Tooth bleaching questions answered.

Tooth bleaching is an exciting treatment option for patients, which has many treatment options and considerations for the dentist. The purpose of this article is to answer questions in a Q&A fashion about different types of tooth bleaching and their applications to various clinical situations and patients' dental situations.

Tray delivery of potassium nitrate-fluoride to reduce bleaching sensitivity.

OBJECTIVE: Tooth sensitivity is a common side effect associated with tooth whitening. The purpose of this study was to determine if bleaching tray delivery of potassium nitrate-fluoride reduces bleaching sensitivity enough to allow continuation of whitening treatment. METHOD AND MATERIALS: Thirty patients were enrolled in a university-approved clinical study and had their teeth bleached at night with 10% carbamide peroxide in a custom-fitted tray. The bleaching tray was a rigid experimental design for which sensitivity was expected. If tooth sensitivity was experienced, the patient applied a gel containing 5% potassium nitrate and 1,000 ppm sodium fluoride in the bleaching tray for various time periods. Log forms were collected upon completion of bleaching, and patient interviews were used to compare effects of the gel before and after sensitivity treatment. RESULTS: Sixteen out of 30 patients experienced tooth sensitivity. Of those 16 patients, 12 used the gel, and 11 of the 12 reported a reduction in sensitivity. Treatment times ranged from 10 minutes before bleaching to 30 minutes before and after. The number of applications ranged from one to continuous use. Some patients were able to continue bleaching after one gel application with no subsequent sensitivity. Other patients were unable to continue bleaching unless they continued using the gel. The incidence of tooth sensitivity (53%) reported in this study is consistent with sensitivity reported in studies using semi-rigid custom-fitted trays made from stone casts with a nonscalloped, nonreservoir design. CONCLUSION: The use of a 5% potassium nitrate-fluoride gel applied in the tray as needed for tooth sensitivity associated with nightguard vital bleaching can reduce sensitivity in a majority of patients and allow most patients to continue bleaching to completion.

Bleaching primary teeth with 10% carbamide peroxide.

Bleaching teeth with 10% carbamide peroxide in a custom-fitted tray has been popular for more than 10 years. However, primary teeth are seldom considered for bleaching due to the need for compliance by the child and the natural whiteness of the primary teeth. This report describes an indication-teeth darkened from trauma-as well as the technique and outcome for bleaching discolored primary teeth.

Teaching nightguard bleaching and other tooth-whitening procedures in North American dental schools.

Tooth-whitening using carbamide peroxide delivered in a custom-fitted tray (nightguard bleaching) is a relatively new procedure, yet it is currently one of the most commonly used types of esthetic dental treatment in private practice. This study determined the extent that nightguard bleaching (NGB) has been included in dental school curricula. All sixty-five dental schools in North America were surveyed about curriculum content and treatment protocol for the use of nightguard and other bleaching procedures, generating an 82 percent response. The survey covered eighteen subject areas related to NGB ranging from clinical requirements and indications to products and recall intervals used. The most commonly taught tooth-whitening procedure was NGB, which was most often taught by operative and restorative faculty. Although no schools had clinical requirements for NGB, 92 percent taught it. The most common indications for NGB were esthetic shade change and pre-restorative lightening of teeth. Unrestored caries, defective restorations, and pre-existing sensitivity were common contraindications. Most schools do not use a specific NGB consent form, but most use written patient instructions. Most schools use at least two different NGB products, bleach for two to four weeks, and use reservoired and scalloped trays. An average of 25 percent of NGB patients were estimated to develop sensitivity, for which treatment recommendations include fluoride, desensitizing toothpaste, and reduced exposure time. Curriculum time and safety concerns were reasons for not teaching NGB (8 percent schools). Most schools indicated that the relative importance of NGB in the curriculum was increasing.

Bleaching and temporomandibular disorder using a half tray design: a clinical report.

A maxillary soft, custom-fitted tray was fabricated for a patient to perform nightguard vital bleaching. Treatment was interrupted after the patient experienced pain in the temporomandibular joint area shortly after wearing the bleaching prosthesis. The tray was trimmed so the labial, incisal and buccal cusps were covered and Sc) the patient had complete tooth-to-tooth contact in the maximum intercuspal position. The prosthesis proved to be retentive even without the presence of the bleaching material. The thick, sticky bleaching material was contained in the half tray design and the tray was held in place. The patient was able to continue the bleaching process for the 2-week duration necessary to achieve successful lightening of the teeth without further TMD symptoms.

Current status of nightguard vital bleaching.

Indications for using a 10% carbamide peroxide material in a custom-fitted tray to whiten teeth include teeth discolored from aging, chromogenic foods and drinks, and smoking, and also brown fluorosis-stained teeth, single dark teeth, and tetracycline-stained teeth. Tetracycline-stains may require 2 to 6 months of nightly treatment, whereas after discolorations generally resolve in 2 to 6 weeks. After an initial relapse in the first 2 weeks after the end of treatment, color tends to be stable for 1 to 3 years, with some treatments being permanent. The ADA has approved only six 10% carbamide peroxide materials, which have extensive research and publications on safety and efficacy. Considering the average cost of $196 per arch, and the noninvasive nature of this treatment, nightguard vital bleaching is probably the safest, most cost-effective, patient-pleasing method to improve the appearance of a smile. However, it should be supervised by a dentist for the proper examination, diagnosis of the cause of discoloration, treatment options, and fabrication and fitting of the carrier. Sensitivity during whitening may be treated with fluoride and potassium nitrate.

Assessing dentin color changes from nightguard vital bleaching.

BACKGROUND: At-home bleaching with 10 percent carbamide peroxide in a custom-fitted tray has been reported to change the color of dentin. The purpose of this study was to validate the color change of dentin and to determine whether the color change was uniform or occurred from the outside (the dentinoenamel junction) to the inside (the pulpal wall). METHODS: The authors sectioned 10 extracted human teeth incisogingivally through the midfacial long axis, and sealed their cut surface against glass microscope slides. Identifying marks were placed on the glass over the tooth sections to serve as a color control and in the dentinal areas closest to the dentinoenamel junction and the pulpal wall. Teeth were bleached for 10 days with 10 percent carbamide peroxide. Photographs were taken from the glass-covered side of the teeth, digitized and converted to gray-scale levels (consisting of 256 shades of gray ranging from black to white). Marked areas were measured with a National Institutes of Health Image software program and analyzed statistically for changes in lightness between the control marks and the inner and outer dentinal marks over time. RESULTS: Paired t-tests and analysis of variance indicated a significant increase in lightness (P = .01) for the inner and outer dentinal areas during bleaching compared with the control areas. No significant differences were found in the rate of change for the inner and outer dentinal areas (P = .89). CONCLUSIONS: The increase in lightness confirms that a significant color change occurred in the dentin during bleaching with 10 percent carbamide peroxide. This change occurred throughout the dentin at a uniform rate, rather than from the outside inward. CLINICAL IMPLICATIONS: The results of this study show that at-home bleaching with 10 percent carbamide peroxide can change the color of dentin, which is important to treat intrinsic stains from tetracycline treatment, trauma and aging or inherited discolorations. The bleaching material easily penetrates the tooth to change the dentin color at the same rate throughout, indicating that the type of stain may be the important factor in determining bleaching success.

Efficacy of nightguard vital bleaching technique beyond the borders of a shortened tray.

PURPOSE: The purpose of this study was to determine if bleaching extends beyond the borders of a shortened tray or if a demarcation line is found. MATERIALS AND METHODS: Fifteen extracted teeth were selected darker than B2 on a Vita Lumin Shade guide (Vita Lumin, Bad Sackingen, Germany). The teeth were mounted in arch-like fashion in dental stone. Alginate impressions were made, and a stone replica of the four arches of teeth was generated. Vacuum-formed bleaching trays were fabricated for each arch, without and with reservoirs, as per the product to be tested. The nonreservoir trays were trimmed to one half the clinical crown length, and the reservoir trays were trimmed 1 mm beyond the border of the half-length reservoir. Measurements were taken from the cementoenamel junction (CEJ) to the tray border for each tooth. The trays averaged 5.1 mm short of the CEJ. The reservoir group was treated with viscous glycerin-based 10% carbamide peroxide (Opalescence, Ultradent Products Inc., South Jordan, Utah); the nonreservoir group with creamy dentifrice-based 10% carbamide peroxide (Platinum, Colgate Oral Pharmaceuticals, Canton, Massachusetts). The trays were loaded and fully seated on the teeth. Excess bleaching material was removed with a toothbrush and water rinse. Each assembly was placed in a humidor with incisal edges down to simulate oral conditions. The process was repeated for fourteen 6- to 8-hour bleaching sessions. Blinded and nonblinded operators determined post-bleaching shades, with consensus reached on differing shades. RESULTS: All teeth demonstrated lightening of 1 to 10 (mean 5.2) increments on the value-oriented shade guide. The bleaching effect extended beyond the tray and no demarcation lines were noted on any of the teeth. CLINICAL SIGNIFICANCE: This in vitro study suggests that successful bleaching occurs beyond the borders of inadvertently shortened trays. The clinician does not necessarily need to remake the tray if the tray does not cover all portions of the tooth.

Carbamide peroxide whitening of nonvital single discolored teeth: case reports.

Patients who present with a single discolored tooth represent a significant restorative challenge. These case reports describe an economic and conservative treatment option for these patients. The situations presented demonstrate techniques for bleaching with carbamide peroxide in a traditional nightguard or with an inside-outside technique to achieve acceptable esthetic results on isolated nonvital discolored teeth. Although these techniques may not be effective in all cases, they do not compromise or eliminate any future treatment options.

Nightguard vital bleaching of tetracycline-stained teeth: 54 months post treatment.

PURPOSE: The purpose of this longitudinal whitening study was to determine the stability, post-treatment side effects, and patient satisfaction after 6 months of active treatment of tetracycline-stained teeth with 10% carbamide peroxide at 0 and 54 months post treatment. MATERIALS AND METHODS: Twelve patients who completed the study (80%) were contacted and asked to participate in a survey concerning their whitening experience. Subjects were asked whether there had been any change in the shade of their teeth after treatment, and if they had experienced any side effects that they believed were treatment-related. Eight of the twelve patients underwent clinical examination. RESULTS: Ten patients (83%) reported no obvious shade change or only a slight darkening not noticed by others. Two (17%) reported a slight darkening that is probably noticeable by other people, but no one reported moderate darkening or significant darkening back to original shade. All respondents (n = 12) denied having to have a crown or root canal that they believed was treatment-related. Examiners who compared preoperative and post-treatment photographs and Vita shade values were in agreement with the patient's perceptions of shade change. The degree of improvement was significant for both the immediate (0 mo) and the 54-month post-treatment comparison with the pretreatment shade (p < .005 and p < .01 respectively). CLINICAL SIGNIFICANCE: Results of this nightguard vital bleaching study indicate that tetracycline-stained teeth can be whitened successfully using extended treatment time, and that shade stability may last at least 54 months after treatment. Patients who participated in this study were overwhelmingly positive about the procedure in terms of shade retention and lack of post-treatment side effects.

The current status of vital tooth whitening techniques.

Tooth whitening of vital teeth continues to have a major impact on the practice of dentistry. The growing public interest in having whiter, brighter teeth is clearly evident in the advertisements from toothpaste manufacturers on "whitening" formulations of their products and by the number of individuals seeking whitening procedures from their dentists. In addition, new over-the-counter whitening products continue to emerge in a marketplace that cannot seem to get teeth white enough, bright enough, fast enough. What new products and procedures have evolved over the past decade to whiten teeth? Are they better, safer, faster, and more effective now? Are dentists meeting public demand for whiter teeth and is this quest having a positive or negative impact on the practice of dentistry or the patient's dental health? I posed these questions to a group of experts on whitening procedures to get their opinions and recommendations.

Nightguard vital bleaching beneath existing porcelain veneers: a case report.

Dentist-prescribed, at-home bleaching with 10% carbamide peroxide was used to lighten the apparent color of teeth with preexisting porcelain veneers. Veneers had been placed over unprepared, tetracycline-stained teeth; the translucency of the veneers over the discolored teeth resulted in a graying of the veneers. A custom-fitted tray with no reservoirs and no gingival scalloping was fabricated. A 10% carbamide peroxide material was applied nightly for 9 months to achieve the maximum change in the underlying tooth color. The patient was pleased with the apparent color change. Tooth sensitivity during treatment was minimal (lasting 4 days total); the patient treated sensitivity by brushing with a potassium nitrate-containing toothpaste or applying fluoride in the tray.

Use of different concentrations of carbamide peroxide for bleaching teeth: an in vitro study.

OBJECTIVE: This in vitro study compared the shade changes in extracted teeth during 2 weeks' whitening with 5%, 10%, or 16% carbamide peroxide. METHOD AND MATERIALS: After color calibration, the sole examiner selected 110 extracted unrestored, noncarious teeth, shade A3 or darker on a value-oriented guide. The teeth were randomly distributed into equal color groups. The control group (11 teeth) was treated with 0.9% saline, while the experimental groups (33 teeth each) were treated with 5%, 10%, or 16% carbamide peroxide. The solutions remained on the teeth for 8 hours. The teeth and tray were rinsed with tap water for 2 minutes, then rehydrated in 0.9% saline for 16 hours in the humidifier. The shade was assessed, and the process was repeated daily for 2 weeks. RESULTS: Repeated-measures analysis of variance indicated a significant difference in overall shade values between the control and all carbamide peroxide-treated groups at days 8 and 15. A Kaplan-Meier Survival Analysis indicated a quicker two-tab color change for the 10% and 16% groups than the 5% group. However, continuation of the 5% treatment to 3 weeks resulted in shades that approached the 2-week 10% and 16% values. CONCLUSION: Lower concentrations of carbamide peroxide take longer to whitening teeth but eventually achieve the same result as higher concentrations. Higher concentrations may cause increased sensitivity.

Nightguard vital bleaching removes brown discoloration for 7 years: a case report.

Nightguard vital bleaching with 10% carbamide peroxide was used to remove a brown stain from the maxillary central incisor of a 13-year-old-boy. After 7 years, during which there was no touch-up treatment, the discoloration had not returned. This conservative technique should be considered before more invasive procedures for the treatment of discolored vital teeth in young patients.

Using double-poured alginate impressions to fabricate bleaching trays.

Esthetic and diagnostic treatment often requires two casts of one arch, one for baseline and one for alterations (diagnostic wax-up, bleaching tray, occlusal analysis). The purpose of this study was to compare the accuracy of stone casts generated from a second pour of a properly handled alginate impression with first-poured casts. A maxillary dentoform was indexed with six reference spaces (#8-15, 9-2, 2-15, and incisal-to-gingival of #3, 9, 14). Irreversible hydrocolloid (Jeltrate) impressions were made in perforated steel trays by a single investigator. Impression material was spatulated for 1 minute. The seated impression and dentoform were wrapped in a damp paper towel to simulate intraoral conditions, and allowed to set for 2 minutes. Upon separation, the impression was stored in a damp towel for 5 minutes. The impression was poured in cast stone (Microstone) according to the manufacturer's instructions. The stone-filled impression was immediately rewrapped in a damp paper towel and allowed to set for 45 minutes at room temperature. Upon removal of the stone, the impression was rinsed with cold water, shaken dry, and repoured in the same manner. Ten impressions were made: the first five impressions were poured to make casts for Group A, then repoured as described above for casts for Group B. The remaining five impressions were poured once to make casts for Group C. The six spaces of each cast were measured three times in random order using a dial caliper and the space average calculated for the cast. At each space, analysis of variance showed no significant difference among Groups A, B, or C (P < 0.05). When alginate impressions that have been poured with cast stone are kept moist during stone setting and repoured within 45 minutes, two casts can be generated from one impression with the same degree of accuracy as two casts made from taking two separate impressions, providing the alginate does not tear during first cast removal.

Dental practices that aid the general practitioner and forensic dentist.

There are practices that improve the efficiency of a general dentistry office and may aid a forensic dentist in making an identification. These practices include maintaining current dental charts, using the accepted post-mortem charting nomenclature, and maintaining quality radiographs as well as complete and legible progress notes.

Simultaneous bleaching of vital teeth and an open-chamber nonvital tooth with 10% carbamide peroxide.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of bleaching a nonvital tooth with an open pulp chamber while simultaneously bleaching the other vital teeth with 10% carbamide peroxide. METHOD AND MATERIALS: Ten discolored nonvital teeth were treated. Each nonvital tooth was prepared as in the conventional "walking bleaching" fashion, so that the gutta-percha was sealed from the pulp chamber. The 10% carbamide peroxide was injected into the chamber of the nonvital tooth and loaded into the custom-fitted tray for all teeth. The nonvital teeth were bleached from both the inside and the outside. The patient closed the orifice with a cotton pellet during the day and changed the cotton pellet after meals. The patient applied fresh solution nightly. RESULTS: All teeth were successfully lightened. The time required to lighten the nonvital tooth was related to the duration of the discoloration. CONCLUSION: With proper patient selection and education, this technique can provide an effective way to lighten nonvital and vital teeth simultaneously, especially where extended treatment time may be required for difficult discolorations.