13 Bleaching

BLEACHING OF
DISCOLOURED TEETH
Dr.Toby Thomas, MDS

Associate Professor,
Department of Restorative Dentistry and
Endodontics
College of Dentistry, University of Majmaah
Al Zulfi
INTRODUCTION
• Discoloration of anterior teeth is a cosmetic

problems that is often the patients primary
concern.
• Although restorative procedures are available,

discoloration can often be corrected totally or
partially by a more conservative approach.
• Bleaching, is relatively simple to perform and

less expensive.
Etiology of Tooth Discoloration
Extrinsic stains - Dietary chromogens and other external elements deposit on
the tooth surface or within the pellicle layer either directly or indirectly.
Intrinsic stains - Stains within the dentine often resulting from systemic or
pulpal origin usually during the formation of the tooth.
Internalized stains are the result of extrinsic stains entering the dentine via tooth
defects such as cracks on the tooth surface.
(Sulieman M et al 2005)
CAUSES OF EXTRINSIC STAINS:
1. Diet
Tea or coffee
Black current juice or cola drinks
2. Bacterial Strains:
Chromophilic bacteria frequently seen in the deciduous
or mixed dentition
3. Medication:
Chlorhexidine reduce plaque formation - disturbing the
pellicle matrix formation, attracts more extrinsic stains.
4. Habits:
Smoking tobacco causes a yellow-brown discolouration
especially on the lingual aspects of the teeth.
Chewing tobacco causes a black-brown stain on the

buccal surfaces of the mandibular posterior teeth.
5) Gingival Hemorrhage
Chronic gingivitis may induce staining from the
breakdown of blood in the gingival sulcus.
INTRINSIC STAINS
1. Pre-eruptive
Amelogenesis imperfecta Fluorosis Alkaptonuria
Erythroblastosis foetalis Porphyria Tetracycline staining
(Plotino et al 2008)
2. Post eruptive
Age Pulpal necrosis Dentin hypercalcification
Intra canal medicaments

Remnants of pulpal tissues Restorations
Obturating materials
Intrapulpal haemorrhage
BLEACHING
Bleaching can be defined as the whitening of a tooth through the application
of chemical agent to oxidise or reduce the organic pigmentation in the tooth.
Advantage:
• Safe procedure
• painless to adults
• No tooth reduction required
• No anaesthesia necessary
• Less expensive
Disadvantage
• Unpredictable results
• Extended treatment time may be necessary
• Post operative hypersensitivity
INDICATIONS
• Discolored teeth due to either extrinsic or intrinsic stains.
CONTRA-INDICATIONS
• Patient selection - Patients with emotional or psychologic problem or those with unrealistic goals do not
make good candidates for bleaching. YOUNG PATIENTS – owing to their large pulp chamber
• Dentinal hypersensitivity – Cases of attrition, erosion, abrasion or abfraction.
• Generalized dental caries and leaking restoration
• Heavily restored teeth - composite restorations do not lighten and become more evident after bleaching.
• Teeth with opaque white spots
• Teeth slated for bonded restorations or orthodontic bracketing - Oxygen produced during bleaching
remains in the enamel or dentin ------ interferes with the bonding agent.
CHEMISTRY OF BLEACHING
Bleaching is a chemical process, which occurs mostly by the oxidation during which the
organic materials are eventually converted into carbon dioxide and water.
In the bleaching process, the oxidizing agent i.e. the bleaching agent has free radicals
with unpaired electrons which it gives up and becomes oxidized, whereas the reducing
agent i.e., the substance being bleached accepts the electrons and becomes reduced.
• Discolorations arise due to the formation of chemically stable,
chromogenic products. Pigments consist of long-chain organic
molecules.
• In bleaching, these compounds which are oxidized: they are split

into smaller molecules which are usually lighter as they reflect
less light.
Bleaching Materials:
Commonly used bleaching agents in dentistry are:
Hydrogen peroxide
Sodium perborate
Carbamide peroxide
Hydrogen Peroxide:
• It is a clear, colorless and odorless liquid.
• Higher concentrations thermodynamically unstable and may explode
unless refrigerated and kept in a dark container.
• Can be used for both intra and extra-coronal bleaching.
Adverse effects:
• Gingival irritation: As there is no barrier to restrict these gels.
• Sensitivity
• Because of its effect on skin and mucous membrane it
resembles a chemical burn.
SODIUM PERBORATE:
• It is a stable white powder. When fresh, it contains about 95%
perborate corresponding to 9.9% of available O 2
• Oxidizing agent
• Is stable when dry,but in the presence of acid,warm air,or water it
decomposes to form sodium metaborate,hydrogen peroxide and
nascent oxygen.
CARBAMIDE PEROXIDE
• Also known as carbamyl peroxide, perhydrol urea, carbamide urea,
urea H2O2 and H2O2 carbamide.
• 10% carbamide peroxide breaks down into urea, ammonia,

carbondioxide and 3.5% hydrogen peroxide.
• It is a clear, colorless odorless liquid. When used as a bleaching

agent it breakdowns to hydrogen peroxide.
BLEACHING TECHNIQUES
Non-vital bleaching:
These procedures are carried out for endodontically / pulpless treated teeth
Indications
• Discolouration of pulp chamber
• Dentin discolouration
• Not amenable to extracoronal bleaching
Contraindications
• Superficial enamel discolorations
• Defective enamel formation
• Severe dentin loss
• Presence of caries
• Discolored composites
• Extensive restorations
WALKING BLEACH:
•Mixture of sodium perborate and inert liquid such as water, saline

or anesthetic solution or even H2O2 can be used but preferably
lower concentrations are placed in the pulp chamber.
•Patient should be informed that bleaching agents work slowly and

significant lightening may not be evident for several days.
•Patient should be evaluated after 2 weeks and the procedure

should be repeated if necessary.
THERMOCATALYTIC TECHNIQUE
• This technique involves placement of the oxidizing agent

in the pulp chamber followed by heat application either
by electric heating devices or specially designed
photoflood lamps for 5min.
• Should not be repeated for more than 5-6 times. Care

should be taken that the temperature of the heating
device does not exceed 114F.
• Lamp unit should be 13 inches away from patient.

Photo-oxidation TECHNIQUE
• In this technique, 30% to 35% of H2O2 solution is

placed in the pulp chamber on a cotton pellet
followed by exposure to the curing light for 20-30
sec.
• For plasma arc or laser 3-5 seconds of exposure

time is sufficient.
• If the bleaching gels are used they have to be

expressed into the access cavity and onto the
labial surface of the tooth and should be exposed
to the curing light from both the sides.
Adverse effects:
• External cervical root resorption
• Chemical burns:-
35% H2O2 is caustic and may cause chemical burns
and sloughing of the gingiva.
• Coronal fracture:-
Increased brittleness of the coronal tooth structure,
particularly when heat is applied
Due to dessication of the dentin and enamel.
Post Bleaching Tooth Restoration:

• A composite restoration is placed 1 or 2 weeks after complete removal of the bleaching materials.
This time period is for the elimination of residual peroxides.
• In case of thermocatalytic or photooxiation bleaching, it has been advised to pack Ca(OH)2

paste in the pulp chamber for a few weeks to counteract acidity caused by bleaching agents and to
prevent root resorption.
Vital bleaching techniques
❑ In-office or Power
❑ Mouth guard or Night guard or At-home
❑ Over-the counter
IN OFFICE TECHNIQUE
Indications:
• Light enamel discoloration
• Mild tetracycline discoloration
• Endemic fluorosis discoloration
• Age related discoloration
Contraindications:
• Severe dark discolorations
• Severe enamel loss
• Proximity of pulp horns
• Hypersensitive teeth
• Large/ poor coronal restorations
darkest stains acid etch for 5 to 10 seconds and
Clean the surface with pumice and water. rinse for 60 seconds.
30 to 35% H2O2 solution on a Apply heat with a heating device Polish bleached surface 1.1% neutral
small cotton pellet or a gauze. or light source at a temperature sodium fluoride gel for 3 to
5 min.
between 125F and 140F (52C
to 60C). Recall the patient after 2 weeks and
evaluate the effectiveness
of bleaching
Light sources used are:

Tungsten-Halogen curing light, Argon laser: Carbon dioxide laser,
xenon plasma arc and diode laser
Adverse effects
1. Post operative pain
2. Pulpal damage
3. Dental hard tissue damage
4. Mucosal damage
Night guard vital bleaching
Indications:-
• Superficial enamel discolorations
• Mild yellow discolorations
• Brown fluorosis discolorations
• Age-related discolorations
Contraindications:-
• Severe enamel loss
• Hypersensitive teeth
• Defective coronal restorations
• Allergy to bleaching gels
• Bruxism
• Pregnant and lactating
• Smoking
• 10 to 15% carbamide peroxide, is the most commonly used as home bleaching agents.
• The patient can have thermal sensitivity and minor irritation of soft tissues
• Treatment may be carried out for 4 to 24 weeks.
• Recall the patient every 2 weeks to monitor stain lightening.
Over-the-counter Products
These systems include
• Tooth pastes – AP-24, Rembrandt

• Mouth rinses – Crest
• Tooth brushes – Spine brush pro whitening
• Dental floss – Super smile
• Teeth whitening strips – Crest
• Chewing gums – Brits smile, Happy dent
• Paint on varnish – Vivastyle
• Brite smile stick or pen
CONCLUSION
• Bleaching is a part of a broader treatment plan for the over all
improvement of a smile. Proper diagnosis, selection of bleaching
materials, placement techniques, and an understanding of the
biologic interaction with soft and hard tissues are all factors that
determine not only immediate success but also long-term success,
safety, and patient satisfaction as well.
.
Thank You

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BLEACHING OF

Dr.Toby Thomas, MDS

• Discoloration of anterior teeth is a cosmetic

• Although restorative procedures are available,

• Bleaching, is relatively simple to perform and

Chewing tobacco causes a black-brown stain on the

Amelogenesis imperfecta Fluorosis Alkaptonuria

Erythroblastosis foetalis Porphyria Tetracycline staining

Age Pulpal necrosis Dentin hypercalcification

Intra canal medicaments

• Discolored teeth due to either extrinsic or intrinsic stains.

• Dentinal hypersensitivity – Cases of attrition, erosion, abrasion or abfraction.

• Generalized dental caries and leaking restoration

• Teeth with opaque white spots

• In bleaching, these compounds which are oxidized: they are split

• 10% carbamide peroxide breaks down into urea, ammonia,

• It is a clear, colorless odorless liquid. When used as a bleaching

•Mixture of sodium perborate and inert liquid such as water, saline

•Patient should be informed that bleaching agents work slowly and

•Patient should be evaluated after 2 weeks and the procedure

• This technique involves placement of the oxidizing agent

• Should not be repeated for more than 5-6 times. Care

• Lamp unit should be 13 inches away from patient.

• In this technique, 30% to 35% of H2O2 solution is

• For plasma arc or laser 3-5 seconds of exposure

• If the bleaching gels are used they have to be

Post Bleaching Tooth Restoration:

• In case of thermocatalytic or photooxiation bleaching, it has been advised to pack Ca(OH)2

Light sources used are:

3. Dental hard tissue damage

These systems include

• Tooth pastes – AP-24, Rembrandt

improvement of a smile. Proper diagnosis, selection of bleaching

materials, placement techniques, and an understanding of the

determine not only immediate success but also long-term success,

safety, and patient satisfaction as well.

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