doi:10.1111/j.1365-2591.2010.01713.
Response of human pulps after professionally
applied vital tooth bleaching
J. F. Kina1, C. Huck1, H. Riehl2, T. C. Martinez1, N. T. Sacono3, A. P. D. Ribeiro4
& C. A. S. Costa5
1
Department of Restorative Dentistry, Araraquara School of Dentistry, São Paulo State University, Araraquara; 2Private Practice,
Bauru; Departments of 3Orthodontics and Pediatric Dentistry, 4Dental Materials and Prosthodontics; and 5Physiology and
Pathology, Araraquara School of Dentistry, São Paulo State University, Araraquara, Brazil
Abstract
Kina JF, Huck C, Riehl H, Martinez TC, Sacono NT,
Ribeiro APD, Costa CAS. Response of human pulps after
professionally applied vital tooth bleaching. International
Endodontic Journal, 43, 572–580, 2010.
Aim To evaluate in vivo the microscopic pulpal
response in sound human premolar teeth subjected to
vital tooth bleaching with a 38% hydrogen peroxide
(H2O2) bleaching gel (Opalescence X-tra Boost) catal-
ysed or not by a halogen light source.
Methodology Twelve pairs of sound maxillary and/
or mandibular premolar teeth from 12 to 18-year-old
patients were selected and randomly assigned to the
following experimental (n = 10) and control (n = 4)
groups: group 1: bleaching gel + halogen light; group
2: bleaching gel; group 3: no treatment (control). The
teeth were extracted 2–15 days after bleaching and
were subjected to routine laboratory processing for
histological analysis of the pulpal response under light
microscopy.
Introduction
Tooth bleaching with hydrogen peroxide (H2O2) has
been performed for over 100 years (Kugel et al. 2006,
Davidi et al. 2008). This thermally unstable chemical
agent with high oxidative power is used in different
Correspondence: Dr Carlos Alberto de Souza Costa, Departa-
mento de Fisiologia e Patologia, Faculdade de Odontologia de
Araraquara, Universidade Estadual Paulista, Rua Humaitá,
1680, Centro, Caixa Postal: 331, Cep: 14801903 Araraquara,
SP, Brasil (Tel.: +55 16 3301 6477; fax: +55 16 3301 6488;
e-mail: casouzac@foar.unesp.br).
572 International Endodontic Journal, 43, 572–580, 2010
Results In almost all specimens of the experimental
groups, the pulp tissue exhibited histological charac-
teristics of normality. Only one specimen in each group
exhibited some dilated and congested blood vessels
among a discrete number of mononuclear inflamma-
tory cells in the peripheral pulp region related to the
buccal surface of the tooth. These specimens had a
slight disruption to the odontoblastic layer, which
characterized discrete tissue disorganization. Some
deposition of reactionary dentine occurred in only
one specimen of group 2.
Conclusions Professionally applied vital tooth
bleaching with a 38% H2O2 gel with or without
activation by a halogen light source did not cause
damage to the pulp tissue of sound human premolar
teeth.
Keywords: hydrogen peroxide, material testing,
metabolism, odontoblasts, tooth bleaching.
Received 27 July 2009; accepted 1 February 2010
concentrations to treat discoloured teeth with healthy
pulps (Papathanasiou et al. 2002, Ferrari et al. 2004,
Gerlach et al. 2005, Buchalla & Attin 2007). Bleaching
agents at high concentrations (30-38%) should only be
used by dentists (Ferrari et al. 2004, Buchalla & Attin
2007). Some bleaching gels have high H2O2 concen-
trations, but this does not necessarily indicate that a
single application of the product is sufficient to achieve
the desired degree of tooth whitening. In fact, clinical
investigations (Haywood 1992, Al Shethri et al. 2003,
Hein et al. 2003) have demonstrated that, in most
cases, excellent aesthetic results are only achieved after
several treatment sessions, over a longer treatment
ª 2010 International Endodontic Journal

time. To overcome this problem, means have been
sought to accelerate the degradation of the bleaching
gel components, especially H2O2, and increase the
release of highly reactive free radicals to decompose the
pigments in the tooth. This should produce a more
rapid whitening effect, reduce the application time and
shorten treatment duration (Reyto 1998, Hein et al.
2003, Eldeniz et al. 2005).
Based on the principle that an increase of tempera-
ture would have a catalytic effect on the chemical
degradation of the peroxide molecule, different proto-
cols associating bleaching agents and heat have been
proposed and applied even before their preliminary
clinical results could corroborated by research-based
evidence (Hein et al. 2003, Eldeniz et al. 2005). The
first report of the empiric use of light to produce heat
and accelerate H2O2 decomposition dates back to the
beginning of the 20th century (Abbot 1918). The use
of heated instruments (Weinberg & Reingold 1997) and
more recently the use of different light sources, such as
halogen light, light-emitting diodes (LEDs) and laser
(Eldeniz et al. 2005, Buchalla & Attin 2007) have also
been described. According to some, the use of light
sources accelerates the chemical decomposition of
H2O2 and produces whiter teeth within a shorter
treatment time (Tavares et al. 2003, Wetter et al.
2004, Davidi et al. 2008). On the other hand, no
significant difference in tooth shade after exposure of
the bleaching gels to different light sources has also
been reported (Papathanasiou et al. 2002, Hein et al.
2003). Although the discussion regarding the aesthetic
results obtained with light activation or not of the
bleaching gel remains inconclusive, the possible dele-
terious effects of the contemporary bleaching agents
and techniques on the dental pulp should be evaluated.
Laboratory studies have demonstrated that bleaching
gel components, such as H2O2, are capable of diffusing
through the teeth to the pulp space (Hanks et al. 1993,
Camargo et al. 2007). Some oxygen-derived free rad-
icals are released from the degradation of the compo-
nents of the bleaching gels applied to enamel. These
highly toxic products of bleaching gel degradation may
interact with cell membrane proteins and trigger an
autocatalytic reaction known as lipid peroxidation,
which may cause irreversible damages to the cell
membrane and even cell death (Cochrane 1991, Walsh
2000). Therefore, it may be speculated that the
activation of bleaching gels by the heat generated by
light irradiation, for example, may increase the diffu-
sion rate of toxic components through enamel and
dentine and cause significant damage to the pulp (Dias
ª 2010 International Endodontic Journal
Kina et al. Human pulp response to vital tooth bleaching
Ribeiro et al. 2009). This possible pulp damage could
explain the fact that approximately 70% of the patients
that have their teeth subjected to external bleaching
therapy with activation by heat, light or laser report
some level of pain or discomfort after treatment
(Nathanson & Parra 1987).
In view of this, the purpose of this in vivo study was
to evaluate microscopically the response of pulps of
sound human premolar teeth subjected to profession-
ally applied vital tooth bleaching with a 38% H2O2
bleaching gel catalysed or not by a halogen light
source.
Material and methods
The research protocol for this clinical investigation was
reviewed and approved by the Research Ethics Commi-
ttee of the University Centre of Araraquara (UNIARA),
Brazil (Process #646). Twelve men and women indi-
viduals aged 12–18 years old who had at least one pair of
sound maxillary or mandibular premolar teeth with
indication for extraction for orthodontic reasons were
selected after an initial screening based on clinical
and radiographic (interproximal and periapical) exam-
inations. All participants or their legal representatives
received verbal and written explanations about the
purpose of the clinical procedures; they all signed an
informed consent form prior to enrolment.
A total of 24 teeth were randomly assigned to the
following experimental (n = 10) and control (n = 4)
groups, according to the treatment performed on the
enamel surface: group 1: bleaching gel application
(Opalescence X-tra Boost; Ultradent Products Inc.,
South Jordan, UT, USA) plus activation with a halogen
light source (Curing Light XL 3000; 3M/ESPE, St. Paul,
MN, USA); group 2: bleaching gel application only; and
group 3: no treatment (control). As teeth were treated
in pairs in the same individual, the study protocol
established that the left premolar should receive the
bleaching agent followed by light activation, and
the contralateral right premolar should receive only
the bleaching gel.
The pair of teeth belonging to the same individual
was cleaned by rubber/pumice prophylaxis, thoroughly
washed and dried with an oil-free air stream. The teeth
allocated to group 1 (left premolar teeth) were subjected
to a professionally applied vital tooth bleaching proto-
col, as follows. A light-cured resin-based gingival barrier
(Opal Dam; Ultradent Products Inc.,) was used for
isolating the soft tissues around to teeth being whitened
and protecting the adjacent teeth. The bleaching gel
International Endodontic Journal, 43, 572–580, 2010 573
 Human pulp response to vital tooth bleaching Kina et al.
was handled according to the manufacturer’s instruc-
tions and was applied to the buccal surface of the teeth
in such a way that a uniform 1-mm layer of material
was formed and left undisturbed for 2 min. At the end
of this period, the bleaching agent was irradiated
for 1.5 min with the halogen light source with
480 mW cm)2 output power, as measured with a
curing radiometer (Demetron; Kerr Corp., Danbury,
CT, USA). During light exposure, the light guide tip of
the curing unit was held 5 mm from the enamel
surface, acting directly on the bleaching gel. The curing
unit was then turned off and the bleaching gel was left
undisturbed on enamel surface for additional 2 min.
After this period, a further 1.5-min of irradiation was
performed as described previously, and the bleaching
agent was left undisturbed on enamel surface for
additional 3 min, completing the first bleaching cycle
with a total application time of 10 min. The bleaching
gel was removed from tooth surface using a saliva
ejector with high-power suction, and the bleaching
cycle was repeated further two times, to give a total of
three applications of 10 min each. After the third
application, the bleaching gel was removed from
enamel surface using a saliva ejector with high-power
suction, and the tooth was rinsed copiously with an air/
water spray and gently dried with sterile gauze. The
teeth allocated to G2 (right premolar teeth) were
subsequently subjected to the same bleaching protocol
consisting of three consecutive 10 min bleaching gel
applications, without halogen light irradiation.
For both groups, an approximately 2 mm thick layer
of a postbleaching desensitizing gel (Lase SensyTM;
DMC, São Carlos, SP, Brazil) was applied on the enamel
surface of the bleached teeth for 5 min. After this time,
the gel was aspirated, the resin-based gingival barrier
was removed with an explorer and the teeth were
rinsed copiously with an air/water spray. Two to fifteen
days after the bleaching procedures, periapical radio-
graphs were taken and the teeth were extracted under
infiltrative local anaesthesia with a vasoconstrictor-
containing anaesthetic agent.
Immediately after extraction, the roots of the teeth
were removed at the middle third and the coronal
segment was immersed in 10% buffered formalin at
room temperature for 72 h, demineralized in Morse
solution (equal volumes of 50% acid formic and 20%
sodium citrate) under agitation, cleared in xylol,
immersed in liquid paraffin for 60 min and embedded
in paraffin under vacuum. Six-micrometre-thick sec-
tions were cut using a rotary microtome, stained with
haematoxylin & eosin and Masson’s Trichrome, and
574 International Endodontic Journal, 43, 572–580, 2010
viewed under a light microscope (Carl Zeiss, Oberko-
chen, Germany) by a calibrated examiner blinded to the
groups. The following histopathological events were
evaluated and classified by a descriptive analysis
according to the criteria presented in Tables 1–3:
inflammatory cell response, pulp tissue disorganization
and reactionary dentine formation.
Results
Table 4 presents the distribution of the teeth according
to the scores attributed to the histopathological events
in each group.
Group 1 (Bleaching gel + halogen light; n = 10)
Only one specimen (extracted 2 days after bleaching)
exhibited some dilated and congested blood vessels
among a discrete number of mononuclear inflamma-
Table 1 Inflammatory cell response
Score Characterization
0 None or a few scattered inflammatory cells
present in the coronal pulp, characteristic of
normal tissue
1 Slight inflammatory cell infiltrate with
polymorphonuclear or mononuclear leucocytes
2 Moderate inflammatory cell infiltrate involving
the coronal pulp
3 Severe inflammatory cell infiltrate involving the
coronal pulp or characterizing abscess
Table 2 Pulp tissue disorganization
Score Characterization
0 Normal tissue
1 Disorganized odontoblastic layer, but
normal pulp core
2 Total disorganization of pulp morphology
3 Pulp necrosis
Table 3 Reactionary dentine formation
Score Characterization
0 Absence
1 Mild hard tissue deposition underneath the region
of the buccal tooth surface subjected to the
bleaching therapy
2 Moderate hard tissue deposition underneath the
region of the buccal tooth surface subjected to
the bleaching therapy
3 Intense hard tissue deposition in the coronal pulp
ª 2010 International Endodontic Journal
 Kina et al. Human pulp response to vital tooth bleaching

Table 4 Distribution of teeth according to the scores attrib- layer. These histological characteristics determined a
uted to the histopathological events in each group discrete disorganization of the pulp tissue in two
Scores specimens. However, one of them did not exhibit a
Histopathological
events Groups 0 1 2 3 Total
significant number of inflammatory cells that could
characterize a local inflammation. The other nine
Inflammatory cell Group 1 9 1 0 0 10
specimens of this group exhibited pulp tissue without
response Group 2 10 0 0 0 10
Group 3 4 0 0 0 4 any evidence of inflammatory response (Fig. 1c,d).
Pulp tissue Group 1 8 2 0 0 10 Discrete deposition of reactionary dentine was observed
disorganization Group 2 9 1 0 0 10 in one specimen extracted 15 days after vital tooth
Group 3 4 0 0 0 4 bleaching.
Reactionary dentine Group 1 9 1 0 0 10
formation Group 2 9 1 0 0 10
Group 3 4 0 0 0 4 Group G2 (Bleaching gel; n = 10)
Group 1, bleaching gel application + halogen light activation;
group 2, bleaching gel application; group 3, no treatment In this group, all specimens exhibited pulp tissue with
(control). normal histological characteristics (Fig. 2a). Only one
specimen (extracted 2 days after bleaching) had a
tory cells in the peripheral pulp region related to the discrete disruption to the odontoblastic layer in the
buccal surface of the tooth on which the bleaching region of the pulp tissue related to the bleached enamel
agent had been applied (Fig. 1a,b). In this region of the surface. It was also possible to observe in this region the
coronal pulp, some dilated and congested blood vessels presence of congested small blood vessels, and the
were found within the partially disrupted odontoblastic occurrence of these histological events characterized a

(a) (b)

(c) (d)

Figure 1 Group 1 (bleaching gel application + halogen light activation). (a) Overview of the integrity of the pulp horn of a
premolar subjected to light-activated vital bleaching. Note that the odontoblastic layer that underlies the dentine presents a
discrete alteration (arrow) in the region of the pulp tissue related to the buccal surface of the tooth on which the bleaching gel was
applied. HE, 32·. (b) Detail of the peripheral region of the pulp related to buccal surface of the tooth, where the bleaching gel was
applied and catalysed with halogen light. Note that the odontoblastic layer is slightly disrupted, has a reduced number of
odontoblasts (compare to Fig. 1d), and exhibits more internally a discrete presence of mononuclear inflammatory cells associated
with dilated blood vessels (arrows). HE, 125·. (c) A continuous and homogeneous odontoblastic layer underlies the dentine
(arrows). Masson’s Trichrome, 32·. (d) Detail of the intact pulp tissue clearly showing the dentine (D), predentine (arrow),
odontoblastic layer (OL), acellular layer (AL), cell-rich layer (CRL) and the pulp core (PC) with balance between fibres, cells and
other extracellular matrix components. HE, 160·.

ª 2010 International Endodontic Journal International Endodontic Journal, 43, 572–580, 2010 575
 Human pulp response to vital tooth bleaching Kina et al.

(a) (b)

Figure 2 Group 2 (bleaching gel application). (a) Histological section of a bleached premolar showing a thin predentine (PD) layer
interposed between the pulp tissue (P) with characteristics of normality, and the tubular dentine (TD). HE, 250·. (b) Note dentine
matrix deposition causing thickening of the predentine (PD) layer. The subjacent pulp tissue is free of inflammation and slightly
disorganized. The odontoblastic layer, though intact, presents a small number of cells (arrows). HE, 250·.

discrete disorganization of the pulp tissue. In one
specimen (extracted 15 days after bleaching), the
predentine layer was slightly thickened, which char-
acterized a discrete deposition of reactionary dentine. In
this specimen, the pulp tissue did not show any
evidence of inflammation, but presented discrete disor-
ganization and a smaller number of odontoblasts
(Fig. 2b).
Group G3 (control group; no treatment; n = 4)
This group served as a control to evaluate the
histological characteristics of the normal pulp and to
compare them to possible tissue alterations resulting
from the vital tooth bleaching procedures performed in
the experimental groups (bleaching gel application
with and without halogen light activation). The teeth
of this group were also used to evaluate the quality of
the laboratorial processing of the specimens. The entire
coronal pulp tissue exhibited well-defined acellular and
cell-rich layers underneath an intact odontoblastic
layer (Fig. 3a,b). The pulp core exhibited an even
number of the cell components, blood vessels and
extracellular matrix structures.
Discussion
Evaluating pulpal response after tooth bleaching is
important as components released from bleaching gels
are capable of diffusing through mineralized tooth
tissues to reach the pulp chamber, possibly causing
oxidative stress and permanent cytotoxic effects (Hanks
et al. 1993, Camargo et al. 2007). H2O2 and free
radicals resulting from its degradation, such as hydro-
xyl ions (OH-) and reactive oxygen species (ROS), can
initiate the chain oxidation of phospholipids present in
the lysosomal and cytoplasmic cell membrane (lipid
peroxidation), with consequent leakage of destructive
enzymes (Walsh 2000) and damage to the pulp cells
that may range from oxidative stress to death (Li 1996,
Floyd 1997, Kanno et al. 2003, Kawamoto & Tsujim-
oto 2004).

(a) (b)

Figure 3 Group 3 (control). (a) Overview of the pulp horn of a sound premolar which was not submitted to bleaching treatment. A
continuous odontoblast layer (arrows) underlying the predentine is observed. HE, 32·. (b) Histological section of a non-bleached
premolar showing normal histological characteristics. In the same way as observed for almost all teeth subjected to vital bleaching
with or without halogen light activation, tubular dentine (D) and predentine (PD) were observed, and the subjacent pulp tissue
exhibited the following well-defined layers: odontoblastic layer (OL), acellular layer (AL) and cell-rich layer (CRL). HE, 250·.

576 International Endodontic Journal, 43, 572–580, 2010 ª 2010 International Endodontic Journal

Using an in vivo methodology that has been
employed extensively to evaluate dental materials and
clinical procedures (de Souza Costa et al. 2006, 2007,
Kina et al. 2008), young premolar teeth from patients
in a predetermined age group (12–18 years old) were
used in the present investigation, in such a way that
the bleaching procedures were performed in teeth with
similar tissue characteristics, especially regarding the
organization and reparative capacity of the pulp-
dentine complex.
Most laboratory studies have demonstrated that the
capacity of the bleaching agent to diffuse through tooth
tissue and reach the pulp chamber is directly propor-
tional to the H2O2 concentration and the contact time
of the product with enamel (Benetti et al. 2004,
Camargo et al. 2007). The higher the H2O2, the deeper
the microporosities created by the product in the
enamel, which favours the diffusion of the peroxide
and its byproducts towards the pulp chamber (Hegedüs
et al. 1999, Kwon et al. 2002, Schiavoni et al. 2006). A
recent study (Trindade et al. 2009) reported that a 35%
H2O2 bleaching gel was capable of diffusing through
bovine enamel/dentine discs causing severe toxic effects
to odontoblast-like cell cultures. In the present in vivo
study, however, the pulp tissue of human teeth
bleached with a 38% H2O2 gel associated or not with
halogen light irradiation had normal histological
characteristics preserved in most cases. It has been
reported that differences observed between the results
of laboratory and in vivo studies can be attributed, at
least in part, to the impossibility of reproducing in the
laboratory setting all the physiological conditions of the
pulp-dentine complex. Teeth with vital pulps have a
dentinal fluid flow produced by the intrapulpal
pressure, cytoplasmatic extensions of odontoblasts
and other intratubular components (Hanks et al.
1993), which may prevent the diffusion of bleaching
gel components through the dentinal tubules. The pulp
also has a lymphatic vessel system that participates in
the elimination of external products by trans-dentinal
diffusion. Furthermore, because of oxidative stress
generated by the presence of free radicals, the defence
system of the pulp cells may be activated, releasing
several endogenous antioxidant agents, such as the
enzymes superoxide dismutase and catalase, which
promote an enzymatic degradation of H2O2 and may
protect the pulp cells from the cytotoxic effects of the
bleaching agent and avoid excessive tissue damage
(Esposito et al. 2003).
Few in vivo studies have evaluated microscopically
the pulpal response in bleached teeth. Seale & Wilson
ª 2010 International Endodontic Journal
Kina et al. Human pulp response to vital tooth bleaching
(1985) evaluated the response of pulps of dogs’ teeth
bleached with a 35% H2O2 gel associated or not with
heat. The authors observed a significant inflammatory
pulpal response immediately beneath the region where
the bleaching agent was applied in 17 of 18 bleached
teeth. The severity of the pulpal alterations was directly
proportional to the duration of heat application, and
evidence of pulp repair was observed in most teeth
92 days after bleaching. In the present study, in which
a bleaching agent containing 38% H2O2 was applied to
the buccal enamel of sound human premolar teeth, no
inflammatory pulpal response occurred in most of
teeth, even when the gel was catalysed by a halogen
light source. A factor that might have contributed to
the differences between the results of these in vivo
studies is the variation in hard tissue thickness between
dogs and humans (approximately 1.7 mm vs. 3.8 mm)
(Shillingburg & Grace 1973). However, not only the
thickness, but also the structural characteristics of the
tissues, such as the degree of mineralization, number
and diameter of the dentinal tubules, might influence
the diffusion of bleaching gel products through enamel
and dentine, and consequently affect the inflammatory
pulpal response. It has also been reported that the pulp-
dentine complex of different species might respond
differently to abuse (Wennberg et al. 1983, Browne
1994, Costa et al. 2000). So, the results obtained in
animal teeth cannot be extrapolated directly to human
teeth (Costa et al. 2003).
The use of a light or heat source to accelerate the
release of free radical from H2O2 and thus promote a
faster bleaching treatment is still a subject of discus-
sion. Some in vivo studies have found no clinical
differences in the effectiveness of the bleaching proce-
dures when the gels were used alone or catalysed with
different light sources (Hein et al. 2003, Kugel et al.
2006). However, the use of light sources to speed up
the bleaching might result in increase in the intrapul-
pal temperature. A previous laboratory study investi-
gating pulpal temperature rise during light-activated
tooth bleaching (Eldeniz et al. 2005) found that the
temperature rise depends significantly on the use of a
variety of light-curing units or a diode laser as the heat
source. The use of diode laser to catalyse the bleaching
gel induced the greatest temperature increase in the
pulp chamber (11.7 C). It has been demonstrated that
an intrapulpal temperature rise of 5.5 C may cause
irreversible thermal pulpal damage (Zach & Cohen
1965). It is also known that the increase of the
temperature in the pulp chamber may facilitate perox-
ide diffusion to the pulp and cause inactivation of
International Endodontic Journal, 43, 572–580, 2010 577
 Human pulp response to vital tooth bleaching Kina et al.
several pulpal enzymes that are important to the
maintenance of physiological cellular functions (Bowles
& Thompson 1986, Bowles & Ugwuneri 1987). How-
ever, the findings of the present study suggest that
light-catalysed bleaching was not more aggressive to
the pulp cells than the application of the bleaching gel
alone. Therefore, it may be speculated that possible
intrapulpal temperature changes were not sufficient to
cause significant damages to the pulpal tissues of the
premolar teeth bleached in the present study, or even
accelerate the trans-enamel and trans-dentinal diffu-
sion of components released from bleaching agent.
Although light and heat are traditionally used as
catalysts, it has been reported that the energy produced
by these sources is not always sufficient to catalyse the
H2O2 (Hein et al. 2003). It may be suggested that
halogen light source used in the present study did not
offer sufficient thermal energy to accelerate the rate of
H2O2 degradation.
The current professionally applied vital tooth bleach-
ing technology is moving towards the use of chemical
catalysts (boosters or activators), such as the one used
in the present study. When mixed with H2O2, these
catalysts are responsible for elevating the pH of the
mixture, which increases the peroxide degradation and
produces more free radicals, increasing the whitening
effect of the bleaching agents. H2O2 decomposition is
reduced in acid environments, which makes it more
stable for storage (Buchalla & Attin 2007). Therefore,
the catalyst is mixed with the H2O2 before the use of the
product, which may favour the bleaching process. In
the present study, although a 38% H2O2-based bleach-
ing gel containing a catalyst (X-tra Boost) was applied
to young permanent teeth, which are considered more
permeable (Mjör et al. 2001), no significant pulpal
alterations were observed in the bleached groups
regardless of halogen light application. This might be
explained by the fact that the bleaching protocol was
performed in a single 30 min session divided into three
10-min applications of the product on the buccal
surface of the teeth. It is known that a single
professionally applied vital bleaching session is not
always sufficient to achieve the expected whitening
outcome and additional sessions are necessary (Al
Shethri et al. 2003). In addition, bleaching is frequently
performed in teeth with restorations, areas of demin-
eralization, cementum or dentine exposure because of
gingival recession, or other situations that may facil-
itate the diffusion of bleaching gel components and
cause more significant pulpal damages. Further in vivo
studies are required to evaluate the response of the
578 International Endodontic Journal, 43, 572–580, 2010
pulps of human teeth subjected to multiple profession-
ally applied vital bleaching sessions.
A recent preliminary in vivo study (Costa et al. 2010)
compared the pulp response of human incisor and
premolar teeth subjected to professionally applied vital
tooth bleaching with a 35% H2O2, using a similar
protocol to that of the present study (three changes of
15 min). All bleached incisor teeth had postoperative
sensitivity. The coronal pulp of these teeth exhibited
large zones of necrosis, and the root pulp tissue showed
mild inflammatory response. On the other hand, no
histological pulpal damage or inflammatory reaction
occurred in the pulp of the premolar teeth. Costa et al.
(2010) speculated that professionally applied vital
tooth bleaching using gels with high H2O2 concentra-
tion may cause pulpal damage and postoperative pain
in incisors teeth because of the limited thickness of the
enamel and dentine, especially when compared to
posterior teeth. However, additional clinical studies are
necessary to confirm the relationship between the
morphological characteristics of the teeth and the
toxicity of the vital bleaching therapies, which may be
used to adjust the protocols according to the teeth to be
bleached.
Conclusion
Vital tooth bleaching with a 38% H2O2 gel with or
without application by a halogen light source did not
cause damage to the pulp tissue of sound human
premolar teeth.
Acknowledgements
The authors acknowledge Ultradent Products Inc.
(South Jordan, UT, USA) for supplying the bleaching
gel used in this study. This study was partially
supported by the Conselho Nacional de Desenvolvi-
mento Cientı́fico e Tecnológico – CNPq (Grant:
130021/2004-0) and Fundação de Amparo à Pesquisa
do Estado de São Paulo – FAPESP (Grant: 2008/
05890-6).
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