doi:10.1111/j.1365-2591.2012.02090.

Ultrasonic activation of internal bleaching agents

M. Cardoso1, C. S. M. Martinelli1, C. A. T. Carvalho2, A. B. Borges2 & C. R. G. Torres2

1

Dental Materials and Prosthodontics Department, Sao Jose dos Campos Dental School, Unesp, Univ Estadual Paulista, Sao Jose
dos Campos, SP; and 2Restorative Dentistry Department, Sao Jose dos Campos Dental School, Unesp, Univ Estadual Paulista,
Sao Jose dos Campos, SP, Brazil

Abstract
Cardoso M, Martinelli CSM, Carvalho CAT, Borges AB,
Torres CRG. Ultrasonic activation of internal bleaching
agents. International Endodontic Journal, 46, 4046, 2013.

Aim To evaluate the effectiveness of ultrasonic

activation of bleaching agents during ex vivo internal
bleaching.
Methodology Fifty canine human teeth were
artificially stained, root filled and divided into five
groups (n = 10) that received SP sodium perborate
plus deionized water (control group), CP 37% carbamide peroxide gel, CPUS 37% carbamide peroxide
gel plus ultrasonic application, HP 35% hydrogen
peroxide gel or HPUS 35% hydrogen peroxide gel
plus ultrasonic application. In groups CP and HP, the
bleaching agent was left inside the pulp chamber for
three applications of 10 min. In groups CPUS and
HPUS, the same process was performed, but
ultrasonic vibration was applied to the bleaching
agent by an alloy tip for 30 s, with 30 s intervals.
Two sessions were performed. The colour was measured initially and after each session by an intraoral
dental spectrophotometer. The variation (D) of the

Introduction
Internal bleaching is a simple, conservative and costeffective treatment for discoloured root filled teeth
(Carrasco et al. 2004, Lee et al. 2004, Lim et al.

Correspondence: Mayra Cardoso, Dental Materials and

Prosthodontics Department, Sao Jose dos Campos Dental
School, Unesp, Univ Estadual Paulista, Avenida Francisco
Jose Longo, 777 CEP: 12245-000, Sao Jose dos Campos, SP,
Brazil (Tel.: +55 12 3947-9032; e-mail: mayra.cardoso@
bol.com.br).

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International Endodontic Journal, 46, 4046, 2013

colour parameters based on the CIELab system L*, a*

and b*, and the colour alteration DE* were calculated
after first and second section. Data were analysed by
one-way ANOVA and Tukeys test.
Results There was no significant difference amongst
groups for DL*, Da* and DE*, but there was a significant difference for Db* in the first and second sessions
(P = 0.0006 and 0.0016, respectively). After the first
session, Db* was significantly greater for groups HP
and HPUS, without a significant difference between
them. For the second session, group HPUS had the
greatest Db* values, but they were similar to groups
HP and SP; group CP had the lowest values, which
were similar to groups CPUS and SP.
Conclusion Ultrasonic activation of bleaching
agents during ex vivo internal bleaching was no more
effective than conventional internal bleaching
procedures, without activation.
Keywords: carbamide peroxide, hydrogen peroxide, internal bleaching, sodium perborate, spectrophotometer, ultrasonic activation.
Received 4 December 2011; accepted 27 May 2012

2004). Currently, the most commonly used internal

bleaching agents (employed at different concentrations) are hydrogen peroxide, carbamide peroxide and
sodium perborate. However, of these three solutions,
hydrogen peroxide appears to be the active ingredient
because of its ability to produce free radicals such as
hydroperoxyl and hydroxyl. Owing to their low molecular weight, these free radicals can penetrate dentinal
tubules readily, where they break the large aromatic
chains of pigments responsible for tooth darkening
into smaller linear chains making the tooth lighter
(Goldstein & Garber 1995, Plotino et al. 2008).

2012 International Endodontic Journal

Cardoso et al. Ultrasonics of bleaching agent

To facilitate the accelerated breakdown of the

bleaching agent, energy can be transferred to it by
heat, light or laser application, thereby making
bleaching more rapid and efficient (de Carvalho et al.
2002, Carrasco et al. 2007a). It is, however,
worthwhile noting that the application of heat has
been discouraged owing to its potential to cause
external root resorption (Harrington & Natkin 1979).
Travassos et al. (2010) reported that some chemical
substances incorporated into hydrogen peroxide can
accelerate the production of free radicals and make
bleaching faster and more efficient without the side
effects of heat application.
The effect of a tooth bleaching agent is related to
its ability to penetrate dentinal tubules and modify
pigment molecules. The more the agent penetrates
tubules, the better the removal of stains (Carrasco
et al. 2003, 2007b). Removal of smear layer from
dentine surfaces prior to bleaching procedure could
also increase the permeability of dentinal tubules.
This removal can be achieved by applying ortho-phosphoric acid (Pashley et al. 1983, Casey et al. 1989,
Banomyong et al. 2007), using an erbium laser (De
Moor et al. 2010) or by the use of irrigating solutions
with ultrasonic activation (Vansan et al. 1990, Carrasco et al. 2004, Kuah et al. 2009).
Applying ultrasonic activation to irrigating solutions before bleaching causes energy to be transferred
within the solution. This energy transfer promotes
agitation within the molecules of the irrigating solution and as a result, increases their dentine permeability (Carrasco et al. 2004). However, the use of
ultrasonic activation on bleaching agents during
bleaching procedures has not been properly investigated. As a result, this study is aimed at evaluating
the effectiveness of applying ultrasonic activation on
bleaching agents during ex vivo internal bleaching.
The hypothesis was that ultrasonic activation would
promote agitation of bleaching agent molecules,
which in turn would cause the molecules to penetrate
deeper into the dentinal tubules and produce a more
efficient bleaching effect.

Materials and methods

Using an ultrasonic scaler, (Profi III Bios; Dabi Atlante,
Ribeirao Preto, SP, Brazil), fifty extracted canine
human teeth were scaled to remove calculus, and then
polished with a bicarbonate jet. Standard oval access
cavities were prepared with a round diamond bur. The
teeth were stored in thymol 0.1% for 1 month, and

2012 International Endodontic Journal

then placed in 2.5% sodium hypochlorite solution for

48 h, followed by irrigation with distilled water.
Artificial staining of the crowns was performed
using a modified procedure based on the studies of
Freccia & Peters (1982) and Yui et al. (2008). The
teeth were immersed in tubes containing defibrinated
sheep blood and centrifuged at 646.1 g for 20 min,
yielding a biphasic solution: plasma (supernatant)
and precipitate. The plasma was removed and the
tubes were centrifuged for a further 20 min. The
tubes containing the teeth were centrifuged at
3400 rpm for 20 min, twice a day for a further
2 days. The tubes were stored at 37 C and at 100%
humidity in an incubator during the staining process.
On the fourth day, the teeth were removed from the
tubes and placed in clean tubes. Three millilitres of
distilled water was added to the blood samples (without the teeth) and the tubes were centrifuged for
20 min to promote the haemolysis of erythrocytes.
This yielded a biphasic solution, containing the
membranous precipitate and the haemolysate. The
second layer was separated and placed in the tubes
containing the teeth, which were centrifuged for
20 min for three consecutive days. On each day after
the centrifugation, the teeth were irrigated with
distilled water, re-inserted into the tubes, and stored
at 37 C and at 100% humidity. After 6 days, the
blood was changed and all aforementioned procedures
were repeated for a further 6 days.
After staining, the teeth were cleaned in running
water and the canals irrigated with deionized water.
The canals were prepared with oscillatory instruments
(Ultradent Products Inc., South Jordan, UT, USA) with
a low-speed engine (Ultradent Products Inc.) and then
filled with gutta-percha (Dentsply Industria e Comercio
Ltda, Petropolis, RJ, Brazil) using a single gutta-percha cone technique and AH Plus sealer (Dentsply
Industria e Comercio Ltda). After 24 h, the gutta-percha was moved to 3 mm below the cement-enamel
junction, and a cervical plug of zinc phosphate
cement (SSWhite Artigos Dentarios Ltda., Rio de
Janeiro, Brazil) was placed 1 mm below the cementenamel junction.
The initial colour of the teeth (after staining) was
measured by an intraoral dental spectrophotometer
(VITA Easyshade; VITA Zahnfabrik H. Rauter GmbH
& Co. KG, Bad Sackingen, Germany). The mean of
three measurements was calculated. To standardize
the position of the spectrophotometer probe, a custom
matrix of colourless hot glue was used for each
sample (Fig. 1). An acrylic cylinder with the same

International Endodontic Journal, 46, 4046, 2013

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Ultrasonics of bleaching agent Cardoso et al.

diameter as the spectrophotometer probe tip was

positioned at the facial middle-third of each tooth and
fixed with flowable resin. The hot glue was injected
around the cylinder, involving the buccal and proximal aspects of the crown and part of the root. After
the glue had cooled, the cylinder and resin remnants
were removed, leaving an opening in which the
spectrophotometer probe tip could be placed.
Colour measurement was based on the CIELab
system CIE1976 (Commission Internationale dEclairage, Vienna, Austria). The CIELab is a colour system
representing a three-dimensional colour space, where
L* represents the light-dark character, a* the
red-green character and b* the yellow-blue character
(Lai et al. 2003, Davi et al. 2010).
Using stratified distribution by L* values, the
samples were divided into five experimental groups of
10 teeth, each according to the bleaching techniques
used: group SP sodium perborate (Whiteness
Perborato; FGM Produtos Odontologicos, Joinvile, SC,
Brazil) plus deionized water; group CP 37% carbamide peroxide gel (Whiteness Super-endo; FGM Produtos Odontologicos); group CPUS 37% carbamide
peroxide gel plus ultrasonic application; group HP
35% hydrogen peroxide gel (Whiteness HP; FGM
Produtos Odontologicos); and group HPUS 35%
hydrogen peroxide gel plus ultrasonic application.
In group SP, a mixture of sodium perborate and
deionized water was inserted into the pulp chamber.
A cotton pellet was placed on it and the cavity was
(a)

sealed with a plug of zinc phosphate cement. The

samples were stored in artificial saliva (Gohring et al.
2004) at 37 C for 1 week, after which the bleaching
agent was removed and the samples were stored in
artificial saliva for another week. A second colour
measurement was carried out. This group was considered the control group and simulated the walking
bleach technique.
In groups CP and HP, the bleaching agent was
inserted into the pulp chamber and left for 10 min.
After this period, the agent was aspirated and
reinserted. This process was repeated until three applications were performed, totalling 30 min. In groups
CPUS and HPUS, the same process was performed.
However, in this case, ultrasonic vibration was
applied to the bleaching agent by means of a thin tip
(Profi III Bios). The ultrasonic vibration was carried
out for 30 s without cooling, with 30-s intervals
every 10 min, also totalling 30 min. The ultrasonic
device was activated at minimum vibration (24 kHz).
The removal of the bleaching agent was accomplished
using an air-water jet after 10 s.
After bleaching, all samples were stored in artificial
saliva at 37 C for 1 week. The artificial saliva was
replaced every day to avoid saturation by hydrogen
peroxide. The colour was measured thereafter. All colour measurements were made by the same operator.
The entire bleaching process was repeated and the
final colour measured. The colour alteration (DE*)
was evaluated by comparison of variations in the L*,
(b)

Figure 1 Custom matrix positioned on a tooth (a) and the spectrophotometer probe tip placed into the matrix for colour
measurement (b).

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International Endodontic Journal, 46, 4046, 2013

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Cardoso et al. Ultrasonics of bleaching agent

a* and b* values (DL*, Da* and Db*) at 1-week and

2-week durations after bleaching, in relation to the
initial period (stained teeth) using the equation (Yui
et al. 2008):
DE
DL
2 Da
2 Db
2 0:5
The data were analysed by one-way
Tukeys test, at 5% significance level.

ANOVA

and

Results
One-way ANOVA revealed no significant difference
amongst the groups for the parameters DL*, Da* and
DE*, but showed a significant difference for Db*, in
the first and second sessions (P = 0.0006 and
0.0016, respectively), as seen in Table 1. Tukeys test
revealed that after the first session, although the
colour variation was significantly greater for groups
HP and HPUS compared to the other groups, there
was no significant difference between them. For the
second session, group HPUS was associated with the
greatest colour variation values, although similar to
groups HP and SP, whilst group CP had the lowest
values, similar to groups CPUS and SP (Table 2 and
Fig. 2).

Discussion
Ultrasonic devices are currently used in endodontics to
activate irrigating solutions. By promoting agitation of
molecules, they increase their permeability into the
dentinal tubules. The hypothesis was that the application of ultrasonic energy directly to the bleaching
agent would promote the same outcome of increasing
the permeability of the dentinal tubules and as a
result, produce a more effective bleaching effect. This
hypothesis, however, could not be confirmed.

Table 1 Results of one-way

DL*
Da*
Db*
DE*
a

1st session
2nd session
1st session
2nd session
1st session
2nd session
1st session
2nd session

ANOVA

test for CIELab parameters

Mean
square

25.164
26.639
2.1427
2.3227
28.7542
31.4959
30.626
34.316

1.8503
2.0297
1.7663
2.0008
5.92466
5.19341
2.2482
2.3919

0.135843
0.106292
0.152316
0.110578
0.000643a
0.001585a
0.078739
0.064629

Significant difference at 5%.

2012 International Endodontic Journal

The beneficial effect of ultrasonic activation of

irrigating solutions is controversial. Some authors
found no effect of ultrasonics in enhancing dentinal
permeability (Pascon et al. 2007) or in removing the
smear layer (Saber Sel & Hashem 2011).
In the present study, the ultrasonic device was activated at minimum energy (24 kHz) to avoid excessive
increases in temperature inside the pulp chamber.
Cameron (1988) showed that ultrasonic activation of
irrigants for 30 s could elevate the root temperature
to 3237 C, under continuous flow, or up to 40 C,
under intermittent flow; the use for 15 s produced no
change in root temperature. However, an application
protocol of intermittent 15-s intervals within 30 min
would be clinically impracticable. The application protocol used in the present study was based on a pilot
study in which ultrasonic application for 30 s led to a
rise in root temperature of less than 10 C (known to
cause bone injury) (Eriksson et al. 1982). The application for 60 s, however, caused a temperature rise of
above 10 C. Thus, this protocol was chosen to prevent excessive increase in temperature whilst ensuring clinical convenience. Although temperature
variation was not assessed in this study, which is a
limitation, it can be assumed that the temperatures
would be higher for ultrasonic activated groups. The
similarity between the activated and nonactivated
groups may be explained by the fact that the intensity
of vibration and/or the time of application may not
have been sufficient. Jiang et al. (2011) in fact found
that higher ultrasonic intensity enhanced the cleaning efficacy of passive ultrasonic irrigation in comparison with lower intensity. Further studies varying time
of ultrasonic application and ultrasonic intensity
would be desirable.
Stains derived from blood products are considered
to be amongst the easiest kinds of stains to remove
from tooth tissues using bleaching procedures. These
stains, which are produced during a short-term

Table 2 Means (standard deviation) values and results of

Tukeys test for Db* parameter
Groups
HP
HPUS
CPUS
CP
SP

1st session
4.29
3.15
1.12
0.63
0.48

(2.61)
(2.14)ab
(2.40)b
(1.64)b
(2.10)b

2nd session
4.64
5.37
1.58
1.44
3.62

(2.62)ab
(2.47)a
(2.38)bc
(2.28)c
(2.55)abc

a-c
For a given time, values with different letter designations
are significantly different (P < 0.05).

International Endodontic Journal, 46, 4046, 2013

43

Ultrasonics of bleaching agent Cardoso et al.

Figure 2 Graphs of mean and standard deviation of colour variation measurements for all parameters after first (1 week) and
second (2 weeks) sessions. Da* and Db* have negative values.

laboratory process, may not be sufficiently tenacious

to distinguish adequately the subtle differences in the
efficacies of different bleaching methods (Casey et al.
1989, Mohammadi et al. 2010).
In the present study, the group SP was used as a
positive control because sodium perborate is considered the safest and easiest control agent for internal
tooth bleaching (Plotino et al. 2008). Although the
use of a negative control group with distilled water or
artificial saliva would also be desirable, it was not
considered essential, as the expectations would be
that immersion in saliva or water would not promote
significant bleaching.
In this study, hydrogen peroxide fostered a more
effective bleaching than carbamide peroxide and
sodium perborate. This is in accordance with the
findings of Lima et al. (2009). Lim et al. (2004),
however, found that carbamide and hydrogen
peroxides were equally effective. The manufacturer
for hydrogen peroxide recommends aspiration and

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International Endodontic Journal, 46, 4046, 2013

reinsertion of the product for a maximum of three

times, respectively. On the other hand, the manufacturer for carbamide peroxide recommends leaving the
product inside the pulp chamber for a few days. In
this study, carbamide peroxide was not used in the
manner recommended by the manufacturer but the
same method as the hydrogen peroxide was
employed. This was because it was not thought
appropriate to introduce another variable between
these groups and the hydrogen peroxide groups.
However, it might have led to overestimated better
results for hydrogen peroxide and detrimental results
for carbamide peroxide.
Clinically, sodium perborate is often placed into the
pulp chamber between visits during bleaching treatments with hydrogen and carbamide peroxides. This
was not carried out in this study to prevent undue
influence of sodium perborate on the bleaching process as the main objective was to analyse the effect
of ultrasonic activation on the peroxides. It could have

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Cardoso et al. Ultrasonics of bleaching agent

led to better results for the other experimental groups

in comparison with the group SP. Furthermore, in a
clinical situation, the pulp cavities are always sealed
with temporary restorations between visits. This
procedure was not considered necessary in this study,
and the possible effects of exposing the pulp chamber
to the storage medium were evenly distributed in all
the samples, as long as the procedure was standardized. In regard to the cervical sealing, the material of
choice in clinical settings would be glassionomer
(Plotino et al. 2008). However, zinc phosphate
performs the same barrier function and was used in
this study for technical convenience.
Hydrogen peroxide can penetrate from the pulp
chamber and reach the external surface of teeth. This
effect is remarkably greater with hydrogen peroxide
than with carbamide peroxide or sodium perborate
(Lee et al. 2004, Palo et al. 2010). In this study, the
samples were stored in artificial saliva after bleaching,
which was replaced every day to avoid saturation by
hydrogen peroxide, preventing whitening to continue.
Finally, the standardization of colour measurement
is a very important procedure in colour assessment
studies. The custom hot gluemade matrix used in
this study allowed reproducibility and reliability in all
colour measurements carried out.

Conclusion
Ultrasonic activation of bleaching agents during ex
vivo internal bleaching was no more effective than
conventional internal bleaching procedures, without
activation.

Acknowledgements
The authors would like to thank Professor Ivan
Balducci for helping with the statistical analysis.

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