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Bleaching

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					Bleaching 11.13.07

1st Century:
    - Roman Physicians advocated brushing teeth with Portuguese urine

1877 Chappel: Oxalic Acid
1879 Taft: Chlorine
1895 Weskale: Hydrogen Peroxide, Ether, Electricity
1918 37% Hydrogen Peroxide, Light, Heat
1939 Younger: 30% Hydrogen Peroxide with ether and heat
1989 Splint, 10% carbamide peroxide
1994 Guidelines for home applied bleaching
1995 Laser PAC light activation

Types of Stain:
   - Tetracycline*
   - Fluorosis*
   - extrinsic environmental stains
   - etc.
* most important for progression of bleaching

AACD Results of what you don’t like about your teeth?
Tooth color 30%
Space between teeth 16%

Bleaching
Non-Vital teeth
   - internal 35-40% hydrogenperoxide
   - tendency for increased external root resorption
Vital Teeth
   - in office
   - at home
   - combination
   - etc

Seven products from four companies have been approved as whitening toothpastes (costs
money and time).
   - Colgate
          o Tartar control plus whitening gell
          o and toothpaste
   - Den-Mat Corp
          o Rembrandt whitening toothpaste, Original
          o Rembrandt Whitening Toothpaste, Mint
   - Procter and gamble
          o Crest crest product
          o Crest product



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    -   Smith Kline
           o Aquafresh something or other

Ingredients:
    - carbamide peroxide or hydrogen peroxide
           o hydrogen peroxide has a much shorter halflife
    - glycerin
    - carbopol
    - sodium hydroxide
    - flavor

Best results: orange, yellow, or light brown.
Bad: dark blue or grey

Great candidates for bleaching:
Teeth were much lighter when younger
Yellow hue
Extrinsic pigmentation
Wants moderate change
Healthy, shapely non restored front teeth
Etc..

Good candidate
Teeth were a little lighter
Brown hue
Want really light teeth

Bad candidate
Teeth were always dark
Etc…

A simple test
- dry the teeth for 90 seconds to predictably demonstrate to both pt and operator the final
tooth color

Toxicity / safety concerns
   - research was performed, and everything is ok

Found difference in color change between study groups as well as a significant increase
in tooth sensitivity.

About flavoring
   - if it smells good, it will stimulate salivation and that’s bad because it will start to
       run the product all over the mouth and may be eaten.

pH – in office



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   -    regulated
   -    mandated to be a neutral pH

OTC pH
  - tend to be on the acidic side

TMJ issues
  - no evidence supports that it makes problems

Pregnancy
   - no studies

In most cases, observed in samples treated with agents of high peroxide content, products
using acidic pre-rinse, or gels with low pH
    - observed alterations varying in ???
    - take home message – changes comparable or less than those cause dby soft drinks
       or fruit juices

Reversible side effects
   - soreness in the mouth/throat
   - soft tissue irritation
           o chemical and mechanical
   - sensitivity

Contraindication
   - pregnant women or nursing mothers
   - children
   - Heavy smokers
   - Insufficient restorations
   - Lesions

Concentration in pulp chamber after 15 minutes
   - found that all bleaching agents will work their way through the enamel and dentin
      into the pulp over time
   - causes an inflammatory response

Thermal hypersensitivity
   - cause unknown
   - maybe due to reversible pulpitis

Inform patient
    - you can’t guarantee results
    - will experience transient sensitivity
    - will rebound after completion
    - must be maintained
    - restorations will not change!



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Sensitivity treatment
   - Passive treatment
            o Bleach less frequently
   - Active treatment
            o Fluoride
            o Blocks tubules
            o Slows fluid movement
            o Potassium nitrate
            o Analgesic effect

Look for in bleaching materials:
   - ADA effectiveness

Only 10% solutions are given approval by the ADA.

Carbamide peroxide
10-44+% on the market

Only five products have been approved by the ADA
   1. colgate oral pharmaceuticals (platunm)
   2. discus dental (nite-white classic)
   3. patterson dental co (patterson brand)
   4. Ultradent products (opalescence)
   5. Rembrant (??)

1st ingredient in OTC
     - Citric Acid

Then they add hydrogen or carbamine peroxide in various concentrations

OTC Products
  - simply white by colgate
         o 18%
         o 30 min for 2-3 weeks
         o Paint-on application
         o No tray required

Clinical comparison of stain removal efficacy of a novel liquid whitening gel containing
18% carbamide peroxide and a commercially available whitening dentrifice. – not a fair
study!

Crest white strips
   - they came to pacific and wanted the research to happen
   - we did some research




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   -    they pulled the products from dentists and went to direct sales from QVC and
        Longs Drug Store
   -    store bought is 6% carbamide peroxide
   -    professional version is 6.5% carbamide peroxide
   -    only really bleaches from about 1pre molar to 1pre molar

Consumer reports:
   - out tests didn’t produce any whitening of tooth enamel with any product – 1998

Opalescence PF
   - contains postassium nitrate and fluoride

Opalescence F
   - contains fluoride

You can not patent the 10% solution.
You CAN patent the delivery system.

Do Lights Work?
Three independent studies all show that the light has no effect.
Gordon Christinsen did a clinical trial – light had no effect.

Most of the lights require some sunscreen to protect the patient’s lips.

Reservoirs on bleaching trays… good or bad?
They are patented by ultradent
So no reservoirs are needed. 

Brite Smile v. Zoom?
Well, discus dental owns both, now.




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