OUR+RESEARCH-


 * Vital bleaching (tooth whitening) is incompatible with the principles of Minimal Intervention. **
 * We are on the AFFIRMATIVE team so we agree with this statement. **
 * Minimal= ** is the smallest possible in amount or least possible in extent (Mount & Hume 2005)
 * Intervention= ** ' defined as an action undertaken to prevent something undesirable'
 * MINIMAL INTERVENTION= ** aims to preserve as much tooth structure as possible, in the most conservative manner possible & thus to limit the amount of undesirable consequences & this is now widely recognised (Mount & Hume 2005).
 * TOOTH WHITENING = **Bleaching is usually used to lighten the shade of teeth that are darkened due to intrinsic and extrinsic discolorations (Strassler,2006)

The topic for debate today is whether vital tooth bleaching follows minimal intervention principles.We are on the affirmative team and so we believe and will prove to you today that vital tooth bleaching DOES NOT follow minimal intervention principles. The definition of minimal is the smallest possible or least possible in extent. and intervention is defined as an action undertaken to prevent something undesirable. Now we acknowledge that there are some circumstances when tooth colour can be 'undesirable' particularly in extreme cases such as tetracycline staining, however it seems that quite often what is 'undesirable' to most people is actually quite normal and healthy tooth structure. Today we are going to prove to you that vital tooth bleaching does NOT follow the principles of minimal intervention due to its effect on the surface integrity and influences on sensitivity and gingival irritation,the safety and toxicity risks and the long term requirements of vital tooth bleaching and rationale for treatments being complete.
 * INTRODUCING OUR TOPIC:****﻿**

There are 2 main types of vital tooth bleaching, these are in office bleaching, at home bleaching (in trays from dentist) or using over the counter products. Each type of bleaching uses different concentrations of either carbamide peroxide or hydorgen peroxide that is applied to the teeth. Carbamide peroxide decomposes to Hydrogen peroxide and urea. Hydrogen peroxide then further breaks down to water and oxygen and urea breaks down to ammonia and carbon dioxide. Vital tooth bleaching allows for both dental professional application and at home use, this means that untrained professionals may be applying these acids to their teeth, without training or proper understanding of the effects? is this being minimally invasive- intervening without being aware of the "undesirable effects" that may occur?
 * Background info into bleaching each type (brief) **

**__Argument 1:__ Surface integrity, sensitivity & gingival irritation** Vital tooth bleaching has been showrn to cause tooth sensitivity, gingival irritation and decreases the surface integrity of the tooth. Gingival mucosal irriation has been shown to occur in 55-75% of treatment groups(using what type of bleaching technique??). This gingival irritation is common with improper fitting trays, improper or excess use of gel. Another negative side effect of vital bleaching is an increase in tooth sensitivity. The by products from the peroxides we described are able to move through dentinal tubules and reach the pulp causing tooth sensititivty. We acknowledge that many studies have proven that this sensititivty usually subsides after approx 48 hours- is it really following the definition of minimal intervention to intervene and cause an undesirable result like sensititivty to achieve the 'perfect' smile.? Studies have also shown that the surface integrity of teeth can be affected by vital tooth bleaching. A study conducted comparing the surface roughness of teeth treated with carbamide peroxide compared with unbleached teeth found that there were ununiform roughness associated with the teeth that had been exposed to the bleach. This study also found that neutral whitening solutions, which have been said to be safer than the acidic whitening, also produced surface roughness, affecting the integrity of the enamel. **__Argument 2:__ Toxicity of bleaching products** Now we have looked at effects of the whitening products on the teeth and oral environment, lets consider the effects of these potent chemicals on the rest of the body. Hydrogen peroxide and carbamide peroxide have been shown to cause mutagenic effects on animals, this is obviously unresearched in humans for ethical reasons, but how many other test on animals have also proven to be true for humans? Is it worth getting cancer to have a whiter smile? Kugel et al, 2006 states that the negative effects of bleaching are increased with the increasing concentration and increasing time of application- when used at home how can the length of time be monitored, if patients are trying to achive a celebrity smile how can we be sure they won't apply the product for too long?, how can we be sure they won't purchase a higher concentation product online to faster results? How can we ensure they apply safely and dont accidently ingest the products?. Is this minimally invasive? I think not!

__** REBUTTAL: **__ - What about the side effects from systematic reviews showing gingival irritation, tooth sensitivity & surface integrity occurring in over 55%-75% of treatment groups (Kihn 2007). - Cochrane reviews (2008) shows studies with only short term use of tooth whitening products and the need for long term analysis to test the long term side effects. - so if the ADA has internet information on their website to safe tooth whitening concentrations, how are those without access to computers going to know what levels they say are safe? And what about those who don't visit the dentist either to access information?
 * - SAFENESS - ** studies regarding toxicity are only on animals & not done on humans so how can this be proven safe?

There are other ways of improving their self esteem such body image, confidence to learn & have knowledge therefore its not all about 'bright white teeth'
 * - AESTHETICALLY PLEASING - ** not apart of MI techniques as by placing the bleaching product is not minimal intervention! Doing nothing is..

Our final argument to prove to you that vital tooth bleaching does NOT follow the principles of MI is that bleaching is defined by Joiner (2010) as part of aesthetic dentistry. Aesthetics is defined as: An Artistically pleasing or beautiful appearance. It involves the branch of philosophy dealing with conception of what is artistically valid or beautiful. Considering these definitions along with that of minimal intervention dentistry does not flow. While Minimal intervention dentistry involves carrying out operative dentistry in a conservative manner to reduce undesirable results, What is termed undesirable in aesthetic dentistry is a perception of the individual,and generally related to striving for the “perfect” smile, that is embedded in society from media. If we as a profession feed into this desire for perfection then where does it stop? another consideration is that whitening does not last forever, it really depends on patients habits- is it worth bleaching and causing the above mentioned damage to the teeth, when these external stain can be avoided by changing patient behaviours.. Vital tooth bleaching will require top ups and also an extra cost to the patient.? is that minimal intervention?" (Neilsen, 2011) (Bartlett & Barton 2005).
 * __Argument 3:__ Aesthetics **

I think this stuff that you have put into the intro is more that should be used as our arguments.. Intro should be definitions and a basic outline of our arguments. ive taken some bits from here and used in the blue speach above, just been copy psting from our info below. i think we have some bloody good arguments. thsoe boys are going down lol To follow minimal intervention techniques means that bleaching should not be done, as by doing nothing is the least and most minimal intervention available. People are born with teeth this colour so why do people want to change it? If teeth are bleached it is not a forever lasting treatment option with further applications needed to produce the effect they may want and therefore at more cost and chance of potential side effects. Tooth bleaching and whitening involves placing many potent chemicals (such as HP and CP) into their mouths and again we are questioning why they would do this as there is chance of ingesting this also? Who knows what systemic affects to the internal organs can occur as studies have not researched this enough to question the safeness of it. And because products can be used both by dental clinicians and at home use, this makes mistakes for untrained individuals and can lead to detrimental oral health and general health problems. But people do not realise this enough, they just look at the final picture of whiter teeth. People are influenced by mass media including; TV, magazines, peer pressure, models etc, but is this realistically the real world that everyday people live in? I think not! Some background information on tooth whitening chemicals includes- Carbamide peroxide decomposes to Hydrogen peroxide & urea. THen HP further decomposes to water & oxygen & the urea breaks down to ammonia & CO2. Some of the by-products pass through the dentianal tubules reaching the pulp, thus causing reversible pulpitis, resulting in tooth sensitivity. (Kihn 2007)
 * BACKGROUND INFO: **

Minimal- Intervention- Bartlett & Bruton 2005 - show a graph of intervention for managment strategies of unaesthetic anterior teeth (p.82) - with increasing levels of intervention from 1.) nothing 2.) vital bleaching possibly in conjunction with microabrasion 3.) porcelain laminate veneers 4.) resin-bonded or dentine-bonded crowns 5.) all ceramic or PFM crowns (porcelain fused to metal) Therefore bleaching is intervening with the tooth structures. Minimal intervention would be doing Nothing in this case.
 * We are the affirmative team and so we believe that Vital Tooth Whitening DOES NOT follow the principles of minimal intervention.**
 * Speaker 1**
 * Definitions:**

__SHould we quickly discuss the types of tooth bleaching available then go onto or arguments?__ - eg. zoom bleaching (with or without activation by light) - higher concentration of carbamide peroxide (H2O2) between 20-35% compared to 10% CP (3.3% HP) home bleach where bleach is topically applied by the dentist to each tooth for specific times (dependant on shade needed).
 * __Vital Office bleaching__

- Trays (custom made for home by taking impression at surgery & pt applying bleach to tray themselves)- 10% CP (3.3%H2O2) home bleach - Whitening strips- flexible polyethylene bleaching strips designed to deliver hydrogen peroxide in gel form directly to the labial surface of anterior teeth. The strips contain 6.5% H2O2 (HP) & usually use for 2 wks - Topically applied systems - in the form of a gel contains 18% carbamide peroxide releasing 6.03% H2O2, applied with applicator to labial surface of teeth (2 wks has shown 3-4 vita shade changes), cost low. - Whitening toothpastes - remove extrinisic stains, but don't affect underlying tooth colour.
 * __At home bleaching__

others include; - sore throat, TMJ dysfunction secondary to long-term tray use & minor orthodontic tooth movement - Cochrane rev (2008- Hasson, Ismail & Neiva) reviewed studies and noted 18/28 studies commonly reported side effects of tooth sensitivity & ginigval irritation (See Table 4) || - This study suggests that High concentrations of Carbamide peroxide such as those used in in-office bleaching can promote surface roughness, which can also be affected by the pH of the product (Cavalli et al, 2008). || - Cervical senstivity is the most common side effect with incidences as high as 50% (Bartlett & Barton 2005) - Tooth sensitivity increased when concentrations of CP was higher eg. 10%->15% CP (Hasson, Ismail & Neiva 2008- Cochrane rev) agreed by Gerlach (2000) where 10-20% HP caused upto 60% more tooth sensitivity || - removes the smear layer from dentine (Kihn 2007) ||
 * VITAL tooth whitening-**
 * **Argument 1:** || **Surface integrity, sensitivity, ginigval irritation** ||
 * **Most common side effects** || - gingival or mucosal irritation & tooth sensitivity (occurs in 55%-75% of tx groups- ) (Kihn 2007)
 * gingival irritation = related to improper fitted trays, improper or excess application of the gel & the use of gel longer than prescribed.
 * sensitivity = Some of the by-products pass through the dentianal tubules reaching the pulp, thus causing reversible pulpitis, resulting in tooth sensitivity. (Kihn 2007) - many whitening products have glycerin which causes the dehydration by absorbing the water during whitening tx & causing sensitivity
 * **Surface integrity** || - A study of surface roughness found that when using carbomide peroxide there as an increase in enamel surface roughness compared with unbleached teeth. This roughness was not uniform across all areas. There was also assessment of the surface roughness associated with almost neutral whitening solutions which has been said to be more safe than the acidic solutions. These were also found to affect enamel surface roughness.
 * **Sensitivity** || - Tooth sensitivity has been found in 15-65% of cases that used 10% carbamide peroxide (much less than what is used in dentist supervised or dentist applied bleaching) which generally lasted up to 4 days and some cases lasting up to 39 days- leading to some of the participants stopping treatment due to discomfort (Tredwin et al., 2006).
 * **Surface alterations** || - Significant surface alterations have been detected after use of H2O2 and carbamide peroxide, such that the surface is at risk of taking up greater stains after bleaching (does this really account for minimally invasive tx that makes the tooth more susceptible to what we are trying to prevent in the first place) (Tredwin et al.,2006).
 * || - There is concern that regular use of the peroxides or their breakdown products may enable overgrowth of undesirable organism, including yeasts, possibly leading to "black hairy tongue". In addition, peroxides may damage the pulp or the soft tissues of the mouth. Delayed wound healing is also a concern as the possible mutagenic effect of strong oxygenating agents (Harris & Garcia-Godoy 2005, p.131). ||
 * || - Harris & Garcia-Godoy (2005) ask you to refer to ADA website to consult for currently accepted products for whitening- but what about those who don't check online, especially for purchasing whitening products, that may not be within acceptable % ranges. They don't know what they are buying, they look at cost- cheap to buy, easily convenient & easy to use & possibly how its advertised?? ||
 * || - within 24 hours of vital bleaching causes the tooth surface to dehydrate (although rehydrating happens quick after this) but white restorations are contraindicated within this 24 hr period following bleaching ||


 * **Argument 2:** || **Aesthetics only, feeding into Perfect sterotype, saturation levels of bleaching- is it worth it?** ||
 * || - Joiner (2010) describes tooth whitening part of aesthetic dentistry. ||
 * **Definition of aesthetics** || - Aesthetics is defined as: An Artistically pleasing or beautiful appearance. It involves the branch of philosophy dealing with conception of what is artistically valid or beautiful. ||
 * || - Considering these definitions along with that of minimal intervention dentistry does not flow. While Minimal intervention dentistry involves carrying out operative dentistry in a conservative manner to reduce undesirable results,What is termed undesirable in aesthetic dentistry is a perception of the individual,and generally related to striving for the “perfect” smile that is embedded insociety from media. ||
 * || - ** operative dentistry ** dentistry concerned with restoration of parts of the teeth that are defective as a resultof disease, trauma, or abnormal development to a state of normal function,health, and esthetics (THIS DOES NOT INCLUDE PATIENTS WANTING WHITER TEETH, [] ||
 * || - "Whitening does not last forever... really depends on patients habits- is it worth bleaching and causing this kind of damage to the teeth, when these external stain can be avoided by changing patient behaviours." (Neilsen, 2011) (Bartlett & Barton 2005). THerefore vital bleaching is not permanent & may require top ups & extra costs to the pt. ||
 * cosmetic || - classifies tooth whitening as 'cosmetic' not 'medical devices' therefore they are not subject to medical device reporting requirements by the Food & drug administration. Therefore are they medically fit to use??? (Kihn 2007) ||

- H2O2 potential to cause cellular damage (Bartlett & Bunton 2005) - An EPA report, in 2004 concluded that available scientific data shows there is a higher risk of cancer from childhood exposure than the same exposure during adulthood (Lee et al., 2005). They say bleaching between ages 2 to 15 yrs should be adjusted 3-fold as a protective measure (due to exposure to agents containing mutagens or carcinogens). || % of what is safe - with increased online buying. || - Kugel et al., 2006 state that 'the degree of whitening correlates directly with the amount of contact time & concentration of the active ingredient, the pH & viscosity. The side effects are usually diminished when lower concentrations are used" So by increasing how long its applied & the % of hydrogen peroxide or carbamide peroxide will increase side effects. SO if pt's are using whitening products at home, how can you monitor time? or if they buy online or elsewhere how does an everyday person know what % is safe to use & the side effects that it can cause? ||
 * **Argument 3:** || **Toxicity? safe levels of Carbamide peroxide and Hydrogen peroxide** ||
 * Induce tumors & mucosal damage in animals || - H2o2 and carbamide peroxide have been shown to induce tumors and mucosal damage in animals, however evidence of this in humans is still under researched. How can we be sure that this doesn’t happen in humans if we don’t have the evidence to prove it (Tredwin et al.,2006)**.**
 * known effects of carcinogens (cancer) || - ** Is this really being minimally invasive? Potentially causing cancer to have white teeth? **Peroxides have mutagenic potential and boost the effects of known carcinogens (Health Mantra.,2008) ||
 * Time?
 * || - There are still risks with tx (even though they say low) causing damaging side effects from hydrogen peroxide & other associated products (Bartlett & Bunton 2005) ||
 * Age limits for bleaching || - SHould it be done on children in the first place? Is it ethical?? ||

- conservative - simple & fast - easy for practitioner to monitor - cost - effective - low risk of post operative discomfort (Bartlett & Brunton 2005) || **Disadvantages;** - active pt participation is required for home-bleaching. The drop-out rate from treatment can be as high as 50%. With this % how serious are pt's when requesting tx to improve the appearnce of their teeth, which serves as a warning if more destructive procedures are undertaken - colour change is thought to be both dose & time dependent - the technique is open to ABUSE - a tray based system can be a problem for pt's who are prone to retching (GAGGING) - should children bleach? ||
 * SPEAKER 2-** i think that this is where the second speaker from our group comes in, to rebut things that they may say- so we need to have arguments against the things we think they may say. Then i think the second speaker will summarise our final points- NICE AND STRONG!
 * Things that they may argue**
 * **Things they may argue** || **our responses** ||
 * * Vital Bleaching is the most cost effective way to enhance the colour of the teeth || * We can discuss the need for continual bleaching,and reaching the saturation point which means teeth will no longer be enhanced and money will have been wasted if the desired colour has not been achieved.
 * we can discuss that scaling and cleaning can help with superficial staining (eg. diet stains, tobacco tars), this should be offered to pt's as they may be happy with the result & don't have to invasively bleach their teeth (Bartlett & Bruton 2005)- THis is more cost effective than bleaching ||
 * * Bleaching is not just about cosmetics- its about enhancing the self esteem, feeling better about yourself || * We can argue that the celebrity smile is often desired but this is not always practical or achievable for everyone. Thetreatments that these people undergo are likely to be expensive and time consumingand is it really helping a persons confidence if we are feeding their desirefor ‘perfection’. It may start with a want for whiter teeth but what next, Angelinaslips, pippa middletons bum and pamelas boobs.. :P – Is this really what we want to be promoting as part of Minimal Intervention ||
 * * "Bleaching, especially at-home bleaching,interests dentists and patients alike because it is the most conservative, non-invasive treatment modality currently available to the dental clinician to change the appearance of teeth. These techniques can include a variety of concentrations of hydrogen and carbamide peroxide, in-office techniques with and without light or heat enhancement, professionally dispensed whitening strips, and tray bleaching. || * Heyman(2005) argues that vital tooth bleaching as long as used correctly is one of the safest and most efficacious ways to improve colour of the teeth- He however also notes that if used incorrectly, that there may be concerns with safety-therefore it cannot be completely ruled out that these treatments are safe-each patient is different and how do we determine what is “safe” when case studies have shown to have side effects to different concentrations of bleach when others have shown nothing. ||
 * **Advantages;**
 * **Advantages;**
 * * Side effects of bleaching show fewer or comparable than those with commonly used dental materials, such as eugenol, dentrifices, mouthwashes & composites (Kihn 2007) a study done by Li (1997) || * ||
 * * It is minimally invasive treatment- you are not cutting away any tooth structure to bleach (such as crowns or veneers), so it is causing no harm to the patient to whiten. || * if you were to be truly following MI principles, by providing a professional clean via scaling & prophylaxis to remove tartar & stain, should help whiten the teeth without using potent bleaching agents. Pts can be quite suprized how much their teeth can whiten after this & be very happy with this less invasive result. Also decreasing chance of whitening side effects (Joiner 2006) ||
 * * ADA approved products to use || * Most studies are short term only, (<6mths), how can this research the long term effects, safeness etc.... (Hasson, Ismail & Neiva 2008)
 * But if people don't read ADA website to get prior knowledge on bleaching products and safe ones to use, how can they protect themselves?? ||


 * WHY IS BLEECHING NOT MI!﻿ **
 * SIDE EFFECTS/RISKS = (we need to look at these things in more detail and try and form some really solid arguments out of them) **
 * Reduction in the hardness and strength of enamel
 * Damaged and inflamed gums
 * Blistering
 * Severe tooth sensitivity
 * Irritation and possibly bleeding in the oesophagus and stomach if some of the bleaching agent is ingested
 * If you have crowns, veneers or fillings these will not change colour at all after bleaching so you could end up with multicoloured teeth
 * On the product side, some whitening treatments are very highly concentrated and are well over the officially recommended level of 6% for the active whitening ingredient. Find out what’s in the product you want to use as they can range from 3% to 35%!

Bleaching agents and heat application can produce pulpal changes.
 * SIDE EFFECTS OF IN OFFICE BLEECHING**
 * Bleaching agents can alter enamel and dentine structure. Reduction in the microhardness of both enamel and dentin has been reported.
 * Peroxides have mutagenic potential and boost the effects of known carcinogens.
 * Long term use can alter the oral flora.
 * Potential for chemical burns of the soft tissues
 * Bleaching can cause a reduction in the bond strength between composite materials and the enamel surface.
 * Use of hydrogen peroxide for internal bleaching can lead to external cervical root resorption. (Health Mantra, 2008)

Adverse soft tissue response to long term contact with the chemicals.
 * SIDE EFFECTS OF AT HOME BLEACHING** (Health Mantra,2008)
 * Excessive ingestion of the chemicals can cause possible systemic effects.
 * Etching of enamel and dentin with associated hypersensitivity.
 * Possible surface alteration of resin, ceramic, glass ionomer and metal restorations.
 * Possible bite alterations and TMJ problems from extended use of trays.

"//patients are more likely to follow through with treatment and pay more money with treatment if there are lights used, even though these have been shown to cause increased sensitivity and not greater effect in whitening//' (Neilsen,2011). - does this sound like minimal intervention- paying for something that is not required or proven effective??
 * Some other possible arguments? may like to use these quotes?**

"Whitening does not last forever... really depends on patients habits- is it worth bleaching and causing this kind of damage to the teeth, when these external stain can be avoided by changing patient behaviours." (Neilsen,2011)

**General Info:** (have included some of this in the argument-we dont have to use those as our main arguments but they are the things that i cna find most info on... Just trying to set stuff out logically :D ) Hydrogen peroxide- Highly soluble in water to give an acidic solution. An oxidising agent – has many industrial uses. Enzymes catalyse the breakdown of hydrogen peroxide into water and oxygen (enzymes from saliva).Patients that do not have sufficient levels of catalyse are at risk of toxicity, and when external sources of hydrogen peroxide are applied to the teeth there is a risk for cells to be overwhelmed causing ulceration and necrosis of soft and hard tisssues. 30% H2O2 can cause severe burns on contact with skin or eyes. Hydrogen peroxide mouthrinses have been linked with mucosal irritation, tastes disturbances. The enzymes in dental pulp have also been shown Carbamide peroxide- precursor of hydrogen peroxide. 10% carbamide peroxide has been found to possibly act as a tumour promoter (such as cigarette smoke) in the presence of mutated cells.
 * Whitening products ** :

Ref for below (Tredwin et al,2006) 1) By the dentist-using 35-50% H2O2 or 35-40% carbamide peroxide (above the levels indicated to possibly act as tumor promoter) 2) Dentist supervised- in a tray applying 35-40% for 3- mins to 2hours 3) Dentist supplied (patient takes home bleach which is applied in a tray or nightguard (5-22% carbamide peroxide) 4) Over the counter products- Tooth sensitivity has been found in 15-65% ofcases that used 10% carbamide peroxide(much less than what is used in dentistsupervised or dentist applied bleaching) which generally lasted up to 4 daysand some cases lasting up to 39 days- leading to some of the participantsstopping treatment due to discomfort.  Sugnificant surface alterations have been detected after use of H2O2 and carbamide peroxide,m such that the surface is atrisk of taking up greater stains afterbleaching(does this really account for minimally invasive tx that makes thetooth more susceptible to what we are trying to prevent in the first place)  To be minimally invasive, tooth whitening and bleaching is intervening with natural tooth colour and therefore NOT MI techniques. People need to realise that HP and CP are potent chemicals placed into the mouth and this can affect oral soft and hard tissues and their general health, especially if it is ingested. By seeing a dental professional for a scale and prophylaxis clean (to remove calculus and staining), teeth colour can improve their whiteness without using the chemicals in the bleaching and whitening, that can cause other side effects. By just having a professional clean people can still be happy with whiter teeth and at a lower cost and less time consuming as bleaching procedures. It is of major concern that home use whitening is unpredictable to monitor and people can abuse concentrations and time of applying the products therefore causing general and oral health problems. People need to remember that what they see on TV and other media campaigns is sometimes not realistically ideal and may not be feasibly available or recommended to all. To conclude; vital tooth whitening and bleaching is not MI principles, with products only short lasting, and known to have various side effects such as sensitivity, gingival irritation, mutagenic potential and changing the enamel hardness to name a few. Therefore why would you want to bleach or whiten your teeth??????
 * Vital tooth bleaching occurs **
 * Tooth Sensitivity **
 * Enamel surface integrity **
 * Toxicity- ** H2o2 and carbamide peroxidehave been shown to indiuce tumors and mucosal damage in animals, howeverevidence of this in humans is still underresearched. How can we be sure thatthis doesn’t happen in humans if we don’t have the evidence to prove it**.**
 * Is this really being minimally invasive? Potentially causingcancer to have white teeth? **
 * CONCLUDING: **

Thank you for listening.....................

Neilsen.B 2011, 'in office tooth whitening', Colorado Springs, date viewed: 23/6/2011, []
 * REFERENCES:**

HealthMantra 2008, 'Tooth Whitening', date viewed:23/06/2011 []

Strassler.H 2006, Vital Tooth Bleeching; an update, Continuing education, the university of Maryland Dental school, date viewed:1/7/20114 []

High-concentratedcarbamide peroxide bleaching agents effectson enamel surface V. CAVALLI, C. A. G. ARRAIS, M. GIANNINI & G. M. B. AMBROSANO []

Joiner.A 2010, Whitening toothpastes: Areview of the Literature, Journal of dentistry, vol 385, pp17-24 []

Tredwin, Naik, Lewis, Scully 2006, Hydrogen peroxide tooth-whitening (bleaching)products: Review of adverse effects and safety issues, the british dentaljournal, vol 200, 371-376 []

AMANDA'S REFERENCES:

Luk, Tam & Hubert 2004- Effect of light enery on peroxide tooth bleaching.

Sarrett, D 2002, Tooth whitening today

Heymann 2005 - Tooth Whitening: facts & fallacies

Kugel, Papathanasiou, Williams, Anderson & Ferreira, 2006 - Tooth whitening: Clinical evaluation of chemical & light-activated tooth whitening systmes

Tredwin, Naik, Lewis & Scully 2006 - Hydrogen peroxide tooth-whitening (bleaching) products: Review of adverse effects & safety issues

Jorgensen, Willam & Carroll, 2002 - Incidence of tooth sensitivity after home whitening treatment

Joiner, 2006 - The bleaching of teeth: A review of the literature

Lee, Zhang, Lee & Li, 2005 - Tooth whitening in children & adolescents: A literature review Hasson, H, Ismail, A & Neiva G 2008, 'Home-based chemically-induced whitening of teeth in adults (Review), The Cochrane Library,

Bartlett & Bunton 2005 'Aesthetic Dentistry' Quintessence Publishing Co Ltd, London.