pH variation among materials used for intracoronal bleaching

Intracoronal tooth bleaching - A review and treatment guidelines

Intracoronal bleaching is a minimally invasive procedure that was introduced into dentistry in the 19th century. The role of that procedure in enhancing the colour of teeth subjected to internal discolouration while being conservative made it extremely popular amongst dental professionals. Different materials and techniques have been utilized over the years attempting to obtain predictable long-term results while minimizing any associated risks. Contemporarily, bleaching agents are mainly based on peroxide-releasing compounds in different formulations and delivery systems. Different theories have been formulated on the bleaching mechanism of such agents, but the exact mechanism is yet to be proven. The effect of hydrogen peroxide-based bleaching agents on the organic structure of enamel and dentine has been extensively investigated to address the effects of bonding of resin-based restorative materials to hard tooth structure. Multiple case reports raised a concern about the contribution of intracoronal bleaching in developing invasive root resorption. Modification of intracoronal bleaching techniques was thus necessary to address such concerns. This review will provide a summary of the important aspects of intracoronal bleaching, focusing on how it applies to the contemporary clinical setting. © 2023 Australian Dental Association.

Effect of Various Bleaching Agents on the Surface Composition and Bond Strength of a Calcium Silicate-based Cement

This study aimed to evaluate the morphological and elemental changes that occur on the surface of calcium silicate-based cement (CSC) and to analyze the bond strength of composite resin to CSC after application of various bleaching agents. One hundred twenty-five CSC blocks (Biodentine) were prepared and randomly divided into five groups according to the bleaching agent applied over the material surface (n=25): SP-DW (sodium perborate-distilled water mixture), SP-HP (sodium perborate-3% hydrogen peroxide [H₂O₂] mixture), CP (37% carbamide peroxide gel), HP (35% H₂O₂ gel), and a control group (no bleaching agent). After 1 week, scanning electron microscopy provided an analysis of the surface morphology and elemental composition for 10 specimens from each group. Composite resin was placed at the center of each cement surface in the remaining specimens (n=15). A universal testing machine determined shear bond strength (SBS) and fracture patterns were identified with a dental operating microscope. Data were analyzed using one-way analysis of variance and Tukey HSD tests. The cement surface in the CP and HP groups presented changes in structure and elemental distribution compared with the remaining groups. The former groups exhibited a decrease in the calcium level and an increase in the silicon level and presented significantly fewer SBS values than the remaining groups ( p<0.05). Most failures were adhesive in the CP and HP groups, while they were predominantly cohesive in the remaining groups. The bleaching agents with higher concentration induced deterioration of the cement surface and negatively affected the bond strength of the composite resin to CSC. The use of CSC is recommended as a cervical barrier when intracoronal bleaching is performed with a mixture of sodium perborate with water or 3% H₂O₂.

Effect of calcium hydroxide on ph changes of the external medium after intracoronal bleaching

AIM

This in vitro study evaluated the effect of calcium hydroxide on pH changes of the external medium after intracoronal bleaching.

MATERIALS AND METHODS

A total of 50 extracted human premolars were prepared and filled with gutta-percha and endodontic sealer. The teeth were randomly divided into five groups according to the bleaching agents employed: (a) Sterile cotton pellet with distilled water (control group); (b) sodium perborate and distilled water; (c) sodium perborate and 10% carbamide peroxide; (d) sodium perborate and 35% hydrogen peroxide; (e) 35% hydrogen peroxide. The teeth were stored in vials containing distilled water and the pH values of the medium surrounding the teeth were analyzed. After 7-day storage, the bleaching agent was removed and replaced by calcium hydroxide, and the distilled water was changed, in which the teeth were kept stored for further 14 days. Measurement of pH of the external medium (distilled water) was performed 7 days after insertion of the bleaching agents, immediately, 7 and 14 days after insertion of the calcium hydroxide. Data were submitted to statistical analysis by the two-way ANOVA and Tukey,s test.

RESULTS

There were pH changes of the external medium at 7- day period after bleaching procedures. These results confirmed the diffusion of bleaching agents to the external medium.

CONCLUSION

Calcium hydroxide increased the external medium pH and was effective for pH alkalinization after intracoronal bleaching.

CLINICAL SIGNIFICANCE

Intracoronal bleaching of endodontically treated teeth may cause cervical root resorption. A possible explanation for this process is the passage of bleaching agents to the periodontal tissues yielding an inflammatory process. In an attempt to keep the neutrality of the periodontal pH, the calcium hydroxide has been recommended.Results of this study showed that this material should be always used after intracoronal bleaching.

pH-changes during intracoronal bleaching: an in vivo study

OBJECTIVES

This study aimed to measure pH changes during 14 days intracoronal bleaching with hydrogen peroxide/sodium perborate and carbamide peroxide/sodium perborate.

MATERIALS AND METHODS

Twenty patients presenting endodontically treated central maxillary incisors with color alterations were divided in two groups (n = 10): Group CP + SP: 37% carbamide peroxide + sodium perborate paste; Group HP + SP: 30% hydrogen peroxide + sodium perborate paste. The pH values were measured using a digital microprocessor at different times: Baseline, 2, 7 and 14 days. Data were analyzed with two-way ANOVA followed by Tukey's test (α = 0.05).

RESULTS

ANOVA showed p < 0.00 which indicated significant difference between the groups. The mean values (± sd) and the results of the Tukey´s test were: HP + SP/14 days-7.98 (±0.58)a; HP + SP/7 days-8.59 (±0.18)b; HP + SP/2 days- 8.83 (±0.32)bc; HP + SP/Baseline-8.83 (±0.01)bc; CP + SP/ Baseline-8.89 (±0.01)bc; CP + SP/14 days-9.11 (±0.58)cd; CP + SP/7 days-9.54 (±0.16)de; CP + SP/2 days-9.66 (±0.08) de. The group HP + SP resulted in significantly lower pH values compared with group CP + SP.

CONCLUSION

It can be concluded that both associations showed alkaline pH values; however, there was significant reduction in the pH values of the 30% hydrogen peroxide associated with sodium perborate after 14 days.

CLINICAL SIGNIFICANCE

The association of hydrogen peroxide and carbamide peroxide with sodium perborate paste presented alkaline characteristics during the 14-day evaluated period. Thus, regarding pH changes, both associations can be considered safe as intracoronal bleaching agents.

Effect of bleaching agents on bonding to pulp chamber dentine

AIM

To determine the effect of intracoronal bleaching agents on adhesion of bonding agents to pulp chamber dentine.

METHODOLOGY

Forty extracted human maxillary anterior teeth were randomly divided into four groups of 10 teeth each. Bleaching agents were sealed in pulp chambers for 7 days, as in clinical use. Group 1 (control): distilled water, group 2: 35% hydrogen peroxide, group 3: sodium perborate mixed with water, and group 4: sodium perborate mixed with 35% hydrogen peroxide. Teeth were stored in saline at 37 degrees C for 7 days. After the bleaching agent was removed, teeth were leached in water for a further 7 days prior to bonding. The crown was cut vertically from mesial to distal and the labial pulp chamber dentine was prepared for bonding with Clearfil SE-Bond and filled with resin composite (Clearfil AP-X). The bonded specimens were kept moist at 37 degrees C for 24 h. Microtensile bond strengths were determined using a universal testing machine. Additional teeth were prepared using the same bleaching procedures to investigate the scanning electron microscopic appearance of the dentine surface.

RESULTS

Mean values (+/-SD) of microtensile bond strength for the experimental groups were: group 1: 5.29 +/- 2.21 MPa, group 2: 5.99 +/- 1.51 MPa, group 3: 9.17 +/- 1.65 MPa and group 4: 3.99 +/- 1.31 MPa. Dentine treated with sodium perborate in water (group 3) had significantly higher mean bond strength when compared with the other three groups (P < 0.05, Tukey's test). Mean bond strength was lowest when dentine was treated with sodium perborate plus hydrogen peroxide (group 4).

CONCLUSIONS

In terms of subsequent bond strength during restoration, sodium perborate mixed with distilled water appears to be the best intracoronal bleaching agent.

Extraradicular diffusion of hydrogen peroxide and pH changes associated with intracoronal bleaching of discoloured teeth using different bleaching agents

AIM

To evaluate the extraradicular pH and hydrogen peroxide (HP) diffusion when either 35% carbamide peroxide (CP), 35% HP or sodium perborate (SP) is used for intracoronal bleaching of artificially discoloured teeth.

METHODOLOGY

Single rooted extracted human premolars were stained with whole blood cells. After shaping and cleaning, they were root filled and a base cement placed 1 mm below the buccal cementoenamel junction (CEJ). Four cemental defects were prepared just below the CEJ on each root surface. The teeth were randomly divided into four groups of 11 specimens, and intracoronally bleached using CP, HP, SP or distilled water (CL). Each tooth was suspended in a vial of distilled water and bleached for 7 days. The pH of the extraradicular distilled water was tested at 0, 1, 2 and 7 days and the HP that diffused through the root quantified using the Ferrous Oxidation-Xylenol Orange 2 Assay. The results were analysed using the one-way anova and Scheffe tests.

RESULTS

Carbamide peroxide produced the greatest increase and HP the least pH change (P < 0.05 except day 1), SP was intermediate. From day 1 onwards, radicular diffusion of HP was greatest with HP and least with CP (P < 0.01), again SP was intermediate. There was no significant difference between CP and SP.

CONCLUSIONS

Carbamide peroxide had very low levels of extraradicular diffusion of HP, in the presence of cemental defects. It could be an alternative to the other intracoronal bleaching agents.

Review of the current status of tooth whitening with the walking bleach technique

Internal bleaching procedures such as the walking bleach technique can be used for whitening of discoloured root-filled teeth. The walking bleach technique is performed by application of a paste consisting of sodium perborate-(tetrahydrate) and distilled water (3% H2O2), respectively, in the pulp chamber. Following a critical review of the scientific literature, heating of the mixture is contra-indicated as the risk of external cervical resorption and the formation of chemical radicals is increased by application of heat. An intracoronal dressing using 30% H2O2 should not be used in order to reduce the risk of inducing cervical resorption. This review provides advice based on the current literature and discusses how the walking bleach technique can lead to successful whitening of non-vital root-filled teeth without the risks of side-effects.

[Evaluation of pH variation and cervical dentin permeability in teeth submitted to bleaching treatment]

External cervical root resorption is one of the disadvantages of the bleaching procedure. There are several mechanisms that may be responsible for causing resorption, such as the chemical and physical action of the utilized materials and the morphology of the cementoenamel junction. The purpose of this study was to investigate the presence of a communication between the pulp chamber and the external root surface. The investigation was carried out by means of pH tests and measurement of dye infiltration into cervical dentin after the bleaching procedure. Thirty-four human permanent incisors were submitted to endodontic treatment. The teeth were assigned to three experimental groups, according to the level at which the filling was cut, and to the sealing of the root canal entrance with glass ionomer cement. Sodium perborate and 30% hydrogen peroxide were utilized for bleaching. pH readings were carried out after 30 minutes, 24 h, 48 h and 72 h from the beginning of the procedure. The teeth were immersed in 0.5% basic fuchsin for 24 h in order to determine possible differences in the permeability of cervical dentin. The results revealed that pH tended to change when the root filling was cut at the entrance of the canal, when 2 mm of the filling were removed, and when the canal entrance was sealed with glass ionomer. Dentinal permeability increased in the three experimental groups, in comparison with the control group. These slight differences may suggest a communication between the pulp chamber and the external root surface.

[Clinical evaluation of external radicular resorption in non-vital teeth submitted to bleaching]

The purpose of this study was to evaluate the presence of external resorption in non-vital teeth submitted to bleaching. The evaluated patients had at least one non-vital tooth, which had been bleached between 1986 and 1996. All teeth were submitted to bleaching with hydrogen peroxide and sodium perborate, as described by Busato et al.5,6. From 193 patients recalled for clinical and radiographic evaluation of bleached teeth, only 43 attended (54 teeth). The average time elapsed after bleaching was 3.5 years. The results revealed that none of the examined teeth had any degree of external cervical resorption.

Effect of hydrogen peroxide and sodium perborate on biomechanical properties of human dentin

This study compared the ultimate tensile strength, micropunch shear strength, and microhardness of bleached and unbleached human dentin. Forty-four intact premolars were root canal treated and randomly divided into four groups. Bleaching agents were sealed in pulp chambers, as in clinical use. Group 1 (control) was treated with water, group 2 with 30% hydrogen peroxide, group 3 with sodium perborate mixed with water, and group 4 with sodium perborate mixed with 30% hydrogen peroxide. The teeth were stored in saline at 37 degrees C for 7 days. The teeth were then sectioned and biomechanical tests were carried out on dentin specimens that were obtained from all teeth. Intracoronal bleaching with 30% hydrogen peroxide and sodium perborate used either alone or in combination weakened dentin. Hydrogen peroxide alone tended to be more damaging than sodium perborate used alone or sodium perborate mixed with hydrogen peroxide.

Safety issues relating to the use of hydrogen peroxide in dentistry

Hydrogen peroxide is used widely in professionally and self-administered products. Hydrogen peroxide is a highly reactive substance which can damage oral soft tissues and hard tissues when present in high concentrations and with exposures of prolonged duration. This report provides an overview of health issues relating to the use of hydrogen peroxide, with an emphasis on safety with prolonged exposure to low concentrations of peroxide products. There is good evidence for the safety of hydrogen peroxide when used at low concentrations on a daily basis over extended periods of time, in self-administered oral health care products such as dentifrices and mouthrinses. These low concentrations neither damage oral hard or soft tissues, nor do they pose a significant risk of adverse long-term effects. Caution should be exercised with the increasingly higher concentration peroxide products used for 'walking' or 'power' bleaching due to the possibility of chemical irritation of oral soft tissues with injudicious use. The volumes of material and application times should be controlled carefully. Thorough education of patients is particularly important with self-applied gels because of the lack of professional supervision with such products. Such education is part of the duty of care of the dentist who supplies bleaching gels for at-home use.

Effect of bleaching agents on dentin permeability to Streptococcus faecalis

Bacterial contamination of dentin may be a contributing factor in the development of bleaching-associated root resorption. In this study, the effect of commonly used bleaching agents on the permeability of dentin tubules to Streptococcus faecalis was evaluated. Sixty extracted bovine incisors were horizontally sectioned apically to the cementoenamel junction. In each tooth, a standard cavity was prepared, the pulp tissue extirpated, and remnants of soft tissue and smear layer were removed. Following rinsing and repeated autoclave sterilization, the teeth were divided into four groups, each treated with one of the following materials: 30% hydrogen peroxide, sodium perborate mixed with 30% hydrogen peroxide, sodium perborate mixed with distilled water, and distilled water alone that served as control. The bleaching agents were sealed in the teeth and incubated at 37 degrees C for 7, 14, and 21 days. At each time interval the bleaching agents were removed and the teeth incubated at 37 degrees C in brain heart infusion infected with S. faecalis. Histological sections were prepared, and the maximal bacterial penetration for each group was measured using a computerized morphometric system. Statistical analysis of the results revealed that teeth treated with either 30% hydrogen peroxide alone or in combination with sodium perborate were significantly more permeable to S. faecalis than those treated with sodium perborate mixed with water (p < 0.0001). Sodium perborate mixed with water did not cause an increase in dentin permeability to S. faecalis and was similar to the water control. In conclusion, it seems that bleaching agents containing hydrogen peroxide in high concentrations may increase bacterial penetration through dentinal tubules.

Effect of various types of sodium perborate on the pH of bleaching agents

Time-dependent changes in the pH value of various types of sodium perborate solutions used as bleaching agents were evaluated. Sodium perborate-monohydrate (MH), sodium perborate-trihydrate (TRH), and sodium perborate-tetrahydrate are available. Each perborate was mixed with 10%, 15%, or 30% fresh hydrogen peroxide or with bidistilled water in a powder to liquid ratio of 2 g:1 ml, respectively. The pH values were recorded at baseline and after 1h, 1 day, 3 days, and 7 days, respectively. At baseline the pH values of MH, TRH, and tetrahydrate in conjunction with 30% H2O2 were 8.7, 7.0, and 7.5, respectively. The pH increased significantly with decreasing concentrations of H2O2. For TRH, MH, and tetrahydrate mixed with bidistilled water more alkaline values were measured at baseline and after 1 h. Due to solidification of the samples, the pH could not be determined for MH starting day 1 and for TRH starting day 3. In conclusion, the pH of bleaching pastes depends on the content of water of crystallization in sodium perborate, H2O2 concentration, and time of measurement. The bulk of the mixtures recorded reached alkaline pH values of 10 to 11. It is recommended that the pH of the mixture being used be checked to avoid potential postbleaching root resorption.

Evaluation of internal sealing ability of three materials

Thirty-six maxillary central incisors were prepared in a manner similar to nonvital bleaching procedures. They were examined with respect to the degree of procion green dye penetration of dentin with and without heating. Cavit, IRM, and zinc phosphate cement were used to evaluate their sealing ability. Cavit and IRM provided better internal sealing of the dentin than did zinc phosphate cement.