Tooth whitening
Tooth whitening or tooth bleaching is the process of lightening the color of human teeth. Whitening is often desirable when teeth become yellowed over time for a number of reasons, and can be achieved by changing the intrinsic or extrinsic color of the tooth enamel. The chemical degradation of the chromogens within or on the tooth is termed as bleaching. Hydrogen peroxide () is the active ingredient most commonly used in whitening products and is delivered as either hydrogen peroxide or carbamide peroxide. Hydrogen peroxide is analogous to carbamide peroxide as it is released when the stable complex is  in contact with water. When it diffuses into the tooth, hydrogen peroxide acts as an oxidising agent that breaks down to produce unstable free radicals. In the spaces between the inorganic salts in tooth enamel, these unstable free radicals attach to organic pigment molecules resulting in small, less heavily pigmented components. Reflecting less light, these smaller molecules create a "whitening effect". There are different products available on the market to remove stains. For whitening treatment to be successful, dental professionals (dental hygienist or dentist) should correctly diagnose the type, intensity and location of the tooth discolouration. Time exposure and the  concentration of the bleaching compound, determines the tooth whitening endpoint. Natural shade. The perception of tooth colour is multi-factorial. Reflection and absorption of light by the tooth can be influenced by a number of factors including specular transmission of light through the tooth; specular reflection at the surface; diffuse light reflection at the surface; absorption and scattering of light within the dental tissues; enamel mineral content; enamel thickness; dentine colour, the human observer, the fatigue of the eye, the type of incident light, and the presence of extrinsic and intrinsic stains. Additionally, the perceived brightness of the tooth can  change depending on the brightness and colour of the background. The combination of intrinsic colour and the presence of extrinsic stains on the tooth surface influence the colour and thus the overall appearance of teeth. The scattering of light and absorption within enamel and dentine determine the intrinsic colour of teeth and because the enamel is relatively translucent, the dentinal properties can play a major role in determining the overall tooth colour. On the other hand, extrinsic stain and colour is the result of coloured regions that have formed within the acquired pellicle on the enamel surface and can be  influenced by lifestyle behaviours or habits. For example, dietary intake of tannin-rich foods, poor tooth brushing technique, tobacco products, and exposure to iron salts and chlorhexidine can darken the colour of a tooth. With increasing age, teeth tend to be darker in shade. This can be attributed to secondary dentin formation and thinning of enamel due to tooth wear which contributes to a significant decrease in lightness and increase in yellowness. Tooth shade is not influenced by gender or race. Staining and discolouration. Tooth discolouration and staining is primarily due to two sources of stain: intrinsic and extrinsic (see  Figure 2). In essence, tooth whitening primarily targets those intrinsic stains in which cannot be removed through mechanics such as a debridement (clean) or prophylaxis, in the dental office. Below explains in-depth the differences between the two sources of which contribute to such discolouration of the tooth's surface. Extrinsic staining. Extrinsic staining, is largely due to environmental factors including smoking, pigments in beverages and foods, antibiotics, and metals such as iron or copper. Coloured compounds from these sources are adsorbed into acquired dental pellicle or directly onto the surface of the tooth causing a stain to appear . Removal of extrinsic staining. Extrinsic staining may be removed through various treatment methods: Intrinsic staining. Intrinsic staining primarily occurs during the tooth development either before birth or at early childhood. Intrinsic stains are those that cannot be removed through mechanical measures such as debridement or a prophylactic stain removal. As the age of the person increases, the teeth can also appear yellower over time. Below are examples of intrinsic sources of stains: Methods. Prior to proceeding to tooth whitening alternatives, it is advised that the patient comes into the dental office to have a comprehensive oral examination that consists  of a full medical, dental, and social history. This will allow the clinician to see if there is any treatment that needs to be done such as restorations to remove cavities, and to assess whether or not the patient will be a good candidate to have the whitening done. The clinician would then debride (clean) the tooth surface with an ultrasonic scaler, hand instruments, and potentially a prophy paste to remove extrinsic stains as mentioned above. This will allow a clean surface for maximum benefits of whichever tooth whitening method the patient chooses. Below will discuss the various types of  tooth whitening methods including both internal application of bleaching and external application through the use of bleaching agents. In-office. Before the treatment, the clinician should examine the patient: taking a health and dental history (including allergies and sensitivities), observe hard and soft tissues, placement and conditions of restorations, and sometimes x-rays to determine the nature and depth of possible irregularities. If this is not completed prior to the whitening agents being applied to the tooth surface, excessive sensitivity and other complications may occur. The whitening shade guides are used to measure tooth colour. These shades determine the effectiveness  of the whitening procedure, which may vary from two to seven shades. These shades may be reached after a single in office appointment, or may take longer, depending on the individual. The effects of bleaching can last for several months, but may vary depending on the lifestyle of the patient. Consuming tooth staining foods or drinks that have a strong colour may compromise effectiveness of the treatment. These include food and drinks containing tannins such as; coffee, tea, red wines, and curry. In-office bleaching procedures generally use a light-cured protective layer that is carefully painted on the gums  and papilla (the tips of the gums between the teeth) to reduce the risk of chemical burns to the soft tissues. The bleaching agent is either carbamide peroxide, which breaks down in the mouth to form hydrogen peroxide, or hydrogen peroxide itself. The bleaching gel typically contains between 10% and 44% carbamide peroxide, which is roughly equivalent to a 3% to 16% hydrogen peroxide concentration. The legal percentage of hydrogen peroxide allowed to be given is 0.1–6%. Bleaching agents are only allowed to be given by dental practitioners, dental therapists, and dental hygienists. Bleaching is least effective when the original  tooth color is grayish and may require custom bleaching trays. Bleaching is most effective with yellow discolored teeth. If heavy staining or tetracycline damage is present on a patient's teeth, and whitening is ineffective (tetracycline staining may require prolonged bleaching, as it takes longer for the bleach to reach the dentine layer), there are other methods of masking the stain. Bonding, which also masks tooth stains, is when a thin coating of composite material is applied to the front of a person's teeth and then cured with a blue light. A veneer can also mask tooth discoloration. In -chair whitening is faster and more effective in comparison to the take-home bleaching options. Some clinicians also make custom bleaching trays, which can take up to a week to create. After the whitening treatment is completed, the patient is able to use these trays for maintenance of their bleaching with at-home kits or for use with desensitising products. Light-accelerated bleaching. Power or light-accelerated bleaching uses light energy which is intended to accelerate the process of bleaching in a dental office. Different types of energy can be used in this procedure, with the most common being halogen , LED, or plasma arc. Use of light during bleaching increases the risk of tooth sensitivity and may not be any more effective than bleaching without light when high concentrations of hydrogen peroxide are used. A 2015 study showed that the use of a light activator does not improve bleaching, has no measurable effect, and rather is likely to increase the temperature of the associated tissues, resulting in damage. The ideal source of energy should be high energy to excite the peroxide molecules without overheating the pulp of the tooth. Lights are typically within the blue light spectrum as this has  been found to contain the most effective wavelengths for initiating the hydrogen peroxide reaction. A power bleaching treatment typically involves isolation of soft tissue with a resin-based, light-curable barrier, application of a professional dental-grade hydrogen peroxide whitening gel (25–38% hydrogen peroxide), and exposure to the light source for 6–15 minutes. Recent technical advances have minimized heat and UV emissions, allowing for a shorter patient preparation procedure. For any whitening treatments, it is recommended that a comprehensive examination of the patient is done including the use of radiographs to aid in the diagnosis of the current condition of  the mouth, including any allergies that may be present. The patient will need to have a healthy mouth and free of periodontal disease or cavities and to have had a debridement/clean done to remove any tartar or plaque build up. It is recommended to avoid smoking, drinking red wine, eating or drinking any deeply coloured foods after this as the teeth may stain considerably straight after treatment. Nanoparticle catalysts for reduced hydrogen peroxide concentration. A recent addition to the field is new light-accelerated bleaching agents containing lower concentrations of hydrogen peroxide with a titanium oxide nanoparticle-based catalyst . Reduced concentrations of hydrogen peroxide cause lower incidences of tooth hypersensitivity. The nanoparticles act as photocatalysts, and their size prevents them from diffusing deeply into the tooth. When exposed to light, the catalysts produce a rapid, localized breakdown of hydrogen peroxide into highly reactive radicals. Due to the extremely short lifetimes of the free radicals, they are able to produce bleaching effects similar to much higher concentration bleaching agents within the outer layers of the teeth where the nanoparticle catalysts are located. This provides effective tooth whitening while reducing the required concentration of hydrogen peroxide and other reactive byproducts at  the tooth pulp. Internal bleaching. Internal bleaching is a process which occurs after a tooth has been endodontically treated. This means that the tooth will have had the nerve of the tooth extirpated or removed through a root canal treatment at the dentist or by a specialist endodontist. Internal bleaching is often sought after in teeth which have been endodontically treated as tooth discolouration becomes a problem due to the lack of nerve supply to that tooth. It is common to have this internal bleaching done on an anterior tooth (a front tooth that you can see when smiling and  talking). A way around this is by sealing off the bleaching agent inside the tooth itself and replacing it every few weeks until the desired shade has been achieved. The amount of time between appointments varies from patient to patient and with operator preference until the desired shade has been achieved. Even though this is a great option, the disadvantage of this treatment is a risk of internal root resorption of the tooth that is being internally bleached. This may not occur in every patient or every tooth, and its occurrence is difficult to determine prior to completing the treatment . At home. At home tooth whitening products are available from dentists or 'over the counter' (OTC). At home whitening methods include over-the-counter strips and gels, whitening rinses, whitening toothpastes, and tray-based tooth whiteners. OTC products can be used for milder cases of tooth staining. Home-based bleaching (following manufacturer's instructions) results in less tooth sensitivity than in-office bleaching. Strips and gels. The plastic whitening strips contain a thin layer of peroxide gel and are shaped to fit the buccal/labial surfaces of teeth. Many different types of whitening strips are available on the market, after  being introduced in the late 1980s. Specific whitening strip products have their own set of instructions however the strips are typically applied twice daily for 30 minutes for 14 days. In several days, tooth colour can lighten by 1 or 2 shades. The tooth whitening endpoint does depend on the frequency of use and ingredients of the product. Whitening gels are applied onto the tooth surface with a small brush. The gels contain peroxide and are recommended to be applied twice a day for 14 days. The tooth whitening endpoint like that of the whitening strips. Rinses. Whitening rinses work  by reaction of the oxygen sources such as hydrogen peroxide within the rinse and the chromogens on or within the tooth. It is recommended to use twice a day, rinsing for one minute. To see an improvement in shade colour, it can take up to three months. Toothpastes. Whitening toothpastes differ from regular toothpastes in that they contain higher amounts of abrasives and detergents to be more effective at removing tougher stains. Some whitening toothpastes contain low concentrations of carbamide peroxide or hydrogen peroxide which help lighten tooth colour however they do not contain bleach (sodium hypochlorite). With continuity of  use over time, tooth colour can lighten by one or two shades. Tray-based. Tray-based tooth whitening is achieved by wearing a fitted tray containing carbamide peroxide bleaching gel overnight or for two to four hours a day. If manufacturer's instructions are followed, tooth whitening can occur within three days and lighten teeth by one or two shades. This type of tooth whitening is available over-the-counter and professionally from an oral health professional. Baking soda. Baking soda is a safe, low abrasive, and effective stain removal and tooth whitening toothpaste. Tooth whitening toothpaste that have excessive  abrasivity are harmful to dental tissue, therefore baking soda is a desirable alternative. To date, clinical studies on baking soda report that there have been no reported adverse effects. It also contains acid-buffering components that makes baking soda biologically antibacterial at high concentrations and capable of preventing growth of "Streptococcus mutans." Baking soda might be useful for cavities-prone patients as well as those who wish to have whiter teeth. Pens. Whitening pens are a convenient way to touch up any dental surface. The plastic, convenient, tube contains a bleaching gel that can be easily applied in hard-to -reach spots. In order to work, the gel needs to stay on the tooth surface for around 20-30 minutes. Indications. Tooth whitening may be undertaken for a variety of reasons, but whitening may also be recommended to some individuals by dental professionals. Contraindications. Some groups are advised to carry out tooth whitening with caution as they may be at higher risk of adverse effects. Risks. Some of the common side effects involved in teeth whitening are increased sensitivity of the teeth, gum irritation, and extrinsic teeth discolouration. Hypersensitivity. The use of bleach with extremely low pH levels in the  tooth whitening procedure may lead to hypersensitive teeth, as it causes the dentinal tubules to open. Exposure to cold, hot, or sweet stimuli may further exacerbate the intensity of the hypersensitive response. Amongst those who receive in-office whitening treatment, between 67–78% of the individuals experience sensitivity after the procedure where hydrogen peroxide and heat is utilised. Although it varies from person to person, sensitivity after whitening treatment can last up to 4–39 days. Potassium nitrate and sodium fluoride in toothpastes are used to ease discomfort following bleaching, however, there is no evidence to suggest that this is a permanent  method to eradicate the issue of hypersensitivity. Irritation of mucous membranes. Hydrogen peroxide is an irritant and cytotoxic. Hydrogen peroxide with concentrations of 10% or higher can cause tissue damage, be corrosive to mucous membranes and cause burning sensation to the skin. Chemical burns can commonly occur whilst bleaching, irritation and discolouration of the mucous membranes may occur if a high concentration of oxidising agent comes in to contact with unprotected tissue. Poorly fitting bleaching trays are amongst the most common reasons for chemical burns. The temporary burning induced by whitening treatments can be reduced by using custom-made plastic  trays or nightguards provided by the dental professional. This prevents the leakage of solution onto the surrounding mucosa. Uneven results. Uneven results are quite common after bleaching. Consuming less foods and drinks that cause surface staining of teeth can contribute to attaining a good result from tooth whitening. Return to original pre-treatment shade. Nearly half the initial change in colour provided by an intensive in-office treatment (i.e., one hour treatment in a dentist's chair) may be lost in seven days. Rebound is experienced when a large proportion of the tooth whitening has come from tooth dehydration (also  a significant factor in causing sensitivity). As the tooth rehydrates, tooth colour "rebounds", back toward where it started. Over-bleaching. Over-bleaching, more often known as the "bleached effect", occurs among treatments that promise a large change over a short period of time e.g., hours. Over-bleaching can emit a translucent and brittle appearance. Damage to enamel. Teeth enamel can have an adverse negative effect by whitening treatment. Evidence from studies show that carbamide peroxide present in whitening gels can damage the enamel surface. Although this effect is not as damaging as phosphoric acid etch, the increased irregularity of the  teeth surface makes the teeth more susceptible to extrinsic staining, thus having an increased detrimental effect on the aesthetics. The increased porosity and changes in surface roughness may have an impact on the formation of supra- and subgingival plaque, thus increasing the adhesion of bacterial species such as "Streptococcus mutans and Streptococcus sobrinus," significant contributors to dental cavities. Dental restorations are susceptible to unacceptable colour change even when using the home-based systems. Weakened dentine. Intracoronal bleaching is a tooth whitening method that uses 30% more hydrogen peroxide. Such tooth whitening methods can weaken the mechanical properties of dentine and  could potentially lead to severe tooth sensitivity. Effects on existing restorations. Dental restorations are susceptible to unacceptable colour change even when using the home-based systems. Ceramic crowns – aggressive bleaching can chemically react with ceramic crowns and reduce their stability. Dental amalgam – exposure to carbamide peroxide solutions increase mercury release for one to two days. The release of amalgam components is said to be due to active oxidation. This increase in amalgam mercury release is proportional to the concentration of carbamide peroxide. Resin composite – bond strength between enamel and resin based fillings become weakened. Many studies have found that 10 -16% carbamide peroxide tooth bleaching gels (containing approximately 3.6-5.76% hydrogen peroxide) leads to an increase in the surface roughness and porosity of composite resins. However, the saliva may exert a protective effect. In addition, changes in the reflectance of the composite have been analysed following whitening with high concentration (30-35%) hydrogen peroxide. This suggests that tooth whitening negatively impacts composite resin restorations. Glass ionomer and other cements – studies suggest that solubility of these materials may increase. Bleachorexia. Bleachorexia is the term that is used to describe an individual that develops an unhealthy obsession with teeth whitening. This condition  is similar to body dysmorphic disorder. The characteristics of bleachorexia are the continuous use of whitening products even though the teeth cannot possibly become whiter, despite the provision of repeated treatment. A person with bleachorexia will continually seek out for different whitening products, hence, it is recommended that a target shade is agreed upon before starting the treatment procedure to help with this problem. Home teeth whitening risks. The use of personalised home whitening trays is a patient administered therapy that is prescribed and dispensed by a dentist. Patients need to actively participate in their treatment and follow the  guidelines given by the dentist accurately. Erratic or inaccurate use of the bleaching trays could cause harm to the patient such as blistering or sensitivity of the teeth and the surrounding soft tissue. Inconsistent use of the bleaching trays can lead to the slowing and irregularity of the whitening process. Some patients with a substantial gag reflex may not be able to tolerate the trays and would need to consider other methods of teeth whitening. Other risks. Evidence suggests that hydrogen peroxide might act as a tumour promoter. Although cervical root resorption is more evidently observed in thermocatalytic bleaching methods , intracoronal internal bleaching may also lead to tooth root resorption. Moreover, severe damage to intracoronal dentine and tooth crown fracture can occur due to this bleaching method. However, the International Agency of Research on Cancer (IARC) has concluded that there is insufficient evidence to prove that hydrogen peroxide is a carcinogen to humans. Recently, the genotoxic potential of hydrogen peroxide was evaluated. The results indicated that the oral health products that contain or release hydrogen peroxide up to 3.6% will not increase the cancerous risk of an individual, hence, it is safe to use in moderation. Maintenance. Despite achieving the  results of treatment, stains can return within an initial couple of months of treatment. Various methods may be employed to prolong the treatment results, such as: History. Teeth whitening remedies have been present since ancient times. Despite seeming absurd, some methods were somewhat effective in their results. The Ancient Romans believed in using urine with goat milk to make their teeth look whiter. Pearly white teeth symbolized beauty and marked wealth. In the Auyrveda medicine system, oil pulling was used as an oral therapy. For this process today, swish coconut or olive oil in your mouth for up to 20  minutes each day. In the late 17th century, many people reached out to barbers, who used a file to file down the teeth before applying an acid that would, in fact, whiten the teeth. Although the procedure was successful, the teeth would become completely eroded and more prone to becoming decayed. Guy de Chauliac suggested the following to whiten the teeth: "Clean the teeth gently with a mixture of honey and burnt salt to which some vinegar has been added." In 1877, oxalic acid was proposed for whitening, followed by calcium hypochlorite. In the late 1920s, mouthwash containing pyrozone (ether  peroxide) was found to reduce cavities while providing a whiter appearance to the teeth. By 1940s and 1950s, ether and hydrogen peroxide gels were used to whiten vital teeth, whereas non-vital teeth were whitened using pyrozone and sodium perborate. In the late 1960s, Dr William Klusmeier, an Orthodontist from Fort Smith, Arkansas, introduced the custom tray bleaching. However, it was not until 1989 that Haywood and Heymann published an article in support of this method. Carbamide peroxide with a shelf life of one to two years, as opposed to hydrogen peroxide with a shelf life one to two months , was seen as a more stable agent for whitening teeth. Society and culture. Teeth whitening has become the most promoted and mentioned methodology in cosmetic dentistry. In excess of 100 million Americans brighten their teeth using different methods; spending $15 billion in 2010. The US Food and Drug Administration only endorses gels that are under 6% hydrogen peroxide or 16% or less of carbamide peroxide. The Scientific Committee on Consumer Safety of the EU consider gels containing higher fixations can be dangerous. As per European Council guidelines, only a certified dental professional can lawfully give tooth whitening products utilizing  0.1–6% hydrogen peroxide, provided the patient is 18 years of age or older. In 2010, the UK General Dental Council became concerned of the "risk to patient safety from poor quality tooth whitening being carried out by untrained or poorly trained staff." A public attitudes survey, conducted by the GDC, showed that 83% of people support "policies of regulating tooth whitening to protect patient safety and prosecuting illegal practice." A group of dental professionals and associations called The Tooth Whitening Information Group (TWIG) was founded to advance protected and beneficial tooth whitening information and assistance to the general population. Reports  can be made to the TWIG through their website with respect to any individual giving unlawful tooth whitening services, or if an individual has personally undergone treatment done by a non-dental professional. In Brazil, all whitening items are classed as cosmetics (Degree II). There are worries that this will bring about increasing abuse of whitening products and thus there have been calls for reanalysis. According to research, tooth whitening can produce positive changes in young participants’ Oral Health Related Quality of Life (OHRQoL) in aesthetic areas such as smiling, laughing, and showing teeth without embarrassment. However, its main side -effect, tooth sensitivity, does negatively affect quality of life.