R E DS ET N

O TR I AS TT IRVY E
R E S T O R AT I V E

D E N T I S T R Y

An Overview of BleachingTechniques:
1. History, Chemistry, Safety
and Legal Aspects
M. SULIEMAN
Abstract: The use of a variety of bleaching techniques has attracted much interest
from the profession, as they are non-invasive and relatively simple to carry out.
Coupled with the uncertain legal situation within the European community, and
especially within the UK, this series of articles hopes to give a broad overview of
bleaching techniques, their efficacy and relative safety, as well as update the current
legal situation.
This article will give an overview of bleaching: history, chemistry and safety. In
addition, it will summarize types of tooth discoloration, along with indications/contraindications for bleaching. Future articles will address in detail both home and power
bleaching techniques, as well as the various ways to bleach non-vital teeth.
Dent Update 2004; 31: 608-616

Clinical Relevance: With the present uncertainty of the legality of bleaching, it is

important to highlight that these techniques are relatively safe and non-invasive
compared to veneers and full coverage crowns.

ooth discoloration creates a wide

range of cosmetic problems and the
dental profession and the public expend
considerable amounts of time and
money in attempts to improve the
appearance of discoloured teeth. The
methods available to manage
discoloured teeth range from:

Removal of surface stain;

Bleaching or tooth whitening
techniques;

Operative techniques to camouflage
the underlying discoloration, such
as veneers and crowns.
M. Sulieman, LDS RCS (Eng.), BDS (Lond.),
MSc, Research Fellow, Division of Restorative
Dentistry, Department of Oral and Dental
Science, University of Bristol Dental School, Lower
Maudlin Street, Bristol BS1 2LY and Private
Practitioner,Wimbledon, London.

608

The use of a variety of bleaching

techniques has attracted much interest
from the profession, as they are noninvasive and relatively simple to carry
out. Contemporary bleaching systems
are based primarily on hydrogen
peroxide or one of its precursors,
notably carbamide peroxide, and these
are often used in combination with an
activating agent such as heat or light.
Bleaching agents can be applied
externally to the teeth (vital bleaching),
or internally within the pulp chamber
(non-vital bleaching).1,2 Both techniques
aim to bleach the chromogens within the
dentine, thereby changing the body
colour of the tooth. A variety of case
reports and small clinical studies have
shown that a 10% carbamide peroxide
gel used in a bleaching tray at night, the
so-called night guard vital bleaching
technique, produces predictable

results,3-11 as do hydrogen peroxide

strips.12 Similarly, power bleaching
using 35% hydrogen peroxide with or
without light and/or heat activation has
also been shown to be effective.13,14

HISTORICAL BACKGROUND
Since the late 1800s, dentists have been
preoccupied with aesthetic procedures,
such as bleaching and tooth
recontouring, but there were different
views on the success of these
procedures. Arguments against
bleaching included the length of time to
achieve a lightening effect and
technique sensitivity, with teeth often
reverting back to their original colour.13
By 1848, non-vital tooth bleaching with
chloride of lime was practised,15 but
according to Kirk, Truman is often
credited with introducing the most
effective technique for non-vital teeth at
the time when chlorine was produced
from a solution of calcium hydrochlorite
and acetic acid, known as Labarraques
solution.16 Many different bleaching
agents were also successfully used on
non-vital teeth, including aluminium
chloride, oxalic acid, pyrozone (etherperoxide), hydrogen peroxide, sodium
peroxide, sodium hypophosphate,
sulphurous acid and cyanide of
potassium.13 Apart from the reducing
agent sulphurous acid, the rest were all
oxidizing agents that worked directly or
indirectly on the organic portion of the
stain.
By the 1860s, vital teeth were also
bleached externally using oxalic acid and
later using hydrogen peroxide or
pyrozone.13 This was followed in the
Dental Update December 2004

R E S T O R AT I V E

early 1900s with the addition of heated

instruments or a light source to
accelerate the process.1 Non-vital tooth
bleaching using pyrozone applied to the
external labial surface of the tooth was
superseded by internal bleaching within
the pulp chamber using 35% hydrogen
peroxide.17
In 1961, Spasser described a method of
sealing a mixture of sodium perborate
with water into the pulp chamber and
leaving it in situ for one week when the
patient would return to have the
procedure repeated until the desired
lightening effect was reached.18 This was
known as the walking bleach technique
and was modified by Nutting and Poe,19,20
using a combination of 30% hydrogen
peroxide and sodium perborate sealed
into the pulp chamber for one week.
These materials used together have a
synergistic effect, but the technique
suffered problems with cervical
resorption, even though it was
recommended that the gutta percha be
sealed before the procedure was
started.21 The thermocatalytic technique
introduced by Stewart also suffered from
the same problem of resorption, thought
to be due to the use of a combination of
high concentration of hydrogen peroxide
and a heated instrument within the pulp
chamber.1 Heithersay22 found the
incidence of resorption associated with
tooth bleaching to be 3.9% and 9.7%
when combined with trauma, while that
associated with orthodontic treatment
was 24.1%.
Recently, newer techniques, such as
inside/outside bleaching, have largely
replaced older techniques, but
essentially still involve filling an open
pulp chamber with 10% carbamide
peroxide, together with external
application with the aid of a custom tray.

DEVELOPMENT OF NIGHT
GUARD VITAL BLEACHING
(NGVB)
Haywood23 attributes the first
description of successful home
bleaching using hydrogen peroxide to
Klusmier in 1968, who noticed that teeth
whitened after treatment of a mouth
injury using Gly-oxide (hydrogen
Dental Update December 2004

peroxide mouthwash) in an orthodontic

retainer. The results were lighter teeth in
addition to healing of the injury.
However, this technique received
worldwide acceptance when described
in 1989 by Haywood and Heymann
using 10% carbamide peroxide in a
custom made tray worn at night, the
Night guard vital bleaching technique.3

DEVELOPMENT OF POWER
BLEACHING
In-surgery bleaching techniques used
since the early 1900s were further
modified in 1991 with the introduction of
30% hydrogen peroxide gels activated
by conventional light curing units rather
than a heat source. This technique is
often referred to as power bleaching.
Although these power gels could be
controlled easily compared to the
previous liquids used, full mouth
isolation was still needed to protect the
gums and surrounding soft tissues. The
power bleaching was frequently
combined with home use tray systems to
maximize the bleaching effect and give a
kick start to the whitening procedure
before the patient continues with NGVB
at home. A further modification to the
power bleaching system was the use of
an argon laser as an activating light
source to replace conventional curing
lights.24 The present day systems are
activated by a variety of light sources:
plasma arc lamps, Xe-halogen, LED light
and diode lasers. However, light sources
are not essential, there are systems that
require chemical activation only and are
merely painted on to the teeth with the
usual use of gum and soft tissue
isolation.25

CURRENT BLEACHING
MATERIALS
The home bleaching materials available
today are a combination of different
concentrations and flavours of both
carbamide peroxide or hydrogen
peroxide used in either custom made
trays or one size fits all type trays. In
addition to these are the relatively new
hydrogen peroxide gels on polyethylene
strips (Whitestrips [Procter and Gamble,

D E N T I S T RY

Cincinnati, Ohio, USA]) applied like

medical plasters on the labial surface
and lapping over the incisal edges of the
teeth. Other recent additions include
disposable trays pre-filled with 9%
hydrogen peroxide gel which can be
adapted to fit around teeth without the
need for impressions or laboratories
(Ultradent Products Inc. 505 West, 10200
South, South Jordan, Utah, USA).
The latest addition to power bleaching
in the UK will be the concept of
ultrasonic power bleaching which
utilizes a 67.5% hydrogen peroxide gel
in upper and lower trays equipped with
ultrasonic technology (SoniWhite
Whitening System [DMDS UK, DMDS
House, 18 Dover Street, Canterbury, UK]).

BLEACHING
CLASSIFICATION
There are many different classifications
of tooth whitening agents and systems
used. These products can be classified
according to the chemicals used or their
place or mode of application/delivery or
mode of action. The whitening of teeth
in general is via extrinsic stain removal,
bleaching or both. The mode of delivery
can be via toothpastes, mouthrinses,
chewing gums, bleaching gels and
liquids with or without trays.

BLEACHING CHEMISTRY
The exact bleaching/whitening
mechanism is not fully understood but
is thought to involve the ingress of
oxidizers and oxygenating molecules via
enamel micropores along a diffusion
gradient and via direct access of
dentine. These reduce or cleave pigment
molecule double bonds either to break
down pigments to small enough
molecules that diffuse out of the tooth,
or to those that absorb less light and
hence appear lighter.
Hydrogen peroxide forms a loose
association with urea to produce urea
peroxide (carbamide peroxide) which is
easily broken down in the presence of
water to release free radicals that
penetrate through the enamel pores and
into the dentine to produce the
bleaching effect. The breakdown of
609

D E N T I S T RY

WHY WHITEN TEETH?

(a)

(b)

2H202
2H20 + 02

With high pH and accelerator (Anionic dissociation):

Using heat and light (Photo dissociation)

H202
H20 + 0

02
0

R E S T O R AT I V E

(Weak free radical)

H + HO2

(Strong free radical)

Figure 1. The breakdown of hydrogen peroxide into reactive free radicals: (a) photo dissociation and
(b) anionic dissociation.

hydrogen peroxide into free radicals that

penetrate through the tooth occurs via
photo dissociation, anionic dissociation
or a combination of the two once the
process starts (Figure 1). Once the
initiation has started both types of
dissociation may occur.
There are many different bleaching
products on the market with various
other additives for enhancing the
bleaching procedure or to reduce
possible side-effects; these will be
considered in future articles.

SAFETY
A number of authors have investigated
the safety of bleaching procedures25-44
but have tended to concentrate mainly
on the use of carbamide peroxide used
in at home bleaching systems.26-30,34-43

TOOTH SENSITIVITY
The evidence on safety published to
date on the whole tends to suggest that
bleaching is a relatively safe
procedure,26-32,36,37,42-43 but some workers
have voiced concerns about potential
structural changes that may occur as a
result of bleaching.34,38-41 Relevant to
this is sensitivity of teeth in some
individuals during bleaching: a problem
that has attracted little research
attention to explain the phenomenon,
even though two-thirds of patients
experience sensitivity during home
bleaching.44

EFFECTS ON PHYSICAL
PROPERTIES

610

Scanning electron microscopy studies of

enamel bleached with carbamide peroxide
show little or no change in morphology,27
while other work shows areas of shallow
erosions28 or more substantial changes in
enamel structure.38-40 Surface hardness
and wear resistance has also been
investigated, with equal disagreements to
the overall effect of bleaching. The
results range from no effect on
toothwear32,45-47 to significant decrease in
hardness and fracture resistance of
enamel.34,41
Recent research involving hardness
testing, erosion/abrasion and SEM work,
using one of the highest concentrations
of hydrogen peroxide for tooth bleaching
procedures and under worst case
scenario conditions of a model in vitro,
failed to show any evidence of
deleterious effects on enamel or dentine.48
One possible reason for the reported
deleterious effect on enamel and/or
dentine of bleaches reflect not the bleach
itself but the pH of the formulation used.

EFFECTS ON ENAMEL/
DENTINE BONDING
Bonds to enamel/dentine may be altered
following bleaching owing to the
presence of hydrogen peroxide. Resin
tags in bleached enamel are less
numerous, less defined and shorter than
those in unbleached enamel.49 The
residual oxygen in the tooth surface also
inhibits the polymerization of the
composite resin and disrupts the
surface.50,51 However, bond strength
improves if the procedure is delayed for
2 weeks post-bleaching.

There are many reasons given by

patients for whitening their teeth and
they include the following:

Youthful appearance;
Changing jobs;
Getting married;
Improving self-esteem.

In a study of patient satisfaction with

their tooth colour, Odioso et al.52
reported up to a 50% indifference, while
30% were dissatisfied and 10% highly
dissatisfied with their tooth colour.
There are many factors that affect tooth
colour, including the thickness or
morphology of enamel, translucency,
external/internal stains, recession and
dentine exposure.

DISCOLORATION
The causes of tooth discoloration are
varied and complex but are usually
classified as being either intrinsic or
extrinsic in nature (Figure 2). Extrinsic
discoloration arises when external
chromogens are deposited on the tooth
surface or within the pellicle layer.
Intrinsic discoloration occurs when the
chromogens are deposited within the
bulk of the tooth, usually in the dentine,
and are often of systemic or pulpal
origin.53,54 A third category of stain
internalization has recently been
described to include those
circumstances where extrinsic stain
enters the tooth through defects in the
tooth structure.53
Intrinsic staining is further divided
into metabolic, inherited, iatrogenic,
traumatic and ageing causes. Iatrogenic
intrinsic staining most often presents
with tetracycline ingestion during tooth
formation and is classically a banded
appearance being yellow, brown, blue,
black or grey in colour, depending on
the severity (Figure 3). Traumatic causes
of discoloration are seen frequently in
the form of enamel hypoplasia, pulpal
haemorrhagic products and root
resorption. The darker tooth colour seen
in ageing is the result of thinning/
textural changes in enamel, as well as
secondary and tertiary dentine
deposition (Figure 4).

Dental Update December 2004

R E S T O R AT I V E

D E N T I S T RY

Figure 2. (a) Intrinsic tooth discoloration

produced by ingestion of excess fluoride
(courtesy of Professor Martin Addy) and (b)
extrinsic staining produced by dietary
chromogens and tobacco.

Extrinsic discoloration is caused by

chromogens that attach to the tooth
directly, such as tobacco, tea, coffee, red
wine, spices, vegetables, medicines and
plaque; or by those that attach
indirectly by combining with another
element to produce the stain. The latter
group include polyvalent metal salts
such as iron supplements and cationic
antiseptics such as chlorhexidine, which
combines with tea to produce the
characteristic black and brown stains.
With time, cracks within teeth gain
external stain which becomes
internalized in the tooth or stains
become internalized as a result of loss of
enamel or recession. Hence, internalized
stains can result from trauma, caries or
restorations. Table 1 shows the types of
tooth discoloration and the typical tooth
colours they produce.

INDICATIONS AND
CONTRA-INDICATIONS
Nearly every patient can have his/her
teeth bleached but not every case is

Figure 3. Tooth discoloration produced by the

incorporation of tetracycline into the dentine
during tooth formation.
612

guaranteed to have a successful

outcome or be enough to satisfy the
aesthetic needs of the patient. The
indications for bleaching are basically
the same for both in-surgery and home
bleaching but the clinician must decide
which method is best suited to the
patients needs.

Indications

Generalized staining;

Ageing;

Smoking and dietary stains such as
those of tea and coffee;

Fluorosis;

Tetracycline staining;

Traumatic pulpal changes.
In addition to tetracycline staining, there
have been many reports of adult teeth
stained by minocycline used to treat
acne. Teenagers prescribed this drug
may see their teeth change to a grey
colour because the drug is laid down in
the secondary dentine and is re-secreted
in the saliva to soak the external surface
of the tooth. Very severe tetracycline
staining may not be amenable to
bleaching alone and combination
treatments such as bleaching and
veneers may be considered. Prior
bleaching reduces the amount of tooth
substance removed in preparation of the
veneers which would otherwise have
been necessary in order to mask the
stain and allow for porcelain build-up.
Fluorosis with multiple spots of varying
colours may require a combination of
bleaching and microabrasion using

hydrochloric acid and abrasives/

polishes.55
As mentioned above, bleaching can
be undertaken for most cases but some
contra-indications are worthy of a
mention. Patients with high expectations
may never be satisfied and should be
identified by asking a simple question as
to what they hope to achieve with the
bleaching procedure. Patients that reply
Dazzling white or words to that effect
should be treated cautiously, while more
reasonable replies may be a freshening
look to the teeth or a little lighter. Decay,
periapical lesions and sensitivity does
not preclude those patients from
bleaching, but these conditions have to
be resolved prior to bleaching.

Contra-indications

Patients high expectations;

Decay and periapical lesions;
Pregnancy;
Sensitivity, cracks and exposed
dentine;

Existing crowns or large
restorations in the smile zone;

Elderly patients with visible
recession and yellow roots.
The most important contra-indication to
bleaching is the patient with very high
expectations that will never be satisfied
following bleaching and for whom other
forms of treatment should be
considered. Existing crowns or
restorations that need to be changed
following bleaching may be considered a
contra-indication for patients that do
not want or cannot afford this extra
financial burden. It is not always

Figure 4. Ageing discoloration produced as a

result of thinning/textural changes in enamel as
well as secondary and tertiary dentine deposition.
Dental Update December 2004

R E S T O R AT I V E

Types of Discoloration

Colour Produced

Extrinsic (Direct stains)

Tea, coffee and other foods
Cigarettes/cigars
Plaque/poor oral hygiene

Brown to black
Yellow/brown to black
Yellow/brown

Extrinsic (Indirect stains)

Polyvalent metal salts and cationic antiseptics
e.g. Chlorhexidine

Black and brown

Intrinsic
(Metabolic causes)
e.g. Congenital erythropoietic porphyria
(Inherited causes)
e.g. Amelo/Dentinogenesis
(Iatrogenic causes)
Tetracycline
Fluorosis
(Traumatic causes)
Enamel hypoplasia
Pulpal haemorrhage products
Root resorption
(Ageing causes)
Internalized
Caries
Restorations

Purple/brown
Brown or black
Banding appearance:
classically yellow, brown, blue, black or grey
White, yellow, grey or black
Brown
Grey black
Pink spot
Yellow
Orange to brown
Brown, grey, black

Table 1. Colours produced by various causes of tooth discoloration.

necessary to change composites

following bleaching because some types
of composites display a chameleon
effect, taking on the shade of the
surrounding tooth, blending in well if
not quite perfectly. The other contraindications mentioned above can be
rectified before embarking on a
bleaching course of treatment. For
instance, in the case of decay; following
removal of the decay and dressing of
the teeth with glass ionomer, bleaching
can be performed and a final definitive
restoration placed about 2 weeks later to
allow for the dissipation of the residual
oxygen that may inhibit the composite
bond to enamel/dentine. Similarly, apical
lesions should be treated and the root
canal filling sealed effectively using a
glass ionomer material prior to
bleaching. The sensitive patient can
have fluoride desensitizing gels applied
to teeth in the bleaching trays for a
period of a few weeks prior to bleaching.
These points will be covered in more
detail in the following article on
bleaching side-effects and their
treatment. Elderly patients with yellow
receded roots present a problem in that
Dental Update December 2004

the roots do not bleach as readily

compared to the crowns, leaving an
obvious mismatch that requires
restorative dentistry to correct. If the
patients are aware of this and are willing
to undergo restorative work to address
this issue, then it cannot be considered
a contra-indication.

WHO BEST TO BLEACH?

Although it is difficult to predict the
result of bleaching teeth for every
individual, there are some guidelines
gained from various studies, reports and
personal experience. For instance, it is
relatively predictable to bleach teeth of
older patients with small pulps and
various accumulated dietary stains as
well as the ageing discoloration caused
by secondary dentine deposition. In the
authors experience, teenagers with
yellow teeth or with basically white
teeth except for the yellow canines tend
to respond well with bleaching. Brown
stains are more difficult to bleach but
generally respond to longer bleaching
regimes as do stains caused by
nicotine.56 White fluorosis spots do not

D E N T I S T RY

tend to bleach but will become less

obvious as a result of the lightening of
the surrounding tooth area.56
Severe tetracycline staining may be
very difficult to bleach but mild to
moderate tetracycline staining tends to
respond to extended bleaching regimes
of 36 months.56 Different brands of
tetracycline present with different
coloured tooth banding, which is
especially difficult to treat as not all
respond well to bleaching, leaving the
possible need to use restorations to
cover the non-responsive band.56

CURRENT LEGAL
SITUATION FOR
BLEACHING WITHIN THE
UK
The European cosmetic directive of 1976
prohibited the use of hydrogen peroxide
in cosmetics except in certain products
and to a limit included in that directive.
Opalescence gel (10% carbamide
peroxide) was introduced in 1992 by
Optident Ltd (Valley Drive, Ilkley, West
Yorkshire, UK) in the UK, and later that
year the cosmetic directive from the EU
was amended to ban the use of
carbamide peroxide in cosmetics, except
in oral hygiene products and only to the
limit of 0.1% hydrogen peroxide. As a
result, in 1993, at the order of the
Department of Trade and Industry (DTI),
this product was withdrawn from the
market.
After the introduction of the Medical
Devices (MD) Directive in 1993 and the
subsequent issue of a CE mark to the
product in Germany in 1994,
Opalescence was re-launched in 1995
with a CE mark. The CE mark is an
obligatory product mark for the
European market, which indicates
compliance certification according to
the requirements formulated in the
approximately 22 European CE Marking
Directives and subsequent European
standards. Therefore, the CE mark is
important for manufacturers and
importers placing products in the
European market. However, the DTI still
viewed this product as a cosmetic and
deemed its supply illegal. Suppliers of
this product were liable to 6 months in
613

R E S T O R AT I V E

D E N T I S T RY

prison and a 5000 fine or both;

enforcement was under the terms of the
Consumer Protection Act of 1987 and
1989 Cosmetic Product Safety
Regulations. The manufacturers of the
product (Ultradent Products, 505 West,
10200 South, South Jordan, Utah, USA)
and its UK distributors then took the
DTI and Department of Health to court
because they alleged that they had
breached article 4 of the MD directive
by obstructing the sale of the product.
At the trial in 1998, the court classified
the product as a medical device.
Subsequently, in the Court of Appeal in
1999, the DTI won the appeal with the
product reclassified as a cosmetic
product and it was taken off the market.
This classification was upheld in 2001
by the law lords but by then certain
products had re-appeared on the dental
market packaged without the whitening
claims, making them cosmetic products,
hence allowing companies to get round
the rules applying to cosmetics.
The legal situation for the dental
profession was further confused in 2000
when the Chief Dental Officer for
England confirmed that the technique of
bleaching was legal:
The Department of Health would not
seek to interfere with a dentists
therapeutic decision to utilize a
bleaching technique where a dentist
considers this to be in the best interests
of the patients overall oral health care.
The issue in dispute is whether
bleaching products are cosmetics or
medical devices, but the current
Governments view is that they are
cosmetic products and are therefore
illegal. Dentists using these products
may be prosecuted by trading standards
officers and are liable to a heavy fine,
prison sentence and a criminal record.
The dental indemnity organizations
generally acknowledge the situation
and, although they will endeavour to
defend their members, cannot give any
guarantee to success in these cases and
warn their members undertaking these
procedures that they are liable to
prosecution. Clinical cases such as
mottled anterior teeth where bleaching is
614

by far less destructive than a veneer or

crown may be argued is in the best
interest of the patient. The use of
consent forms has attracted attention in
that you cannot give consent to an
illegal procedure but this was used in
legal defence to protect against some
perverse sexual acts. The situation here
cannot be compared at all and, under
current guidance to practice issued by
the General Dental Council, the use of
consent forms must be advocated. In
addition, simple information to the
patient should be provided outlining the
procedure, its prognosis and possible
side-effects, as well as the alternative
treatments available.
There have been many moves to
correct this legal situation by the
profession making presentations on
efficacy and safety to the EU, but to
date there is no change even though the
technique of tooth bleaching is
currently practised throughout the rest
of Europe, the USA and the rest of the
world.
Recently, LACORS (the co-ordinating
body to trading standards offices) has
issued a statement to its offices in
England recognizing that the level of
permissible hydrogen peroxide under the
current legislation is far too low and that
discussions are ongoing with the DTI
and the EU to raise this limit. In the
meantime, it advises that its members
take a low key approach in enforcement
and treat breaches accordingly.

REFERENCES
1.
2.

3.
4.
5.

6.

7.

Greenwall L. Bleaching Techniques in Restorative

Dentistry. London: Martin Dunitz, 2001.
Friedman S. Internal bleaching: long term
outcomes and complications. J Am Dent Assoc
1997; 128 (Suppl.): 5154.
Haywood VB, Heymann HO. Nightguard vital
bleaching. Quintessence Int 1989; 20: 173176.
Howard J. Patient-applied tooth whiteners. J Am
Dent Assoc 1992; 132: 5760.
Kowitz GM, Nathoo SA, Rustogi KN,
Chemielewski MB, Wong R. Clinical comparison
of Colgate Platinum Tooth Whitening system and
Rembrandt Gel Plus. Comp Contin Educ Dent 1994;
17: S4651.
Matis BA Cochran MA, Eckert G, Carlson TJ. The
efficacy and safety of a 10% carbamide peroxide
bleaching gel. Quintessence Int 1998; 29: 555563.
Reinhardt JW, Eivins SC, Swift EJ. Clinical study of
nightguard vital bleaching. Quintessence Int 1993;
24: 379384.

8.

9.

10

11.

12.

13.

14.

15.

16.
17.
18.
19.

20.

21.

22.

23.
24.
25.

26.

27.

28.

29.

Russell CM, Dickinson GL, Johnson MH. Dentistsupervised home bleaching with ten per cent
carbamide peroxide gel: a six month study. J Esthet
Dent 1996; 8: 177182.
McCaslin AJ, Haywood VB, Potter BJ, Dickinson
GL, Russell CM. Assessing dentin colour changes
from night guard vital bleaching. J Am Dent Assoc
1999; 130: 14851490.
Heymann HO, Swift EJ, Bayne SC, et al. Clinical
evaluation of two carbamide peroxide tooth
whitening agents. Compend Contin Educ Dent 1998;
19: 359362.
Papathanasiou A, Bardwell DS, Kugel G. A clinical
study evaluating a new chairside and take-home
whitening system. Compend Contin Educ Dent
2001; 22: 289294.
Gerlach RW, Zhou X.Vital bleaching with whitening
strips: summary of clinical research on
effectiveness and tolerability. J Contemp Dent Prac
2001; 2: 115.
Haywood VB. History, safety and effectiveness of
current bleaching techniques and application of the
night guard vital bleaching technique. Quintessence
Int 1992; 27: 471488.
Sulieman M, Addy M, Rees JS. Development and
evaluation of a method in vitro to study the
effectiveness of tooth bleaching. J Dent 2003; 31:
415422.
Dwinelle WW. Ninth Annual Meeting of American
Society of Dental Surgeons. Article X. Am J Dent
Sci 1850; 1: 5761.
Kirk EC. The chemical bleaching of teeth. Dent
Cosmos 1889; 31: 273283.
Pearson HH. Bleaching of discoloured teeth. J Am
Dent Assoc 1958; 56: 6465.
Spasser HF. A simple bleaching technique using
sodium perborate. NY Dent J 1961; 27: 332334.
Nutting EB, Poe GS. A new combination for
bleaching teeth. J Southern Calif Dent Assoc 1963;
31: 289.
Nutting EB, Poe GS. Chemical bleaching of
discoloured endodontically treated teeth. Dent
Clin North Am 1967; Nov: 655662.
Harrington GW, Natkin E. External resorption
associated with bleaching of pulpless teeth. J Endod
1979; 5: 344348.
Heithersay GS. Invasive cervical resorption: an
analysis of potential predisposing factors.
Quintessence Int 1999; 30(2): 8395.
Haywood VB, Drake M. Research on whitening
teeth makes news. NC Dent Rev 1990; 7(2): 9.
Reyto R. Laser tooth whitening. Dent Clin North
Am 1998; 21(4): 755762.
Christensen G. Why resin curing lights do not
increase tooth lightening. Status Report. CRA
Newsletter 2000; 24/6: 3.
Covington J, Friend G, Lamoreaux W. Carbamide
peroxide tooth bleaching effects on enamel
composition and topography. J Dent Res 1990; 69:
175 (abstr. No. 530).
Haywood VB, Leech T, Heymann HO, et al.
Nightguard vital bleaching: effects on enamel
surface texture and diffusion. Quintessence Int
1990; 21: 801806.
Haywood VB, Houck V, Heymann HO. Nightguard
vital bleaching: effects of varying pH solutions on
enamel surface texture and colour change.
Quintessence Int 1991; 22: 775782.
Haywood VB, Heymann HO. Nightguard vital
bleaching: how safe is it? Quintessence Int 1991; 22:
515523.

Dental Update December 2004

R E S T O R AT I V E

D E N T I S T RY

30. Haywood VB. History, safety and effectiveness of

current bleaching techniques and applications of
the nightguard vital bleaching technique.
Quintessence Int 1992; 23: 471488.
31. Haywood VB. Nightguard vital bleaching: current
concepts and research. J Am Dent Assoc 1997;
128(Suppl.): 19S25S.
32. Hunsaker KJ, Christensen GJ, Christensen RP.
Tooth bleaching chemicals influence on teeth
and restorations. J Dent Res 1990; 69: 303 (abstr.
No. 1558).
33. Scherer W, Cooper H, Ziegler B, et al. At home
bleaching system: effects on enamel and
cementum. J Esthet Dent 1991; 3: 5456.
34. McCraken MS. Effects of vital bleaching on the
hardness of enamel. Presented at the American Dental
Association Student Table Clinic, Seattle, Oct. 1991.
35. Kalili T, Mito R, Caputo AA, et al. In vitro
toothbrush abrasion and bond strength of
bleaching enamel. J Dent Res 1991; 70: 546 (abstr.
No. 2243).
36. Seghi RR, Denry I. Effects of external bleaching on
indentation and abrasion characteristics of human
enamel in vitro. J Dent Res 1992; 71: 13401344.
37. Murchison DF, Charlton DF, Moore BK.
Carbamide peroxide bleaching: effects on enamel
surface hardness and bonding. Operative Dent
1992; 17: 181185.
38. Shannon H, Spencer P, Gross K, et al.
Characterisation of enamel exposed to 10%
carbamide peroxide bleaching agents. Quintessence
Int 1993; 24: 3944.
39. Bitter NC. A scanning electron microscopy study of
the effect of bleaching agents on the enamel. A

BOOK REVIEW
Human Disease For Dentists. D.J.
Gawkrodger, ed. Blackwell Publishing
Ltd, Oxford, 2004 (296pp., 29.99). ISBN
0-63206-453-6.
I was intrigued by the ambitious scope of
this publication, especially considering
the compact size. The book is intended as
a guide to human disease for dental
students, dentists and professional
complementary to dentistry.
My review of this publication was
based on its usefulness to me in my role
as a busy GDP and I also asked the
opinion of the PCDs I work with, to gain
their perspective as to the book's
usefulness in the day-to-day care of the
dental patients we see.
Firstly, I found the list of contributors
was an impressive 35 healthcare
professionals. It was a little
disappointing, however, that only one of
these held a dental qualification.
Section One of the book deals with
medical history-taking and examination,
616

preliminary report. J Prosthet Dent 1990; 67: 852855.

40. Bitter NC. A scanning electron microscopy study
of the long term effect of bleaching agents on the
enamel surface in vivo. Gen Dent 1998; 46: 8488.
41. Bitter NC, Sanders JL. The effect of four bleaching
agents on the enamel surface: a scanning electron
microscopy study. Quintessence Int 1993; 24: 817
824.
42. Zalkind M, Arwaz JR, Goldman A, Rotstein I.
Surface morphology changes in human enamel,
dentin and cementum following bleaching: a
scanning electron microscope study. Endodont
Dent Traumatol 1996; 12: 8284.
43. McCraken MS, Haywood VB, et al.
Demineralisation effects of 10% carbamide
peroxide. J Dent Res 1996; 24: 395398.
44. Nathonson D.Vital tooth bleaching: sensitivity and
pulpal considerations. J Am Dent Assoc 1997;
128(Suppl., April): 41S44S.
45. Kozak KM, Duschner HH, GotzH, White DJ,
Zoladz JR. Effects of peroxide gels on enamel and
dentin in vitro. Research presented at the 30th
Annual Meeting of the American Association for
Dental Research, March 710, 2001.
46. White DJ, Kozak KM, Duschner HH, Gotz H,
Zoldaz JR. Effects of whitening peroxide gels on
exposed surface dentine in vitro. Research
presented at the 30th Annual Meeting of the
American Association for Dental Research, March 7
10, 2001.
47. Nathoo SA, Chmielewski M, Kirkup RE. Effects of
Colgate Platinum Professional Tooth whitening
system on microhardness of enamel, dentin and
composite resins. Compend Contin Educ Dent

1994; 17(Suppl.): S627S630.

48. Sulieman M, Addy M, MacDonald E, Rees JS. A
safety study in-vitro for the effects of an in-office
bleaching system on the integrity of enamel and
dentine. J Dent 2004; 32: 581590.
49. Titley KC, Torneck CD, Smith DC, Chernecky R,
Adibfar A. Scanning electron microscopy
observations on the penetration and structure on
the resin tags in bleached and unbleached bovine
enamel. J Endodont 1991; 17(2): 7275.
50. McGukin RS, Thurmond BA, Osovitz S. In vitro
enamel shear bond strengths following vital
bleaching. J Dent Res 1991; 70: 377.
51. Haywood VB. Ask the experts. Self-cured
composites and bleaching. J Esthet Dent 1999;
11(3): 122123.
52. Odioso LL, Gibb RD, Gerlach RW. Impact of
demographic, behavioural and dental care
utilization parameters on tooth colour and
personal satisfaction. Comp Contin Educ Dent
2000; 21(Suppl.): 3541.
53. Addy A, Moran J, Newcombe R, Warren P.
The comparative tea staining potential of
phenolic, chlorhexidine and ant-adhesive
mouthrinses. J Clin Periodontol 1995; 22: 923
928.
54. Watts A, Addy M. Tooth discolouration and
staining. A review of the literature. Br Dent J
2001; 190: 309316.
55. Croll TP. Enamel microabrasion for removal
of superficial discolouration. J Esthet Dent
1989; 1: 1420.
56. Haywood VB. A comparison of at-home and inoffice bleaching. Dent Today 2000; 19(4): 4453.

which is covered in detail. In my

personal opinion, the section on clinical
examination would have benefited from
offering more specific, practical advice
on the sequential examination of the
head and neck.
Section Two comprises 16 chapters,
forming the bulk of this publication, and
deals with various diseases and
conditions ranging from cardiovascular
to neurological to ear, nose and throat.
There is also a 48 page colour
illustration section at the back of the
book, which is referred to in the text and
relates primarily to manifestations of
diseases which could easily be observed
under dental examination.
Within this main section there is
perhaps a little too much diverse
information. For example, the chapter
covering Opthalmological diseases
covers 6 pages. A better use of the
space would perhaps be a section which
covered anaphylactic shock or a similar
dentally related medical condition.
Many of the diseases are dealt with
superficially and the publication is not

intended as a mini medical textbook. At

the end of each chapter, however, there
are references for further reading and
related websites, which is a useful
research tool.
The section on accident and
emergency, although useful, dealt purely
with sudden collapse and covered CPR
and management of a head injury.
An informative section on
anaesthetics and pharmacology is
followed by a question and answer
session which both myself and my
colleagues found useful and thought
provoking.
To summarize, as a GDP I found this to
be a helpful
textbook, with
easily accessible
information that
achieved its
objective and
would certainly
complement
other texts on the
subject.
Dental Update December 2004