home

Hey Nicole, Look what I found when I was googling tooth whitening although its the opposing sides info, I bet the other group find this too. Any how thought it may help us Munners = Whitening Debate = Vital bleaching (tooth whitening) is incompatible with the principles of Minimal Intervention. We are AGAINST this statement i.e. Whitening IS compatible with the principles of MI.

Details of Assignment: - Becasue we are the opposing team we always present 2nd to the affirmitive. - Be preprared on both sides of argument. - Know articles the other team are likely to use and have 'flaws' in the research ready. - Need plently of evidence to support our claims.

INRODUCTION/OPENING ARGUMENT DEFINITION OF MI

- **Minimal** = 'the smallest possible in amount or least possible in extent' (p vii Mount & Hume 2005) - **Intervention** = 'an action undertaken to prevent something undesirable' (p vii Mount & Hume 2005) //Dont you think having dicoloured, yellow, stained teeth can be considered 'undesirable'!!// - **MI** = 'the concept to carry out operative dentistry in the most conservative manner possible and thus to limit the amount of undesirable consequences' (p vii Mount & Hume 2005) //Although Mount and Hume are talking about 'operative dentistry' here and whitening cannot really be considered 'operative' we believe Mount and Hume would have wanted tooth whitening under the hat of MI, otherwise they would'nt have keep using this word 'undesirable'!!// " In many situations, teeth that are acceptable in anatomy and occlusion but are discoloured receive crowns instead of the more conservative tooth bleaching or veneer placement" ( christensen, 2005, p. 1564)

- Tooth whitening is the most minimal way to change the colour of otherwise, healthy teeth. For example people who choose to have crowns or veneers placed on teeth to change the colour are removing healthy tissue that can never be replaced. Vital Tooth whitening doesnt remove any tooth structure, only the stains.

- Justino et al 2004 descibes tooth bleaching as a 'conservative, non-restorative treatment for discoloured teeth' (p. 220)

The reasons people undergo tooth whitening is much more extensive that just for cosmetic reasons. Not only is tooth whitening completely safe and accepted in the community it increases peoples self esteem, self worth and confidence. When people are proud of their smile their confidence boosted and this in turn opens up new oportunties whether it be have new found confidence to go for that job or to ask someone on a date. Without a healthy self esteem and confidence people live unhappy, less productive lives. Where not saying everyong should go out and get hollywood glamour smiles but a healthy, natural coloured smile is important for everyone.
 * Importance of Tooth whitening**

Tooth bleaching has been described in the literature a early as 1889 (Auschill et al 2005). In 1989 the first at home bleaching trays were designed using 10% CP (Caballero et al 2005, Delfino et al 2009, Rodrigues et al 2005). So people have been using these materials for over 20 years and no long term side effects have been reported so far. In office use of hydrogen peroxide to whiten teeth has been happening since the beginning of the 20th century (over 100 years!) (Rodrigues et al 2005)
 * History**

Carbamide Peroxide was used as an oral antiseptic many years before it was applied as a gel for home bleaching (Perdiagao et al., 2004) Used for many years to tx periodontal diseases (Price et al., 2000)
 * Background on Peroxides**

TYPES OF VITAL WHITENING (what do we need to include??) - microabrasion WHY IS WHITENING MI? - - -
 * bleaching**
 * decolourisation or whitening process that can occur in solution or on a surface (Joiner, 2006)
 * most popular bleaching method using carbamide peroxide or hydrogen peroxide (Christensen, 2005, Joiner, 2006)
 * either 25% once a day application of carbamide peroxide OR 8.7% hydrogen peroxide both statisically showed lightening of 2 shades lighter (Joiner, 2006)
 * 35% HP produced greatest and most rapid bleaching compared to lower conc (sulieman et al., 2004)
 * 2 keys factors for whitening teeth = concentration of peroxide and duration of application (Joiner, 2006, Perdiagao et al., 2004)
 * the higher the concentration, the lower the frequency of gel application required for uniform bleaching (Joiner, 2006)
 * in office whitening** - ie zoom
 * tooth sensitivity is common (Christensen, 2005) but subsides when tx ceased (Perdiagao et al., 2004)
 * colour returns to teeth relatively soon (Christensen, 2005)
 * Dentist-controlled - able to discuss desired result prior (Auschill et al 2005, Christensen, 2005)
 * Higher level of whitening agent used over short period of time eg. 25-35% hydorgen peroxide (JOiner, 2006), 15-40% HP (Perdiagao et al., 2004), 35-38% HP (Auschill et al 2005)
 * High % of HP = faster result that can be noticed after a single visit (Auschill et al 2005)
 * a chemical catalyst is added to HP immediately prior to bleaching, the oxygen is released rapidly -> whitening. (Perdiagao et al., 2004)
 * applied to teeth and activated by heat or light (Joiner, 2006)
 * take home whitening** - ie peroxide trays
 * 10% CP most common bleaching agent used for take home - safety and effectiveness, durability (Auschill et al 2005, Basting, 2003, Perdiagao et al., 2004)
 * uses relatively low levels of whitening agent (10%) over a period of atleast 2 weeks (Auschill et al 2005, Joiner, 2006, Cavalli 2004a, Yu, 2008)
 * pH for at-home between 5.66-7.35 (Perdiagao et al., 2004)
 * dentist has control over procedure - instructions on use, precautions, outcome (Chrsitensen, 2005, Perdiagao et al., 2004)
 * DISADVANTAGE: pts easy to find carbamide perox and hydrogen perox in local supermarket and can self prescribed amount and duration, does not match with existing restorations (Christensen, 2005)
 * mass market whitening products** - strips, gels, toothpastes
 * dentist do not prefer as patients may not consult with dentist before use (Auschill et al 2005, Christensen 2005) - challenges with colour match with existing restorations or after prep before crown is inserted which alter the colour outcome of tooth (Christensen, 2005)
 * contain low levels of whitening agent eg. 3-6% of hydrogen peroxide, twice per day appliation for up to 2 weeks (Joiner, 2006)
 * strips not advisable - gel spreads onto gingiva (Dalh & pallesen 2003)

POINTS TO RESEARCH/Advantages of tooth whitening POINTS THAT OTHER TEAM MAY CHALLENGE/disadvantages of tooth whitening
 * Mechanism of action**
 * not clearly researched of understood (Joiner, 2006)
 * hydrogen peroxide diffuses through enamel (due to low molecular weight) to reach dentine --> interacts with organic materials found within tooth structure --> reduction in colour --> lighter shade (Joiner, 2006, Cavalli, 2004a)
 * IN MORE DETAIL:
 * 1) When in contact with soft tissues or saliva Carbamide peroxide (10-15%) diffuses into 3-5% hydrogen peroxide and 7-10% urea
 * 2) hydorgen peroxide further degrades into oxygen and water
 * 3) Urea degrades into ammonia and cardon dioxide
 * 4) "mechanism of action is thought to be due to the ability of hydrogen peroxide to form oxygen free radicals that interact with adsorbed coloured organic molecules and oxidise these macro-molecules and pigment stains, producing dental discolouration into smaller and lighter molecules" (taken straight from Cavalli, 2004b) (Auschill et. al. 2005, Cavalli, 2004a, Basting, 2003, Ren, 2009, Yu, 2008, Oltu & Gurgan 2000)
 * 10% carbamide peroxide and 5.3% & 6% hydrogen peroxide has been shown to decrease tooth yellowness and increase in tooth whiteness (Joiner, 2006)
 * tetracycline staining: dark staining derived from photo-oxidation ot tetracycline molecules bound within tooth structure. peroxide affects tetracycline stain by chemical degradation where unsaturated quinone type structures found in tetracycline leading to less coloured molecules (JOiner, 2006)
 * **Possible Challenge points** || **Our argument** ||
 * Enamel changes - increased porosities

- Low concentrations (10%) of CP can promote varying degrees of surface porosity/structural change/tensile strength - depending on bleaching agent (Cavalli, 2004a, Cavalli, 2004b, Price et al., 2000, Oltu & Gurgan 2000)

- In general, CP bleaching has been reported to increse porosity, pitting, erosion and demineralisation of enamel prism (Attin et al., 2004, Cavalli, 2004b)

- Rodrigues et al 2005 - Concuded that in office CP 37% and at home 10% CP decreased enamel microhardness. BUT this study also found that the placebo agent also decreased the enamel microhardness in te control group! Quote p. 1065: "The percentage of microhardness loss in this study ranges from 3.4 to 6.8%, values indicating that mineral loss was low. Transient mineral loss from enamel generally could be expected to be reversed through re-mineralization in few days after bleaching treatment, especially when using a fluoride toothpaste"

Weakens dentine - 30% HP weakens mechanical properties of dentine (Dahl & Pallesen, 2003) || - Change on enamel surface can result from HIGH conc of CP used in in-office whitening, however adverse effects not thoroughly studied (Cavalli, 2004a)

- When used under supervision of dentist - considered safe RE general toxicity, risk of cell mutation or carcinogenesis (Cavalli, 2004b)

- 10% CP applied for 12 hours significant decrease in enamel hardness and flouride application improved remin of enamel.(sulieman et al., 2004)

- 10% CP (pH 6) has no effect on the enamel microhardness or surface morphology (Lopes et al 2002)

- Extracted premolars exposed to commercially available 10% CP gel for 245hrs found no effect on surface morphology on tooth surface replicas under SEM (scanning electron microscopy) (sulieman et al., 2004)

- Some studies have found NO significant changes in enamel microhardness when using SHORT TERM regimens of CP (Auschill et al 2005, Basting, 2003)

- High conc CP detrimental to enamel integrity but damage less than after phosphoric acid etch (Dahl & Pallesen, 2003)

- Auschill et al 2005's randomised, examiner blind clinical study concluded that vital bleaching is harmless to dental pulps and created no changes to enamel surface texture.

- 14 days after treatment has stopped dentine is back to normal (Justino et al 2004) || - HIGH conc of CP 35-37% = alteration in enamel roughness, enamel erosion evident which resembled acid etch pattern when compared with unbleached teeth (Cavalli, 2004a)
 * Enamel changes - has an erosive effect

- 3% HP (pH 6.4) can cause mild erosion areas (Lopes et al 2002) || - 10% (low) CP gel developed as safe and conservatie method to minimise adverse effects AND no difference in enamel surface morphology and enamel mineral profile seen in unbleached and bleached group when 35% CP used (Cavalli, 2004a)

- High conc CP detrimental to enamel integrity but damage less than after phosphoric acid etch (Dahl & Pallesen, 2003) ||
 * Enamel changes -decreases bond strength for restorative treatments

- Bleaching agent containing HP used with pre-op etch and heat application, extensive structural changes to enamel seen (Cavalli, 2004a)

HP and CP based bleaching agents adversely affect the immediate bond strength of resins to enamel (pre-op) (Justino et al 2004, Perdiagao et al., 2004) || - High concentration of CP indicated for in-office whitening in substitute of HP solutions (Cavalli, 2004a) was done in the past, however no internal structural changes or decreased intrinsic strenth of enamel has been reported as consequence of in-office bleaching (Cavalli, 2004b)

- Decrease in bond strength may be due to changes in mineral content of the enamel (adverse effect on bond strength appears to depend on type of bonding system and may not be significant after 2 weeks (Price et al., 2000)

- After 24 hrs, no difference in the strengths of dental composite resin cement bonds to bleached and non bleached enamel (Dahl & Pallesen, 2003) || Urea contribute to enamel roughness and structural changes (Cavalli, 2004a) || - Due to alkaline property of urea, has beneficial side-effects, raises hydrogen ion conc pH of bleaching solution thus reducing adverse effects (Cavalli, 2004a)
 * Enamel changes - Urea

CP breaks down -> HP + Urea HP breaks down -> oxygen + water Urea -> Ammonia + CO2 -> elevates pH of bleaching agent (more basic environment within 15mns) (Price et al., 2000, Sulieman et al, 2004) || - Tooth whitening causes sensitivity (Justino et al 2004)
 * Tooth sensitivity

- Not enough research to determine SAFETY of PROLONGED use of carbamide peroxide and hydrogen peroxide,more research needed (Christensen, 2005)

- Sens is common ranging from 15- 78% depending on types of whitening agents (Ren, 2009). || - Duration of complaint of teeth sensitivity usually short term, symptom generally cease within a few days. use of fluoride in conjunction with whitening treatment can efffecively reduce tooth sensitivity (Ren, 2009,)

- Sensitivity generally assoc. with previously sensitive teeth, incr freq, higher conc of carb peroxide (20%), pH (Perdiagao et al., 2004), ging recession (Dahl & Pallesen, 2003)

- Bleaching process did not cause removal of smear layer to expose dentine tubules (sulieman et al., 2004)

- Tooth sensitivty is common but mild during the whitening process but eases after treatment (Auschill et al 2005, Caballero et al 2005)

- For take home whitening the tray size, fit and thickness can affect the amount of sens experienced. Trays with a resevoir avoid too much material spilling out and reduced gingival sens, Trays that are cut just short of the gingival margin prevent sore teeth from possible tooth movement. The removal fo sharp edges and protrusions can also decrease gingival irritation. Trays made with thin, less ridgit materials aviod pain from orthodontic movement (Pohjola et al 2002) || - Gingival & soft tissue irritation following at-home or in-office whitening (Auschill et al 2005, Price et al, 2000, Ren, 2009) when using 30-35% conc HP (Dahl & Pallesen, 2003)
 * Altered taste/sensation ||  ||
 * Gingival irritation

"A court ruling resulted in a ban of peroxide containing tooth whiteners in the United Kingdom" (Perdiagao et al., 2004, p. 187) Can induce damage in oral epithelial cells-> premalignant changes

- HP shown to have a weak local carcinogenic-induced potential (Auschill et al 2005, Dahl & Pallesen, 2003) //What doesnt cause cancer these days??!// || - Gingival irritation generally transient and NO lasting effects on gingival soft tissues have been reported (Auschill et al 2005, Ren, 2009)

- Dentist supervised home bleaching products used in custom fitting tray are made to minimise contact of bleach with gingivae and other soft tissues (Auschill et al 2005, Price et al., 2000)

- To prevent soft tissue/gingival irritation, avoid overfilling tray without removing excess material and bleaching max and mandib teeth simultaneously. (Dahl & Pallesen, 2003)

- Dentist monitored, at home tooth whitening gels containing 10% carbamide peroxide has NO carciogenic risk and does not cause irreversible damage to enamel. (Perdiagao et al., 2004)

- Gingival irritation can be minimised during in office bleaching by using rubber dam (Auschill et al 2005) || - Acidic properties in bleaching agents can cause changes in mineral content of enamel (Basting, 2003) ..by inverting the ratio between organic and inorganic components and increasing solubulity (Perdiagao et al., 2004)
 * Enamel changes - change in mineral content increasing solubility
 * Enamel changes - change in mineral content increasing solubility

- Reduction in enamel microhardness (Price et al., 2000) after two weeks of whitening (Perdiagao et al., 2004) || 1. Initial decrease in enamel microhardness followed by increase in hardness of enamel - probably due to remin effects of saliva (Justino et al 2004,Sulieman et al., 2004)). If HP demin enamel surface, remin would reharden enamel by next day (Sulieman et al., 2004)

2. Also, use of remin slutions eg. fluoride could inhibit decrease in enamel microhardness. remin in saliva that calcium and phosphate ions also (Delfino et al 2009), good oral hygiene can increase remin of bleached enamel (Basting, 2003, Ren, 2009)

3. Past studies showed effects of tooth whitening on enamel less severe when storage media was saliva (Justino et al 2004, Ren, 2009). Although this was in vitro, can be translated to real situations.

4. Recent study showed whitening gel with 0.5% fluoride added can accelerate the rehardening of soft enamel in 5-day period after treatment, thus whitening effects on microhardness of enamel is TEMPORARY and REVERSIBLE (Ren, 2009).

5. Present study - glass ionomer cement gradual increase in surface microhardness due to calcium and phosphate ion in saliva (Yu, 2008)

- At 4 weeks, decrease in microhardness reversed (Perdiagao et al., 2004) Haywood and others (cited in Price et al., 2000, p. 421) found no significant differences between enamel tx with 10% CP and enamel stored in distilled water. || - Whitening agent appear to have softening affect on composite/compomer (Attin et al., 2004, Dahl & Pallesen, 2003, Yu, 2008) not known if related to peroxide conc or pH (price et al. 2000)
 * Whitening can affect restorations

- 25-35% HP showed that shear and tensile bond strength of all composite restorative materials tested were significantly reduced when composite application (incl acid etching pretx) was performed immediately, ie. within 1 day, after completion of bleaching regime (Attin et al., 2004).

- Cracks observed on microfilled specimens after 10% CP for 4 wks

- Mercury release from amalgams after exposure to CP for periods ranging from 8hrs to 14-28hrs. Depending on type of amalgam & bleching agent, mercury released ranged from 4-30x higher than saline controls.

- Bleaching may increase solubility of GI and other cements || - 3 x 30mn bleaching conducted at 1 wk intervals (recommended by manufac) did not result in detrimental effects of surface finish of compomers, RMGIC, GIC. (Attin et al., 2004)

- Low conc 6% HP gel did not cause significant dissolution or increased wear rate of GIC and do not alter surface texture of either high copper amalgam or type 3 gold alloy (Attin et al., 2004) || BEFORE & AFTER PICTURES (we could have them playing in the background, or just for our intro on a power point??) - -

CELEBRITY PICTURES! (who wouldn't want to look like this??!) - White teeth can improve the appearance of your whole face! Take a look at these pictures for example (show celebrities!) -

CC's resources
 * **Articles** ||
 * 1. Christensen, GJ 2005, 'Are snow-white teeth really so desirable?', //Journal of the American Dental Association,// vol.136, pp.933-935. ||
 * 2. Joiner, A 2006, 'The bleaching of teeth: A review of the literature', //Journal of Dentistry,// vol.34, pp.412-419. ||
 * 3. Cavalli, V, Arraris, CAG, Gianni, M & Ambrosano, GMB 2004a, 'High-concentrated carbamide peroxide bleaching agents effects on enamel surface', //Journal of Oral Rehabilitation,// vol.31, pp.155-159. ||
 * 4. Cavalli, V, Gianni, M & Carvalho, RM 2004b, 'Effect of carbamide peroxide bleaching agents on tensile strength of human enamel', //Academy of Dental Materials,// vol.20, pp.733-739. ||
 * 5. Basting, RT, Rodrigues, AL & Serra, MC 2003, 'The effects of seven carbamide peroxide bleaching agents on enamel microhardness over time', //Journal of the American Dental Association,// vol.134, pp.1335-1342. ||
 * 6. Sarrett, DC 2002, 'Tooth whitening today', //Journal of the American Dental Association,// vol.133, pp.1535-1538. ||
 * 7. Ren YF, Amin, A & Malmstrom 2009, 'Effects of tooth whitening and orange juice on surface properties of dental enamel', //Journal of Dentistry,// vol.37, pp.424-431. ||
 * 8.Yu, H, Li, Q Hussain, M & Wang Y 2008, 'Effects of bleaching gels on the surface microhardness of tooth-coloured restorative materials in situ', //Journal of Dentistry,// vol36, pp.261-267. ||

Sarah's resources Medicina Oral Patologia Oral Cirugia Bucal, vol.11, pp.E94-E99. || Journal of Applied Oral Science, vol.17, no.4, pp.284-288. ||
 * **Articles (THU)** ||
 * 1. Perdigao, J, Baratieri, LN, Arcari, GM 2004,' Contemporary trends and techniques in tooth whitening: a review', //Pract Proced Aesthet Dent//, vol. 16, no. 3, pp. 185-192. ||
 * 2. Thosre, D, Mulay, S 2009, 'Smile enhancement the conservative way: tooth whitening procedures', //J Conserv Dent//, vol. 12, no . 3 pp. 164-168. ||
 * 3. Price, RBT, Sedarous, M, Hiltz, GS 2000, 'The pH of tooth-whitening products', //J Can Dent Assoc//, vol. 66, no. 8, pp. 421-6. ||
 * 4. Hahl, JE, Pallesen, U 2003, 'Tooth bleaching a critical review of the biological aspects', //Crit. Rev. Oral Biol. Med.,// vol. 14, no. 4, pp. 292-304. ||
 * 5. Christensen, GJ 2005, 'The advantages of minimally invasive dentistry', //American Dental Association//, vol.136, no.11, pp.1563-1565. ||
 * 6. Attin, T, Hannig, C, Wiegand, A, Attin, R 2004, 'Effect of bleaching on restorative materials and restorations - a systematic review', //Dental Materials,// vol. 20, no. 9, pp. 852-861 ||
 * 7. Sulieman, M, Addy, M, Macdonald, E, Ress, JS 2005, 'The bleaching depth of a 35% hydrogen peroxide based in-office product: a study in vitro', //Journal of Dentistry//, vol. 33, no. 1, pp. 33-40. ||
 * 8. Sulieman, M, Addy, M, Macdonald, E, Ress, JS 2004, 'A safety study in vitro for the effects of an in-office bleaching system on the integrity of enamel and dentine', //Journal of Dentistry//, vol. 32, no. 7, pp. 581-590. ||
 * 1. Caballero, AB, Navarro, LF & Lorenzo, JA 2005, 'At-home vital bleaching: a comparison of hydrogen peroxide and carbamide peroxide treatments',
 * 2. Delfino, CS, Chinelatti, MA, Carraso-Guerisoli, LD, Batista, AR, Froner, IC & Palma-Dibb, RG 2009, 'Effectiveness of home bleaching agents in discoloured teeth and influence on enamel microhardness',
 * 3. Mount & Hume 2005, 'Preservation and Restoration of Tooth Stucture', 2nd edn, Knowledge Books and Software, AUS ||
 * 9. Rodrigues, JA, Marchi, GM, Ambrosano, GMB, Heymann, HO, Pimenta, LA 2005, 'Microhardness evaluation of in situ vital bleaching on human dental enamel using a novel study design', //Dental Materials//, vol. 21, no. 11, pp. 1059-1067. ||
 * 10. Oltu, U, Guran, S 2000, 'Effects of three concentrations of carbamide peroxide on the structure of enamel', //Journal of Oral Rehabilitation//, vol. 27, no. 4, pp. 332-340. ||
 * 11. Lopes, GC, Bonissoni, L, Baratieri, LN, Vieira, LCC, Monteiro, Jr. S 2002, 'Effect of bleaching agents on the hardness and morphology of enamel', //Journal of Esthetic and Restorative Dentistry//, vol. 14, no. 1, pp. 24-30 ||
 * 12. Justino, LM, Tames, DR, Demarco, FF 2004, 'In Situ and In Vitro Effects of Bleaching with Carbamide Peroxide on Human Enamel', //Operative Dentstiry//, vol. 29, no. 2, pp. 219-225. ||
 * 13. Auschill, TM, Hellwig, E, Schmidale, S, Sculean, A, Arweiler, NB 2005, 'Efficacy, Side-effects and Patients' Acceptance of different bleaching techniques (OTC, in-office, at home)', //Operative Dentistry//, vol. 30, no. 2, pp. 156-163. ||
 * 14. Pohjola, Rm, Browning, WD, Hackman, ST, Myers, ML, Downey, MC 2002, 'Sensitivity and Tooth Whitening Agents', //Journal Esthetic Restorative Dentistry//, vol. 14, no. 2, pp. 85-91. ||

GOOD QUOTES:

'In all cases the adverse effects on the teeth and soft tissues were mild and reversible' (p. 95 Caballero et al 2005)

'Vital tooth bleaching is considered a safe, effective, minimally invasive, non-destructive and well-accepted procedure for the treatment of discolored teeth' (p. 284 Delfino et al 2009) 'The best avaliable evidence is that permanent damage is not a concern' (p. 90 Pohjola et al 2002) Talking about take home trays.

ARTCILES FOR WHITENING (ie it is safe, effective and minimally invasive) - Auschill et al 2005 - Cabarello et al 2005 - Delfino et al 2009

ARTICLES AGAINST WHITENING - - - = =