R E S T O R A T I V E RD

E S
E TNOTRI AS TT I RV YE D E N T I S T R Y

An Overview of Bleaching
Techniques: 3. In-Surgery or
Power Bleaching
M. SULIEMAN

or cleave double bonds of large organic

Abstract: The use of in-surgery bleaching techniques has increased recently within the
profession following the introduction of various new systems. Many dentists and patients
molecules. Tooth whitening after a single
alike prefer the in-surgery procedures to lighten teeth as it takes the responsibility for the power bleaching session using 35% HP
procedure firmly away from the patient to the dentist; a situation with which both sides has been shown to be effective in both
may be more comfortable. clinical2 and laboratory studies.3,4,5 The
This article will review various in-surgery or power bleaching procedures. In addition,
indications/contra-indications of
it will detail the procedure involved and how and when to combine bleaching techniques.
in-surgery bleaching were covered under
the bleaching review in the first article,
Dent Update 2005; 32: 101-108
but specific mention should be given
Clinical Relevance: There are many power bleaching systems currently available to to areas of localized or developmental
improve the appearance of teeth in the surgery.
stains where in-surgery bleaching is
indicated in order for complete control
of the whitening process to be taken over
by the clinician.

T he concept of high concentration

hydrogen peroxide used in-surgery
to produce an almost immediate ‘on the
the procedure of lightening teeth is taken
in-surgery. There are specific situations,
such as single tooth bleaching within
ADVANTAGES OF POWER
BLEACHING
day’ whitening result dates back to the an arch, or even small areas on teeth The main advantages of the power
early 1900s.1 This was further modified that need to be lightened, where in- bleaching technique are:
in the 1990s with the introduction of surgery or power bleaching is advocated.
gels, as opposed to liquids, applied The dentist here has complete control ● The time factor – produces immediate
to teeth using gauze squares. Other throughout the procedure and is able to results in-surgery which can be
modifications included the replacement stop when the desired shade/effect is
used to motivate the patient to
of high intensity light used as a heat achieved. However, very often power
continue with home bleaching top-up
source with conventional halogen units, bleaching can be used to give a kick
treatment.
plasma arc lamps, LED lights, Xe- start to the lightening process in order
● Avoiding problems with home
halogen lights and lasers. Then as now, for the patient to see immediate results
bleaching procedures such as:
it is generally preferred by both dentists before being encouraged to comply with
– wearing trays that may cause
and patients that the responsibility for the home bleaching regimen. Power
bleaching is thought to work by the patients to gag;
permeation of oxygenating perhydroxyl – distaste for home bleaching gel.
free radicals through enamel micropores
M. Sulieman, LDS RCS (Eng.), BDS (Lond.), along a diffusion gradient and into the Home bleaching is often reported by
MSc, Research Fellow, Division of Restorative patients to give a metallic taste in the
Dentistry, Department of Oral and Dental dentine where it oxidizes the stains
Science, University of Bristol Dental School, and thereby bleaches the teeth. The mouth which is thought to disappear
Lower Maudlin Street, Bristol BS1 2LY; Private free radicals are thought to attach to within a couple of hours of removal of
Practitioner,Wimbledon, London. the trays from the mouth.
inorganic stain molecules and reduce

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 R E S T O R AT I V E D E N T I S T R Y

10% carbamide peroxide8 but, with

(a) (b) the growth in popularity of in-surgery
bleaching techniques, more work has
been published on the use of 35%
hydrogen peroxide for power bleaching
procedures. The safety of 35% hydrogen
peroxide for power bleaching has been
extensively researched in a recent study
which investigated the abrasion, erosion,
(c) hardness and structural changes on both
Figure 1. Dehydration related shade
change during power bleaching: (a) enamel and dentine; the conclusion
pre-bleaching shade C3; (b) shade of the study was that 35% HP had no
immediately post bleaching procedure
(A1); and (c) shade at two weeks post deleterious effects on either enamel or
bleaching (A2). dentine.8
There are many different materials
available but, broadly speaking, they
are either based on 35% carbamide
peroxide or hydrogen peroxide of the
same or higher concentration. Hydrogen
peroxide is more widely used as the
DISADVANTAGES OF 50% hydrogen peroxide used. The need power bleaching agent, but the range
POWER BLEACHING for a meticulous protocol in handling, of concentrations in use today varies
Disadvantages of power bleaching include: applying, removal and disposal of these from about 17–50%; bleaching times
materials is essential. also vary. Thirty-five percent carbamide
● The caustic nature of the 35–50% peroxide yields approximately 10%
hydrogen peroxide and is used in certain
hydrogen peroxide makes isolation SAFETY FACTORS IN
bleaching systems sometimes known
and protection mandatory; POWER BLEACHING
● The increased surgery time required, as 'waiting room bleach', as the patient
Handling of hydrogen peroxide products wears the custom-made trays full of the
making the procedure more
to avoid the risk of tissue burns to the material and waits in the waiting room of
expensive for the patient;
lips, cheeks, gingiva, the rest of the face the surgery. It is available in a powder/
● Dehydration of the teeth may occur,
or eyes makes isolation and protection liquid combination mixed together to
thereby giving a falsely lighter
techniques mandatory in the course of produce a gel or in a ready made gel
shade immediately post treatment.6 power bleaching. to which liquid is added. There are
The main safety issue concerning the many different combinations available
This last factor can cause further activating lights used in power bleaching
problems with patients perceiving depending on the system or activation
is heat generation and its effect on method used. These bleaching materials
there is colour regression or rebound the pulp. Recent research showed the
following re-hydration of the teeth will be discussed later in the article with
increase in the intra-pulpal temperature the various activation systems available.
(Figure 1). Some manufacturers have with most bleaching lamps was below
addressed this problem by producing the critical threshold of a 5.5 °C increase
gels that contain 10–20% water which thought to produce irreversible damage. CASE SELECTION /
re-hydrates the teeth throughout the The only lamp that produced an intra- BLEACHING PROTOCOL
bleaching procedure, while others have pulpal temperature increase above this Patients that present with decay,
tackled the problem by using lower threshold was the laser-based lamp periapical lesions or have existing
concentrations of hydrogen peroxide and this was also found to be below thermal sensitivity should be treated
(15%), which is a water-based solution, the critical temperature once the power for these issues prior to the bleaching
thereby increasing the water content by output was reduced from 3W to 2W.7 procedure. It is acceptable for decayed
20%. Most of the research on bleaching anterior teeth to have the decay
However, by far the biggest efficacy and safety has tended to excavated and dressed with a temporary
disadvantage of the power bleaching concentrate on the use of home glass ionomer filling material until two
procedure is the caustic nature of the 35– applied bleaching materials such as weeks after the bleaching treatment.

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 R E S T O R AT I V E D E N T I S T R Y

This will allow the clinician to shade discussed with the patient, a consent
match the permanent restoration to the form should be signed and the patient
new lighter tooth shade and also allow should be referred for a hygiene session
for enough time to elapse for dissipation about a week to ten days prior to the
of oxygen free radicals from the tooth bleaching procedure.
which may otherwise compromise the
composite bond to tooth.
Some authors advocate the use of
Operative Procedure
full mouth periapical radiographs to ● Shade assessment on the day with
the teeth wet and dry followed Figure 2. Isolation of teeth, gingivae and
document the size and vitality of pulps soft tissues: paint-on gingival dam extending
to predict sensitivity levels or check for by photographs with shade tab in situ. from tooth margin across the gingivae into the
periapical pathology9. In view of the ● External stain removal using a interdental spaces and mucosa. Cheek and
pumice/water slurry and a bristle tongue retractor keeps soft tissues away from
current ionization radiation regulations the bleaching gel.
and the unnecessary exposure of the brush or sodium bicarbonate with air
patient to high levels of radiation, abrasion units.
other forms of vitality testing such as ● Isolation: there are many forms of
ethyl chloride or electric pulp testers isolation that can be used, depending exposed dentine caused by recession
are advised instead. Any teeth that on the type of power bleaching or developmental defects.
require root canal therapy should have procedure used, or the dentist's ● Soft tissue retraction: cheek and
this carried out prior to the bleaching particular preference. Rubber dam lip retractors are placed to pull
procedure. is a good method of isolation used in these tissues away from the
Patients should also be made aware that combination with caulking putty teeth and bleaching gel. There are
the procedure may need to be repeated beneath it on the gingival area. The many products available, some
or topped up with home bleaching to teeth should also be ligated with of which have inbuilt suction
achieve optimal results, especially if waxed dental floss to prevent seepage facility (NOLA Full Arch isolation,
the existing shade is dark or there’s of the fizzing hydrogen peroxide Orthocare-UK) which is very useful,
tetracycline staining. solution through to the underlying while others have a tongue guard
Case selection and preparation of gingivae. Obviously, the use of to prevent the forward movement
the patient for bleaching including rubber dam is contra-indicated when of the tongue on to the teeth and
diagnosis of the cause of discoloration simultaneous dual arch power bleaching gel. Further tissue
were covered in the previous article bleaching is used. Light bodied protection is provided by gauze
on home bleaching. As in the previous impression materials used in the past and cotton wool rolls placed
article, special mention is again given for isolation did not provide reliable inside the lips and cheeks
to those patients with high expectations protection and have been replaced by to keep them away from the gel.
for the bleaching procedure who may the newer paint on dam materials Vaseline should be used on the
never be satisfied with the results. such as Opal dam (Ultradent lips to reduce cracking of the lips
Alternative treatments should be sort for Products, South Jordan, Utah, USA). and prevent them from drying up.
these patients following establishment These are light cured resin barrier A low volume saliva ejector should
of their expectation level by asking a materials that are painted on to the be placed at the back of the patient's
few pertinent questions. Only the actual gingivae around and in between mouth and the dental chair should be
operative procedure will be covered in the teeth to be bleached (Figure 2). adjusted to allow the patient to
this article. It is essential to ensure that the swallow comfortably any saliva that
Following the assessment of the material covers a wide area of is not removed.
teeth, the shade should be agreed with gingivae and mucosa around the ● Bleaching cycle: power bleaching
the patient and recorded in the notes. teeth and flows interdentally so that products would normally be
A pre-operative photograph with the it prevents leakage of the hydrogen refrigerated and should therefore be
shade tab in situ should always be taken peroxide to these areas. It may also allowed to reach room temperature
under standardized lighting conditions be advisable to place the for at least an hour prior to the
without using the dental operating light material lingually or palatally in procedure or be activated by running
which would washout the shade. After interdental areas. The material can the syringe under warm water for
all the relevant explanations, options, also be used to cover areas that are a few minutes. A fresh mix of gel is
limitations and prognosis have been not intended for bleaching, such as mandatory as these products have

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 R E S T O R AT I V E D E N T I S T R Y

within the bleaching kits.

● Polishing with a diamond polishing
paste gives a high lustre look to
the teeth and further enhances the
appearance of the teeth.
● Application of a neutral colourless
fluoride gel such as Gelkam (Colgate-
Palmolive Limited, Guildford, UK)
may help in cases where there was
Figure 3. Power bleaching gel applied to teeth Figure 4. Soft tissue damage with the use
of 35% hydrogen peroxide: gingival blanching sensitivity experienced during the
on both arches in the smile zone to a depth of
approximately 2–3 mm layer.The gel is slightly around the lower right canine and first premolar procedure.
lipped across the incisal edge and palatal/lingual as a result of the peroxide free radicals seeping ● Final shade assessment and post-
surface in cases where there is no incisal wear under the gingival barrier protection.This is not
operative photographs should be
and only if a tongue guard is present on the necessarily painful to the patient but should be
cheek retractor to prevent inadvertent tongue treated with copious amounts of water and then taken with both start and final shade
protrusion causing soft tissue damage. the placement of a neutralizer cream usually tabs in situ.
provided in the bleaching kit. ● Patients should be given post-
operative instructions. These include:
– The use of a fluoride gel or
a very short active time before teeth wiped using damp gauze before potassium nitrate containing
which the free radicals are depleted; being lightly dried. toothpaste in cases that
any gel remaining should be disposed ● A further fresh mix of gel is now experience thermal sensitivity.
of after use. The consistency of some applied to the teeth, activated as – Dietary advice to avoid
preparations can be altered by varying before and left in place for the same acidic drinks, fruits, tea, coffee
the hydrogen peroxide liquid content length of time. After removal of the and smoking for 48 hours. It is
but generally the mix should be gel using suction, the teeth are thought that the oxidizing free
creamy and slightly spreadable, washed with copious amounts radicals are still active within the
similar to that of acid etch gel, so that of water before light drying. The teeth for a further 48 hours post
it can be easily applied using a brush application and activation procedure bleaching.
or plastic spatula. is repeated one more time before – Shade regression of about half a
● A 2–3 mm layer of freshly mixed final washing and drying of the teeth. shade unit tends to occur about
gel should be applied to all the labial Therefore contact of the bleaching a week to ten days post bleaching.
surfaces of teeth in the smile zone and agent with the teeth is for three 10- Patients should be made aware
lipped over to cover the incisal edges minute cycles, often known as passes. of this to avoid disappointment.
and extend slightly lingually or Hence, power bleaching procedures ● Top up home bleaching kits should be
palatally (Figure 3). This should usually involve three 10-minute given to those cases that require
only be done in the absence of passes, but some systems use three or further bleaching.
exposed dentine caused by incisal four 20-minute passes with lower
wear. The smile zone varies between concentrations of hydrogen peroxide,
patients but is commonly from the while others use 3-minute passes CURING LIGHTS
first or second premolar to its contra- repeated five times with total Various types of curing lights are used to
lateral counterpart. bleaching time being 15 minutes. activate the bleaching gel or expedite the
● Activation with or without a light ● After removal of the isolation dam whitening effect. Initially, conventional
source depends on the bleaching the gingivae and surrounding mucosa curing lights were used but these were
system used. are examined for blanching or areas quickly joined by lasers and plasma
● The gel is left in place for a length of redness indicating hydrogen arc lamps. In addition, some systems
of time dependent on the system and peroxide seepage through the are activated by a chemical reaction on
concentration of hydrogen peroxide isolation (Figure 4). Areas of damage mixing two gels, while others utilize a
used, usually about 10 minutes, but should be thoroughly washed with dual activation system.
can range from 3–20 minutes at a copious amounts of water before the
time. application of a neutralizing agent,
● The gel is suctioned off the teeth such as vitamin E, usually supplied Halogen Curing Lights
using high volume suction and the Curing lights such as Demetron 501

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 R E S T O R AT I V E D E N T I S T R Y

(Kerr Dental Ltd, Peterborough, UK) Metal Halide Lamp

can be used with a number of different The Zoom light (Discus Dental, Culver
systems such as Polar Office (SDI, City, CA 90232, USA) is used with a
Victoria 3153, Australia) or Quick White two part 25% hydrogen peroxide gel
Net (DMDS UK, Canterbury, UK). in a dual arch technique employing
Activation is via the light’s bleach mode three 20-minute passes followed by the
for 30 sec per tooth and, generally, the application of sodium fluoride gel.
application involves three 10-minute
passes. Some products available, such as
Figure 6. Diode laser (830 nm,Velopex Diode, CHEMICAL ACTIVATION
Opalescence Xtra (Ultradent Products, Medivance Instruments Ltd, London, UK) in
South Jordan, Utah, USA) are based on use activating the bleaching gel in 30-second Systems such as Opalescence Xtra-
a pre-mixed 35% hydrogen peroxide gel bursts per tooth with the gel left in situ for ten Boost (Ultradent Products, South
minutes.The procedure is repeated for a further
that contains carotene which converts two 10-minute applications. Jordan, Utah, USA) are based on 38%
light energy to heat and therefore hydrogen peroxide two part gel system.
increases the activation of the hydrogen It consists of one syringe, containing
peroxide by encouraging further hydrogen peroxide, that is chemically
breakdown into active free radicals. (Figure 5). However, some authors have activated by mixing with the second
recommended the use of a combination syringe, containing a unique proprietary
of carbamide peroxide (22%) and activator that increases the pH to 7
Plasma Arc Lamp
hydrogen peroxide (38%) for 20-minute for maximum activation. When mixed
Systems that use these lights are usually passes repeated three times, but this together, a supercharged bleaching agent
based on three 10-minute passes with protocol must be questioned in terms is produced that does not require light
light activation in whitening mode for 3 of possible penetration into the pulp activation.
sec per tooth performed twice during the chamber and whether there is any benefit
pass. Alternatively, a full smile adaptor in combining 22% carbamide peroxide,
is used to illuminate both arches together DUAL ACTIVATED SYSTEMS
which breaks down into approximately
for the full 10-minute pass with the light 7.5% hydrogen peroxide. Hi Lite (Shofu Dental Products,
switching on and off in 5-sec bursts but Tonbridge, Kent, UK ) is a system that
giving out lower intensity. contains both ferrous and manganese
Diode Lasers sulphate which are chemically and light
Both 830 nm and 980 nm wavelength activated, respectively, to accelerate
Xe-Halogen Technology
diode lasers can be used for tooth the bleaching process to 7–9 minutes.9
These systems utilize a full smile bleaching in combination with 35–50% The system is based on 35% hydrogen
illuminator placed a few centimetres hydrogen peroxide gel. The gel is peroxide blue gel that is activated using
in front of both arches to activate 35% produced by mixing the hydrogen a conventional light curing unit. After
hydrogen peroxide gel with the usual peroxide liquid with a powder mainly about 2 minutes, the gel changes colour
protocol being three 10-minute passes containing fumed silica and a blue to green, following oxidization, and then
dye. The blue dye absorbs the laser to cream, before finally becoming chalky
wavelength and heats up to cause the coloured on complete inactivation. At
controlled breakdown of the hydrogen this point it is removed and a fresh mix
peroxide to oxidizing perhydroxyl free is applied, with the procedure being
radicals. repeated up to six times in one session.
The system is also based on applying
2–3 mm of gel to teeth in the smile
WAITING ROOM BLEACH
zone and three 10-minute passes with
TECHNIQUE
activation using 1–2 W of laser energy
for 30 sec per tooth (Figure 6). It is Thirty-five percent carbamide peroxide
essential that all present, including the is activated by holding the syringe under
Figure 5. Xe-Halogen light (Luma Arch, DMDS dentist, patient and nurse are correctly hot running water for a few minutes
UK, Canterbury UK) used in dual-arch activation prior to use. The gel is placed in the
protected with eye protective glasses as
of the power bleaching gel.The light is placed a
ocular damage is a real risk with the use custom-made tray, which is then put
few centimetres in front of both arches and is
usually applied in three 10-minute passes. of these lasers. in the mouth of the patient where the

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 R E S T O R AT I V E D E N T I S T R Y

excess material is removed. The patient procedure as hypothesized. continuing with home bleaching. It can
is then asked to sit in the waiting room also be used on teeth with different stain
for about 30 minutes to an hour. After aetiologies, but must be carried out with
COMBINING BLEACHING meticulous care and attention owing to
this time has elapsed, the patient returns
TECHNIQUES the caustic nature of the 35% hydrogen
and the gel is suctioned and rinsed off
the teeth. The procedure can be repeated Combining different bleaching peroxide used.
2–3 times more in the one session. techniques serves a number of purposes The goal of modern dentistry is
including improving the effectiveness maximum preservation of tooth
of the whitening procedure, especially substance with excellent aesthetics.
COMPRESSIVE BLEACHING when there are stains of varying Bleaching alone or in combination with
TECHNIQUE aetiology or cases of tetracycline minimally invasive adhesive dentistry
This technique, reported by Miara,10 staining. It is also used to motivate those fulfils this goal very often without the
suggests that the power bleaching patients whose compliance levels for need to progress to the much more
technique can be made more effective home bleaching is questionable. The destructive techniques of veneers,
by compressing the gel against the teeth. patient is encouraged by the almost crowns and bridges.
This is based on the observation that, on immediate results produced by power
decomposition of the power bleaching bleaching to continue with top-up
gel, small bubbles appear in the gel home treatment to achieve maximum REFERENCES
1. Greenwall L. Bleaching Techniques in Restorative
that indicate the release of oxygen whitening results. It is also desirable to
Dentistry. London: Martin Dunitz, 2001: pp.
ions and, unlike in home bleaching combine techniques in cases where a 24–29.
techniques, these ions migrate and a non-vital tooth is involved or single teeth 2. Rosenstiel SF, Gegauff AG, Johnston WM.
small proportion of them will permeate with multiple stains. Duration of tooth colour change after bleaching.
the enamel. In order to enable the J Am Dent Assoc 1991; 123: 54–59.
3. Sulieman M, Addy M, Rees JS. Development and
permeation of oxidizing ions through
ULTRASONIC evaluation of a method in vitro to study the
the enamel, the nascent oxygen must be
TECHNOLOGY effectiveness of tooth bleaching. J Dent 2003; 31:
guided under pressure.10 415–422.
The procedure involves the usual The latest addition to in-surgery 4. Sulieman M, Addy M, MacDonald E, Rees JS.
isolation and placement of 35% bleaching systems is the SoniWhite The effect of hydrogen peroxide concentration
hydrogen peroxide gel, such as Whitening System (DMDS UK, on the outcome of tooth whitening: an in-vitro
Canterbury, UK) which utilizes study. J Dent 2004; 32: 295–299.
Opalescence Xtra, in a custom-made
ultrasonic technology with a 6–7.5% 5. Sulieman M, Addy M, MacDonald E, Rees JS. The
tray, which is put in place and any bleaching depth of a 35% hydrogen peroxide
excess material is removed before hydrogen peroxide gel in upper and
based in-office product: a study in-vitro. J Dent
the lingual and buccal edges of the lower trays. The procedure only involves 2004; 33: 33–40.
tray are sealed with light cured resin approximately two cycles of 5 minutes 6. Barghi NB. Making a clinical decision for vital
material, to prevent any leakage during but it is thought that the use of the tooth bleaching: at-home or in-office? Compend
ultrasonic energy indirectly encourages Contin Educ Dent 1998; 19(8): 831–838.
gel decomposition. Once the edges are
7. Sulieman M, Addy M, Rees JS. Surface and intra-
sealed, the gel is activated using either a the production of more oxygen-free
pulpal temperature rises during tooth
halogen light or a plasma arc lamp. After radicals that permeate through the tooth
bleaching: a study in-vitro. Br Dent J 2005; In
30 minutes, the gel and isolation are to produce the whitening effect. press.
removed and the teeth are washed, with 8. Sulieman M, Addy M, MacDonald E, Rees JS. A
the procedure being repeated on another safety study in-vitro for the effects of an in-office
CONCLUSION bleaching system on the integrity of enamel and
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Power bleaching may frequently dentine. J Dent 2004; 32: 581–590.
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came from, where we are today. J Am Dent Assoc
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evaluation. Concerns with this technique patients a single visit is enough to satisfy 10. Miara P. An innovative chairside bleaching
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treatment is required. Power bleaching results. Pract Perio Aesth Dent 2000; 12(7):
hydrogen peroxide into the pulp chamber
should be used in cases where time is 669–678.
after only 15–20 minutes.11 In addition, 11. Bowles WH, Ugwuneri Z. Pulp chamber
there is no proof that the presence of the at a premium, with patients requiring
penetration by hydrogen peroxide following
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