The Efficacy of Three Different In-office Bleaching Systems and Their Effect on Enamel Microhardness

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1 Operative Dentistry, 2008, 33-5, The Efficacy of Three Different In-office Bleaching Systems and Their Effect on Enamel Microhardness O Polydorou E Hellwig P Hahn Clinical Relevance Light activation does not seem to increase the efficacy of the bleaching agents tested. After the bleaching procedure, color stability and enamel dehydration are supposed to be two very important parameters in order to evaluate the efficacy of bleaching systems. SUMMARY This in vitro study evaluated and compared the efficacy of three in-office bleaching systems and investigated their effect on enamel microhardness. Three groups of 12 teeth (third molars) each were bleached as follows: Group A: Opalescence Xtra Boost (38% HP), Group B: Easywhite Ready *Olga Polydorou, DDS, Dr med dent, assistant professor, University Medical Center Freiburg, Dental School and Hospital, Department of Operative Dentistry and Periodontology, Freiburg, Germany Elmar Hellwig, DDS, Dr med dent, PhD, professor and head, University Medical Center Freiburg, Dental School and Hospital, Department of Operative Dentistry and Periodontology, Freiburg, Germany Petra Hahn, DDS, Dr med dent, PhD, associate professor, University Medical Center Freiburg, Dental School and Hospital, Department of Operative Dentistry and Periodontology, Freiburg, Germany *Reprint request: Hugstetter Straße 55, Freiburg o Br, Germany; olga.polydorou@uniklinik-freiburg.de DOI: / (30% HP) with plasma unit and Group C: Zoom2 system (25% HP with the Zoom2 unit). The teeth were stained with tea for 24 hours, followed by the appropriate bleaching procedure. Each bleaching cycle was conducted for 15 minutes. The bleaching procedure was repeated until a shade change of six tabs (VITA shade guide) was obtained. The shade of the teeth was evaluated before, immediately after bleaching and one month later, both visually and digitally. Additionally, the change of shade tabs per minute was calculated. For the digital evaluation, the photos were taken under the same circumstances and the L*a*b* values were calculated using Photoshop. Five additional enamel samples for each group were prepared, and Knoop microhardness was evaluated before and after 15 minutes of bleaching. According to the visual shade evaluation, the treatment cycles required to reach the defined level of bleaching were: 1.58 for Group A (23.7 minutes), 1.02 for Group B (16.2 minutes) and 1.25 for Group C (18.7 minutes). Immediately after bleaching, a significant difference was found

2 580 Operative Dentistry between Groups A and B (p=0.0094). However, one month after the bleaching procedure, no significant difference could be observed among the three groups. According to the digital evaluation, no significant differences were found among the three bleaching systems for each of the L*a*b* values and the three times tested (p>0.05). No significant difference (p=0.055) was noticed among the three groups regarding microhardness after bleaching. INTRODUCTION Recently, there has been an increased demand for tooth bleaching in order to improve the esthetic appearance of patients, because it is an easy, conservative method. The bleaching process usually uses hydrogen peroxide, either directly or indirectly via its generation in a carbamide peroxide gel. There are several methods and approaches described in the literature for bleaching vital teeth, including using different bleaching agents, application times, product forms and application modes. For the in-office bleaching of vital teeth, a high percentage of hydrogen peroxide (25%-38%) is used with or without light activation. Because excessive heating can cause irreversible damage to pulp, more contemporary methods have been reported for activating the bleaching agent by using various sources with a range of wavelengths and spectral power, such as halogen curing units, plasma arc lamps, lasers and light-emitting diodes. 1 The use of light can activate peroxide to accelerate redox reactions during the bleaching process. 1 When light is applied to a bleaching product, a small fraction of bleach is absorbed and its energy is converted into heat. 1 It is believed that this is the primary mechanism of action for all light-activated bleaching procedures. 1 Some products, which are used in light-activated bleaching procedures, contain ingredients (colorants), such as carotene, in order to increase light absorption and, as a result, heat conversion. 1-2 Additionally, it has been speculated that the light source can energize tooth stain, aiding in the overall acceleration of the bleaching process. Although the efficacy of different bleaching agents and their effect on the mechanical properties of enamel has been investigated by several studies, the potential effect of the light activation on the efficacy of bleaching products is not well documented. The data published in recent years show controversial results regarding the use of light activation for achieving better esthetic results. According to Ziemba and others, 3 changes in tooth shade were significantly better for subjects who were exposed to a bleaching gel (20% hydrogen peroxide) and a dental whitening lamp (Zoom2) compared to those subjects who were only exposed to bleaching gel. In their clinical study, Ziemba and others examined whether an ultraviolet light enhanced the whitening efficacy of a peroxide gel containing a photo-fenton activator. The clinical data were collected on the gingival index, shade score and self-assessed dentinal hypersensitivity. In this study, shade evaluation was performed immediately after the bleaching procedure. There are additional in vitro studies 4-5 that showed better bleaching results after activation using a light unit (laser, xenon arc lamp). In contrast to these studies, other authors 6-7 showed that the use of light (LumaArch, Optilux 500, and Zoom) did not demonstrate any benefit over the chemically-activated toothbleaching system. Additionally, in the literature, tooth dehydration is mentioned as a probable cause for immediate tooth lightening, 8-9 and it is presumably greater with increased tooth heating, 2 which can be produced by light activation. In the literature, several studies reported surface alterations in enamel after vital bleaching, while controversial results have been reported concerning the effect of bleaching on enamel microhardness The controversial results of existing reports and the continuous appearance of new bleaching products and light activation units that are on the market demand more research in this field. Therefore, the current study: a) evaluated and compared the efficacy of one chemically-activated and two light-activated in-office bleaching systems using visual evaluation of the color change of enamel, b) evaluated the hypothesis that visual color evaluations can give comparable changes as objective color evaluations, such as digital evaluation and c) investigated the effect of the three bleaching systems on the microhardness and surface texture of the enamel. METHODS AND MATERIALS Thirty-six freshly extracted third molars were selected and immersed in 0.9% NaCl. Prior to experimental use, the teeth were cleaned and examined for the absence of disease, cracks or other surface defects. The roots were removed, and each tooth was separately immersed for 24 hours in a standardized tea solution using the method described by Sulieman and others. 15 The tea solution was produced by boiling 2 g of tea (extra strong black tea) in 100 ml of distilled water for five minutes and filtered to remove the tea from the infusion. Following staining, the teeth were polished to remove external discoloration. They were embedded in Technovit (Heraeus-Kulzer GmbH, Hanau, Germany) blocks and randomly divided into three groups of 12 teeth each. The three different groups were bleached as follows: Group A with a chemically-activated bleaching system: Opalescence Xtra Boost (38% HP, Ultradent Products, Inc, South Jordan, UT, USA). Group B

3 Polydorou, Hellwig & Hahn: Efficacy of Three Bleaching Systems 581 Table 1: The Vita Shade Guide with 16 Shades Ranked From the Lightest Color on the Left to the Darkest Color on the Right B1 A1 B2 D2 A2 C1 C2 D4 A3 D3 B3 A3.5 B4 C3 A4 C with Easywhite Ready (30% HP, Deltamed GmbH, Friedberg, Germany) using a Plasma lamp (Den-Mat, Santa Maria, CA, USA). This light unit produces Plasma Arc light. Group C with the Zoom2 whitening system (25% HP) using the Zoom2 lamp (Discus Dental Europe BV, Ettlingen, Germany). The Zoom2 light unit produces ultraviolet (UVA) light. During the bleaching procedure, the teeth were horizontally placed with their oral side lying in 0.9% NaCl. The bleaching procedure, which occurred on the buccal side of each tooth, was for 15-minute cycles. After each cycle, the teeth were cleaned with isotonic NaCl-solution, the color was visually evaluated and the bleaching procedure was repeated until the expected esthetic result was achieved. In this study, a change of six tabs on the Vita shade guide compared to baseline was desired. For this purpose, the shade guide tabs were arranged from B1 to C4, corresponding to a grade of whitening from 1 to 16 (Table 1). 16 Prior to the bleaching procedure and after achieving the six shade tabs change, the shade of each tooth was evaluated using two different techniques: Visual evaluation with a standard Vita shade guide (Vita, Zahnfabrik, Germany). One evaluator conducted the visual evaluation immediately after the bleaching application, calibrating it to the shade measurement. For the visual evaluation, the teeth were placed on a black mat carton to simulate the black background of the mouth cavity. The shade evaluation occurred in a photo laboratory, where the light was always stable for all the teeth. Digital evaluation using Photoshop 7.0 (Adobe Systems, Inc, San Jose, CA, USA). For the digital evaluation, two images were taken with a digital camera (Canon DS126061) under the same light conditions before and immediately after the bleaching procedure. In order to standardize light conditions, a black box and light ring with standard light intensity were used. For each picture, on the bottom of the box, lying on a black velvet cloth, the vita shade guide, a grey scale and the representative tooth were used. The grey scale, in combination with the vita shade guide, was used in order to control and certify the light and color conditions. For analysis of the images taken with Photoshop 7.0, the L*a*b* color space, as established by the Commission Internationale de l Eclairage (CIE) in 1976, 6 was used. The L*a*b* values were estimated from the middle of the buccal side of each tooth. From each Photoshop image, three different measurements of the L*a*b* values were performed. Using the three measurements of the two pictures, the mean L*a*b* values for each tooth were calculated. After one month s storage in 0.9% NaCl, the visual and digital evaluation of the tooth color was repeated. For statistical analysis, regarding digital evaluation, the mean L*a*b* values of each tooth for each tested time period were used (significance level of 0.05). For the visual evaluation, the mean treatment time (minutes) per group required to achieve the six shade tab changes was calculated from the number of cycles per group. Both mean values were used for the statistical analysis. Fifteen additional enamel-dentin samples from freshly extracted third molars were prepared and embedded in Technovit (Heraeus-Kulzer GmbH). The enamel surfaces of the samples were flattened, then polished up to 4000 grit in a lapping and polishing unit with water irradiation. The samples were randomly divided into three groups (n=5). They were bleached for 15 minutes using the bleaching procedure described for the different groups. Five Knoop microhardness (Miniload, Leitz, Wetzlar, Germany) measurements were made on the top surface of each sample before and after the bleaching procedure using a load of N. For the statistical analysis of microhardness, the mean values of the five measurements of every tested period of each bleaching system were used (significance level of 0.05). RESULTS Figure 1 shows the Δ-values of the L*a*b* parameters and the shade tab changes for the three groups. According to the visual shade evaluation, the teeth from Group A needed 1.58 cycles, the teeth from Group B required 1.08 cycles and the teeth in Group C needed 1.25 cycles in order to achieve the desired color. This means that the mean treatment time (minutes) required to reach the defined level of bleaching was 23.7 (±7.7) for Group A, 16.2 (±4.3) for Group B and 18.7 (±6.8) for Group C. For the visual shade evaluation, the statistical analysis (Chi-Square [contingency table x 2 Test]) regarding the time (minutes) needed showed a statistical difference between Groups A and B (p=0.0094). No significant difference relating to the time needed to reach the bleaching endpoint was found between Groups A and C (p=0.0977) and Groups B and C (p=0.2733). These results are also certified by the effect measures ( median shifts ) of the rank analysis of variance according to the Kruskal-Wallis tests.

4 582 Operative Dentistry Figure 1. The Δ-values and the shade tab changes for the three groups are presented (A: Opalescence Xtra Boost, B: Easywhite Ready and Plasma lamp, C: Zoom2 system and Zoom 2 unit). The ΔL*1, Δa*1 and Δb*1 values represent the changes directly after the bleaching procedure in comparison to the initial values. The ΔL*2, Δa*2 and Δb*2 represent the changes one month after the end of the bleaching procedure compared to the initial values. STC 1 and STC 2 represent the shade tab changes immediately after the bleaching procedure and one month after the bleaching procedure, respectively. Figure 2. Degrees of color change per minute. Differences between initial values and immediately after the bleaching procedure. Most important coefficient: median value. Exploratory applied statistical tests for two group comparisons: Mann- Whitney-U-Test; p 0.05 denotes a statistically significant difference (compare median values). A significant difference was observed between Opalescence Xtra Boost and Easywhite Ready. After correlating the mean shade change of each group with the time needed, the tabs of the shade changed per minute were calculated for each group: shade tabs/minute were achieved by bleaching with Opalescence Xtra Boost, shade tabs/minute with Easywhite Ready and Plasma and shade tabs/minute with the Zoom2 system. If the bleaching methods were compared with regard to the degree of color change per occurrence, a tendency to differ emerged (p=0.08, rank analysis of variance according to the Kruskal-Wallis test) in terms of the difference between the initial values and those values directly after bleaching. This is due to the difference in Opalescence Xtra Boost and Easywhite Ready for which higher values were found (p=0.044, Figure 2). After one month s storage, no significant difference was observed among the three bleaching systems (p>0.05, Figure 3). Figures 4, 5 and 6 show the L*a*b* values for the three groups tested. For statistical analysis of the mean L*a*b* values, the Repeated measures analysis of variance, with two between factors and 1 within factor, was used. Significant differences were found for all three bleaching methods among the three tested time points regarding each of the L*a*b* parameters (L*: p<0.0001, a*: p<0.0001, b*: ). However, no significant difference was found among the three bleaching methods for each of the L*a*b* parameters and for each of the three time points tested (p>0.05). Figure 1 presents the changes in L*a*b* values (Δ-values [ΔL, Δa and Δb]) of the three tested groups directly after bleaching and one month after bleaching compared to the initial values. According to Figure 1, one month after bleaching, the ΔL values of Group A decreased, compared to the values directly after bleaching. According to the Vita shade guide values, the color of two of the teeth in Group A improved after one month. The mean color change of the vita scale increased from 8.8 to 9 shade tab changes, while the mean changes of the teeth in Group B or Group C were reduced from 8.5 to 7 shade tab changes and from 7.3 to 6.9 shade tab changes degrees, respectively. For microhardness, Figure 7 shows the mean values and standard deviations of the three groups tested before and at the end of the bleaching procedure. An increase in microhardness after bleaching was observed in each of the three treated groups (difference between before and after bleaching: Group A: 22.7 KHN, Group B: KHN, Group C: KHN). For statistical analysis of these data, the Repeated analysis of variance with 1 between and 1 within factor was used. No significant difference (p=0.055) was found among the three groups regarding change of microhardness after the bleaching procedure. DISCUSSION In the current study, three different bleaching systems were tested and compared regarding their efficacy and influence on the microhardness of enamel. The teeth were stained using a technique applied in several previous studies. 5,13,17 The brand of tea was chosen because it had been used in a number of previous experiments where it reproducibly brought about stain development as measured by spectophotometry. 15,18 However, tea as a

5 Polydorou, Hellwig & Hahn: Efficacy of Three Bleaching Systems 583 chromogen may be questioned on the basis that intrinsic discoloration of teeth is caused by other chromogens, 19 except when dentin becomes exposed. In the current study, the roots of the teeth were removed in order to allow for penetration of the chromogen into dentin. Therefore, the current method, using tea as a chromogen, could produce intrinsic stain similar to that shown in the literature. 5,15 According to the current results, the teeth bleached with Opalescence Xtra Boost required more time in order to reach the desired aesthetic result of the minimum six color tabs change compared with the other two groups. This could mean that bleaching using a light unit can reduce the time needed to bleach. However, a significant difference was only found between Opalescence Xtra Boost and Easywhite Ready when using a plasma lamp. No significant difference could be observed between the Opalescence Xtra Boost and Zoom2 whitening system using the Zoom2 unit or between the Zoom2 whitening system with the Zoom2 unit and Easywhite Ready with a plasma unit. A very important parameter regarding color change is durability of the change. The visual data of the current study showed that the mean color of the vita scale of teeth bleached with Opalescence Xtra Boost improved from 8.8 to 9 shade tab changes, while the mean changes of teeth bleached with Easywhite Ready or Zoom2 were reduced from 8.5 to 7 shade tab changes and from 7.3 to 6.9 shade tab changes, respectively. Therefore, the statistical analysis showed no significant difference among the three groups for this time period. There are not much data in the literature regarding the difference in stability of color after bleaching among the different bleaching products and methods. Luk and others 2 tested the whitening effects of various combinations of peroxide bleaches (35% HP, 10% CP) and light sources. Their findings, that the results immediately after treatment were more affected by the type of light activation, while the results after one week were affected by the bleaching material used, agreed with the results of the current study. Luk and others considered that color changes one week after treatment can be more important than immediate color changes for assessing the effectiveness of bleaching. 2 Their results are in agreement with the observations of the current study, which indicate that the effect of the light activation did not seem to be stable over time. A severe color relapse is mentioned in studies by Zekonis and others, 20 Al Shetri and others 21 and de Silva Gottardi and others, 22 who found color change with a severe relapse over time after chemically-activated bleaching. Further research is necessary to investigate color relapse when light-activated bleaching is used. Figure 3. Degrees of color change per minute. Differences between initial values and one month after the bleaching procedure. Most important coefficient: median value. Exploratory applied statistical tests for two-group comparisons: Mann- Whitney-U-Test; p 0.05 denotes a statistically significant difference (compare median values). No significant difference was found among the three groups. Figure 4. Mean values of the L* measurement for each group and each tested time period (L1: before bleaching, L2: after bleaching, L3: one month after the end of bleaching) (A: Opalescence Xtra Boost, B: Easywhite Ready and Plasma lamp, C: Zoom2 system and Zoom2 unit). Figure 5. Mean values of the a* measurement for each group and each tested time period (a1: before bleaching, a2: after bleaching, a3: one month after the end of bleaching) (A: Opalescence Xtra Boost, B: Easywhite Ready and Plasma lamp, C: Zoom2 system and Zoom2 unit).

6 584 Operative Dentistry Figure 6. Mean values of the b* parameter for each group and each tested time period (b1: before bleaching, b2: after bleaching, b3: one month after the end of bleaching) (A: Opalescence Xtra Boost, B: Easywhite Ready and Plasma lamp, C: Zoom2 system and Zoom2 unit). Figure 7. Mean values and the standard deviations of Knoop microhardness of the groups (A: Opalescence Xtra Boost, B: Easywhite Ready and Plasma lamp, C: Zoom2 system and Zoom2 unit) before and after bleaching are presented. The CIELab system is adequately related to human eye color perception in all three dimensions of color space. 6 In the current study, the three bleaching systems did not differ significantly in terms of the L*a*b* values at each of the three different points in time that were tested. However, the L*a*b* values changed significantly among the three time periods. When analyzing the three color dimensions separately, the L* values, which depict the sample lightness, appeared to increase significantly in all three groups after bleaching. One month after bleaching, the L* values were still significantly higher compared to those before bleaching, but they were lower compared to the values received directly after bleaching. The a* and b* values, which depict chroma, were shown to have a different behavior. The a* values are a measure of redness (positive a*) or greenness (negative a *). The b* value is a measure of yellowness (positive b*) or blueness (negative b*). The a* and b* values approach zero for neutral colors (white, greys). As shown in Figures 4, 5 and 6, all three bleaching systems, significantly reduced the yellowness and redness of the teeth. These parameters remained on significantly lower levels even one month after the bleaching procedure. According to these results, it can be concluded that the lightness (L*), redness (a*) and yellowness (b*) were improved after bleaching, and the results remained improved one month after completion of the bleaching process. These results are in agreement with other studies, 2,23-24 which found the L* and b* pre-treatment colorimental results were shown to be affected by bleaching procedures. However, these studies 2,24-25 did not find any significant difference in the a* values. The fact that the a* values after bleaching and one month later went from positive to minus values means that the redness changed to greenness, which could be due to the fact that tea was used to discolor the teeth. Additionally, the fact that the changes that occurred at the a* parameter were very small compared with the changes to the L* and b* parameters could be the reason for the different results of the studies performed under different protocols. In the current study, the digital pictures were taken after the bleaching process, which was certified by the visual evaluation of the color. According to the results of the current study, the digital evaluation showed a significant difference for each of the three L*a*b* parameters among the three tested periods, which certified that the shades achieved with the visual estimation were significantly lighter compared to the initial ones. However, according to the visual evaluation, one month after the bleaching procedure, the shade of the teeth bleached with Opalescence Xtra Boost was stable; they had a tendency to be lighter compared to the teeth bleached with the Zoom2 system or Easywhite Ready and plasma light activation, both of which were shown to be darker than directly after bleaching. The digital evaluation revealed that, one month after the bleaching procedure, all the teeth, independent of the bleaching system used, were a little darker compared with the shade achieved directly after bleaching. However, it can be concluded from Figure 1 that this result was observed more frequently in the teeth bleached with the Zoom2 system as far as reversal of lightness (L*) and the teeth bleached with Easywhite Ready and plasma activation regarding yellowness (b*). The loss of lightness and yellowness in these two groups can explain the fact that the visual evaluation showed the shade of teeth bleached with Opalescence Xtra Boost to be more stable after one month. However, when using tea to discolor teeth, the authors could not accept the hypothesis made at the beginning of this study that visual color evaluations provide equally comparable changes as objective color evaluations. Additionally, the stability of the color change of the

7 Polydorou, Hellwig & Hahn: Efficacy of Three Bleaching Systems 585 bleached teeth is one of the questions that needs to be answered for the different types of bleaching in order to compare efficacy of the teeth. Based on the results of the current study, no conclusions can be made regarding the additional effect of light activation on the whitening effect of the materials. The results were different between the two light activation systems tested compared with the non-light activation system used, while no significant difference was found between the two systems. According to Luk and others, 2 the application of various light sources significantly improved the bleaching efficacy of some bleaching agents but not others. When Opalescence Xtra (35% HP) was used, the application of light activation (halogen light) resulted in the highest difference compared with the non-activated application mode. However, when using QuickWhite (35% HP), the halogen unit did not produce the same results. In this way, it can be concluded that the additional effect of the light depended on the bleaching material used. Sulieman and others 5 also showed that the use of light activation of the bleaching agent has beneficial effects. In contrast, Hein and others 7 demonstrated no additional effect of the three light sources tested (plasma arc lamp, halogen lamp and xenon halogen tungsten lamp) over the bleaching gel alone for three commercial products in a split mouth clinical design. The difference among the materials tested, the methodologies and the products used for artificial staining in the different studies published could explain the different results. The significant temperature increase that is produced when light activation units are used 1,5 creates an added problem, which focuses on bleaching with light activation and possible pulpal damage. Therefore, it is difficult to standardize the advantages and disadvantages of this method. In regard to enamel microhardness, no significant difference was found among the three groups regarding the effect of each bleaching system on microhardness compared with the baseline of each group. An increase in microhardness values was observed for the bleaching products tested. This is in contrast to the study by Rodrigues and others, 25 where bleaching with different concentrations of carbamide peroxide resulted in lower enamel microhardness values, suggesting demineralization of the enamel treated with bleaching products. 12,26 Other studies 14,27 have reported no significant changes in surface microhardness after bleaching. In the results of the current study, a tendency of microhardness to increase was found, which is in agreement with de Oliveira and others, 13 who reported that bleaching could even significantly increase enamel microhardness during in vitro bleaching treatment. The unique composition of the bleaching materials used in the different studies could have an effect on the results. Additionally, the experimental design used, as shown by Justino and others, 28 could affect the results. The adverse effects of bleaching on enamel were evident in specimens bleached in vitro but were not seen in the experimental in situ design. 28 CONCLUSIONS Light activation does not appear to result in better bleaching efficacy compared with chemical bleaching alone. According to the current study, light activation required less time to reach the desired aesthetic result compared with non-light activated bleaching; however, the results of activated bleaching treatment were less stable than non-light activated treatment after one month. The current findings show that visual color evaluation is not as precise as digital color evaluation. The effect of bleaching on enamel microhardness was not significant for all three in-office bleaching systems. Acknowledgements The authors thank the The German Association of Dental Manufacturers (VDDI) for their financial support during the current study. (Received 17 October 2007) References 1. Buchalla W & Attin T (2007) External bleaching therapy with activation by heat, light or laser A systematic review Dental Materials 23(5) Luk K, Tam L & Hubert M (2004) Effect of light energy on peroxide tooth bleaching Journal of the American Dental Association 135(2) Ziemba SL, Felix H, MacDonald J & Ward M (2005) Clinical evaluation of a novel dental whitening lamp and light-catalyzed peroxide gel The Journal of Clinical Dentistry 16(4) Wetter NU, Barroso MC & Pelino JE (2004) Dental bleaching efficacy with diode laser and LED irradiation: An in vitro study Lasers in Surgery and Medicine 35(4) Sulieman M, Addy M, MacDonald E & Rees JS (2005) The bleaching depth of a 35% hydrogen peroxide based in-office product: A study in vitro Journal of Dentistry 33(1) Dietschi D, Rossier S & Krejci I (2006) In vitro colorimetric evaluation of the efficacy of various bleaching methods and products Quintessence International 37(7) Hein DK, Ploeger BJ, Hartup JK, Wagstaff RS, Palmer TM & Hansen LD (2003) In-office vital tooth bleaching what do lights add? Compendium of Continuing Education in Dentistry 24(4A) Jones AH, Diaz-Arnold AM, Vargas MA & Cobb DS (1999) Colorimetric assessment of laser and home bleaching techniques Journal of Esthetic Dentistry 11(2)

8 586 Operative Dentistry 9. Amengual Lorenzo J, Cabanes Gambau G, Cervera Sánchez C, Forner Navarro L & Llena Puy MC (1996) Clinical study of a halogen light-activated bleaching agent in non-vital teeth: Case reports Quintessence International 27(6) Shannon H, Spencer P, Gross K & Tira D (1993) Characterization of enamel exposed to 10% carbamide peroxide bleaching agents Quintessence International 24(1) Ernst CP, Marroquin BB & Willershausen-Zonnchen B (1996) Effects of hydrogen peroxide-containing bleaching agents on the morphology of human enamel Quintessence International 27(1) Attin T, Kielbassa AM, Schwanenberg M & Hellwig E (1997) Effect of fluoride treatment on remineralization of bleached enamel Journal of Oral Rehabilitation 24(4) de Oliveira R, Basting RT, Rodrigues JA, Rodrigues AL Jr & Serra MC (2003) Effects of a carbamide peroxide agent and desensitizing dentifrices on enamel microhardness American Journal of Dentistry 16(1) Duschner H, Gotz H, White DJ, Kozak KM & Zoladz JR (2006) Effects of hydrogen peroxide bleaching strips on tooth surface color, surface microhardness, surface and subsurface ultrastructure, and microchemical (Raman spectroscopic) composition The Journal of Clinical Dentistry 17(3) Sulieman M, Addy M & Rees JS (2003) Development and evaluation of a method in vitro to study the effectiveness of tooth bleaching Journal of Dentistry 31(6) Leonard RH Jr, Bentley C, Eagle JC, Garland GE, Knight MC & Phillips C (2001) Nightguard vital bleaching: A longterm study on efficacy, shade retention, side effects, and patients perceptions Journal of Esthetic and Restorative Dentistry 13(6) Sulieman M, Addy M, MacDonald E & Rees JS (2004) The effect of hydrogen peroxide concentration on the outcome of tooth whitening: An in vitro study Journal of Dentistry 32(4) Sharif N, MacDonald E, Hughes J, Newcombe RG & Addy M (2000) The chemical stain removal properties of whitening toothpaste products: Studies in vitro British Dental Journal 188(11) Watts A & Addy M (2001) Tooth discolouration and staining: A review of the literature British Dental Journal 190(6) Zekonis R, Matis BA, Cochran MA, Al Shetri SE, Eckert GJ & Carlson TJ (2003) Clinical evaluation of in-office and athome bleaching treatments Operative Dentistry 28(2) Al Shetri SE, Matis BA, Cochran MA, Zekonis R & Stropes M (2003) A clinical evaluation of two in-office bleaching products Operative Dentistry 28(5) de Silva Gottardi M, Brackett MG & Haywood VB (2006) Number of in-office light-activated bleaching treatments needed to achieve patient satisfaction Quintessence International 37(2) Rosenstiel SF, Gegauff AG & Johnston WM (1991) Duration of tooth color change after bleaching Journal of the American Dental Association 122(4) Gegauff AG, Rosenstiel SF, Langhout KJ & Johnston WM (1993) Evaluating tooth color change from carbamide peroxide gel Journal of the American Dental Association 124(6) Rodrigues JA, Marchi GM, Ambrosano GM, Heymann HO & Pimenta LA (2005) Microhardness evaluation of in situ vital bleaching on human dental enamel using a novel study design Dental Materials 21(11) Featherstone JD, ten Cate JM, Shariati M & Arends J (1983) Comparison of artificial caries-like lesions by quantitative microradiography and microhardness profiles Caries Research 17(5) Pugh G Jr, Zaidel L, Lin N, Stranick M & Bagley D (2005) High levels of hydrogen peroxide in overnight tooth-whitening formulas: Effects on enamel and pulp Journal of Esthetic and Restorative Dentistry 17(1) Justino LM, Tames DR & Demarco FF (2004) In situ and in vitro effects of bleaching with carbamide peroxide on human enamel Operative Dentistry 29(2)

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