FORMAT A) Introduction B) Effect of bleaching agents on properties of restorative materials C) Reasons for the impact of bleaching agents on properties

of restorative materials and clinical consequences. D) Effect of bleaching agents on bond strength of restorative materials to enamel and dentin. E) Reasons for the impact of bleaching agents on bond strength of restorative materials and clinical consequences. F) Effect of bleaching agents on marginal quality of restorations. G) H) linical consequences of the impact of bleaching agents on restorations. onclusion

I) References.

I"TRO#$ TIO" An Evolving %istory & 'leaching is not ne( ) The earliest efforts to lighten teeth through bleaching too* place more than a century ago+ (ith bleaching agents painted directly on the tooth surface or pac*ed inside a nonvital tooth. The earliest agent reportedly used (as o,alic acid+ described by chapel in !-... Follo(ing e,periments (ith various forms of hlorine+ %arlan described in !--/ (hat is believed to be the first use of hydrogen pero,ide+ (hich he called hydrogen dio,ide. 'leaching nonivital or pulpless teeth changed less rapidly. The first reported instance of bleaching nonvital teeth (as in !-01+ (hen a dentist named 2arreson applied chloride to the tooth surface. The results (ere not inspiring+ and there (ere fe( follo(ers. In !01-+ 3earson reali4ed the dentist could ta*e advantage of the nonvital tooth5s lac* of a pulp. %e pac*ed same hydrogen pero,ide agent being used for bleaching of vital teeth+ supero,ol+ in the pulp chamber for 6 days. 'y the late !078s the standard method (as established by "utting and 3oe+ (ho sealed a mi,ture of 68 1 hydrogen pero,ide and sodium perborate in the pulp chamber for up to a (ee*. hemistry of 'leaching & 'leaching is a chemical process for (hitening materials (hich is (idely used in industry. The three most prominent commercial bleaching processes are pero,ide+ chlorine+ and chloride+ in that order. The strength is designated most frequently by volume rather than by percentage of pero,ide. Thus+ although they are interrelated proportionately+ 9..1 : hydrogen pero,ide is termed !88 volume+ 61 : is !68 volume+ and 18 : is 988 volume+ volume indicating the volume of o,ygen released by one volume of the designated %9O9. 'leaching processes are comple,+ the vast ma;ority (or* by o,idation. The o,idation < reduction reaction (hich ta*es place in the bleaching process is *no(n as a redo, reaction. In a redo, reaction of the o,idi4ing agent =e.g.+ hydrogen pero,ide> has free radicals (ith unpaired electrons+ (hich it gives up+ becoming reduced ? the reducing agent =the substance being bleached> accepts the electrons and becomes o,idi4ed>. In dental bleaching =Fig 9@6>+ hydrogen pero,ide diffuses through the organic matri, of the enamel and dentin. 'ecause the radicals have unpaired electrons+ they are e,tremely electroplcific and unstable and (ill attac* most other organic molecules to achieve stability+ generating other radicals. These radicals can react (ith most unsaturated bonds+ resulting in disruption of electron con;ugation and a change in the absorption energy of the organic molecules in tooth enamel. Aimpler molecules that 9

reflect less light are formed+ creating a successful (hitening action. This process occurs (hen the o,idi4ing agent =hydrogen pero,ide> reacts (ith organic material in the spaces bet(een the inorganic salts in tooth enamel. Effect of bleaching agents on properties of restorative materials & omposite resins & !8@!7 : carbamide pero,ide bleaching gels =i.e.+ 6.7 < 1..7 : %9O9> may lead to a slight+ but significant increased in surface roughness and amount of porosities of microfilled and hybrid composite resins. rac*ing (as also seen in microfilled composites. hanges in the surface reflectance in microfilled and hybrid composites after application of highly concentrated tooth (hiteness (ith 68 < 61 : %9O9+ Aalivary proteins absorbed on to the surface of composite materials decreased after bleaching (ith pero,ide containing agents+ (hich is suggested to have an influence on bacterial adhesion of cariogenic bacteria such as streptococcus sobrinus and streptococcus mutans+ but not of Actinomyces viscosus. It has been claimed that under clinical conditions in the mouth+ E color difference have been reported to be relevant and perceptible only (hen higher than 6.6 or 6.7. App of !8 1 % 9O9 or heated 68 : %9O9 resulted in composite color changes (hich (ere presumably clinically detectable (ith E ranging bet(een 9 and !! for the different materials and shades tested. In contrast+ use of !8 : carbamide pero,ide gel led to color changes of composite resins less than E 9. %o(ever+ even !8 : carbamide bleaching agents (ere able to remove e,trinsic stains from composite restorative materials. Feldspathic porcelain & Tur*er and 'is*in =9886> evaluated the effects of bleaching agents on feldspathic porcelain. !8@ !7 : carbamide pero,ide gels =applied for - hour per day for 68 days> (ere able to significantly decrease surface hardness of the porcelain material tested. 7 : %9O9 gel on feldspathic porcelain does not have any effect on surface te,ture. 3olyacid < modified resin < based composites = ompomer> & %ighly concentrated bleaching regimes induced o o o Aurface degradation+ Aoftening An inc in fluoride release and

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hanges in the coefficient of thermal e,pansion+ (hen those bleaching agents (ere continuously applied for !@1 days. In some products even crac*s (ere observed.

Effects of 2I & In glass ionomer cement+ silicone dio,ide is in high concentrations in the undeserved core material surrounded by the Al9B and the Al9B or a9B cations. The result is a set cement consisting of an agglomeration of unreacted po(der particles surrounded by a silica gel held together in an amorphous matri, of hydrated calcium and aluminum polysalts. After application of !8 : carbamide pero,ide+ more core is e,posed because of the erosion of the matri, represented by an increased of e,posed silica particles. Cefferson in =!009> e,amined alterations of atomic (eight percentages in 2I after contact (ith !8 1 carbamide pero,ide (ith p% /.1 and reported that the dissolution of 2! and silicate cements included three steps & a> Aurface (ash < off b> #iffusion in the solid state c> Aurface corrosion (ith the cores of the silica more e,posed and a decreased of surface aluminum content. Additionally+ it (as recently proved that a lo( concentrated 7 : % 9O9 gel did not cause significant dissolution or increased (ear rate of 2I by Mair D. in 988/. 'y using highly concentrated bleaching regimes+ no surface microhardness changes (ere observed in polyacid modified resin@based composites or resin < modified 2I + by EA3 A$ in 9889. Effect on temporary restorations & %ydrogen pero,ide and carbamide pero,ide both cause microscopic changes in the surfaces of some temporary restorative materials. Macroscopically+ IRM =reinforced FO@E composition> restorations e,posed to %9 pero,ide may appear crac*ed and s(ollen. Methacrylate temporary resins discolor =become organgish> (hen e,posed to 3. Cefferson et al in !009 described a decrease in aluminum and an increase in porosity in 4inc o,ide cement after immersion in acidic !8 : carbamide pero,ide solutions. a9B gel+ (ith a matri, formed by oo < anions relative to

The bis@ acryl composite region provisional material didn5t change color+ same (ith polycarbonate cro(ns. 3ractitioners should inform patients that provisional restorations may develop orange discoloration during the "2G' procedure. For patients (ho are highly conscious of esthetics and (ho need esthetic provisional cro(n restorations during the bleaching process+ bis < acryl composite resin or polycarbonate cro(n forms may be the materials of choice.

'leaching agents affect the organic substance of the material by rapidly brea*ing the inter loc*ing bond bet(een eugenolate and other IRM particles+ resulting in relatively high 4inc o,ide levels at the surface.

#isintegration and recrystalli4ation occurs.

Amalgam and other dental alloys & Do( concentrated hydrogen pero,ide gels =7:> donot alter the surface te,ture of either high copper amalgam or type III gold alloy. %o(ever+ evaluation of corrosion current density of various dental alloys revealed that the application of !8: carbamide pero,ide solution on non@polished amalgam samples and "i@ r may cause corrosion of these materials+ but not of noble alloys. 'leaching agent caused lo(er corrosion potential for the polished amalgam compared to non@ polished =According to anay A+ 9889>. If amalgam is e,posed to !8 : carbamide pero,ide or !8 : % 9O9 preparations+ there (ill be mercury and silver. Active o,idation (as held to be responsible for the increased release of amalgam components and also for greening of the tooth < amalgam interface. The %g release from amalgam also modified by the presence of biofilm on amalgam containing saliva+ bacteria and polysarcharide. arbamide pero,ide may have facilitated the degradation of the amalgam surface by removing the protective surface films+ there by e,posing the Ag < %g matri,. The unprotected amalgam surface (as further o,idi4ed+ thus leading to chemical dissolution of the mercury phase and release of available %g to the surrounding solution. Ingestion+ in halation+ or absorption of %g by patients may be to,ic to body tissues+ causing a variety of systemic adverse effects. from the to,icologic point of vie(+ mercury compounds fall into several categories. Elemental mercury vapor.

Inorganic mercury salts. Organic mercury compounds. #ental amalgam contains inorganic mercury bound to intermetallic compounds. Mercury is released from amalgam either as mercury vapor or mercuric ions. It may then be absorbed by the oral mucosa and the respiratory and 2IT (ith a ris* of to,ic systemic effects. %g released from dental amalgams during mouth guard bleaching may increased the total mercury burden+ the clinical must e,ercise caution and ta*e measures to minimi4e undesirable mercury release.

Reasons for the impact of bleaching agents on properties of restorative materials and clinical consequences & 'leaching agents caused erosion on the surface of the composite matri,. 'ailey and A(ift =!009> suggested that the surface changes could have been caused by comple, interactions (ith in multi@component bleaching products. hemical softening of composite resins is believed to occur in vivo+ contributing to (ear of resin in both stress < bearing and non@stress bearing areas. Aoftening is caused by chemicals (ith solubility parameters similar to that of the resin matri,. The bis < 2MA resin polymer can be softened by chemicals (ith solubility parameters in the range of !-.9 to 90.. =M3a>. A (ide variety of solvents have solubility parameters (ith in that range. The alterations in color of the restorative materials have been attributed to o,idation of surface pigments and amine compounds+ (hich have also been indicated as responsible for color instability of restorative materials over time. Increase in porosities are as a result of the deleterious impact of the o,idi4ing bleaching agent son the polymer < matri, of resin < based materials. ullen #R =!006> found that there is significant reduction in diametral strength of % 9O9 < bleached microfilled composite resins compared (ith the results of the posterior or hybrid composite resins+ that if the resinous matri, (as the site of o,idation and degradation. Microfilled composite resins contain a greater concentration of resinous matri, than hybrid composite resins contain. 68 1 %9O9 is an aggressive o,ident+ capable of degrading the polymer matri, of resin rich microfilled composite resins.

#ue to the negative influences of the o,idi4ing agents on the resin matri, led to (ater upta*e of the restorative materials (ith complete or partial debondig of fillers causing reduced surface integrity and loss of hardness of the materials.

3olishing of the restorations after bleaching is advisable at least+ since the increased surface roughness is held to be responsible for increased adherence of certain cariogenic microorganisms to the outer surface of tooth colored restorative materials after contact (ith different bleaching agents as assessed by Mor et al =!0-->.

In order to reduce patient e,position to amalgam components+ polishing of amalgam restorations prior to starting of a bleaching therapy should be performed to reduce corrosion potential of the amalgam restorations.

Additionally+ pre@coating of amalgam surfaces (ith a protective varnish such as copalite =!8 1 copal resin in a combination of ether+ alcohol and acetone> seems to be advisable to reduce release of %g in to the surrounding environment during bleaching (ith !8 : carbamide pero,ide.

Effect of bleaching agents on bond strength of restorative materials to enamel and dentin & 'ond strength of composite resins to enamel & 91 < 61 : %9O9 uniformly sho(ed that both shear bond strength and tensile bond strength of all composite restorative materials tested (ere significantly reduced (hen composite application =including acid < etching pretreatment> (as performed immediately+ i.e.+ (ith in H day+ after completion of bleaching regime. It (as sho(n that resin tags in bleached enamel subsequently acid etched (ith 6. : phosphoric (ere less defined+ more fragmented and penetrated to a less depth than in unbleached enamel controls. =Amith # !00!>. Recommendations for application of composite materials onto carbamide pero,ide bleached enamel ranged from ! day+ 6@. days+ to 6 (ee*s. The effect of bonding agent on composite bond strength to enamel bleached (ith carbamide pero,ide gels seem to depend on the bonding agent used. =acetone> Only one study dealt (ith the adhesion of resin modified 2I cements to pre@bleached enamel. It (as sho(n that the cement used for brac*et bonding (as not affected by pre@bleaching of enamel (ith !8 : carbamide pero,ide at 9/ hour and !/ days after bleaching according to %ome(ood . =988!>. .

'ond strength of composite resins and glass ionomer cements to dentin& There is reduction is dentin bond strength for composite and 2.I. for both bleaching (ith 68@61 : %9O9 and 78@9! : 3. Reasons for the impact of bleaching agents on bond strength of restorative materials and clinical consequences & 'leaching (ith %9O9 or %9O9 releasing agents may result in significant decrease of enamel calcium and phosphate content and in morphological alterations in the most superficial enamel crystallites. The enamel and dentin organic matri, (as altered by the o,idi4ing effect of %9O9. These aspects may lead to an enamel surface+ (hich did not allo( for formation of a strong and stable bond bet(een the composite applied and the superficial etched enamel layer. Furthermore+ reduction in bond strength in % 9O9 treated enamel and dentin could be caused by residual O9 present in enamel and dentin pores after completion of the bleaching treatment. To dissolve remnants of pero,ide+ cavities can also be cleaned (ith catalase or !8 : sodium as corbate. %o(ever+ approach of these agents might be time < consuming or e,pensive+ so that further investigations are needed to optimi4e their use under clinical conditions. Ao it is therefore more feasible to follo( the above mentioned recommendations to allo( for contact time of at least . days (ith %9O9 to avoid the reduction of adhesion of composites to enamel. 3roper 6 (ee*s must. Effect of bleaching agents on marginal quality of restorations & omposite resin & 3re < restorative nonvial+ intra@coronal bleaching in the sense of (al*ing < bleach < technique using mi,tures of 6. : carbamide pero,ide or pastes consisting of 68 : % 9O9 and sodium perborate leads to a higher rate of microlea*age in composite of both the access cavity and class <G cavities placed immediately after termination of bleaching. In class G restorations+ the increase of microlea*age after intra@coronal application of 6. : carbamide pero,ide (as only detected in dentin margins and not in enamel margins. =Ahinohara et al in 988!>.

Ahort@term use of intracoronal microlea*age of access cavities.

a=O%>9 medicament for .@days after completion of (al*ing <

bleach therapy (as able to reverse the < negative influences of the % 9O9 application on Atudy done by Glu*api et al =9886> proved that microlea*age rates of labial restorations (ith enamel margins only+ (ere significantly increased after !8 : carbamide pero,ide bleaching. Aimilar findings (ere reported by Tur*un and Tur*um in =988/> that significant reduction in sealing of access cavities (ith composite resins up to ! (ee*s after application of !8 : carbamide pero,ide into the pulp chamber. 3olyacid < modified resin < based composites+ resin < modified 2I + amalgam and temporary materials & Only t(o studies addressed to the impact of pot operative bleaching =61 : % 9O9 or 6@!7 : 3> on restorations (ith enamel margins fabricated (ith polyacid < modified resin < based composites+ resin < modified 2I =9886>. In both studies+ no deterioration of marginal seal (as revealed. Marginal lea*age of amalgam restorations (ith enamel margins only (ere also not negatively influenced by pre@operative e,ternal bleaching (ith !8 : carbamide pero,ide. It (as indicated that temporary restorative materials+ such as FOE cement and 4inc o,ide phosphate cement+ did not provide an optimal seal (hen used for provisional restoration of the access cavity during internal bleaching (ith the (al*ing bleach technique using a mi, of 68 : %9O9 (ith sodium perborate as bleaching agent. The most favorable results (ith respect to cavosurface seal during internal bleaching (ere demonstrated for hydraulic filling materials+ such as cavil and coltosol. 3enetration of the pulp chamber by bleaching agents in restored teeth & It (as observed that during e,ternal bleaching (ith 68 : hydrogen pero,ide or !8@61 : carbamide pero,ide gel higher levels of %9O9 penetrated into the pulp chamber in teeth (ith restorations placed in enamel as compared to sound teeth. linical consequences of the impact of bleaching agents on restorations & E,ternal root resorption has been related to bleaching of endodontically treated teeth =%eller et al !009>. It may be prevented by placing a base in the root canal opening. 0 or amalgam. #one by O(nes 'M in !00- and Glu*api %

Temporary dressing of pulp chamber (ith e,ternal root resorption.

a=O%>9 has also been indicated to prevent

Iehoe =!0-.> found that bleaching agents reduced the p% in the amelo@cemental ;unction+ stimulating osteoclastic activity+ (hich could start e,ternal root resorption. 3lacing a=O%>9 paste into the pulp chamber could increase p%+ thus+ inhibiting the osteoclastic activity. The above mentioned studies underline that pre and post operative bleaching procedures may < very affect marginal seal of restorations.

Moreover+ restorations and margins of restorations could be regarded as a possible path(ay facilitating pero,ide penetration into the pulp chamber. 3ero,ide penetration into the pulp chamber is held responsible for 3ulpal reactions such as increase in tooth hypersensitivity+ during e,ternal bleaching of vital teeth. #entists should therefore e,amine restorations meticulously before starting a bleaching therapy and rene( insufficient fillings prior to bleaching in order to achieve an optimal seal of the pulp chamber and thus reducing the ris* of adverse effects.

onclusions & 'leaching procedures can be used (ith little fear of damage to e,isting restorations. In addition+ bleaching may improve the outcome of many restorative procedures. Di*e if porcelain veneered teeth become dar*er over time due to regression of the original bleaching effect+ they may be rebleached by applying 3 to the lingual surfaces. This procedure is effective because pero,ide is able to diffuse freely Thro5 the tooth from the unrestored areas of enamel+ as porcelain veneers are translucent and life li*e. In case of ceramic cro(ns < frequently+ (hen a single anterior cro(n is required+ the ad;acent teeth have a shade that is very difficult to match (ith ceramic materials. 'leaching can be used to change the shade of the ad;acent teeth to one that is more easily replicated in porcelain. Also+ a single ceramic cro(n that originally matched the ad;acent teeth (ill appear lighter than ad;acent teeth because those teeth have discolored over the years from aging and dietary habits. In many cases+ the ad;acent natural teeth can be bleached to improve their match (ith the cro(n+ eliminating the need to replace the cro(n to correct the aesthetic mismatch. %ome bleaching agents should not be used indiscriminately (hen composite resin restorations are present. The patient should be informed that bleaching may accelerate the natural aging process of composite resin restorations. !8

The patient must also reali4e that restorations frequently must be replaced to ensure proper shade matching if bleaching is successful. Finally+ if posterior composite resin restorations are present+ the patient should be instructed to be careful to confine the bleaching gel to the anterior segment of the tray. 'onding of adhesively attached restorations to prebleached dental hard tissue is significantly reduced. Therefore+ it is recommended to delay placement of restorations after termination of bleaching therapy for at least !@6 (ee*s.

'efore deciding (hether to veneer or bleach+ carefully e,amine the patient5s enamel+ tooth position+ and arch form. First loo* at the enamel shade and structure. %o( much translucency is present and (here is it located J The danger of bleaching translucent enamel is that it may become more translucent+ there by possibly creating the illusion of a dar*er+ rather than lighter+ tooth is dar*ness from the bac* of the mouth bleeds Thro5.

ompromised tooth position or arch arrangement may influence the decision (hether to bleach or bond. Although bleaching may (ell lighten the teeth+ the end result may still not please the patient+ (hiter may still be malpositioned and hence unattractive. Therefore+ either bonding or laminating may be a better choice (here it is possible to simultaneously create the illusion of straighter teeth REFERE" EA&

!>Effect of three bleaching agents on the surface properties of three different esthetic restorative materials. C 3rosthet #ent 9886? -0 & /77@.6. 9> Effects of home bleaching products on composite resins. Kuintessence Int !009 ?96 &/-0@0/. 6> The effect of bleaching agents on the microhybridness of dental aesthetic restorative materials. C Oral Rehabil 9889 ? 90& 71.@7!. /> 3ero,ide bleaches < effect on tensile@ strength of composite resins. C 3rosthet #ent !006? 70& 9/.@0.

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1> The effect of current bleaching agents on the color of light polymeri4ed composites in vitro. C 3rosthet #ent 9886? -0& /./@-. 7> Effects of carbamide pero,ide on dental luting agents. C Endod !009? !-& !9-@69. .> In vitro evaluation of the effect of a current bleaching agent on the electrochemical corrosion of dental alloys. C Oral Rehabil 9889? 90&!8!/@0. -> In vitro microlea*age of composite restorations after non vital bleaching. Kuint Int 988!? 69& /!6@..

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