Rama Univ J Dent Sci 2017 Mar;4(1):47-50.

Fluorosis and vital tooth bleaching

Case Report
Report of Two Cases using Vital Tooth Bleaching on Fluorosed Teeth
Saha P, Sawhny A, Paul S, Raina A
Abstract: Discoloration of tooth is a common esthetic problem caused by either intrinsic or
extrinsic factor. The normal color of such a tooth can be restored by decolorizing the stain with a
powerful oxidizing agent such as 35% hydrogen peroxide which is directly placed on the labial
surfaces of the tooth to be treated. The bleaching agent is commercially available in the form of a
gel. This process involves the application of light to activate the bleaching agent. Effective results
were obtained when the process of bleaching was correctively performed on the patient. In
today’s world of immediate gratification, in-office bleaching is one of the most requested
procedures in many dental offices, a great way to get a fast and immediate change in the color of
their teeth. This article throws a light on how we have achieved normal tooth colour by using 35%
Hydrogen peroxide in the following case series.

Key words: Bleaching agents; Dental; Dentin desensitizing agents; Fluorosis; Hydrogen peroxide.

INTRODUCTION the thickness of dental structure.3 Final

The demand for esthetic dentistry has outcome of bleaching influenced by
increased continuously and the smile has patient’s age original shade of the tooth
become an integral part of social colour, concentration of bleaching agent,
attractiveness of a person.1 Tooth time for which the bleaching agent is
discolouration of is a common esthetic exposed to the tooth structure.4
problem caused by either intrinsic or
extrinsic factor. Bleaching is the most Different light sources can be used for in-
conservative treatment option when office bleaching for heating up the gel to
compared to other restorative techniques accelerate the dissociation of H2O2 into
used to treat the tooth discolouration.1 There oxygen radicals such as halogen lamps, light
are two main types of bleaching procedures - emitting diode, plasma arc lamps and lasers
- non-vital bleaching which is done on a with different wavelengths.2 In this case
tooth that is root canal treated and no longer series in-office bleaching was performed
has nerve innervations, vital bleaching is using 35% H2O2 and light emitting diode as
performed on teeth that have live nerves. the light source.

The most common type of vital tooth CASE REPORTS

whitening uses a gel like whitening solution Case 1: A 25 year old male reported to the
applied directly to the tooth surface like Department of Conservative Dentistry and
hydrogen peroxide, sodium perborate, Endodontics, Rama Dental College Hospital
carbamide peroxide followed by a heating and Research Institute with discolored
up of the gel. Vital bleaching is an in-office maxillary and mandibular anterior tooth.
procedure which uses high concentration of After clinical examination the case was
hydrogen peroxide and often referred to as diagnosed that the discolouration of the
“one hour bleaching.”2 tooth in this patient was due to both extrinsic
and intrinsic stains. The extrinsic yellowish
Hydrogen peroxide (H2O2) is a chemical and reddish stains observed in the patient
substance with high oxidative potential. It is were due to high consumption of tea and
highly unstable and they dissociate into non-smoked chewable tobacco in the form
water, oxygen and free radicals when they of gutka and the intrinsic brownish
come in contact with the tissues, the latter discolouration was due to mild to moderate
accounting for the observed bleaching effect fluorosis according to Dean’s fluorosis index
due to their ability to oxidize organic (Fig 1). In office bleaching procedure was
pigments. It is known that the diffusion of then explained to the patient. After taking
H2O2 through the dentin depends on the his consent the treatment was performed.
concentration of the gel, the period of time
that the agent is in contact with the tooth and

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surfaces of the teeth using a small cotton

pellet (Fig 4). Then light source (LED) light
source was activated for 30mins. After that
the light source was removed and allowed
the teeth to cool down for 5mins. Then
pumice was used on the teeth to remove
residual exposed gel from enamel surface.

Figure 1: Preoperative treatment (Case 1).

Case 2: A 30 year old male patient reported

with the chief complaint of discolored and
un-esthetic appearance of anterior teeth in
relation to maxillary central and lateral
incisor to the Department of Conservative
Dentistry and Endodontics, Rama Dental Figure 3: Gingival Barrier application (Case 1).
College Hospital Research Institute with
discolored. On examination the case was
diagnosed as moderate to severe fluorosis
according to Dean’s fluorosis index (Fig 2).
First tooth vitality was carried out by using
electronic pulp tester for maxillary and
mandibular anterior teeth and all teeth were
found to be vital.
Figure 4: Bleaching agent applied (Case 1).

Thorough irrigation was done and the teeth

were dried. Then the teeth were polished
with the composite resin polishing cup.
Following which it was observed that the
discoloration was eliminated (Fig 5 (case 1)
& 6 (case 2)). The patients were asked to
return in 10 days to evaluate the results (Fig
Figure 2: Preoperative treatment (Case 2). 7). Using standard visual examination and
shade guide (VITA Classical) a noticeable
The treatment procedure followed in both shade change occurred. The post operative
the patients was same. Radiographic shades were now an A1 for both the patients.
examination was also carried out to check Final polishing of the teeth was performed
the presence of periapical pathologies. A after the desired shade improvement for both
shade guide (VITA Classical) was used for the patients. The patients noticed a marked
matching the shade by visual examination improvement and were very happy with the
and the color shade B1 was chosen for the final outcome.
first patient and shade B2 for the second
patient as the best match with patient’s
natural teeth. Oral prophylaxis and polishing
was carried out before starting the bleaching
procedure.

For these patients pola-office was chosen.

This material contains 35% H2O2. All teeth
were cleaned with pumice slurry and air
dried. After that gingival barrier was applied
and light cured for 20 seconds (Fig 3). Later Figure 5: Post operative treatment (Case 1).
35% H2O2 gel was applied on the labial

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Rama Univ J Dent Sci 2017 Mar;4(1):47-50. Fluorosis and vital tooth bleaching

side effects produced by peroxide radicals.6

Pola office consists of 35% H2O2 and 0.5%
dentin desensitizing agent (Potassium
nitrate).

Many in-vitro studies have shown that

penetration of bleaching into pulp chamber
when bleaching agent has exposed to tooth
surface for 60mins. Hanks et al concluded
that bleaching agent took around 15mins to
Figure 6: Post operative treatment (Case 2). reach into the pulp chamber. As molecular
size and weight of peroxide molecule is very
low and has the ability to denature the
protein present in dentin, that is why it
moves easily through dentinal tubules and
reach to the pulp chamber. In-vivo studies
show a reverse result of in-vitro studies.8 In-
vivo studies by Cohen and Robertson shows
either no or very minimal inflammation of
pulp when exposed to 35% H2O2.
Figure 7: After 10 days recall (Case 1). The protective mechanism of pulp against
bleaching agent is by breakdown of peroxide
DISCUSSION molecule by enzyme peroxidase and
Before starting the bleaching procedure, catalase. Anderson reported heameoxigenase
proper clinical evaluation and history taking 1 enzyme is protective enzyme present in
is important to know the etiology endothelial cells and odontoblasts present
responsible for tooth discoloration and the near the bleached enamel and prevent the
degree of discoloration. Non-vital and diffusion of bleaching molecule into the pulp
traumatic tooth usually looks discolored chamber.4 Another factor responsible for
hence before bleaching procedure electric diffusion of bleaching molecule into the pulp
pulp test should be performed to avoid chamber is positive pressure within the pulp
wrong diagnosis and treatment planning. As chamber and osmotic pressure of the
both isolation and protection of mucosal bleaching agent.9
tissues are essential we have also followed
the same in the above cases. Dentists may Heat and light application may initially
also wish to consider prescribing NSAIDs increase whitening due to greater
prior to treatment since post operative dehydration which reverses with time.
sensitivity is unpredictable.5 In-office Actual color change will not be evident until
bleaching may represent a degree of 2-6 weeks after bleaching treatment. The
biological damage to the dentin-pulp average number of in-office visit for
complex. maximum whitening is 3, with a range of 1-
6 visits, so the patient should be prepared for
There are many factors known to increase additional in-office treatments.3 Hence 35%
sensitivity such as high concentration of H2O2 has been preferred in the above cases
H2O2, high enamel permeability, prolonged for better results in the stipulated time.
use of bleaching agents, heat during the
application of accelerator LED light and CONCLUSION: Vital tooth bleaching is an
differences in the structural morphology of effective, conservative and esthetic
enamel and dentin with pores which treatment modality to change the appearance
facilitate the infiltration of bleaching agent. of teeth. It has gained a lot of popularity
Sensitivity issues have led some among the general public due to its fast and
manufacturers to release bleaching gels with immediate change in teeth color. In today’s
lower concentrations of H2O2 and world of immediate gratification, in-office
desensitizing agent in order to minimize the bleaching is the most requested procedures

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in many dental offices. As per newer Office teeth Whitening: Case Report.
bleaching material evolution into the field of Int J of Oral Health Med Res, 2016;
conservative dentistry, in-office bleaching is 3(3): 70-72.
safe without any adverse effect on tooth 5. Ingle JI, Bakland LK, Baumgartner.
Ingle’s Endodontics. 6th edi.
structure when proper concentration of
Hamilton,Ontario: People’s Medical
bleaching agents and instructions is to be Publishing House USA; 2013. 1389 p.
followed. 6. Cohen S, Hargreaves KM. Pathways of
the Pulp. 10th edi. St.Louis,Missouri:
Author affiliations: 1. Priyanjit Saha, PG Mosby; 2011. 521 p.
student, 2. Dr. Asheesh Sawhny, MDS, 7. Gopikrishna V, Chandra BS.
Professor, 3. Dr. Saurav Paul, PG student, 4. Dr. Grossman’s Endodontic Practice. 12th
Aakrati Raina, PG student. Department of edition Gurgaon: Wolters Kluwer,
Conservative Dentistry & Endodontics Rama New Delhi; 2010. 352 p.
Dental College, Hospital & Research centre. 8. Hanks CT, Fat JC, Wataha JC,
Kanpur- 208024, Uttar Pradesh, India. Concoran JF. Cytotoxicity and dentin
permeability of carbamide peroxide and
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How to cite this article: Saha P, Sawhny A, Paul S, Raina A. Report of Two Cases using Vital Tooth Bleaching on
Fluorosed Teeth. Rama Univ J Dent Sci 2017 Mar;4(1):47-50.

Sources of support: Nil Conflict of Interest: None declared

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