bleaching treatment. While there may be several types of stains, we found that these
usually have well-defined contours and are whitish. Some of these stains can be
transient and become imperceptible with the color stabilization and rehydration of
the dental element after bleaching. Often, these white spots already existed but only
became apparent after the color change produced by the treatment. On the other
hand, yellow teeth with enamel whitish stains may be candidates for tooth whiten-
ing to have the stains attenuated.
Considering the texture or color changes of the surface layers of enamel, enamel
microabrasion using acidic and/or abrasive agents has been suggested as an excellent
alternative to improve the appearance of the teeth (Croll 1997) by camouflaging the
white spots when they are not very deep (Chap. 9). Although some studies (Paic et al.
2008; Rodrigues et al. 2013) showed that the wear of the tooth surface after this pro-
cedure is minimal, it is necessary to consider that these changes can reach different
depths. Additionally, the aprismatic enamel layer may also be affected during removal,
in addition to the removal by enamel etching by hydrochloric acid in the microabra-
sive material. These changes may substantially alter the permeability of dental hard
tissues. This issue has concerned some researchers, especially when bleaching with
35 % HP is carried out immediately after the microabrasion procedure, as the HP dif-
fusion over the tooth structure in these conditions is about 20 % higher (Briso et al.
2014a). This increase in HP diffusion may decrease the safety of the procedure
considerably.
Thus, in most cases, the microabrasive treatment is complemented with bleaching
because of the yellowish color of the teeth after erosion of the enamel. However, for con-
venience, aesthetic rehabilitation is initiated by performing the bleaching treatment,
which may be sufficient to make the intrinsic enamel stains partially or totally impercep-
tible, as previously described. If the enamel microabrasion is still deemed necessary, teeth
will invariably present a more yellowish appearance due to enamel removal and conse-
quent proximity to dentin. In these cases, a waiting period of 7 days is recommended
before at-home bleaching is initiated with low-concentration bleaching products.
4.3.3 C
hange in Hardness/Susceptibility to Caries/
Demineralization/Importance of Saliva
The effect of bleaching agents on dental enamel has been extensively studied in the
literature (Kwon et al. 2002; Spalding et al. 2003; Cavalli et al. 2004; Faraoni-
Romano et al. 2008; Forner et al. 2009). Morphological changes, increased surface
porosity, exposure of prisms, reduced organic content, change in the calcium/phos-
phate proportion, and reduced microhardness, are the main changes that occur in
enamel upon bleaching. These changes depend on the contact time of the gel with
the dental substrate, the CP/HP concentration in the product, and the pH of the
product during its use.
Soares et al. (2013b) showed that 16 % CP gel resulted in the formation of deeper
pores on the enamel surface compared to those formed with 10 % CP, along with a
more pronounced loss of calcium and phosphorus. Taking into account that the only
variable was the CP concentration, being all the other parameters standardized (pH
of the bleaching gel, the interval between applications, and the total treatment time),
the concentration of the bleaching gel was responsible for the more pronounced
changes observed when a 16 % CP gel was used. Current literature also demon-
strates that the use of high HP concentrations induces more pronounced alterations
in the ultimate tensile strength of human enamel accompanied by changes in the
enamel’s internal micromorphology and some intraprismatic material loss (da Silva
et al. 2005) (more information in Chap. 6).
As the pH of at-home CP bleaching gels ranges from 5.6 to 7.3 and the urea
released during the degradation of CP increases the pH within 15 min, the original pH
of these gels is unlikely to have any association with structural changes in the enamel,
even with prolonged contact time with the tooth surface. Thus, the pores are formed
on the enamel surface after bleaching as a result of the disruption of enamel protein
matrix and subsequent loss of the crystalline material surrounded by this matrix. This
hypothesis derives from the observation in several studies that enamel dissolution
occurs heterogeneously, with areas of erosion interleaved with areas of intact enamel
(Kwon et al. 2002; Spalding et al. 2003; Cavalli et al. 2004). As the distribution of
proteins and other organic materials are uneven on the enamel surface, the defects
observed after bleaching occur heterogeneously (Kwon et al. 2002). Other studies
have demonstrated that the dissolution occurs primarily in the interprismatic regions
and in the enamel hypomineralization areas, which are the regions with the greatest
amount of organic material (Spalding et al. 2003; Cavalli et al. 2004).
When gels with high HP concentration were used for in-office whitening, the
morphological changes on the enamel surface were significant enough to be
observed even after a single application of the product on enamel, increasing the
density of pits and different degrees of porosity (Kwon et al. 2002; Spalding et al.
2003). These changes may have been caused synergistically by the oxidative effect
of HP and its acidic pH. Although the average pH of in-office bleaching products
is around 6.5, many gels have a pH between 3.6 and 5.0 (Price et al. 2000), which
are pH values below the critical pH for enamel dissolution (5.5). Recent studies
have shown that the pH of bleaching product has a direct relationship with the
roughness of tooth enamel after bleaching and that the pH of bleaching agents
tends to decrease with increased contact time with the tooth structure (Trentino
et al. 2015; Abe et al. 2016).
Despite the various morphological changes observed on the enamel surface, stud-
ies have shown that these changes are mild to moderate. However, the contact of
bleaching products with dentin can cause more severe changes. Reduction in wear
resistance (Faraoni-Romano et al. 2009), decreased hardness (Faraoni-Romano et al.
2008; Forner et al. 2009), and increased surface roughness (Faraoni-Romano et al.
2008) have been described to be more pronounced in enamel. These findings may be
explained by the specific composition of dentin, which has a greater organic content
than enamel. Additionally, dentin has increased susceptibility to the HP oxidative
action and acidic pH of the bleaching gels, as the critical pH value for the dentinal
dissolution is between 6.2 and 6.7 (Faraoni-Romano et al. 2009). Therefore, the con-
tact of bleaching agents with exposed dentin areas is highly contraindicated.
As the changes in the enamel are considered subtle, it remains a challenge how
to extrapolate these results to the in vivo situation, where factors such as saliva and
the presence of fluoride may act to remineralize tooth structure (Kwon et al. 2002).
Studies that performed bleaching in situ (Rodrigues et al. 2005; Faraoni-Romano
et al. 2009) or applied human or artificial saliva to specimens in between the bleach-
ing steps (Spalding et al. 2003; Faraoni-Romano et al. 2008; Sasaki et al. 2009)
showed insignificant changes in the enamel, which is attributable to the remineral-
izing action of saliva. Sasaki et al. (2009) also demonstrated that the storage in
artificial saliva of specimens bleached for 14 days resulted in a significant increase
in microhardness. In their study, Spalding et al. (2003) observed under scanning
electron microscopy that bleaching with 35 % HP followed by immersion in human
saliva for 1 week resulted in the formation of a granular blanket on the enamel sur-
face, which was probably due to remineralization process by saliva. Soares et al.
(2013a) observed that the use of solutions with 0.2 and 0.05 % sodium fluoride for
1 min after each application of the bleaching gel prevented the structural changes
observed in the enamel when gels containing 10 and 16 % CP were used. Kemaloğlu
et al. (2014) also demonstrated that fluoridated solutions (2.1 % sodium fluoride)
significantly prevent mineral loss in enamel subjected to 38 % HP bleaching gels.
Although these changes tend to reverse when in contact with saliva and fluoride,
the use of peroxides in demineralized areas may worsen existing conditions. In this
context, during clinical examination, the practitioner must pay attention to the pres-
ence of incipient carious lesions that may have become wider due to the bleaching
treatment. In a recent study conducted by our group, we found that the application
of a 35 % HP gel (three times for 15 min) on specimens with demineralized enamel
to simulate incipient lesion caries resulted in a more intense HP diffusion over the
tooth structure than that observed in healthy and bleached specimens. In the same
study, we found a greater reducing effect on enamel microhardness when deminer-
alized specimens were bleached, wherein the bleaching increased the depth of
demineralization of incipient caries lesions. The surface and subsurface morphol-
ogy were also more heavily affected in the previously demineralized enamel sub-
jected to bleaching (Briso et al. 2015).
Thus, at the end of the bleaching treatment, the presence of saliva and use of fluo-
rides to promote mineral saturation in the tooth structure are important to promote
a reduction in the demineralization process and an increase in the remineralization
of tooth structures. Prior to tooth bleaching, the dental professional should perform
a careful examination in order to detect the presence of exposed dentin areas, enamel
hypomineralization, and incipient carious lesions, considering that application of
bleaching gel is contraindicated in these regions.
4.3.4 Effects on Restorations
Patients who undergo bleaching treatment may have various types of restorations.
Successful tooth bleaching relies on the direct contact of the bleaching gel with the
teeth and, hence, with the restorations, which may affect the characteristics of the
restorative material (Türker and Biskin 2003). The main changes are related to the
surface roughness (Türker and Biskin 2002, 2003), microhardness (Türker and
Biskin 2002), color (Gurbuz et al. 2013), and the marginal integrity of the restora-
tions (Ulukapi et al. 2003).
4.3.4.1 Roughness
Surface roughness is an important characteristic of restorative materials.
Adequate surface polishing of restorations results in lower risk of plaque reten-
tion and better aesthetics, which ultimately increase the longevity of restorations
(Steinberg et al. 1999). The effect of bleaching agents on the roughness of restor-
ative materials is controversial in the literature. Slight changes in surface rough-
ness of resin hybrid materials after in-office bleaching (Hayacibara et al. 2004)
and formation of microscopic cracks on the surface of the composite (Mourouzis
et al. 2013) have been reported, as well as minimal effects on dental amalgam,
composite resin, glass ionomer, and porcelain exposed to bleaching products (de
A Silva et al. 2006).
In any case, new polishing should be considered in restorations subjected to
bleaching treatment, as no matter how mild, roughening of the restorative materials
might occur. Research studies that use the same bleaching products and methodolo-
gies are rare, making a direct comparison of results impossible. In actual clinical
practice, restorations are simultaneously subjected to the formation of biofilm, tooth
brushing, and mastication, besides the chemical challenges in the oral cavity – con-
ditions that are hardly simulated in laboratory studies. Meanwhile, saliva could
dilute the bleaching gel, often reducing its concentration and its effect on the surface
of the restorative materials (Wattanapayungkul et al. 1999; Steinberg et al. 1999; de
A Silva et al. 2006).
The roughness of indirect restorative materials, such as fiber-reinforced com-

posites and porcelain, increases after exposure to bleaching agents.
The Bis-GMA and UDMA matrix of indirect resins is greatly affected by the action
of bleaching products, causing the erosion of the resin matrix and the consequent dis-
placement of filler particles. In turn, porcelains may also exhibit changes in surface
roughness (Türker and Biskin 2003; Schemehorn et al. 2004; Torabi et al. 2014b) that
are attributed to the reduction in SiO2 and K2O2 molecules (Moraes et al. 2006). These
findings, however, are opposed to those of a previous study that observed polished
porcelains had a higher resistance to bleaching products (Butler et al. 2004). These
controversial results reported in the literature can be explained by the different method-
ologies and bleaching products used. While some studies use actual dosages, others
subject their specimens to long periods of exposure to the bleaching product.
4.3.4.2 Hardness
The hardness of a material essentially relates to its properties, which in turn inter-
feres with its durability (Atash and Van den Abbeele 2005; AlQahtani 2013).
Reports showed reduced Vickers and Knoop hardness of resin materials when
exposed to bleaching agents. Reactive oxygen species are believed to promote the
cleavage of polymer chains, degrading the organic matrix that leads to the chemical
softening of resin (Taher 2005; de Alexandre et al. 2006; Briso et al. 2010a;
AlQahtani 2013). For the same reason, the hardness of the pit and fissure sealants
subjected to bleaching with low concentrations of CP was reduced. In this case, the
materials that showed the lowest microhardness values were those without filler
particles because of the higher percentage of organic matrix in their composition (de
Alexandre et al. 2006).
An in vitro study (Torabi et al. 2014a) also demonstrated changes in porcelain
microhardness. Although these values were significant, the release of SiO2 was not
clinically observed. An important factor to be emphasized is that glazed surfaces
seemed less susceptible to hardness changes, while the opposite was observed in
polished surfaces (Torabi et al. 2014a). Thus, finishing porcelain surfaces prior to
the bleaching treatment is recommended.
It is noteworthy that the bleaching products are highly unstable and that their pH
can affect the Knoop hardness of the restorative materials. For this reason, some
bleaching agents may cause more changes than others. Therefore, the selection of
bleaching agents that keep the pH around 7 throughout the complete bleaching pro-
cedure is recommended (Briso et al. 2010a).
4.3.4.3 Change in Color, Brightness, and Fluorescence

These properties have great importance to the aesthetic restorations of composite
resin and porcelain. The color, brightness, and fluorescence of direct and indirect
restorative materials are known to undergo changes during the bleaching treatment
(Canay and Cehreli 2003; Hubbezoglu et al. 2008; Li et al. 2009; Kara et al. 2013).
However, the color change that occurs in the dental tissue is much more intense,
making it imperative to replace the aesthetic restorations once the bleaching treat-
ment is completed. Therefore, it is recommended to wait until the dental tissue is
rehydrated and reaches color stability, which occurs approximately 7–15 days after
completion of the bleaching treatment.
Significant changes in brightness and fluorescence of restorative materials

were also found after bleaching, reinforcing the need to replace aesthetic restora-
tions as part of treatment plans (Yalcin and Gurgan 2005; Gurbuz et al. 2013;
Klukowska et al. 2013; Bueno et al. 2013). In porcelain subjected to low-concen-
tration bleaching agents, these changes were observed and attributed to the type
and structure of the crystals present in the porcelain studied. Composite resins
for indirect restorations are more susceptible to color changes during bleaching
than ceramics, showing less color stability in chemical challenges (Kara et al.
2013). We must, however, take into account that none of these studies were con-
ducted in a situation identical to the oral environment, where the presence of
saliva could change the outcome.
4.3.4.4 Microleakage and Effects on Bond Strength

Currently, restorative techniques are based on the adhesive bonding of resin materi-
als to tooth structure. Some studies showed changes in the marginal sealing of res-
torations subjected to bleaching treatment (Owens et al. 1998), causing a decrease
in the bond strength (Cavalli et al. 2005).
Moreover, class V restorations subjected to bleaching treatment have been
reported to present the greatest changes in the adhesive interface with dentin, mak-
ing these regions more prone to the occurrence of microleakage (Bektas et al. 2013).
The difference between the substrates suggests that the deleterious action of perox-
ides is more pronounced in tissues with higher organic content (Carrasco-Guerisoli
et al. 2009). This fact was also confirmed by White et al. (2008), who showed that
the occurrence of microleakage at cavity margins of class I restorations was not
influenced by treatment with different bleaching products.
Taking into account the findings reported in the recent literature, a thorough
evaluation of preexisting restorations is crucial, and, in the case of defective mar-
gins, protection of tooth-restoration interface with materials such as pit and fissure
sealants or adhesive systems is recommended.
As mentioned previously, the restorations of teeth with great aesthetic involve-
ment should be replaced after bleaching. In such cases, residual oxygen from the
decomposition of bleaching agents may be present within the dental tissues, nega-
tively interfering with the interaction of the adhesive system with the tooth structure
as well as the degree of conversion of restorative materials (Cavalli et al. 2005;
Briso et al. 2014b). This requires an interval of 7–15 days between the end of the
bleaching treatment and the replacement of the restorations to eliminate all the
excess oxygen (Briso et al. 2014b).
Previous studies suggested the use of antioxidants in order to reduce this interval,
aiming to counteract the negative effects of the presence of oxygen in the tooth
structure (Freire et al. 2009; Garcia et al. 2012; Briso et al. 2014b; Arumugam et al.
2014). Although many antioxidants have been studied, such as lycopene, proantho-
cyanidin, and α-tocopherol (Arumugam et al. 2014), sodium ascorbate at the con-
centration of 10 % is the most widely studied (Briso et al. 2014b). Its application is
recommended for 5–10 min prior to performing the restorative procedures (Freire
et al. 2009; Briso et al. 2012, 2014b). Its use has been associated to a significant
improvement in the marginal sealing of the restorations performed, increased bond

strength, and the micromechanical interactions that occur between the adhesive sys-
tem and the tooth substrate (Abraham et al. 2013).
The clinician must exert some caution when performing restorations immedi-
ately after the bleaching treatment, as at this time the teeth can appear dehy-
drated and with unstable color, but a color rebound may occur after a few weeks.
4.4 Tooth Sensitivity
4.4.1 Symptoms
Reactive oxygen species from bleaching products quickly reach the pulp-dentin
complex, triggering a series of biological reactions that may change the pulp condi-
tion, causing pain to patients (Markowitz 2010). Tooth sensitivity is the most fre-
quent clinically detectable side effect of the bleaching treatment, and its occurrence
raises concerns for practitioners and causes disturbance to patients, causing them to
drop out of the treatment (Rahal et al. 2014).
The penetration of HP in dental pulp results in the release of biochemical
mediators involved in the inflammatory process, which sensitize the pulp noci-
ceptors and play a role in pain modulation by causing an increase in vascular
permeability and vasodilation, changing the sensitivity threshold of nerve fibers
(Markowitz 2010). Moreover, when the peroxide from bleaching agents comes in
contact with MDPC-23 odontoblast cells during in-office dental bleaching, sig-
nificant changes in their morphology may occur and the mitochondrial respira-
tion rate decreases (Costa et al. 2010; Soares et al. 2014b). Despite the obvious
differences between the experimental models, tests conducted in Wistar rats also
confirm the aggressive potential of the in-office bleaching treatment. Such dam-
ages were proportional to the intensity of the therapy used (Cintra et al. 2013). In
turn, a recent study on human teeth showed that excessive exposure to peroxides
may lead to a slight disturbance in the odontoblast layer on premolars and coagu-
lation necrosis areas in lower incisors subjected to the in-office bleaching treat-
ment (Costa et al. 2010).
All of these occurrences have encouraged authors to carry out studies with the
aim to minimize these side effects (Giniger et al. 2005; Armênio et al. 2008; Tay
et al. 2009). Among clinical analyses, neurosensory investigations through quantita-
tive sensory tests have led to the conclusion that patients who undergo bleaching
treatments experience different levels of discomfort, a fact observed when the pain-
ful tooth sensitivity threshold was altered (Rahal et al. 2014).
In clinical practice, the methods used to minimize patient discomfort rely on
the administration of analgesics and/or the use of topical desensitizing agents,
which may be added into the composition of bleaching agents (Jorgensen and
Carroll 2002; Croll 2003; Giniger et al. 2005; Haywood 2005; Armênio et al.
2008; Tay et al. 2009; Basting et al. 2012). Several types of desensitizing agents
with different action mechanisms have been used, some having physical action
that seals the dentinal tubules and others having neural action that blocks nerve
stimulation (Tay et al. 2009; Basting et al. 2012; Palé et al. 2014).
In fact, some desensitizers are effective and reduce the discomfort caused by the
bleaching treatment. A recent report (Rahal et al. 2014) showed a reduction in the
neurosensorial response of teeth treated with a desensitizer after bleaching. In this
split-mouth design study, the bleaching treatment was performed in the upper arch.
Only one hemiarch received the topical desensitizer containing 5 % potassium
nitrate and 2 % sodium fluoride. The results obtained after the use of the desensitizer
showed a clear reduction in sensitivity.
Despite all these studies on tooth sensitivity, products or techniques that restrict
the action of peroxides on dental pigments or that effectively modulate the penetra-
tion of peroxides in the pulp tissue have not yet been developed. Dentists have very
limited information on the potential for tooth sensitivity when considering tooth
bleaching as a therapy in which a HP-based drug is topically applied to tooth
enamel, thus causing undesirable side effects. Therefore, a patient-specific individu-
alized treatment is indispensable for delivering a controlled peroxide dosage in
function of each individual patient’s conditions.
In case of teenage patients who have wide pulp chambers, they should be treated
in a highly conservative manner, using low-concentration bleaching materials and
restricting their use to a few hours per day or simply discontinue the use for a few
days at a time.
In general, special attention should be given to the dosage used. Sometimes,
the practitioner may intuitively consider that the greater the amount of peroxide
that penetrates into dentin, the greater the color changes obtained. However, all
bleaching therapies (at-home and in-office) may provide similar results, taking
an average of 3 weeks for chromatic saturation (Bernardon et al. 2010). In the
case of the in-office technique with 35 % HP, the 30-min application time has
been proven to provide the same results as the 45-min exposure to bleaching.
Additionally, the continuous renewal of the bleaching product every 15 min has
proven to be unnecessary to achieve bleaching results, as the product retains its
activity throughout the clinical session (Marson et al. 2015). While the dosage
most often adopted for in-office bleaching (35 % HP from 45 to 60 min with
multiple changes) denotes great effectiveness in promoting peroxide penetration
into the pulp tissue, it does not result in effective bleaching of the teeth (Costa
et al. 2010; Soares et al. 2014b).
Another factor to be considered is the condition of the oral environment, which
should also be carefully analyzed. Besides recommending various bleaching tech-
niques, the practitioner must pay attention to the alternative routes of peroxide dif-
fusion, which can be neglected by the operator, greatly favoring the penetration of
the peroxide into the pulp chamber.
4.4.2 Protection Protocols
The treatment options currently adopted by clinicians can result in all the unwanted
biological effects previously mentioned. This is especially important when no
concern is given to the suitability of the oral cavity for receiving a HP-based prod-
uct and when dosage is not adjusted for each type of patient. Thus, in addition to
the care in the indication of a suitable dosage for the patient, we must highlight
some specific conditions in which the penetration of peroxide into the pulp tissue
is increased, thereby causing great possibility of undesirable side effects to
patients.
4.4.2.1 Incipient Carious Lesions

Owing to the difficulty of diagnosis or negligence, incipient carious lesions often do
not receive adequate attention prior to tooth bleaching. Several studies showed that
both at-home and in-office bleaching treatment provides transitional histological
changes in the enamel (Akal et al. 2001; Bistey et al. 2007). However, performing
in-office bleaching treatment on enamel with incipient carious lesions accelerates
the evolution of the caries lesion to deeper enamel areas (De Arruda et al. 2012;
Briso et al. 2015).
The presence of demineralized areas has also been recently associated to the
amount of peroxide that reaches the dentin-pulp complex. Demineralized substrate
has been found to offer lower resistance to the penetration of HP (Briso et al. 2015),
resulting in higher posttreatment sensitivity. Thus, bleaching is totally contraindi-
cated for teeth presenting demineralized areas. Once the demineralized areas are
detected and the contributing factors are identified, the practitioner must establish
the most appropriate therapeutic approach for each specific case (Hicks et al. 1984;
Hunt 1990; Willmot 2004). Usually the treatment is initiated with daily low-
concentration fluoride rinses (0.05 %). Depending on the case, the practitioner may
increase the fluoride dosage with weekly application of 5 % fluoride varnish or
1.23 % acidulated fluoride-phosphate gel (Pinto 2001) in the weeks prior to the
bleaching treatment until the remineralization of the region is observed.
The application time varies according to the product used, the first being applied
to the tooth surface for 4 min according to the American Dental Association Council
on Scientific Affairs (Pinto 2001; Braxton et al. 2014), while the varnish is main-
tained on the treated surface for 24 h. After remineralization of lesions is detected,
the bleaching treatment can be performed. In cases where the stains show again
signs of activity during the bleaching treatment, discontinuation of treatment and
remineralization of new lesions are recommended.
4.4.2.2 Presence of Cracks in the Enamel

The presence of cracks in the enamel is common in buccal surfaces, though rarely
valued by practitioners. These changes appear as fissures within the enamel, extend-
ing mainly to the cervical-incisal axis, even reaching the dentin-enamel junction
and causing fractures in the tooth structure (Abbott and Leow 2009).
These defects on the enamel surface represent a rapid penetration route of the
peroxides used in the in-office bleaching treatment (Briso et al. 2014a) and may be
harmful to pulp health and increase transoperative and postoperative pain. Thus,
regardless of the bleaching technique used, sealing these cracks with adhesive mate-
rials is recommended.
4.4.2.3 Exposed Dentin Areas

Exposed dentin areas, especially in the cervical and incisal regions, are common in
the oral cavity.
Exposed dentin facilitates the diffusion of peroxide, causing sensitivity during

the course of treatment. For this reason, it is essential to protect these areas
with appropriate resin materials.
In the cervical region, two distinct conditions determine the type of treatment,
namely the presence and absence of cavitation. When cavitation is observed, this
area should be protected with resin-modified glass ionomer, with the possibility of
leaving the ionomer material underneath the final composite restorations with com-
posite resin after the bleaching treatment.
On the other hand, when the cervical dentin tissue is exposed without cavitation,
the insertion of the restorative material will invariably result in an anatomical over-
contour in the region. For this reason, we indicate the application of an adhesive
system as a means of sealing the dentinal tubules in the region. The material of
choice for these cases is a self-etching adhesive, as its acidic monomers slightly etch
dentin, followed by immediate penetration of the fluid resin, while minimizing the
incidence of etching in areas not protected by the adhesive (Yousaf et al. 2014).
However, because of its high solubility in the oral environment, in case of longer
bleaching treatments, the sensitivity may relapse. For this reason, reapplications of
the adhesive are often necessary (Baracco et al. 2012). Similarly, exposed dentin in
incisors, especially lower incisors and canines, is common. These regions must also
be protected before the bleaching treatment, although in this case, a pit and fissure
sealant is recommended (Fig. 4.9).
4.4.2.4 Presence of Restorations with Marginal Gaps

The presence of restorations on teeth that will receive bleaching treatment should be
carefully evaluated, as the presence of fractures and marginal gaps represent places
of easy diffusion of peroxides. These areas should be protected by sealing the tooth/
restoration interface to reduce or prevent the penetration of the bleaching material
into the dental tissue (Patri et al. 2013).
Although no material has the ability to hermetically seal the tooth/restoration
interface (Gokay et al. 2000; De Munck et al. 2005; Cenci et al. 2008), the movement
of dentinal fluid toward the tooth surface (Vongsavan and Matthews 1991), associ-
ated with the use of sealing materials, is believed to be a deciding factor to implement
a b
c d
Fig. 4.9 (a) Incisal region with dentin exposure. (b) Acid etch with 35 % phosphoric acid (total-
etch technique). (c) Application of dentin/enamel adhesive. (d) Exposed dentin area is sealed and
teeth are ready to undergo bleaching treatment
an adequate protective measure for dental tissues. The adhesive systems and the pit
and fissure sealant are materials of choice for marginal sealing of these restorations
because they have good penetration and flow, forming an effective physical action in
these regions, at least during the course of the bleaching treatment.
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Human Pulpal Responses to Peroxides
5
Diana Gabriela Soares, Josimeri Hebling, and Carlos Alberto
de Souza Costa
Abstract
It is known that most patients subjected to professional tooth bleaching report

posttreatment hypersensitivity that varies from slight to intolerable. The pathway
for tooth bleaching-induced sensitivity has been correlated with the capability of
hydrogen peroxide (H2O2), the main active component of bleaching gels, to dif-
fuse through enamel and dentin to reach the pulp tissue. Since H2O2 is a toxic
reactive oxygen species with a high oxidative power, it is expected that the con-
tact of this molecule with the pulp tissue promotes oxidative cells damage lead-
ing to local connective inflammation that trigger nociceptive stimulus. However,
as this clinical symptom is transient, discussion about how relevant is this adverse
collateral effect to the pulp-dentin complex remains. Then, in this chapter, the
authors describe some relevant clinical and laboratorial data currently provided
by a number of in vitro and in vivo studies in which traditional in-office (profes-
sional) and at-home bleaching therapies were tested, as well as discuss alterna-
tive tooth bleaching protocols that may prevent or at least minimize the negative
effects of these esthetic treatments to the pulp tissue vitality.
D.G. Soares • Carlos Alberto de Souza Costa (*)

Department of Physiology and Pathology, Araquarara School of Dentistry, UNESP,
Araquarara, SP, Brazil
e-mail: casouzac@foar.unesp.br
J. Hebling
Department of Orthodontics and Pediatric Dentistry, Araquarara School of Dentistry, UNESP,
Araquarara, SP, Brazil

82 D.G. Soares et al.
5.1 Introduction
Despite the well-known role played by hydrogen peroxide (H2O2) on oxidative cells
stress and inflammatory tissue reactions induction, this molecule has been widely
used as the main active principle for bleaching therapies performed in vital teeth.
The results of randomized clinical trials for a wide array of bleaching products have
shown that a number of patients undergoing H2O2-based bleaching therapies com-
plain about tooth sensitivity (Reis et al. 2011, 2013; He et al. 2012; Tay et al. 2012;
Santana et al. 2014; de Paula et al. 2015).
Overall, to be regarded as an esthetically effective therapy, the H2O2 present in
the bleaching gels has to diffuse through enamel to reach dentin substrate in which
the intrinsic pigments are mainly located. This effect is possible since H2O2 features
high stability in comparison to other reactive oxygen species (ROS) due to its low
oxidation potential. After reaching dentin, the H2O2 molecule must give rise to other
free radicals with higher oxidation potential and capable of promoting effective
chromogen decomposition. However, dentin is a highly permeable tubular substrate
that provides an easy pathway for inward H2O2 diffusion to reach the pulp chamber.
Indeed, several laboratory studies (Gökay et al. 2000, 2004, 2005; Camargo et al.
2007; Ubaldini et al. 2013) have demonstrated that high concentrations of residual
H2O2 remain undissociated within hard tooth structures, and these nonreacted mol-
ecules are able to contact pulp cells. According to these studies, the higher the
concentration of H2O2 on the bleaching gel and the contact time with tooth struc-
ture, the higher the detection of residual H2O2 inside pulp chamber.
The presence of high concentrations of H2O2 in the extracellular environment is
considered a dangerous condition, since this molecule can diffuse through cellular
membranes. Once in the cell cytoplasm, H2O2 may be dissociated into several toxic
free radicals, leading to an oxidative stress condition, which is correlated with a pleth-
ora of cellular alterations, ultimately with cell death. The sensitivity of cells to undergo
oxidative stress during periods of high ROS exposure appears to be cell type specific
(Ceçarini et al. 2007). It has been shown that human dental pulp cells feature a high
sensitivity to the oxidative stress mediated by H2O2 in vitro. Therefore, the same
amount of H2O2 capable of causing complete depletion on human dental pulp cells
viability has no significant toxic effect on primary culture of human gingival fibroblasts
and other cell lineages (Zhu et al. 2012). Consequently, to understand the biological
effects of residual H2O2 released from bleaching gels on pulp tissue, our research group
has carried out innovative laboratory studies using artificial pulp chambers, as well as
in vivo histopathological investigations in human teeth. An overview of the scientific
and clinical data obtained in such studies is presented in this chapter.
5.2 In-Office Bleaching Mediating Toxicity on Dental Pulp

Cells
About 86–90 % of patients subjected to professional in-office bleaching therapy

(i.e., 30–40 % H2O2 bleaching gels applied onto dental structure for 30–60 min at
each bleaching session) report posttreatment tooth sensitivity (Tay et al. 2012;
5 Human Pulpal Responses to Peroxides 83
Fig. 5.1 Patient subjected to a professional in-office tooth bleaching therapy, which can be esthet-
ically regarded as a success. However, the patient reported postbleaching sensitivity in the anterior
teeth (Images provided by Dr. Heraldo Riehl) (a) Clinical condition before bleaching therapy,
(b) In-office bleaching therapy with a 35% H2O2 gel, (c) Post-bleaching clinical condition.
Santana et al. 2014), with intensity varying from moderate to severe in around 60 %
of cases (Fig. 5.1) (Tay et al. 2012). The prevalence of tooth sensitivity may reach
100 % when traditional in-office therapy is associated with light sources (Reis et al.
2011).
Recent clinical studies have demonstrated that the prevalence and intensity of
tooth sensitivity is restricted to anterior teeth and proportional to the tooth size, with
incisors being the most susceptible teeth (de Almeida et al. 2012; Bonafé et al.
2013). Therefore, the toxic potential of traditional in-office therapy on pulp cells has
been the focus of a number of preliminary studies carried out by our research group.
When a 35 % H2O2 gel was applied for three consecutive periods of 15 min onto
3.5-mm thick enamel/dentin discs (simulating upper central incisors) adapted to
artificial pulp chambers (APC), gel components that diffused through dental struc-
ture (extract) caused toxic effects to pulp cells. In such laboratorial studies the
extracts were applied to the cells for 1 or 24 h. After a 1-h contact time, the
odontoblast-like cells, an immortalized cell lineage from rat dental papillae, fea-
tured 50–60 % of cell viability reduction (Soares et al. 2013a, b; Duque et al. 2014;
de Almeida et al. 2015; Soares et al. 2015a). Almost 100 % of cell viability reduc-
tion was observed after 24-h exposure of pulp cells to these extracts (Coldebella
et al. 2009; Trindade et al. 2009). Cell morphology was completely disturbed, with
cells showing apoptotic body-like structures, as shown on Fig. 5.2. Human dental
pulp cells exposed to the bleaching gel extracts were even more vulnerable, cor-
roborating data previously reported in the literature. Around 97 % of cell viability
reduction was observed in human pulp cells after only 1-h contact time. The
Fig. 5.2 (a) Scanning electron micrograph showing the morphology of normal odontoblast-like
MDPC-23 cells. Original magnification = ×3,000. (b) Scanning electron micrograph showing a
MDPC-23 cell exposed for 1 h to the extract obtained after simulated traditional in-office bleach-
ing therapy. Original magnification = ×3,500
intensity of the negative effects caused by the 35 % H2O2 bleaching gel on pulp cells
was proportional to their contact time with dental structure, which was directly
related to the amount of H2O2 capable of diffusing through enamel/dentin discs
(Soares et al. 2013a, b, 2015a; Duque et al. 2014). Also, association of this in-office
bleaching technique with light sources increased significantly the in vitro cytotoxic-
ity (Dias Ribeiro et al. 2009), since this procedure leads to more intense H2O2 diffu-
sion through tooth structure, as previously demonstrated (Camargo et al. 2009).
According to our data, pulp cell viability reduction after tooth bleaching seems
to be associated with cell membrane rupture and oxidative stress generation, in a
time/concentration dependent fashion. In fact, these effects are proportional to the
H2O2 dosage capable of reaching the cells, with high concentrations leading to cell
death by necrosis following two pathways: (1) direct contact with free radicals from
extracellular H2O2 decomposition, leading to cell membrane rupture; (2) the onset
of a pathologic oxidative stress condition after H2O2 diffusion through cell mem-
brane and further decomposition into free radicals on cytoplasm, culminating with
lipid peroxidation (Soares et al. 2014a, 2015c).
Since the amount of H2O2 capable of reaching cells after trans-enamel and trans-
dentinal diffusion is the main pathway for bleaching-induced cell toxicity, reducing
this phenomenon is highly required for minimizing the oxidative damage on pulp
cells, turning bleaching into a safe procedure compatible with pulp health. More
recent data collected by our research group determined that decreasing the H2O2
concentration in the bleaching gel by 50 %, and applying the gel from 5 to 45 min
on enamel, may decrease 11.3- to 4.5-fold, respectively, the toxicity of in-office
tooth bleaching to pulp cells compared with simulated traditional therapy (35 %-H2O2
3 × 15 min) (Soares et al. 2014a). These alternative protocols using a 17.5 % H2O2
gel allowed such cells to overcome the low initial oxidative damage and feature a
regenerative phenotype through time (Soares et al. 2014a, 2015b).
According to our data, the degree of disturbance on the expression of odontoblas-
tic markers (ALP, DSPP, DMP-1, and mineralized nodule deposition) after tooth
bleaching, was related to the oxidative stress intensity and to the overexpression of
IL-1β, TNF-α, IL-6, and COX-2 on remaining cells (Soares et al. 2015b, 2016a). It
has been demonstrated that both oxidative stress intensity and pro-inflammatory
mediator dosage have direct relationship on pulp tissue regeneration capability.
Exposure of human dental pulp cells to high doses of pro-inflammatory mediators,
such as TNF-α and IL1-β, may negatively interfere with their odontoblastic markers
expression and mineralization rate, whereas low dosages seem to have an opposite
effect (Min et al. 2006; Paula-Silva et al. 2009; Alongi et al. 2010). Nevertheless, it
was demonstrated that human dental pulp cells under intense oxidative stress trig-
gered by long-term exposure to H2O2 had the expression of DSPP and DMP-1 mRNA
downregulated associated with no mineralized matrix deposition. Conversely, the
treatment of these cells with nontoxic concentrations of H2O2 enhanced ALP activity
and calcified nodule deposition as well as increased DSPP, OPN, and OCN expres-
sion (Lee et al. 2006, 2013; Min et al. 2008; Matsui et al. 2009).
Therefore, the lower the concentration of H2O2 in contact with pulp cells
after tooth bleaching, the higher the regenerative capability of human pulp
tissue to overcome the oxidative damage.
With this in mind, future studies should focus on strategies for reducing the
amount of residual H2O2 and other free radicals capable of diffusing through the
dental structure to reach the pulp chamber, since these toxic molecules play a cen-
tral role on pulp tissue damage.
Recent data obtained in our lab demonstrated that bleaching gels containing
8–10 % H2O2 minimize significantly the initial toxicity on human dental pulp cells
(Soares et al. 2015a). Also, we observed that these bleaching gels are capable of
promoting the same color alteration on thin enamel/dentin discs as high concen-
trated gels applied on thick discs (unpublished data). Therefore, tailoring the bleach-
ing regimen to the tooth size appears to be an interesting alternative to achieve an
effective, safe, and biocompatible in-office bleaching technique.
Therefore, tailoring the bleaching regimen to the tooth size appears to be

an interesting alternative to achieve an effective, safe, and biocompatible in-
office bleaching technique.
5.3 Effects of At-Home Bleaching on Pulp Cells In Vitro
The at-home bleaching therapy with 10 % carbamide peroxide (CP) agents has been
considered the safest method for tooth bleaching since minimal clinical adverse
effects have been reported in literature (Boushell et al. 2012). The scientific data
obtained in recent years by our research group has demonstrated that the application
of 10 % CP gel from 1.5 to 8 h onto dental structure does not result in significant
toxic effects on both odontoblast-like cells and human dental pulp cells (Soares
et al. 2011; Lima et al. 2013; Duque et al. 2014; Almeida et al. 2015). According to
our data, application of 10 % CP gel for 4 h onto 3.5 mm enamel/dentin discs results
in 16 times less intense H2O2 diffusion in comparison to the traditional in-office
bleaching protocol, i.e., 35 % H2O2 gel 3 × 15 min (Duque et al. 2014). Nevertheless,
higher CP concentrations (15–22 %) are available for at-home tooth bleaching, with
the appeal of promoting a faster bleaching outcome.
Data collected from our group showed that increasing CP concentration from 10
to 16 % increases the toxicity of this treatment to pulp cells (Soares et al. 2011).
Taking into consideration that clinical studies have demonstrated that higher con-
centrations of CP gels cause the same bleaching outcome as that achieved by using
10 % CP gel (Matis 2003; Meireles et al. 2010, Basting et al. 2012), the use of
higher concentration products has no advantage and may be more toxic to pulp
tissue.
H2O2-based at-home bleaching products are also available. We have observed
that the application of 6 % H2O2 gels from 45 min to 1.5 h have no toxic effect on
odontoblast-like cells, instead the amount of H2O2 capable of diffusing through den-
tal structure and interact with the cells was twice as high as that of the 10 % CP gel
(Almeida et al. 2015). Also, a 10 % H2O2 whitening strip (WS) applied for 1 h on
tooth structure did not cause trans-enamel and trans-dentinal cytotoxicity to this
same pulp cell lineage. The WS resulted in about 13 times lower H2O2 diffusion
than that observed for traditional in-office bleaching therapy with the 35 % H2O2 gel
(Soares et al. 2013b). Despite the interesting results obtained with WS, this treat-
ment is currently carried out without direct professional supervision. Therefore,
there is a risk of overuse associated with this over-the-counter at-home bleaching
technique, which, in turn, may cause higher toxic effects to pulp cells. According to
our data, the toxic effect of the WS and CP was time dependent; the toxicity of these
products increases significantly after 1-h daily application during 5 consecutive
days (Lima et al. 2013; Soares et al. 2013b).
The main concern regarding at-home bleaching relies on the fact that it is a
patient-applied therapy; therefore, there is a risk of gel application on exposed den-
tin areas, craze lines, and restoration interfaces that may increase H2O2 diffusion
through hard tooth structures. Also, the inappropriate use of the tray may result in
gel overflow, with extended soft-tissue exposure and likely material ingestion.
Therefore, it is imperative that this treatment is performed under professional super-
vision. Also, the professional should perform a detailed clinical evaluation before
prescribing this therapy.
5.4 Histopathological Analysis of Human Dental Pulp

After In-Office Bleaching
Based on data collected in in vitro studies, it is believed that the presence of high
concentrations of H2O2 within the pulp chamber is responsible for the intense oxida-
tive stress condition that causes cell membrane disruption associated with pulp cell
death by necrosis (Soares et al. 2014a, 2015b, c, 2016a). This kind of cytotoxic
effect also promotes extensive damage on the neighboring tissue, since lysosome
enzymes and other toxic substances are leached from dying cells, causing a ripple
effect. Consequently, acute inflammatory reaction is expected with expression of a
plethora of pro-inflammatory cytokines and chemokines, followed by expression of
hyperalgesia mediators, such as prostaglandins (Cooper et al. 2010; Markowitz
2010; Pashley 2013; Cooper et al. 2014). These cellular events have been correlated
with the clinical symptoms of tooth sensitivity. In order to detect these events on
human pulp tissue, our group associated with other research groups around the
world has conducted histopathological analysis on human teeth subjected to profes-
sional in-office bleaching therapies. In many of these studies, sound premolars and
mandibular incisors scheduled to be extracted for orthodontic reasons were selected,
after respective approval by Ethical Committees. Therefore, the volunteers (or legal
guardians for patients below 18 years of age) received all necessary explanations
including the experiment rationale, the clinical procedures to be performed and pos-
sible risks, and signed a consent form explaining the research protocol.
When a bleaching gel with high concentration of H2O2 (38 %) was applied for
three times of 10 min each in sound mandibular incisors from young patients (age
mean 16.2 years), intense pulpal damage occurred in about 75 % of samples. Pulp
necrosis was observed in a wide area of coronal pulp tissue. Deposition of reaction-
ary dentin in part of the coronal and root pulp tissue associated to mild local inflam-
matory response was also detected in bleached incisors (Fig. 5.3).
Fig. 5.3 (a) Pulp horn (PH) of a human lower incisor subjected to a professional in-office bleach-
ing with 38 % H2O2. Note the large area of necrosis. H/E, ×64. (b) Intense deposition of tertiary
dentin is observed (arrows) in the radicular pulp chamber, in which a small area of residual pulp
(P) tissue with inflammation can be seen. H/E, ×64. (D dentin)
On the other hand, pulps of premolars subjected to the same bleaching protocol
with the 38 % H2O2 gel showed the following histopathological features: tubular
dentin and predentin, intact odontoblastic layer, and cell-free zone and cell-rich
zone, such as observed in control groups (nonbleached incisors and premolars)
(control teeth – Fig. 5.4).
In this experiment, the mean of dentin thickness was 1.82 ± 0.08 mm for bleached
incisors and 3.10 ± 0.11 mm for bleached premolars. Only patients who had their
incisors bleached reported tooth sensitivity (de Souza Costa et al. 2010). Similar
results were found when sound mandibular incisors (mean age 18.2 years) were
bleached with a 35 %-H2O2 gel applied on enamel for 3 consecutive periods of
15 min each or 1 period of 45 min. Similar pulp tissue responses were found for
both tested protocols with the 35 %-H2O2 gel. The majority of bleached incisors
(80 %) exhibited large zone of coagulation necrosis in the coronal pulp tissue asso-
ciated to mild/moderate inflammatory response on surrounding tissue. Tertiary den-
tin adjacent to the necrotic tissue was observed in 25 % of those teeth, associated
with reactionary dentin in the lateral walls of the coronal and root pulp chambers
(Fig. 5.5). Moderate deposition of reactionary dentin with no coronal pulp necrosis
occurred in only 20 % of samples, which exhibited mild inflammatory pulp reaction.
All patients subjected to bleaching protocol reported tooth sensitivity (Roderjan
et al. 2015).
These data corroborate those obtained from clinical investigations, in which the
authors demonstrated that tooth sensitivity is restricted to anterior teeth subjected to
in-office bleaching (de Almeida et al. 2012; Bonafé et al. 2013). According to these
authors, teeth bleached with 35 %-H2O2 gel applied on enamel for 3 consecutive
periods of 15 min each had tooth sensitivity in 76.6 % of lateral incisors, 53.3 % of
central incisors, and 30 % of canines, with no discomfort reports for premolars.
Fig. 5.4 Pulp horn (PH)

of a human tooth
exhibiting normal
histological features. Note
the odontoblasts (arrows)
underlying the tubular
dentin (D) and the
subjacent cell-free zone. A
number of small blood
vessels among collagen
fibers and fibroblasts can
be observed. Masson’s
Trichrome, ×125
Thus, one can conclude that enamel/dentin thickness plays an important role in
H2O2 diffusion across hard tooth structures to reach pulp chamber, causing tissue
damage and postbleaching sensitivity, which are more intense in anterior than in
posterior teeth.
Another investigation showed that partial pulp necrosis occurred in 60 % of man-
dibular incisors of elderly patients (54–62 years old; mean 58.2 ± 4.3) in comparison
with 100 % of young patients (18–30 years old; mean 20.1 ± 4.3) that were bleached
using the same in-office bleaching therapy. Additionally, areas of pulp necrosis
were larger in young teeth. The main dentin thickness on young and elderly patients
was 1.77 ± 0.08 mm and 1.99 ± 0.10 mm, respectively. As observed in the previous
study, the histological sections evidenced a number of differentiated odontoblast-
like cells that deposited a layer of reparative dentin below the necrotic area. These
pulp responses against bleaching products are similar to those observed after cal-
cium hydroxide application on pulps of sound teeth mechanically exposed (Roderjan
et al. 2014). Therefore, it seems that even in human pulps strongly damaged by in-
office tooth bleaching procedures, the pulp cells subjacent to the necrotic tissue are
capable of maintaining their phenotype, confirming the data collected in previous
in vitro studies carried out by our research group.
Based on these data, tooth sensitivity experienced by patients subjected to in-
office bleaching with 35–38 % H2O2 may be associated with inflammatory reac-
tion caused by oxidizing toxic compounds from bleaching gels capable of
reaching the pulp chamber, producing an intense chemical irritation of pulp cells.
Because of the fact that in-office tooth bleaching causes pulp damage, the release
of cell-derived factors, such as prostaglandins, would excite or sensitize pulpal
nociceptors. Additionally, we believe that the fluid shifts that occur in dentinal
tubules due to vasodilation and increased pulp pressure during local tissue
inflammation may trigger impulses in the intradentinal pulpal nerve fiber end-
ings, causing the intense tooth sensitivity that has been claimed by patients sub-
jected to this professional in-office therapy. However, further studies are needed
to assess in detail this topic.
Fig. 5.5 Radicular pulp

(RP) tissue of a bleached
human lower incisor. Note
the lateral deposition of
reactionary dentin (RD),
which exhibits a reduced
number of tubules with
cytoplasm processes within
them. Masson’s Trichrome,
×180
5.5 Tooth/Restoration Interface as a Pathway for Bleaching

Inducing Toxicity
Recent clinical trials showed that the intensity of tooth sensitivity is increased when
traditional in-office tooth bleaching is performed in anterior teeth that have adhesive
restorations with no clinical sign of margins degradation (Bonafé et al. 2013). It
seems that the presence of restorations in tooth to be bleached may enhance H2O2
diffusion into the pulp chamber. In addition, dental materials used to restore dental
cavities interfere significantly with this H2O2 diffusion through enamel and dentin
(Gökay et al. 2000, 2004; Benetti et al. 2004; Camargo et al. 2007). Therefore, as
several restorative materials and bleaching protocols are available in clinical prac-
tice, the question related to the safety of tooth bleaching performed in restored teeth
remains a concern (Fig. 5.6).
Previous studies demonstrated that different adhesive systems have variable
degrees of susceptibility to H2O2, as follows: one-step self-etch > two-step self-etch
> etch-and-rinse systems (Van Landuyt et al. 2009; Didier et al. 2013; Dudek et al.
2013; Roubickova et al. 2013). According to the results collected in our laboratory,
self-etch adhesive interfaces act as a pathway for H2O2 diffusion from tooth surface
into pulp chamber, increasing significantly the toxicity of a 35 %-H2O2 gel on pulp
cells (Soares et al. 2015d). Nevertheless, no significant difference concerning cyto-
toxicity and trans-enamel and trans-dentinal diffusion of H2O2 was observed when
etch-and-rinse adhesive restorations where bleached with a 20 or 35 % H2O2 gels for
45 min (Soares et al. 2014c). One can conclude that the compromised bond perfor-
mance of some self-etch adhesives to enamel and dentin creates a more permeable
tooth/restoration interface, facilitating H2O2 diffusion through dental structure.
Resin-modified glass-ionomer cements (RMGIC) interface seem to present the
same susceptibility to H2O2 as self-etch adhesive systems. The shear bond strength
of RMGIC to tooth structure is significantly lower than those observed for etch-and-
rinse adhesive systems, due to the low cohesive strength of GIC (Marquezan et al.
2011; Bonifácio et al. 2012; Nujella et al. 2012). According to our results, applying
a 35 %-H2O2 gel onto enamel/dentin discs containing RMGIC interfaces subjected
Fig. 5.6 Anterior teeth with resin composite restorations (arrows) that were selected by a clini-
cian for professional bleaching (Images provided by Dr. Heraldo Riehl)
to hydrolytic degradation allowed for a more intense H2O2 diffusion through hard
dental structures, as well as increased the in vitro cytotoxicity to odontoblast-like
cells, leading to increased oxidative stress and IL-1β overexpression as well as dis-
turbing the odontoblastic markers expression (Soares et al. 2016b).
Therefore, clinicians should pay attention when selecting the bleaching protocol
to be applied in patients that have a number of restored teeth, especially incisors.
The materials used for restoring carious and noncarious lesions, as well as the integ-
rity of restoration margins, should be also analyzed in detail in order to prevent, at
least in part, damage to pulp tissue and possible postbleaching pain.
5.6 Strategies to Prevent Tooth-Bleaching Mediating Pulp

Cells Oxidation
The primary strategy for minimizing pulp tissue damage is based on reducing
the amount of residual H2O2 capable of reaching the pulp tissue.
As discussed above, reducing the H2O2 concentration on bleaching gels, as well

as the contact time of these toxic products with tooth structure, seems to have a posi-
tive biologic effect. According to our results, a 17.5 % H2O2 bleaching gel reduced
significantly the trans-enamel and trans-dentinal toxic effects of the therapy to pulp
cells, which is commonly observed after professional in-office tooth bleaching
using 35 % H2O2 gels (Soares et al. 2014a). It was demonstrated that even a concen-
tration of 17.5 % H2O2 decreased the human pulp cell viability by 86 %, 77 %, and
65 % after applying the product on enamel/dentin discs for 45, 15, or 5 min, respec-
tively (Soares et al. 2014a). These bleaching protocols also induced intense overex-
pression of pro-inflammatory mediators and caused reduction on odontoblastic
markers expression, demonstrating that the remaining cells were under pathologic
oxidative stress (Soares et al. 2015b). Regarding the esthetic bleaching effective-
ness, similar color alteration as traditional protocol (with 35 % H2O2 gels) was
achieved after four sessions when the 17.5 % H2O2 gel was applied for 45 min on
enamel. However, application of this gel for 15 or 5 min on enamel did not result in
the same bleaching outcome as that of high concentrations, even after six sessions
(Soares et al. 2014b). A more positive biological effect on human dental pulp cells
was achieved when less concentrated bleaching gels were used (8–10 % H2O2); but
the bleaching effectiveness remained as the main drawback for these alternative
tooth bleaching therapies (Soares et al. 2015a).
Strategies based on increasing H2O2 decomposition into hydroxyl radicals (OH•)
in order to eliminate residual H2O2 that can diffuse deeply into enamel and dentin to
reach the pulp tissue in concentrations high enough to cause intense tissue damage
and postbleaching sensitivity has been evaluated currently. It is known that OH• has
higher oxidation potential (E0 = 2.8 V) in comparison to H2O2 (E0 = 1.8 V), which in
turn make its interaction with chromogens more effective. Also, since OH• is
considered as a transient molecule (half-life of 10−9 s), diffusion of high concentra-

tions of this free radical into the pulp chamber is not expected. Indeed, some
researchers have demonstrated that incorporation of chemical substances contain-
ing iron or manganese as active principles on bleaching gels enhanced the bleaching
effectiveness and minimized H2O2 diffusion into the pulp chamber (Torres et al.
2010, 2013). These molecules accelerate H2O2 decomposition into OH• by means of
a Fenton reaction. Results obtained by our research group demonstrated that incor-
poration of ferrous sulfate on the thickening agent of a 35 %-H2O2 gel reduced in
about 15 % the negative effect of the bleaching product on odontoblast-like cells
(Duque et al. 2014). We also have determined that manganese chloride and hemic
peroxidase have a positive effect on reducing the toxicity and oxidative stress on
pulp cells mediated by a 35 %-H2O2 gel in vitro (unpublished data). All these mol-
ecules also increased the esthetic bleaching effectiveness and decreased signifi-
cantly the H2O2 diffusion through hard tooth structures. Therefore, we believe that
the chemical activation of low-concentrated in-office bleaching gels will open new
perspectives for obtaining effective and biocompatible products and therapies that
will turn this esthetic procedure more safe and painless.
Other research groups have proposed the prebleaching administration of anti-
inflammatory drugs (Paula et al. 2013) and/or topic application of sodium fluoride/
potassium nitrate desensitizing agents (Reis et al. 2011) as palliative alternatives to
minimize postbleaching tooth sensitivity. However, both anti-inflammatory drugs
and desensitizing agents do not prevent the pulpal damage caused by the ROS-
mediated oxidative stress. Administration of antioxidant agents seems to have a
more rational appeal, since these agents may act limiting the extension of oxidative
damage by donating an electron to the arriving free radicals (Moores 2013). Previous
studies performed by our group demonstrated that antioxidant molecules, such as
alpha-tocopherol (vitamin E) and ascorbic acid (vitamin C), were capable of pre-
venting the H2O2-mediated pulp cells damage, since they inactivate extracellular
ROS arising from bleaching gels, as well as the intracellular ones released by cells
that undergo oxidative stress (Lima et al. 2010a, b; Vargas et al. 2014a, b). We also
observed that oral administration of ascorbic acid (200 mg/kg) 90 min prior applica-
tion of a 35 %-H2O2 bleaching gel during 5 min on rat molars protected the pulp
tissue against the toxic effects of this therapy (Lima et al. 2016). All bleached teeth
from animals with no ascorbic acid pretreatment featured large necrosis areas on
coronal pulp 6 and 24 h after bleaching (Fig. 5.7).
On the other hand, the smaller necrotic area, mainly located at the upper zone of
the pulp horn, was observed in 80 % of the animals that received oral administration
of ascorbic acid before tooth bleaching. Also, 24 h after bleaching, only 40 % of
teeth exhibited punctual areas of necrosis associated with discrete disorganization
of reminiscent pulp tissue (Fig. 5.8) (Lima et al. 2016).
Therefore, one can conclude that antioxidant therapy may prevent the strong
immediate pulp damage caused by in-office tooth bleaching procedure and enhance
the pulpal healing with time. However, more studies are necessary in this research
field to determine the ideal and safe doses of antioxidant agents to be administrated
for human beings.
Fig. 5.7 First molar of rat

subjected to bleaching
treatment. Note the wide
necrosis (N) of the coronal
pulp tissue. The radicular
pulp (RP) is well
maintained in spite of the
notable inflammatory
reaction and a small local
area of edema (arrow).
Masson’s Trichrome, 32×
Fig. 5.8 (a) Coronal pulp (CP) of a molar of rat that received oral administration of ascorbic acid
(200 mg/kg) 90 min prior application of bleaching agent. Despite the intense damage in part of the
pulp horn (arrow), a large area of the subjacent coronal pulp is preserved. Masson’s Trichrome,
125×. (b) Seven days after tooth bleaching, complete pulpal healing (P) was observed in teeth of
rats treated with ascorbic acid. Masson’s Trichrome, 96× (D dentin)
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Part II
Current Techniques for Dental Whitening
with Peroxides: Evidence Supporting
Their Clinical Use
At-Home Tooth Whitening
6
Jorge Perdigão, Alessandro D. Loguércio, Alessandra Reis,
and Edson Araújo
Abstract
Peroxides have been used to whiten teeth for over a hundred years. The popular-
ity of dental whitening has increased with the introduction of nightguard vital
whitening in 1989, as the appearance of the dentition and the color of the teeth
have increasingly become a concern for a large number of people. Current meth-
ods for at-home whitening include materials prescribed by dental professionals,
bleaching products available over the counter to use without the involvement of
a dental professional, and “do-it-yourself” methods widely advertised on the
Internet. This chapter compares the efficacy of the most popular at-home whiten-
ing techniques, including dental professional-prescribed at-home tray whitening
with carbamide peroxide (a precursor of hydrogen peroxide), over-the-counter
whitening, and combined in-office with at-home tray whitening. At-home tooth
whitening with a custom-fitted tray is the safest and most effective technique if
carried out under the supervision of a dental professional. This chapter reviews
the advantages and disadvantages of different at-home whitening techniques,
respective side effects, and treatment recommendations based on current scien-
tific information. Clinical cases will illustrate clinically relevant at-home whiten-
ing techniques.
J. Perdigão, DMD, MS, PhD (*)

Division of Operative Dentistry, Department of Restorative Sciences, University of
Minnesota, 515 SE Delaware St, 8-450 Moos Tower, Minneapolis, MN 55455, USA
e-mail: perdi001@umn.edu
A.D. Loguércio, DDS, MS, PhD • A. Reis, DDS, PhD
Department of Dental Materials, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
e-mail: aloguercio@hotmail.com; reis_ale@hotmail.com
E. Araújo, DDS, MS, PhD
Department of Dentistry, Federal University of Santa Catarina, Campus Universitário,
Florianópolis, SC, Brazil
e-mail: edson_araujo@hotmail.com

102 J. Perdigão et al.
Fig. 6.1 Retracted view of a 28-year-old

patient who bleached his maxillary teeth
with 10 % carbamide peroxide gel
(Opalescence 10 %, Ultradent Products,
Inc.) in a custom-fitted tray overnight for 3
weeks. In the first appointment patient had
stated that he did not want to whiten the
mandibular teeth. He later decided to have
the lower teeth bleached with 10 %
carbamide peroxide in a custom-fitted tray
6.1 Introduction
In an independent survey conducted on behalf of the American Academy of

Cosmetic Dentistry (2004), 99.7 % of adults in the USA believed that a smile is
an important social asset. When respondents were asked, “What would you most
like to improve about your smile,” the most common response was “whiter and
brighter teeth.” More recently, Hendrie and Brewer (2012) reported that devia-
tion from normal tooth spacing and/or the presence of yellowed teeth have nega-
tive effects on ratings of attractiveness and these effects are markedly stronger
in females.
In 1989, Haywood and Heymann introduced the nightguard vital bleaching
(NGVB) technique using a vacuum-formed custom-fitted “soft plastic nightguard,
approximately 2-mm thick (similar to an athletic mouthguard)” filled with
Proxigel (Reed & Carnrick Pharmaceuticals), a 10 % carbamide peroxide gel
available over the counter as a Food and Drug Administration (FDA)-approved
antiseptic (Haywood and Heymann 1989). Teeth were treated for 2–6 weeks and
evaluated at 2 and 5 weeks to assess color change. This at-home whitening tech-
nique with carbamide peroxide in a custom-fitted tray, which is commonly referred
to as “at-home whitening,” “at-home bleaching,” or “tray whitening,”1 has become
very popular worldwide. Numerous clinical studies and reports have described the
effectiveness (Fig. 6.1) and safety of tray whitening (Reinhardt et al. 1993; Kihn
et al. 2000; Cibirka et al. 1999; Matis et al. 1998, 2006; Meireles et al. 2008b; Li
2000; ADA Council on Scientific Affairs 2010, 2012). According to the American
Dental Association Council on Scientific Affairs (ADA) (2010), “data accumu-
lated over the last 20 years indicate no significant, long-term oral or systemic
health risks associated with professional at-home tooth bleaching materials con-
taining 10 % carbamide peroxide.” Carbamide peroxide is a precursor of hydrogen
peroxide, as described in Chap. 3. Besides at-home whitening with carbamide
peroxide in a custom-fitted tray, there are currently other techniques that involve
at-home whitening:
1
The terms “whitening” and “bleaching” are used interchangeably in the literature.
6 At-Home Tooth Whitening 103
Fig. 6.2 Frontal view of a

38-year-old patient 5 min
after she applied a
bleaching strip to her
maxillary teeth
1. Dentist-administered in-office whitening followed by at-home whitening with a

peroxide-based gel in a custom-fitted tray, also known as jump-start technique.
In-office bleaching is performed first by a dental professional to provide an initial
jump-start bleaching effect. Then, the patient is prescribed at-home whitening
(Kugel et al. 1997), usually 10–20 % carbamide peroxide gel for daily application,
which is to be used until the desired shade is obtained (Deliperi et al. 2004).
2. Dentist-administered, custom-fitted bleaching tray containing a higher concen-
tration of carbamide peroxide (usually ≈ 35 %), also known as waiting-room
whitening. Patient wears the tray filled with carbamide peroxide gel for periods
of 30 min to 1 h while waiting in the dental office.
3. Over-the-counter (OTC) tooth-whitening products for home use without professional
supervision, such as gels, rinses, paint-on films, strips (Fig. 6.2), and kits with prefab-
ricated “thermoforming” or “thermofitting” trays that can be molded in hot water by
the user at home (please see Chaps. 1 and 4 for more information on OTC whitening
products). Dual-arch trays prefilled with a silicone material, from which the patient
can make a custom-fitted prosthesis, are available online from auction sites.
OTC tooth-whitening products were not included in the list of accepted whitening
agents by the now extinct American Dental Association Seal of Acceptance Program.
Some toothpastes are also marketed as having a whitening effect. They typically
contain an abrasive to remove and/or prevent surface stains, such as hydrated silica,
calcium carbonate, dicalcium phosphate, dihydrate, calcium pyrophosphate, alu-
mina, perlite, and sodium bicarbonate (Joiner 2010). The inclusion of peroxides in
toothpaste is much more challenging in terms of formulation and the short exposure
time. A toothpaste with 0.5 % calcium peroxide has been shown to reduce natural
extrinsic stain after 6 weeks (Ayad et al. 1999). In the European Union, the maximum
concentration of peroxide allowed in toothpastes and mouth rinses is 0.1 % (European
Commission Scientific Committee on Consumer Products 2007). According to the
same document, most clinical studies with peroxide-containing toothpastes are spon-
sored by the respective manufacturers and rarely published.
Indications for at-home whitening with carbamide peroxide gel in a custom-

fitted tray:
• Yellow teeth caused by aging (Fig. 6.1), which is discussed in Sect. 6.4.4.1.
• Tetracycline staining, especially degrees I and II (Jordan and Boksman 1984)
(Fig. 6.3), which is discussed in Sect. 6.4.4.2.
a b
Fig. 6.3 (a) A 23-year-old patient with a history of antibiotic intake when she was a child. Although
patient did not recall which type of antibiotic she had been prescribed, the clinical exam suggested
that the discoloration was compatible with tetracycline staining. (b) Aspect after 4 months of at-
home whitening with 10 % carbamide peroxide gel with potassium nitrate and sodium fluoride
(Opalescence 10 % PF, Ultradent Products, Inc.) overnight in a custom-fitted tray. Patient returned
to clinic for monthly recalls. She did not experience any sensitivity or any other side effects
a b
Fig. 6.4 (a) This 38-year-old patient was born and raised overseas in an “area where everybody
had brown teeth”. He used to drink water from a water well when he was a child in his home coun-
try. According to the patient’s account, all his siblings who lived in the same area had “brown
teeth.” The medical history revealed no significant findings. After an intra-oral exam, patient was
informed that at-home whitening might improve the appearance of his teeth as long as he under-
stood that the treatment could span over a few months. Patient agreed to have his teeth whitened
with 10 % carbamide peroxide gel with potassium nitrate and sodium fluoride (Opalescence 10 %
PF, Ultradent Products, Inc.) at-home in a custom-fitted tray. Patient was scheduled for monthly
recalls. (b) After 3 months of treatment, the appearance of the teeth improved considerably. Patient
was very happy, in spite of confessing that he did not wear the tray on a daily basis. Patient chose
to stop the treatment for a few months and then restart (Reprinted with Permission from Perdigao
J (2010) Dental whitening – revisiting the myths. Northwest Dent 89:19–21, 23–6. (Northwest
Dentistry, The Journal of the Minnesota Dental Association))
• Yellow/brown stains from enamel fluorosis (Fig. 6.4) or from idiopathic causes,
which are discussed in more detail in Sect. 6.4.4.3. Clinical solutions related to
this topic can be found in Chaps. 12, 13, and 15.
• Discolored tooth caused by calcific metamorphosis (Fig. 6.5), which is discussed
in more detail in Sect. 6.4.4.4.
• Whitening of anterior teeth prior to esthetic rehabilitation with veneers (Fig. 6.6)
or direct resin-based composite restorations (Chap. 14).
• Dietary stains
a b
Fig. 6.5 (a) Frontal view of maxillary incisors in a 26-year-old patient whose chief complaint was
her discolored tooth #9 (FDI 2.1). Patient had had a traumatic injury to this tooth when she was 12
years old. No other signs or symptoms were associated with this tooth. Response to percussion was
identical in all her maxillary anterior teeth. Although the response to cold was negative, the pulp
responded to the electric pulp tester. (b) Periapical radiograph showing a calcified pulp space in
tooth #9 (FDI 2.1). (c) Clinical aspect after 2 weeks of at-home whitening with 10 % carbamide
peroxide gel with potassium nitrate and sodium fluoride (Opalescence 10 % PF, Ultradent Products,
Inc.) in a custom-fitted tray. Patient decided to bleach for another period of 2 weeks, but she did
not return for the recall appointment
Contraindications for at-home whitening with carbamide peroxide gel in a

custom-fitted tray:
• Patient’s unrealistic expectations.

• Patient unsure if he/she is willing to carry out the treatment on a daily basis.
• Smoking. As a precautionary measure, patients are informed to refrain from
smoking between 2 h before inserting the tray and 2 h after removing the tray.
This relative contraindication derives from the findings of the “hamster study”
(Weitzman et al. 1986), as discussed in detail in Chap. 3. More recently, it has
been reported that at-home bleaching does not induce DNA damage to the
gingival tissue of smokers during a 3-week treatment (de Geus et al. 2015c).
However, smokers had slightly darker teeth after 1 month of at-home bleach-
ing. This may be an important detail of information to disclose to patients prior
to starting the bleaching treatment (de Geus et al. 2015a). A clinical study also
concluded that bleaching with 10 % carbamide peroxide during 3 h daily for 3
weeks is effective in smokers even after 1 year, but dental prophylaxis may be
necessary to remove extrinsic stains caused by diet and smoking (de Geus et al.
2015b).
a b
Fig. 6.6 (a) A 22-year-old patient with several resin-based composite restorations in his discolored
maxillary incisors. Tooth #9 (FDI 2.1) was not restored. (b) Clinical aspect after 2 weeks of overnight
at-home whitening with 10 % carbamide peroxide gel with potassium nitrate and sodium fluoride
(Opalescence 10 % PF, Ultradent Products, Inc.) in a custom-fitted tray. (c) Porcelain veneers were
bonded with a etch-and-rinse adhesive and a light-cure resin-based luting cement on teeth #7 (FDI
1.2), #8 (FDI 1.1), and #10 (FDI 2.2) 5 weeks after patient completed the bleaching treatment
• Pregnancy and breastfeeding. There is not enough available evidence concerning

either the teratogenicity or the safety for breastfeeding infants of the ingredients
of whitening agents.
• Root (dentin) hypersensitivity. Preexisting tooth sensitivity must be treated prior
to starting the whitening treatment to block any patent dentinal tubules.
• Gingival recession with discolored roots, especially in elderly patients. Radicular
dentin does not respond to whitening as well as coronal dentin does (Haywood
2003).
• Possible allergy to inactive components of the bleaching gel.
• Acatalasemia. A hereditary disorder in which the blood catalase activity level is
below normal (European Commission Scientific Committee on Consumer
Products 2007).
• G6PD deficiency. A genetic disorder of erythrocytes that lack the enzyme G6PD,
causing them to destroy prematurely and preventing patient with this disorder to
break down hydrogen peroxide (European Commission Scientific Committee on
Consumer Products 2007).
• Some patients with xerostomia, as dry mouth may affect the degradation of
hydrogen peroxide (European Commission Scientific Committee on Consumer
Products 2007).
Table 6.1 Advantages and disadvantages of at-home whitening with a custom-fitted tray super-
vised by a dental professional
Advantages Disadvantages
Very effective, durable whitening Tooth sensitivity
Backed with clinical and laboratory research Patient compliance
Safe Relatively long treatment time
Low cost compared to in-office procedures Over-the-counter whitening methods are less
expensive
• Discolored endodontically treated teeth do not typically respond to external tray

whitening as well as vital teeth do. However, some cases of light staining in end-
odontically treated teeth that have darkened recently can be successfully bleached
externally using ≈ 20 % carbamide peroxide gel in a specially designed bleaching
tray (Fig. 6.7). The prognosis of the at-home whitening treatment in these cases
depends on the nature and duration of the discoloration.
• Deep white spot lesions. White spots deeper than 0.5 mm may be better camou-
flaged with other treatment modalities, including microabrasion, enamel etching
followed by resin infiltration (Chaps. 9, 10, 12, and 13), or removal of the discol-
ored area and restoration with a dentin adhesive and a resin-based composite
material (Chap. 15, Sect. 15.3).
6.2 Advantages and Disadvantages of At-Home Whitening
Two major advantages of at-home whitening are its efficacy (Fig. 6.1) and stability
of posttreatment color (Table 6.1) (Swift et al. 1999; Ritter et al. 2002). After 10
years, 43 % of patients that whitened their teeth with 10 % carbamide peroxide for 6
weeks deemed the color to be stable (Ritter et al. 2002).
A major disadvantage of at-home whitening is patient’s compliance (Table 6.1),
as the dental professional is unable to monitor the daily treatment. Meireles et al.
(2008a) asked subjects to return all used and unused bleaching gel syringes to
ensure compliance based on the amount of gel used. This method, however, may be
difficult to implement on a regular basis.
Another disadvantage of at-home whitening compared to in-office whitening is
the longer treatment time for the former. However, one session of in-office whiten-
ing is not usually sufficient to achieve optimal results (Al Shethri et al. 2003), result-
ing in a similar overall treatment time for the two techniques.
6.3 Efficacy and Durability
There are several variables that influence the treatment outcome, including the tech-
nique, the type of bleaching agent, the concentration, and the application time
(Joiner 2006; Buchalla and Attin 2007; Meireles et al. 2008b; Matis et al. 2009a).
a b
e
d
Fig. 6.7 (a) A 24-year-old patient suffered a traumatic injury to her tooth #8 (FDI 2.1). After 4 years,
her tooth became darker without any symptoms. The patient immediately visited her dentist who diag-
nosed pulpal necrosis. (b) A root canal treatment was performed and the lingual access preparation
restored with a resin-based composite material. (c) A special bleaching tray was fabricated to bleach the
discolored tooth following an at-home regimen. (d) A lower tray was fabricated and customized to serve
as stabilizer for the upper one-tooth tray. The lower tray was not used as a bleaching tray. (e) Patient
wearing the upper bleaching tray and the lower stabilizing tray. (f) After 5 days of at-home whitening
with 22 % carbamide peroxide gel (Whiteness Perfect 22 %, FGM) for 2 h twice daily
6.3.1 At-Home Whitening in a Custom-Fitted Tray
Dentist-prescribed overnight bleaching with carbamide peroxide in a custom-fitted

tray has been shown to be the safest, most effective method of tooth whitening
(Haywood 2003; Matis 2004; Matis et al. 2009a).
Two clinical studies evaluated the 2-year effectiveness of tray whitening with carb-
amide peroxide (Swift et al. 1999; Meireles et al. 2010). In the first study, 29 patients
had their maxillary teeth treated with a 10 % carbamide peroxide gel nightly for 2
weeks. Teeth became eight shades lighter after 2 weeks of treatment when color was
measured with the Vita Classical A1-D4 shade guide (VITA Zahnfabrik H. Rauter
GmbH & Co. KG) organized by value (lighter to darker). Twenty-four patients were
recalled after 2 years. Teeth in 20 patients (83.3 %) had darkened an average of two
shades, which occurred during the first 6 weeks posttreatment. The lightening effect
remained statistically significant at 2 years. Overall, patients were satisfied with the
shade. In the second study (Meireles et al. 2010), 92 patients whitened their maxillary
anterior teeth with 10 % carbamide peroxide or with 16 % carbamide peroxide in a
custom-fitted tray for 2 h/day during 3 weeks. Shade evaluations were carried out at
baseline, 1 month, 6 months (Meireles et al. 2008b), 1 year (Meireles et al. 2009), and
2 year post-bleaching (Meireles et al. 2010). Although the 16 % carbamide peroxide
group showed some reversal of the whitening effect at 1 year (Meireles et al. 2009),
both treatment groups had the same median tooth shade 1 year after bleaching, which
was lighter than at baseline. At 2 years, the median tooth shade remained lighter than
at baseline for both carbamide peroxide concentrations tested.
Boushell et al. (2012) evaluated patients’ satisfaction and reported side effects of
at-home whitening with 10 % carbamide peroxide in a custom-fitted tray up to 17 years
posttreatment. Thirty-one participants who had completed clinical studies using 10 %
carbamide peroxide were contacted at least 10 years posttreatment. Patient satisfaction
with tray whitening was determined to last an average of 12.3 years posttreatment.
In case the patient perceives that there has been a color regression and is willing
to touch-up the teeth color, the original bleaching tray may be applied for 2 or 3
nights using the same 10 % carbamide peroxide gel. In case the tray no longer fits
the patient’s teeth as a result of recent restorations or extracted teeth, disposable
trays prefilled with 6 %, 10 %, or 15 % hydrogen peroxide gel (Opalescence Go,
Ultradent Products, Inc.) may be used 2 or 3 days. The respective manufacturer
recommends decreasing contact times with increasing hydrogen peroxide concen-
tration. For the lowest concentration, the manufacturer suggests that patients wear
the disposable tray for 60–90 min daily, whereas for the highest hydrogen peroxide
concentration the recommended contact time is 15–20 min daily.
Patients often inquire if they need to refrain from a potentially staining diet
during and after at-home whitening. Current evidence from controlled clinical
trials suggests that coffee does not interfere with the outcome of whitening nor
does it affect tooth sensitivity (Rezende et al. 2013). Peroxide-based whitening
agents are effective in preventing any staining from coffee or red wine during the
treatment (Cortes et al. 2013). As a result, the need for a white diet during the
bleaching treatment has been challenged. A study determined whether a white
diet is necessary by evaluating the effects of coffee, tea, wine, and dark fruits on
tooth whitening during the bleaching process (Matis et al. 2015). From five pub-
lished studies, the authors concluded that a nonwhite diet was not significantly
associated with less tooth whitening, and there was only a weak positive associa-
tion between tooth whitening and diet for subjects who consumed large amounts
of coffee/tea.
After the whitening regimen is completed, both coffee and red wine cause enamel
color change. Red wine, however, stains enamel more intensely than coffee (Cortes
et al. 2013).
6.3.2 Jump-Start Whitening
The objective of the jump-start technique is to boost the bleaching effect with the
in-office treatment, then improve color stability with the at-home component to
reach a more esthetic result compared to in-office bleaching alone (Deliperi et al.
2004; Matis et al. 2009b). Clinical evidence, however, does not support this assump-
tion. Two recent clinical studies reported that the results of the combined in-office/
at-home technique were similar to those obtained only with the at-home technique
(Bernardon et al. 2010; Dawson et al. 2011). Therefore, the in-office component of
the combined jump-start technique does not improve the treatment outcome and
may be considered redundant. Nevertheless, this technique may motivate some
patients, as the whitening effect is visible immediately.
A more recent version of the jump-start technique is known as deep whitening
technique (Kör Whitening, Evolve Dental Technologies, Inc) (Sulieman 2008). This
technique currently includes three different modalities, according to the severity of
the discoloration: (A) 2 weeks of at-home overnight whitening with 16 % carbamide
peroxide, followed by one in-office whitening session with 34 % Tri-Barrel
Hydremide™ peroxide2; (B) in-office “conditioning” visit with 13 % Tri-Barrel
Hydremide™ peroxide in whitening trays followed by 3–4 weeks of at-home over-
night whitening, and a final in-office whitening session with 34 % Tri-Barrel
Hydremide™ peroxide; (C) in-office “conditioning” visit with 13 % Tri-Barrel
Hydremide™ peroxide in whitening trays, followed by 6–8 weeks of at-home over-
night whitening, and a final in-office whitening session with 34 % Tri-Barrel
Hydremide™ peroxide. All three methods require periodic at-home maintenance
after the treatment.
Currently, there is no independent scientific evidence to back the use of the

so-called deep whitening technique.
2
Hydremide is a trademark by Evolve Dental Technologies, Inc. Tri-barrel hydremide peroxide is
1 barrel of hydrogen peroxide gel, 1 barrel of carbamide peroxide gel, and the third barrel contains
an activator. The term hydremide derives from combining HYDROgen (peroxide) with carbaMIDE
(peroxide).
The trays used in the deep bleaching technique are specially made trays (Kurthy
2001). As per the respective manufacturer, these trays provide better sealing than
conventional bleaching trays, enabling the whitening agent to be active all night as
opposed to other tray whitening methods (Kör Whitening 2015). The manufactur-
er’s website also states: “Clinical Research associates as well as other researchers
have found that whitening gel in conventional whitening trays is only strongly active
for 25–35 minutes. This is due to rapid contamination of the whitening gel by
saliva.” However, this statement is not supported by independent research. It has
been shown that hydrogen peroxide releases all of its peroxide in 30–60 min, with a
quick decline, while carbamide peroxide releases about 50 % of its peroxide in 4 h,
then experiences a slow decline (Haywood 2005).
More than 50 % of the carbamide peroxide active agent is available after

2 h. The percentage of carbamide peroxide recovered from tray and teeth is
10 % at 10 h (Matis et al. 1999).
The use of light sources to allegedly activate the peroxide during the in-office
component of the jump-start technique has been used in many dental offices.
According to Christensen (2003), “all whitening methods are successful to some
degree” but “the use of lights with bleaching has been mainly a marketing tool.”
6.3.3 Over-the-Counter (OTC) Whitening
Sales of OTC bleaching products have increased dramatically in recent years (Chap.
1), driven not only by their lower cost compared to professional tooth-whitening
techniques but also by strong consumer demand for esthetic dental care and easy
access through online auctions and e-commerce sites. Additionally, OTC bleaching
products are easy to use and convenient for the patient (Kugel 2003). Concentrations
as high as 44 % carbamide peroxide are available from online auctions sites and
retailers. Non-dental options are the latest trend, including mall kiosks, salons, and
spas. More recently, whitening has been performed in passenger ship cruises (ADA
Council on Scientific Affairs 2010).
How does the efficacy of OTC whitening products compare to that of the dentist-
prescribed at-home whitening? While there are many studies comparing OTC whit-
ening with dentist-prescribed whitening, there are only a few independent clinical
studies (Serraglio et al. 2016). A study (Bizhang et al. 2009) measured tooth shade
with spectrophotometry and concluded that 6 % hydrogen peroxide whitening strips
applied twice a day for 30 min each for 2 weeks are not as effective as at-home
whitening with 10 % carbamide peroxide overnight for 2 weeks. Kishta-Derani
et al. (2007) evaluated four paint-on films self-adhering solutions that are brushed
on the tooth surface. These paint-on films contained hydrogen peroxide, sodium
percarbonate or carbamide peroxide. Two of the paint-on films did not result in any
significant whitening effect after 2 weeks of daily application. The results obtained
with OTC whitening are not as pleasant and the procedure is not as safe as those
methods prescribed by a dental professional (Haywood 2003). For similar concen-
trations of hydrogen peroxide, OTC bleaching strips cause more gingival irritation
and tooth sensitivity than at-home tray whitening, as discussed in Chap. 4.
Given that OTC whitening products are not custom-fitted to the patient’s mouth,
they are not the ideal vehicle for the application of peroxide-based gels. Ill-fitting
trays may result in soft tissue injury, poor patient compliance, and malocclusion
problems (Kugel 2003).
6.4 At-Home Whitening with a Custom-Fitted Tray

Supervised by a Dental Professional
6.4.1 Treatment Plan
The correct diagnosis of the origin of the discoloration is critical, as different treat-
ment options lead to different clinical outcomes. It is, therefore, imperative that the
dental professional understands the etiology of each specific tooth discoloration
case to be able to diagnose and prescribe the proper treatment for each patient.
Please refer to Chap. 1 for further details.
A full-mouth exam and recent periapical radiographs of the anterior teeth are
essential during the diagnostic appointment. Intra-oral photographs are extremely
valuable to document the pretreatment tooth color for future comparisons and to
include in the patient’s record. Pulp testing is always necessary for single-tooth discol-
orations. Patient must be informed that existing anterior esthetic restorations, includ-
ing porcelain and resin-based composites, will not lighten with bleaching agents,
except for superficial extrinsic stains (Fig. 6.8). These restorations must be replaced
after the whitening treatment is completed to ensure an acceptable esthetic outcome.
Additionally, patient must also be informed that amalgam restorations that come in
contact with the bleaching gel may generate a “greening effect” of the tooth structure
in areas immediately adjacent to the amalgam material (Haywood 2002).
Fig. 6.8 Existing resin-based composite

restorations on teeth #8 (FDI 1.1) and #9
(FDI 2.1) after at-home whitening of the
maxillary arch with 10 % carbamide
peroxide with potassium nitrate and
sodium fluoride (Opalescence 10 % PF,
Ultradent Products, Inc.) in a custom-fitted
tray for 3 weeks
Haywood (2003) defined nightguard vital bleaching as a three-step technique:
1. Whitening material, which is usually a thick peroxide-based gel

2. Application prosthesis, currently known as the bleaching tray
3. Treatment regimen
Haywood (2003) suggested that wearing a tray on only one arch might improve
patient’s compliance, as patient can directly observe the color change in one arch
compared to the arch that is not undergoing treatment. Additionally, the interocclu-
sal thickness of both maxillary and mandibular trays may exacerbate TMJ disorder
symptoms (Robinson and Haywood 2000).
6.4.2 Whitening Material
Carbamide peroxide in concentrations between 10 and 22 %,3 and hydrogen

peroxide in concentrations from 4 to 8 % have been used for at-home bleaching
for different periods of time (Joiner 2006; Meireles et al. 2008b; Matis et al.
2009a). A recent systematic review and meta-analysis of at-home whitening
concluded that carbamide peroxide results in a slightly better whitening effi-
cacy than hydrogen peroxide when applied in a custom-fitted tray (Luque-
Martinez et al. 2016).
The bleaching agent for at-home application that has been more frequently scru-
tinized in the dental literature is 10 % carbamide peroxide (Matis 2004). Chemically,
carbamide peroxide is a crystalline material containing a molecule of urea com-
plexed with a single molecule of hydrogen peroxide – 10 % carbamide peroxide
contains approximately 3.3–3.5 % hydrogen peroxide (Cooper et al. 1992; Sulieman
2008; ADA Council on Scientific Affairs 2010). Carbamide peroxide is preferred
over hydrogen peroxide because it is more stable than hydrogen peroxide, providing
a nonaqueous formula of available hydrogen peroxide (Fischer 1995).
Current carbamide peroxide bleaching gels contain glycerin as a humectant and
flavor enhancer; and a thickener, usually a polymer (Carbopol,4 The Lubrizol
Corporation). Carbopol polymers are cross-linked high molecular weight homo-
and copolymers of acrylic acid, therefore containing active carboxyl groups. These
polymers are slightly acidic, which lowers the pH of the bleaching gel. Accordingly,
bases such as sodium hydroxide may be used to make the gel less acidic. Similar
thickeners and bases are also used in the composition of hydrogen-peroxide-
containing OTC bleaching strips.
3
The chance of a mismatch between the advertised concentration and the actual concentration is
very high (Matis et al. 2013).
4
Carbomer 934P or Carbopol 934P (The Lubrizol Corporation) is primarily used in commercially
available oral formulations, including bleaching gels for tray whitening.
a b
c d
e f
Fig. 6.9 Custom-made bleaching tray for at-home whitening. (a) Occlusal view of the tray inserted
onto the stone model. The model has been trimmed to remove the palatal area to enhance the
vacuum over the teeth and obtain a tighter adaptation of the heated tray material to the teeth. (b)
Frontal view of the model after the tray was scalloped around the gingival margins. (c) Frontal
view of the scalloped tray. (d) Lingual view of the scalloped tray. (e) Incisal view of the scalloped
tray. (f) Demonstrating to patient how to load the bleaching gel into the tray
6.4.3 Bleaching Tray Design
Several brands of thermoplastic materials are available to fabricate bleaching trays.

We currently use a 0.035″-thick ethylene vinyl acetate material that is heated prior
to forming the tray around the stone model in a vacuum or pressure device, as
shown in the video Fabrication of a Whitening Tray. After cooling, the tray is then
trimmed in a horseshoe shape (Fig. 6.9). The fine trimming must follow the scal-
loped contour of the free gingival margin (Haywood 1997b). The design has evolved
to a scalloped tray slightly short of the free gingival margin (0.5–1.0 mm) to prevent
possible irritation caused by the contact of the gel with the soft tissues (Chap. 4).
The scalloped design is contraindicated with low-viscosity bleaching gels, as the gel
is more likely to leak to the mouth and irritate the tongue and lips (Haywood 2003).
In specific situations, including clinical cases of one-tooth whitening, the tray may
be slightly extended gingivally. In case of inadvertent fabrication of shortened trays,
successful whitening still occurs beyond the borders of the short tray without
demarcation lines on the teeth (Oliver and Haywood 1999), as peroxides diffuse
easily through enamel.
The use of tray reservoirs to make space to retain the bleaching gel has been
patented (Fischer 1992). It remains, nevertheless, a controversial issue. Light-cured
block-out resin spacers are recommended by some manufacturers, but the use of
spacers to create reservoirs for the bleaching gel does not seem to increase the suc-
cess of home bleaching (Javaheri and Janis 2000; Matis et al. 2002). The bleaching
gel remains active for longer periods when reservoirs are used (Matis et al. 2002),
which may be the reason why tray reservoirs result in higher rates and higher inten-
sity of gingival inflammation during at-home bleaching (Kirsten et al. 2009).
The tray is then tried-in after fine trimming to check for a tight fit, making sure
that the patient does not feel any sharp edges. The dental professional must examine
the soft tissues very carefully at this stage to identify areas of compression that may
cause discomfort to the patient. It is crucial to demonstrate how to dispense the right
amount of gel into the tray, usually one drop (Fig. 6.9f). To verify the gel covers the
buccal aspect of the tooth the patient is instructed to ensure that a very slight amount
of gel has extruded from the tray at its gingival border. Then, the excess gel is wiped
out with a toothbrush or a cotton swab to prevent the contact of the gel with the
mucosa. The bleaching gel may also be applied from the lingual in case the buccal
enamel is covered with restorative material (Fig. 6.10). Haywood and Parker (1999)
described a case of porcelain veneers bonded to tetracycline-stained teeth that
resulted in a graying of the veneers. A custom-fitted tray with no reservoirs and no
gingival scalloping was used to bleach the teeth with 10 % carbamide peroxide
applied nightly for 9 months.
• The use of spacers for the bleaching gel does not improve the success of
home bleaching.
• The bleaching gel remains active for longer periods of time when spacers
are used.
• The use of a reservoir in the tray may result in higher intensity of gingival
inflammation.
6.4.4 Treatment Regimen
6.4.4.1 Physiological Discoloration

The recommended duration of the treatment for the original nightguard vital whit-
ening technique with 10 % carbamide peroxide was 2–6 weeks (Haywood and
a b
c d
Fig. 6.10 (a) A 43-year-old patient visited the University of Minnesota School of Dentistry
Comprehensive Care Clinic to ask for a second opinion about her front maxillary teeth. She had
direct resin-based composite veneers placed approximately 20 years back, but the restorative mate-
rial had become discolored with “black spots all over.” The patient was not sure if porcelain
veneers were indicated for her clinical situation. (b) The lingual view of the maxillary incisors
depicted a slight grayish dentin discoloration. Although the medical history was negative for anti-
biotic ingestion, the patient vaguely recalled having some fever episodes and possibly taking anti-
biotics in her childhood. We then informed the patient that we might be able to whiten her teeth if
she agreed to wear a tray with 10 % carbamide peroxide gel with potassium nitrate and sodium
fluoride (Opalescence 10 % PF, Ultradent Products, Inc.) for 2–6 months at night. After the patient
agreed and signed the respective consent form, a custom-fitted tray was fabricated and the patient
instructed to apply the whitening gel into the lingual aspect of the tray to whiten the teeth from the
lingual surface. Patient was also instructed to return to the clinic every month. (c) Retracted frontal
view after three months of at-home whitening. Note that the composite stains were removed by the
peroxide oxidative action. Patient did not experience any sensitivity or any alterations of the soft
tissues at each periodical recall. (d) Lingual view after 3 months. Compare the shade with that of
b. Old resin-based composite restorations were removed at a subsequent appointment and enamel
polished with diamond pastes. After observing the final result, patient was unsure whether or not
she wanted veneers. She decided that she did not want any other treatment (Reprinted with
Permission from Perdigao J (2010) Dental whitening – revisiting the myths. Northwest Dent
89:19–21, 23–6. (Northwest Dentistry, The Journal of the Minnesota Dental Association)
Heymann 1989). Currently, the typical treatment time for teeth that are inherently
discolored by aging or discolored by diet and chromogenic diet is from 2 to 4 weeks,
especially if the treatment is carried out overnight.
Although higher concentrations of peroxides result in a faster rate of whitening
than 10 % carbamide peroxide, they reach a similar final result (Matis et al. 2000;
Meireles et al. 2009; Basting et al. 2012). Higher concentrations, however, increase
the incidence of tooth sensitivity (Matis et al. 2000). We have only prescribed 10 %
carbamide peroxide for at-home whitening of physiological discoloration in the last

10 years. This concentration is the only one that has been approved by the American
Dental Association (ADA Seal Product Category 2015).
A clinical study tested four different application times of 10 % carbamide perox-
ide – 15 min, 30 min, 1 h or 8 h. After 16 days, 15 out of 15 (100 %) subjects that
had bleached for 8 h/day were satisfied with the results, while only 5/15 subjects
that had bleached 1 h per day were satisfied with the results (Cardoso et al. 2010).
Matis et al. (2009a) pooled data from nine clinical studies from the same research
center, which included in-office and tray whitening. These authors concluded (1)
whitening is most effective when bleaching gel is placed in trays and the trays are
used overnight; and (2) tray whitening during the daytime for shorter periods of
time was the second most effective whitening method.
Current clinical evidence suggests that 10 % carbamide peroxide is as

effective as higher concentrations but results in lower incidence of sensitivity
than higher concentrations (Matis et al. 2000). Overnight tray whitening with
10 % carbamide peroxide results in whiter teeth and more durable results than
whitening for a few hours during the daytime (Matis et al. 2009a; Cardoso
et al. 2010).
Should the recommended treatment be 2–4 weeks overnight for all patients?
This treatment regimen is usually adequate for shades A and B (reddish-brownish
and reddish-yellowish, respectively) in the Vita Classical A1-D4 shade guide
(VITA Zahnfabrik H. Rauter GmbH & Co. KG). When the tooth color has a gray
component (C and D shades, Vita Classical A1-D4 shade guide) or when teeth are
discolored by the accumulation of tetracycline stains in dentin, teeth do not
respond to whitening as well, especially when the stain accumulates in the cervi-
cal third.
The prescription of at-home bleaching treatments to child and teenage patients
has become a pertinent issue, as parents often ask their family dentists about the
possibility of whitening young patients’ teeth. Croll (1994) described a protocol for
“at-home” tooth bleaching in young patients. According to Croll and Donly (2014),
tray whitening of the permanent dentition in children and teenagers is safe and can
be performed in a similar manner as for adults. The American Academy of Pediatric
Dentistry has published a policy since 2009 on the use of dental bleaching for child
and adolescent patients (American Academy of Pediatric Dentistry Council on
Clinical Affairs 2015). However, this policy does not address the recommended
contact time of the gel with the dentition of young patients. While there is an abun-
dant amount of information on the safety of at-home bleaching gels for adults, stud-
ies focused on the tolerable carbamide peroxide concentration and respective
contact time with the tooth surface for young patients in terms of pulpal health are
lacking. With this in mind, stronger evidence may be needed to start recommending
tray whitening in child and teenage patients on a regular basis.
6.4.4.2 Tetracycline-Stained Teeth

Tetracyclines and their derivatives are broad-spectrum antibiotics active against both
Gram-positive and Gram-negative bacteria as well as infections caused by
Mycoplasma, Rickettsia, and Chlamydia. They are also used in rheumatoid arthritis,
chronic respiratory diseases, and in the management of periodontal disease (Seymour
and Heasman 1995; Tilley et al. 1995; Sánchez et al. 2004; Tredwin et al. 2005).
Tetracyclines are contraindicated during pregnancy because they cross the placenta
and are toxic to the developing fetus (Sánchez et al. 2004), causing tooth discoloration
and enamel hypoplasia if administered during the period of tooth development.
The affinity of tetracycline for dental tissues was first described by Shwachman
et al. (1958–1959) in pediatric patients with cystic fibrosis of the pancreas treated
with long-term antibiotic therapy. Soon thereafter, Zegarelli et al. (1960) reported
similar findings in 38 of 52 children with cystic fibrosis of the pancreas treated with
tetracycline. In 1962, Davies and coworkers suggested that tetracycline is deposited
on the organic matrix of bones and teeth prior to calcification (Davies et al. 1962).
The fluorescence of the pigment and the histological findings confirmed the clinical
observation that the pigmentation was due to tetracycline (Wallman and Hilton
1962). When 50 out of 64 newborns that had been given tetracycline in the neonatal
period were followed up, 46 of them were found to have yellow or brown discolor-
ation of the teeth, with or without enamel hypoplasia. The greater the total dose of
tetracycline per birth weight, the greater was the change. The severity of the stain
and its pattern depended on the tetracycline type, dosage, and duration of therapy
(Wallman and Hilton 1962).
The affinity of tetracycline for mineralizing tissue is the result of binding to
calcium to form a tetracycline-calcium orthophosphate insoluble complex
(Gassner and Sayegh 1968; Eisenberg 1975). Chelation with iron has also been
reported for tetracycline-induced tooth discoloration (Salman et al. 1985; Bowles
and Bokmeyer 1997). Teeth with tetracycline deposits emit yellow fluorescence
when observed under ultraviolet light in a darkened room as opposed to the bluish
fluorescence characteristic of nonpigmented teeth. The tetracycline stain under-
goes degradation by exposure to light, which results in darker staining with age
(Abou-Rass 1988).
In 1978, it was reported that minocycline was a viable alternative to treat cases
of acne that did not respond to treatment with other tetracyclines (Cullen 1978).
Minocycline is a semisynthetic tetracycline derivative used for the treatment of acne
for those suffering from rheumatoid arthritis, and chronic respiratory infections
(Tilley et al. 1995; Tredwin et al. 2005). In 1980, in a letter to the editor of the
Journal of the American Academy of Dermatology, a dermatologist described a
42-year-old patient who had been on minocycline, 100 mg two to three times a day,
for approximately 4–5 years (Caro 1980). The patient’s dental hygienist had noted
the development of a gray discoloration of the patient’s teeth. Additionally, the
patient also stated that she retained a tan for longer than normal and that the skin and
fingernails had a gray appearance. The patient’s dental crowns had to be restained
to match the gray color of the natural dentition. In 1985, a retrospective cohort study
found that 4 of 72 patients who had minocycline therapy during adolescence had
a b
Fig. 6.11 (a) 38 year old patient with history of tetracycline ingestion. She was diagnosed with
mild tetracycline staining. Additionally, the maxillary central incisors had white spot areas in the
incisal third. (b) After 3 months of at-home whitening with 10 % carbamide peroxide with potas-
sium nitrate and sodium fluoride (Opalescence 10 % PF, Ultradent Products, Inc.) in a custom-
fitted tray with monthly recalls. Both the tetracycline stains and the white spot areas were
successfully camouflaged, in spite of a residual gray band in the cervical third
minocycline-associated tooth discoloration, which occurred after only 4 weeks of

treatment in one case (Poliak et al. 1985). Other cases of post-eruptive tooth stain-
ing with minocycline have been described (Salman et al. 1985; Bowles and
Bokmeyer 1997; Cheek and Heymann 1999). Discoloration caused by minocycline
is usually green-gray/blue-gray (Tredwin et al. 2005). Besides discoloration of
teeth, minocycline may also cause a blue staining of the sclera, ears, and oral
mucosa, which may be irreversible (Dodd et al. 1998; LaPorta et al. 2005; Johnston
2013). Minocycline also causes discoloration of nonvital teeth (Dabbagh et al. 2002;
Kim et al. 2010) as discussed in Chap. 8.
The esthetic management of patients with tetracycline-stained teeth is a
challenge since the degree of staining varies from mild to severe (Jordan and
Boksman 1984).
1. Mild tetracycline staining (Fig. 6.11) is usually very receptive to whitening. This
staining is yellow to gray with minimal or no banding and is uniformly spread
throughout the tooth, but more confined to the incisal three-quarters of the crown.
2. Moderate tetracycline staining (Fig. 6.12) may vary from a uniform deep yellow
discoloration, which is responsive to bleaching, to a dark-gray discoloration
band located between the cervical fifth of the crown and the tooth surface located
incisally to the band.
3. Severe tetracycline staining (Fig. 6.13) appearing blue-gray or dark gray, accom-
panied by significant banding across the tooth. Although whitening will some-
how lighten these teeth, they may not become esthetically acceptable without
bonded restorations.
Clinical studies have demonstrated that mild-to-moderate tetracycline stains can

be removed relatively well (Figs. 6.3, 6.11, and 6.12) using the at-home whitening
technique with carbamide peroxide in a custom-fitted tray, even though an extended
a b
Fig. 6.12 (a) A 39-year-old patient with a history of tetracycline ingestion during infancy. He was
informed that long-term whitening (2–6 months) might lighten his teeth. However, there was no
assurance given of the final whitening result. Patient agreed to carry out the treatment by wearing
a custom-fitted tray with 10 % carbamide peroxide gel (Opalescence 10 %, Ultradent Products,
Inc.) every night. Instructions were carefully given to the patient, and a new appointment set up for
within 1 month (and every month thereafter). (b) Final result after 6 months. No sensitivity was
reported at any recall period; no alterations of soft tissues were observed. Patient started whitening
the lower arch immediately after the completion of the treatment in the upper arch (Reprinted with
Permission from Perdigao J (2010) Dental whitening – revisiting the myths. Northwest Dent
89:19–21, 23–6. (Northwest Dentistry, The Journal of the Minnesota Dental Association))
a b
Fig. 6.13 (a) Severe tetracycline staining in a 42-year-old patient. (b) Final aspect after 6 months
of at-home whitening with 10 % carbamide peroxide gel with potassium nitrate and sodium fluo-
ride (Opalescence 10 % PF, Ultradent Products, Inc.) in a custom-fitted tray with monthly recalls.
As expected, and as the patient had been informed, the cervical third was the most resistant area to
whitening
treatment time may be required to achieve satisfactory results (Leonard et al. 2003).
For mild-to-moderate tetracycline-stained teeth, the recommended treatment is 2–6
months with monthly recalls to evaluate the tooth color and potential side effects
(irritation of soft issues, exacerbation of symptoms from TMJ disorders, and tooth
sensitivity). The stains that are most difficult to remove are those located at the cer-
vical third. If no improvement in tooth color is observed within the first 3 months, it
is unlikely that any improvement will occur (Deliperi et al. 2006). In fact, the maxi-
mum lightening effect occurs during the first month (Matis et al. 2006). Therefore,
patients with tetracycline-stained teeth must be informed that a residual gray stain
may still be perceptible at the end of the treatment at the cervical third. These clini-
cal cases may need a longer bleaching regimen (Matis et al. 2006).
Patients with tetracycline-stained teeth participated in a clinical trial of tray whit-

ening with 10 % carbamide peroxide for 6 months. The 90-month follow-up deter-
mined the stability, posttreatment side effects, and patient satisfaction (Leonard
et al. 2003). Shade was stable at least 90 months after treatment. Patients in this
study were overwhelmingly positive about the procedure in terms of shade retention
and lack of posttreatment side effects, as 60 % of the subjects reported no obvious
shade change or only a slight darkening not noticed by others.
A total of 44 subjects bleached their tetracycline-stained teeth overnight for 6
months using trays with reservoirs, and then followed for 5 years. This was a split-
mouth design study that used two of three different concentrations of carbamide
peroxide – 10 %, 15 %, or 20 %. More than 65 % of the maximum tooth whitening
remained for all carbamide peroxide concentrations. However, 15 and 20 % carb-
amide peroxide caused significantly more sensitivity than 10 % carbamide peroxide
(Matis et al. 2006). In this study, there was a reversal of color change in tetracycline-
stained teeth at 5 years.
Although at-home whitening with 10 % carbamide peroxide for up to

6 months remains the first choice for whitening tetracycline-stained teeth,
these patients may need to rebleach or touch-up the tooth color approximately
5 years after the original treatment.
6.4.4.3 Fluororis and Fluorosis-Like Enamel Hypocalcifications

Excessive fluoride intake may result is dental fluorosis, which is a hypomineraliza-
tion of enamel characterized by opaque white areas or discolorations ranging from
yellow to dark brown (Horowitz et al. 1984). The severity of fluorosis is correlated
with the amount and duration of fluoride ingestion during tooth development
(Robinson and Kirkham 1990). In more severe cases the enamel surface becomes
pitted, displaying porosities on the surface (Chap. 15). The degree of enamel hypo-
mineralization may vary on different parts of the tooth surface due to the variation
in enamel thickness (Fejerskov et al. 1990). Not all white or brown demineralized
enamel areas are caused by fluorosis; therefore, they may be considered idiopathic
(Cutress and Suckling 1990; Croll 2009) (Fig. 6.14). The term enamel “dysminer-
alization” has been used when referring to fluorosis-like enamel discolorations
(Croll 1990).
Dental fluorosis was referred to as mottled teeth in 1916 by McKay and Black
because fluoride had not yet been recognized as the cause for this discoloration.
McKay and Black summarized very precisely the major characteristics of mottled
teeth including “the suspicion which is thrown on the water supply in the causative
relation” and “localization in definite geographical areas, and its occurrence in the
native children thereof”.
A precursor of the in-office whitening technique for mottled teeth (e.g., enamel
fluorosis) was published by Smith and McInnes in 1942. The successful bleaching
technique consisted of direct application of a bleaching mixture of 5 ml of Superoxol
a b
Fig. 6.14 (a) A 22-year-old patient whose chief complaint was “yellow teeth.” She also had white
spots on tooth #9 (FDI 2.1) and tooth #10 (FDI 2.2). (b) The at-home whitening treatment with
10 % carbamide peroxide gel with potassium nitrate and sodium fluoride (Whiteness Perfect 10 %,
FGM) in a custom-fitted tray highlighted the white spot areas
and 1 ml of ether. Heat was then applied by the patient according to his/her particu-
lar tolerance, using a modified soldering iron.
The efficacy of at-home whitening to treat discolorations caused by fluorosis or
by idiopathic causes depends on the stain (Haywood 2003). At-home whitening
usually lightens enamel brown stains (Fig. 6.4), but it may not work so well for
some white areas (Haywood and Leonard 1998; Bodden and Haywood 2003;
Perdigao 2010). In case the enamel demineralization is superficial (<0.5 mm), tray
whitening may camouflage the white spots without removing them (Fig. 6.11).
Conversely, at-home whitening may highlight the whitish areas in cases of deeper
white spots (Fig. 6.14). A few applications of a microabrasion suspension (Croll and
Cavanaugh 1986a, b; Croll 1997), which contains hydrochloric acid (HCl) and sili-
con carbide, may be used to disguise the white spots (for more information on
enamel microabrasion, please refer to Chaps. 9 and 12). The microabrasion com-
pound is applied by rubbing onto the enamel surface, removing a thin layer of
enamel (Donly et al. 1992; Paic et al. 2008). However, it is difficult to predict when
enamel microabrasion will remove a stain completely from a tooth (Celik et al.
2013), as the defect may be deeper than microabrasion can reach.
Resin-infiltration after enamel etching with HCl (Chaps. 10 and 13) may be the
current treatment modality best suitable for white spots (Senestraro et al. 2013).
Robinson et al. (1976) introduced a combination of HCl enamel etching with the
application of a low-viscosity resorcinol-formaldehyde resin as a potential cario-
static treatment. Among several research papers on the topic of enamel etching with
HCl followed by resin infiltration published in the 2000s, it is worth highlighting
two from the same research group. Paris et al. (2007) used confocal microscopy to
study resin infiltration of carious lesions using 15 % HCl to etch enamel, followed
by immersion in ethanol for 30 s and the application of a commercial dentin adhe-
sive, ExciTE (Ivoclar Vivadent). In 2009, Paris and Meyer-Lueckel described the
masking of white spots with resin infiltration using 15 % HCl etching followed by a
drying step with ethanol, and a very low viscosity light-cured resin (tetraethylene
glycol dimethacrylate). Please refer to Chap. 10 for details.
Haywood and Leonard (1998) reported the use of nightguard vital bleaching
with 10 % carbamide peroxide to remove a brown stain from the maxillary central
incisor of a 13-year-old patient. Without any further treatment, the discoloration had
not returned after 7 years.
6.4.4.4 Single-Tooth Whitening

Traumatic injury of the pulp of vital teeth may result in calcific metamorphosis or
dystrophic calcification. The pulp produces reparative dentin that may obliterate
partially or completely the entire pulp space (Holcomb and Gregory 1967; Stroner
and Van Cura 1984; Amir et al. 2001). Teeth with pulpal calcific metamorphosis are
often more opaque and darker than adjacent teeth (Fig. 6.5a) and usually respond
positively to vitality tests. The presence of reparative dentin does not usually result
in delayed responses to the electric pulp tester (Seltzer et al. 1963).
Denehy and Swift (1992) described a method for lightening vital teeth with
calcified pulpal spaces. The tray coverage of the adjacent teeth is trimmed to pre-
vent their contact with the bleaching gel (Fig. 6.15). In case the patient desires to
lighten the other teeth in addition to the tooth with calcific metamorphosis, these
authors recommended bleaching the single discolored tooth first and then making
a new full-coverage tray to lighten the entire arch (Denehy and Swift 1992).
Another technique being currently used for whitening individual teeth with discol-
oration caused by calcific metamorphosis uses an especially designed one-tooth
tray (Fig. 6.16).
Teeth discolored from trauma usually bleach well, especially vital teeth without
radiographic evidence of internal or periapical pathology. One-tooth whitening of
teeth with calcific metamorphosis is a very conservative treatment without the need
to remove tooth structure.
6.5 Side Effects
Chapters 3, 4 and 5 include a comprehensive description of adverse effects caused

by peroxide-based whitening agents.
Although the safety and efficacy of 10 % carbamide peroxide is well docu-
mented (Matis et al. 1998, 2000, 2009a; Swift et al. 1999; Ritter et al. 2002;
Leonard et al. 2003; Zekonis et al. 2003; Meireles et al. 2009), vital tooth whiten-
ing, irrespective of method, causes side effects (Li 2011). One study concluded that
there were minimal clinical side effects up to 17 years post nightguard vital bleach-
ing with 10 % carbamide peroxide (Boushell et al. 2012). In this study, the Löe’s
gingival index and external cervical resorption findings were considered within
normal expectations.
Two treatment-related predictors for side effects are bleaching gel concen-
tration and contact time (Bruzell et al. 2013).
a b
c d
Fig. 6.15 (a) A 51-year-old patient with discolored tooth #8 (FDI 1.1) who came to our clinic
asking for a second opinion. His dentist had recommended a full-coverage tooth-colored restora-
tion for esthetic reasons. Patient had an old resin-based composite restoration on the mesial-lingual
aspect, which he did not want to have removed. Tooth responded positively to cold applied from
the lingual surface, although less intensely compare to the other maxillary front teeth. (b) Periapical
radiograph showing a calcified pulpal space on tooth #8 (FDI 1.1) and a coronal radiolucent image
corresponding to the existing resin-based composite restoration. The diagnosis was calcific meta-
morphosis. (c) Patient whitened the discolored tooth with 10 % carbamide peroxide gel with potas-
sium nitrate and sodium fluoride (Opalescence 10 % PF, Ultradent Products, Inc.) in a custom fitted
tray using the technique described by Denehy and Swift (1992). The tray coverage of the adjacent
teeth was trimmed to prevent their contact with the bleaching gel. Only tooth #8 (FDI 1.1) was
bleached. (d) After 3 weeks of tray whitening of tooth #8 (FDI 1.1). Patient was extremely satisfied
with the result. We recommended the replacement of the discolored restoration, which was still
visible after the tooth whitened considerably. Patient decided that he did not want to have the res-
toration replaced
6.5.1 Changes in Physical Properties and Ultra-morphology

of Enamel and Dentin
Most studies indicate that whitening agents containing peroxides have no perma-
nent significant deleterious effects on enamel and dentin surface morphology,
surface microhardness, and chemical composition (Sulieman et al. 2004; Joiner
2007), while other studies show enamel erosions and changes in the enamel
structure, as discussed in Chap. 4 (Haywood et al. 1991; Shannon et al. 1993;
a b
Fig. 6.16 (a) A 25-year-old patient with discolored #9 (FDI 2.1). Patient had an accident when she
was 21 years old. (b) After radiographic exam and clinical exam, the diagnosis was calcific meta-
morphosis. The tooth responded to cold stimulus applied form the lingual aspect. (c) and (d) A tray
was fabricated to cover only the discolored tooth. (e) Single-tooth tray inserted onto tooth #9 (FDI
2.1) and the lower stabilizing tray to prevent the upper single tooth tray from dislodging. The lower
tray was not used as a bleaching tray. (f) Clinical aspect after 3 weeks of daily whitening with 10 %
carbamide peroxide gel with potassium nitrate and sodium fluoride (Whiteness Perfect 10 %, FGM)
for 4 h daily. This patient had decided that she did not want to perform the treatment overnight
Bitter 1998). Microhardness has been the most frequently used method for evalu-
ating the effects of peroxides on enamel and dentin (Joiner 2007). Lopes et al.
(2002) found no adverse effects on enamel microhardness and surface morphol-
ogy with 10 % carbamide peroxide, but bleaching with 3 % hydrogen peroxide
affected negatively the enamel hardness and surface morphology, which may
have been caused by the lower pH of the hydrogen peroxide material. Other
authors (Efeoglu et al. 2007) measured significant reduction in the mineral con-
tent of the enamel surface (but not dentin) after bleaching with 35 % hydrogen
peroxide for 2 h.
It has been reported that peroxides increase the porosity of enamel (Ben-Amar
et al. 1995), alter the chemical composition of dentin (Rotstein et al. 1992), reduce
the ultimate strength of enamel (Cavalli et al. 2004; da Silva et al. 2005), reduce the
flexural strength and flexural modulus of dentin (Tam et al. 2005), and induce mor-
phological alterations in the hydroxyapatite crystallites (Perdigao et al. 1998;
Perdigao and Lopes 2006).
A study tested the effects of the Carbopol polymer and glycerin (separately and
in association) on the physical properties of enamel and dentin in addition to the
effects of 10 % carbamide peroxide (Basting et al. 2005). The baseline microhard-
ness was not recovered during the 14-day posttreatment phase. All the materials
tested and their associations changed the microhardness of dental tissues, even in
the presence of artificial saliva. There was a tendency toward lower microhardness
after treatment with the Carbopol polymer.
The change in chemical composition of dentin post-bleaching may be due to a
reduction of the organic component in dentin (Rotstein et al. 1992). Treatment with
30 % hydrogen peroxide causes changes in the chemical structure of the dentin and
cementum, making them more susceptible to degradation. Exposure to 30 % hydro-
gen peroxide for 24 h also causes a significant decrease in the hardness and Young’s
modulus of intertubular dentin, as measured with AFM and nanoindentation (Chng
et al. 2005). The effect of hydrogen peroxide on dentin may be a result of both its
strong oxidizing action and its low pH. Peritubular dentin is more resistant to the
effects of hydrogen peroxide than intertubular dentin, which may be a result of the
higher mineral content of peritubular dentin. Enamel treatment with carbamide per-
oxide for 6 h per day during 14 days, followed by storage in artificial saliva in
between each application, resulted in significant reduction of the ultimate tensile
strength of enamel, regardless of the concentration of carbamide peroxide (10 %,
15 %, 16 % and 20 %) (Cavalli et al. 2004).
Another study (da Silva et al. 2005) evaluated the effects of peroxide bleaching
regimens on the ultimate tensile strength of human enamel. All different bleaching
procedures (7.5 % hydrogen peroxide, 30 min per day for 14 days; 10 % carbamide
peroxide 6 h per day for 5 days; 10 % carbamide peroxide 6 h per day for 14 days;
35 % carbamide peroxide, two applications of 30 min with a 5-day interval between
applications; 37 % carbamide peroxide, two applications of 30 min with a 5-day inter-
val between applications; 35 % hydrogen peroxide, two applications of 15 min with a
7-day interval between applications) significantly reduced enamel ultimate tensile
strength. This reduction in the ultimate tensile strength was accompanied by changes
in the enamel internal micromorphology, with a possible loss of interprismatic matrix

and presence of porosities at the prism-fractured ends in the bleached fractured enamel
might indicate that some intraprismatic material was also lost. These features were
more pronounced in the group treated with 35 % hydrogen peroxide.
Different at-home whitening regimens with several concentrations of carbamide
peroxide have also been shown to reduce both the flexural strength and flexural
modulus of dentin (Tam et al. 2005). This reduction was not observed for in-office
treatment with hydrogen peroxide possible due to the shorter treatment time com-
pared to that of carbamide peroxide.
Ultra-morphological studies with Transmission Electron Microscopy (Perdigao
and Lopes 2006) revealed that the treatment of enamel with 10 % carbamide perox-
ide did not result in changes in the morphology of the crystallites immediately
below the enamel surface (Fig. 6.17), but this alteration was pronounced when
enamel was treated with 38 % hydrogen peroxide following the recommendations
for in-office whitening (Perdigao and Lopes 2006). This is in agreement with other
authors, who found that the most severe changes in enamel topography occurred
with products of lower pH (Shannon et al. 1993). The periphery of the crystals was
not well defined as in the control group denoting a mottled etched pattern and loss
of structural arrangement.
When teeth are exposed to a 10 % carbamide peroxide gel for 6 h they lose
1 μg/mm2 of calcium. If teeth are exposed to a cola beverage for 2.5 min (the time
equivalent to drinking a 16 oz. beverage) the amount of calcium lost from these
teeth is also 1 μg/mm2 (McCracken and Haywood 1996). Orange juice causes
more harm to enamel surfaces than whitening materials (Sulieman et al. 2004).
Therefore, adverse effects on enamel and or dentin caused by whitening materials
may reflect the pH of the formulation used rather than the bleaching agent itself
(Sulieman et al. 2004). Some of these alterations caused by peroxide bleaching
materials on the dental hard tissues may be transient and reversed when treated
with a fluoride solution.
The data obtained in all the in vitro studies mentioned in this section may have
to be analyzed with caution. The clinical relevance of some of the methods used to
assess the effects of peroxides on dental hard tissues may not reflect the clinical
conditions accurately. Studies have used whitening agents of low pH, which may
have caused microscopic erosion and other alterations of the substrate that were not
accounted for in the research methodology (Joiner 2007).
6.5.2 Decrease in Bonding Effectiveness
As discussed in Chap. 4, peroxide bleaching materials significantly decrease the

bond strength of resin-based composite to bleached enamel and dentin, both for at-
home vital whitening and for intra-coronal nonvital whitening (Cavalli et al. 2001;
Shinohara et al. 2005). For enamel specifically, 10 % carbamide peroxide reduces
the bond strengths of resin-based composite to etched enamel (Cvitko et al. 1991;
Barghi and Godwin 1994; Ben-Amar et al. 1995; Spyrides et al. 2000), and increases
a b
Fig. 6.17 (a) Transmission electron micrograph of untreated human enamel. Original
magnification = ×150,000. (b) Transmission electron micrograph of human enamel bleached with
10 % carbamide peroxide gel (Opalescence 10 %, Ultradent Products, Inc.) for 2 weeks, 8 h
daily. Specimens were stored in artificial saliva at 37 °C between bleaching sessions. Original
magnification = ×150,000. (c) Transmission electron micrograph of human enamel bleached with
38 % hydrogen peroxide (Opalescence Xtra Boost, Ultradent Products, Inc.), four consecutive
applications of 15 min each. The ultra-morphology of the enamel crystallites is substantially
different from those shown in a and b. Original magnification = ×150,000
enamel surface porosity (Ben-Amar et al. 1995). This reduction may be as high as
76 % of the bond strengths to unbleached enamel (Spyrides et al. 2000). Removal of
surface enamel prior to bonding restores bond strengths to normal level (Cvitko
et al. 1991). The use of acetone-based adhesives or drying agents, such as 70 %
alcohol and acetone, may also restore bond strength of resin-based composite to
enamel immediately after bleaching (Barghi and Godwin 1994; Niat et al. 2012).
The enamel and dentin bond strengths remain low for the first 2 weeks post-
bleaching. After a lapse of 2 weeks, the bond strengths return to the level at of
untreated substrates (Cavalli et al. 2001; Shinohara et al. 2005). Increased concen-
tration of carbamide peroxide did not extend the time needed prior to bonding.
Dentists must wait for at least 2 weeks after the patient completes the whit-
ening treatment prior to performing any adhesive restorative procedure.
Resin-enamel interfaces in enamel bleached with 10 % carbamide peroxide

exhibit extensive nanoleakage compared to those of the unbleached control group
(Lai et al. 2002). Reduction of resin-enamel bond strength in bleached etched
enamel may be caused by a delayed release of oxygen that affects the polymeriza-
tion of resin components (Lai et al. 2002). Although enamel bond strengths to
beached enamel are reduced after bleaching, this reduction can be reversed with
treatment with an antioxidant prior to bonding, such as 10 % sodium ascorbate (Lai
et al. 2002; Türkün and Kaya 2004).
6.5.3 Pulp Injury
Because this topic is extensively and elegantly discussed in Chap. 5, we will only
cite two studies that suggest the relatively innocuous nature of 10 % carbamide
peroxide to the human pulp. To study the pulp injury potential of 10 % carbamide
peroxide, an ex vivo study included 16 patients who had four premolars scheduled
to be extracted for orthodontic reasons (Fugaro et al. 2004). Tooth #5 was bleached
for 4 days, tooth #12 was treated for 2 weeks, tooth #21 was bleached for 2 weeks
followed by 2 weeks without treatment and tooth #28 was not treated, serving as
the control. All whitening treatments were performed overnight with 10 % carb-
amide peroxide. All teeth were extracted at the same time and prepared for histo-
logical evaluation at two different research centers. Slight pulpal changes caused
by 10 % carbamide peroxide were detected in 16 of the 45 bleached teeth. Neither
moderate nor severe reactions were observed. The slight histological changes
sometimes observed after bleaching tend to resolve within 2 weeks posttreatment
(Fugaro et al. 2004).
The apparent safety of nightguard vital bleaching may be due to the response by
odontoblasts with increased heme oxygenase-1 (HO-1) production. Seventeen
intact first premolars scheduled for orthodontic extraction were bleached with 10 %
carbamide peroxide for 4 h immediately preceding extraction. Fourteen additional
premolars from the same individuals were not bleached. Upon extraction and histo-
logical evaluation, no significant differences were found in the concentration of the
enzyme HO-1 in the pulp, which is normally increased in cells subjected to oxida-
tive stress (Anderson et al. 1999). Please refer to Chap. 5 for in-depth information
on the topic of pulp injury with whitening agents.
6.5.4 Tooth Sensitivity
Since this topic is discussed in more detail in Chaps. 4 and 5, we will include here
additional information on tooth sensitivity related to at-home whitening with a
custom-fitted tray.
Tooth sensitivity seems to be the most common lateral effect of whitening with
carbamide peroxide, which results from the penetration of peroxides into the pulp
space, but sensitivity usually relapses with termination of treatment (Haywood
Table 6.2 Predictors for tooth Gingival recession

sensitivity during at-home whitening History of sensitive teeth
treatment Contact time of the bleaching gel with teeth
Changing the bleaching gel more than once/day
Concentration of carbamide peroxide > 10 %
1997a). A slightly higher incidence of sensitivity is associated with higher concen-

trations of carbamide peroxide (Matis et al. 2000). Another factor that could play a
role in sensitivity is the pH of the bleaching gel as the pH of whiteners used with the
at-home technique can be as low as 5.6 (Price et al. 2000).
In a clinical study, while 71 % of subjects who used 20 % carbamide peroxide
reported tooth sensitivity, only 37 % of subjects who used 10 % carbamide peroxide
experienced tooth sensitivity (Basting et al. 2012). The chance of moderate tooth
sensitivity is 10 %, while there is a very slight chance of severe sensitivity (4 %).
Patients can be advised that there is a 40–50 % chance that they will experience mild
sensitivity with 15 % or 20 % carbamide peroxide (Jorgensen and Carroll 2002).
Sensitivity tends to occur early in treatment and diminishes with time. As reported
in some studies, sensitivity rates are similar for the bleaching gel and placebo, indi-
cating that the active peroxide ingredient is not always responsible for causing tooth
sensitivity.
There are a few predictors for tooth sensitivity associated with at-home whiten-
ing (Table 6.2). Patients with gingival recession are more likely to experience tooth
sensitivity during home whitening treatment (Jorgensen and Carroll 2002). Other
predictors are a history of sensitive teeth, enamel craze lines, and patients who
changed the whitening solution more than once a day, contact time of the bleaching
agent with the teeth, or the utilization of higher concentrations of carbamide perox-
ide such as 20 % (Haywood 1997a; Leonard et al. 1997; Gerlach et al. 2000; Cardoso
et al. 2010; Basting et al. 2012; Özcan et al. 2014). In a clinical study in which
patients used a 10 % carbamide peroxide gel, subjects whose bleaching regimen was
8 h daily experienced significantly more sensitivity than those who bleached for 1 h
per day (Cardoso et al. 2010).
A multicenter, questionnaire-based prospective study reported tooth sensitivity
after 14 days and after 1-year posttreatment (Bruzell et al. 2013). The prevalence of
experienced tooth sensitivity at the first recall was independent of bleaching proce-
dure (at-home vs. in-office), whereas prevalence of gingival irritation was higher
after in-office treatment. At the second follow-up (1 year), two and three patients
reported side effects attributed to the bleaching treatment in the at-home and in-
office groups, respectively.
Peroxides diffuse very quickly into dentin reaching the pulp chamber, but the
rate of penetration depends on the concentration and composition of the whitening
agent and the thickness of the hard tissue (Hanks et al. 1993; Thitinanthapan et al
1999; Gokay et al. 2000). Some specific brands of 10 % carbamide peroxide gels
result in greater concentration of hydrogen peroxide within the pulp chamber than
other similar concentrations, regardless of the diffusion time (Hanks et al. 1993). In
extracted teeth, significantly less peroxide reaches the pulp from a 15 % carbamide
peroxide gel (equivalent to 5.25 % hydrogen peroxide) than from a 5 % hydrogen
peroxide gel within a 15-min period (Cooper et al. 1992), which attests the lower
rate of decomposition of the carbamide peroxide compared to hydrogen peroxide.
When hydrogen peroxide is applied for periods longer than 15 min, it is capable of
diffusing through 0.5 mm of patent dentin, damaging pulpal tissue (Hanks et al.
1993). Clinically, 0.5 mm corresponds to areas of deep noncarious cervical lesions.
In case teeth are already sensitive prior to starting the treatment, this might indicate
that the dentin tubules are patent, which would make bleaching strongly contraindi-
cated. Pulpal tissue has limited volume to expand from injury; therefore, it may
have a compromised response to inflammatory stimuli because of pressure associ-
ated with edema, causing sensitivity (Heyeraas and Kvinnsland 1992). In case heat
is used, such as in the jump-start technique, pulpal enzymes may be significantly
inhibited (Bowles and Thompson 1986).
Manufacturers have added potassium nitrate and sodium fluoride to the composi-
tion of their whitening gels to prevent sensitivity during at-home bleaching treat-
ment. Carbamide peroxide gels for the at-home technique typically contain 0.11 %
(w/w) fluoride and 3 % (w/w) potassium nitrate (Chen et al. 2008).
The use of sodium fluoride daily after bleaching does not affect the bleaching
efficacy of carbamide peroxide but reduces the intensity of tooth sensitivity
(Armênio et al. 2008). The application of a 5 % potassium nitrate and fluoride gel in
the bleaching tray has been shown to reduce the incidence of tooth sensitivity in
patients undergoing at-home whitening with 10 % carbamide peroxide in a custom-
fitted tray (Haywood et al. 2001).
Clinical studies have reported that potassium nitrate and sodium fluoride added
to a 10 % carbamide peroxide gel reduced sensitivity over a 2-week at-home treat-
ment when compared to a 10 % carbamide peroxide gel without desensitizer (Tam
2001; Browning et al. 2008; Navarra et al. 2014). The application of 3 % potassium
nitrate and 0.11 % fluoride desensitizing agent for 30 min prior to at-home whiten-
ing with 10 % carbamide peroxide decreases tooth sensitivity when compared with
a placebo in a population at risk for tooth sensitivity (Leonard et al. 2004). Another
clinical trial reported that the use of 5 % potassium nitrate and 2 % sodium fluoride
prior to at-home vital bleaching with 16 % carbamide peroxide did not affect the
bleaching efficacy but reduced the number of days during which patients experi-
enced tooth sensitivity (Kose et al. 2011). To corroborate the effectiveness of potas-
sium nitrate and sodium fluoride, their use prior to in-office bleaching with 35 %
hydrogen peroxide also reduces tooth sensitivity significantly (Tay et al. 2009;
Wang et al. 2015).
Some clinicians recommend brushing with potassium-nitrate-containing tooth-
paste for 2 weeks before initiating the at-home whitening treatment with a custom-
fitted tray. This pretreatment has been shown to be beneficial to patients by reducing
tooth sensitivity during whitening (Haywood et al. 2005). Dentists have also recom-
mended the application of the desensitizing toothpaste in the bleaching tray for up
to 30 min (Haywood 2003). This recommendation may not be safe, as the tooth-
paste may contain ingredients that cause soft tissue reactions when the toothpaste is
left in contact with the soft tissue for that period of time.
Other desensitizers have been used. A clinical study compared the efficacy of
two desensitizers included in the composition of carbamide peroxide gels. Potassium
nitrate was found to be as effective as amorphous calcium phosphate (ACP) to pre-

vent sensitivity (Matis et al. 2007). However, 15 % carbamide peroxide gel with
potassium nitrate and sodium fluoride achieved significantly greater whitening
results than a 16 % carbamide peroxide gel with amorphous calcium phosphate
(ACP) (Matis et al. 2007). When comparing potassium nitrate with potassium oxa-
late as desensitizers included in the composition of 10 % carbamide peroxide gels,
it was reported that the gel with potassium oxalate caused significantly more sensi-
tivity at 1 week than the 10 % carbamide peroxide gel with potassium nitrate or
10 % carbamide peroxide gel without any desensitizer (Perdigao et al. 2013).
• Brushing with potassium-nitrate-containing toothpaste for 2 weeks prior to the

bleaching treatment reduces tooth sensitivity during the treatment.
• Potassium nitrate is the recommended desensitizer to use with at-home whiten-
ing treatments (Tam 2001; Matis et al. 2007; Wang et al. 2015), as it reduces
postoperative sensitivity without reducing efficacy when added to 10 % carb-
amide peroxide (Browning et al. 2008).
• The penetration of peroxides into dentin can be reduced by application of a
desensitizing agent or a fluoride varnish (Hannig et al. 2011).
6.6 Recommendations for Dental Professionals
• Refrain from being too optimistic when predicting the post-treatment tooth color.
• If the patient’s shade falls in the C or D range in the Vita Classical A1-D4 shade
guide, the final result will not be as pleasant as that for patients in the A or B
shade range.
• Prescribe 10 % carbamide peroxide with desensitizer included in the bleach-
ing gel.
• Inform patient that sensitivity is likely to occur; prescribe potassium-nitrate-
containing toothpaste to replace patient’s regular toothpaste. This toothpaste may
be more effective if used during 2 weeks prior to starting the bleaching
regimen.
• The application of a gel of potassium nitrate and sodium fluoride prior to at-
home bleaching decreases tooth sensitivity and reduces the number of days dur-
ing which patients experience tooth sensitivity.
• Recommend that patient wears the bleaching tray preferably overnight.
• Give patient written instructions:
– Brush and floss before placing the tray.
– Insert the tray snugly over the teeth; gently tap the tray to move the gel into
place and adapt tray to the teeth
– Watch for excess gel along the tray border; remove it with a toothbrush or
with a cotton swab. Rinse mouth with water and do not swallow the gel.
– Wear tray for the time recommended.
– Brush and floss after removing the tray; wash tray thoroughly with water to
remove the residual gel.
• Smokers should refrain from smoking from 2 h prior to inserting the tray in the
mouth to 2 h after removing the tray
6.7 Frequently Asked Questions
To summarize the contents of this chapter we present below a series of questions

and answers on the topic of at-home whitening.
6.7.1 Patients
Do I need to refrain from a potentially staining diet during and after tray whitening?
Current evidence from controlled clinical trials suggests that coffee, tea, red
wine, do not interfere considerably with the outcome of whitening.
Is it OK that I wear my tray filled with 10 % carbamide peroxide for 2 h per day?
That would be perfectly fine, but it will take longer to achieve the desired lighten-
ing effect compared to bleaching overnight. Current clinical evidence suggests that
overnight tray whitening results in whiter teeth and more durable results than whit-
ening for a few hours during the daytime.
My teenage daughter wants to have her teeth bleached. Is it safe?
As discussed in Sect. 6.4.4.1 our opinion is that we may need stronger evidence
to recommend tray whitening in child and teenage patients.
I have some yellowish tooth-colored fillings in my front teeth. Will they get whiter if
I bleach my teeth?
They may look slightly lighter as a result of the oxidation of the surface pigment
(Fig. 6.10c), but in most cases tooth-color filling materials will not bleach (Fig. 6.8).
Existing tooth color fillings (resin-based composite restorations) may need to be
replaced after the whitening treatment is completed to make your smile look
uniform.
How does the efficacy of OTC bleaching products compare to that of the dentist-
prescribed at-home whitening?
One of the very few independent studies, mentioned earlier in this chapter, con-
cluded that 6 % hydrogen peroxide whitening strips applied twice a day for 30 min
each for 2 weeks are not as effective as at-home whitening with 10 % carbamide
peroxide overnight for 2 weeks. Another study concluded that some paint-on
products are ineffective. A recent systematic review reported that OTC products
should be assessed independently.
OTC bleaching strips also cause more tooth sensitivity and gingival irritation
than at-home tray whitening prescribed by a dental professional. In summary, at-
home whitening with 10 % carbamide peroxide in a custom-fitted tray is safer and
more effective than OTC bleaching treatments. The results obtained with OTC whit-
ening are not as pleasant and the procedure is not as safe as those methods currently
prescribed by a dental professional.
6.7.2 Dental Professionals
You usually prescribe 10 % carbamide peroxide for your clinical cases of at-home
whitening in a custom-fitted tray. What is the evidence?
Dentist-prescribed overnight bleaching with carbamide peroxide in a custom-

fitted tray is the safest and most effective method of tooth whitening. Although higher
concentrations of peroxides result in a faster rate of whitening than lower concentra-
tions they reach a similar final result. Additionally, lower concentrations of carb-
amide peroxide result in lower incidence of sensitivity than higher concentrations.
The durability of the whitening effect is another factor that needs to be taken into
account. Patients who had whitened their teeth using 10 % carbamide peroxide in a
custom-fitted tray were contacted at least 10 years posttreatment. Patient satisfaction
with tray whitening was determined to last an average of 12.3 years posttreatment.
Do you also perform in-office whitening? Or do you only prescribe at-home

whitening?
Some patients choose not to be treated with at-home tray whitening for several
reasons. We always inform these patients that we also perform in-office whitening,
but that several sessions may be needed to obtain an acceptable final tooth color.
Patients must also be informed that in-office whitening is more likely to cause
tooth sensitivity than at-home whitening with a custom-fitted tray. Other potential
adverse effects of in-office whitening with >30 % hydrogen peroxide are described
in Chaps. 4, 5, and 7.
Does fluoride help in preventing sensitivity during my treatment?
The use of sodium fluoride daily after bleaching does not affect the bleaching
efficacy of carbamide peroxide and may reduce the intensity of tooth sensitivity.
Do higher concentrations of carbamide peroxide result in whiter teeth?
Current evidence from controlled clinical trials suggests that higher concentra-
tions result in a faster rate of whitening than lower concentrations with a similar
final result. At 1 year, 16 % carbamide peroxide concentration does not increase the
longevity of the whitening effect compared to 10 % carbamide peroxide. A slightly

higher incidence of sensitivity is associated with higher concentrations.
What concentration of peroxide is best for our patients?
From the previous question/answer, the efficacy of 10 % carbamide peroxide is

similar to that of higher concentrations; therefore, we only recommend 10 % carb-
amide peroxide, except for cases of external whitening of lightly discolored end-
odontically treated teeth in which the stain is recent.
What is the recommended duration of at-home whitening treatments?
We currently inform our patients that discolorations caused by aging and chromo-
genic foodstuff usually achieve a satisfactory lighter color after 2–4 weeks of over-
night tray whitening with 10 % carbamide peroxide. However, this result depends on
the patient’s compliance. The ideal final color is not reached if patient does not wear
the tray daily. For gray tooth shades, C’s and D’s in the Vita Classical A1-D4 shade
guide, we recommend 4–6 weeks of overnight tray whitening with 10 % carbamide
peroxide, with the prospect of a residual darker area at the cervical third of the teeth.
What is the best desensitizing agent to use with peroxides?
There is strong evidence that the only desensitizer that has been shown to reduce
sensitivity during whitening treatment is potassium nitrate. The evidence also
shows that the combination of potassium nitrate with sodium fluoride in toothpaste
is capable of preventing tooth sensitivity when used for 2 weeks prior to starting
the whitening treatment, or as a gel when applied 30 min prior to the inserting of
the bleaching tray. The inclusion of potassium nitrate in the composition of the
carbamide peroxide whitening gel may also help in the prevention of tooth
sensitivity.
Is the jump-start technique more efficient than the at-home technique alone?
Current evidence from controlled clinical trials suggests that tray whitening
alone results in similar outcomes compared to the jump-start technique. However,
some clinicians claim that the jump-start technique motivates patients, as the initial
results are visible immediately after the initial in-office whitening component.
Can tetracycline-stained teeth be bleached with at-home whitening regimen using a

carbamide peroxide gel?
Yes, but it depends on the intensity of the stain. Please refer to Sect. 6.4.4.2.
Do dentists have to wait for 2 weeks after the conclusion of the whitening treatment
before they can place bonded restorations on recently whitened teeth? Does this
apply to internal and to external whitening?
Yes. This principle applies to all peroxide-based whitening regimens and

techniques.
How do we know that the concentration written on the syringe corresponds to the
concentration of peroxide inside the syringe?
The chance of a mismatch between the advertised concentration and the actual
concentration is very high. For bleaching some gels, the actual concentration is
between 16 % and 36 % lower than the label indicates.
I heard in a dental convention and recently read in a manufacturer’s site that gel in
conventional whitening trays is only strongly active for 25–35 min…
As discussed in Sect. 6.3.2, more than 50 % of the active agent is available after 2 h.
The percentage of carbamide peroxide recovered from tray and teeth is 10 % at 10 h.
Does at-home whitening affect the vitality of the pulp?
For in-depth information on pulpal inflammation triggered by peroxide-based

bleaching agents, please refer to Chap. 5. In case heat is used, such as in the jump-
start technique, pulpal enzymes may be significantly inhibited.
Acknowledgment Dr. Jorge Perdigão would like to extend his special thanks to:
1. University of Minnesota School of Dentistry students for their help and inspiration.
2. Graduate students and faculty members of the University Rey Juan Carlos School of
Dentistry Post-Graduate Program in Esthetic Dentistry for their assistance with some
clinical cases.
3. Dr. George Gomes and Dr. Filipa Oliveira for their dedication and hard work.
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In-Office Whitening
7
Alessandro D. Loguercio, Leandro M. Martins,
Luciana M. da Silva, and Alessandra Reis
Abstract
In this chapter, the step-by-step procedure of in-office whitening (or in-office
bleaching) and the efficacy and side effects of this bleaching modality will be
presented. Other characteristics of this protocol such as the number of clinical
appointments required to achieve effective whitening, concentration of the
bleaching products, the effects of dentin dehydration and demineralization on
the final outcome, as well as bleaching-induced tooth sensitivity will be
addressed. At the end, some frequently asked questions will be answered.
7.1 Introduction
In-office whitening is a treatment option in the dental bleaching armamentarium.

Not every patient can wear tray delivery products. Some patients do not adapt well
to the at-home protocol due to the need of the daily usage of a bleaching tray as well
as the need to wait for some weeks to see the results of the treatment. In some cases,
in-office bleaching is performed to motivate patients before starting an at-home
protocol in the combined or jump-start technique.
This is the reason why in-office bleaching should be considered an alternative
option to the more traditional and safer at-home bleaching procedures. Several
aspects of in-office bleaching modality will be discussed in this chapter to provide
A.D. Loguercio (*) • A. Reis (*)

Department of Restorative Dentistry, State University of Ponta Grossa, Ponta Grossa,
PR, Brazil
e-mail: aloguercio@hotmail.com; reis_ale@hotmail.com
L.M. Martins • L.M. da Silva
Department of Restorative Dentistry, Federal University of Amazonas, Manaus, AM, Brazil

146 A.D. Loguercio et al.
clinicians with a better understanding of the protocol and particularities of the tech-
nique and facilitate its incorporation into the daily practice with confidence.
7.2 Efficacy
In-office whitening is performed with high concentrations of hydrogen peroxide

(HP), usually ranging from 15 to 40 %. Regardless the concentration of the bleach-
ing gel, HP is the active molecule that acts as a strong oxidizing agent through the
formation of free radicals, reactive oxygen molecules, and HP anions (Bowles and
Ugwuneri 1987).
Previous studies have claimed that tooth shade is affected by the intrinsic organic
chromophores present in the dental structure (Fuss et al. 1989; Watts and Addy
2001; Sulieman et al. 2003; Joiner 2006). Organic chromophores are colorful chem-
ical molecules, which consist of complex molecules such as aromatic compounds or
bioinorganic metallic complexes such as chelates (Eimar et al. 2012b). These chem-
ical compounds can be easily identified with Fourier Transform Infra-Red (FTIR)
and Raman spectroscopies (Eimar et al. 2012b). However, studies using these tech-
niques researchers were never able to detect any of these potential chromophores
(Fattibene et al. 2005; Eimar et al. 2011, 2012a). More recently, researchers sug-
gested that HP whitens teeth by mere oxidation of the transparent organic matrices.
This process turns them whiter and more opaque, which results in whiter dental
appearance (Kawamoto and Tsujimoto 2004; Eimar et al. 2012b).
Some particularities of in-office bleaching should, however, be discussed. The
lighter appearance of teeth immediately after an in-office bleaching session cannot
be only attributed to the oxidizing action of the HP into the dental organic substrate.
Apart from oxidization, dental dehydration and enamel demineralization are
expected to occur. As in-office bleaching is usually performed under isolation (rub-
ber dam or light-cured gingival barrier plus lip and cheek retractors), dental dehy-
dration will be always associated with the procedure. This effect is demonstrated
when a rubber dam is used to isolate the teeth even for short periods of time
(Fig. 7.1). A recent research paper (Burki et al. 2013) demonstrated that the applica-
tion of a rubber dam alone, even for a short period of 10 min, would cause a lighten-
ing of the tooth for a ∆E of 7.3, without any actual bleaching having occurred.
Dehydration of teeth can make them appear whiter by increasing enamel opacity.
Light can no longer scatter from hydroxyapatite crystal to crystal (Fondriest 2003;
Burki et al. 2013). Loss of translucency on dehydration causes more reflection,
masking the underlying color of dentin, and thus appears lighter. This “lightened”
teeth (by dehydration) return to a normal color after a period of hours or days
(Fig. 7.1).
Apart from dehydration, enamel demineralization results from the low pH of
most bleaching products currently available. Most in-office bleaching gels are deliv-
ered in low pH because they are more stable in acid solutions than in basic solutions.
When HP is to be stored, a weak acid is usually added to the solution to prevent it
from decomposing (Chen et al. 1993), which makes the bleaching product acidic
7 In-Office Whitening 147
a b
Fig. 7.1 The effect of rubber dam on lightness can be observed in these three photographs.
(a) Patient’s smile before rubber dam isolation. (b) The rubber dam was placed in the upper dental
arch and left undisturbed for 10 min. (c) The effect of dehydration is observed immediately after
rubber dam removal (Images provided by Camilo Andrés Pulido Mora, DDS, MS)
enough to produce enamel demineralization. The pH of in-office bleaching gels

may vary from 2.0 to 9.0 (Price et al. 2000; Freire et al. 2009; Majeed et al. 2011).
Therefore, taking into consideration that transient dental dehydration and demin-
eralization occurs concomitantly to the permanent effect of dental bleaching during
in-office bleaching, the result of in-office bleaching cannot be assessed immediately
after the in-office bleaching session. The reliability of color measurements is ques-
tionable if carried out immediately after treatment, leading to the conclusion that
in-office whitening is as efficient as at-home bleaching.
The effect of color change when evaluated before complete dental rehydration
occurred in the study of Matis et al. (2007). The graphic below shows the changes
in L* (Fig. 7.2) and b* (Fig. 7.3) parameters after a single in-office bleaching ses-
sion. In the “x” axis, time 0 means the color taken immediately after in-office
bleaching and the other times represent weekly measures up to 6 weeks. In general,
color change (L* and b* parameters) seems much more pronounced when they were
measured immediately after the procedure (time 0), with significant reductions of
L* and increases of b* after 1–2 weeks due to the dental rehydration and remineral-
ization. Therefore, the “real” bleaching effect (produced by oxidization) can only be
measured 1–2 weeks after the end of the in-office bleaching.
The difference between the “whitening outcome” observed immediately after
bleaching and that measured 1 week later has been erroneously interpreted as color
rebound, with some researchers concluding that in-office bleaching is not as efficient
Fig. 7.2 Variation in the 5

ΔL* in a 6-week period Pola office 35 %
after a single in-office 4 Zoom 25 %
bleaching with different
Delta L*
3 One-hour smile 35 %
products (Adapted from
Matis et al. 2007)
2
0
0 1 2 3 4 5 6
Weeks
Fig. 7.3 Variation in the 0

Δb* in a 6-week period 0 1 2 3 4 5 6
after a single in-office −1
bleaching with different
products (Adapted from
−2
Delta b*
Matis et al. 2007)
−3
Pola office 35 %
−4 Zoom 25 %
One-hour smile 35 %
−5
Weeks
as at-home bleaching (Matis et al. 2007). Several studies have demonstrated that 1
week of at-home bleaching with 10 or 16 % carbamide peroxide gel usually results
in a change of two to four shade guide units in the value-oriented Vita Classical
A1-D4™ shade guide (VITA Zahnfabrik H. Rauter GmbH & Co.KG, Bad Säckingen,
Germany) (Zekonis et al. 2003; Bernardon et al. 2010; da Costa et al. 2010; Rezende
et al. 2013). This is approximately equivalent to the change reported after a single
in-office bleaching session with 35 % HP gel when used for 45–60 min (Zekonis
et al. 2003; Bernardon et al. 2010; Kossatz et al. 2011; Reis et al. 2011b).
There are also other factors that may explain the general belief that in-office
bleaching is not effective. It is known that the whitening effect is related to the con-
centration, application time, and the number of changes of the in-office bleaching
gel (Dietschi et al. 2006; Joiner 2006; Matis et al. 2007). In an ongoing systematic
review of the literature (Luque-Martinez et al. 2016) we observed a high heteroge-
neity among studies in many issues, such as type of materials, concentration of the
products, and significant variations in in-office bleaching protocols.
Inefficient bleaching protocols will not lead to a satisfactory bleaching outcome.
For instance, some studies performed only a single in-office bleaching session (da
Costa et al. 2010; Giachetti et al. 2010; Moghadam et al. 2013; Pintado-Palomino
et al. 2015), which is not enough to reach patient’s satisfaction (de Silva Gottardi
et al. 2006; Salem and Osman 2011). At least two or three bleaching sessions may
need to be performed to obtain a similar whitening degree of a 2 or 3-week at-home
bleaching (Marson et al. 2008b; Tay et al. 2009; Bernardon et al. 2010; Basting
et al. 2012; Reis et al. 2011b, 2013).
Similar variation occurs in regard to product application time. While a 40–50-
min application is related with a significant whitening outcome, there are reports
of shorter application times, such as 10–20 min (Auschill et al. 2005; Giachetti
et al. 2010; Mehta et al. 2013). A very recent clinical study reported that a single
15-min application of the 35 % HP does not achieve the same degree of whiten-
ing produced by two and three 15-min applications of the same product (Kose
et al. 2015).
Some manufacturers advocate the application of their products with light activa-
tion (quartz–tungsten halogen light curing units, LEDs, and lasers) to optimize the
bleaching outcome (Ziemba et al. 2005; Kishi et al. 2011; Bortolatto et al. 2014).
The benefits of this association are rather controversial (Buchalla and Attin 2007;
He et al. 2012), but it seems to be useless for high-concentrated HP gels (Marson
et al. 2008b; Alomari and El Daraa 2010; Kossatz et al. 2011; He et al. 2012). For
low-concentrated HP gels this light association may have some benefits, but this
still requires further evaluations (Ziemba et al. 2005; Ontiveros and Paravina 2009;
Bortolatto et al. 2014). This will be discussed in more detail in the section of fre-
quently asked questions in this chapter.
This variation makes the comparison of the in-office bleaching protocols very
difficult. However, efficient whitening has been observed in studies that employed
35 % HP, with reports of overall color change of five to eight shade guide units after
two in-office bleaching sessions (Marson et al. 2008b; Tay et al. 2009; Bernardon
et al. 2010; Strobl et al. 2010; Reis et al. 2011a). This wide range of color change
probably is the result of the small variations in the HP concentration, number of
bleaching sessions, and baseline color of the participants in the clinical trials
(Rezende et al. 2015b).
7.3 Adverse Effects
As in-office bleaching is used with higher HP concentrations, there are more con-
cerns about adverse effects in comparison with at-home bleaching. The two most
frequent adverse effect of in-office bleaching is bleaching-induced tooth sensitivity
(TS) and gingival tissue burning.
7.3.1 Bleaching-Induced Tooth Sensitivity (TS)
While effective bleaching is reported to occur with in-office bleaching, several pub-
lications have reported that patients undergoing bleaching procedures frequently
complain of painful and uncomfortable sensations arising in the treated teeth.
Although pain in bleached teeth can be evoked by cold or other stimuli, most
patients complain of tingling or shooting pain (zingers) of very short duration but
variable frequency (Haywood 2005) without provoking stimuli (Markowitz 2010).
Unfortunately, this side effect is very frequent. The reported risk of bleaching-
induced TS in clinical trials of dental bleaching is quite variable but easily exceeds
50 %. A recent study that evaluated the individual patient data of 11 clinical trials
regarding bleaching produced a more accurate estimate of these risks. For in-office
bleaching in higher concentration (35 %), the risk of TS was reported to be 62.9 %
(95 % CI 56.9–67.3), which was not too different from that reported for 10–16 %
carbamide peroxide for at-home bleaching (51 % with a 95 % CI 41.4–60.6)
(Rezende et al. 2015b). Although the risk of TS was reported to be similar, the
intensity of TS was very different between bleaching protocols. In a 0–4 pain scale,
the overall mean intensity of bleaching-induced TS for in-office bleaching was
2.8 ± 2.9, while for at-home bleaching was 0.5 ± 0.9 (Rezende et al. 2015b).
The etiology of bleaching-induced TS is not fully understood. Since the hydro-
dynamic theory of dentin sensitivity has been widely accepted as the explanation of
dentinal sensation, some authors have used this theory to explain bleaching-induced
TS (Swift 2005). However, pain during and following bleaching treatment can
affect intact teeth lacking dentin exposure and this is in sharp contrast with the
hydrodynamic theory (Markowitz 2010).
In face of that, other investigators have hypothesized that bleaching-induced TS
may result from some degree of pulpal inflammation due to the higher amount of HP
that reaches the pulp. It is widely known that HP can pass easily through the enamel
and dentin to the pulp (Cooper et al. 1992) and can cause damage to the pulp cells as
seen in Chap. 5 (Costa et al. 2010). Further proof of this passage of HP is the fact that
color changes in dentin next to the pulp occur as fast they do at the dentin–enamel junc-
tion (McCaslin et al. 1999; Haywood 2005). Pulp tissue damage is likely to lead to the
release of cell-derived factors, such as adenosine triphosphate (Cook and McCleskey
2002) and prostaglandins, which excite or sensitize pulpal nociceptors (Huynh and
Yagiela 2003) causing the bleaching-induced TS (please refer to Chap. 5).
Several factors may affect the ability of HP to permeate the dental structures and
consequently the damage produced by the bleaching gels. For instance, the amount of
HP that permeates dental pulps is higher in teeth with restorations (Gokay et al. 2000;
Patri et al. 2013; Parreiras et al. 2014). In restored teeth, the depth and size of the res-
torations (Parreiras et al. 2014), as well as the type of adhesive and restorative material
(Gokay et al. 2000), may also play a significant role on the amount of HP penetration.
The tooth type is another important factor. Literature findings report that for the
upper dental arch (Bonafe et al. 2013), the tooth that was reported to give most
complaints of bleaching-induced TS was the upper lateral incisor. The thinner
enamel and dentin layers of incisors compared to other teeth may allow the fast pas-
sage of HP to the pulp, allowing less time for the production and release of protec-
tive enzymes against damage by HP. This was also in agreement with recent
histological studies of human pulps after in-office bleaching (Costa et al. 2010;
Roderjan et al. 2015). In one study (Costa et al. 2010), the authors observed notable
damage to the pulp tissue of lower incisors but not to premolars (Chap. 5).
Baseline color was strongly associated with TS in a recent study that pooled the
data from 11 studies from the same research group (Rezende et al. 2015b). In other
words, the darker the teeth, the lower the intensity and risk of TS. Darker teeth
probably have higher organic content to retain the HP in the enamel and dentin sub-
strates, allowing less surplus HP to travel to the pulp tissue. Under these circum-
stances, it is possible that less HP comes in contact with the pulp tissue, which
generates lower TS. This, however, is a hypothesis yet not supported by basic research.
Several approaches have been tested to minimize the adverse side effect of TS. The
administration of some drugs perioperatively during in-office bleaching, such as
selective anti-inflammatory drugs (etoricoxibe) (de Paula et al. 2013), nonsteroid anti-
inflammatory drugs (ibuprofen) (Charakorn et al. 2009; Paula et al. 2013), antioxi-
dants (ascorbic acid) (de Paula et al. 2014), and corticoids (dexamethasone) (Rezende
et al. 2015a), was not effective to prevent the risk as well as the intensity of TS as
confirmed by a recent systematic review of the literature (Faria et al. 2015). Under
per-oral administration, several factors such as the immune system, lymphatic drain-
age, urinary excretion, and morphological characteristics of the dentin substrate may
modulate the amount of the medicine that reaches the plasma and extracellular fluid
around pulp cells, making these approaches not effective.
The most effective measures to minimize this side effect were through the applica-
tion of topical desensitizers (Wang et al. 2015). The preoperative application of a gel
composed of 5 % potassium nitrate and 2 % sodium fluoride for 10 min was capable
to reduce the risk of TS by half, as well as the intensity of TS (Tay et al. 2009). The
effect of fluoride in this process is not clear and the desensitizing effect of the associa-
tion of sodium fluoride and potassium nitrate seems to be more related to the presence
of potassium nitrate. This substance penetrates the enamel and dentin to travel to the
pulp where it creates a calming effect on the nerve by affecting the transmission of
nerve impulses (Ajcharanukul et al. 2007). After the nerve depolarizes in the pain
stimulus response, it cannot repolarize, so the excitability of the nerve is reduced.
Potassium nitrate has almost an anesthetic effect on the nerve (Haywood 2005).
In regard to the action of fluorides, it is hypothesized that the precipitation of
calcium fluoride crystals in dentin can reduce the functional radius of the dentinal
tubules and also the permeability of this tissue to the hydrogen peroxide. By doing
so, less hydrogen peroxide reaches the pulp chamber, reducing the tooth sensitivity.
This, however, is yet to be confirmed, as this process seems to occur only when
there are exposed dentin surfaces.
Another study showed that previous desensitization with Gluma desensitizer
(Heraeus Kulzer), composed of 5 wt% glutaraldehyde and 35 % weight% HEMA
(Baba et al. 2002; Qin et al. 2006), for 1 min significantly reduced sensitivity of the
anterior teeth during and after whitening compared with a placebo pretreatment (Mehta
et al. 2013). The authors of this study hypothesized that glutaraldehyde (molar mass
100 g/moL) and HEMA (molar mass 130 g/moL) might penetrate through enamel and
dentin along the same pathway as the peroxide radicals. On the way to the pulp, glutar-
aldehyde might react by cross-linking with enamel matrix proteins and with proteins in
the dentin tubular liquid, thus reducing easy passage of the HP radicals to the pulp.
Although some opinion leaders claim that application of desensitizer gels prior
to in-office bleaching affects the bleaching efficacy, this was not confirmed by
recent meta-analyses of the literature (Wang et al. 2015), probably because the
desensitizer gels used are transparent.
Fig. 7.4 Chemical burning

of the cervical gingiva of
several teeth after an
in-office bleaching
application with a
high-concentration
hydrogen peroxide
7.3.2 Gingival Tissue Irritation
As long as adequate protection of the gingival tissues is performed with a light-

cured gingival barrier or rubber dam isolation, gingival burning (Fig. 7.4) is not
expected to occur. This is usually not reported in clinical trials of in-office bleaching
studies and reflects the clinical experience of the study authors. As seen in Chap. 4,
in case this occurs the dentist should apply a drop of catalase and/or sodium bicar-
bonate (usually provided by the manufacturer) on the ulcerated lesion to arrest the
burning effect. No other measure is usually required; but in case the patient feels
any discomfort, a corticoid ointment may be prescribed to relieve pain.
7.4 Treatment Regimen with Step-By-Step Procedures
As mentioned earlier, in-office bleaching protocols vary significantly in the clinical

reports. The application time of the bleaching gel, the number of bleaching sessions,
whether or not the protocol is associated with light and the number of product
refreshment on the dental surface are some examples.
In this chapter, we will describe all steps involved in an effective bleaching pro-
tocol and also report some of the variations of each step as long as they can still
result in an effective whitening outcome. For didactic reasons, this section will be
described in steps.
7.4.1 Making a Decision About the In-Office Bleaching Gel
There are many in-office bleaching products in the dental market, which makes their
choice quite difficult. They vary in the active concentration of HP, which ranges
usually from 15 to 40 % and in terms of pH (Freire et al. 2009; Price et al. 2000;
Majeed et al. 2011). There are some products that contain other additives such as
calcium gluconate and calcium phosphates and desensitizing agents (sodium fluo-
ride, potassium nitrate). These systems also vary in their mode of application: most
of them require product refreshment during a single in-office session, while for
some products; a single 40–50-min application is required.
The literature is scarce regarding the comparison of these systems both in terms
of effectiveness and side effects, and, therefore, the choice of these products is
usually based on empirical evidence. Comparison of in-office bleaching gels with

different HP concentrations is also scarce. A single study that compared the color
change and bleaching-induced TS of 20 % versus 35 % HP with 2 % calcium gluco-
nate reported no significant difference in the risk of TS and a significant lower
degree of whitening for the 20 % HP gel (Reis et al. 2013).
As previously mentioned, whitening products should have a relatively alkaline
pH to minimize potential damage, but there is a wide pH variation among in-office
bleaching gels (Price et al. 2000; Freire et al. 2009; Majeed et al. 2011). This varia-
tion could be the result of the different formulations used by each manufacturer,
because bleaching agents contain stabilizers and other inorganic components that
allow them to be stored for prolonged periods. In-office bleaching gels are delivered
in low pH because they are more stable in acidic solutions than in basic solutions.
When the HP is manufactured, a weak acid is usually added to the solution to pre-
vent it from decomposing (Chen et al. 1993).
Some investigators have reported that the HP delivered in an alkaline medium
increases the effectiveness of bleaching in the wool industry. This effectiveness is
explained by the fact that the dissociation constant of the HP is about 11.5. In fact,
the findings of one study showed that in a pH = 9.0, the dissociation rate of the HP
was 2.7 times higher than that in an acidic solution (pH = 4.4) (Frysh et al. 1995) and
this was recently confirmed by Torres et al. (Torres et al. 2014). They observed
in vitro that the efficacy of hydrogen peroxide bleaching is directly proportional to
the increase of the pH of the bleaching gel. These variations, however, did not seem
to produce differences in tooth-bleaching effectiveness when products with acidic
and alkaline pH were compared, although a significant decrease of tooth sensitivity
has been shown for alkaline gels (Kossatz et al. 2012).
Additionally, it is worth mentioning that alkaline gels usually show more stable
pH during application than acidic gels (Marson et al. 2008a), which allows them to
be applied in a single application without the need of several product replenish-
ments (Reis et al. 2011a, b; Kossatz et al. 2012).
Although there is biological plausibility to choose bleaching products containing
desensitizing agents such as potassium nitrate, to the best of the authors’ knowledge no
randomized clinical trials have compared the TS levels produced by in-office gels with
and without desensitizer agents. Only at-home clinical studies evaluated this hypothe-
sis (Navarra et al. 2014; Gallo et al. 2009) as previously mentioned in the Chap. 6.
In summary, we recommend the use of 35 % alkaline gels, containing desensitiz-
ing agents. As mentioned in the section on frequently asked questions, reduced HP
concentration can be used in the combined or jumped-started technique. In regard to
the presence of desensitizing agents, we still recommend products containing it.
The absence of evidence that desensitizing containing gels can reduce TS cannot be
interpreted as evidence of absence of an effect. These studies are usually low pow-
ered and we cannot rule out the fact that desensitizing-containing gels can provide
some beneficial effect. Until high-powered studies are published, we should work in
the conservative way and use such type of products, as they do not have any known
detrimental effects. Finally, products should be applied according to the respective
manufacturer’s instructions.
Fig. 7.5 The baseline

tooth color being recorded
with a value-oriented shade
guide after performing a
dental prophylaxis
7.4.2 Determination of the Baseline Tooth Color
This procedure allows dentist and also the patient to monitor color change during
the bleaching protocol (Fig. 7.5). Patients usually very quickly get used to the new
tooth color and may not remember what color their teeth were before protocol. This
is even more important when both dental arches are bleached simultaneously. Shade
recording can be a procedure with a value-oriented or bleach shade guide (Fig. 7.5),
spectrophotometer, or by means of dental photographs.
Some authors encourage whitening one dental arch at a time (Haywood 2005),
because it minimizes TS, allows the patient to monitor the opposing arch to com-
pare progress, and it also encourages compliance. However, this procedure
increases significantly the cost of the bleaching protocol, as it requires more
dental visits.
Another advantage of color recording is that baseline dental color can predict the
whitening degree obtained after dental bleaching. A recent multivariable regression
analysis (Rezende et al. 2015b) identified a significant relationship between base-
line color and age in relation to color change estimates. After adjustment for the
other variables, every increase of one shade guide unit (in the value-oriented Vita
Classical A1-D4™ shade guide) in the baseline color resulted in an increase of
approximate 0.66 in the final color change in ΔSGU and 2.48 for the ΔE, meaning
that the darker the baseline tooth color, the higher the degree of whitening. In an
opposite trend, the degree of whitening is negatively affected by the participant’s
age (Rezende et al. 2015b).
This allows for the dentist to manage the patient’s expectations in regard to the
bleaching outcomes. Older patients with lighter baseline color may request more
than the two bleaching sessions to achieve the same whitening degree than younger
patients with darker baseline dental color.
It is important to perform a dental prophylaxis recording the baseline tooth color.
A recent published paper showed a significant difference (average of two ΔE units
of change) on tooth color when measured before and after dental prophylaxis. This
may reach the threshold for clinical detection (ΔE = 3.0) for some patients (de Geus
et al. 2015).
7.4.3 Application of a Desensitizing Agent
As reported earlier, one of the main side effects of in-office dental bleaching is
TS. Although this side effect cannot be completely eliminated, the number of
patients that experience TS and the intensity of TS can be reduced by previous
application of a desensitizing gel composed of 5 % potassium nitrate (Tay et al.
2009; Wang et al. 2015). Desensitizers composed of glutaraldehyde and HEMA was
also reported to be effective to reduce the bleaching-induced TS, and can be an
alternative to the potassium nitrate gel (Mehta et al. 2013).
This procedure can be performed before or after isolation of the dental arch, as the
material is not aggressive to the gingival tissue. However, as the gel is usually agitated
with the aid of a rotating brush it is recommended to apply the desensitizer before the
protection of the soft tissues. The buccal surface of all teeth to be bleached should be
covered with a 1-mm thick layer of the desensitizer and left in place for at least 10 min
(Fig. 7.6). At the end of this period, the product should be agitated in each dental sur-
face for 20 s with a rotating brush before removal. The inclusion of this step into the
in-office bleaching protocol does not jeopardize the whitening efficacy of the hydrogen
peroxide (Tay et al. 2009). After this period, the product should be removed with gauze
(Fig. 7.7) or with a saliva ejector before application of the in-office bleaching gel.
Rinsing can be performed as a final step for complete removal of the product.
7.4.4 Protection of the Soft Tissues
Hydrogen peroxide in high concentrations, such as those used for in-office bleach-
ing, may cause burning of the dental tissues (Fig. 7.4). Several attempts should be
made to avoid contact with the soft tissues.
The use of lip and cheek retractors associated with a light-cured gingival barrier
(Fig. 7.8) is quite common. The former can maintain lips, cheeks, and even tongue
away from the bleaching gel while the latter prevents the contact of the bleaching
gel with the gingival tissue. An increased frequency of micronuclei of cells from the
gingival tissue (which is an evidence of genotoxicity) was observed in patients
Fig. 7.6 Application of a

desensitizing gel composed
of 5 % potassium nitrate
for 10 min (Dessensibilize
KF 2 %, FGM, Joinville,
SC, Brazil). After this
period, the product should
be agitated in each dental
surface for 20 s with a
rotating brush before
removal
Fig. 7.7 Removal of the

desensitizing gel with
dental gauze or high-speed
suction. After removal of
the excesses, water rinsing
was performed
Fig. 7.8 A lip and cheek

retractor (ArcFlex, FGM,
Joinville, SC, Brazil) is
applied, followed by the
application of a light-cured
gingival barrier to protect
the marginal gingival tissue
submitted to in-office bleaching (Klaric et al. 2013), which may be the result of soft
burning or even the contact with the gingival barrier. To avoid this, the light-curing
gingival barrier should be adequately light cured (Fig. 7.8), according to the respec-
tive manufacturer’s recommendations, and clinicians should look at the teeth from
an incisal aspect to detect any sealing failure of the gingival tissue.
Rubber dam isolation can also be used for protection of the soft tissues. However,
before rubber dam installation, a thick layer of petroleum jelly should be applied on
the gingival tissue of the teeth to be bleached. Due to the hydrophobic nature of the
petroleum jelly, the bleaching gel will be prevented from contacting the gingival
tissue even if eventual isolation failure occurs.
7.4.5 Application of the In-Office Bleaching Gel
After choosing the in-office bleaching product, the manufacturer’s instructions

should be followed (Fig. 7.9 and 7.10). Variations to what is advocated by manufac-
turers may lead to either whitening at reduced speed or increased TS rates (Reis
et al. 2011b; Kose et al. 2015). By increasing the number and/or time of application,
one may increase the degree of whitening obtained but at the time the risk of TS is
also increased. In an opposite trend, reducing the number and/or time of application
reduces the probability of TS but also limits the degree of whitening.
Most in-office bleaching gels require replenishing the product during a period
that varies from 40 to 50 min. Some products require two, three, or four product
replenishments in each clinical session. There are some products, however, that are
indicated for a single 40–50-min application without replenishment. These products
usually possess a basic pH that allows them to be used for longer application times
without increasing the risk of TS (Kossatz et al. 2012; Reis et al. 2013). The product
should be firstly removed with a cotton pellet, gauze, or high-speed suction
(Fig. 7.11) before rinsing the dental surfaces with water. This procedure prevents
any kind of soft tissue burning.
A recent clinical trial evaluated the impact of changing the bleaching protocol of
a high-concentration (35 %) in-office bleaching product. Instead of performing three
15-min applications as suggested by the manufacturer, the product was kept for
45 min without replenishment. A reduction of the bleaching speed and increase in the
TS intensity was observed, probably as a result of the slow but significant reduction
of the pH of the product throughout the 45-min application (Reis et al. 2011b).
Fig. 7.9 The 35 %

hydrogen peroxide
in-office bleaching gel
(Whiteness HP Blue 35 %,
FGM, Joinville, SC,
Brazil) is mixed and
applied in all teeth to be
bleached
Fig. 7.10 After some time

in place, bubbles are
visible in the gel, which
result from the
decomposition of the
hydrogen peroxide
a b
Fig. 7.11 (a) A suction tip was first used to remove the gel prior to (b) water rinsing of the tooth
surfaces
As discussed in more detail in the section on frequently asked questions, some

manufactures advocate the application of their products with light activation
(quartz–tungsten halogen light curing units, LEDs or lasers) to optimize the bleach-
ing outcome (Ziemba et al. 2005; Bortolatto et al. 2014). A recent systematic review
of the literature concluded that light increases the risk of TS during in-office bleach-
ing, and light may not improve the bleaching effect when high concentrations of HP
(25–35 %) are employed. Therefore, dentists should use the light-activated system
with great caution or avoid its use altogether (He et al. 2012). However, for low-
concentrated HP gels the benefits of such association is yet to be determined.
Some manufacturers advocate the application of their products with light activa-
tion (quartz–tungsten halogen light curing units, LEDs, and lasers) to optimize the
bleaching outcome (Ziemba et al. 2005; Kishi et al. 2011; Bortolatto et al. 2014).
The benefits of this association are rather controversial (Buchalla and Attin 2007;
He et al. 2012), but it seems to be useless for high-concentrated HP gels (Marson
et al. 2008b; Alomari and El Daraa 2010; Kossatz et al. 2011; He et al. 2012). For
low-concentrated HP gels, this light association may have some benefits; but this
still requires further evaluations (Ziemba et al. 2005; Ontiveros and Paravina 2009;
Bortolatto et al. 2014). This is discussed in more detail in the section on frequently
asked questions in this chapter.
A single in-office bleaching session is usually not enough to achieve patient’s
satisfaction (de Silva Gottardi et al. 2006; Salem and Osman 2011). Studies that
demonstrate that in-office bleaching is as effective as at-home bleaching usually
performed two to three in-office bleaching sessions. Because in-office whitening
often takes more than one appointment to achieve the adequate whitening, appoint-
ments generally are scheduled at least 1 week apart to allow the discomfort to dis-
sipate. However, this procedure is purely based on empirical evidence.
Several clinical studies from our research group indicated that the TS induced by
in-office only cause complaints during the initial 48 h post bleaching. Also, a recent
randomized clinical trial revealed that a 2-day interval between two in-office bleach-
ing sessions did not increase the risk and intensity of bleaching-induced TS (de
Paula et al. 2015). However, in this paper, a calcium-containing alkaline gel applied
for a single 40-min application without replenishment was used (de Paula et al.
2015), which prevent us from generalizing this protocol to all in-office bleaching
gels present in the market.
In the clinical case, two clinical appointments were required to achieve patient
satisfaction. The color achieved after the end of the bleaching procedure should be
recorded with the same instrument used to record the baseline color. This measure-
ment, however, should be done 4–7 days after the last in-office bleaching session to
avoid the effects of dehydration and demineralization on the final outcomes (Fig. 7.12).
7.5 Durability of Color Change and Need for Touch-Up
As explained earlier in this chapter, the very short color reversal that occurs within
some days after the in-office bleaching session cannot be interpreted as lack of
effectiveness of the in-office bleaching protocol. In a way to avoid patient’s
a b
Fig. 7.12 One week after the second in-office bleaching session, the color of the patient’s teeth
was checked. (a) Teeth reached B1 color (the lightest color in the value-oriented Vita Classical
shade guide), which is five tabs lighter than the baseline patient’s teeth (A2) at the beginning of the
treatment (b)
frustration, they should be instructed that a slight darkening is expected to occur in

the following days as a result of dental rehydration and remineralization, and this
does not necessarily mean that the bleaching was not efficient. An adequate mea-
surement of the baseline tooth color will allow dentist to monitor the degree of color
change that was due to the oxidizing nature of the hydrogen peroxide gel.
Although there are many randomized clinical trials reporting the immediate effects
of several bleaching techniques, few of them evaluated the long-term efficacy of in-
office bleaching (Giachetti et al. 2010; Mondelli et al. 2012; Tay et al. 2012). The few
studies reported in the literature showed that in-office bleaching has stable results in
periods ranging from 9 months to 2 years (Giachetti et al. 2010; Tay et al. 2012).
On the other hand, we may expect darkening of the dental structure in longer
periods of time. As teeth grow older, there is a continuous deposition of secondary
dentin by the pulp and higher enamel wear. Both factors together increase the yel-
lowish appearance of the teeth. Additionally, we cannot rule out the effect of the
staining produced by beverages and food (Meireles et al. 2010). Although this is
usually an extrinsic staining and therefore may be easily removed by prophylaxis, it
may affect the patient’s overall perception of whiter teeth.
Based on the aforementioned explanations, touch-up bleaching may be per-
formed whenever color rebound is detected. Specific protocols and products were
discussed in the Chap. 6. Other option is to apply a new single in-office bleaching
session that may achieve satisfactory results. It may be emphasized, however, that
the literature lacks randomized clinical trials on this topic.
7.6 Frequently Asked Questions
7.6.1 Do We Need Lights to Activate Peroxidases?
As heat and light can accelerate the dissociation of hydrogen peroxide (Ontiveros
2011), both methods have been associated with in-office bleaching as early as 1918
(Abbot 1918). However, as we already mentioned earlier in this chapter, the
literature findings point out that there is no advantage of associating it with high
concentrations of HP gels (Marson et al. 2008b; Alomari and El Daraa 2010;
Kossatz et al. 2011; He et al. 2012).
At first glance, this seems to be contradictory. In fact, from chemical theories,
one knows that in the simplest chemical reactions, the highest concentration of reac-
tants raises collisions per unit time, and hence increases the reaction rate. However,
if the reaction is complex and involves a series of consecutive steps, there might be
a limit to which the increased concentration leads to faster reaction rates. We
hypothesize that 35 % HP alone already produces enough free radicals for oxidizing
organic component of dentin, and, thus, the increase in free radicals produced by the
light activation might be useless. Consequently, the further increases in HP radicals
produced by light activation do not lead to faster bleaching due to the presence of
unknown rate-determining steps in the oxidizing mechanism of tooth bleaching.
On the other hand, this may not be the case when using low HP gels. Randomized
clinical trials that evaluated the effect of light associated with low HP concentration
seemed to show a faster whitening degree (Tavares et al. 2003; Ontiveros and Paravina
2009). This may not be the case when using low HP concentrated gels. For these gels
it seems that the limiting factor of the oxidizing reaction rate was the amount of free
radicals, and thus the association with light, which likely increases the amount of free
radicals, may produce a faster reaction rate and a whitening degree similar to that of
the 35 % HP gel associated or not with light (He et al. 2012; Bortolatto et al. 2014).
However, these findings are still preliminary and require further evaluations.
7.6.2 Are Light-Activated Peroxides Available?
Some manufacturers indicated that their products contain orange-red color of caro-
tene as colorants and these compounds can be considered as activators because they
absorb primarily at wavelengths of blue lights. If the bleaching agent absorbs the
light energy of this wavelength, it heats and thus decomposes (Ontiveros 2011).
Unfortunately, a literature review indicated that although the temperature of the car-
otene-containing bleaching gel can increase considerably, this increase was not high
enough to accelerate HP decomposition significantly (Buchalla and Attin 2007).
Another option is the addition of some metals to enhance the oxidizing power of
the HP, as ferrous compounds or titanium dioxide. The photolysis of HP associated
with these compounds needs to be activated by a very specific wavelength, which
depends on the metals included (Ziemba et al. 2005; Kishi et al. 2011; Ontiveros
2011; Bortolatto et al. 2014).
For instance, one manufacturer combined iron with a low-concentrated HP for-
mulation. With ferrous compounds, HP can be combined with iron known as Fenton
reagent. Fenton reagents result in disproportion in which the iron is simultaneously
reduced and oxidized to form both hydroxyl and peroxide radicals by the same
HP. When Fe reacts (with or without UV radiation), the process is renewed and the
redox reaction is further fueled (Ontiveros 2011). This is the reason why products
that contain ferrous components recommend light activation by ultraviolet lights
(Kugel et al. 2009; Ontiveros and Paravina 2009). The use of UV lamps requires
care. Patients, dentist, and auxiliaries should be protected because of the known
damage the ultraviolet radiation can cause on the skin. It should be mentioned that
Fenton reaction occurs with or without ultraviolet light activation. Perhaps, futures
studies should focus on the evaluation of the bleaching efficacy of these bleaching
systems without the use of UV lights.
Some low-concentrated HP gels (6–15 %) containing semiconductors of tita-
nium oxide nanoparticles doped with nitrogen have shown good bleaching efficacy
comparable to 35 % HP gels (Bortolatto et al. 2014; Martin et al. 2015). When
exposed to blue light (LED/Laser device), these nanoparticles catalyze the forma-
tion of hydroxyl radicals from HP (Sakai et al. 2007). As these titanium oxide
bleaching formulations can be used with visible lights they are safer than the previ-
ous formulations that recommend UV light activation.
7.6.3 Manufacturers Recommend Several Consecutive

Applications of the In-Office Whitening Gel? How Many
Applications Are Needed? For How Long?
Clinicians should follow the manufacturer’s instructions for application of the in-
office bleaching gels. There are some products that are necessary to be refreshed
two to four times in a 40–50-min clinical session, while other products require that
the product be left undisturbed for the whole period it stands on the dental surface.
It is suggested that acidic gels and those that do show reduction of the pH over time
should be refreshed; alkaline gels that keep the pH alkaline during application can
be left on the surface for the whole application period.
However, this can be changed based on the patient’s profile. In case the profes-
sionals are dealing with a very sensitive patient, the number of product refreshments
as well as its application time can be reduced. This will probably reduce the risk and
intensity of TS (Kose et al. 2015) but will also require more applications to achieve
patient’s satisfaction.
Usually, two to three in-office bleaching sessions using 35 % HP are required to
show a significant color change (Marson et al. 2008b; Tay et al. 2009; Bernardon
et al. 2010; Strobl et al. 2010; Reis et al. 2011a), but unfortunately this can vary
depending on the baseline color of the participants in the clinical trials (Rezende
et al. 2015b).
7.6.4 Are Calcium Phosphate and Fluoride Containing Gels

Effective to Decrease Tooth Sensitivity Caused by In-Office
Bleaching?
As previously mentioned, there are numerous studies that have exhibited micro-
structural changes of enamel surface induced by in-office bleaching agents (Dahl
and Pallesen 2003) and it results from the low pH of most bleaching products
available in the market. Also, clinicians believe that these superficial alterations to
the enamel surface increase TS induced by in-office gels, mainly because the sur-
face becomes more porous to passage of HP.
This led different clinicians to evaluate whether the preoperative application of
remineralizing agents (Loguercio et al. 2015) or the addition of different remineral-
izing products to in-office bleaching formulations (fluoride, calcium phosphate
compounds, etc.) (Basting et al. 2012; Kossatz et al. 2012) might have an impact on
the reduction of bleaching-induced TS. These studies failed to find a reduction of
the bleaching-induced TS; however, no detrimental effect on the whitening effi-
ciency was detected (Basting et al. 2012; Kossatz et al. 2012; Loguercio et al. 2015).
A recent literature review that investigated the impact of bleaching procedures on
enamel surface indicated that these adverse on enamel effects are minimal. Laboratory
studies that simulated the intraoral conditions as closely as possible reported that as
soon as bleached enamel comes in contact with saliva, remineralization occurs and
within a few days no adverse effects can be measured (Attin et al. 2009). This was
also confirmed by in vivo studies when in-office gels were used after prolonged and
repeated applications (Spalding et al. 2003; Cadenaro et al. 2008, 2010).
7.6.5 Why Are Some In-Office Whitening Products Referred

to as “Chemically Activated”?
As previously described, the in-office gels are more stable in acid solutions than in
alkaline solutions (Chen et al. 1993). This is why the majority of bleaching gels
commercially available are presented in two syringes/bottles, one containing the HP
product and other containing the colorants, thickening agent, etc.
When clinicians mix both syringes/bottles, a “chemical activation” occurs by
mixing two components of the respective bleaching gels, which can indeed increase
HP decomposition and the in-office gels are ready to use. This has led to erroneous
interpretation of in-office gels being “chemically activated.” Actually, the main func-
tion of the activating gel component (synonymously referred to as “catalyst” or
“booster”) is to increase the pH of the mixed gel to achieve a alkaline pH close to the
pKa of the hydrogen peroxide (pka = 11.0), thereby increasing the decomposition
rate of peroxide and the formation of oxidative radicals (Buchalla and Attin 2007).
7.6.6 Does the “Jump-Start” Technique Improve the Final Result

of a Whitening Treatment?
As indicated in the Sect. 7.2, there are several factors that may explain the clini-
cian’s belief that in-office bleaching is not efficient when compared to at-home
bleaching. Thus, the combination of in-office and at-home bleaching (“combined
bleaching technique”) has been suggested for some clinicians as a way to potentiate
the bleaching effect and improve color stability (Kugel et al. 1997; Deliperi et al.
2004; Matis et al. 2009; Bernardon et al. 2010).
However, considering that both bleaching techniques (in-office and at-home

techniques) are effective, the main advantage of the “jump-start” technique is for
some patients who demand faster ways of bleaching (Matis et al. 2009; Bernardon
et al. 2010). In this way, the “jump-start” technique, as the name suggests, is
commonly used to motivate the patients to comply with the at-home bleaching
protocol.
Usually, the in-office bleaching is applied before starting the at-home protocol;
however, the in-office bleaching can be incorporated in any moment, mainly when
there is a low response to the at-home bleaching. The number of in-office bleaching
sessions associated with the at-home procedure will be dictated by the patients’
demand and the whitening response to the procedure.
Usually, clinical studies that performed the combined or jump-start bleaching
technique have used high hydrogen peroxide concentrations for the in-office phase
(Kugel et al. 1997; Deliperi et al. 2004; Matis et al. 2009; Bernardon et al. 2010).
This means that high levels of bleaching-induced TS were reported (Kugel et al.
1997; Deliperi et al. 2004; Matis et al. 2009; Bernardon et al. 2010).
More recently, a clinical study that compared a low and high concentration of HP
combined with 10 % carbamide peroxide for at-home bleaching showed that both
protocols yielded the same whitening effect. The constant delivery of the at-home
bleaching gel for the 2 weeks following the in-office bleaching might have compen-
sated for the lower HP concentration of the in-office gel. However, the use of the
low HP concentration for the in-office phase of the bleaching protocol reduced the
risk and intensity of bleaching-induced TS (Rezende et al. 2016).
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Intracoronal Whitening
of Endodontically Treated Teeth 8
Jorge Perdigão, Andressa Ballarin, George Gomes,
António Ginjeira, Filipa Oliveira, and Guilherme C. Lopes
Abstract
Several techniques have been used within the last 170 years to lighten discolored
endodontically treated teeth. Internal whitening or intracoronal whitening offers
some advantages over more invasive treatments, as: (1) it is relatively easy to
carry out; (2) it involves the removal of minimal tooth structure; and (3) the cost
of treatment is low compared to that of other restorative options including full-
and partial-coverage restorations.

A. Ballarin, DDS
Private Practice, Florianópolis, SC, Brazil
e-mail: andressaballarin@hotmail.com
G. Gomes, DMD, MSD
Rey Juan Carlos University, Madrid, Spain
e-mail: georgegome@gmail.com
A. Ginjeira, MD, DMD, PhD
Department of Endodontics, University of Lisbon School of Dentistry, Cidade Universitária,
Lisbon, Portugal
e-mail: antonio.ginjeira@fmd.ulisboa.pt
F. Oliveira, DMD
Private Practice, Lisbon, Portugal
e-mail: filipaoliveira.email@gmail.com
G.C. Lopes, DDS, MS, PhD
e-mail: guilherme.lopes@ufsc.br

The whitening techniques currently used to lighten darkened endodontically

treated teeth are based on the release of active oxygen inside the pulp chamber
and subsequent diffusion into the dentinal tubules. Hydrogen peroxide in a con-
centration of approximately 30–35 % and/or sodium perborate have been the
chemicals most often used as oxygen sources. The prognosis of intracoronal
whitening is good for discolorations of endodontically treated teeth caused by
necrotic pulp tissue or blood components, with a short-term success rate of
50–90 %. However, the long-term success rate is considerably lower, as some
color regression may occur after the initial bleaching effect.
Undesirable side effects of intracoronal whitening include occasional external
cervical resorption and, more rarely, ankylosis. External cervical resorption has
been often associated with anterior teeth that had been endodontically treated as
a result of traumatic injury in young patients. Other side effects, such as altera-
tion of enamel morphology and decrease in physical characteristics of enamel
and dentin, are minimal and transient according to some authors, or inexistent
according to other authors. This chapter will review the clinical techniques and
provide step-by-step guidelines for the dental professional to carry out internal
whitening of endodontically treated teeth.
8.1 Introduction
Root canal therapy often results in tooth discoloration (Kingsbury 1861). When the
clinician believes that preserving the patient’s own tooth structure is the most appropri-
ate treatment, intracoronal whitening (or internal whitening or internal bleaching1) may
be indicated for esthetic reasons. While internal bleaching is a conservative technique
compared to more invasive procedures such as veneers or full-coverage esthetic resto-
rations, it results in a relatively low long-term success rate (Brown 1965; Howell 1981).
Ancient Egyptians and Romans used various methods to whiten teeth. Romans used
urine because it contains ammonia, a cleaning agent now found in many household
products. Egyptians used a paste of vinegar and pumice, combining the eroding effect
of acetic acid with the abrasive effect of pumice. Intracoronal whitening of discolored
endodontically treated teeth has been described in the dental literature since the nine-
teenth century (Dwinelle 1850; Fitch 1861). Dwinelle (1850) used chloride of lime or
bleaching powder (currently known as calcium hypochlorite) and soda to successfully
lighten nonvital teeth. The procedure was known as “bleaching” as consequence of the
use of bleaching powder. In May 1884, in a lecture to the Section of Oral and Dental
Surgery of the American Medical Association, Harlan described for the first time the
use of hydrogen peroxide to bleach root canal-treated teeth (Harlan 1884):
In order to bleach a pulpless tooth the operator must first fill the root at least one third its
length… Discolored dentine if hard need not be cut away. With the rubber dam adjusted
over the adjacent teeth, including the one to be operated upon, the cavity is thoroughly
washed with H2O2 repeatedly and then carefully dried….
1
The terms “whitening” and “bleaching” are used interchangeably in the literature.
8 Intracoronal Whitening of Endodontically Treated Teeth 171
Other bleaching agents were more popular among dentists until the 1900s (Chap.
1), including sodium peroxide, oxalic acid, potassium cyanide, chlorine- and sulfur-
based materials, and pyrozone (a mixture of ether and hydrogen peroxide) (Kingsbury
1861; Truman 1881; Kirk 1893). By 1903, the allusion to the use of hydrogen perox-
ide to bleach nonvital teeth had become more usual in the dental literature (Buckley
1903; Miller 1903).
More recently, sodium perborate, hydrogen peroxide, and carbamide peroxide
have been the materials of choice for intracoronal whitening (Brown 1965; Boksman
et al. 1983; Carrillo et al. 1988; Vachon et al. 1998). Two materials have been
favored, namely, 30–35 % hydrogen peroxide (Superoxol) and powdered sodium
perborate, which have been used either alone or in combination (Weisman 1963;
Freccia et al. 1982). Hydrogen peroxide generates free radicals and active oxygen
(Kashima-Tanaka et al. 2003).
8.2 Etiology of Discoloration in Endodontically Treated

Teeth
Discoloration of nonvital teeth can be classified as intrinsic and/or extrinsic (Hattab

et al. 1999; Plotino et al. 2008). Extrinsic stains (Chap. 1), by definition, are caused by
extrinsic agents and located on the outer surface of the teeth. Intrinsic stains result
from the incorporation of chromogenic materials into dentin either during odontogen-
esis or after eruption (Plotino et al. 2008). Intrinsic stains can be caused by local or by
systemic causes (Fig. 8.1). This chapter will focus on stains of intrinsic origin.
Metabolic
Systemic Congenital
Iatrogenic
(systemic drugs)
Natural sources
Intrinsic
Aging
Stains
Calcific metamorphosis
Endodontic sealer
Intrapulpal hemorrage
Local Intracanal medicaments
Pulp necrosis
Pulp remains
Restorative materials
Root resorption
Fig. 8.1 Causes of intrinsic stains

8.2.1 Systemic Causes of Posteruptive Intrinsic Stains
The developing dentition can be affected by a number of systemic factors, including

metabolic and genetic diseases that cause intrinsic tooth discoloration (Plotino et al.
2008). Systemic factors also include drug-induced discolorations, including those
from the intake of antibiotics and excess fluoride. In the case of fluoride its source
can be either iatrogenic or from natural sources, such as drinking water.
Although most publications refer to aging as a local cause of intrinsic discolor-
ation, the physiological continuous deposition of secondary dentin throughout the
life of an individual may be considered both a systemic and a local cause of intrinsic
discoloration, as reactionary tertiary dentin forms in response to external stimuli,
such as tooth attrition and bacteria from caries lesions. The deposition of both sec-
ondary dentin and tertiary dentin results is a narrower pulp space with time. Thicker
dentin affects the light-transmitting properties of teeth, resulting in a gradual dark-
ening of the tooth and increased opacity. In addition, the chemical structure and
physical properties of dental hard tissues change over time.
8.2.2 Local Causes of Posteruptive Intrinsic Stains
Local causes of posteruptive intrinsic stains include intrapulpal hemorrhage, residual

pulpal tissue after endodontic therapy, calcific metamorphosis, endodontic materials,
restorative materials such as amalgam, and root resorption. Other less frequent causes
are trauma to developing teeth and periapical infection of primary teeth (Hattab et al.
1999). Besides being responsible for posteruptive pigmentation of vital teeth (Chap.
6), the antibiotic minocycline also causes discoloration of nonvital teeth. In one case,
minocycline was utilized in the root canal as a component of antibiotic paste resulting
in blue discoloration of immature necrotic permanent teeth in children (Dabbagh et al.
2002). In another case, minocycline was applied as a component of a triple antibiotic
mixture inside a root canal of a tooth with a necrotic pulp, as an attempt to disinfect
the root canal system for revascularization. Minocycline resulted in tooth discolor-
ation 6 weeks after the triple antibiotic paste had been applied (Kim et al. 2010).
Necrotic pulps may cause tooth discoloration as a result of the decomposition of
the pulpal tissues producing colored byproducts that infiltrate the dentinal tubules.
Discoloration related to improper endodontic treatment may be caused by trauma
inflicted during pulp extirpation or obturation materials left in the pulp chamber.
Another cause of discoloration in endodontically treated teeth is the residual pulp
tissue left in the pulp horns when the access to the pulp chamber is under-prepared
(Brown 1965; Faunce 1983). Evidence suggests that stains in endodontically treated
teeth are not just confined to the pulp chamber, but they penetrate into the dentin
substrate showing through dentin and enamel (van der Burgt and Plasschaert 1986).
Fitch (1861) stated, “the disintegration of the red corpuscles of the blood is
another source of discoloration. The hematine, or iron, which is supposed to con-
stitute the pigment of these globules, passes readily into the tubules of the dentine
from the pulp chamber of the tooth, whenever the red disks are disintegrated, and
the discoloration becomes more or less permanent. These red globules may be dis-
solved or broken up.” Spasser (1961) reported that “in many cases, the hemolysis
of red blood cells with the release of hemoglobin, especially when associated with
hemorrhage following pulp extirpation or trauma” was responsible for the discol-
oration of endodontically treated teeth. More recently other authors have corrobo-
rated this theory. Diffusion of blood components into the dentinal tubules caused
by pulp extirpation or traumatically induced internal pulp bleeding is one of the
causes for discoloration of nonvital teeth (Arens 1989). Products of blood (eryth-
rocytes) decomposition, such as hemosiderin, release iron. The iron can be trans-
formed to ferric sulfide with hydrogen sulfide produced by bacteria, which causes
a dark brownish discoloration of the tooth (Brown 1965; Glockner et al. 1999;
Attin et al. 2003). Other end products of hemoglobin decomposition, biliverdin and
bilirubin, are themselves known causes of color alteration in the skin and mucosae,
being responsible for jaundice in some systemic diseases (Shibahara et al. 2002;
Leuschner 2003).
Coronal discoloration of endodontically treated teeth may also be caused by end-
odontic sealers (Fig. 8.2), such as Grossman’s cement and AH26 silverfree (Dentsply
Caulk) (van der Burgt and Plasschaert 1985; van der Burgt et al. 1986). Temporary
restorative materials, such as classical ZOE, Cavit (3M ESPE), and I.R.M. (Dentsply
Caulk), also result in discoloration of endodontically treated teeth (van der Burgt
et al. 1986). Two mineral trioxide aggregate (MTA)-based endodontic materials,
ProRoot MTA (Dentsply Tulsa Dental Specialties) and MTA Angelus (Angelus
Indústria de Produtos Odontológicos), have also been reported to cause tooth
Fig. 8.2 Clinical case of a recent discoloration (a) caused by endodontic sealer (b) in the pulp
chamber. This tooth lighten with the walk bleach technique using sodium perborate mixed with
distilled water after only one session (c, d)
discoloration when used over a period of 12 weeks (Jang et al. 2013). The discolor-
ation was observed at the MTA-dentin interface and intracoronal dentin surface.
Removal of the discolored MTA resolved the discoloration.
8.3 Treatment Plan Considerations
When referring to whitening of nonvital teeth, Salvas (1938) wrote, “bleaching

teeth is, at best, more or less of an unsatisfactory operation. Although we may suc-
ceed in restoring the color of a tooth, it is seldom permanent.” The unpredictability
of intracoronal whitening has not changed considerably since Salvas wrote these
statements in 1938.
Taking into consideration that the treatment outcome as well as the durability of
the treatment varies for each clinical situation, the patient must be informed of these
inherent limitations of intracoronal whitening. Another detail that the patient must
be aware of is that root dentin does not respond well to bleaching, either external or
internal (Kwon 2011). This is especially significant in case there is gingival reces-
sion that has resulted in exposed root surface.
The indications and contraindications for intracoronal whitening are displayed in
Table 8.1. Prior to starting an internal whitening procedure to lighten single or mul-
tiple teeth, it is crucial to understand all treatment options available for each specific
clinical case. The prognosis of internal whitening depends on several factors, includ-
ing the etiology and the duration of the discoloration. Additionally, a history of trau-
matic injury to the tooth or teeth may be associated with subsequent external cervical
resorption. It is also important to understand that the intrinsic discoloration in end-
odontically treated teeth affects dentin but not enamel (van der Burgt et al. 1986). A
precise diagnosis relies on accurate clinical and radiographic exams. The presence of
craze lines on the enamel structure and marginal microgaps in existing restorations
may result in seepage of the intracoronal bleaching agents to the surrounding tissues.
For this reason, the use of transillumination to diagnose microgaps and craze lines is
Table 8.1 Indications and contraindications for internal whitening of endodontically treated teeth
Indications Contraindications
Discolorations from pulpal trauma or Inadequate root canal treatment
pulp remains
Discolorations that do not respond to Untreated caries lesions and abfraction lesions
external bleaching techniques
Dentin discolorations of various Loss of coronal tooth structure that prevents sealing of
origins, including endodontic sealers the bleaching material inside the pulp chamber
Defective restorations or enamel craze lines that may
result in seepage of the bleaching material to the
periodontal tissues
Patient’s high expectations
Pregnancy
Discoloration caused by oxidation of metals (silver,
amalgam)
Discolorations restricted to enamel
extremely important. The treatment plan must be based on existing evidence to

improve the chance of clinical success.
Intraoral photographs are essential to document the baseline color. Although the
color of darkened endodontically treated teeth is not usually within the range of uni-
versal shade guides, the clinician may still take a photograph with a tooth tab from
the Vita Classical A1-D4 shade guide (VITA Zahnfabrik H. Rauter GmbH & Co.
KG) next to the darkened tooth. This will provide an excellent comparative reference
for the postoperative versus the preoperative color.
8.4 Whitening Techniques for Endodontically Treated Teeth
Superoxol used to be the most commonly used intracoronal bleaching material.

More recently, water has been used (instead of hydrogen peroxide) mixed with
sodium perborate (Ari and Ungör 2002; Plotino et al. 2008). Sodium perborate
(NaBO3) is a white crystalline powder that contains about 95 % of the perborate cor-
responding to 9.9 % available oxygen (Rotstein and Friedman 1991). In contact with
water, sodium perborate decomposes with the liberation of hydrogen peroxide and
later of oxygen. Sodium perborate is, therefore, a hydrogen peroxide precursor (Ari
and Ungör 2002). Warm air and acidic solutions also initiate the decomposition of
sodium perborate. A thick creamy paste of sodium perborate with water is currently
recommended, left in the pulp chamber for varying periods of time.
Two techniques for bleaching endodontically treated teeth have been used
through the years, namely, the thermocatalytic technique and the walking bleach
technique. Other bleaching techniques include combined thermocatalytic and walk-
ing bleach techniques (Freccia et al. 1982).
8.4.1 Thermocatalytic Technique
In the thermocatalytic technique, heat is used to activate the release of nascent oxy-
gen from the oxidizing agent or agents, often hydrogen peroxide and sodium perbo-
rate (Ari and Ungör 2002). Several sources of heat have been utilized as adjunct
activation methods, including ultraviolet (UV) lights, infrared lights, flamed instru-
ments, and electrical sources of light and heat. Fischer (1911) reported heating
hydrogen peroxide with a special mercury arc light with a quartz lens, or Kromeyer’s
lamp, to irradiate the teeth with ultraviolet (UV) rays to mimic the sunlight. Prinz
(1924) recommended using heated solutions consisting of sodium perborate and
Superoxol for cleaning the pulp cavity. Dietz (1957) recommended a 20-in. infrared
light for the thermocatalytic technique in case only one appointment was feasible.
In 1963, the use of 30 % hydrogen peroxide with a source of light and heat from a
distance of 5 cm was reported (Weisman 1963).
In light of the risk of side effects from heating hydrogen peroxide in the
pulp chamber space (Madison and Walton 1990), including external cervical
resorption, the thermocatalytic technique is no longer advocated.
8.4.2 Walking Bleach Technique
For the walking bleach technique, hydrogen peroxide or water is mixed with sodium
perborate, but heat is not used to trigger the release of nascent oxygen. The use of
an intracoronal mixture of sodium perborate mixed with Superoxol or water has
been described as a successful technique (Kirk 1893; Nutting and Poe 1967; Rotstein
et al. 1993a). Saline and anesthetic have also been used instead of water (Madison
and Walton 1990). Propylene glycol, which is largely used as in the pharmaceutical
and food processing industry as a humectant and preservative, has also been sug-
gested in some countries as a vehicle for the intracoronal bleaching paste in lieu of
water. There is, however, no evidence that propylene glycol is more effective than
water to mix with sodium perborate for internal whitening.
The first description of the walking bleach technique using a mixture of sodium
perborate and distilled water was published in 1938 (Salvas 1938). The mixture was
left in the pulp space for a few days, while the access cavity was sealed with provi-
sional cement. This same technique was revived in 1961 (Spasser 1961) and modified
in 1967 (Nutting and Poe 1967), when 30 % hydrogen peroxide was used instead of
water to improve the bleaching effectiveness of the mixture. Although 30 % hydrogen
peroxide may boost the efficacy of internal whitening, the procedure can be success-
fully accomplished without hydrogen peroxide (Salvas 1938; Spasser 1961).
Clinically, the walking bleach technique of sodium perborate mixed with water
has been reported to be effective. In 57 out of 95 teeth (60 %), a good or acceptable
result was obtained after one or two visits (Holmstrup et al. 1988). The remaining
38 teeth (40 %) were treated over 3–9 visits. The method used sodium perborate
moistened with water and the access cavity was temporarily restored with Cavit
(3M ESPE) between visits. While 55/69 (79.7 %) of the teeth examined at 3 years
still had a good or acceptable result, 14 teeth (20.3 %) showed recurrence of discol-
oration that was considered unacceptable. The total number of teeth with an unac-
ceptable result either initially or after 3 years was 25 % of the treated teeth. Despite
recurrence, all examined teeth showed less discoloration than before bleaching.
Interestingly, it has been reported that patients treated with the walking bleach tech-
nique brush more often than other patients, developing a superior dental hygiene
regimen (Abou-Rass 1988).
In vitro and clinical studies have shown that three applications of sodium
perborate mixed with water are equally effective as applying sodium perbo-
rate and the 30 % hydrogen peroxide solution (Rotstein et al. 1991c; Rotstein
et al. 1993a; Holmstrup et al. 1988).
With the advent of the at-home vital whitening technique (Chap. 6), carbamide
peroxide (also known as urea peroxide) has been advocated for the walking bleach
technique alone or in combination with sodium perborate (de Souza-Zaroni et al.
2009). Aldecoa and Mayordomo (1992) suggested a 4-week treatment with 10 %
carbamide peroxide mixed with sodium perborate as a “second phase” of internal
whitening once the first phase of bleaching with hydrogen peroxide mixed with
sodium perborate was completed. The association of carbamide peroxide with
sodium perborate is more effective than that of water with sodium perborate (Yui
et al. 2008). Another study reported contradictory findings, as the sodium perbo-
rate mixed with 37 % carbamide peroxide association proved to be as effective as
sodium perborate mixed with distilled water for intracoronal bleaching (de Souza-
Zaroni et al. 2009).
As several concentrations of carbamide peroxide gels are available for the at-
home whitening technique, the use of 10, 17, or 37 % carbamide peroxide has been
studied regarding the ensuing infiltration of peroxide into radicular dentin. All three
concentrations resulted in significantly lower penetration of peroxide into radicular
dentin than a combination of Superoxol with sodium perborate. However, 37 %
carbamide peroxide resulted in significantly more penetration of peroxide that 10 or
17 % carbamide peroxide (Gokay et al. 2008).
Although there are different materials currently available for the walking
bleach technique, the combination of water with sodium perborate is still
preferred, as it may reduce the risks of side effects.
8.4.3 Combined Techniques
Freccia et al. (1982) stained extracted teeth with blood and then compared the results
of three nonvital bleaching techniques: thermocatalytic technique, walking bleach, and
a combined technique. Although the techniques were equally effective in bleaching
blood stained teeth, the walking bleach technique consumed the least operator time.
8.5 Factors That Influence the Prognosis of Intracoronal

Whitening
8.5.1 Duration of Discoloration
The prognosis may depend on the duration of the discoloration (Brown 1965; van
der Burgt and Plasschaert 1986). Brown (1965) reported that the shorter the time the
tooth has been discolored, the more successful bleaching is. Teeth that had been
discolored for less than 1 year had an 87.5 % success rate, while for teeth that had
been discolored over 5 years, the success rate dropped to 66 %.
8.5.2 Intensity of Discoloration
Severely discolored teeth have less chance of successful bleaching (75 %) than teeth
with moderate or slight discolorations (90–100 %) (Brown 1965). Gradual discolor-
ations tend to bleach more efficiently than rapid discolorations.
8.5.3 Potential for Color Regression
Some color relapse may occur in about 50 % of bleached teeth after 1 year, and
even more after a longer period (Brown 1965; Howell 1981). Teeth that are more
difficult to bleach are more likely to discolor again (Howell 1981). Specific end-
odontic sealers result is higher risk of color relapse than others (van der Burgt
and Plasschaert 1986). The probability of color reversal is much higher when the
discoloration is due to metallic stains or silver-containing medicaments (Freccia
et al. 1982).
Brown (1965) performed a survey on 80 teeth that had been bleached using 30 %
hydrogen peroxide, and compared standardized photographic records of the teeth
taken before and after bleaching, and at intervals of l–5 years. The author found that
20 (25 %) teeth failed, of which 14 teeth failed to respond to treatment at all, while
in 6 teeth the color relapsed after initially successful bleaching. Of the 60 (75 %)
successfully bleached teeth, 23 showed no postoperative change, but in 37 teeth
there was some color regression.
Stability of nonvital discolored teeth subjected to combined thermocatalytic and
walking bleach intracoronal techniques was evaluated at 16 years (1989–2005)
(Amato et al. 2006). The series comprised 50 patients (age range 7–30). After 16
years, 35 cases were evaluated. In 22 of these cases (62.9 %) the color had remained
stable and was similar to that of adjacent teeth, indicating a successful outcome of
the combined bleaching technique. There were 13 cases (37.1 %) classified as fail-
ures because of marked color relapse. Radiographically none of the cases re-
examined underwent internal or external root resorption. However, there is
insufficient evidence in terms of efficacy and safety to substantiate the use of the
combined technique over the walking bleach technique.
8.5.4 Patient’s Age
The success rate of the internal whitening technique is 50–90% without a direct
relationship between success and patient’s age (Brown 1965; Howell 1981).
However, other authors have stated that young teeth bleach faster than old teeth
because the dentinal tubules are wider in younger teeth (van der Burgt and
Plasschaert 1986).
Dietz (1957) reported a direct relation between the age of a tooth and its resis-
tance to bleaching, suggesting that more permanent results were obtained with teeth
of the older age groups. Camps et al. (2007) evaluated the diffusion of hydrogen
peroxide through human dentin in patients under 20 years old and in patients
between 40 and 60 years old. The teeth were endodontically treated, and a defect
was created at the CEJ. The access cavities were filled with 20 % hydrogen peroxide
gel. The amount of diffusing hydrogen peroxide was assessed at 1, 24, 48, and
120 h. Diffusive flux and maximal diffusion were higher through young teeth than
through old teeth.
8.5.5 Type of Discoloration
The prognosis for success of any bleaching technique depends on the cause of the
discoloration (Freccia et al. 1982). When the discoloration is a result of products of
pulpal decomposition within the dentinal tubules, the prognosis is usually very good.
Recent discolorations from endodontic sealers are also easy to whiten (van der Burgt
and Plasschaert 1986) (Fig. 8.2). When the discoloration is due to metallic stains or
silver-containing medicaments, bleaching is more difficult and it is sometimes not
possible to achieve satisfactory results. In fact, internal discoloration caused by oxi-
dation of metals (silver, amalgam) cannot be removed by whitening treatments
(Attin et al. 2003).
8.6 Adverse Effects
Hydrogen peroxide is the main toxic substance that has been used for internal
bleaching (Chaps. 4 and 5). Hydrogen peroxide is a reactive oxygen species (ROS)
(Bax et al. 1992) with oxidative ability (Kashima-Tanaka et al. 2003), as seen in
Chap. 3. It is well known that free radicals and ROS exert biological actions such as
inflammation, carcinogenesis, aging, and mutation (Valko et al. 2007). ROS also
play an important role in tissue injury at sites of inflammation in various diseases
(Valko et al. 2007).
8.6.1 External Cervical Resorption (ECR)
Table 8.2 displays a summary of the findings in clinical studies of internal whitening
and the reported number of external cervical resorption (ECR) cases. ECR is the
loss of tooth hard tissue as a result of odontoclastic activity (Patel et al. 2009).
Figure 8.3 shows cone-beam computed tomography images of ECR in endodonti-
cally treated teeth that had been unsuccessfully whitened internally prior to the
restorative procedures.
It has been reported that hydrogen peroxide is the cause of dentin and cementum
alterations leading to complications such as ECR (Harrington and Natkin 1979;
Lado et al. 1983; Montgomery 1984). Hydrogen peroxide seeps through the den-
tinal tubules into the surrounding tissues causing destruction of cells, which triggers
an inflammatory process that may lead to ECR. A study suggested that the combina-
tion of heat and hydrogen peroxide is responsible for ECR (Madison and Walton
1990). However, other studies reported clinical cases of ECR in which heat was not
used (Goon et al. 1986; Friedman et al. 1988). Even though the walking bleach
technique with sodium perborate and hydrogen peroxide is less harmful than the
thermocatalytic bleaching technique, ECR may also occur with the walking bleach
technique (Goon et al. 1986; Latcham 1986; Friedman et al. 1988). As hydrogen
peroxide has been used in most studies that reported ECR, several authors have
Table 8.2 Clinical studies of internal whitening
180
History of
Number of teeth ECR trauma Outcome
Harrington and 4 central incisors were root All with ECR; all resorptive All 4 teeth No reported outcome
Natkin (1979) canal treated in 4 patients lesions occurred in the cervical
whose age ranged from 11 to third of the root
15 years of age. In 3 of the 4
cases, the thermocatalytic
bleaching technique was
carried out from 6 to 15
years after the trauma and
completion of root canal
therapy
Same authors reported 3
extra cases that developed
ECR
Cvek and Lindvall 11 teeth with ECR after 2 teeth – superficial ECR that did 10/11, when
(1985) bleaching with 30 % H2O2 not progress; patients were
5 teeth – ECR followed by 11–16 years old
ankylosis. 4 teeth – ECR was
progressive and associated with
radiolucency in the adjacent
alveolar bone
Abou-Rass (1988) 112 severely tetracycline- No report of ECR after 3–15 years No history of 7 % failure – 8/112 teeth were noticeably dark
stained teeth in 20 patients trauma at the cervical zone
were root canal treated and Intracoronal restorative failures were relatively
internally bleached with a high (7 %), endodontic failure was only 2 % and
thick paste of sodium there was no evidence of external root
perborate in 30 % H2O2. resorption
Procedure was repeated after
1 week if needed.
J. Perdigão et al.
8
History of
Friedman et al. 58 bleached teeth were 4/58 (6.9 %); resorption started No trauma for 43 teeth (74 %) were bleached once, 15 teeth
(1988) re-examined after 1–8 years apically; 2 teeth had advanced the 4 teeth with(26 %) were more than once; all teeth bleached
ECR; 2 teeth had arrested ECR, ECR with 30 % H2O2; 29/58 teeth (50 %) were found
one of them had been bleached esthetically satisfactory; 17/58 teeth (29 %)
with the walking bleach technique were clinically acceptable; 12/58 teeth (21 %)
were unacceptable, of which 4 had received
full-coverage restorations
Holmstrup et al. 95 teeth, walking bleach No report of ECR at 3 years 91/95 teeth had In 57 teeth (60 %), a good or acceptable result
(1988) technique with sodium history of after 1 or 2 visits. The remaining 38 teeth were
perborate moistened with trauma treated over 3–9 visits. Satisfactory initial result
water in 90 % of the cases After 3 years, recurrence of
discoloration was observed in 20 % of the teeth
Anitua et al. (1990), 258 intact tetracycline-stained No report of ECR at 4 and 6 years No history of Color relapse for 6/258 teeth (2.3 %) at the
Aldecoa and teeth underwent elective trauma 4-year recall; 10 % of teeth after 6 years
Mayordomo (1992) root-canal treatment; GIC
cervical barrier 1 mm below
CEJ, walking bleach
technique with 30 % H2O2
Intracoronal Whitening of Endodontically Treated Teeth
and sodium perborate;

repeated 2–3 times every 4
weeks. A mix of 10 %
carbamide peroxide + sodium
perborate was then applied
for 4–6 weeks
Heithersay et al. 204 teeth were re-examined 4 teeth (1.96 %) developed invasive 151/204 Not reported, as this study was based on
(1994) after 1–19 years; all teeth had ECR. All of these teeth had a (77.9 %) had radiographic evaluations
been treated with a combi- history of traumatic injury and the history of
nation of thermocatalytic and level of gutta-percha was at the traumatic injury
walking bleach procedures CEJ without a barrier
using 30 % H2O2
181
(continued)
Table 8.2 (continued)
182
History of
Glockner et al. 5-year clinical follow-up of Not reported Not reported Treatment was successful in 68 patients (79 %)
(1999) teeth bleached with 30 % after 5 years
H2O2 with sodium perborate,
walking bleach technique for
1 week; procedure repeated
until satisfactory results
obtained
Amato et al. (2006) Thermocatalytic technique None of the 13 failures had 42 of the initial 22 teeth (62.9 %) the color had remained stable
used with 35 % H2O2 and radiographic signs of 50 teeth has a and was similar to that of adjacent teeth; 13
sodium perborate heated ECR. However, authors stated that history of cases (37.1 %) classified as failures because of
with light source; 50 teeth for the 9 teeth for which the root trauma marked color relapse
initially selected, 35 were canal that had been re-treated, 2 of
evaluated at 16 years them showed fistula, pain and a
peri-radicular and/or latero-
radicular bone lysis area that had
failed to disappear or had
reappeared
Excluding case reports of one tooth
J. Perdigão et al.
Fig. 8.3 Cone-beam computed tomography (a) with reconstructed three-dimensional (3D) image
(b) showing an ECR lesion on tooth #8 (FDI 1.1). This tooth had been treated with intracoronal
whitening in two different occasions, but did not respond to the treatment. The ECR lesion was
diagnosed after the tooth was restored with a cast post-and-core and a full-coverage restoration
(Images courtesy of Prof. Eduardo Vilain de Melo, Florianópolis, Brazil)
opposed the use of hydrogen peroxide for internal whitening to prevent ECR
(Montgomery 1984; Cvek and Lindvall 1985).
The first cases of ECR associated with intracoronal bleaching were published in
1979 (Harrington and Natkin 1979). This paper involved four cases of post-trauma
pulpal necrosis in permanent teeth of young patients, ranging from 11 to 15 years of
age. The four cases developed ECR lesions in the cervical third of the root. In three
of the cases, intracoronal bleaching was performed 6–15 years after the trauma and
subsequent endodontic treatment. Superoxol and a heat source (bleaching tool and
a heat lamp) were used for the thermocatalytic bleaching technique. Although trau-
matic injury to the teeth was a common factor in the patients’ history, other studies
reported cases of root resorption in teeth without history of trauma (Lado et al.
1983; Goon et al. 1986; Friedman et al. 1988).
The same clinical report (Harrington and Natkin 1979) described three additional
similar cases in which ECR also occurred. The authors hypothesized that ECR may
have been caused by (1) the bleaching materials passing through the wide dentinal
tubules into the periodontal ligament, which triggered an inflammatory resorption; or
(2) an injury to the periodontal tissues by heat from the heat lamp or bleaching tool
used in these cases.
Contrary to suggestions that ECR is more frequent in traumatized teeth of young
patients some authors have reported that bleaching-related ECR is not more likely
to occur in young teeth with wide dentinal tubules (Friedman et al. 1988). In this
study resorption occurred in 3 of 34 teeth of patients older than 20 years, but only in
1 of 24 teeth of patients younger than 20 years.
Bleaching with sodium perborate and water has been advocated as a low risk
alternative to sodium perborate and hydrogen peroxide to prevent ECR lesions
(Holmstrup et al. 1988; Madison and Walton 1990). As discussed in Sect. 8.4.2, the
walking bleach technique with a paste of sodium perborate and water is currently
the standard intracoronal bleaching technique.
Several factors associated with ECR have been described in the literature:
(a) A causal relationship between a specific bleaching technique and ECR is still
not clear. Friedman et al. (1988) reported that ECR was not dependent on the
bleaching method. Authors reported that 7 % of the teeth displayed ECR in 58
cases monitored during a period of 1–8 years. Contrary to previous reports, the
lesions initiated apical to and not at the cementum-enamel junction (CEJ).
(b) A factor that may increase the risk of ECR associated with hydrogen peroxide
used in internal whitening is the anatomy of the CEJ. The penetration of hydro-
gen peroxide is significantly higher in teeth with cementum defects at the CEJ
than in those without defects (Rotstein et al. 1991b). To prevent the seepage of
hydrogen peroxide to the periodontal tissues, Madison and Walton (1990) sug-
gested that bleaching procedures should be confined to the supragingival part of
the pulp chamber to prevent chemicals from contacting tubules that communi-
cate with the cervical periodontal tissues.
The placement of a cervical barrier between the pulp chamber and the end-
odontic filling material has been advocated (He and Goerig 1989; Anitua et al.
1990). Originally the location of the barrier was 1 mm apical to the CEJ (He and
Goerig 1989). Other authors suggested that the barrier should be placed from
the CEJ level to 2 mm below the CEJ with a minimum thickness of 1 mm
(Costas and Wong 1991; Rotstein et al. 1992b). When the barrier was placed
2 mm below the CEJ the esthetic bleaching result from a walking bleach tech-
nique with sodium perborate and Superoxol was more acceptable than when the
barrier was placed at the CEJ level (Costas and Wong 1991). A 1 mm-thick
Fig. 8.4 (a, b) A periodontal probe is used to determine the level of the epithelial attachment from
the incisal edge of the tooth. This will serve as guide for placement of the root canal barrier
Fig. 8.5 Diagram depicting a coronal extension

of the barrier that matches the contour of the
epithelial and increases the safety of the bleaching
procedure by sealing a wider area against the
leakage of peroxides to the periodontal tissues
(Adapted from Steiner and West 1994). D dentin
tubules, B cervical barrier, P paste of sodium
perborate and distilled water
I.R.M. (Dentsply Caulk) barrier resulted in an increased penetration of hydro-

gen peroxide compared to a 2 mm-thick barrier (Rotstein et al. 1992b).
A mesial, distal, and labial periodontal probing is used to determine the level
of the epithelial attachment from the incisal edge of the tooth (Fig. 8.4). This
will guide the dental professional to decide the location of the barrier. A coronal
extension of the barrier to match the contour of the epithelial attachment
(Fig. 8.5) has been proposed to increase the safety of the bleaching procedure
by sealing a wider area against the leakage of peroxides to the periodontal tis-
sues (Steiner and West 1994).
ZOE-based materials, such as I.R.M. (Dentsply Caulk), and classical glass-
ionomer cement (GIC) materials are not currently recommended for the cervical
barrier, as they do not completely prevent leakage of bleaching agents into the
coronal part of the root canal (Rotstein et al. 1992b; Brighton et al. 1994).
(c) The pH of the paste left inside the pulp chamber is more acidic when the consis-
tency is too liquid (Rotstein and Friedman 1991). Kehoe (1987) had reported that
the pH of dentin and cementum became more acidic after sealing the walking
bleach material in the pulp space of endodontically treated teeth, creating the ideal
environment for osteoclastic activity. Rotstein and Friedman (1991) reported that
thick pastes used with the walking bleach technique are alkaline and their alkalin-
ity increases with time. Initially, the pH of sodium perborate mixed with distilled
water without dilution was 9.87, but it increased gradually to 10.70 during the fol-
lowing 14 days. The initial pH of sodium perborate mixed with Superoxol was
7.40 and it reached a value of 10.58 after 14 days. In both cases, a marked increase
in pH occurred during the first 48 h. Accordingly, it is unlikely that ECR is caused
by the acidity of current materials used for intracoronal bleaching.
(d) The type of sodium perborate used in the walking bleach paste is another factor
to consider, as the amount of hydrogen peroxide leakage to the periodontal tis-
sues may depend on the form of sodium perborate used. The use of sodium-
tetrahydrate mixed with water is recommended as a bleaching agent to reduce
the risk of potential development of bleaching-related ECR (Weiger et al. 1994).
(e) Superoxol mixed with sodium perborate increase the solubility of dentin and
cementum. It was concluded that 30 % hydrogen peroxide might cause altera-
tion in the chemical structure of the dentin and cementum, such as reduction of
the organic component, making them more susceptible to degradation (Rotstein
et al. 1992a).
(f) The removal of the smear layer from the dentin walls of the access cavity may
increase the diffusion of the whitening agent through the dentinal tubules. Since
there is a higher hydrogen peroxide diffusion when the access cavity is etched
with phosphoric acid or rinsed with EDTA followed by NaOCl (Surapipongpuntr
et al. 2008; Camps et al. 2010), it may be prudent to preserve the smear layer to
decrease the risk of ECR (Camps et al. 2010). Hydrogen peroxide is a potent
stimulator of osteoclastic bone resorption. A significant increase in bone resorp-
tion was noted when rat osteoclasts, cultured on bovine cortical bone, were
exposed to hydrogen peroxide (Bax et al. 1992).
(g) Some authors have suggested that bacteria in the gingival sulcus or in the pulp
chamber may play a role in the root resorption process (Cvek and Lindvall
1985; Rotstein et al. 1991a; Heling et al. 1995). Hydrogen peroxide in high
concentrations may increase bacterial penetration through dentinal tubules
(Heling et al. 1995). This pathway for bacterial invasion may be a consequence
to structural defects or pathological alterations of the cementum (Rotstein et al.
1991b).
(h) Ca(OH)2 (calcium hydroxide) is effective in arresting external inflammatory
root resorption (Heithersay 1975). Several cases of bleaching-induced root
resorption have been treated successfully by intracoronal application of
Ca(OH)2 (Montgomery 1984; Gimlin and Schindler 1990). The pH increases in
dental tissues after endodontic treatment with Ca(OH)2, which has a positive
influence on the local environment of the resorption areas by preventing osteo-
clastic activity and by stimulating the repair processes of the tissue (Tronstad
et al. 1981). As dentinal tubules become wide open when resorption occurs, a
communication between the pulp cavity and the periodontal tissues is formed.
It has been proposed that Ca(OH)2 placed in the pulp cavity penetrates the den-
tinal tubules to increase the pH in the root periphery and to promote repair
(Tronstad et al. 1981). However, both Ca(OH)2 paste and the resulting hydroxyl
ions have been shown to diffuse poorly through dentin (Wang and Hume 1988;
Fuss et al. 1989). Additionally, the therapy with Ca(OH)2 was not capable of
stopping the resorptive process in clinical cases of young patients treated with
the walking bleach technique (Goon et al. 1986; Latcham 1986; Friedman
1989). Bleaching-induced resorption in dogs was observed regardless of the
presence of Ca(OH)2, suggesting that Ca(OH)2 is unable to always prevent root
resorption associated with internal bleaching (Rotstein et al. 1991a).
(i) The resorption process does not seem to involve macrophages (Jimmenez Rubio
and Segura 1998), as no correlation was found between the mechanism of
action of sodium perborate and the adhesive properties of macrophages.
8.6.2 Ankylosis
Cvek and Lindvall (1985) followed up 11 maxillary incisors in 9 patients with radio-
graphic evidence of post-intracoronal bleaching ECR. Ten of the teeth had been end-
odontically treated as a consequence of traumatic injury at ages 11–16 years. The
bleaching treatment was performed in the traumatized teeth 12–90 months (mean of
48 months) after the accident. In five teeth, the resorption was associated with anky-
losis, which may have been caused by loss of vitality of periodontal tissue attached
to the root surface as a result of hydrogen peroxide seepage from the pup chamber.
8.6.3 Alterations in the Physical Properties of the Residual

Tooth Structure
Intracoronal bleaching affects the ultimate tensile strength and ultrastructure mor-
phology of bovine dentin. Cavalli et al. (2009) used sodium perborate, 35 % carb-
amide peroxide, 25 % hydrogen peroxide, and 35 % hydrogen peroxide. Bleaching
was performed four times within a 72 h interval. Dentin ultimate strength was sig-
nificantly higher for the control group, in which dentin was not bleached. More
details on this topic are discussed in Chap. 4.
Different intracoronal whitening agents affect dentin fracture strength (Carrasco-
Guerisoli et al. 2009). Bovine teeth were subjected to several intracoronal bleaching
techniques. Controls were treated with either sodium perborate mixed with 10 %
hydrogen peroxide or no bleaching agent. Whitening systems with higher pH did
not result in perceptible changes of dentin ultrastructure. Apparently, both low pH
and hydrogen peroxide oxidation play a role in altering the ultrastructure of dentin
during internal dental bleaching. The use of alkaline products with reduced time of
application, as those used for in-office whitening techniques, may prevent such
morphological alterations (Carrasco-Guerisoli et al. 2009).
Restorative procedures using composite resin have been described to success-
fully restore the fracture resistance of bleached endodontically treated teeth (Roberto
et al. 2012).
8.6.4 Decrease in Enamel and Dentin Bond Strengths

Immediately After Whitening
As described in Chap. 6, dentin and enamel bond strengths are significantly

reduced in recently bleached teeth. A delay in adhesive restorative procedures is
recommended for endodontically treated teeth that are bleached internally, even in
cases in which a paste of sodium perborate with water is used without added
hydrogen peroxide or carbamide peroxide. A waiting period of at least 2 weeks
after bleaching is recommended prior to performing adhesive restorations with
resin-based composite in both enamel and dentin (Shinohara et al. 2005).
Nonetheless, some patients may not be able to return for a subsequent appoint-
ment to have the access cavity restored definitely with an adhesive technique.
Since the access preparation will have to be restored immediately, the application
of catalase may be indicated in these cases. Rotstein (1993) reported that one
application of catalase for 3 min following intracoronal whitening of nonvital
teeth totally eliminated the residual hydrogen peroxide from the pulp chamber
and from surrounding periodontal tissues.
8.6.5 Chemical Burns of Soft Tissues
The application of catalase on the mucosa has a protective effect against the hydro-
gen peroxide-induced injury in animals (Rotstein et al. 1993b). Tripton et al. (1995)
reported the in vitro ability of a concentration of catalase >20 U/ml to supress the
toxic effects of peroxide on mucosal fibroblasts. As described in Chap. 4, sodium
bicarbonate may also be used to treat these chemical burns caused by hydrogen
peroxide.
8.7 The Walking Bleach Technique
Figure 8.6 shows a diagram of an endodontically treated tooth before removal of the
access cavity restoration (A) and after the bleaching paste is sealed in the pulp
chamber (B). Figure 8.7 is a step-by-step clinical sequence of the walking bleach
technique.
1. Clinical and radiographic exam (Fig. 8.7a–c).

(a) It is important to determine the likely source of the discoloration, as some
stains are more difficult to remove as discussed in Sect. 8.5.5.
(b) Check for defective coronal restorations that might have caused microleak-
age and subsequent internal discoloration. Defective restorations must be
replaced temporarily to prevent the bleaching material to leak into the mouth.
(c) In case of active periodontitis, internal whitening is deferred and the patient
referred to a specialist.
(d) Evaluate the quality of the root canal treatment and status of periodontal/
periapical tissues.
(e) Do not perform internal bleaching if a periapical radiolucency is observed
in the respective radiograph.
2. It is of utmost importance to inquire the patient about his/her expectations.
Inform patient of the number of sessions that may be needed, how slow the pro-
cess may be initially, and the respective limitations, including the potential for
color regression and the possibility that the color of intact teeth is not attained.
3. Document the pretreatment tooth color with dental photography placing a
shade guide (Vita Classical A1-D4 shade guide (VITA Zahnfabrik H. Rauter
GmbH & Co. KG) adjacent to the discolored tooth. It is important to document
the preoperative color for future reference.
Fig. 8.6 Diagram of an

endodontically treated
tooth before removal of
the access cavity
restoration (a) and after
the bleaching paste is
sealed in the pulp chamber
(b). G Gutta-percha, R
restoration of the access
cavity, B cervical barrier,
P paste of sodium
perborate and distilled
water, T temporary
restoration between
walking bleach sessions
a b c
d e
f g
Fig. 8.7 Clinical sequence of the walking beach technique. (a) Preoperative frontal view showing
a gray/brown discoloration of tooth #9 (FDI 2.1). Patient mentioned that this tooth had been darker
than the other teeth for at least 7 years. (b) Preoperative palatal (lingual) view. (c) Periapical radio-
graph. (d–i) Probing sequence to determine the level of epithelial attachment. (j) Isolation with
rubber dam. (k) Removal of coronal restoration and any residual pulp tissue left in the pulp horns.
(l) A periodontal probe is used to transfer the exact depth level for placement of the root canal bar-
rier. (m) Lingual view of gutta-percha removal from the root canal cervical area using a System B
Heat Plugger (Kerr Endodontics). (n) Frontal view of the System B Heat Plugger (Kerr Endodontics)
showing the rubber stop reference corresponding to the same length shown in the periodontal
probe of (l). (o) A resin-modified glass-ionomer material (Vitrebond Plus, 3M ESPE) is applied
into the root canal as a 2 mm-thick cervical barrier between the pulp chamber and the endodontic
filling material. (p) The RMGIC material is light cured from the cavity access for 40 s. Any excess
material must be removed with carbide bur in slow speed. (q) Sodium perborate is mixed with
distilled water to a consistency of slightly moist sand and inserted into the pulp chamber with a
plastic instrument or other suitable instrument. (r) The pulp chamber is filled with the bleaching
paste short of the access cavo-surface margin. (s) Residual liquid is removed with dry cotton pel-
lets by gently compressing the paste. A clearance of 1.5 mm is needed to insert a temporary resto-
ration. (t) Reinforced zinc oxide eugenol (ZOE) cement (I.R.M., Dentsply Caulk) is used as
temporary restorative material. (u) Frontal view of tooth #9 (FDI 2.1) immediately after removing
the rubber dam. The tooth is apparently lighter as a result of dehydration. (v) Frontal view of tooth
#9 (FDI 2.1) at the beginning of the second walking bleach session. (w) Frontal view of tooth #9
(FDI 2.1) after three walking bleach sessions
h i
j k
l m
n o
p q

r s
t u
v w
4. Periodontal probing determines the level of the epithelial attachment from the
incisal edge of the tooth (Fig. 8.7d–i). This will serve as guide for placement of
the root canal barrier.
5. Rubber dam isolation is required. The use of a light-cured resin to seal the gin-
gival margin and the interdental papillae may be needed, such as Opaldam
(Ultradent Products Inc.).
6. The restorative material is removed from the access cavity and from the
pulp chamber (Fig. 8.7j, k). The angulation of the bur must be parallel to
the long axis of the anterior tooth being bleached. Often inexperienced
clinicians remove the materials from the access preparation with the bur
angled facially (Fig. 8.8), which results in inadvertent removal of sound
dentin. In rare cases, the dentin structure on the buccal aspect is heavily
discolored; therefore, it must be carefully removed in slow speed to avoid
facial perforation.
7. At this time, check for residual discolored pulp tissue in the pulp horns and
remove it if necessary.
8. A periodontal probe is used to transfer the exact depth level (Fig. 8.7l) for place-
ment of the root canal barrier using the reference measured in Fig. 8.7d–i.
Fig. 8.8 Clinicians must

be very careful when
removing the restorative
materials from the access
preparation to avoid
removing too much sound
tooth structure from the
buccal aspect, causing
enamel perforation
9. The root canal obturation material is removed from the cervical area of the root
(Fig. 8.7m, n), using a System B Heat Plugger (Kerr Endodontics) or a Peeso
reamer. A 2-mm thick layer of a resin-modified glass ionomer material, also
known as RMGIC (Fig. 8.7o) is applied into the root canal as a cervical barrier
between the pulp chamber and the endodontic filling material (Fig. 8.6) to pre-
vent the escape of hydrogen peroxide apically into the root canal and to the
periodontal tissues. A polycarboxylate cement may also be used in lieu of the
RMGIC, as both materials bond chemically to dentin. Ideally the cervical bar-
rier should match the contour of the epithelial attachment, as proposed by
Steiner and West (1994) (Fig. 8.5). The RMGIC material is light cured from the
cavity access for at least 40 s (Fig. 8.7p). Any excess material in the pulp cham-
ber must be removed with a carbide but in slow speed.
10. Sodium perborate is mixed with distilled water (anesthetic solution and
saline have also been used) to a consistency of slightly moist sand. This mix
must possess enough consistency to be inserted into the pulp chamber with
a plastic instrument (Fig. 8.8q) or plugged with an amalgam carrier. In case
the mix is too runny, it is extremely difficult to insert it adequately into the
pulp chamber. Once the paste is inside the pulp chamber (Fig. 8.8r), the
residual liquid is removed with dry cotton pellets by gently compressing the
paste (Fig. 8.7s).
11. A clearance of at least 1.5 mm is needed to insert a temporary restoration into

the access cavity. The area must be gently air-dried, otherwise the restorative
material will dislodge easily. Some clinicians use Cavit (3M ESPE) as the tem-
porary restorative material but it may dissolve in the mouth and result in an
open access cavity. Reinforced zinc oxide eugenol (ZOE) cement I.R.M.
(Dentsply Caulk) (Fig. 8.7t) is recommended. Another temporary restorative
technique involves the use of a temporary low-viscosity resin-based material
without an intermediate adhesive after acid etching enamel. This will provide a
short-term efficient seal and micromechanical retention. After removing the
rubber dam, the tooth is often dehydrated (Fig. 8.7u).
12. Patient is informed that he/she needs to return for a subsequent appointment in
1 week to possibly repeat the procedure, and 2 weeks thereafter (Fig. 8.7v, w).
Alternative options may have to be considered when results of intracoronal
whitening are not acceptable after the third internal bleaching session.
13. A waiting period of at least 2 weeks after the conclusion of the bleaching treat-
ment is recommended prior to performing the definitive adhesive restorations
with composite.
8.8 Summary
Internal whitening of endodontically treated teeth is still a good esthetic resource

especially when a full-coverage restoration is not indicated or the patient prefers not
to have the tooth restored with a full-coverage restoration. Patient must be informed
that the chance of color relapse is greater than 25 %. Although ECR and ankylosis
seem to occur more frequently in teeth that were exposed to traumatic injury and
were bleached intracoronally with hydrogen peroxide, the absence of trauma and
whitening with water/perborate mixture may still pose a slight risk of root ECR and
ankylosis.
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J 41:485–492
Part III
Enamel Etching Techniques for
Improvement of Tooth Color
Enamel Microabrasion for Removal
of Superficial Coloration and Surface 9
Texture Defects
Kevin J. Donly and Theodore P. Croll
Abstract
Enamel microabrasion is a method of removing superficial enamel coloration
defects. Brown, white, and multicolored spots and streaks in tooth surfaces have
been called “dysmineralization,” and in some cases, such as fluorosis, their
cause is known. In other cases in which etiology of the defect is unknown, the
proper diagnosis is “idiopathic enamel dysmineralization.” Decalcification
defects, which are white, result from acid dissolution of the outer layer of
enamel and are the first stage in the dental caries process. Analogous to derm-
abrasion on skin surfaces, enamel microabrasion permanently removes color-
ation defects with a compound made of dilute hydrochloric acid and a fine
abrasive powder, in a water-soluble silica gel. The enamel surface is reduced
microscopically by simultaneous abrasion and erosion, and enamel loss is insig-
nificant and unrecognizable. This chapter reviews the procedure of microbra-
sion of enamel surfaces and gives examples of treatment for decalcification,
dysmineralization, and surface texture improvement. A fourth case shows
27-year postoperative results.
K.J. Donly, DDS, MS

Department of Developmental Dentistry, The University of Texas Health Science Center at
San Antonio (School of Dentistry), San Antonio, TX, USA
T.P. Croll, DDS (*)
Department of Developmental Dentistry, The University of Texas Health Science Center at
San Antonio (School of Dentistry), San Antonio, TX, USA
Private Practice, Pediatric Dentistry, Doylestown, PA, USA
Department of Pediatric Dentistry, University of Washington School of Dentistry,
Seattle, WA, USA
e-mail: willipus@comcast.net

202 K.J. Donly and T.P. Croll
9.1 Introduction
In the early 1900s, Dr. Walter Kane used muriatic (hydrochloric) acid to erode
endemic brown and white fluorosis discoloration from the anterior teeth of people
in Colorado. Forty-four-year postoperative results of one of those patients (E. E.G.)
were pictured in an article by Dr. Robert McCloskey, published in the Journal of the
American Dental Association (McCloskey 1984). She had been treated in 1926 as a
16-year-old. Sixty years after Dr. Kane’s treatment (1986), the same patient was
photographed, then 76 years old (Fig. 9.1) (Croll 1987). A stark difference was
noted in the appearance of her incisors and canine teeth, compared to the untreated
posterior teeth. Some considered Dr. Kane’s method a type of dental bleaching, but
actually, the hydrochloric acid was dissolving the outermost layer of enamel that
contained the unsightly brown and white discoloration. As evidenced by the 60-year
postoperative view, the amount of enamel lost in treatment was unrecognizable and
of no long-term consequence (Fig. 9.1). E.E.G. reported that her “upper and lower
front teeth” (anterior) were treated by Dr. Kane, and “the teeth in back” (premolars
and molars) were not. She also remembered that Dr. Kane had warmed the teeth
with careful application of a flame, using a small torch. She did not recall any dis-
comfort from that. The results, as seen in the photograph, are dramatic and the
treated teeth give a much better appearance than those not “color-corrected” with
Dr. Kane’s muriatic acid/heat method.
Croll used a combination of 18 % hydrochloric acid mixed with fine grit labora-
tory pumice with the idea that combining chemical erosion with mechanical abra-
sion would also reduce the enamel surface microscopically, but more rapidly, and
with the clinician in control. In 1986, Croll and Cavanaugh first reported this type
of approach and termed the treatment “enamel microabrasion” (EM) (Croll and
Cavanaugh 1986a, b). After much more experience, a textbook followed (Croll
1991).
Enamel microabrasion is analogous to dermabrasion on skin surfaces. It repre-
sents a most conservative method of removing intrinsic, yet superficial, enamel dys-
mineralization (ibid, pg 22), decalcification, and texture defects avoiding the need for
restorative masking with artificial materials such as bonded resin-based composite or
bonded porcelain veneers. Successful microabrasion removes an insignificant and
unrecognizable amount of surface enamel and with it, the offending discolored or
Fig. 9.1 Sixty-year results

of eliminating brown
fluorosis stain using
hydrochloric acid. Anterior
teeth treated, posterior
teeth untreated
9 Enamel Microabrasion for Removal of Superficial Coloration 203
Fig. 9.2 A scanning

electron microscopic view
of the polished enamel
surface following
microabrasion and the
natural appearance of
enamel below the polished
surface in this fractured
(fx) enamel specimen
“maltextured” layer. Oftentimes, enamel microabrasion can be combined with dental

bleaching (Haywood and Heymann 1989) for optimum enhancement of tooth appear-
ance (Cvitko et al. 1992; Killian 1993; Croll 1992, 1998).
Enamel microabrasion has become a routine clinical procedure in dentistry
(ADA treatment code D9970) and commercial microabrasion products (PREMA®,
Premier Dental Products, Plymouth Meeting, PA) (OPALUSTRE®, Ultradent
Products, South Jordan, UT) are available to facilitate treatment. These products
contain a low concentration of hydrochloric acid (6–9 %) and silicon carbide abra-
sive powder in a silica gel, for rotary application. Research has shown that use of
these products, followed by natural remineralization, creates a lustrous enamel sur-
face that not only is more resistant to acid challenge, but also accumulates less
dental plaque than untreated surfaces (Segura et al. 1997a, b). Polarized light micro-
scope and scanning electron microscope studies have revealed that microabrasion
results in an enamel surface with a superficial layer of compacted, aprismatic min-
eral that gives a glass-like clinical appearance. The microabrasion technique
removes some surface enamel but also packs some of the abraded calcium and phos-
phate into the interprismatic spaces to create a highly dense and polished surface
(Fig. 9.2) (Berg and Donly 1991; Donly et al. 1992). Combining mechanical abra-
sion and chemical erosion inspired the terms “abrosion effect” (Donly et al. 1992)
and its result, the “enamel glaze.”
9.2 Enamel Microabrasion Procedure
The enamel microabrasion procedure can be outlined as follows:
1. Determination is made whether the tooth discoloration or texture defect is rela-

tively superficial. Enamel microabrasion is not indicated for tooth discolorations
such as seen with tetracycline dentinal stain, dentinogenesis imperfecta, or deep
enamel hypoplastic or hypocalcification defects. EM treatment is indicated for
enamel dysmineralization discolorations such as seen with brown and white fluo-
rosis, idiopathic brown or white stain, or superficial enamel texture anomalies.
2. Pretreatment photographs are always advised, both for medico-legal consider-
ations, and for education of the patient and parents.
3. Local anesthesia is used only if needed to facilitate rubber dam placement.

4. Rubber dam application or isolation with OpalDam® or OpalDam Green®
(Ultradent Products, South Jordan, UT) is recommended. Protective eyewear for
the patient is mandatory.
5. To hasten treatment results, a cylindrical diamond bur can be used at slow speed,
to initiate enamel surface microreduction (Croll 1993).
6. Using either the PREMA® Enamel Microabrasion Compound with rotary pol-
ishing cups or OPALUSTRE® with OpalCups™, a small portion of slurry is
applied to the tooth surface. A high-torque gear-reduction hand piece can be
used, but with careful application to avoid splattering, treatment can be achieved
safely with a standard slow-speed angle. After 5–10 s, using moderate pressure,
the microabrasion compound is rinsed with water, and results observed.
7. Five 10-s applications are repeated until the coloration defect is eliminated.
Determination of tooth appearance should be made while the tooth is wet.
8. After completion of microabrasion, the treated teeth should be saturated for sev-
eral minutes with a fluoride-containing gel.
9.3 Representative Cases
Enamel microabrasion treatment of three patients is documented below. One had

decalcification (Croll and Bullock 1994), another, enamel dysmineralization, and
the third, congenital enamel texture malformation (Killian and Croll 1990). A fourth
case is shown with 27-year postoperative enamel microabrasion results combined
with tooth bleaching in the adult years.
9.3.1 Case One
A 16-year-old boy had white decalcification markings in the gingival half of his
maxillary anterior teeth, related to inadequate oral hygiene during his orthodontic
therapy (Figs. 9.3a–d). There was a caries lesion associated with the decalcification
on the maxillary left canine tooth (Fig. 9.3b). The maxillary premolars also had
facial decalcification spots. A small shear fracture was noted on the maxillary left
first premolar, perhaps occurring during orthodontic bracket removal (Fig. 9.3b).
The fractured region was smoothed with a fine-tipped diamond bur. White decalci-
fication areas were seen on some mandibular teeth also, but none were noticeable
when the patient spoke or smiled, and none had associated caries.
Treatment is shown in Fig. 9.3a–d.
9.3.2 Case Two
A 10-year-old boy had white and brown idiopathic white and brown dysmineraliza-
tion, chiefly of the labial surfaces of the maxillary central incisors (Fig. 9.4a). The
cause of the white and brown dysmineralization could have been too much systemic
a b
c d
Fig. 9.3 (a) Decalcification from inadequate hygiene during orthodontics. (b) Left lateral view.
Note canine Class V caries lesion and small shear fracture of first premolar. (c) Operative field and
eye protection. PREMA® applied. (d) Three months after enamel microabrasion and resin-based
composite restoration of the maxillary left canine tooth
a b
c d
Fig. 9.4 (a) A 10-year-old with white and brown idiopathic enamel white and brown dysmineral-
ization. (b) PREMA® applied with rubber applicator tip. (c) Fluoride gel applied after microabra-
sion completed. (d) Immediately after enamel microabrasion treatment
a b
c d
Fig. 9.5 (a) An 8-year-old with pitting type amelogenesis imperfecta. (b) Slow-speed diamond
initiates enamel microreducation. (c) OPALUSTRE® slurry applied with rubber cup/brush assem-
bly (OpalCup™). (d) Three months after enamel microabrasion, enamel texture is normal
fluoride in the years of amelogenesis, but the permanent first molars where not
affected, and the parents could not identify a source of excess fluoride in the child’s
first decade. In addition, the family’s water source was not fluoridated. The diagno-
sis was recorded as idiopathic white and brown enamel dysmineralization, possibly
related to excess fluoride consumption in the early years. The parents were con-
cerned only with the maxillary central incisors at the time of treatment. Additional
enamel microabrasion for other teeth would be considered later. PREMA®
Compound was used to treat these teeth (Fig. 9.4a–d).
9.3.3 Case Three
An 8-year-old girl had a pitting type of amelogenesis imperfecta (Fig. 9.5a). The
labial surface of her maxillary incisors had multiple round notches that did not pen-
etrate deeply into the surface. The maxillary central incisors were affected much
more than the lateral incisors. Although the appearance of these incisors could have
been substantially improved with bonded resin-based composite, it was felt that the
enamel defects were superficial enough to be eliminated, rather than covered up
(Killian and Croll 1990).
To hasten the procedure, an initial portion of the enamel removal was achieved
with a slow-speed diamond bur prior to placement of the rubber dam (Fig. 9.5b) (Croll
1993). OPALUSTRE® Enamel Microabrasion Slurry was used in the same manner
as PREMA® Compound in the other cases shown here. Ultradent’s OpalCup™ with
Fig. 9.6 (a) Enamel microabrasion of a 10-year-old in 1985, documented (Croll 1991). (b) Tooth
appearance 27 years after enamel microabrasion and 2 years after custom-tray carbamide peroxide
“home bleaching.”
internal brush bristles was used to apply the slurry to all four incisors (Fig. 9.5c).
Three months later, the incisors gave a much improved appearance (Fig. 9.5d).
9.3.4 Case Four
In 1985, a 10-year-old girl had white and brown idiopathic enamel dysmineraliza-
tion discoloration of her maxillary central incisors. Enamel microabrasion was
completed and treatment was documented, before, immediately after, and 5 years
later, (Fig. 9.6a) (Croll 1991). Twenty-five years after treatment, the patient had
custom-tray carbamide peroxide tooth bleaching, for additional tooth color improve-
ment (Fig. 9.6b).
9.4 Discussion
After more than a quarter of a century of experience, clinical observations, and

research, the following is known about enamel microabrasion:
• Enamel microabrasion is more conservative of tooth structure than treatments

such as porcelain or resin-based composite veneering. It also is significantly less
expensive.
• Enamel microabrasion results are permanent. The discoloration or texture abnor-
malities are removed not masked with artificial material that eventually will
require additional intervention.
• The glass-like surface resulting from the abrasion/erosion combination resists
acid dissolution and bacteria accumulation better than untreated enamel smooth
surfaces (Segura et al. 1997a, b).
• Many intrinsic enamel surface defects are superficial enough to be eliminated
without need to replace the lost enamel. Slight and moderate white and brown
fluorosis discolorations are good examples of this type of dysmineralization.
Teeth with deeper enamel defects are to be repaired with traditional restorative
methods. In cases for which the clinician is unsure how deep the defect pene-
trates the surface, there is nothing to lose except clinical time, by attempting
microabrasion initially.
• White enamel dysmineralization sometimes does not need to be completely
removed during the microabrasion procedure. Even though residual white streaks
or spots may show when the tooth is completely dry, such defects are often cam-
ouflaged when the tooth surface is saturated with body temperature saliva.
Appearance of microabraded teeth should be assessed when wet with saliva,
which is their usual state.
• Mechanical stripping of enamel with burs or disks can also remove superficial
defects, but not in such a controlled manner and with the ensuing “enamel glaze”
formation. However, time can be saved by beginning with mechanical enamel
microreduction (diamond burs or disks), followed by completion of treatment
with rotary application of the microabrasion compound.
• In many cases, the most striking results occur when enamel microabrasion is
combined with dental bleaching. Microabrasion removes unsightly superficial
defects and creates a lustrous smooth surface while tooth bleaching whitens the
deep intrinsic yellow colorations of dentin that shine through the translucent
enamel surface. Microabraded teeth that also undergo dental bleaching with
hydrogen peroxide products, give a bright, white, and healthy appearance of long
duration.
Authors’ Acknowledgment The authors gratefully acknowledge Quintessence Publishing

Company for their gracious consent to reproduce the photographs in this chapter, and portions of
the text, which originally appeared in Croll TP, Donly KJ: Enamel microabrasion for removal of
decalcification, dysmineralization, and surface texture defects. American Journal of Esthetic
Dentistry 2013; 3(92):92–99.
Authors’ Disclaimer The authors have no financial interest in any product or com-
pany mentioned in this chapter. The second author (TPC) formerly had financial
interest in PREMA® and OPALUSTRE® by virtue of patent licensing agreements,
which ended with expiration of the patents.
References
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(eds) Microabrasion. Quintessence Publishing Co., Chicago, pp 55–60
Croll TP (1987) A case of enamel color modification: 60-year results. Quintessence Int
18:493–495
Croll TP (1991) Enamel microabrasion. Quintessence Publishing Co., Chicago
Croll TP (1992) Enamel microabrasion followed by dental bleaching: case reports. Quintessence
Int 23:317–321
Croll TP (1993) Hastening the enamel microabrasion procedure. J Am Dent Assoc 124:87–90
Croll TP (1998) Aesthetic correction for teeth with fluorosis and fluorosis-like enamel dysmineral-
ization. J Esthet Dent 10:21–29
Croll TP, Bullock GA (1994) Enamel microabrasion for removal of smooth surface decalcification
lesions. J Clin Orthod 28:365–370
Cvitko E, Swift EJ, Denehy GE (1992) Improved esthetics with a combined bleaching technique:
a case report. Quintessence Int 23:91–93
Killian CM (1993) Conservative color improvement for teeth with fluorosis-type stain. J Am Dent
Assoc 124:72–74
Killian CM, Croll TP (1990) Enamel microabrasion to improve enamel surface texture. J Esthet
Dent 2:125–128
McCloskey RJ (1984) A technique for removal of fluorosis stains. J Am Dent Assoc 109:63–64
Segura A, Donly KJ, Wefel JS (1997a) The effects of microabrasion on demineralization inhibition
of enamel surfaces. Quintessence Int 28:463–466
Segura A, Donly KJ, Wefel JS, Drake D (1997b) Effect of enamel microabrasion on bacterial colo-
nization. Am J Dent 10:272–274
Resin Infiltration After Enamel Etching
10
Sebastian Paris and Hendrik Meyer-Lueckel
Abstract
Buccal white spot lesions are an unpleasant but frequent side effect of orthodontic
treatment with fixed appliances but also developmental defects such as fluorosis
appear as “white spots.” Resin infiltration was originally developed to arrest the
progression of noncavitated caries lesions. The technique uses low-viscosity res-
ins that penetrate the porous lesion body of white spot lesions. After infiltration,
the material is light cured and thus blocks the diffusion pathways for acids and
dissolved minerals. A positive side effect of resin infiltration is that infiltrated
lesions lose their whitish appearance and look more similar to sound enamel. This
effect can be used to camouflage aesthetically impairing white spot lesions. Using
resin infiltration much less enamel is removed compared to micro-abrasion or
restorative approaches. Nonetheless, significantly better aesthetic results com-
pared with noninvasive approaches such as fluoridation can be achieved.
10.1 White Spot Lesions
White spots are among the most frequent dental aesthetic impairments. While
most whitish discolorations are early, noncavitated caries lesions, they may also
represent developmental defects with various etiologies such as fluorosis,
S. Paris (*)
Department of Operative Dentistry and Preventive Dentistry, Center of Dentistry, Oral
Medicine and Maxillofacial Surgery, Charité – Universitätsmedizin Berlin,
Assmannshauser Str. 4-6, 14197 Berlin, Germany
e-mail: sebastian.paris@charite.de; http://zahnerhaltung.charite.de/
H. Meyer-Lueckel
Department of Operative Dentistry, Periodontology and Preventive Dentistry,
RWTH Aachen University, Pauwelsstr. 30, 52074 Aachen, Germany

212 S. Paris and H. Meyer-Lueckel
posttraumatic lesions, or molar incisor hypomineralization (MIH). Common for

all these defects is an increased porosity of the enamel that causes the whitish and
chalky appearance.
Sound enamel is relatively translucent for the visible light. Due the homoge-
neous nature of enamel, which mostly consists of apatite crystals, light passes the
enamel with only minor scattering (Fig. 10.1a). In white spot lesions, of whatever
origin, the enamel structure is interspersed with porosities and voids. Apatite or
enamel has a refractive index of 1.62, whereas the content of the porosities has a
refractive index of approximately 1.33 when the lesion is wet or 1.0 when the lesions
is dry (Kidd and Fejerskov 2004). Due to the different refractive indices of the dif-
ferent media, light is broken at the millions of interfaces between the pores and the
enamel and thus the light is scattered (Fig. 10.1b). Because the difference in refrac-
tive index is even higher between dry pores and enamel compared to wet pores,
dried lesions appear more whitish compared with wet lesions.
10.1.1 Initial Caries
Caries is formed after tooth eruption by dissolution of enamel induced by cariogenic

acids being produced by cariogenic bacteria during fermentation of carbohydrates. In
the past, caries was often regarded as a transmittable disease caused by an infection
with bacteria like Streptococcus mutans (Keyes 1960). Today, caries is rather seen as
a process triggered by the frequent intake of fermentable carbohydrates (sugars) and
characterized by an ecological shift in the oral microbiology toward acidogenic and
aciduric bacteria (Marsh 2003). Moreover, it is emphasized that multiple (mostly
protective) factors such as oral hygiene, access to fluorides, or amount and composi-
tion of saliva influence the caries process (Paris and Meyer-Lückel 2012).
Fig. 10.1 Schematic illustration of the origin of the whitish opaque appearance of initial caries
and developmental defects. (a) Sound enamel is relatively translucent for visible light. Light beams
(arrows) are primarily broken within the dentin. (b) In white spot lesions, pores contain media with
a lower refractive index compared to enamel. Therefore, the light is scattered between the pores
and the surrounding apatite crystals. Thus, the lesion appears whitish
10 Resin Infiltration After Enamel Etching 213
The cariogenic bacteria produce organic acids (e.g., lactic acid), which diffuse
into the tiny pores of enamel and there dissolve the enamel apatite. This causes an
increasing porosity within the enamel. Thus, in the initial stages of the disease the
caries lesion is characterized by porous enamel. The word “initial” may be some-
what misleading because lesions that appear as white spots are often several hun-
dred micrometer deep, often extending up the enamel dentin junction or even deeper.
It may take weeks to months and years until a caries lesion reaches a stage where so
much mineral is lost that the lesion collapses and a cavity forms. Nevertheless, car-
ies is a dynamic process. If the interplay of multiple etiological factors shifts toward
less cariogenic conditions, lesions can take up mineral from the saliva again and
start to remineralize. Usually de- and remineralization cycles alternate several times
a day, but if over time remineralization overweighs demineralization, the lesion
does not progress but arrests. This remineralization is usually confined to the outer
surface of the lesion where over time a so-called pseudo-intact surface layer is
formed. This surface layer has usually a thickness of approximately 20–40 μm (but
sometimes even more then 100 μm) and is considerably less porous than the under-
lying lesion body (Meyer-Lueckel et al. 2007). Thus, arrested or remineralized
lesions look very similar to active progressing caries lesions except the higher min-
eralized surface. For this reason, it is a challenge to differentiate inactive lesions
(enamel scars) from active progressing caries.
When white spot lesions arrest, along with the minerals also organic components
such as food pigments can be incorporated into the surface layer. This is why some
lesions may get a brownish discoloration and thus are called “brown spots”
(Fig. 10.2).
Caries lesions usually develop in tooth sites where plaque formation is fostered
such as in the fissure system or interproximal. On oral or buccal smooth surfaces
plaque formation is usually increased at the cervical margin. Quite frequently, buccal
caries lesions are observed after treatment with fixed orthodontic brackets. These
appliances hamper the natural cleaning as well as oral hygiene and thus promote
plaque formation. After removal of the brackets, these surfaces may be easily cleaned
again. This improvement in oral hygiene leads to an arrest of many buccal white spot
lesions. These lesions do not need any further treatment, as they are not signs of
active disease, but enamel scars. From an aesthetic point of view, however, both
active and inactive caries lesions are unattractive and may need intervention.
Fig. 10.2 Buccal caries lesions. A

21-year-old patient with high caries
risk several months after debonding of
orthodontic brackets. Non- and partly
cavitated caries lesions are located in
the cervical part of the buccal sur-
faces. The partly yellowish-brownish
discoloration is a sign of inactivation.
Thus, the lesions currently do not
progress any more but are considered
as an aesthetic impairment
Buccal early caries lesions can be easily differentiated from developmental

defects (see below) as caries only forms in plaque stagnation areas and thus caries
on buccal surfaces is confined to cervical areas or the areas around the bracket base
(Lovrov et al. 2007; Mitchell 1992).
10.1.2 Developmental Defects
Developmental defects are caused by a disturbance during enamel formation.

Multiple factors such as toxic agents, infections, trauma, or irradiation have been
elucidated. The resulting defects can be quantitative (with a lack of enamel volume)
or qualitative (with a deficiency of enamel structure) or a combination of both. Here
we concentrate on qualitative defects, which are characterized by increased enamel
porosity.
10.1.2.1 Fluorosis
Today, enamel fluorosis is probably the most prevalent developmental defect of
human teeth. It is caused by chronic intoxication with fluorides during the phase of
enamel formation. It is believed that daily fluoride doses of 40 μg/kg bodyweight
may increase the risk of fluorosis in children and doses above 100 μg/kg almost
certainly cause dental fluorosis (Twetman and Ekstrand 2013).
Histologically, enamel fluorosis is characterized by an increased porosity in the
enamel (Thylstrup and Fejerskov 1978). In mild forms only the superficial enamel
is affected. In severe forms nearly the complete enamel is porous and the surface
may show pits and breakdowns. Clinically mild fluorosis appears as cloudy whitish
discolorations following the perikymata lines. This is the reason for their wavy
appearance. In more severe forms, the white lines converge to white spots that affect
from up to the complete cusp (Fig. 10.3). Very severe forms show complete opaque
and chalky enamel with pitting and often brownish discolorations. Fluorosis can be
distinguished from caries, since fluorosis usually affects multiple homologous teeth,
which were formed during the same period. Therefore, fluorosis is often seen on
homologous teeth.
Fig. 10.3 Dental fluorosis: note

the cloudy appearance
10.1.2.2 Posttraumatic Defects

Another quite prevalent class of developmental defects is caused by traumatic inju-
ries of primary incisors that cause a disturbance of enamel formation in the perma-
nent successors (Diab and elBadrawy 2000). These defects can comprise qualitative
defects (white or yellow-brown discolorations), quantitative defects (enamel hypo-
plasia), or combinations of both (Diab and elBadrawy 2000). Posttraumatic defects
are mostly unilateral and just affect one or two teeth.
10.1.2.3 Molar Incisor Hypomineralization (MIH)

MIH is a developmental defect that affects the first permanent molars and incisors.
In some cases, also second permanent molars and primary teeth show alterations.
MIH lesions may appear as distinct and clearly demarcated whitish to yellowish
discolorations (Willmott et al. 2008; Takahashi et al. 2009). As in other “white
spots,” the whitish opaque discoloration is caused by an increased porosity of the
enamel (Fig. 10.4). In contrast to fluorosis, the opacity is always distinct as the
porosity affects the complete enamel depth from the surface up the enamel dentin
junction. Yellowish, brownish discolorations are caused by organic components,
which fill the porosities. In severe forms the increased porosity may also lead to
enamel breakdown (Weerheijm 2003).
The etiology of MIH is still unclear. It is commonly believed that the disease is
multifactorial and that causing factors must be present during mineralization of the
first molars and incisors, which means up to the first 4 years of life. As possible etio-
logical factors, problems during pregnancy, infectious diseases, or intoxication with
antibiotics or dioxins have been discussed (Takahashi et al. 2009).
10.2 Resin Infiltration
The technique of resin infiltration was originally developed to arrest noncavi-

tated caries lesions. The mineral loss of early caries lesions results in the forma-
tion and growth of porosities in the enamel matrix. These pores act as diffusion
pathways for acids into the enamel and dissolved minerals out of the enamel.
Caries infiltration aims to penetrate these pores with low viscosity light curing
resins – so called infiltrants – that infiltrate the porous enamel driven by
Fig. 10.4 Molar incisor hypominer-

alization (MIH). The disease is
characterized by whitish opaque to
yellowish (cheesy), distinct and
clearly demarcated discolorations on
incisors and first permanent molars
(Image by M. Petrou)
capillary forces (Paris et al. 2010). When the resin is light cured, it blocks the
diffusion pathways and protects the remaining apatite crystals (Meyer-Lueckel
and Paris 2008).
One positive side effect of resin infiltration is an immediate color change of the
whitish lesion once it is infiltrated. The infiltrant resin has a refractive index of 1.52,
which is close to that of enamel (1.62). Therefore, light scattering between the
enamel pores and the surrounding enamel is significantly reduced when the pores
are filled with resin instead of water or air (Fig. 10.5). Under best conditions, the
resin-infiltrated lesions are optically masked and “disappear” (Paris and Meyer-
Lueckel 2009; Eckstein et al. 2015).
To achieve resin infiltration of porous enamel, the lesions need to be conditioned.
As the pseudo-intact surface layer has a much lower porosity compared with the
underlying lesion body, it hampers penetration of the infiltrant resin and thus must
be removed. This can be achieved by etching the lesion with 15 % hydrochloric acid
(HCl) gel for 2 min.
In the next step, the lesion must be properly desiccated. As the penetration of the
infiltrant resin infiltration is based on capillary action, any other liquid within the
porous enamel network would inhibit any infiltration. Usually, the desiccation is
achieved by a combination of air-blowing, an application of ethanol and another air-
blowing subsequently. Finally, the infiltrant resin is applied for 3 min. Although infil-
trants are chemically similar to many commercial bonding agents, it is strongly
recommended not to misemploy adhesives or bonding agents for caries infiltration but
to use the commercially available infiltrant kit. Infiltrant resins show a much higher
penetrability compared with bonding agents and thus ensure a deeper infiltration. But
Fig. 10.5 Masking of white spot lesions by resin infiltration. As the infiltrant resin has a similar
refractive index as enamel, light scattering within the white spot lesion is significantly reduced
(compare with Fig. 10.1)
even with an infiltrant the relatively long application time of 3 min is recommended to
ensure a preferably complete infiltration of the lesion body (Fig. 10.6).
Currently, there is only one commercial kit for caries infiltration on the market:
Icon (DMG, Hamburg, Germany) is available for proximal or vestibular lesions. For
infiltration of aesthetically relevant white spot lesions, the vestibular kit is
recommended.
a b
c
d
f
e
Fig. 10.6 Masking of fluorosis by resin infiltration. (a) Baseline. The patient complained
about whitish discolorations (dental fluorosis) in the upper front. (b) After cleaning and appli-
cation of light curing dam, the fluorosis becomes more distinct due to desiccation of the teeth.
(c) The lesions surface layer is eroded by etching with 15 % HCl for 2 min. (d) After rinsing
the etchant and drying, the teeth look frosty due to the etching pattern. Notice that the lesions
are still visible as only the surface layer was eroded. Now ethanol is applied to check the
completeness of surface layer erosion (for explanation, please see text). The ethanol is subse-
quently evaporated to desiccate the lesion as much as possible. (e) During application of the
infiltrant resin, an immediate color change can be observed. After 3 min, resin surplus is
removed and the material is light cured. A second infiltration step compensates possible
polymerization shrinkage. (f) After polishing the lesions, the lesions in the upper front are
nearly completely masked. After some days the aesthetic result is usually even better due to
rehydration of teeth
10.3 Case Selection
10.3.1 Infiltration of Buccal Caries
Many patients in need for an aesthetic rehabilitation of buccal white spots had a
treatment with fixed orthodontic appliances. It should be ensured that the patho-
genic factors causing the caries are under control before aesthetic rehabilitation is
planned. Thus, orthodontic brackets should be removed and patients should be able
to maintain a proper oral hygiene. To improve the aesthetics of teeth with white spot
lesions, several treatment options should be considered:
• Enhancing remineralization
• Bleaching
• Resin Infiltration
• Micro-abrasion
• Composite restorations
• Veneers
In this list of treatment options, the invasiveness increases from remineralization

methods toward the aesthetic rehabilitation using veneers. At the same time, the
predictability of the aesthetic outcome improves. Thus, the choice of treatment is
influenced by the predictable aesthetic outcome of a technique being expected by an
individual patient as well as the loss of enamel that has to be removed in order to
achieve the respective aesthetic result. In this context, it should be considered that
especially for young patients in doubt, the less invasive methods should always be
preferred and restorations should be postponed as long as possible (Qvist 2008).
Caries infiltration is “located” in the middle of the various treatment options and
thus may be an interesting micro-invasive approach to achieve good aesthetic results
with a minimum loss of enamel. To predict the aesthetic outcome of caries infiltra-
tion two factors should be considered:
Lesion depth: The deeper the lesions are, the harder it is to achieve a complete
camouflage by resin infiltration. Thus, the more whitish a lesion appears even before
drying, the harder it is to reach a complete masking.
Lesion activity: Active lesions are easier to infiltrate compared with inactive
lesions. As mentioned above the pseudo-intact surface layer inhibits the penetration
of the underlying lesion body and active caries lesions usually exhibit shallower and
lower mineralized surface layers compared with inactive lesions. Therefore, for
active lesions less surface erosion is required and often better aesthetic results are
observed in most cases. For this reason, it might be considered to treat buccal lesions
shortly after removal of orthodontic brackets.
10.3.2 Infiltration of Developmental Defects
Due to their histological similarity to caries lesions also developmental hypominer-

alized defects can be resin infiltrated. It could be shown that good aesthetic results
can be expected for cases of mild to moderate fluorosis (Auschill et al. 2015; Attal
et al. 2014; Gugnani et al. 2014). Similarly, mild posttraumatic lesions (Munoz
et al. 2013) may also be camouflaged by resin infiltration. For MIH lesions, how-
ever, both in vitro results (Crombie et al. 2014) as well as clinical reports (Kim et al.
2011) showed rather unreliable aesthetic results. It seems that yellowish or brown-
ish discolored MIH lesions show inferior aesthetic outcomes compared with whitish
lesions. This might explain why MIH lesions are obviously harder to be infiltrated
as these discolorations are associated with a high content of organic material. Thus,
in these lesions infiltration is possibly hampered by the organic material that fills the
enamel pores and thus blocks resin penetration. Nonetheless, an infiltration of the
underlying lesion and a “superficial” composite restoration of ca. 100–200 μm in
depth might be a very minimal invasive technique to be used in MIH teeth where
infiltration alone did not work.
Aesthetic indications for caries infiltration:

• Active noncavitated vestibular caries lesions
• Mild fluorosis (TSIF 1–3)
• Mild developmental defects caused by trauma or infection
Limitations of caries infiltration:
• Inactive lesions
– Here longer etching or micro-abrasion might be required.
• Enamel breakdown
– A combination of infiltration and subsequent restoration with com-
posites is possible.
• MIH lesions
– Studies showed that MIH lesions are in 50 % of the cases aestheti-
cally insufficiently camouflaged due to only partial infiltration.
Contraindications for caries infiltration:
• Dentin caries or cavities into dentin
– The infiltrating resin is too hydrophobic to infiltrate the relatively
wet dentin.
10.4 Treatment
Before treatment, teeth should be cleaned using prophylaxis paste. To isolate the
gingiva and protect it from the applied chemicals, rubber dam is strongly recom-
mended. As for conventional rubber dam usually ligatures are necessary, light curing
rubber dam has been shown to be easier applicable and more convenient for the
patient. During application of light curing dam, it should be ensured that on the one
hand the plastic dam seals the gingiva tightly but on the other hand does not cover
cervical lesions. For lesions that are located very close to the cervical gingival mar-
gin, retraction cords help to displace the gingiva before application of the liquid dam.
In the next step, the surface layer is eroded by application of 15 % hydrochloric
acid gel (Icon etch) for 2 min. In most cases, it is advisable to cover all buccal
aspects with the etching gel to achieve a homogeneous appearance. Separation of

the proximal contact points is usually not necessary. Before rinsing the etching gel,
it is advisable to remove the bulk of the gel with a suctor in order to avoid flushing
the strong acid into the oral cavity.
The etching step not only removes the outer 30–40 μm of the surface layer but
also most brownish discolorations of caries lesions as most of these discolorations
are located in the outer lesion surface. Thus, after etching most lesions show a
chalky, brightly whitish appearance. In the next step, the lesion needs to be properly
desiccated. This is achieved by air-blowing followed by application of ethanol (Icon
etch), which is also evaporated by air-blowing subsequently.
This step should also be used to check sufficient erosion of the surface layer.
Buccal lesions, especially more inactive ones may have thick and highly mineralized
surface layers. In this case, 2 min etching with 15 % HCl may not be sufficient to
erode the complete surface layer and infiltration of the lesion body might be impaired.
During the penetration of the ethanol into the air-dried lesion, a similar color
change as during the later resin infiltration should be observed within the first 3–4 s
after application. The color change from whitish chalky to nearly enamel colored dur-
ing this “re-wetting test” is usually not as distinct as during application of the resin,
but gives a good estimate of the later aesthetic outcome. If this color change during
application of ethanol on the dried lesion fails to appear and the lesion remains whit-
ish, it is quite likely that the surface layer is not completely eroded yet. In this case, a
second application of the etching gel for another 2 min is recommended. In some
cases – especially in “older” inactive lesions – even a third application or micro-abra-
sion of 100–150 μm is necessary. For that purpose the 15 % HCl etching gel can be
mixed with some pumice and then rubbed on the lesion surface using rubber cup
polishers. Care should be taken not to abrade too much enamel. In contrast to classical
micro-abrasion, not the complete lesion but only the surface layer needs to be removed.
To check the completeness of erosion, after each etching step the “re-wetting
test” should be repeated. If the result is positive, the lesion can be finally desiccated.
The drying of the lesion is an absolutely essential step, as resin infiltration is based
on capillary forces that only work when the pores within the lesion body are filled
with air but not water.
Subsequently, teeth are properly dried and the infiltrant (Icon infiltrant) is applied.
Again an immediate color change is usually observed. The resin is now allowed to
infiltrate the lesion body for approximately 3 min. Before light curing all excess resin
is removed from the lesion surface using foam pellets or cotton rolls so that only the
resin inside the lesion remains and is light-hardened. Due to the polymerization shrink-
age, the resin now should be applied a second time for 1 min, the excess removed, and
the material hardened.
To polish the surface, which is still roughened from the etching step and to
remove the oxygen-inhibited resin layer, the lesions now should be polished. This
step is quite important as the acid-roughened surface that contains a thin oxygen-
inhibited resin layer otherwise attracts food stains, which may lead to swift discol-
oration of the treated surfaces.
The whole procedure for one jaw usually takes about 20–30 min. The immediate
masking of the lesions is quite satisfactory for the patient in most cases. As during
treatment the teeth are desiccated, the final aesthetic result after some days is usu-
ally even better compared to directly after treatment.
Treatment procedure for caries infiltration to camouflage white spot

lesions:
1. Cleaning of teeth
2. Isolation by rubber dam or liquid dam
3. Etching with 15 % HCl for 2 min
4. Rinsing and drying
5. Re-wetting with ethanol to check completeness of surface layer erosion:
if negative repeat steps 3–5; if positive move on with step 6
6. Desiccation of ethanol
7. Application of infiltrant for 3 min
8. Removing of resin surplus
9. Light curing
10. Polishing
10.5 Conclusion and Outlook
Although a complete masking cannot be achieved by resin infiltration in every

case, a significant improvement of aesthetics is usually observed in the majority
of lesions. While shallower caries lesions can often be completely masked, in
deep caries lesions at least an improvement is observed. Currently, there are only
few long-term data available on the color stability of resin-infiltrated lesions.
However, it seems that infiltrated lesions show similar staining as sound enamel
(Eckstein et al. 2015; Paris et al. 2013). Fluorotic white spots and those caused by
traumatic injury can be masked quite well. For MIH lesions, aesthetic results
might not be as good.
In conclusion, resin infiltration is a micro-invasive approach that adds to the
existing armamentarium of treatment options to improve the aesthetics of buccal
white spot lesions. Due to its relatively easy application, low costs, and satisfying
results it may be considered as the first in line treatment option in many cases of
vestibular white spot lesions.
References
Attal JP, Atlan A, Denis M, Vennat E, Tirlet G (2014) White spots on enamel: treatment protocol
by superficial or deep infiltration (part 2). Int Orthod 12(1):1–31. doi:10.1016/j.
ortho.2013.12.011
Auschill TM, Schmidt KE, Arweiler NB (2015) Resin infiltration for aesthetic improvement of
mild to moderate fluorosis: a six-month follow-up case report. Oral Health Prev Dent
13(4):317–322. doi:10.3290/j.ohpd.a32785
Crombie F, Manton D, Palamara J, Reynolds E (2014) Resin infiltration of developmentally hypo-

mineralised enamel. Int J Paediatr Dent 24(1):51–55. doi:10.1111/ipd.12025
Diab M, elBadrawy HE (2000) Intrusion injuries of primary incisors. Part III: effects on the per-
manent successors. Quintessence Int 31(6):377–384
Eckstein A, Helms HJ, Knosel M (2015) Camouflage effects following resin infiltration of post-
orthodontic white-spot lesions in vivo: one-year follow-up. Angle Orthod 85(3):374–380.
doi:10.2319/050914-334.1
Gugnani N, Pandit IK, Goyal V, Gugnani S, Sharma J, Dogra S (2014) Esthetic improvement of
white spot lesions and non-pitted fluorosis using resin infiltration technique: series of four
clinical cases. J Indian Soc Pedod Prev Dent 32(2):176–180. doi:10.4103/0970-4388.130996
Keyes PH (1960) The infectious and transmissible nature of experimental dental caries. Findings
and implications. Arch Oral Biol 1:304–320
Kidd EAM, Fejerskov O (2004) What constitutes dental caries? Histopathology of carious enamel
and dentin related to the action of cariogenic biofilms. J Dent Res 83 Spec No C:C35–38
Kim S, Kim EY, Jeong TS, Kim JW (2011) The evaluation of resin infiltration for masking labial enamel
white spot lesions. Int J Paediatr Dent 21(4):241–248. doi:10.1111/j.1365-263X.2011.01126.x
Lovrov S, Hertrich K, Hirschfelder U (2007) Enamel demineralization during fixed orthodontic
treatment – incidence and correlation to various oral-hygiene parameters. J Orofac Orthop
68(5):353–363
Marsh PD (2003) Are dental diseases examples of ecological catastrophes? Microbiology 149(Pt
2):279–294
Meyer-Lueckel H, Paris S (2008) Progression of artificial enamel caries lesions after infiltration
with experimental light curing resins. Caries Res 42(2):117–124. doi:10.1159/000118631
Meyer-Lueckel H, Paris S, Kielbassa AM (2007) Surface layer erosion of natural caries lesions
with phosphoric and hydrochloric acid gels in preparation for resin infiltration. Caries Res
41(3):223–230. doi:10.1159/000099323
Mitchell L (1992) Decalcification during orthodontic treatment with fixed appliances – an over-
view. Br J Orthod 19(3):199–205
Munoz MA, Arana-Gordillo LA, Gomes GM, Gomes OM, Bombarda NH, Reis A, Loguercio AD
(2013) Alternative esthetic management of fluorosis and hypoplasia stains: blending effect
obtained with resin infiltration techniques. J Esthet Restor Dent 25(1):32–39.
doi:10.1111/j.1708-8240.2012.00527.x
Paris S, Meyer-Lückel H (2012) Paradigmenwechsel. In: Meyer-Lückel H, Paris S, Ekstrand KR
(eds) Karies, Wissenschaft und klinische Praxis. Thieme, Stuttgart, pp 70–75
Paris S, Meyer-Lueckel H (2009) Masking of labial enamel white spot lesions by resin infiltra-
tion – a clinical report. Quintessence Int 40(9):713–718
Paris S, Hopfenmuller W, Meyer-Lueckel H (2010) Resin infiltration of caries lesions: an efficacy
randomized trial. J Dent Res 89(8):823–826. doi:10.1177/0022034510369289
Paris S, Schwendicke F, Keltsch J, Dorfer C, Meyer-Lueckel H (2013) Masking of white spot
lesions by resin infiltration in vitro. J Dent. doi:10.1016/j.jdent.2013.04.003
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Part IV
Clinical Application of Combined Techniques
Internal Whitening and At-Home Tray
Whitening 11
Andressa Ballarin, Guilherme C. Lopes, and Jorge Perdigão
Abstract
Tooth whitening outcomes may be optimized when different bleaching tech-
niques are combined. For patients with generalized physiological tooth discol-
oration and darkened endodontically treated teeth, internal tooth whitening of
these nonvital teeth followed by at-home whitening of both arches is the rec-
ommended treatment. Dentists must inform their patients about the expected
outcomes of each procedure and provide an evidence-based choice.
11.1 Introduction
As discussed in Chap. 1, there are currently several tooth bleaching techniques

available to clinicians. One of the advantages of at-home bleaching is its efficacy,
which is readily noticed and viewed very favorably by patients (Swift et al. 1999).
The dental professional often treats patients who have generalized discoloration of
vital teeth as a result of physiological aging or extrinsic factors and one (or several)
darkened endodontically treated tooth. However, discolored nonvital teeth do not usu-
ally respond to external tray whitening as well as vital teeth do, with the exception of
A. Ballarin, DDS
Private Practice, Florianópolis, SC, Brazil
e-mail: andressaballarin@hotmail.com
G.C. Lopes, DDS, MS, PhD (*)
e-mail: guilherme.lopes@ufsc.br
J. Perdigão, DMD, MS, PhD
Department of Restorative Sciences, University of Minnesota,
515 SE Delaware St, 8-450 Moos Tower, Minneapolis, MN, USA

226 A. Ballarin et al.
recent discolorations, as seen in Chap. 6, Fig. 6.7. This chapter illustrates a combined
technique in which a darkened nonvital tooth is first treated with internal whitening to
reach a tooth color similar to that of the remaining vital teeth, followed by at-home
whitening of both arches with 10 % carbamide peroxide in a custom-fitted tray.
11.2 Clinical Technique
This clinical case involved a 31-year-old patient whose chief complaints were the
discoloration of a maxillary right canine and the “yellow look” of the other teeth.
The medical history was not contributory to dental treatment. Upon clinical and
radiographic exam, the patient was informed that the discoloration on tooth #6
(FDI 1.3) was related to the respective root canal treatment. Patient was also
informed that internal whitening might result in color relapse after some time.
The small risk of external root resorption associated with this procedure, as
described in Chap. 8, was also mentioned to the patient. The treatment plan
included intra-coronal whitening of tooth #6 (FDI 1.3) followed by restoration
with an adhesively luted glass fiber post and a resin-based composite direct res-
toration. The next step in the treatment plan would be at-home whitening of both
arches with 10 % carbamide peroxide in a custom-fitted tray. Tooth #6 (FDI 1.3)
would be evaluated 6 months after the restoration to decide if a full-coverage
ceramic restoration might be needed. The patient accepted this treatment plan.
Figures 11.1, 11.2, 11.3, 11.4, 11.5, 11.6, 11.7, 11.8, 11.9, 11.10, 11.11, 11.12,
11.13, and 11.14 illustrate the treatment sequence.
Fig. 11.1 Preoperative

view of patient’s smile
showing severe
discoloration of the
maxillary right canine
(tooth #6, FDI 1.3) and
generalized discoloration
of the remaining dentition
(A3, Vita Classical shade
guide)
Fig. 11.2 Close-up

magnification of tooth #6
(FDI 1.3)
11 Internal Whitening and At-Home Tray Whitening 227
Fig. 11.3 Periapical

radiograph of root-canal-
treated tooth #6 (FDI 1.3)
Fig. 11.4 A periodontal

probe is used to determine
the level of the epithelial
attachment from the incisal
edge of the tooth. This will
serve as guide for
placement of the root canal
barrier (Chap. 8)
Fig. 11.5 After isolation

with rubber dam and a
#212 clamp, the restorative
material was removed from
endodontic access
preparation. The root canal
obturation material was
removed from the cervical
area
Fig. 11.6 The same periodontal

probe is used to check if the root
canal obturation material is
removed to a level 2 mm apical to
the CEJ, calibrated to the first
measurement obtained with the
periodontal probe as in Fig. 11.4
Fig. 11.7 A 2-mm thick layer of

a resin-modified glass ionomer
(RMGIC) material is applied as a
cervical barrier between the pulp
chamber and the endodontic filling
material to prevent leakage of
bleaching agent apically into the
root canal and to the periodontal
tissues. Any excess of RMGIC
must be removed after light curing
Fig. 11.8 Enamel was

acid-etched for 15 s with
35 % phosphoric acid to
provide micromechanical
retention of the resin-based
temporary filing material
Fig. 11.9 A thick paste of

sodium perborate and
distilled water was inserted
into the pulp chamber
space. The residual liquid
was removed with dry
cotton pellets by gently
compressing the paste. A
dry cotton pellet was
inserted, leaving a
clearance of 1.5 mm for
the provisional restoration
of the access preparation
Fig. 11.10 After carefully

air-drying the cavo-surface
margin, a temporary
low-viscosity resin-based
material without an
intermediate adhesive is
inserted and light-cured
Fig. 11.11 Postoperative

view after 3 weekly
sessions of intra-coronal
whitening with sodium
perborate and distilled
water
Fig. 11.12 Postrestorative

periapical radiograph
depicting a glass fiber post
bonded to root dentin and a
coronal resin-based
composite restoration
Fig. 11.13 Once the intra-coronal

whitening treatment was completed
and tooth #6 (FDI 1.3) restored,
patient was prescribed at-home
whitening with 10 % carbamide
peroxide with potassium nitrate and
sodium fluoride (Whiteness Perfect
10 %, FGM) in a custom-fitted tray
for 2 weeks

view of patient’s smile
after at-home whitening of
both arches with 10 %
carbamide peroxide gel
Reference
Swift EJ Jr, May KN Jr, Wilder AD Jr, Heymann HO, Bayne SC (1999) Two-year clinical evalua-
tion of tooth whitening using an at-home bleaching system. J Esthet Dent 11:36–42
At-Home Tray Whitening and Enamel
Microabrasion 12
Jorge Perdigão, Jennifer M. Homer#, and Carmen Real
Abstract
Enamel microabrasion has been used to remove hypomineralized areas caused
by enamel fluorosis or those caused by an idiopathic condition. The combination
of at-home whitening with 10 % carbamide peroxide in a custom-fitted tray and
enamel microabrasion is discussed and illustrated in this chapter as a successful
treatment combination in cases of brown fluorosis stains that are not completely
eliminated with at-home whitening.
12.1 Introduction
In 1986, Croll and Cavanaugh described the “enamel microabrasion” technique

(Croll and Cavanaugh 1986a, b), which combines chemical erosion with mechani-
cal abrasion (Chap. 9). The microabrasion paste, which contains hydrochloric acid
(HCl) and silicon carbide, is applied by rubbing onto the enamel surface, removing
#
Dr. Homer is a former University of Minnesota School of Dentistry student.

J.M. Homer, DDS
Private Practice, Menomonee Falls, WI, USA
e-mail: jennifer.m.homer@gmail.com
C. Real, DDS
Division of Comprehensive Care, Department of Primary Dental Care, University of
Minnesota, Minneapolis, MN 55455, USA
e-mail: real0007@umn.edu

a microscopic layer of enamel (Donly et al. 1992). Patients usually report to be

satisfied with the aesthetic results upon completion of the enamel microabrasion
treatment (Loguercio et al. 2007).
The combination of in-office whitening with enamel microabrasion has been
reported in the literature. Bertassoni et al. (2008) used in-office whitening followed
by enamel microabrasion to camouflage white spot areas caused by fluorosis. The
effect of the in-office whitening component of the treatment was not clear in this
article, as no preoperative image was published. Celik et al. (2013a) reported that
combining enamel microabrasion and in-office bleaching was more effective in the
aesthetic management of fluorosed teeth than enamel microabrasion without whit-
ening. However, authors did not include a control group with in-office bleaching
without microabrasion. Whitening might have lightened the fluorotic brown stains
without enamel microabrasion. As described in Chap. 4, bleaching with 35 % hydro-
gen peroxide immediately after the enamel microabrasion procedure increases the
diffusion of hydrogen peroxide through enamel by 20 % (Briso et al. 2014), which
makes the use of in-office whitening contraindicated as a first step in the manage-
ment of enamel fluorosis cases.
Other authors have combined enamel microabrasion with at-home whitening.
Ardu et al. (2007) treated enamel fluorosis stains using microabrasion to eliminate
the superficial enamel layer, followed by at-home bleaching and direct resin-based
composite restorations. These authors started with enamel microabrasion and then
prescribed a home bleaching technique “to better harmonize tooth color and pro-
duce whiter teeth.” Celik et al. (2013b) also advocated the use of enamel microabra-
sion as a first option in the management of fluorosis stains. Nonetheless, they
concluded that enamel microabrasion was not very effective in removing fluorosis
brown stains. The authors attributed this difficulty in removing the brown stains to
the discoloration of the hypocalcified subsurface areas from external sources, prob-
ably associated with the penetration of staining agents.
Currently, there are two commercial enamel microabrasion materials available
(e.g., PREMA, Premier Dental Products; Opalustre, Ultradent Products Inc.). These
products contain a low concentration of hydrochloric acid and silicon carbide abra-
sive powder in a silica gel. Sundfeld and colleagues (2007) reported that 1–10 appli-
cations of 60 s on each tooth of Opalustre (6.6 % HCl) removed 25–200 μm of
enamel. Given that enamel microabrasion technique is less conservative than at-
home whitening in a custom-fitted tray, our recommendation is to start with the
least invasive technique (whitening) and, in case it does not result in an acceptable
aesthetic result, perform enamel microabrasion after whitening.
12.2 Clinical Case
The chief complaint of this 29-old-female patient was related with the brown stains
of her maxillary central incisors (Fig. 12.1a, b). The medical history and the clinical
exam led to the diagnosis of enamel fluorosis. After radiographic exam, the treat-
ment plan presented to the patient consisted of long-term at-home whitening with
12 At-Home Tray Whitening and Enamel Microabrasion 235
10 % carbamide peroxide with potassium nitrate and sodium fluoride in a custom-

fitted tray overnight with monthly recalls. The patient was informed that whitening
is not always successful in removing fluorosis-related stains and that enamel micro-
abrasion and/or direct resin-based composite restorations might be indicated after
the conclusion of the whitening treatment. Side effects of at-home whitening were
also explained in detail. We also informed the patient that enamel microabrasion
removes a microscopic layer of enamel.
The patient agreed with the treatment plan. After preliminary impressions and
fabrication of custom-fitted soft bleaching trays, we prescribed Opalescence 10%PF
(Ultradent Products Inc.) and demonstrated how to dispense the bleaching gel into
the tray. Due to scheduling conflicts, the patient was only able to return after 7
weeks (Fig. 12.2a, b). The brown stains were significantly lighter at this first recall.
The patient had no permanent side effects such as tooth sensitivity or soreness of the
gingival tissues, but she did report mild tooth sensitivity during the first few days of
the treatment. At this time, we suggested one extra month of at-home whitening fol-
lowing the same regimen.
The second recall took place 4 weeks later (Fig. 12.3a, b). There had been a
slight improvement in the color of the maxillary incisors. At this time, in agreement
with the patient, we decided to perform the enamel microabrasion technique with
Opalustre (Ultradent Products Inc.) on the four maxillary incisors (Fig. 12.4a, b).
a b
Fig. 12.1 (a, b) Pre-operative view of the discolored maxillary central incisors displaying brown
stains caused by fluorosis
a b
Fig. 12.2 (a, b) Clinical aspect after 7 weeks of overnight at-home whitening with 10 % carb-
amide peroxide with potassium nitrate and sodium fluoride in a custom-fitted tray
Six consecutive applications of 60 s each were carried out, with water rinsing
between each application. Figure 12.5 depicts the intense dehydration immediately
after removing the rubber dam.
The patient returned to clinic 2.5 months later (Fig. 12.6). Although the patient
was extremely happy with the color improvement, we suggested a few more weeks
of at-home whitening with 10 % carbamide peroxide gel. Figure 12.7a, b represents
the final result after 3 weeks of at-home whitening. At this time, the patient decided
that she did not want to pursue further treatment.
a b
Fig. 12.3 (a, b) Patient retuned to clinic 4 weeks after the first recall
a b
Fig. 12.4 (a, b) The four maxillary incisors were treated with an enamel microabrasion com-
pound (Opalustre, Ultradent Products Inc.). Six consecutive applications of 60 s each were carried
out with water rinsing between each application
Fig. 12.5 Intense dehydration of

the teeth immediately after
removing the rubber dam
12 At-Home Tray Whitening and Enamel Microabrasion 237
Fig. 12.6 The patient returned to

clinic 2.5 months after the enamel
microabrasion procedure. The
patient was extremely satisfied
with the color improvement of her
anterior teeth. We suggested a few
more weeks of at-home whitening
with the same 10 % carbamide
peroxide gel and the same
bleaching tray, following the same
regimen that she had been
prescribed in the beginning of the
treatment
a b
Fig. 12.7 (a, b) Clinical aspect after 3 extra weeks of at-home whitening with 10 % carbamide
peroxide with potassium nitrate and sodium fluoride in a custom-fitted tray. At this time the patient
decided that she did not want to pursue any further treatment, as she was extremely happy with the
esthetic outcome
Acknowledgments We would like to express our gratitude to Dr. Patricia Nguyen, formerly a
University of Minnesota dental student, and to Dr. David W. Klein for their help with the clinical
case. Special thanks to all University of Minnesota Comprehensive Care Clinic Orange Group
students.
References
Ardu S, Stavridakis M, Krejci I (2007) A minimally invasive treatment of severe dental fluorosis.
Quintessence Int 38:455–458
Bertassoni LE, Martin JMH, Torno V, Vieira S, Rached RN, Mazur RF (2008) In-office dental
bleaching and enamel microabrasion for fluorosis treatment. J Clin Pediatr Dent 32:185–188
Briso AL, Lima AP, Gonçalves RS, Gallinari MO, dos Santos PH (2014) Transenamel and trans-
dentinal penetration of hydrogen peroxide applied to cracked or microabrasioned enamel. Oper
Dent 39:166–173
Celik EU, Yıldız G, Yazkan B (2013a) Comparison of enamel microabrasion with a combined
approach to the esthetic management of fluorosed teeth. Oper Dent 38:E134–E143
Celik EU, Yildiz G, Yazkan B (2013b) Clinical evaluation of enamel microabrasion for the aes-
thetic management of mild-to-severe dental fluorosis. J Esthet Restor Dent 25:422–430
Loguercio AD, Correia LD, Zago C, Tagliari D, Neumann E, Gomes OM, Barbieri DB, Reis A
(2007) Clinical effectiveness of two microabrasion materials for the removal of enamel fluoro-
sis stains. Oper Dent 32:531–538
Sundfeld RH, Croll TP, Briso AL, Sundfeld RH, Croll TP, Briso AL, de Alexandre RS, Sundfeld
Neto D (2007) Considerations about enamel microabrasion after 18 years. Am J Dent
20:67–72
At-Home Tray Whitening and Resin
Infiltration After Acid Etching with HCl 13
Abstract
The treatment of discolored anterior teeth may involve combined techniques.
This clinical sequence illustrates the successful bleaching of “yellow” teeth with
at-home whitening using 10 % carbamide peroxide in a custom-fitted tray, fol-
lowed by masking idiopathic white spots with enamel etching with HCl followed
by resin infiltration.
13.1 Introduction
As discussed in Chap. 6, not all white or brown spots are caused by fluorosis.
Some of these stains may be considered idiopathic (Cutress and Suckling 1990).
Enamel “dysmineralization” has been used to refer to fluorosis-like discolorations
(Croll 1990).
The concept of resin infiltration after enamel etching with hydrochloric acid
(HCL) was introduced by Robinson et al. (1976) as a potential cariostatic treatment.
Croll (1987) used a clear resin sealant on phosphoric-acid-etched enamel to saturate
the surfaces with resin for smooth surface enamel defects. The research group of
G. Gomes, DMD, MSD

Esthetic Dentistry, Rey Juan Carlos University, Madrid, Spain
F. Oliveira, DMD
e-mail: filipaoliveira.email@gmail.com

240 G. Gomes et al.
Paris and Meyer-Lueckel (2009) described the masking of white spots with resin
infiltration using 15 % hydrochloric acid etching followed by a drying step with
ethanol, and a very low viscosity light-cured resin (tetraethylene glycol dimethacry-
late). Please refer to Chap. 10 for details.
The major concern that brought this 28-year-old male patient to seek dental care
was the “white areas” in his maxillary anterior teeth. Additionally, the patient was
not happy with the overall “yellow” color of his teeth. The patient’s medical history
did not shed any light into the cause of the white spots. The patient recollection was
that these whitish areas were visible since his teenage years. The diagnosis was
idiopathic discoloration.
The clinical exam revealed that the periodontal condition was excellent with no
probing depths >3 mm. There were a few areas of gingival recession without root
sensitivity. Periapical radiographs of the anterior teeth did not disclose any
pathology.
The treatment plan presented to the patient included at-home whitening with
10 % carbamide peroxide gel (with potassium nitrate and sodium fluoride) in a
custom-fitted tray overnight for 3 weeks, followed by enamel etching with 15 %
hydrochloric acid (HCl) and resin infiltration. Figures 13.1, 13.2, 13.3, 13.4, 13.5,
13.6, 13.7, 13.8, 13.9, 13.10, 13.11, 13.12, 13.13, 13.14, 13.15, 13.16, 13.17, 13.18,
13.19, 13.20, 13.21, and 13.22 describe the sequential steps that resulted in a suc-
cessful outcome.

view of the patient’s
maxillary anterior teeth.
An A2 Vita Classical
A1-D4 shade tab (VITA
Zahnfabrik H. Rauter
GmbH & Co. KG) is
shown as reference
13 At-Home Tray Whitening and Resin Infiltration After Acid Etching with HCl 241
Fig. 13.2 Higher

magnification view of
maxillary incisors with
white spots. Tooth #9 (FDI
2.1) had the widest white
spot areas
Fig. 13.3 Scalloped

custom-fitted bleaching
tray short of the gingival
tissues to prevent tissue
irritation
Fig. 13.4 Aspect of

anterior teeth after 9 days
of at-home whitening with
10 % carbamide peroxide
gel with potassium nitrate
and sodium fluoride
(Whiteness Perfect 10 %,
FGM) in a custom-fitted
tray overnight
242 G. Gomes et al.
Fig. 13.5 Aspect of

of at-home whitening. The
patient was extremely
happy with the lighter
color of his teeth
Fig. 13.6 The patient was

scheduled for a resin
infiltration procedure 2
weeks after finishing the
at-home whitening
treatment
Fig. 13.7 Teeth were cleaned with

a suspension of pumice and water
and thoroughly washed with water.
Area was isolated with rubber dam.
A 15 % HCl gel (Icon-Etch, DMG)
was applied to the white spot areas
of tooth #9 (FDI 2.1). The
respective manufacturer provides an
application tip in the respective kit;
however, we prefer a small round
brush to ensure application accuracy
Fig. 13.8 The 15 % HCl

gel was extended to the
other white spot areas and
left undisturbed for 2 min
Fig. 13.9 The gel was

thoroughly rinsed with
water for 30 s with the
high-speed suction tip
positioned as close as
possible to the area being
washed. The white spots
on tooth #9 (FDI 2.1) were
etched a second time with
15 % HCl gel for 2 min, as
recommended by the
manufacturer
Fig. 13.10 The teeth were

thoroughly rinsed with
water and inspected to
make sure that all residual
gel had been removed
Fig. 13.11 The teeth were

air-dried with water- and
oil-free air for 15 s
Fig. 13.12 A generous

amount of Icon-Dry
(DMG), which is
composed of ethanol, was
applied to the white spot
areas and left undisturbed
for 30 s. The teeth were
air-dried with water- and
oil-free air for 15 s
244 G. Gomes et al.
Fig. 13.13 An abundant

amount of Icon-Infiltrant
(DMG), which contains
TEGDMA
(triethyleneglycol
dimethacrylate), initiators
and stabilizers, was applied
to the areas that had been
etched with 15 % HCl and
left undisturbed for 3 min
Fig. 13.14 Excess

material was gently
air-blown for 5 s to prevent
pooling around the incisal
edge
Fig. 13.15 Excess resin

was removed with cotton
pellets and dental floss
Fig. 13.16 The resin was

light-cured for 40 s in each
tooth
Fig. 13.17 Icon-Infiltrant

(DMG) was reapplied and
left undisturbed for 1 min.
Excess was removed as
described above, followed
by light curing for 40 s in
each tooth
Fig. 13.18 Aspect of the

anterior teeth immediately
after light curing
Fig. 13.19 The treated

areas were polished with
rubber points in slow speed

treated teeth immediately
after removing the rubber
dam
246 G. Gomes et al.

view

view
References
Croll TP (1987) Bonded resin sealant for smooth surface enamel defects: new concepts in “micro-
restorative” dentistry. Quintessence Int 18:5–10
Croll TP (1990) Enamel microabrasion for removal of superficial dysmineralization and decalcifi-
cation defects. J Am Dent Assoc 120:411–415
Cutress TW, Suckling GW (1990) Differential diagnosis of dental fluorosis. J Dent Res 69 Spec
No:714–720; discussion 721
Paris S, Meyer-Lueckel H (2009) Masking of labial enamel white spot lesions by resin infiltration-
-a clinical report. Quintessence Int 40:713–718
Robinson C, Hallsworth AS, Weatherell JA, Künzel W (1976) Arrest and control of carious
lesions: a study based on preliminary experiments with resorcinol-formaldehyde resin. J Dent
Res 55:812–818
At-Home Tray Whitening and Direct
Resin-Based Composite Restorations 14
Abstract
As discussed in Chap. 6, the esthetic appeal of anterior teeth may benefit from
at-home whitening prior to esthetic rehabilitation with veneers or prior to recon-
touring clinical crowns with direct resin-based composite restorations. This clin-
ical case illustrates the treatment details of a patient who wanted to change the
color and the length of her anterior teeth.
14.1 Introduction
Carbamide peroxide in a custom-fitted tray is a very effective method to change the

intrinsic color of teeth and to remove external stains from the tooth surface. When
the treatment plan involves dental whitening followed by direct resin composite
bonding procedures (recontouring anterior teeth, direct resin composite veneers,
bonding orthodontic brackets, among others), the dental professional must take into
consideration (as discussed in Chaps. 4 and 6) that enamel and dentin bond strengths
remain low for the first two weeks post-bleaching. For enamel specifically, 10 %
carbamide peroxide reduces the bond strengths of resin-based composite to etched
Electronic supplementary material The online version of this chapter (doi:10.1007/978-3-

319-38849-6_14) contains supplementary material, which is available to authorized users.
G. Gomes, DMD, MSD (*)

Post-Graduate Program in Esthetic Dentistry, Rey Juan Carlos University, Madrid, Spain
F. Oliveira, DMD
J. Perdigão, DMD, MS, PhD
Division of Operative Dentistry, Department of Restorative Sciences, University of Minnesota,
515 SE Delaware St, 8-450 Moos Tower, Minneapolis, MN 55455, USA

248 G. Gomes et al.
enamel (Cvitko et al. 1991; Barghi and Godwin 1994; Ben-Amar et al. 1995;
Spyrides et al. 2000), and increases enamel surface porosity (Ben-Amar et al. 1995).
This reduction may be as high as 76 % of the bond strengths to unbleached enamel
(Spyrides et al. 2000).
After a lapse of 2 weeks, the bond strengths return to the level of untreated sub-
strates (Cavalli et al. 2001; Shinohara et al. 2005). Therefore, a minimum waiting
period of 2 weeks is recommended after the patient completes the whitening treat-
ment prior to performing any adhesive restorative procedure. In case the patient is
unable to wait for 2 weeks, it has been shown that removal of surface enamel prior
to bonding restores enamel bond strengths to normal level (Cvitko et al. 1991).
This chapter illustrates a combined technique in which at-home whitening of both
arches with 10 % carbamide peroxide in a custom-fitted tray was first completed, fol-
lowed by direct resin composite recontouring of the patient’s anterior teeth.
A 34-year-old female patient called the dental office to set up an appointment pri-
marily because she was concerned about the ‘how short her upper front teeth were’.
Additionally, the patient ‘wanted to have whiter teeth’.
During her appointment, the patient did not mention any other complaints. She
just wanted to improve the esthetics of her maxillary anterior teeth as well change
the appearance of her smile (Fig. 14.1a, b). The clinical examination revealed no
discomfort during function. The temporomandibular joint was asymptomatic. Upon
clinical and radiographic examination, the treatment plan presented to the patient to
improve the esthetics of her smile included at-home whitening with 10 % carbamide
peroxide with potassium nitrate and sodium fluoride in a custom-fitted tray over-
night for 2 weeks, followed by recontouring the incisal edges of the maxillary inci-
sors with direct resin-based composite to increase the length of the clinical crowns.
We also suggested the correction of the mesio-buccal line angle of tooth # 9 (FDI
2.1) and adjustment of the length of the maxillary canines with direct resin-based
composite. The patient agreed with the proposed treatment plan. Figures 14.2, 14.3,
14.4, 14.5, 14.6, 14.7, 14.8, 14.9, 14.10, 14.11, 14.12, 14.13, 14.14, 14.15, 14.16,
14.17, 14.18, and 14.19 show the treatment sequence step by step.
a b
Fig. 14.1 (a) Preoperative view of the patient’s smile. (b) Preoperative view of the patient’s max-
illary anterior teeth. Note the reduced length of the anterior teeth
14 At-Home Tray Whitening and Direct Resin-Based Composite Restorations 249
Fig. 14.2 Aspect of

of at-home whitening. The
patient was satisfied with
the lighter color of her
teeth
a b
Fig. 14.3 (a) Stone model of maxillary anterior teeth. (b) The stone model was waxed-up to
establish a harmonious length and shape of the anterior teeth. The patient was very happy with this
blueprint of her teeth. (c) A matrix made of putty-consistency VPS (vinylpolysiloxane) impression
material was prepared from the waxed-up model. This silicone index was used as guidance for the
lingual contour and to establish the new incisal edge position
250 G. Gomes et al.
a b
Fig. 14.4 (a) A mock-up was made with bis-acryl composite (Protemp 4 (also known as Protemp Plus),
3M ESPE) to allow the patient to foresee the esthetic outcome of the new restorations. (b) Diagnostic
resin-based composite restorations were made prior to the adhesive procedure, to verify the stratification
and thickness of each composite layer and the color. (c) Diagnostic restoration upon removal
Fig. 14.5 Teeth were

cleaned with a suspension
of pumice and water and
thoroughly washed with
water. Area was isolated
with rubber dam
Fig. 14.6 Enamel was

roughened with Sof-Lex
disks (3M ESPE)
Fig. 14.7 The VPS matrix

was tried-in
Fig. 14.8 The teeth were etched

with 32 % phosphoric acid
(Scotchbond Universal Etchant, 3M
ESPE) for 15 s. The etchant was
thoroughly rinsed for 20 s. The
two-step etch-and-rinse adhesive
(Adper Single Bond Plus (also known
as Adper Scotchbond 1 XT and
Adper Single Bond 2), 3M ESPE)
was vigorously applied for 15 s
Fig. 14.9 The adhesive

was gently air-dried to
evaporate the solvent
Fig. 14.10 The adhesive

was light-cured for 15 s
252 G. Gomes et al.
Fig. 14.11 A thin palatal

(or lingual) layer of
resin-based composite
(Filtek Supreme Ultra (also
known as Filtek Supreme
XTE and Filtek Z350 XT),
3M ESPE) was applied
with the VPS matrix using
shade B1B for the central
incisors and shade B1E for
the lateral incisors
Fig. 14.12 This palatal

enamel layer was
light-cured from buccal
and from lingual for 40 s
each
Fig. 14.13 The incisal

opaque halo was replicated
using shade A2D (central
incisors) and shade B1B
(lateral incisors), the same
shades that had been used
for the diagnostic
restoration (Fig. 14.4b) as
the dentin replacement
shades
Fig. 14.14 After light

curing the incisal opaque
halo, the dentin layer was
reproduced leaving space
for the opalescent layer.
The dentin layer was
light-cured for 40 s
Fig. 14.15 An opalescent

layer (shade AT or Amber
Translucent) was applied
between the A2D dentin
replacement composite layer
and the A2D incisal opaque
halo. The enamel layer was
reproduced using shade
XWE for the central incisors
and shade B1E for the lateral
incisors. The restorations
were light-cured for 40 s
each from buccal and lingual
aspects

restored teeth after
polishing and removing the
rubber dam
254 G. Gomes et al.

view of the patient’s smile
a b
Fig. 14.18 (a) Preoperative right side view of the patient’s smile. (b) Postoperative right side view
of the patient’s smile
a b
Fig. 14.19 (a) Preoperative left side view of the patient’s smile. (b) Postoperative left side view
of the patient’s smile
References
Barghi N, Godwin JM (1994) Reducing the adverse effect of bleaching on composite-enamel
bond. J Esthet Dent 6:157–161
Ben-Amar A, Liberman R, Gorfil C, Bernstein Y (1995) Effect of mouthguard bleaching on
enamel surface. Am J Dent 8:29–32
Cavalli V, Reis AF, Giannini M, Ambrosano GM (2001) The effect of elapsed time following
bleaching on enamel bond strength of resin composite. Oper Dent 26:597–602
Cvitko E, Denehy GE, Swift EJ Jr, Pires JA (1991) Bond strength of composite resin to enamel
bleached with carbamide peroxide. J Esthet Dent 3:100–102
Spyrides GM, Perdigao J, Pagani C, Araújo MA, Spyrides SM (2000) Effect of whitening agents
on dentin bonding. J Esthet Dent 12:264–270
Restorative Options for Discolored
Teeth 15
Edson Araújo and Jorge Perdigão
Abstract
Although dental professionals have an armamentarium of techniques for dis-
guising or removing tooth discolorations, these techniques are not always suc-
cessful. This chapter will focus on restorative options for discolored vital and
nonvital teeth.
15.1 Dental Fluorosis Treated with Porcelain Crowns
As described in Chap. 6, excessive fluoride intake may result in dental fluorosis,

characterized by opaque white areas or discolorations ranging from yellow to dark
brown (Horowitz et al. 1984). In more severe cases, the enamel surface becomes pit-
ted with porosities. One of the problems when restoring fluorosed teeth is the low
bond strength obtained between resin-based composites and unground fluorotic
enamel when using self-etch adhesives (Ermis et al. 2007). A two-step etch-and-rinse
adhesive, on the other hand, results in statistically similar enamel bond strengths
when applied to fluorotic enamel compared to normal enamel (Ermis et al. 2007).
The clinical case depicted in Fig. 15.1 is that of a 20-year-old female patient who
decided to seek dental treatment because her self-esteem was extremely low as a
result of the appearance of her teeth. This patient had lived in a rural area during
E. Araújo, DDS, MS, PhD

e-mail: edson_araujo@hotmail.com

258 E. Araújo and J. Perdigão
a b
c d
Fig. 15.1 (a) Nonretracted frontal view of patient’s anterior teeth. (b) Retracted view showing
enamel fluorosis in all teeth. (c) Close-up view of maxillary incisors. (d) Lateral close-up view of
anterior teeth
childhood. According to the information given to her mother by the patient’s local
dentist, the drinking water contained excessive fluoride. Other children in the same
community had discolored white or brown teeth, according to the patient’s mother
recollection. Consequently, the diagnosis for this clinical case was dental fluorosis.
Out of the six maxillary anterior teeth, only tooth #8 (FDI 1.1) would fall into
TSIF score 6 as per Horowitz et al. (1984), and TF index score 5, as per Thylstrup
and Fejerskov (1978). The other five maxillary anterior teeth would fall into TSIF
score 7 (Horowitz et al. 1984) and TF index score 6 (Thylstrup and Fejerskov (1978).
Clinical and radiographic exams did not disclose any problem with soft tissues,
pulp vitality, and periodontal health. Esthetically, the shape of the anterior teeth was
not harmonious. The lateral incisors looked too short while the central incisors were
square shaped. A waxed-up model was prepared to reflect longer clinical crowns
with a more pleasant proportion. This model was used to explain to patient how a
change in the size of the clinical crowns might enhance her smile.
The following treatment plan was agreed with the patient:
1. Direct resin-based composite veneers to mask the discolorations as an immedi-

ate solution to improve the patient’s self-confidence (Fig. 15.2). Patient was
informed that the aspect of her smile would improve considerably but she might
still notice a few areas of discoloration.
2. A second phase of the treatment included a gingivoplasty procedure to recontour
the tissue (Fig. 15.3) and lengthen the clinical crowns. After soft tissue healing,
minimally invasive preparations for porcelain crowns were carried out, followed
15 Restorative Options for Discolored Teeth 259
Fig. 15.2 Clinical aspect

after direct resin-based
composite was bonded to
the slightly roughened
enamel, using a two-step
etch-and-rinse adhesive
Fig. 15.3 Gingivoplasty
to recontour the gingival
tissue
Fig. 15.4 IPS e.max Press

(Ivoclar Vivadent) lithium
disilicate restorations as
received from the dental
laboratory
by thin porcelain restorations bonded to enamel to restore function and esthetics

(Figs. 15.4 and 15.5).
15.2 D
ental Fluorosis Treated with At-Home Whitening
and Porcelain Veneers
The major complaint of this 19-year-old female patient was related to the color of
her front teeth (Figs. 15.6, 15.7, 15.8, 15.9, and 15.10). She described major social
difficulties at school because of her “unpleasant smile.” She had no medical
a b
Fig. 15.5 (a) Clinical aspect immediately after bonding the ceramic restorations with a two-step
etch-and-rinse adhesive (Adper Single Bond Plus, 3M ESPE) and a dual-cured resin-based luting
composite material (RelyX ARC, 3M ESPE). (b) Patient’s smile 2 days after the restorations were
bonded
a b
Fig. 15.6 (a) Nonretracted frontal view showing the wide yellowish discoloration on teeth #8
(FDI 1.1) and #9 (FDI 2.1) and white spot areas in other teeth. Some teeth display single pitted
enamel areas. (b) Retracted view. The lower incisors also have yellowish discolorations along the
perikymata. (c) Close-up view of the maxillary incisors
conditions and no history in her family related to alterations in the appearance of

teeth. The clinical exam revealed that the periodontal condition was excellent.
Radiographically, there were no structural areas of concern in the periodontal and
periapical areas.
Similar to the patient shown in Sect. 15.1, this patient had lived in the same rural
area. Other children in the same community had discolored teeth, including some of
her family members.
Fig. 15.7 Preparation of

maxillary teeth for
porcelain veneers. Patient
was not anesthetized
because the preparation
was limited to enamel
a b
Fig. 15.8 (a) Porcelain veneers fabricated with IPS e.max Press (Ivoclar Vivadent) lithium disili-
cate. (b, c) The thickness of the veneers ranged from 0.2 mm to 0.3 mm
The diagnosis for this clinical case was dental fluorosis. This patient’s fluorosis
level would fall into TSIF score of 4 (Horowitz et al. 1984) and a TF index score of
4 (Thylstrup and Fejerskov 1978). The treatment plan proposed to the patient was
at-home whitening with 10% carbamide peroxide gel in a custom-fitted tray for one
month and possibly every month thereafter up to 5–6 months, depending on the
outcome after the first month. In case at-home whitening did not result in “whiter”
teeth, we would try enamel microbrasion (Chap. 9) or a more invasive restorative
procedure, such as direct or indirect veneers. Patient was informed that microabra-
sion is usually less conservative than at-home whitening. Patient accepted this ini-
tial treatment plan.
a b
Fig. 15.9 The veneers were cemented with a two-step etch-and-rinse adhesive system (Adper
Single Bond Plus, 3M ESPE) and a light-cure resin-based luting composite material (RelyX
Veneer, 3M ESPE) (a–c). One week after the luting procedure, the integration of the porcelain
restorations with the gingival tissue was excellent
Fig. 15.10 Patient’s smile

1 week after the veneers
were bonded
Patient returned to the dental office after 5 weeks. No visible changes had
occurred with the color of her teeth. Patient’s compliance might have been respon-
sible for the apparently unsuccessful whitening regimen, as patient mentioned that
she forgot to wear the trays for a few days. At this point we asked patient if she
wanted to start the enamel microabrasion procedure, which she declined. She
wanted a “more permanent solution.”
After presenting the restorative treatment options to the patient, which
included direct resin-based composite veneers or porcelain veneers, she returned
2 weeks later to start the clinical procedure for 8 thin porcelain veneers in her
maxillary teeth.
15.3 E
namel Idiopathic Hypomineralization Treated
with Direct Resin-based Composite
As mentioned in Chap. 6, at-home whitening may highlight the enamel hypominer-

alized areas and make them more pronounced in case they are located deep in the
enamel. The photograph shown in Fig. 15.11a is that of a 19-year-old female patient
who had bleached her teeth a few months earlier with 10% carbamide peroxide in a
custom-fitted tray for 3 weeks. All the patients’ anterior teeth were vital without any
clinical or radiographic signs of pathology, except for the enamel hypomineralized
area on tooth #10 (FDI 2.2).
According to the patient’s description, the white enamel area of tooth #10 (FDI
2.2) became wider and more opaque with the whitening treatment (as shown in
Chap. 6, Figs. 6.14a, b). Clinically, the white opaque enamel area exhibited a con-
cavity in the central area of the lesion, denoting loss of enamel (Fig. 15.11).
Transillumination confirmed that the center of the lesion had a thinner area of tooth
structure compared to the periphery (Fig. 15.12). The increased opacity of the tooth
structure surrounding the more translucent zone suggested that the defect was deep
inside the tooth and therefore not amenable to enamel microabrasion.
The treatment plan was removal of the hypomineralized area (Fig. 15.13), etch-
ing with 35% phosphoric acid for 15 s, and restoration with a two-step etch-and-
rinse adhesive (Adper Single Bond Plus, 3M ESPE) followed by a resin-based
composite (Filtek Supreme Ultra, 3M ESPE). After inserting and light curing the
resin-based composite, the restoration was finished with Sof-Lex XT disks (3M
a b
Fig. 15.11 (a) Smile of a 19-year-old female patient who had bleached her teeth a few months
earlier with 10% carbamide peroxide in a custom-fitted tray for 3 weeks. (b, c) Tooth #10 (FDI 2.2)
displayed an enamel hypomineralized area with a concavity in the central area of the lesion denot-
ing loss of enamel
Fig. 15.12 Transillumination
confirmed that the center of the
hypomineralized area had a
thinner area of tooth structure
compared to the periphery
a b c
Fig. 15.13 The porous enamel was removed with a diamond bur
ESPE) (Fig. 15.14a) followed by characterization of the secondary anatomy

(Fig. 15.14b) with a composite finishing bur. A felt disk (Diamond Flex, FGM) and
a fine diamond paste (Diamond Excel, FGM) and used for the final polishing step
(Fig. 15.14c). Figure 15.15 is a close-up photograph of the final aspect of restored
tooth #10 (FDI 2.2) showing an optimal esthetic integration with the other anterior
teeth. Figure 15.16 portrays the patient’s new smile.
a b c
Fig. 15.14 After etching with 35% phosphoric acid for 15 s, a two-step etch-and-rinse adhesive
was applied, gently air dried and light cured, followed by a nanofilled resin-based composite;
(a) Finishing with aluminum oxide disks; (b) Placing secondary anatomy with a fine diamond
finishing bur; (c) The final polishing step was carried out with a felt disk impregnated with a fine
diamond paste
Fig. 15.15 Close-up
photograph of the restored
tooth
Fig. 15.16 The patient’s

new smile
15.4 R
estorative Solution for a Case of Unsuccessful Intra-
coronal Whitening
As described in Chap. 8, intra-coronal whitening of endodontically treated teeth has

a fairly good prognosis for discolorations caused by necrotic pulp tissue or blood
components, with a short-term success rate of 50–90 %. However, the long-term
success rate is considerably lower as some color regression may occur after the
initial bleaching effect.
This 35-year-old female patient was concerned about the discoloration of her
right maxillary central incisor (Figs. 15.17, 15.18, 15.19, 15.20, 15.21, and 15.22).
According to the patient this tooth had been endodontically treated 6 years ago and
immediately became darker. Her dentist performed three intra-coronal whitening
treatments three years later, followed by two sessions of external in-office whiten-
ing. In spite of a slight improvement in the tooth color patient never felt that the
tooth was esthetically acceptable.
Medical history was not contributory. Radiographically tooth #8 (FDI 1.1) had
no evidence of root resorption or periapical pathology. The radiographic aspect of
the root canal treatment was considered excellent. The clinical exam revealed a few
areas of incipient caries lesions on the posterior area, besides defective resin-based
view showing the
discoloration of tooth #8
(FDI 1.1)
Fig. 15.18 After
replacement of resin-based
composite restorations and
preparation of tooth # 8
(FDI 1.1) for a porcelain
crown
Fig. 15.19 Shade matching
Fig. 15.20 High-opacity lithium

disilicate coping try-in (IPS
e.max Press HO, Ivoclar
Vivadent)
Fig. 15.21 Characterization of

the opaque ceramic coping
Fig. 15.22 Final aspect after

adhesive cementation of the
lithium disilicate ceramic crown
composite restorations in the anterior segment. The treatment plan proposed to the
patient to solve the compromised esthetics included replacement of the resin-based
composite restorations on teeth #7 (FDI 1.2), #9 (FDI 2.1) and #10 (FDI 2.2),
followed by a bonded porcelain crown to correct the discoloration of tooth #8
(FDI 1.1).
References
Ermis RB, De Munck J, Cardoso MV, Coutinho E, Van Landuyt KL, Poitevin A, Lambrechts P,
Van Meerbeek B (2007) Bonding to ground versus unground enamel in fluorosed teeth. Dent
Mater 23:1250–1255
Horowitz HS, Driscoll WS, Meyers RJ, Heifetz SB, Kingman A (1984) A new method for assess-
ing the prevalence of dental fluorosis – the tooth surface index of fluorosis. J Am Dent Assoc
109:37–41
Thylstrup A, Fejerskov O (1978) Clinical appearance of dental fluorosis in permanent teeth in rela-
tion to histologic changes. Community Dent Oral Epidemiol 6:315–328

Tooth Whitening An Evidence Based Perspe

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What is the book about?

What is the book about?

What restorative treatment was performed for the patient?

What restorative treatment was performed for the patient?

Jorge Perdigão

ISBN 978-3-319-38847-2 ISBN 978-3-319-38849-6 (eBook)

Library of Congress Control Number: 2016948412

© Springer International Publishing Switzerland 2016

Printed on acid-free paper

This Springer imprint is published by Springer Nature

Minneapolis, MN, USA Jorge Perdigão

Part I Tooth Whitening with Peroxides

1 Introduction to Tooth Whitening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Part II Current Techniques for Dental Whitening with Peroxides:

6 At-Home Tooth Whitening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Part III Enamel Etching Techniques for Improvement of Tooth Color

9 Enamel Microabrasion for Removal of Superficial Coloration

Part IV Clinical Application of Combined Techniques

11 Internal Whitening and At-Home Tray Whitening . . . . . . . . . . . . . . . 225

Edson Araújo Department of Dentistry, Federal University of Santa Catarina,

1.1 History of Tooth Whitening

Tooth whitening is a conservative and effective method to lighten discolored teeth

S.R. Kwon, DDS, MS, PhD, MS

© Springer International Publishing Switzerland 2016 3

1.2 Current Tooth Whitening Techniques

Table 1.1 History of tooth whitening

Table 1.1 (continued)

Table 1.2 Summary of current vital tooth whitening techniques

in-office whitening, followed by at-home whitening, with over-the-counter whiten-

1.3 Diagnosis and Treatment Planning

1.3.1 Check List During Examination

1.3.2 New Challenges in Tooth Whitening

1.3.2.1 Failed Attempts of Tooth Whitening

Fig. 1.2 Patient complained about

Fig. 1.3 Generalized

1.3.2.3 Tooth Whitening in Children

Fig. 1.5 Patient

1.3.2.4 Tooth Whitening on Teeth with Veneers and Orthodontic

1.3.3 Monitoring the Progress of Tooth Whitening

Fig. 1.6 continued

Kwon SR, Meharry M, Oyoyo U, Li Y (2015b) Efficacy of do-it-yourself whitening as compared

2.1 Etiology of Discolorations

S.R. Kwon, DDS, MS, PhD, MS

© Springer International Publishing Switzerland 2016 21

2.1.1 Extrinsic Stains

Tooth discoloration is broadly classified as extrinsic or intrinsic, depending on the

Metallic stains are common in industrial workers exposed to metal-containing

2.1.2 Intrinsic Stains

In contrast to the superficial nature of extrinsic stains, intrinsic discolorations are

2.1.2.1 Dental Fluorosis

2.1.2.2 Tetracycline Staining

2.1.2.3 Developmental Defects and Others

2.2 Mechanism of Peroxide Action

2.2.1 Phase One: Diffusion

2.2.2 Phase Two: Interaction

2.2.3 Phase Three: Surface Change and Color

Ma X, Li R, Sa Y, Liang S, Sun L, Jiang T, Wang Y (2011) Separate contribution of enamel and

Y. Li, DDS, MSD, PhD

© Springer International Publishing Switzerland 2016 35

2.1 Etiology of Discolorations

2.1.1 Extrinsic Stains

2.1.2 Intrinsic Stains

2.1.2.1 Dental Fluorosis

2.1.2.2 Tetracycline Staining

2.1.2.3 Developmental Defects and Others

2.2 Mechanism of Peroxide Action

2.2.1 Phase One: Diffusion

2.2.2 Phase Two: Interaction

2.2.3 Phase Three: Surface Change and Color

4.2 Effect on Oral Soft Tissues

4.2.1 At-Home Bleaching

4.2.2 OTC Products

4.2.3 In-Office Bleaching

4.3 Effect on Oral Hard Tissues

4.3.1 Change in Color of Tooth Structure

4.3.2 Microabrasion and Tooth Bleaching

4.3.4 Effects on Restorations

4.3.4.3 Change in Color, Brightness, and Fluorescence

4.3.4.4 Microleakage and Effects on Bond Strength

4.4 Tooth Sensitivity

4.4.2 Protection Protocols

4.4.2.1 Incipient Carious Lesions

4.4.2.2 Presence of Cracks in the Enamel

4.4.2.3 Exposed Dentin Areas

4.4.2.4 Presence of Restorations with Marginal Gaps