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Year : 2014  |  Volume : 2  |  Issue : 3  |  Page : 149-153

Combined in-office and take-home bleaching in vital teeth

1 Department of Semiology and Clinics, Faculty of Dentistry, University Federal of Pelotas, Pelotas, Turkey
2 Tutorial Education Program (PET), Faculty of Dentistry, University Federal of Pelotas, Pelotas, Turkey

Date of Web Publication29-Oct-2014

Correspondence Address:
Josue Martos
Department Semiology and Clinics, Faculty of Dentistry, Gonçalves Chaves Street 457, 96015-560 Pelotas, RS
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-4619.143599

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The aim of this paper is to describe vital teeth bleaching employing a combination of techniques: In-office and at-home. We applied a 35% hydrogen peroxide with a pen applicator for the in-office process and 16% carbamide peroxide for in-home bleaching. We have concluded that, in-office bleaching in combination with take-home bleaching using hydrogen peroxide is an excellent option for esthetic and conservative treatment of teeth that have been chromatically altered.

Keywords: Esthetic, therapeutics, tooth bleaching, tooth discoloration, vital tooth

How to cite this article:
Martos J, Kinalski MA. Combined in-office and take-home bleaching in vital teeth . J Res Dent 2014;2:149-53

How to cite this URL:
Martos J, Kinalski MA. Combined in-office and take-home bleaching in vital teeth . J Res Dent [serial online] 2014 [cited 2020 Sep 24];2:149-53. Available from: http://www.jresdent.org/text.asp?2014/2/3/149/143599

  Introduction Top

The demand for esthetic treatments such as tooth whitening has increased considerably; however, in order for bleaching to be successful, a correct diagnosis is fundamental in reference to the nature of tooth darkening and the technique to be used. [1],[2],[3],[4] The pigmentation or darkening of teeth varies greatly in its etiology, clinical appearance, location, severity, and adherence on dental structures; it can be classified as extrinsic, intrinsic, or a combination of both. [5] By differentiating or recognizing the etiological agent, we define all of the planning required to perform the bleaching treatment, the technique, the whitening agent to be used, and the number of sessions. In addition, will provide the highest level of tooth whitening for each tooth without injury to the patient's health. [3]

Dental bleaching agents may be in the form of gel syringes, foil self-adhesives, and varnish, which is applied with brushes or pens. When presented in liquid form, they must be mixed with a thickener gel. Some products used in the office allow mixing system in syringes, which avoids the use of auxiliaries containers and helps to provide the correct ratio of components. Other systems recently introduced are bleaching gels with applicators in the form of pens and brushes. In those products, the bleaching agents are ready to use. In-office tooth whitening is a procedure that utilizes gels with higher percentages of hydrogen peroxide (30-35%) than home bleaching treatments; they provide quicker results. Home bleaching, in turn, uses concentrations of carbamide peroxide or hydrogen peroxide ranging from 10% to 20%, which is sufficient and effective for dental whitening. [6],[7]

To obtain results that are less aggressive to the pulp tissue and more durable with respect to the longevity of the bleaching, the current trend is to use a combination of techniques-in-office and at-home. [8],[9] The aim of this paper is to describe bleaching treatments in vital teeth, which employ a combination of techniques-in-office and at-home.

  Case report Top

A 25-year-old female patient was referred to the dental clinic reporting dissatisfaction with the appearance of her smile [Figure 1], [Figure 2], [Figure 3]. At the initial clinical examination and anamnesis, it excessive yellowing was observed, indicating that a bleaching procedure might be appropriate. The periodontal health of the patient was satisfactory, and a radiographic examination revealed no abnormalities of the supporting tissues.
Figure 1: Initial aspect of the maxillary and mandibular teeth

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Figure 2: Initial clinical aspect of the maxillary teeth

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Figure 3: Smile aspect of the patient

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The pattern of the enamel stain suggested that a combination of tooth whitening techniques, in-office and at-home, would be a viable option in this case. After careful prophylaxis, the operative area was isolated with a lip retractor (OptiView, KerrHawe, Switzerland). Before starting the bleaching procedure, an appropriate color was chosen, especially for the anterior teeth, using a color scale (Vitapan 3D-master, Vita Germany) [Figure 4]. It was applied using a photopolymerized gingival barrier rounding the cervical area of the teeth for gingival protection (Gingi Dam, Villevie, Dentalville, Joinville, Brazil) [Figure 5].

The in-office bleaching treatment was performed with a 35% hydrogen peroxide via a pen applicator known as Twist Pen (Mix One Supreme, Villevie, Dentalville, Joinville, Brazil). Placing the bristles of the applicator tip to the teeth with a rotation at the rear of the pen performs the application of the bleaching agent. The bleaching material is applied by brushing the pen over the enamel surface of the teeth to be whitened, following the instructions of the manufacturer; it does not require any source of activating light or heat [Figure 6], [Figure 7], [Figure 8].
Figure 4: Initial color aspect using a vitapan color scale

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Figure 5: Photopolymerized gingival barrier applied

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Figure 6: In-office bleaching treatment with a 35% hydrogen peroxide gel

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Figure 7: The bleaching gel does not require any source of activating light or heat

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Figure 8: Approximate aspect of the initial application of the bleaching gel

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Two clinical sessions were performed for each arch, with a 1-week interval between sessions. At each visit, three 15-min applications were performed, totaling 45-min of contact with the gel structure at each session. After 15-min of contact, the bleaching agent was gently removed using gauze soaked in water and then the tooth surfaces were washed [Figure 9] and [Figure 10]. After drying, another 15-min application was performed. Completed the procedure in the maxillary teeth [Figure 11], bleaching was started in the mandibular arch [Figure 12].
Figure 9: Immediate aspect of the first application of the bleaching gel

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Figure 10: Remotion of the gingival barrier

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Figure 11: Clinical aspect after the two clinical sessions

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Figure 12: Bleaching gel application in mandibular arch

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After that, molding was performed using gypsum, and resulting in models [Figure 13] and [Figure 14]. Silicone impression trays were made on the models and cut approximately 2 mm beyond the gingival margin, following the gingival contour [Figure 15]. In the continuity with the proposed treatment, the patient also conducted home bleaching with carbamide peroxide 16% (16% Night Mix, Villevie) for 2 h daily for 15 consecutive days [Figure 16] and [Figure 17]. The patient was instructed both orally and in writing regarding the use of the tray and the proper handling of the bleaching gel.
Figure 13: Confecction of the silicone trays in both archs

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Figure 14: Detailled aspect of the silicone trays

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Figure 15: Silicone trays prepared

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Figure 16: Home bleaching with carbamide peroxide 16%

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Figure 17: Silicone tray in position

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At the conclusion of the bleaching procedure, the teeth were evaluated; a favorable change in terms of the chromatic color of the teeth, using as a parameter the Vitapan scale range from A3 to A1, was observed. After application of the bleach, the teeth were subjected to a polishing felt and polishing slurry and then a desensitizer based on sodium fluoride and potassium nitrate was applied (Sensis 2% Villevie, Dentalville Joinville, Brazil) for a period of 10-min [Figure 18]. The patient presented no sensitivity during or after the use of the stain remover and bleaching product. Four months after the procedures, a good final appearance was observed [Figure 19] and [Figure 20].
Figure 18: Fluor gel application after the bleaching

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Figure 19: Final aspect of the in-office and home bleaching association

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Figure 20: Smile aspect of the patient

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  Discussion Top

Despite the fact that whitening is a conservative alternative to more radical procedures such as veneers or prosthetic crowns, it has the intended effect only if all of the etiologic factors in terms of the nature of tooth darkening are considered in order to understand and to correct this condition when it is thought to be necessary. [1],[2],[3],[4],[10],[11],[12],[13]

The combination of the two techniques has provided more durable and predictable results when compared to the use of only the in-office technique. [8],[9] It has been recommended that the time of use of the bleach be shortened to reduce side effects such as tooth sensitivity and gingival irritation. Such side effects occur to a lesser extent when the bleaching gel is used for a short period (2 h), independently the concentration of bleaching agents. [7]

In reference to the bleaching procedure without the use of auxiliary sources of light, [7],[10] we found that the teeth were satisfactorily cleared of discoloration with excellent clinical results. Nevertheless, the association of this technique in conjunction with supervised home dental bleaching appears to be an excellent therapeutic option. [8] We should be vigilant regarding excessive bleaching, that is, when it reaches the point of saturation, which is the maximum possible amount of bleaching that should be performed. The bleaching reaches the point of saturation when the maximum amount of bleaching has occurred; after beyond this point, no more bleaching occurs. Clinically, we observed this particularity when patients continued to achieve the same bleach results with the continued application of the whitening agent. At this point, it is necessary to know when to stop the procedure because, at the time that the disadvantages start to become evident, the patients begin to lose all of the aesthetic benefits of the bleaching process.

  Conclusion Top

If done in accordance with appropriate diagnosis, in-office bleaching in combination with take-home bleaching using hydrogen peroxide is an excellent option for aesthetic and conservative treatment of teeth that have been chromatically altered.

  References Top

Attin T, Manolakis A, Buchalla W, Hannig C. Influence of tea on intrinsic colour of previously bleached enamel. J Oral Rehabil 2003;30:488-94.  Back to cited text no. 1
Haywood VB. History, safety, and effectiveness of current bleaching techniques and applications of the nightguard vital bleaching technique. Quintessence Int 1992;23:471-88.  Back to cited text no. 2
Martos J, Nova Cruz LE, Silveira LF. Aesthetic periodontal surgery associated with tooth whitening using the Twist Pen system - Case report. Full Dent Sci 2010;1:129-34.  Back to cited text no. 3
Hattab FN, Qudeimat MA, al-Rimawi HS. Dental discoloration: An overview. J Esthet Dent 1999;11:291-310.  Back to cited text no. 4
Zekonis R, Matis BA, Cochran MA, Al Shetri SE, Eckert GJ, Carlson TJ. Clinical evaluation of in-office and at-home bleaching treatments. Oper Dent 2003;28:114-21.  Back to cited text no. 5
Marson FC, Sensi LG, Araujo FO, Junior SM, Araújo E. Clinical evaluation of the night-guard bleaching technique. Rev Dental Press Estét 2005;2:84-90.  Back to cited text no. 6
Marson FC, Sensi LG, Reis R. New concept for the in-office bleaching technique. Rev Dental Press Estét 2008;5:55-66.  Back to cited text no. 7
Deliperi S, Bardwell DN, Papathanasiou A. Clinical evaluation of a combined in-office and take-home bleaching system. J Am Dent Assoc 2004;135:628-34.  Back to cited text no. 8
Matis BA, Cochran MA, Wang G, Eckert GJ. A clinical evaluation of two in-office bleaching regimens with and without tray bleaching. Oper Dent 2009;34:142-9.  Back to cited text no. 9
Travassos AC, Rocha Gomes Torres C, Borges AB, Barcellos DC. In vitro assessment of chemical activation efficiency during in-office dental bleaching. Oper Dent 2010;35:287-94.  Back to cited text no. 10
Perdigão J, Baratieri LN, Arcari GM. Contemporary trends and techniques in tooth whitening: A review. Pract Proced Aesthet Dent 2004;16:185-92.  Back to cited text no. 11
Martos J, Silveira DW, Silveira LF, Ramos OL. Enamel microabrasion associated with dental bleaching to treat sequelae of amelogenesis imperfecta. J Restor Dent 2013;1:36-9.  Back to cited text no. 12
Kugel G, Ferreira S. The art and science of tooth whitening. J Mass Dent Soc 2005;53:34-7.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20]

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