Effect of different bleaching protocols on whitening efficiency and enamel superficial microhardness

Biological action of bleaching agents on tooth structure: A review

The use of bleaching agents to remove stains is one of the main dental procedures to improve the aesthetics of teeth. This review presents the main agents used for tooth whitening, existing clinical protocols, and the structural changes that may occur through their use. The main bleaching agents consist of hydrogen peroxide and carbamide peroxide, which are used in bleaching techniques for vital teeth. These techniques can be performed in the office by a professional or by the individual in a home en-vironment under professional guidance. Bleaching agents come in a variety of concentrations and there are over-the-counter products available on the market with lower concentrations of hydrogen peroxide. Due to the chemical characteristics of the agents, changes in the organic and inorganic content of the tooth structure can be observed. These changes are related to morphological changes characterized by in-creased permeability and surface roughness, such changes compromise the mechanical resistance of the tooth. Furthermore, bleaching agents can promote molecular changes after reaching the dental pulp, resulting in oxidative stress of pulp cells and the release of pro-inflammatory mediators. Despite the bleaching effectiveness, tooth sensitivity is considered the main side effect of use. Therefore, among the heterogeneity of protocols, those that used the bleaching agent for a prolonged time and in lower con-centrations presented more harmful effects on the tooth structure.

Effect of Various Vital Bleaching Systems on Clinical Outcomes and Patient Satisfaction

Objective To evaluate the clinical behavior of different bleaching products - the hydrogen peroxide (H2O2), carbamide peroxide (CP), and titanium dioxide bleaching systems. Methods Three bleaching systems with different concentrations (H2O2 15%, 38%, CP 15%, 35%, and titanium dioxide 20% H2O2) were used. Sixty participants with discolored teeth were enrolled and equally divided into six groups. Each group was rendered the assigned bleaching protocol against the control group, which received plain dentifrice polishing. Each case was evaluated immediately, two weeks, three months, six months, and one year after the bleaching treatment. The clinical evaluation was made for color change by (shade guide and digital images with L*a*b* parameters), tooth sensitivity, gingival irritation, and participants' satisfaction. Results All bleaching systems showed color improvement after bleaching regimens with significant effect showed by in-office titanium dioxide 20% H2O2 followed by 38% H2O2 with Δ=10.26 and Δ=6.52, respectively, when compared to other bleaching techniques. Higher sensitivity was recorded in group III with 50% of the participants reporting postoperative sensitivity. Higher gingival irritation was recorded in group IV (15% CP) where 60% of the patients reported gingival irritation. Thirty-five of the 60 participants (58.5%) recorded that the treatment whitened their teeth "moderately" and "a lot" while seven participants recorded "a slight" difference. There was a highly significant difference in participants' satisfaction between all bleaching groups (p < 0.05). Conclusion It is evident that there is a development of dental sensitivity and gingival irritation irrespective of the bleaching system used. The color assessment showed that the desired result can be achieved with variable levels of patient satisfaction with excellent overall results with the titanium dioxide system.

Influence of ceramic thickness, background and cement shade on the translucency of zirconia reinforced lithium silicate and lithium disilicate ceramics

Background

Although, the influence of cement and background shade on the final color and translucency of zirconia reinforced lithium silicate (ZLS) and lithium disilicate (LDS) ceramics has been previously investigated, there is still little data on the translucency of LDS and ZLS ceramics in decreased thickness (0.4 and 0.6 mm). The aim of this study was to investigate ceramic thickness', background and cement shades' effects on the zirconia reinforced lithium silicate (ZLS) and lithium disilicate (LDS) ceramics' translucency.

Material and Methods

Totally 160 square-shaped A1 shade LDS and ZLS samples produced in 0.4 and 0.6 mm thicknesses were cemented with light and neutral shade resin cement on A2 and A3 shade composite resin backgrounds. The color notations of specimen were measured and translucency parameter (TP) values were calculated. Factorial ANOVA and Tamhane's T2 multiple comparison statistical analyzes were used.

Results

Highest TP values (11.82±0.97) were obtained in ZLS specimens that were 0.4 mm in thickness, cemented on A2 background with light shade resin cement. While, the lowest TP values (9.60±0.55) were calculated in LDS samples that had 0.6 mm thickness, cemented on A3 background with neutral shade resin cement.

Conclusions

Material type, thickness, and background shade affected TP values of specimens. The cement and background shade used might change the final translucency of ZLS and LDS ceramics that had 0.4 and 0.6 mm thickness. Key words:Ceramics, lithium disilicate, spectrophotometry, zirconia, dental materials.

EFFECTS OF PROFESSIONAL ORAL HYGIENE AND TEETH WHITENING ON THE MICROELEMENT COMPOSITION OF ENAMEL

OBJECTIVE

Aim: The objective of this study is to investigate the impact of professional teeth cleaning and the substances used in modern dentistry for whitening on the microelement composition of tooth enamel.

PATIENTS AND METHODS

Materials and Methods: To study the morphology and microelement composition of the enamel, scanning electron microscopy was performed using the MiraLM microscope equipped with a Schottky field emission electron gun from Tescan.

RESULTS

Results: A comparative analysis between the areas subjected to mechanical cleaning and those where it was not applied revealed a significant difference in the research results, particularly in carbon, which changed from 25.16±1.04 to 32.02±1.8. An analysis of the enamel's chemical composition before and after whitening revealed a decrease in carbon from 45.91±1.20 to 42.46±1.74. The change in phosphorus content was determined to be from 9.77±0.39 to 9.56±0.75. A decrease in calcium from 15.96±0.64 to 15.21±1.22 and magnesium from 0.07±0.01 to 0.01±0.01 was also observed.

CONCLUSION

Conclusions: Professional dental hygiene does not have a direct impact on the microelement composition of enamel, such as the levels of calcium, phosphorus, fluoride, and other microelements. However, it can have an indirect and temporary influence due to the use of abrasive materials that affect dental deposits, pellicle, and the surface layer of enamel. Teeth whitening can affect the microelement composition of enamel, but these changes are mostly temporary and associated with processes of demineralization/ remineralization and oxygenation.

Microhardness change of human dental enamel due to power bleaching with different gels

AIM

Since the introduction of bleaching treatments in the office, different lights have been suggested to accelerate the bleaching reaction. This study aimed to evaluate the microhardness of tooth enamel after office bleaching using different materials.

Quantitative Measurements of the Depth of Enamel Demineralization before and after Bleach: An In Vitro Study

Objective

This study is aimed at determining two main points. First, if the Canary System™ (CS), initially used to assess caries, can measure a decalcification depth of bleached enamel quantitatively, and second, whether or not whitening has a harmful effect on enamel. This device can be considered a useful tool in the clinical assessment of the progression of demineralization after bleaching.

Materials and Methods

This study collected sixty human premolars that are in a good state recently extracted for orthodontic reason. To properly disinfect and preserve the premolars, they were stored in a saline solution and later in distilled water for a period of two weeks to allow the premolars to rehydrate. Later, 24 hours before the experiment, the premolars were introduced into a solution of artificial saliva to acquire back their minerals. The mineral content of the teeth was measured by the Canary System™ before bleaching. The teeth were bleached with 30% hydrogen peroxide (fläsh HP 30%), 30 min per week and for 3 consecutive weeks to simulate the conditions of strong bleaching in the clinic. The extent of demineralized enamel was measured by the Canary System™ at three points on the enamel surface of each tooth. The data were averaged for each application of the bleaching product. The demineralization extent of the teeth was measured by the Canary System™ before and after bleaching. The significance level was set at 0.05, and SPSS version 26 was used. The data were analyzed by using Wilcoxon's and Student's tests.

Results

Mineral loss occurred after the first bleaching session; the Canary System™ detected a decalcification in the first bleaching session (532 ± 322 μm) compared to the other sessions (p ≤ 0.05), while no significant change was detected between the second and the third sessions (p > 0.05).

Conclusion

Based on the findings of the present study, under in vitro conditions, it was possible to measure the demineralization extent of bleached enamel with the Canary System™.

Effect of conventional and power office bleaching with diode laser and led light on enamel microhardness

Aim: The present study aimed to asses enamel microhardness after office bleaching with diode laser and LED light compared to the conventional bleaching procedure. Methods: Thirty-nine human premolar teeth were collected and randomly divided into three groups regarding of the bleaching technique. Group 1: Snow O bleaching gel with LED light-curing unit; Group 2: Snow L bleaching gel with diode laser irradiation; and Group 3: Opalescence Boost bleaching gel with no light source in group 3. Enamel surface changes were evaluated in one tooth in each study group and one intact tooth as a reference under a scanning electron microscope (SEM). In the remaining samples (n=12), enamel microhardness was determined by Vickers microhardness test before and after bleaching. Data were analyzed with repeated-measures ANOVA to compare microhardness changes, followed by post hoc Tukey tests at the 0.05 significance level. Results: Enamel microhardness decreased in all the groups after bleaching, with the maximum decrease in microhardness in the Snow O bleaching group with LED light, which was significantly higher than the other groups (P=0.002). The two other groups did not exhibit any significant difference in microhardness decrease (P>0.05). Conclusion: Based on the limitations of this study, it can be concluded power bleaching with 980nm diode laser was less time-consuming compare to conventional bleaching procedure and yielded better outcomes in terms of enamel surface microhardness compared to the use of an LED light-curing unit.  

Effect of a Self-Assembly Peptide on Surface Roughness and Hardness of Bleached Enamel

After bleaching, enamel surfaces are damaged, contributing to erosion and tooth sensitivity. Although fluoride is used after bleaching to try and revert alterations, it is not capable of repairing tooth structure. This study compared the effect of a self-assembly peptide (P11-4), with and without fluoride, and sodium fluoride (NaF 2%) on the Knoop microhardness (KHN) and surface roughness (Ra (μm)) of bleached enamel with an in-office bleaching regimen. Enamel blocks of bovine teeth (5 × 5 × 2 mm) with standardized surface hardness were bleached with 35% carbamide peroxide, following the manufacturer’s instructions. The teeth were randomly divided into the following groups (n = 7) according to post-bleaching treatment: no treatment (negative control) (C-); 2% NaF (NaF); Curodont™ Repair (Repair); and Curodont™ Protect (Protect). Specimens were stored in artificial saliva at 37 °C. To evaluate the effect of the post-bleaching treatments, KHN and Ra were measured before bleaching (baseline) and 24 h and 7 days after bleaching. Data were submitted to repeated measures ANOVA and Bonferroni tests (α = 0.05). There were significant interactions between the study factors (p = 0.001). After 7 days, Repair (572.50 ± 79.04) and Protect (583.00 ± 74.76) specimens showed increased surface KHN, with values higher than the NaF (465.50 ± 41.50) and C- (475.22 ± 58.95) baseline values. There was no significant difference in KHN at 24 h among groups (p = 0.587). At 24 h after bleaching, Repair was significantly different from all groups (p < 0.05). Repair showed the lowest Ra (μm) values (0.133 ± 0.035). After seven days, there was no significant difference in Ra values among groups when compared to the baseline. The use of P11-4-based materials after bleaching resulted in the fastest recovery to baseline enamel properties.

Surface Morphological Changes and Predisposition to Staining in Dental Enamel Bleached with Different Hydrogen Peroxide Concentrations

Background:

The tooth bleaching treatment can cause structural changes in the surfaces of the teeth; these changes can increase the absorption of staining agents.

Purpose:

This study assessed surface morphological changes and predisposition to staining in dental enamel bleached with different hydrogen peroxide (HP) concentrations, with or without the use of a light source (LS).

Methods:

25 bovine incisor specimens were divided into five groups (n = 5): Control- no treatment; HP35 - hydrogen peroxide 35%; HP35+LED - hydrogen peroxide 35% + light emission; HP20 - hydrogen peroxide 20%; and HP7 - hydrogen peroxide 7,5%. Twenty days after bleaching, the specimens were immersed in staining solutions four hours a day for 28 days. The morphological alterations of the bovine enamel surface were evaluated by means of scanning electron microscopy, X-ray dispersive energy spectroscopy and predisposition to the staining of the brightened enamel by means of colorimetry.

Results:

ANOVA with Tukey's test (p<0.05) showed that HP7 had the highest ΔL values (p=0.176) (brightest), with a better lightening effect. The bleached groups exhibited morphological changes in the enamel. The groups did not exhibit significant changes in oxygen, calcium, and phosphorus values (p=0.020). The presence or absence of light was not significant (p=0.007) for the predisposition to staining in bleached teeth.

Conclusion:

The time of exposure to the staining solution was significant for staining bovine dental enamel. High concentrations of HP were not necessary for achieving effective bleaching. HP caused an increase in enamel porosity and depressions. The light source did not influence bleaching.

Effects of 35% hydrogen peroxide solution containing hydrated calcium silicate on enamel surface

OBJECTIVES

The objectives of this study were to develop a novel bleaching material containing hydrated calcium silicate (hCS) particles and investigate the effects of hCS on the bleaching efficacy, microhardness, and surface morphology of bovine enamel.

MATERIALS AND METHODS

To prepare the hCS particles, white Portland cement was mixed with distilled water and ground into a fine powder. The particles in various proportions were then mixed with 35% hydrogen peroxide solution (HP), while HP without hCS was used as a control (HP), and teeth whitening gel was used as a commercial control (CC). Following the thrice application of experimental and control solutions on the discolored bovine enamel surface for 15 min, color change (n = 10), microhardness (n = 10), and micromorphology (n = 2) of the enamel surface were analyzed.

RESULTS

The Δ E^* of the enamel surface treated with the experimental solution containing hCS was significantly higher than that of the CC, but there were no significant differences between the different hCS contents. The experimental solution containing hCS reduced the percentage of microhardness loss on the enamel surface, and the percentage of microhardness loss significantly decreased as the content of hCS increased (p < 0.05). The erosion pattern was only observed on enamel surfaces treated with HP and CC.

CONCLUSIONS

This study suggests that HP containing hCS is effective in bleaching efficacy. In addition, hCS could also minimize the microhardness loss of tooth structure caused by HP and maintain enamel surface morphology.

CLINICAL RELEVANCE

This novel bleaching material is promising for inhibiting demineralization and promoting the remineralization of teeth during bleaching treatment in dental clinics.

A comparative evaluation of the effect of three different concentrations of in-office bleaching agents on microhardness and surface roughness of enamel - An in vitro study

BACKGROUND

To evaluate the changes in the micro-hardness and surface roughness of enamel treated with three different concentrations of in-office bleaching agents.

MATERIALS AND METHODS

In this in vitro study, 60 human incisors were divided into two groups (Group A and Group B). To obtain the baseline values, a Vickers tester was used to determine the surface microhardness in Group A, and a Surtronic tester was used for evaluation of surface roughness in Group B. Each group was then further subdivided into three subgroups and subjected to bleaching with Dash (Groups A1 and B1), Pola Office (Groups A2 and B2), and Opalescence Boost (Groups A3 and B3) containing 30%, 35%, and 40% hydrogen peroxide (HP), respectively. Samples were again subjected to testing to obtain the postbleaching values. Pre- and postbleaching data were analyzed by paired t-test. Intergroup comparison was carried out using one-way ANOVA (P ≤ 0.05).

RESULTS

A significant decrease in microhardness values was observed following bleaching in all the three groups, with Group A1 showing maximum percentage decrease (2.58%), followed by Group A2 (1.23%) and Group A3 (0.73%). Furthermore, an increase in surface roughness was observed following bleaching, with Group B1 showing maximum percentage increase (14.80%), followed by Group B2 (8.25%) and Group B3 (5.79%). However, there was no significant difference in either microhardness or surface roughness when comparing the postbleaching values among the three bleaching agents.

CONCLUSION

In-office bleaching agents may adversely affect the microhardness and roughness of enamel surface which are not related to the concentration of HP used.

Combination of strontium chloride and photobiomodulation in the control of tooth sensitivity post-bleaching: A split-mouth randomized clinical trial

Objective

This split-mouth randomized controlled clinical trial assessed the effect of 10% strontium chloride in combination with photobiomodulation (PBM) for the control of tooth sensitivity (TS) post-bleaching.

Methods

The upper/lower, right and left quadrants of fifty volunteers were randomized and allocated to four groups (n = 25): PLACEBO—placebo gel + simulation of PBM; Placebo + PBM; STRONTIUM—10% strontium chloride + simulation of PBM; and PBM + STRONTIUM—10% strontium chloride + PBM. All groups received tooth bleaching treatment with 35% hydrogen peroxide. For the PBM treatment, the laser tip was positioned in the apical and cervical regions of the teeth bleached in the respective hemi-arch. The laser system was operated in continuous mode, using 1.7 J of energy. A dose of 60 J/cm² was applied to each point for 16 seconds under 808 nm near-infrared light (100mW of power), with a point area of 0.028 cm². TS was assessed during a 21-day follow-up, using the modified visual analogue scale.

Results

In the intragroup assessment, the Friedman test indicated that PBM + STRONTIUM promoted the greatest reduction in TS after the second week of treatment (p ≤ 0.05). The Wilcoxon-Mann-Whitney test indicated that the groups Placebo + PBM, STRONTIUM, and STRONTIUM + PBM did not differ statistically (p ≥ 0.05) in the first and third weeks of treatment The group PLACEBO exhibited the greatest TS in the first three days after each bleaching session.

Conclusion

The combination of 10% strontium chloride with PBM was effective in reducing post-bleaching TS; however, the combination of 10% strontium chloride with PBM was effective in reducing post-bleaching TS; however, it did not differ from the individual use of Placebo + PBM or STRONTIUM groups assessed after 21 days of follow-up.

Impact of Bleaching before or after Veneer Preparation on Color Masking Ability of Laminate Veneers: An In Vitro Study

Purpose

This study evaluates the effect of bleaching before or after veneer preparation and the depth of preparation on color masking ability of laminate veneers. Methods. Sixty extracted premolars were artificially stained to vita shade A4, verified by digital spectrophotometer (Vita Easy Shade V), and then divided into three groups: NB = nonbleached, BBP = bleaching before preparation, and BAP = bleaching after preparation. Based on the preparation depths, each group was further divided into two subgroups: S1 = 0.5 mm and S2 = 1.0 mm. BBP and BAP were subjected to one session of in-office bleaching using 35% hydrogen peroxide. IPS e-max CAD veneers of 0.5 and 1.0 mm thickness (corresponding to the preparation depths) of the same shade and translucency (HT A1) were cemented immediately to the bleached surfaces. Immediately after cementation, the color change ΔE between the baseline (after staining) and the resulted shades was measured using the Vita Easy Shade V digital spectrophotometer and CIELab color system.

Results

Bleached groups exhibited a significant ΔE value compared to the nonbleached group (p < 0.05). BAP showed the highest ΔE value. No significant difference was found between BBP and BAP. S2 revealed a significant ΔE value than S1 (p < 0.05). No significant difference was found between S1of BAP and S2 of NB, BBP, and BAP (p > 0.05). Regarding the color coordinates, the difference between the tested groups was highly significant in lightness (ΔL∗) (p < 0.001), while no significant differences were found in green/red value (Δa∗) and yellow/blue value (Δb∗) (p > 0.05).

Conclusions

In cases of severe tooth discoloration, one session of in-office bleaching before or after veneer preparation and the preparation depth do not influence the color masking ability of laminate veneers.

Efficacy of In-office Bleaching on Microhardness of Permanent Teeth with Antioxidant Re-hardening

Background:

Bleaching procedures affect surface enamel structure and decrease its bonding ability to resin composite restorative materials. The application of re-hardening materials to bleached enamel surfaces may prevent this decrease in micro-hardness.

Objective:

This in-vitro study aims to evaluate the surface micro hardness of human teeth enamel subjected to bleaching with Zoom Advanced Power 2 AP (Phillips, USA), and Opalescence Boost (Ultradent, USA) and compare the re-hardening effects of 10% Sodium Ascorbate, 2% acidulated phosphate fluoride gel, and a 5% Potassium nitrate 0.22% Sodium Fluoride + Calcium Nitrate gel.

Methods:

Ninety human third molar teeth were used. The specimens were randomly assigned to 5 groups. After the bleaching procedure, the specimens were treated with APF, Sodium Ascorbate or Relief gel as re-hardening agents with 30 teeth in each group. Enamel micro-hardness was measured with Vickers Micro-hardness Tester. The data were evaluated with Kolmogorov-Simirnov, one-way ANOVA, Dunnett’s test, post-hoc Tukey and T-tests.

Results:

Statistical analysis revealed no significant differences among initial enamel groups’ micro-hardness values (P>.05); however, significant differences occurred between initial and after bleaching treatment group value for G3 (P< .05). After re-hardening, only the Sodium Ascorbate group showed a statistically significant increase with hardness values (P< .05) for G4 and G5.

Conclusion:

Bleaching treatment conducted with light had no adverse effect on enamel micro-hardness. Sodium Ascorbate can be useful after bleaching to change the adverse effects of bonding on the enamel.

Chemical composition and roughness of enamel and composite after bleaching, acidic beverages and toothbrushing

Background

In this study was assessed the surface roughness and chemical composition of tooth enamel and composite resin after bleaching treatment, immersion in acidic beverages, and simulated toothbrushing.

Material and Methods

One hundred and twenty dental blocks (10 x 10 x 3 mm) were randomly assigned (n = 10) according to surface treatment [none (N), bleaching (B), toothbrushing (T), and B+T] and storage medium [saliva (S), whiskey (W), and orange juice (O)]: experimental groups - N+S, N+W, N+O, B+S, B+W, B+O, S+T, W+T, O+T, B+S+T, B+W+T, and B+O+T. Two bleaching sessions were conducted using 38% hydrogen peroxide (3 applications). Surface roughness was measured using a roughness tester and composition was determined by micro energy-dispersive X-ray fluorescence spectrometry (µ-EDXRF) before and after treatments. Calcium/phosphorus (Ca/P) ratio in enamel and silica (Si) content in composite were evaluated. Data were statistically analyzed by ANOVA and Tukey’s test (α = 0.05).

Results

Overall, increased values of surface roughness for enamel and composite were observed mainly after immersion in orange juice and bleaching/toothbrushing association. Moreover, this association and immersion in whiskey resulted in lower Ca/P ratio and after aging methods, bleached and bleached/toothbrushed groups showed decreased in Ca/P ratio compared to initial values. All groups showed Si content decrease at the end, except the group without surface treatment and immersed in saliva, and bleaching followed by immersion in orange juice and toothbrushing caused the highest Si reduction.

Conclusions

Bleaching and toothbrushing combination strengthened the effects caused by acidic drinks on roughness and chemical composition of enamel and composite.

Key words:Tooth bleaching, toothbrushing, physical properties, chemical properties.

Dental enamel bleached for a prolonged and excessive time: Morphological changes

This work aimed to evaluate the roughness, microhardness, ultrastructure, chemical composition and crystalline structure in submitted teeth to a prolonged home bleaching regimen with 10% carbamide peroxide (10% PC) for different periods. The specimens were divided into the following groups: G1: negative control (application of water-soluble gel); G2: tooth whitening group (positive control), under application time recommended by the manufacturer (4h/14 days); G3: prolonged whitening 50%, under prolonged time recommended by the manufacturer in 50% (4h/21 days); G4: excessive whitening 100%, under exceeded manufacturer recommended time by 100% (4h/ 28 days). The results were evaluated descriptively and analytically. There were no changes in the roughness in any of the evaluated groups. However, the microhardness decreased in the G4 group. Scanning electron microscopy showed changes in the enamel surface of groups G2, G3 and G4. Dispersive X-ray spectroscopy identified changes in the concentration of chemical elements O, Mg, P, K in all groups. Thus, this study showed that prolonged home bleaching could cause changes in the ultrastructure, chemical composition and microhardness of the enamel.