BLEACHING OF DISCOLORED TEETH

Contents
Introduction
History
Causes of Tooth Discolouration
Bleaching Materials
Mode of Supply
Chemistry of Bleaching
Bleaching Techniques
o Non-vital leaching
o !ital leaching
Conclusion
"eferences
BLEACHING OF DISCOLORED TEETH
INTRODUCTION:
Discoloration of anterior teeth is a cosmetic prolems that is often the
patient#s primary concern$ %lthough restorative procedures are availale&
discoloration can often e corrected totally or partially y a more conservative
approach i$e$ leaching& 'hich is relatively simple to perform and less e(pensive$
HISTORY:
% professional response to the unrelenting quest for 'hite teeth dates ac)
at least *+++ years$
,irst century "oman physicians maintained that rushing teeth 'ith urine&
particularly -ortuguese urine& 'hitened teeth$
In the ./++#s& after arading the enamel 'ith coarse metal files& aquafortis&
a nitric acid solution 'as applied to 'hiten the teeth$
0uy de Chauliac& in .1
th
century recommended a tooth 'hitening procedure
in 'hich teeth 'ere gently cleaned 'ith a mi(ture of honey and urnt salt to 'hich
some vinegar 'as added& 'hich 'as considered authoritative for nearly /++ years$
The introduction of clinical procedure of vital tooth leaching 'as done y
Chapple in .233& 'ho used o(alic acid as the leaching agent$
The first mention of pero(ide as a leaching agent 'as in .221 y Harlan&
'hich he called hydrogen dio(ide$
*
In .222& Taft and %t)inson suggested calcium hypochlorite to e an
effective tooth 'hitening solution$
In .4.5& 6ane proposed the use of .27 HCl to the ro'n fluoride stain$
%lthough not regarded as the leaching agent& it is capale of removing the stains
as it dissolves the surface of teeth$
In .4.2& %ot found that the leaching action of hydrogen pero(ide could
e greatly enhanced y the addition of heat and light$
In .4/3& %mes proposed the comination of 8 parts of .++7 H
*
9
*
'ith
.part of ether activated y heat as the treatment for the stains caused y fluoride$
In .4/4& :ounger proposed the use of /+7 H
*
9
*
& ether and heat for the
stains caused y fluoride
In .455& the use of HCl comined 'ith H
*
9
*
'as advocated y McInnes for
the stains caused y fluoride$
Non-vital leaching 'as introduced y 0arretson in .248 'ho applied
chloride to the tooth surface ut could not achieve very good results$
In .482& -earson reported the use of supero(ol sealed 'ithin the pulp
chamer$ He found that 'ithin / days& the o(ygen releasing capacity of the
solution had 'hitened the e(perimental teeth to some e(tent$
In .453& Nutting and -oe refined this method and termed as ;'al)ing
leach< 'here they pac)ed a mi(ture of /+7 H
*
9
*
and sodium perorate in the
pulp chamer for . 'ee)$
In .424& Hay'ood and Heymann introduced a technique for leaching vital
teeth 'hich they called Night guard vital leaching$ In this technique& the use of
/
Caramyl pero(ide 'as introduced 'hich 'as placed in a molded tray& 'hich the
patient places over his teeth for hours at a time$
In .44*& "emrandt introduced 'hitening tooth pastes and en=yme ased
dentifrices$
In .441& >ight activation of the leaching agents 'as introduced 'hich
further led to activation of leaching agents y argon laser& C9
*
laser and plasma
arc$
In .444& Diode laser 'as introduced as a vector in tooth 'hitening$
,rom .448 till date a variety of concentrations of leaching gels containing
remineralising agents& fluoride and pero(ide free chemicals have een availale$
Etiology of Tooth Discolo!"tion:
The etiology of tooth discolouration may e e(trinsic or intrinsic or oth$
E#t!insic st"ins Int!insic st"ins
.$ Diet related
*$ Bacterial strains
/$ Medications
1$ Haits
.$ -re-eruptive
a? %l)aptonuria
? %melogenesis imperfecta
c? ,luorosis
d? @rythrolastosis foetalis
e? -orphyria
f? Tetracycline staining
g? Aaundice
*$ -ost eruptive
a? %ge
? -ulpal necrosis
c? Intrapulpal haemorrhage
d? Dentin hypercalcification
e? Iatrogenic discoloration
1
- "emnants of pulpal tissues
- Intra canal medicaments
- 9turating materials
- "estorations
.$ %malgam
*$ -ins and posts
/$ composites
E#t!insic St"ins:
These are caused y the daily inta)e of sustances such as food and
everages or the use of toacco products$ These sustances tend to adhere to the
enamel#s hydro(yapetite structure and here y discolor the teeth or reduce the
'hiteness of teeth$ 9ver a period they may penetrate the enamel layer and
gradually give rise to intrinsic discolorations$
N"thoo$s Cl"ssific"tion:
.$ N. type dental stain or direct dental stainB Coloured material inds to the
tooth#s surface and causes discoloration$ The color of chromogen is similar to
that of dental stain$
*$ N* type dental stain or direct dental stainB Colored material changes color after
inding to the tooth$
/$ N/ type dental stain or indirect dental stainB Colourless material or a pre-
chromogen inds to the tooth and undergoes a chemical reaction to cause a
stain$
8
CAUSES OF E%TRINSIC STAINS:
&' Diet:
These stains affects multiple teeth and appears as yello' or ro'n stains of
varying intensities$ Consumption of strong tea or coffee immediately after orange
or grape Cuice is a common cause of e(ternal discoloration$
Blac) current Cuice or cola drin)s act y oth etching and staining the tooth
simultaneously$
(' B"cte!i"l St!"ins:
Chromophilic acteria frequently seen in the deciduous or mi(ed dentition
can cause a dotted or lac)-line stain$ It has een documented that this type of
acteria is associated 'ith lo'er-than normal caries rates and the removal may
result in recoloni=ation of the oral cavity y a more cariogenic flora$
)' *e+ic"tion:
Chlorhe(idine acts in reducing plaque formation y disturing the pellicle
matri( formation& 'hich attracts more e(trinsic strains not readily removed y
tooth rushing$
,' H"-its:
Smo)ing mariCuana may produce characteristic linear& green
circumferential rings at the cervical margins$ Smo)ing toacco causes a yello'-
ro'n discolouration especially on the lingual aspects of the teeth$ Che'ing
toacco causes a lac)-ro'n stain that is most noticeale on the uccal surfaces
of the mandiular posterior teeth$
5
Int!insic St"ins:
These are stains 'ithin the matri( of enamel and dentin caused y the
deposition or incorporation of sustances 'ithin these structures$ These stains may
e caused during the developmental stage i$e$& pre-eruptively or after the eruption
into the oral cavity$
&' .!e/e!0ti1e +iscolo!"tions:
a$ %l)aptonuriaB- %lso )no'n as phenyl)etonuria or ochronosis$ It is a recessive
genetic disorder resulting in dar) ro'n pigmentation of the permanent teeth$
$ %melogenesis imperfectaB- It affects oth primary and permanent dentition and
can e further sudivided into hypomaturtion& 'here the enamel is chipped off
from the underlying dentin$ HypocalcificationD 'here the thic)ness of enamel
is normal ut is soft in consistency and completely arades soon after eruption&
'hich results in a tooth 'ith cro'n that ranges in appearance from a dull
opaque 'hite to a dar) ro'n$ In addition& these teeth are usually rough and
pitted$ Hypoplastic& 'here the enamel is quiet thin& smooth& hard and yello' in
appearance& 'ith occasionally pitting$
c$ Dentinogenesis imperfectaB- Esually affects the primary teeth more seriously
than the permanent dentition$ The clinical cro'ns appear reddish-ro'n to
gray opalescent$ 9ften the enamel is friale and rea)s off soon after eruption$
The e(posed softened dentin then rapidly arades a'ay$
d$ ,luorosisB- Blac) and Mc6ay first reported this condition in .4.5$ The
optimum concentration of fluoride in the drin)ing 'ater for the dental
development is .ppm$ Fhen the inta)e approaches *ppm& noticeale 'hite
spots occur in the enamel& 'hen it approaches /ppm& patchy ro'n
3
discolouration of the enamel occurs$ Higher concentrations than this can result
in pitting and anomalies in the enamel formation$ The high concentration of
fluoride is elieved to cause a metaolic alteration in the amelolasts 'hich
results in a defective matri( and improper calcification$ The teeth can e
affected y fluorosis from the second trimester in utero through age 4$
e$ @rythrolastosis fetalisB- This is a lood disorder of the neonate 'hich might
discolor the teeth from ro'n to greenish-lue$ This condition is usually self-
treating and the staining resolves as the child matures$
f$ -orphyriaB- In this condition& the haematoporphyrin pigment creates a
characteristic reddish-ro'n discolouration of the teeth )no'n as
@rythrodontia$ More commonly seen in the primary dentition than the
permanent dentition$ The colouration is dispersed throughout the enamel&
dentin and cemetnum and fluoresces red under ultraviolet light$
g$ Tetracycline stainingB
The tooth discolouration caused y incorporation of systemic tetracycline
'as first reported in .485 y Sch'ashman and Schuster$ Since& it crosses the
placental arrier can affect oth the primary and permanent dentition$
Though the e(act mechanism of staining is not fully understood& it is
elieved that the tetracycline molecule inds to the calcium of the tooth forming
tetracycline orthophosphate$
The clinical appearance of tetracycline-stained teeth ranges from light
yello' to dar) grey ands$ Esually the dar)er shades are confined to the gingival
.G/
rd
of the teeth and the lighter shades 'ill often e located e(clusively in the
incisal .G/
rd
$
2
Fhen the tetracycline stained teeth are e(posed to sunlight& they gradually
turn to shades of dar) grey or ro'n$ Cohen and -ar)in#s suggest this as the
reason 'hy laial surfaces of the incisors dar)en 'hile the molars remain yello'
for a longer period of time$ Studies have sho'n that further e(posure of such teeth
to various light sources such as sunlight& incandescent or ultraviolet lights
produces a susequent lightening of the tetracycline stain$ It has een postulated
that tetracycline incorporated into hydro(yapetite& 'hen o(idi=ed y light
produces the red quinone product 1& .* anhydro-1-o(o-1-dedimethylamino
tetracycline H%9DTC?$ Continued photoo(idation of %9DTC photolyses or
leaches the red quinone$ %ddition of diluted H
*
9
*
yields an irreversile leaching
of the red quinone$
The severity of tooth discolouration depends on four factors associated 'ith
tetracycline administration$
.$ %ge at the time of administrationB %nterior primary teeth are susceptile to
discolouration y systemic tetracycline from 1 months in utero through 4
months post partum$ %nterior permanent teeth are susceptile from /
months post partum to 2 years$
*$ Duration of administrationB Severity is directly proportional to the length of
time the medication 'as administered$
/$ DosageB Severity is directly proportional to the administered dosage$
1$ Type of TetracyclineB
a$ Chlortetracycline H%ureomycin?B 0ray-ro'n
$ Dimethylchlortetracycline H>edermycin?B :ello' stain
4
c$ Do(ycycline H!iramycin?B Does not cause stain
d$ 9(ytetracycline HTerramycin?B :ello' stain
e$ Tetracycline H%chromycin?B :ello' stain
Aordan and Bo)sman has classified the tetracycline staining as follo'sB-
a? -rimary stainingB >ight yello' or light grey& slight ut uniformly
distriuted 'ithout anding$
? Secondary stainingB Dar)er or more e(tensive yello' or grey staining
'ithout anding$
c? Tertiary stainingB Severe staining characteri=ed y dar) grey or lue
discoloration& usually 'ith anding$
*inocycline St"ining:
It is found that Minocycline& a semisynthetic derivative of tetracycline
stains the teeth of adolescents 'ho 'ere eing given the drugs for severe acne$
Minocycline& although comines poorly 'ith calcium& has the aility to chelate
'ith iron and form insolule comple(es$
Some minocycline stains may e responsive to leaching 'hile others 'ith
severe anding may require veneers$
-2 3"n+ice:
Bluish green or ro'n staining of primary teeth is seen in children 'ho
suffered severe Caundice during infancy$ These stains are the result of postnatal
staining of the dentin y iliruin or iliverdin$
.+
(' .ost/e!0ti1e +iscolo!"tions:
"2 Age:
In older patients& colour changes in the cro'n occur physiologically as a
result of e(tensive secondary dentin formation& thinning and optical changes of the
enamel$ ,ood and everages also have a cumulative discolouring effect ecause of
the inevitale crac)& cra=ing and incisal 'ear of the enamel and underlying dentin$
In addition& amalgam and other coronal restorations that degrade over time cause
further discoloration$ Bleaching 'ould e more effective in older patients 'ith
smaller pulps and generally tend to e less sensitive$
-2 .l0"l Nec!osis:
Bacterial& mechanical or chemical irritation to the pulp may result in tissue
necrosis and release of disintegration y products that may penetrate tuules and
discolour the surrounding dentin$ The degree of discolouration is directly related
to ho' long the pulp has een necrotic$ The longer the discolouration products are
present in the pulp chamer& the greater the discolouration$
c2 Int!"0l0"l h"e4o!!h"ge:
It is the most common result of traumatic inCury to a tooth& 'hich results in
disrupted coronal lood vessels& haemorrhage and lysis of erythrocytes$ Blood
disintegration products& presumaly as iron sulfides permeate dentinal tuules to
stain the surrounding dentin& 'hich tends to increase 'ith time$
If the pulp ecomes necrotic& the discoloration usually remains$ If the pulp
survives& the discolouration may resolve and the tooth reverts to its original shade$
..
Sometimes& mainly in young individuals the tooth remains discoloured even if the
pulp responds to vitality$
+2 Dentin hy0e!c"lcifi"tion:
It is the e(tensive formation of tertiary or irregular secondary dentin in the
pulp chamer or on canal 'alls& 'hich may occur follo'ing certain traumatic
inCuries 'hich did not result in pulpal necrosis$ In such cases& temporary disruption
of lood supply occurs follo'ed y partial destruction of odontolasts$ These are
replaced y undifferentiated mesenchymal cells that rapidly form irregular dentin
on the 'alls of the pulp lumen$ %s a result& the translucency of the cro'ns of such
teeth gradually decreases& giving rise to a yello'ish or yello'-ro'n
discoloration$
e2 I"t!ogenic Discolo!"tions:
.$ "emnants of pulpal tissuesB-
-ulp fragments remaining in the cro'n& usually in the pulp horns& may
cause gradual discoloration$ Therefore& the pulp horns must e opened up and
e(posed during access to ensure removal of pulpal remnants and to prevent
retention of sealer at a later stage$
*$ Intracanal medicamentsB-
Several intracanal medicaments are liale to cause internal staining of the
dentin$ -henolics or iodoform ased medicaments sealed in the root canal and
chamer are in direct contact 'ith dentin sometimes for longer periods& allo'ing
penetration and o(idi=ation$ These compounds have a tendency to discolour the
dentin gradually$
.*
/$ 9turating materialsB
It is a frequent and severe cause of single tooth discolouration$ Incomplete
removal of oturating materials and sealer remnants in the pulp chamer& mainly
those containing metallic components& often results in dar) discoloration$
1$ "estorationsB
a? %malgamB-
Silver alloys have severe effects on dentin ecause of the dar) coloured
metallic components that can turn the dentin dar) grey$ Fhen used to restore
lingual access preparations or a developmental groove in anterior teeth as 'ell as
in premolars& amalgam may discolour the cro'n& such discolorations are difficult
to leach and tend to rediscolour 'ith time$ "eplacing the amalgam restoration
'ith an esthetic restoration usually corrects the prolem$
? -ins and -ostsB
Metal pins and prefaricated posts are sometimes used to reinforce a
composite restoration in the anterior teeth$ Discolorations from inappropriately
placed pins and posts is caused y a metal seen through the composite or tooth
structure$ in such cases& coverage of the pins 'ith a 'hite cement or removal of
the metal and replacement of the composite restoration is indicated$
c? CompositesB
Microlea)age around composite restoration causes staining$ 9pen margins
may allo' chemicals to enter et'een the restoration and the tooth structure and
discolour the underling dentin$ In addition& composites may ecome discoloured
./
'ith time& affecting the shade of the cro'n& 'hich needs to e replaced 'ith a ne'
'ell sealed restoration$
Ble"ching *"te!i"ls:
The most commonly used leaching agents in dentistry are hydrogen
pero(ide& sodium perorate and caramide pero(ide$
Hy+!ogen .e!o#i+e:
It is a clear& colourless and odourless liquid$ Higher concentrations of these
solutions must e handled 'ith care as they are thermodynamically unstale and
may e(plode unless refrigerated and )ept in a dar) container$ Because of its
ischemic effect on s)in and mucous memrane it resemles a chemical urn$ It is
especially painful if it comes in contact 'ith the nail ed or the soft tissue under
the finger nail$ It can e used for oth intra and e(tra-coronal leaching$
So+i4 0e!-o!"te:
It is a stale 'hite po'der$ Fhen fresh& it contains aout 487 perorate
corresponding to 4$47 of the availale o(ygen$ It is stale 'hen dry and
decomposes in the presence of acid& 'arm air or 'ater$
/ types of sodium perorate preparations are availale& Monohydrate&
trihydrate and tetrahydrate$ They differ in o(ygen content& 'hich determines their
efficacy$ Commonly used preparations are al)aline& their pH depends on the
amount of hydrogen pero(ide released and the residual metaorate$ It is used for
intracoronal leaching& more easily controlled and safer than concentrated
hydrogen pero(ide solutions$
.1
C"!-"4"+e 0e!o#i+e:/
%lso )no'n as urea pero(ide& caramyl pero(ide& perhydrol urea&
perhydelure& caramide urea& urea H
*
9
*
and H
*
9
*
caramide$ It is a clear&
colourless odourless liquid$ Fhen used as a leaching agent it rea)do'ns to
hydrogen pero(ide$
-reviously used only for e(tracoroanl leaching$
>ee et al H*++1?& found that caramide pero(ide had very lo' levels of
e(traradicular diffusion of pero(ide in the presence of cemental defects$ Therefore&
it could e an alternative to the other intracoronal leaching agents$ /87
caramide and /87 H
*
9
*
'ere more effective than Na perorate after 3 days$
En5y4es:/
There are certain en=ymes 'hich are found to have a considerale
leaching efficiency on oth e(trinsic and intrinsic stains$ These en=ymes are
otained either from plants or microorganisms$ These en=ymes are effective either
'ithout pero(ides or 'ith very little 7 of pero(ides H+ to .7?$
.$ >accases I act on the molecular o(ygen and yield hydrogen pero(ide
'ithout any need for hydrogen pero(ide$ They are otained from fungi @$g$
Mycelipthora thermophila$ These en=ymes are found to e effective against
intrinsic stains$
*$ 9(idases I act on the molecular o(ygen and yield hydrogen pero(ide$ @$g$
>-amino acid o(idase I Trichoderma har=ianum& glucose-o(idase I
%spergillus species& Jylitol o(idase I Streptomyces species$ They are
found to e effective against e(trinsic stains$
.8
/$ -ero(idaseB- %ct on hydrogen pero(ide and yield 'ater$ These en=ymes
require very little 7 of hydrogen pero(ide for their action$ They are
otained from plants e$g$ Horse radish pero(idase or from microorganisms$
@$g$ Halopero(idase from Curvularia species$ They are found to e
effective against oth e(trinsic and intrinsic stains along 'ith >accases$
*o+e of S00ly:
Hy+!ogen 0e!o#i+e:/
SolutionB !arious concentrations of hydrogen pero(ides are availale& ut /+7 to
/87 staili=ed solutions are the most commonly used$ They can e used either
alone or mi(ed 'ith sodium perorate$
0elB %lso availale in the form of Silicon dio(ide gels containing various
concentrations of hydrogen pero(ide H5 to /27?$ "ecently introduced is the
9palescence (tra oost 'hich contains /27 hydrogen pero(ide for quic)er results
and 'hich does not even require light activation HSyringes?$
These gels are also availale in preloaded disposale 'hitening tray 'here
the concentration of hydrogen pero(ide is aout 47$ It is availale as Tres 'hite
from ultradent 'hich consists of a delivery tray Houter tray 'ith handle? and a
disposale adaptive tray Hinner tray 'ithout handle?$ The inner tray consists of a
gingival arrier gel on the order of the tray and 47 H
*
9
*
gel inside the tray$ Both
the trays are centered on the arch and lightly pressed into place& the outer tray is
then removed and the inner tray is adCusted$ It is advised to 'ear /+ to 5+ minG3-
.+ days$
.5
Teeth 6hitening st!i0s:/ These are fle(ile pieces of plastic or polyethylene that
have een coated on one side 'ith a thin film of hydrogen pero(ide gel$ The idea
of the teeth 'hitening strips 'as to reduce the thic)ness of the pero(ide gel$
The thic)ness of the leaching gels on the 'hitening strips is aout +$*mm
'hile that of a paper is +$.mm$ It is K to
.
G
8
th
quantity compared to the tray
leaching$
The concentration of the hydrogen pero(ide gels on the 'hitening strips
varies from 57 to .+7$ The teeth 'hitening strip )it consists of half the strips
designed to adapt the upper arch and half the lo'er arch$ It is advised to use these
strips for /+ min t'ice a day$ 57 gel strips for .1 days and .+7 gel strips for 3
days$
DisadvantageB- The length of the strips is small so that they adapt only to the
anterior teeth$
%dverse effectsB
.$ 0ingival irritationB %s there is no arrier to restrict these gels$
*$ Sensitivity
So+i4 .e!-o!"te:
It is supplied in a granular form& that has to e ground into a po'der efore
using$ It is either mi(ed 'ith 'ater or hydrogen pero(ide to form a thic) paste and
is pac)ed into the pulp chamer$
C"!-"4i+e 0e!o#i+e:
The most common mode of supply is in the form of gels& 'hich are
supplied in syringes$ It is availale in various concentrations ranging from / to
.3
187$ Ho'ever& popular commercial preparation contain aout .+7 caramide
pero(ide 'ith a mean pH of 8 to 5$8$
>eonard et al$ studied the use of different concentrations of caramide
pero(ide for leaching teeth and found that lo'er concentrations of caramide
pero(ide ta)e longer time to 'hiten teeth ut eventually achieve the same result as
higher concentrations& 'hich may cause increased sensitivity$
Bleaching preparations containing caramide pero(ide usually include
glycerine or propylene glycol& sodium stannate& phosphoric or citric acid and
flavour additives$ Some preparations contain carapol& a 'ater solule polyacrylic
acid polymer as a thic)ening agent 'hich prolongs the release of active pero(ide
and improves shelf-life$
En5y4es:/
These en=ymes either alone or in comination 'ith pero(ides are added to
the mouth 'ashes or tooth pastes$ Their concentration ranges from + to *+7 'ith
+ to .7 of pero(ides if used$
Che4ist!y of -le"ching:
Bleaching is a chemical process& 'hich occurs mostly y the o(idation
during 'hich the organic materials are eventually converted into carondio(ide
and 'ater$ The most commonly used leaching agent is hydrogen pero(ide 'hich
requires the least time for the desirale action$
In the leaching process& the o(idi=ing agent i$e$ the leaching agent has
free radicals 'ith unpaired electrons 'hich it gives up and ecomes o(idi=ed&
.2
'hereas the reducing agent i$e$& the sustance eing leached accepts the electrons
and ecomes reduced$
Hy+!ogen 0e!o#i+e -le"ching:
H
*
9
*
has the aility to produce free radicals i$e$& H
*
9 Hperhydro(yl-stronger
free radical? and 9 Hnasant o(ygen-'ea)er free radical?$ In pure aqueous form&
hydrogen pero(ide is acid& has reduced rea)do'n and e(tended shelf life$
Ioni=ationB-
H
*
9
*
H
*
9 L 9 HHigher percentage of the 'ea)er free radical?
H L H9
*
H>o'er percentage of stronger free radical?
The perhydro(yl is the more potent free radical in the leaching process$ In
order to promote the formation of perhydro(yl& the hydrogen pero(ide needs to e
made al)aline$
9ptimum pH I 4$8 to .$2 at 'hich ioni=ation$
H
*
9
*
H
*
9 L 9 H>o'er percentage of 'ea)er free radical?
H L H9
*
HHigher percentage of stronger free radical?
This reaction results in greater leaching efficacy in the same time as at
other pH levels$ Thus& H
*
9
*
is most effective et'een pH of 4$8 I .+$2$ In the
presence of decomposition catalysts and en=ymes the H
*
9
*
ionises as follo's$
*H
*
9
*
*H
*
9 L 9
*
Fhere no free radicals are produced and the leaching is ineffective$ Some
of these en=ymes may e present in the mouth$ Therefore& it is important to ma)e
the teeth free of deris and dry 'hen applying the leaching agent$
.4
Ble"ching "ction on tooth s!f"ce:
Fhen applied on the tooth& hydrogen pero(ide diffuses through the organic
matri( of the enamel and dentin$ The radicals released from H
*
9
*
have unpaired
electron 'hich ma)e them e(tremely electrophilic and unstale and thus 'ill
attac) the organic molecules to achieve staility& generating other radicals$ Such
reactions lead to the formation of simpler molecules that reflect less light$
During initial leaching process highly pigmented caron-ring compounds
are opened and converted into chains 'hich are lighter in colour$ @(isting caron
doule-ond compounds& usually pigmented yello' are converted into hydro(yl
groups 'hich are usually colourless$ %s these processes continue the leached
material continually lightens$ % point is reached at 'hich only hydrophilic
colourless structure e(ist$ This is the material#s saturation point$ >ightening then
slo's do'n& if the leaching process is still continued& it egins to rea) do'n the
caron ac) ones of proteins and other caron-containing materials$ Compounds
'ith hydro(yl groups are split& rea)ing the material into yet smaller constituents$
>oss of enamel ecomes rapid& 'ith the remaining material eing quic)ly
converted into C9
*
or H
*
9$
So+i4 0e!-o!"te:/
Sodium perorate 'hen mi(ed 'ith 'ater decomposes to form sodium
metaorate and hydrogen pero(ide releasing 9
*
$ Fhen mi(ed 'ith supero(ol it
decomposes to form sodium metaorate and 'ater releasing 9
*
$ The o(idation is
slo' and is active over a long period of time$
*+
C"!-"4i+e 0e!o#i+e che4ist!y:
Caramide pero(ide used as leaching agent rea)s do'n into H
*
9
*
$ .+7
caramide pero(ide produces /$57 H
*
9
*
$
CH
*
N
*
9 H
*
9
*
NH
/
H
*
9
*
C9
*
Then& the ioni=ation of H
*
9
*
is the same$
Caramide pero(ide products contain either a caropol or glycerine ase$
The caropol ase slo's the release of H
*
9
*
& ut this does not change the
efficiency of the leaching treatment$ It is slightly acidic to e(tend the shelf-life$
BLEACHING TECHNI7UES:
Before carrying out the leaching process& it is important to assess the type
of stain$ Certain e(trinsic stains can e removed y regular intense mechanical
rushing 'ith cleaning agents containing arasives or surfactants$ Ho'ever& the
intrinsic stains cannot generally e removed y such processes$
Basically leaching techniques areB-
.$ Non-vital
a$ Fal)ing leach
$ Thermocatalytic
c$ E! light photoo(idation
*$ !ital
a$ In-office
$ Night guard
c$ 9ver the counter
*.
&' Non/1it"l -le"ching:
These procedures are carried out for endodontically treated teeth$
IndicationsB-
a? Discolouration of pulp chamer
? Dentin discolouration
c? Discolourations not amenale to e(tracoronal leaching
ContraindicationsB-
a? Superficial enamel discolourations
? Defective enamel formation
c? Severe dentin loss
d? -resence of caries
e? Discoloured composites
f? @(tensive restorations
In any of the non-vital leaching techniques& there are certain steps 'hich are
common$
.$ "adiographic assessment of the status of the periapical tissues and the
quality of endodontic oturation$ If the oturation is inadequate& the tooth
should e retreated prior to leaching$
*$ If there are any lea)ing or discoloured restorations& they have to e
replaced$
/$ @valuate the tooth colour 'ith a shade ta y ta)ing photographs at every
appointment$
**
1$ 9raase or vaseline should e applied to the gingival tissues& follo'ed y
isolation 'ith ruer dam 'hich should fit tightly at the cervical margin of
the tooth to prevent possile lea)age of the leaching agent onto the
gingival tissues$ 9pal dam can also e used$
8$ "emove all restorative material from the access cavity& e(pose the dentin
and refine the access$ !erify that the pulp horns and other areas containing
pulp tissue are clean$
5$ "emove the oturation material to Cust elo' laial gingival margin$
9range solvent& chloroform or (ylene on a cotton pellet may e used to
dissolve sealer remnants$
3$ Ne(t is the application of the arrier material$ This is one of the most
important step as the improper location& material and the shape of the
arrier material could lead to e(ternal cervical resorption$
.l"ce4ent of -"!!ie!:
Many studies have suggested using the laial cementoenamel Cunction as a
guide for arrier placement$ Ho'ever& cementoenamel Cunction is not level& ut
rather curves in an incisal direction on the pro(imal sides of the tooth$ Therefore&
placement of a flat arrier leaves the pro(imal dentinal tuules unprotectedD this is
the site 'here cervical resorption egins$ Therefore& care should e ta)en to
protect the pro(imal dentinal tuules y the location and shape of the arrier$ To
determine the location of the arrier& three periodontal proings are made 'ith a
custom ;transfer periodontal proe<$ This is a periodontal proe carefully curved
to match the laial contour of the tooth$ ,irst& a laial recording is made& follo'ed
y mesial and distal$ These proings are made to determine the position of the
*/
epithelial attachment from the incisal edge of the tooth$ The internal level of the
arrier 'ill e placed .mm incisal to the corresponding e(ternal tuules that lead
from the pulp chamer apical to the epithelial attachment so that the internal
leaching agents are confined to the access cavity$ By sutracting .mm from each
of the three proings a template is created for the location and shape of the arrier$
-ositioning the palatal portion of the arrier equal or coronal to the arrier#s
pro(imal height protects the palatal cementoenamel Cunction 'ithout
compromising the esthetic results$ The resultant shape of the arrier from the
facial vie' is a 8-o-sle+ tnnel9 and from the pro(imal vie' resemles a 8s:i
slo0e9$
In cases 'ith gingival recession& the root 'ould not e completely leached
using the cemetnoenamel Cunction guideline as a reference$ Instead& a more
iologically critical and esthetically essential landmar) is to relate the arrier to
the epithelial attachment$
Numer of material such as I"M& Minc phosphate& =inc polycaro(ylate&
0IC and cavit have een used as the intracoronal isolating arrier material 'here
light cured 0IC and cavit have sho'n more promising results compared to the
others$
;"l:ing Ble"ch:
.$ In this technique& a mi(ture of sodium perorate and inert liquid such as 'ater&
saline or anaesthetic solution or even H
*
9
*
can e used ut preferaly lo'er
concentrations are placed in the pulp chamer$ Studies have sho'n more
*1
numer of e(ternal cervical resorption cases 'ith the comination of sodium
perorate and /+7 hydrogen pero(ide$
Studies 'ith different types of sodium perorae& 'ater and H
*
9
*
have sho'n
that the comination of sodium tetraorate 'ith 'ater 'as quiet effective$
Timpavat et al$ found the ond strength to e etter 'ith Naperorate L
H
*
9$ @(cess liquid from sodium perorate should e removed y tamping 'ith
a cotton pellet$
*$ @(cess leaching paste from the undercuts in the pulp horns should e
removed and the access cavity should e sealed 'ith a temporary filling
H-referaly I"M? 'hich should e at least /mm$
/$ "uer dam should e removed and the patient should e informed that
leaching agents 'or) slo'ly and significant lightening may not e evident for
several days$
1$ -atient should e evaluated after * 'ee)s and the procedure should e repeated
if necessary$
The!4oc"t"lytic:
This technique involves placement of the o(idi=ing agent& generally /+7 to
/87 H
*
9
*
in the pulp chamer follo'ed y heat application either y electric
heating devices or specially designed photoflood lamps for 8min$ this process
should e continued until the desirale results are achieved$ Should not e
repeated for more than 8-5 times$ Care should e ta)en that the temperature of the
heating device does not e(ceed ..1,$ >amp unit should e ./ inches a'ay from
*8
patient$ Metal clamps should not e used$ "ecall the patient in a 'ee) to assess the
colour after rehydration$ "epeat the procedure& if necessary$
-otential damage y this method is the e(ternal cervical root resorption
caused y irritation to the cementum and periodontal ligament$ Therefore&
application of highly concentrated H
*
9
*
and heat during intracoronal leaching is
questionale$
.hoto/o#i+"tion:
In this technique& /+7 to /87 of H
*
9
*
solution is placed in the pulp
chamer on a cotton pellet follo'ed y e(posure to the curing light for *+-/+ sec$
,or plasma arc or laser /-8 seconds of e(posure time is sufficient$ If the leaching
gels are used they have to e e(pressed into the access cavity and onto the laial
surface of the tooth and should e e(posed to the curing light from oth the sides$
A+1e!se effects:
.$ @(ternal cervical root resorptionB- It is one of the most commonly noticed
complication 'ith intracoronal leaching using hydrogen pero(ide$ It is
asymptomatic and is generally noticed during routine e(amination$ The e(act
cause of this response is not fully understood& although a numer of
mechanisms have een postulated$
a? In .+7 of all teeth& the cemento-enamel Cunction is defective or asent&
resulting in a portion of the tooth eing devoid of cementum coverage$ /87
H
*
9
*
may denature the dentin& involving a foreign ody response y
elements in the appro(imating gingival tissue causing cervical resorption$
*5
? Internally applied /87 H
*
9
*
may directly contact periodontal memrane
may passing through patent dentinal tuules or lateral canals or accessory
foramina$
c? Bleaching agents may infiltrate et'een the gutta-percha and root canal
'alls$ They could then communicate 'ith the periodontal ligament through
dentinal tuules& lateral canals or ape( 'hich can cause resorption
any'here along the length of the canal$
d? Heat application 'hile using high concentrations of H
*
9
*
may enhance
e(ternal cervical root resorption$
e? /87 H
*
9
*
mi(ed 'ith sodium perorate can lo'er the pH in the
periodontal memrane& 'hich may increase the li)elihood of cervical
resorption$
f? -revious traumatic inCury may act as a predisposing factor$
*$ Chemical urnsB- /87 H
*
9
*
is caustic and may cause chemical urns and
sloughing of the gingiva$ Therefore& 'hen using such solutions the soft tissues
should al'ays e protected 'ith !aseline or oraase and ruer dam or 'ith
opal dam$
/$ Coronal fractureB- Increased rittleness of the coronal tooth structure&
particularly 'hen hat is applied& is also thought to result from leaching$ This
may e due to dessication of the dentin and enamel$ This 'as noticed clinically
ut has not yet proven conclusively$
Sggestions fo! s"fe! -le"ching:
*3
.? !erification of adequate endodontic oturatiion I This provides an
additional arrier against damage y o(idi=ers to the periodontal ligament
and periapical tissues$
*? -rotect the oral mucosa y !aseline or oraase$
/? @ffective isolation y opaldam or ruer dam$ Ese of interpro(imal 'edges
and ligatures may provide a etter seal$
1? Ese of protective arriers I In most of the clinical reports of the post
leaching cervical root resorption protective arrier 'as not used$ The
arrier of adequate thic)ness should protect the dentinal tuules and
confirm to the e(ternal epithelial attachment$
8? %cid etching should e avoided as it does not enhance the leaching
process& ut causes undesirale periodontal ligament irritation$
5? %void strong o(idi=ers$
3? %void heat$
2? "ecall the patient periodically and e(amine clinically and radiographically$
.ost -le"ching tooth !esto!"tion:
-ermanent restoration of the tooth is essential for long-term successful
leaching$ Coronal microlea)age especially that of lingual access restoration and a
lea)ing restoration may lead to rediscolouration$ Therefore& a composite
restoration is advised as early as possile$ This should e planned . or * 'ee)s
after complete removal of the leaching materials$ This time period is for the
elimination of residual pero(ides$
*2
The use of catalase for / min has een proposed for the removal of residual
pero(ides 'here adequate onding can e acquired$
In case of thermocatalytic or photoo(iation leaching& it has een advised
to pac) CaH9H?
*
paste in the pulp chamer for a fe' 'ee)s prior to placement of
final restoration to counteract acidity caused y leaching agents and to prevent
root resorption$
<it"l -le"ching techni=es:
There are various techniques for leaching vital teeth depending on the
degree of staining$
.$ In-office or -o'er
*$ Mouth guard or Night guard or %t-home
/$ 9ver-the counter
&' In/office:
IndicationsB-
.$ >ight enamel discoloration
*$ Mild tetracycline discoloration
/$ @ndemic fluorosis discoloration
1$ %ge related discoloration
ContraindicationsB
.$ Severe dar) discolorations
*$ Severe enamel loss
/$ -ro(imity of pulp horns
*4
1$ Hypersensitive teeth
8$ -resence of caries
5$ >argeG poor coronal restorations
TechniquesB-
.$ ,amiliari=e the patient aout causes of discoloration& procedure to e
follo'ed and the treatment outcome$
*$ Ma)e radiographs to detect the presence of caries& defective restorations
and pro(imity to pulp horns$
/$ @valuate tooth colour 'ith shade tas y ta)ing photographs at all the
appointments$
1$ %pply !aseline or oraseal and then isolate 'ith ruer dam y using 'a(ed
dental floss or 'edgets for additional sealing$ %void using metal clamps& as
they are suCected to heat$
8$ Do not inCect a local anesthetic$
5$ -osition protective sunglasses over the patient#s and operator#s eyes$
3$ Clean the enamel surface 'ith pumice and 'ater$
2$ ,or the dar)est or most severely stained areas acid etch 'ith /87
phosphoric acid for 8 to .+ seconds and rinse 'ith 'ater for 5+ seconds$
4$ -lace a small amount of /+ to /87 H
*
9
*
solution into a dappen dish$ %pply
the H
*
9
*
liquid on the laial surface of the teeth using a small cotton pellet
or a piece of gau=e$ Bleaching gel can also e used instead of solution
'hich can e etter controlled$
/+
.+$ %pply heat 'ith a heating device or light source$ The temperature should e
controlled that the patient does not feel any discomfort& usually et'een
.*8, and .1+, H8*C to 5+C?$ "e'et the enamel surface 'ith H*9* as
necessary$ If the tooth ecomes too sensitive& discontinue the leaching
procedure immediately$ Do not e(ceed /+ min even if satisfactory results
are not otained$
Heating can e carried out y thermostatically controlled electric heating
device or a stainless steel instrument such as Foodson No$* heated over flame$
There are different light sources availale for photo-o(idation conventional
leaching light$ This supplies energy to enhance the leaching action of H
*
9
*
y
adding heat$ The heat causes more vigorous release of o(ygen and facilitates the
dissolution of pigments$ It is slo' and often uncomfortale for the patient$
Tngsten/H"logen c!ing light:
These curing light provides heat and stimulates the initiation of the
chemical reaction y activating the light sensitive chemicals in the leaching
agent$ This is a time consuming process Hi$e$& 1+ to 5+ sec per application per
tooth?$
A!gon l"se!:
It emits a visile lue light$ The action it is to stimulate the catalyst in the
chemical$ There is no thermal effect 'ith this$ It is easy to use and is est for
removal of initial dar) stains& such as those caused y tetracycline$ Ho'ever& it
ecomes less effective as the teeth 'hitens and 'hen there are fe'er stain
molecules$
/.
C"!-on +io#i+e l"se!:
It emits invisile infra red light$ They interacts directly 'ith the catalyst-
pero(ide comination$ It removes the stains regardless of the tooth colour$ It emits
heat and can enhance the leaching effect initiated y the argon laser$
%enon 0l"s4" "!c light:/
It is a non-laser& high intensity light 'hich produces a great deal of heatD
therefore& it can e applied only for a rief / sec period$ The action is thermal and
stimulates the catalyst in the chemical$ %lthough it is very fast& there is a greater
potential for thermal trauma to the pulp and surrounding soft tissues than 'ith
other light sources$
Dio+e l"se! light:/
It is a true laser light produced from solid-state source$ It is ultra fast ta)ing
/ to 8 sec to activate the leaching agent$ This does not produce heat$
..$ "emove the heat source and allo' the teeth to cool do'n for at least 8 min$
Then 'ash 'ith 'arm 'ater for . minute and then remove the ruer dam$ Do
not rinse 'ith cold 'ater since the sudden change in temperature may damage
the pulp or can e painful to the patient$
.*$ Dry the teeth and gently polish them 'ith a composite resin polishing cup$
./$ Treat all the etched and leached surfaces 'ith .$.7 neutral sodium fluoride
gel for / to 8 min$
.1$ Inform the patient that cold sensitivity is common& especially during the first
*1 hrs and advise to use a fluoride rinse daily for * 'ee)s$
/*
.8$ "ecall the patient after * 'ee)s and evaluate the effectiveness of leaching y
sing the same shade ta used pre-operative assessment$ "epeat the procedure if
necessary$
//
A+1e!se effects:/
.$ -ost operative painB
% common immediate postoperative prolem is pulpalgia characteri=ed y
intermittent shooting pain$ It may occur during and after the leaching session and
usually persists for et'een *1 and 12 hrs$ The intensity of pulpalgia is related to
the duration and temperature of the leaching procedure$ Therefore& shorter
leaching periods are recommended$ If long term sensitivity to cold develops&
topical fluoride treatments and desensiti=ing tooth pastes should e used to
alleviate these systems$
*$ -ulpal damageB-
@(tra coronal leaching 'ith hydrogen pero(ide and heat has een
associated 'ith some pulpal damage$ %lthough no significant irreversile effects
on the pulp have een found& these procedure should e carried out 'ith caution
and not in the presence of caries& areas of e(posed dentin or in close pro(imity to
pulp horns$ Defective restorations must e replaced prior to leaching$
/$ Dental hard tissue damageB
Hydrogen pero(ide causes morphologic and structural changes in enamel&
dentin and cementum and reduces the micro-hardness of these structures$ These
changes may cause dental hard tissues to e more susceptile to degradation and
to secondary caries formation$ Therefore& teeth should e 'ell polished after the
leaching procedure$
/1
1$ Mucosal damageB
Elceration and sloughing of the mucosa may e caused 'hen the highly
concentrated pero(ide sustances come in contact 'ith the mucosa$ 0enerally& the
mucosa appears 'hite ut does not ecome necrotic or leave scar tissue$ The
associated urning sensation is e(tremely uncomfortale for the patient and can e
treated y e(tensive 'ater rinses until the 'hiteness is reduced$ In more severe
cases& a topical anesthetic& limited movements and good oral hygiene aid healing$
%pplication of protective cream or catalase can prevent mot of these
complications$ !itamin @ oil can also e applied immediately after contact$
Night g"!+ 1it"l -le"ching:
IndicationsB-
.$ Superficial enamel discolorations
*$ Mild yello' discolorations
/$ Bro'n fluorosis discolorations
1$ %ge-related discolorations
ContraindicationsB-
.$ Severe enamel loss
*$ Hypersensitive teeth
/$ -resence of caries
1$ Defective coronal restorations
8$ %llergy to leaching gels
5$ Bru(ism
3$ -regnant and lactating
2$ Smo)ing
/8
Techni=e:/
This technique has een 'idely advocated as a home leaching technique
'ith a 'ide variety of materials$ Numerous products are availale& mostly
containing .$8 to .+7 hydrogen pero(ide or .+ to .87 caramide pero(ide& that
degrade slo'ly to release hydrogen pero(ide$ Caramide pero(ide products are
the more commonly used at home leaching agents$
.$ ,amiliari=e the patient 'ith the proale causes of discolouration&
procedure to e follo'ed and the e(pected outcome$
*$ Carry out thorough oral prophyla(is
/$ %ssess the colour of the teeth 'ith a shade ta y ta)ing photographs at all
the appointments$
1$ Ma)e alginate impressions of oth the arches$ Cast the impression y
ta)ing care not to incorporate voids or drags in the impression$ %pply
appro(imately +$8mm thic)ness of loc) out material to the desired laial
surfaces to provide reservoir spaces in the tray$ It should e . to .8mm
short of the gingival margin and should not e(tend onto the incisal edges
and occlusal surfaces$ @(tending the loc)-out material onto the incisal
edges or occlusal surfaces can cause the margins of the tray to open upon
occluding or the tray to impinge on the soft tissues$ Cure the loc)-out
material on each tooth for *+ to 1+ seconds$ No' heat the tray material on
the vacuum former unit until it sags appro(imately * K inches& then adapt it
to the cast and allo' it to cool$ It is then trimmed 'ith a scalpel or elastic
)nife appro(imately +$*8 to +$/mm occlusally from the gingival margin
/5
facially and lingually in a scalloped manner$ The tray is then placed on the
cast and the e(tensions are chec)ed$ No' gently flame polish the edges one
quadrant at a time 'ith a torch$ Fhile still 'arm& hold the periphery of each
segment firmly against the model for / sec 'ith a 'ater-moistened finger$
9ther'ise& after trimming the tray 'ith scalpel a ruer 'heel in a
micromotor can e used to smoothen the rough edges$
8$ Insert the mouth guard to ensure proper fit$ "emove and apply the
leaching agent in the space of each tooth to e leached$ "einsert the
mouth guard over the teeth and remove e(cess leaching agent$
5$ ,amiliari=e the patient 'ith the use of leaching agent and 'earing the
mouth guard$ The procedure is usually performed / to 1 hrs a day and the
leaching agent is replenished every /+ to 5+ min$ Some clinicians
recommend 'earing the guard during sleep for etter long-term esthetic
results$ The duration of 'earing the mouth guard and replenishing the
leaching agent depends on the severity of staining& concentration of the
leaching agent and the manufacturer#s instructions$
3$ Instruct the patient to rush and rinse their teeth after meals$ The guard
should not e 'orn eating$ Inform the patient aout thermal sensitivity and
minor irritation of soft tissues and to discontinue use of the guard if
uncomfortale$
2$ Treatment may e carried out for 1 to *1 'ee)s$ "ecall the patient every *
'ee)s to monitor stain lightening$ Chec) for tissue irritation& oral lesions&
enamel etching and lea)y restorations$ If complications occur& stop the
treatment and re-evaluate the feasiility of continuation at a later date$
/3
"ediscoloration 'ith this technique is not more frequent than the other
technique$
A+1e!se effects:
.$ Systemic effectsB Controlled mouth guard leaching is considered relatively
safe$ Ho'ever& accidental ingestion of large amounts of these gels may e
to(ic and cause irritation to the gastric and respirator mucosa$ Bleaching gels
containing caropol are usually more to(ic$ Therefore& it is advisale to pay
specific attention to any adverse systemic effects and to discontinue treatment
immediately if they occur$
*$ Dental hard tissue damageB- In vitro studies indicate morphologic and chemical
changes in enamel& dentin and cementum associated 'ith some agents used for
mouth guard leaching$
/$ Tooth sensitivityB Transient tooth sensitivity to cold may occur during or after
mouth guard leaching$ In most cases& it is mild and ceases on termination of
treatment$ Treatment for sensitivity consist of discontinue the use of mouth
guard for fe' days or the reduction of 'earing or the use of desensiti=ing
agents$
1$ Mucosal damageB- Minor irritations or ulcerations of the oral mucosa have
een reported to occur during the initial course of treatment$ -ossile causes
are mechanical interference y the mouth guard& chemical irritation y the
leaching agent and allergic reactions to gel components$ In most cases&
readCustment and smoothing the orders of the guard 'ill suffice$ Ho'ever& if
tissue irritation persists& treatment should e discontinued$
/2
8$ Damage to restorationsB Some in vitro studies suggest that damage of
leaching gels to composite resins may e caused y softening and crac)ing of
the resin matri($ Ho'ever& there are fe' other studies 'hich did not find any
significant adverse effects on either surface te(ture or colour of restorations$
0enerally& if composite restorations are present in esthetically critical areas&
they may need replacement to improve colour matching follo'ing successful
leaching$
It has also een reported that oth .+7 caramide pero(ide and .+7 hydrogen
pero(ide may enhance the lieration of mercury and silver from amalgam
restorations and may increase e(posure of patients to to(ic yproducts$
Coverage of the amalgam restorations 'ith a protective layer of dental varnish
prior to the leaching gel application may prevent such ha=ards$ Enpolished
restorations corrode more$
5$ 9cclusal disturancesB- Typcially& occlusal prolems related to the mouth
guard may e mechanical or physiologic$ ,rom a mechanical point of vie'& the
patient may occlude only on the posterior teeth rather than on all teeth
simultaneously$ "emoving posterior teeth from the guard until all of the teeth
are in contact rectifies the prolem$ ,rom a physiologic point of vie'& if the
patient e(periences TMA pain& the posterior teeth can e removed from the
guard until only the anterior guidance remains$ In such cases& 'earing time
should e reduced$
Studies have found that %t-home leaching for * 'ee)s is more effective
than in-office leaching / times at / different appointments$
/4
>eonard et al$ studied the desensiti=ing agent efficacy during 'hitening in
an at-ris) population and suggests that the use of an active /7 6N9
/
and +$..7 ,
desensiti=ing agent for /+ min prior to 'hitening may decrease tooth sensitivity
'hen compared 'ith placeo in a population at ris) for tooth sensitivity$
0am=e H*++/? had suggested that .+ gm of Caramide pero(ideG day can e
considered as a safe dose for the prevention of systemic effects in a person G day
can e considered as a safe dose for the prevention of systemic effects in a person
of 3+ )g 't$
Alte!n"ti1e Techni=es:
.$ %cid-pumice techniqueB-
a? In this technique& .27 HCl is mi(ed 'ith fine flour of pumice to ma)e a
thic) paste$
? This paste is applied to the enamel surface 'ith a piece of 'ooden tongue
lade or crushed orange 'ood stic)$ @(erting firm pressure& the paste is
'or)ed into the enamel surface 'ith a s'irling motion for 8 seconds$ The
enamel surface is then rinsed for .+ seconds 'ith 'ater$
c? The paste is re-applied until the desired lightening is achieved$
d? The thic) paste of sodium icaronate and 'ater are applied to neutrali=e
the surface$
e? -olish 'ith a fine fluoride prophyla(is paste and superfine aluminium o(ide
composite resin polishing discs$
f? %pply .$.7 neutral sodium fluoride gel for 1 min$
1+
This technique can e used in comination 'ith the night guard leaching
using lo'er concentration leaching agents$
(' *cInne$s techni=e:/
This technique uses a comination of 8 parts of /+7 H
*
9
*
& 8 parts of /57
HCl and . part of diethyl ether$ The solution is applied directly to the stained areas
for . to * minutes 'ith cotton applicators$ Fhile the surface is 'et& a fine cuttle
disc is run over the stained surfaces for .8 seconds$ This process is repeated until
the desirale results are achieved& during susequent appointments$
)' *"c!o "-!"sion:
This technique can e comined 'ith night guard vital leaching to achieve
etter results$ In this technique the severely dar) stains are removed 'ith diamond
points& follo'ed y finishing 'ith caride urs and polishing y using the
composite polishing disc$ ,urther lightening is achieved y night guard leaching$
C2 O1e!/the/conte!:
Many home leaching products are availale over the counter or through
mail order& radio and television advertisements$ This approach is not
recommended as overuse and ause are a concern$
These systems include
Tooth pastes I %--*1& "emrandt
Mouth rinses I Crest
Tooth rushes I Spine rush pro 'hitening
Dental floss I Super smile
1.
Teeth 'hitening strips I Crest
Che'ing gums I Brits smile& Happy dent
-ain on varnish I !ivastyle
Brite smile stic) or pen
Tooth -!shes:
Certain po'ered tooth rushes are availale 'hich are said to remove the
e(trinsic stains mechanically$ @$g$ Spin rush pro-'hitening$
."int on 1"!nish:/
%pplied 'ith a rush$ 9n application it contains 57 caramide pero(ide$
9nce& it is dried the concentration increases$
Insolule in saliva and remains on teeth for *+ min$ susequently removed
'ith a tooth rush$
%dvantagesB-
.$ Can e applied e(actly 'herever it is needed$
*$ Contains D-panthenol I -rovitamin
/$ Noticeale after 3 days
Che6ing g4s:
Brite smile& Happy dent
Supersmile 'hitening flossB
It is the 'orld#s first floss treated 'ith Calpro( Hnot 'a(ed? to safely
'hiten et'een teeth and a)ing soda for fresher reath$ "emoves stuorn stains
and odour causing plaque under the gum$
1*
Calpro( is a clinically proven 'hitening agent 'hich gently dissolves the
protein pellicle& removing stains and plaque in the process$
Boil and BiteB-
.$ Boil a pot of 'ater and then sumerge the mouthpiece into it for 8 to .8
sec$ Mouthpiece egin to 'ilt$
*$ -lace the mouthpiece into the mouth and press against the front of your
teeth 'ith your fingers an the ac) of your teeth 'ith your tongue$ >et it
cool$
/$ "emove the mouthpiece from the mouth and cut the handle$
1$ Squee=e 'hitening gel and place it for .-/ hrs$
&2 Tooth 0"stes:/
They contain en=ymes that are thought to help to rea) do'n the organic
protein components of the stains$
@$g$ "emrandt 'hitening contaisn citro(ain& derived from papaya
Aanina ultra'hite opal contains Bromelain& 'hich is derived from
-ineapple$
(2 Tooth -!sh:/
It is clinically proven that it 'hitens the teeth in .1 days$ "emoves up to
227 of surface stains I toacco& 'ine& tea and coffee after .1 days of use$
Increased ristle density& concave polishing strips and ne' cup shaped
pattern designed to enhance the retention of dentifrice at the rush-tooth surface
interface$
1/