COSMETIC WHITENINGCOSMETIC WHITENING

Dr. Fazal ur Rehman QaziDr. Fazal ur Rehman QaziBDS,FCPSBDS,FCPSAsst. ProfAsst. Prof

DEPT OF OPERATIVE DENTISTRYDEPT OF OPERATIVE DENTISTRY

Discoloration of teethDiscoloration of teeth

Intrinsic discoloration

Extrinsic discoloration

Extrinsic stains

““located on the surface of the tooth and located on the surface of the tooth and are most easily removed by external are most easily removed by external

cleaning.”cleaning.”

Extrinsic color changes may be due to: Extrinsic color changes may be due to: poor oral hygienepoor oral hygiene ingestion of chromatogenic foods and drinksingestion of chromatogenic foods and drinks tobacco use.tobacco use.

Intrinsic stainsIntrinsic stains““located within the tooth and are accessible only located within the tooth and are accessible only

by bleaching.”by bleaching.” Intrinsic color changes may be caused by :Intrinsic color changes may be caused by :

agingaging ingestion of chromatogenic foods and drinkingestion of chromatogenic foods and drink tobacco usagetobacco usage microcracks in the enamelmicrocracks in the enamel tetracycline medicationtetracycline medication excessive fluoride ingestionexcessive fluoride ingestion severe jaundice in infancysevere jaundice in infancy dental cariesdental caries restorationsrestorations

FEW FACTSFEW FACTS

Aging is most common cause of Aging is most common cause of discoloration.discoloration.

Yellow discoloration of aging responds Yellow discoloration of aging responds quickly to bleaching. quickly to bleaching.

Tetracycline stained teeth are the Tetracycline stained teeth are the slowest to respond to bleaching.slowest to respond to bleaching.

Brown-fluoresced teeth are Brown-fluoresced teeth are moderately responsive.moderately responsive.

Tetracycline StainingTetracycline Staining

• First degree First degree Light yellow, brown or gray uniformly distributed Light yellow, brown or gray uniformly distributed

throughout the crown, with no evident banding.throughout the crown, with no evident banding.

• Second degree Second degree Darker or gray uniform staining, with no banding.Darker or gray uniform staining, with no banding.

• Third degree Third degree Dark gray or blue staining with marked banding. Dark gray or blue staining with marked banding.

• Fourth degree Fourth degree These stains are too dark. These stains are too dark.

VITAL BLEACHINGVITAL BLEACHING

Commonly known as, Commonly known as, tooth tooth whiteningwhitening is a noninvasive method is a noninvasive method

of lightening dark or discolored teeth.of lightening dark or discolored teeth.

Vital BleachingVital BleachingAdvantagesAdvantages

Low costLow cost High success rateHigh success rate No tooth alterationNo tooth alteration

Vital Bleaching Vital Bleaching

DisadvantagesDisadvantages Unpredictable resultsUnpredictable results Need Re-treatmentNeed Re-treatment Possible side effectsPossible side effects Transient sensitivity sensitivity

Dental bleaching agentsDental bleaching agents

CompositionComposition Carbamide peroxideCarbamide peroxide 5% to 40%5% to 40% Carbopol ( slow oxygen Carbopol ( slow oxygen

releasing)releasing) Glycerin (thickening agent)Glycerin (thickening agent) Sodium hydroxideSodium hydroxide Flavors and fluorideFlavors and fluoride

Mode of actionMode of action

In saliva Carbamide peroxide converts to In saliva Carbamide peroxide converts to hydrogen peroxide, the active bleaching hydrogen peroxide, the active bleaching agent, and urea.agent, and urea.

Hydrogen peroxide, typically generates Hydrogen peroxide, typically generates short-lived oxygen intermediates, such as short-lived oxygen intermediates, such as hydroxyl radicalhydroxyl radical

It enters enamel or dentine and diffuse to It enters enamel or dentine and diffuse to areas of discoloration and breaks down some areas of discoloration and breaks down some of the double bonds in discolored or stained of the double bonds in discolored or stained compounds, results in whitened appearance.compounds, results in whitened appearance.

Hydrogen

peroxide

UREACarbamid

e peroxide

hydroxyl

radical

DOUBLE BONDS

Bleaching Techniques

In-office bleaching technique Laser bleaching Dentist-prescribed, home applied

bleaching tray method whitestrips method Non vital bleaching

In-office bleaching technique

Also known as power bleachingAlso known as power bleaching This application technique uses a higher This application technique uses a higher

concentration of hydrogen peroxide.concentration of hydrogen peroxide. Require isolation and close patient Require isolation and close patient

monitoring throughout the procedure.monitoring throughout the procedure. Local anesthesia is contraindicated b/c Local anesthesia is contraindicated b/c

they hinder pts communication abt they hinder pts communication abt procedural discomfort (gingival burning, procedural discomfort (gingival burning, improper rubber dam clamp placement).improper rubber dam clamp placement).

In-office bleaching technique

Ideal for pts who need quick results Ideal for pts who need quick results or for those who have stubborn or for those who have stubborn unresolved stains.unresolved stains.

In-office BleachingIn-office Bleaching(Clinical Protocol)(Clinical Protocol)

Clean teeth with Clean teeth with pumicepumice

Record pre-op shadeRecord pre-op shade

Isolate teeth as Isolate teeth as close to the gingival close to the gingival margin as possible margin as possible with rubber dam (no with rubber dam (no tears, leakage, fully tears, leakage, fully inverted)inverted)

Mix the Mix the thickening agent thickening agent with 35% hydrogen with 35% hydrogen peroxide to a non-peroxide to a non-slumping slumping consistency.consistency.

Place the gel Place the gel material on the material on the teeth for 30 minteeth for 30 min

May need to May need to “refresh” with “refresh” with hydrogen peroxide hydrogen peroxide liquid if the gel liquid if the gel appear too dryappear too dry

Rinse and clean; Rinse and clean; remove rubber dam remove rubber dam and record post-and record post-op shadeop shade

Laser bleaching

Lasers are also used within the clinical Lasers are also used within the clinical setting for dental bleaching.setting for dental bleaching.

The laser generates heat that The laser generates heat that increases the resorption rate of increases the resorption rate of hydrogen peroxidehydrogen peroxide

Time-consumingTime-consuming Quick resultsQuick results Very expensiveVery expensive

Dentist-prescribed, home applied bleaching

Tray method First step is fabrication

of trays Tray design include

soft or rigid, reservoir or nonreservoir, and scalloped or non- scalloped trays

Soft trays are preferred Soft trays are preferred for ease of fabrication for ease of fabrication and pt comfort.and pt comfort.

Reservoir are used with Reservoir are used with the more highly viscous the more highly viscous bleaching material.bleaching material.

Scalloped prevents Scalloped prevents from gingival irritation from gingival irritation from bleaching gel.from bleaching gel.

The patient should The patient should wear the nightguard for wear the nightguard for 2 to 6 hrs a day.2 to 6 hrs a day.

Side effects of home Side effects of home bleachingbleaching

Thermal sensitivityThermal sensitivity ;; result of permeation of peroxide into result of permeation of peroxide into

dentinal tubules.dentinal tubules. can be prevented by decreasing the can be prevented by decreasing the

wear time, decreasing solution wear time, decreasing solution concentration.concentration.

Gingival irritationGingival irritation ;; result of contact with bleaching result of contact with bleaching

solution and ill fitted tray.solution and ill fitted tray. can be prevented by well fitted tray of can be prevented by well fitted tray of

trayless methods.trayless methods.

whitestrips method

Trayless methodTrayless method Each application Each application

involves the involves the alignment and alignment and folding of the strip folding of the strip into place.into place.

whitestrips method

Advantages Advantages

convenienceconvenience

ease of useease of use

potential for potential for better tolerabilitybetter tolerability

costcost

DisadvantagedDisadvantaged

less tooth less tooth coveragecoverage

potential potential difficulty in keeping difficulty in keeping strips in placestrips in place

Recommended agents for Recommended agents for bleachingbleaching

35% hydrogen peroxide for in office 35% hydrogen peroxide for in office bleaching bleaching

10% carbamide peroxide for home 10% carbamide peroxide for home bleachingbleaching

Factors affecting bleaching Factors affecting bleaching (in office and at home)(in office and at home)

Surface cleanlinessSurface cleanliness Concentration of peroxideConcentration of peroxide Temperature (in-office)Temperature (in-office) pHpH TimeTime AdditivesAdditives Sealed environment (non-vital)Sealed environment (non-vital)

Safety factorsSafety factors

Tooth and pulpal problemsTooth and pulpal problems SensitivitySensitivity Mineral lossMineral loss

Soft tissue responseSoft tissue response Systemic effectsSystemic effects

Contraindications of Contraindications of bleachingbleaching

Discoloration due to restorationsDiscoloration due to restorations Children with large pulp horns and Children with large pulp horns and

cracks(In office)cracks(In office) Pregnant and allergic pts (home Pregnant and allergic pts (home

bleaching) bleaching) exposed roots and severe enamel exposed roots and severe enamel

loss(in office)loss(in office) Pts with TMD (home bleaching)Pts with TMD (home bleaching)

Interference with composite Interference with composite restorationsrestorations

Hydrogen peroxide interferes with Hydrogen peroxide interferes with bonding so a delay of 7-10 days is bonding so a delay of 7-10 days is advised advised

Existing composite restorations may Existing composite restorations may be disked back to allow maximum be disked back to allow maximum exposure of tooth surface for exposure of tooth surface for bleachingbleaching

Non vital bleaching

  When the discoloration When the discoloration is from within the pulp is from within the pulp chamber, from necrotic chamber, from necrotic pulp tissue or from pulp tissue or from staining agents that are staining agents that are present in the pulp present in the pulp chamber, the bleaching chamber, the bleaching treatment need to take treatment need to take place within the pulp place within the pulp chamberchamber

Techniques for non vital Techniques for non vital bleachingbleaching

Thermocatalytic techniqueThermocatalytic technique

Walking bleachingWalking bleaching

Inside-outside bleachingInside-outside bleaching

RecommendatioRecommendationsns

Sodium Sodium perborate perborate mixed with mixed with water water

OROR

10% carbamide 10% carbamide peroxideperoxide

Cervical resorptionCervical resorption Occurs in 7% of casesOccurs in 7% of cases Young ageYoung age Deficiency in cementumDeficiency in cementum Injury to PDLInjury to PDL InfectionInfection Lack of seal over GPLack of seal over GP High conc. Of peroxideHigh conc. Of peroxide HeatHeat

Potential ResultsPotential Results

Alternatives to bleachingAlternatives to bleaching

MicroabrasionMicroabrasion MacroabrasionMacroabrasion Veneers (Direct and Indirect)Veneers (Direct and Indirect) Crowns Crowns

Direct Composite VeneersDirect Composite Veneers

Bleaching before and after Bleaching before and after veneersveneers