Curing Lights for Composite Resins

Now a days LED lights have become popular and cheap. They also do not need to have bulb replaced. To buy a LED lightcure unit for Rs 5000/email to webmaster Light units have come a long way since the Nuva Light (Dentsply/Caulk) was introduced in the mid-1970s.It used ultra violet light to activate special kind of filling material, the standard now is visible light units that use a quartz-tungsten-halogen (QTH) bulb as their light source to produce a filtered blue light. By following incremental placement of resin and proper maintenance of the curing units, these units perform well. New resin curing lights are being introduced now which utilize high intensity fast cure, low intensity slow cure and a combination of both.

Recent research indicates that there may be some advantages to curing composite resins by varying the intensity of the QTH light. Routinely the QTH light is turned on for 40-60 seconds for curing the resins and the light is turned off. This constant exposure to intense light source may cause the resin composite to polymerize too quickly. Stresses induced by rapid polymerization compromise the strength of the recently formed bond of the material to the tooth structure and lead to leakage. By using a different light technique we may be able to reduce the amount of polymerization stress. There are two techniques, which use short duration, and low intensity light followed by a longer duration of high intensity 1. Stepped technique 2. Ramp mode 3. Pulse delay cure technique Ramp mode:The ramp mode begins at reduced intensity before gradually moving to 100% intensity. This function is designed to reduce polymerization shrinkage.

Stepped technique: here, the low intensity exposure is immediately followed by the high intensity exposure. The first commercially available light unit this technique was Elipar Highlight (ESPE). It uses a 10-second exposure of light at 150 mW/cm Followed by 30-50 seconds at 700mW/ cm Pulse delay technique incorporates a waiting period between exposures. The VIP light from BISCO used the pule delay cure technique, a very short (3 second) exposure at 200 mW/cm2 is first used to harden the composite resin. After a waiting period of three minutes, a 30-second exposure at 600 mW/cm2 is used. The waiting period allows stress relaxation and the restoration can be finished and polished at this time. In both cases the low intensity light exposure theoretically allows the resin's newly induced stresses a chance to dissipate. These techniques are the subjects of research and it is wise to delay purchasing new units based on these technologies. Curing Traditional curing lights use 488 nm wavelength blue light, which is filtered and passed onto the composite resin to be cured. This generates a large amount of heat and a lot of energy is wasted. And its intensity is not strong enough. With Argon laser the wavelength is right for the curing of composite resin. Laser curing is deeper and faster because of its higher intensity. Studies have shown that laser curing of composite resin is more complete. This will lead to less post operative sensitivity and discomfort. Accucure 3000 (Laser Med) utilises continuous energy output at 4 intensity levels of 320, 480, 640 and 730 mW/cm2 Plasma Arc System: Newer resin composite formulations have an impressive hardness, better marginal adaptation and better control of internal stresses. When internal tension is reduced, the degree of shrinkage is less important. Some studies have shown that polymerization and shrinkage are not linked to the time of photo activation. Rapid polymerization, reducing the time of exposure to less than 5 seconds improves patient comfort and reduces the time needed to complete the procedure.

Apollo 95 E (DMD) is an example of plasma Arc lamp and it utilizes a maximum intensity output of 1930 mW/cm2 The lasers and plasma arc lights have been shown to produce highest heat increases on the surface (upto21 C) and within the restoration upto 14 C. Compared to these halogen lights produce most temperature increase within the pulp chamber ( increase of 2 C) Light Cure Units- What features to look for while buying Light curing unit is an indispensible part of a dental clinic today. Below are some of the terms useful to understand choose right kind of light for your clinic. Cordless: Light can be easily charged on its base and then can be moved easily for convinience or chair to chair in a operatory with many chairs. Curing Light Foot Print Amount of space unit occupies when placed on your working space, smaller the better. Intensity Curing light output range is measured in nanometers. Most composites utilize camphoroquinone(CQ) polymerizing initiators that are activated by light emitted in and around 468 nm. Other composites,including some flowable resins, require initiation in the 429 nm range. Tip size Wand tip diameters should extend beyond the margins of the restoration. A larger restoration requires a wand tip that illuminates the entire surface of the composite simultaneously.A porcelain or direct veneer requires the largest wand tip, 12mm or wider. Curing programs pulse, step, ramp How Teeth Whitening Works
To understand how GO SMiLE works, it's important to understand the basic structure of teeth. Enamel, the outer, somewhat translucent surface of teeth, is very hard, but it's also porous. Our whitening serum was scientifically designed to remove not only outer stains on the teeth, but also get through the tiny pores in the enamel and whiten below the surface, in the dentin. Dentin is the deeper layer, where stains from food, drinking, and smoking accumulate over time, making your teeth look darker often brown or yellow, rather than white and bright.

GO SMiLE's whitening serum contains the optimal concentration of hydrogen peroxide potent, but safe. Our patented Ampoule Technology enables the hydrogen peroxide to stay stable, fresh, and potent, which makes it most effective. After it's applied, the peroxide breaks down and releases highly reactive ions parts of the peroxide molecule that are so small and chemically active that they travel through the pores in the enamel, reaching into the

teeth to fight stains. When the ions reach the stains, they break chemical bonds in the stains, which causes them to become colorless, visibly whitening the teeth!

How Smile Whitening Light Works

GO SMiLE's PhD scientists theorized that technologies that assist in breaking down hydrogen peroxide into its active components will "accelerate" or "boost" the whitening process. Smile Whitening Light is the result of a lengthy design and development process it's the ultimate whitening "accelerating" device for at-home use. It brings cutting-edge dentist-approved technology into your home, to make teeth whitening faster and easier than ever.

Smile Whitening Light works powerfully with GO SMiLE Whitening Ampoules, to whiten teeth quickly in just one sitting! After the whitening serum is applied, the light is shone onto the teeth for three 10-minute sessions.

Lights on their own can't effectively or safely whiten teeth. However, certain wavelengths of light energy can activate the peroxide in our whitening ampoules to accelerate whitening. The serum absorbs the energy, which photochemically "excites" the peroxide molecules into breaking down faster. It provides "activating energy" that speeds up and improves the performance of whitening.

When applied to teeth coated with the serum in Whitening Ampoules, Smile Whitening Light improves the chemical reaction that occurs. It makes more efficient use of the same amount of peroxide speeding up the reaction, producing more of the ions that whiten teeth maximizing the action and efficacy of the whitener.

GO SMiLE scientists were very careful about what kind of light to use and chose LEDs for their safety and effectiveness. They knew that heat, or very short wavelengths of light, could provide a great deal of energy. However, both can damage living tissue, cause pain, and can even destroy the nerves and pulp of teeth. Some whitening lights contain UV light - the same wavelength that can cause skin damage. It's very important to choose the correct wavelength of light that will work safely!

Smile Whitening Light has been scientifically engineered to provide the best, exclusive combination of safe light wavelengths for tooth whitening. It accelerates the whitening process without generating a damaging level of heat or radiation. Rather than providing just one color of light, these LEDs were selected to emit a broader range of the appropriate wavelengths. This leads to maximum absorption by the formula and efficient acceleration of whitening.

Smile Whitening Light is a scientifically engineered, patent-pending design to efficiently illuminate the entire "smile zone", and the energy-efficient LED bulbs will work for thousands of hours.

Smile Whitening Light optimizes the performance of Whitening Ampoules, so you can get whiter teeth in just one sitting, safely, comfortably, and effectively!

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POWER BLEACHING A SOLUTION FOR DISCOLOURED TEETH

1 Chandrasekhar M, Director, Professor and Head, Department of Conservative Dentistry 2 Jaya prakash D patil, Professor and Head, Department of Conservative Dentistry 3 Ramesh T, Assistant Professor, Department of Conservative Dentistry

1,3 Government Dental College and Hospital, Rajiv Gandhi Institute of Medical Sciences, Kadapa. 2 Sri Sai College of Dental Surgery , Vikarabad, Andhra Pradesh.

Contents
[hide]

1 ABSTRACT 2 KEY WORDS 3 INTRODUCTION 4 Case report 1 5 Case report 2: 6 Discussion

o o o

6.1 Indications for power bleaching 6.2 Advantages of power bleaching

5 5 5

6.3 Disadvantages of power bleaching

7 Mechanism of action of power bleaching 8 CONCLUSION 9 References

ABSTRACT
Bleaching is an effective method for restoring the colour of the discoloured teeth. It is a safe procedure with few side effects, and is much less invasive than other techniques such as veneering or crowning of teeth, which require tooth preparation. This article focuses on the in office bleaching method called power bleaching with discussion of two cases using this method.

KEY WORDS
Vital Bleaching, Hydrogen peroxide, Silicondioxide. Discoloured teeth, Sensitivity

INTRODUCTION
Discoloration of teeth is a cosmetic problem that is often the patients primary concern. Although many restorative procedures are available, discoloration can often be corrected totally or partially by a more conservative approach i.e. bleaching, which is relatively simple to perform and less expensive. Bleaching has become an integral part of esthetic dental service, recently becoming the single most requested esthetic procedure for adults.
1

Tooth bleaching accounts for the majority of the more than 60 million cosmetic

dental procedures performed in the United States every year. In olden days bleaching was done by means of a liquid of 35% hydrogen peroxide and the application of heat. This was very laborious for the patients and the dentist. There are three forms of vital bleaching: clinically administered, dentist supervised, and dentist prescribed at-home bleaching.
2

Clinically administered bleaching is also referred to as in-office or

power bleaching. The introduction of the faster and safer light-activated units for power bleaching has popularized the in-office technique. BEYOND (Beyond Dental & Health USA Inc) is one of the successful commercially available power bleaching systems in which the harmful ultraviolet light and heat are filtered out and a Powerful 150 watt halogen bulb emits a high-intensity blue light (480-520 nanometers wavelength) for faster whitening results is utilized. The advantages of this system include increased patient comfort levels and decreased risk of developing tooth sensitivity. Armentarium (Fig.1)

Polishing sand Lip protection cream Cotton rolls and swabs Gauze face cover

Syringe light-cure gingival protection dam with tip 1.0ml Bottle 35% hydrogen peroxide Silicon dioxide catalyst Mixing spatula & brush HVE Tip 1.1% Neutral sodium fluoride gel Cheek retractor Light curing unit VITA Shade guide Dual barrel syringe Beyond whitening gel

Case report 1
A 24 year old male patient came to the Department of Conservative Dentistry with a chief complaint of discoloration of his teeth (Fig.2). The patients medical history was noncontributory. Extensive clinical and radiographic examination was done, a diagnosis of dental flourosis was established. Treatment options were considered and the power bleaching suited the condition aptly. Pre operative photographs were taken, the shade was assessed using a vita shade guide and the shade was found to be D3. protective eye goggles were worn by the patient to avoid any harmful effect by the light used for power bleaching. Polishing sand was applied to the teeth prior to the application of moist gauge and face cover. Lip protection cream was applied on to the lips. The cheek retractor and the cotton rolls were placed. The gingival protective dam was placed along the cervical margins of the teeth (Fig.3)using the tip attached to the syringe available in the kit and light cured to stabilize the dam in the place. A fresh mix was prepared by mixing, 35 % hydrogen peroxide and silicon dioxide catalyst and the mix was applied on to the teeth using a brush(Fig.4). A 2 mm layer of whitening agent was applied on the incisors canines and first premolars as the smile line was extending upto the first premolars. The high intensity blue light emitted was kept for 8 minutes(Fig.5). The unit automatically turned off after 8 minutes as the cycle completed. Post bleaching instructions were given.The post treatment photographs shows the desired result(Fig.6)

Fig.1.Beyond whitening kit Fig .2.Pre operative photograph with vita shade guide showing D3 Fig .3.Application of gauge and face cover

Fig. 4. Light cured gingival protection dam and the application of whitening agent Fig .5. Intensifying light directed at 90 degrees with protective eye wear to the patient

Pre Operative Photograph Post Operative Photograph Fig.6.D3 shade to A1 shade

Case report 2:
A 19 year old mal patient visited the dental clinic with the chief complaint of discoloration of his teeth and wanted the treatment(Fig.7). Patients medical history was noncontributory. Extensive clinical and radiographic examination was done; a diagnosis of dental flourosis was established. Treatment options were considered and the power bleaching suited the condition apply. All the steps of power bleaching as mentioned in the case 1 were performed and a satisfactory result was achieved as illustrated below. (Fig.8 and Fig.9) Fig.7. Pre operative photograph Fig .8. Light cured gingival protection dam and the application of whitening agent

Pre Operative Photograph Post Operative Photograph Fig.9. A3 shade to B1 shade

Discussion
In office bleaching has various names like chairside bleaching, power bleaching, laser bleaching, dentist administered bleaching, and dentist supervised bleaching. There are various materials available for power bleaching
3,4

1. 35% hydrogen peroxide liquid, liquid/powder products or gels called power gel or laser gel 2. 35% Carbamide peroxide 3. Dual activated bleaching systems. The Beyond Power Whitening system utilizes a proprietary 35% hydrogen peroxide bleaching gel that has a pH of about 5.5. The protocol for the Beyond whitening system includes the use of a halogen bleaching light

(named the "Power Whitening Accelerator"). When the light is placed into position, it is capable of simultaneously illuminating all of the patient's teeth being treated (both upper and lower). The wavelength of the light emitted from this unit is in the range of 480 to 520nm (meaning that the light has a blue-green coloration). The company suggests that the use of their bleaching light assists with the effectiveness of their bleaching gel and therefore the tooth whitening process as a whole.

Indications for power bleaching

1: Developmental or acquired stains 2: Stains in enamel or dentine 3: For removing yellow or brown stains 4: Age - yellowed smiles 5: For blending white color changes 6: Mild to moderate tetracycline stains. Our cases were indicated for power bleaching as mentioned above.

Advantages of power bleaching

1. Patient prefer power bleaching over home bleaching because

They do not have time for home bleaching. Inability to tolerate wearing the trays. Gagging reflex

2. Less teeth sensitivity 3. Less procedure time 4. Immediate results

Disadvantages of power bleaching

1. Expensive 2. Frequent appointment needed 3. Dehydration of teeth leading to false evaluation of shades 4. Caustic effects on the oral tissues 5. Dental assistants also subjected to tissue burns during handling 6. Short shelf life of hydrogen peroxide 7. Greater cost of retreatment compared with home bleaching

Mechanism of action of power bleaching

This technique works by lightening the enamel to give appearance of whiteness.
6

The exact mechanism is

still unknown, but various theories are given in literature. One theory suggests that large organic molecules responsible for stains are reduced to less noticeable molecules by process of oxidation. Hydrogen peroxide acts as an oxidant and an oxygenator. Stain removing process is selective with lesser side effects
6

. Another

theory is that peroxide penetrates into enamel and dentine and oxidizes tooth discoloration. The passage of nascent oxygen into the tooth structure occurs first in enamel and then in dentine.
7

CONCLUSION
We presented treatment of discolored teeth by new in office bleaching technique called as Beyond which is a type of power bleaching. Power bleaching provides a white healthy smile in a short span of time with limited shortcomings. Power bleaching is latest in cosmetic smile technology and is overcoming the limitations of home bleaching.

Tooth Whitening: Current Status

Kimberly Marshall, DDS; Thomas G. Berry, DDS, MA; and James Woolum, DDS, MS
The Compendium of Continuing Education in Dentistry
Abstract This article reviews the history of tooth whitening and its rapid evolution and briefly discusses tooth whitening agents and protocols. The active ingredients and mode of action during the whitening process are explained. The factors affecting the speed of whitening and its final results are discussed, as well as adverse effects and safety precautions. Protocols are explained in detail, and the predicted outcomes, including those for tetracycline-stained teeth, are covered. Tooth whitening has been used for more than 150 years to improve the appearance of teeth. 1 While the safety and efficacy of these old procedures were questionable, they were somewhat successful. They were also time consuming and involved the use of potentially dangerous chemicals. These protocols were primarily used for nonvital teeth. Almost a century ago, a pyrozone (ether peroxide) mouthwash proved effective in reducing caries and whitening teeth.2 Because these methods were performed in office, they often required multiple appointments. By the 1940s, hydrogen peroxide and ether were used to whiten vital teeth.3 In the late 1950s, nonvital teeth were treated with pyrozone and sodium perborate. Klusmier is credited with introducing tray bleaching in the 1960s, 4 but it was not until Haywood and Heymann published an article in 1989 that the procedure became well accepted.5 The introduction of carbamide peroxide greatly aided this acceptance because it was more stable chemically than hydrogen peroxide. Carbamide peroxide has a shelf life of 1 to 2 years compared with 1 to 2 months for hydrogen peroxide. Although other agents have been tried with varying degrees of success, the agent most commonly used in tray whitening techniques is carbamide peroxide combined with additives for flavor, color, desensitizing properties, and viscosity level.

This article is intended for the general practitioner or any practitioner who may speak to patients about whitening options. The article summarizes the current status of whitening techniques and discusses the following about tooth whitening:

Mode of action Factors affecting the whitening process Safety and effects Types of techniques Special considerations for tetracycline stains

Mode of Action
The bleaching process allows the oxidizing agent to enter the enamel and dentin to produce a chemical action with discolored particles within the tooth structure. Hydrogen peroxides low molecular weight enables it to diffuse through the tooths organic matrix. The whitening agents exact action is not known, but it is theorized that free radicals attack organic molecules to achieve stability. This, in turn, releases other radicals to react with other unsaturated bonds to change the absorption energy of organic molecules. The result makes the molecules reflect less light so the tooth appears lighter. Early in the process, bleaching opens more highly pigmented carbon-ring compounds and converts them to lighter-colored chains (hydroxyl groups).6-8

Factors Affecting Speed of the Whitening Process

Several factors or conditions can alter the speed at which whitening occurs. While these effects are not precisely predictable, they should be considered before the whitening process is begun.

Surface Cleanliness
The target surfaces must be carefully cleaned to distinguish extrinsic from intrinsic stains. Removal of debris and surface film permits the whitening agent maximum contact with target surfaces. The whitening process may be delayed a few days if the prophylaxis causes any tooth or tissue sensitivity.

Peroxide Concentration
Higher concentrations produce a more rapid whitening effect.9 This effect is not linear (eg, 20% does not double the speed of 10%). Higher concentrations are more likely to result in increased tooth sensitivity. A 10% carbamide peroxide concentration is equal to approximately 3.4% concentration of hydrogen peroxide. Carbamide peroxide, while less concentrated than hydrogen peroxide, is much more stable with a shelf life of 1 to 2 years as opposed to hydrogen peroxides shelf life of only 1 to 2 months. A concentration of 10% carbamide peroxide degrades in the mouth to approximately 3.4% hydrogen peroxide and 6.5% urea.

Temperature of the Agent

The higher the agents temperature, the faster the oxygen release, which speeds the reaction. 10 The chemical reaction rate can be doubled by an increase of 100C.11 The speed of the color change may not be altered, and the rise in temperature may cause more pulpal sensitivity. To allow monitoring of any heat-provoked sensitivity, teeth should not be anesthetized during an in-office treatment that produces heat.12 The increased speed of the chemical reaction achieved by increasing the temperature may help explain the effect of some bleaching lights used with in-office procedures. The lights benefit may be partially a product of its heat, not its specific light wave.

pH of the Agent
Agents with low pH can produce tooth-surface alterations. This can be avoided by using agents with a pH in the range of 7. The urea released during carbamide peroxide breakdown raises the pH above 8 for several hours. Hydrogen peroxide has an optimal range of 9.5 pH to 10.8 pH. A pH of 10.8 results in a whitening rate 50% faster than does 9.5 pH.13,14

Time
Results of the whitening process are directly related to the time the agent is in contact with the teeth. The longer the duration, the greater the degree of whitening is. However, extended periods may increase the likelihood of sensitivity.14,15

Safety and Effects

Many patients worry bleaching will harm their teeth or soft tissues or produce a systemic problem. Tooth whitening, whether through an in-office procedure or at-home delivery system, is very safe when the proper protocols are implemented.16 It is important to explain this to patients to let them weigh the benefits and minimal risks.

Systemic Effects
Soft Tissue
The whitening agents are available in various concentrations ranging from 10% carbamide peroxide (equal to 3.4% hydrogen peroxide) to 38% hydrogen peroxide. If the higher concentration agents contact the soft tissues, they can produce a chemical burn that turns the tissues temporarily white (Figure 1 and Figure 2). Although tissues quickly return to their normal color once they rehydrate, they may be mildly uncomfortable for a few hours. The patient may be distressed by the temporary appearance of the whitened soft tissues. A rubber dam or other protective barrier is mandatory to effectively seal off the tissues (Figure 3). In-office systems usually supply a light-cured resin in a syringe to apply around the cervical areas to confine the agent to the teeth (Figure 4 and Figure 5). In addition, flexible spreaders should be placed in the mouth to prevent the cheeks or lips from contacting the whitening agent.

Hard Tissue
Tooth sensitivity can occur in at least 50% of patients. Marson and Sensi reported as many as 63% experienced sensitivity.17 Consequently, patients should be warned of this. It would seem logical to assume that patients with certain conditions, including erosion, gingival shrinkage, leaking restorations, caries lesions, abrasion/attrition, and

large pulps, would be particularly prone to developing significant sensitivity. However, research has not demonstrated that these conditions are dependable predictors of sensitivity. 18-20 For many patients, sensitivity is not a significant problem. Symptoms may begin on the second or third day of tray whitening, starting with an awareness of a tingling sensation and/or slight cold sensitivity. Often, this sensitivity diminishes without any significant discomfort. If the patient experiences increasing sensitivity, he or she should cease bleaching for 1 to 2 days. Persistent sensitivity, especially if severe, can be treated with 5% potassium nitrate with fluoride incorporated into a gel similar to bleaching gel. Potassium nitrate has a numbing or calming effect on nerve transmission.21,22 Fluoride acts as a tubule blocker to limit the fluid flow to the pulp. 23-25 It is placed into the bleaching tray in the same way as the bleaching agent.26 Generally, the patient notices some decrease in discomfort within a few hours. Bleaching-provoked tooth sensitivity is transitory, eventually disappearing even without treatment once the bleaching is completed. Sensitivity is thought to be caused by dentinal dehydration.27 Application of hydrating agents (eg, VivaSens, Ivoclar Vivadent, www.ivoclarvivadent.us; Seal & Protect, DENTSPLY Caulk, www.dentsply.com) prior to bleaching may reduce or prevent this dentin dehydration. Use of amorphous calcium phosphate has also been shown to be effective in preventing or eliminating dentin hypersensitivity both during and after bleaching treatment. It is deposited on the tooth surface and then mimics, to some extent, sclerotic dentin.28,29 Tooth sensitivity is difficult to predict. Patients with large pulps, loss of enamel, or carious lesions can be especially susceptible to sensitivity.30 However, studies have not indicated that tooth conditions, carious lesions, sex, or age is a predictor of sensitivity.30 The significant predictor appears to be pre-existing tooth sensitivity. These patients are the most likely to develop any discomfort. They can receive effective treatment with the potassium nitrate/fluoride gel or with amorphous calcium phosphate (MI Paste, GC America,www.gcamerica.com) prior to beginning treatment or with bleaching gel interspersed throughout treatment.

Whitening and Existing Restorations

A decrease in surface microhardness of both microhybrid and nano-resin composites has been noted after exposure to Crest Night Effects (Procter and Gamble, www.pg.com), Colgate Simply White Clear Whitening Gel (ColgatePalmolive Co, www.colgate.com), and Opalescence Quick (Ultradent, www.ultradent.com).31Polishing restorations prior to and after exposure to bleaching agents is recommended. 32 Often, patients with existing anterior restorations desire whitening their remaining teeth. They should be reassured that whitening agents will not injure restorative materials or alter their color. Teeth color will lighten, so existing restorations will appear darker. It may become necessary to replace restorations to match the new tooth shade. Teeth with facial veneers can be lightened somewhat if the underlying tooth is too dark. The agent is placed into the tray on the lingual side of the tooth for several days to a few weeks. Patients should be informed that the change will be viewed through the veneers so improvements will likely not be dramatic.

Whitening and Future Restorations

Multiple studies have shown the effects on bonding to tooth structure recently exposed to bleaching agents with a significant decrease in polymerization of adhesives applied to teeth immediately after bleaching. A 14-day delay before bonding achieved significant improvement in polymerization.33,34 Consistently, enamel bond strengths exhibit significantly lower bond strength when bonding was done immediately following bleaching. 35

Types of Techniques
Various methods of tooth whitening procedures achieve some degree of success. These methods include tray bleaching, in-office direct application, placement of whitening strips, application of paint-on materials, and whitening toothpaste and mouthwash. Although the specific procedures or techniques differ, all whitening techniques rely on placement of a concentration of hydrogen peroxide or a hydrogen peroxide-releasing solution on the tooth and holding it against the surface for a specified period. Clinical studies have examined all these methods and demonstrated varying degrees of success. The specific techniques and predicted success are discussed in this article.

In Office
Currently, in-office procedures use a relatively high concentration of hydrogen peroxide ranging from 25% to 38% in a gel solution. The gel helps confine the material to the target areas and avoid contact with soft tissues. With such high concentrations, isolation of the teeth from the soft tissues becomes critical, as previously described. If the agent contacts soft tissues, affected areas should be noted, immediately rinsed with water to begin rehydrating the tissues, and then covered with an ointment such as Orabase B (Colgate-Palmolive) to decrease discomfort and hasten return to normal color. The patient should be informed that the whitened condition of affected tissue is temporary and soft tissues should return to normal coloration in approximately 30 mins without residual effects. Most patients experience little postoperative discomfort. Concentrations as high as 38% hydrogen peroxide produce fast results; however, the ultimate effect is not greater than with at-home tray bleaching with 10% carbamide peroxide. Although the original in-office bleaching agents were applied without any other aids, some companies now advocate procedures involving specially designed lights to enhance the effects. These lights are advertised to significantly speed the whitening process. The bleaching agent is applied to the target teeth, and then the teeth are exposed to the light for 15 to 20 mins. This procedure is repeated two to three times during the appointment. Limited evidence concerning the actual benefits of the lights is available. However, a recent study indicated that bleaching lights appear effective at speeding the whitening process for some patients.36 More research is needed to confirm these results. In-office procedures have several potential advantages: whitening occurs more rapidly, they do not require patient compliance, and they facilitate focusing on specific teeth if extra applications are needed to match other teeth. This may be the treatment of choice for patients unable or unwilling to undergo the slower at-home procedures and may

provide more patient compliance than is required for tray bleaching. However, the cost is greater because of the chair-time required and single treatment sessions may have limited results.37 Manufacturers have advertised dramatic in-office bleaching results, claiming that the whitening effect can be as dramatic as an eight- to 10-shade improvement. While that may be possible, the change should not be measured immediately after the bleaching appointment is completed. Isolation of the teeth to protect the soft tissues results in tooth dehydration. Dehydration causes teeth to appear whiter.38 Teeth take only 30 mins or less to dehydrate. However, teeth may require 1 hour to regain moisture after the normal intraoral environment has been re-established. Therefore, shade change comparisons made immediately after an in-office bleaching procedure are misleading. A better comparison is made 1 to 2 weeks postbleaching. The duration that the agent remains on the teeth depends on its strength and the susceptibility of the teeth to develop sensitivity. Systems generally call for coating the teeth for 20 to 30 mins, rinsing away the agent, and then reapplying for another 20 to 30 mins. After each application period, the patient is asked if tooth sensitivity is occurring. If so, the procedure is discontinued until a subsequent appointment. Generally, three applications per appointment can be accomplished without significant tooth sensitivity during or after the procedure. Manufacturers generally supply follow-up whitening agents to continue the whitening action initiated by the in-office procedure.39 These follow-up agents generally contain carbamide peroxide in a gel. It is either applied by the patient into a custom tray or already loaded in a manufacturer-supplied tray. The agents strength ranges from a relatively mild 10% carbamide peroxide to a much stronger 30% or even to a 10% hydrogen peroxide. The intention is to continue the whitening action for the next several days to achieve the desired final results. A recent publication from the State University of New York compares an in-office bleaching technique with and without a light compared with an at-home bleaching kit.40 In this study, it was found that using an at-home kit with a relatively strong 32% carbamide peroxide for 3 mins daily produced a result of nine shades lighter after 4 weeks. Using the same kits, another group wore the trays for 15 mins a day, which resulted in a 12-shade difference in the same time frame.40

At Home
Generally, at-home treatment (tray bleaching) has been the most popular dentist-supervised tooth whitening method. It is generally less expensive, and the technique lends itself to an extended whitening regimen if tooth discoloration persists. The technique is relatively simple and easily accomplished. The only special equipment required is a vacuum-forming unit to create a well-fitting whitening tray designed specifically for the individual patient. The tray should be made on an accurate cast of the patients dentition. The cast should be trimmed to minimal thickness and with the palate or tongue space removed from the cast. This trimming promotes a better vacuum around the cast to create a better-fitting tray. The tray should be formed from a soft plasticized sheet of clear material, such as ethyl vinyl acetate, that is approximately 0.035 inches thick. This material is easy to adapt and soft enough to fit comfortably. Although

instructions for tray fabrication may recommend that the tray be trimmed short of the gingival margins to avoid contact of the agent with the tissues, research has not indicated that 10% to 15% carbamide peroxide irritates soft tissues. Tray borders must be well adapted and smooth to prevent irritation of the lips and cheeks and/or to keep the tongue from rubbing against rough edges (Figure 6 and Figure 7). The ethyl vinyl acetate tray material can be softened when heated with a brush flame and smoothed using finger pressure. In addition, there seems to be no significant advantage to creating a reservoir space for extra gel on the trays facial surface despite some manufacturers instructions. While it appears logical to create space for extra bleaching agents for prolonged/increased action, no research confirms its effectiveness. One study found that the amount of gingival inflammation is increased when trays are fabricated with reservoirs compared with nonreservoir trays. 41 The patient should practice placing the tray in the office to ensure that he or she can do it correctly. While seating the tray may seem simple, the patient may not understand how to do it the first time. Figure 6 and Figure 7Proper adaptation and trimming of a whitening tray on a maxillary cast. Tray showing both the buccal and lingual aspects scalloped. Use of a relatively low-strength agent such as 10% carbamide peroxide will require considerable time to achieve the desired effect. The key to success lies in holding the agent in intimate contact with the tooth surfaces for the necessary time.42 The custom tray loaded with whitening gel will achieve this if left in the mouth for the time required (Figure 8 and Figure 9). Some systems use a much stronger agent25% to 38% carbamide peroxide or 10% or higher hydrogen peroxide. These more concentrated agents should be in place for only 30 mins. Recommended time to wear the tray varies depending on the agents strength. Figure 8 and Figure 9Prior to at-home whitening. Following approximately 10 days of at-home tray whitening. Studies have shown that carbamide peroxide gel provides some bleaching effect even up to 6 hours after tray insertion.42 It is at maximal effectiveness for the first 2 hours before its strength begins to diminish. The best recommendation is to advise the patient to wear the tray during sleep. The patient should brush his or her teeth and then insert the tray before bedtime. This recommendation has two advantages: the time the agent contacts the teeth is maximized and the wearing time is during sleep when saliva flow is less. However, patients who do not tolerate wearing the tray during sleep can do the bleaching during the day. For the best benefits from the gel, the patient should wear the tray at least 2 hours. The higher the concentration of peroxide, the more rapid the change. 43,45 This faster change has disadvantages, however, because stronger agents increase the likelihood of tooth sensitivity.44,46 If the patient persists with the whitening process despite increasing sensitivity, significant discomfort may occur and take some time to resolve.

Over the Counter

With the growing popularity of tooth whitening in the last 15 years, the number of over-the-counter (OTC) products have proliferated. These products appear, in some cases, with strong advertising but have little research to prove their efficacy. They may use a stock tray system, a tray that can be softened and custom-formed to some extent, or a paint-on process. While the actual bleaching agent may be similar to the dentist-supplied-and-supervised agent, it is

the method of placing and holding the agent on the teeth that determines the products efficacy. As previously stated, an important factor to successful whitening is the time the teeth are exposed to the whitening agent. The whitening effect of many OTC products, including toothpastes and mouthwashes, is questionable because of the limited period that they are in contact with the teeth. Research has proven one OTC system is effective.47,48 Crest Whitestrips (Procter and Gamble) has had about 15 years of success. This product involves placement of a strip resembling a Band-Aid over the anterior teeth for 30 mins twice daily. The system has some disadvantages, however. It may be difficult to adapt to misaligned teeth. The strip covers from canine to canine only in many mouths. The result is that the anterior teeth may lighten several shades but the premolars retain their original color. The patient may also wish to cover the premolars; however, this means using extra strips, adding to the cost. Other systems may work; however, research has shown that results vary greatly depending on the agent employed and the means of applying and retaining it on the teeth. A paint-on system from Colgate has been shown to be effective but has the disadvantage of requiring the patient to carefully coat the target teeth and then keep the agent in place for approximately 30 mins. Some patients may find this difficult or tedious.49,50 Patients need to be warned that they may spend considerable money on some OTC products without achieving the results that are predictably obtained with a dentist-supervised-and-directed method. Other products such as toothpaste are advertised as tooth whitening agents. While they may contain the same type of peroxide as the dentist-supplied agents, they do not remain on the teeth long enough to provoke the chemical process that eliminates the undesired coloration. Research does not show that whitening toothpastes are any more effective than regular toothpaste.51

Special Considerations for Tetracycline Trays

Some discolorations are highly persistent. Tetracycline discoloration can prove almost impossible to completely eliminate and difficult to lighten to an acceptable degree. Tetracycline medications are very effective antibiotics but can create a tooth esthetic problem. Treatment of an expectant mother during the third trimester or a child during tooth formation stages between 3 and 4 months of age and again at 7 to 8 years allows tetracycline to accumulate in the tooth buds.52,53 Presumably, treatment with tetracycline performed in expectant mothers in their first trimester should be safe; it is usually not done for precautionary reasons. If taken long term during early adulthood (eg, acne treatment), it can produce discoloration. This is especially true if ingested during secondary dentin formation, during growth periods, or following tooth trauma. The result is a distinctive and persistent discoloration with varying intensities of yellow, gray, blue, or brown. Its most characteristic overtone is a bluish gray. Tetracycline-discolored teeth do eventually lighten from bleaching albeit much more slowly than teeth stained by other agents.54 In fact, whitening tetracycline-discolored teeth may take 2 to 12 months of daily treatment to achieve a satisfactory result. However, teeth usually retain grayish overtones. Teeth will generally lighten from the incisal toward the gingiva, so teeth heavily stained in the cervical area have the most limited prognosis. 55

Vital tooth bleaching has provided a partial solution to these problems. Although tetracycline stains are persistent, they do eventually respond. Studies documenting treatment of tetracycline-stained vital teeth are limited; however, they demonstrate that stains can be minimized, if not completely eliminated. The improvement in coloration can be enough to allow use of more translucent and esthetic porcelain for veneers to complete the esthetic improvement. There is a persistent belief that tetracycline stains do not respond to either at-home or in-office power bleaching or even to a combination of the two. Patients may decide, therefore, to forego treatment. The procedure for whitening these teeth may involve both in-office and at-home whitening procedures. The in-office procedure with 35% hydrogen peroxide serves as a jump-start to initiate the process. This is followed by at-home whitening, as previously discussed. The at-home treatment can be interspersed with occasional in-office boosts to the process. The patient must be informed that the incisal two thirds of the tooth will likely demonstrate the greatest color improvement. The gingival one third will be distinctly slower in improvement and may never completely lose a bluish or grayish tint. This is because the enamel is much thinner at the cervical area of the tooth so the underlying stained dentin remains.

Conclusion
Although manufacturers continue to package their products differently, especially OTC products, the basic ingredients remain constant. Whitening action is accomplished by release of hydrogen peroxide or carbamide peroxide that becomes hydrogen peroxide. Specific additives improve the taste, help confine the agent to the teeth, decrease likelihood of sensitivity, and/or prolong shelf life. In-office procedures are effective; however, one appointment is unlikely to be sufficient. Use of lights to enhance bleaching effects has not been fully proven effective at this point. OTC products vary widely in efficacy, primarily because of variations in methods of applying and retaining the bleaching agent to the teeth. Decades of whitening teeth have proven the process to be effective and safe if done according to accepted protocols.