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C H A P T E R
S E C T I O N
14
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Bleaching
Bleaching and Its Relevance to Esthetic Dentistry
George Freedman
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s the techniques and materials available to dentists have
improved over the past few decades, better and more
conservative restorations have become possible. Extensive prepa-
ration and tooth destruction have given way to a genuine
concern for the preservation of tooth structure. Most recently,
much attention has been devoted to the esthetic aspects of den-
tistry and the patients concerns regarding appearance. Te past
three decades have been the most dynamic period that the pro-
fession has ever seen.
As the populations dental awareness has grown, so has its
demand for a natural (or preferably supernatural) smile. Te one
inescapable fact is that patients are very eager to have whiter and
brighter smiles. Te desire for whiter teeth is the strongest
driving force in peoples quest for dental treatment. Whereas oral
health and function are paramount for the practitioner, the
patients attention tends to focus rather exclusively on appear-
ance and esthetics. In the cultural environment encouraged by
toothpaste advertisements and Hollywood and bolstered by the
personal need to appear healthy and young, discolored or dark
teeth are no longer socially acceptable. Patients are therefore
seeking, and even self-administering, dentist-mediated as well as
exotic and questionable treatments to achieve the whiter smiles
they desire. It is the dentists responsibility to supervise patients
who seek to undergo a whitening treatment to ensure that the
maximum cosmetic beneft is within the boundaries of oral and
systemic health.
BRIEF HISTORY OF CLINICAL
DEVELOPMENT AND EVOLUTION
OF THE PROCEDURE
Te desire for whiter teeth is not completely a recent phenom-
enon. Even in Biblical times white dentition was considered,
attractive, youthful, and desirable. In third-century BC Greece,
Teophrastus wrote that it was considered a virtue to shave
frequently and to have white teeth.
If any attention was paid to dental hygiene and appearance
during the Middle Ages, there is little surviving documentation.
Life spans were short, education was minimal, and the primary
concerns were survival, food, and shelter.
Guy de Chauliac, a fourteenth-century surgeon, commented
extensively on his dental observations and produced a set of rules
for oral hygiene that included the following tooth-whitening
procedure: Clean the teeth gently with a mixture of honey and
burnt salt to which some vinegar has been added. His texts were
considered authoritative for the subsequent 300 years.
Te following era of dentistry brought the study of dental
anatomy and oral disease and a great interest in the prosthetic
replacement of teeth whose loss could not yet be avoided. As the
craft of dental technology expanded, dentists were better able to
replicate both form and function. Ten, in the nineteenth
century, dentistry began its recognizably modern form of restor-
ing carious and even infected teeth. Tese advancing skills
resulted in patients retaining their teeth for a greater portion of
their lives, and an expectation that these aged teeth could be
made visually acceptable.
Patient demands, combined with rapidly advancing medical
chemistry, resulted in the frst vital tooth bleaching agents and
procedures. Chapple proposed oxalic acid as the material of
choice in 1877. Shortly after, Taft suggested calcium hypo-
chlorite as an efective whitening solution. Te frst mention
of peroxide as a whitening agent was over a century ago; in 1884
Harlan published a report concerning a material that he called
hydrogen dioxide.
Some of the more arcane bleaching proposals at the turn of
the century included electric currents and ultraviolet waves
(Rosenthal). Obviously, neither of these really caught on with
the mainstream dentist. Acid dissolution of brown fuoride
stains was yet another approach to discoloration. Tis technique
was frst documented by Kane in 1916. Te technique involved