Dental Bleaching by FGM Dental Group

Brazil and FGM

Experts in beauty!

Brazil is a country full of natural beauty, resulting from the diversification of climate, landscapes and ethnicities. Brazilian people have different beauty traces, ranging from fair to dark skin, blonde to brown hair and blue to black eyes. Beauty is a major concern for Brazilian people and therefore Brazil is the 3rd country in the world, to consume cosmetics¹ and the 2nd one in cosmetic surgeries² performed. Also, one of the biggest worldwide known specialists in esthetic surgeries is Brazilian; Dr. Ivo Pitanguy. There are more plastic surgeons per capita in Brazil than in any other country in the world3 and Brazil is ranked as the best place in the world to undergo a cosmetic surgery4. Brazilian practitioners’ performance is acknowledged beyond Brazilian boundaries and it is considered as world reference. Brazil´s expertise in beauty is also extended to other areas such as dentistry, specifically esthetic dentistry. The high esteem and lust for pursuing a beautiful smile has led brazilian industry to embrace the segment. Brazil is widely acknowledged by manufacturing restorative materials of high quality and mainly by offering advanced products and techniques for dental bleaching. Consumption for that type of procedure is amongst the top of the world. All this evolution was closely followed by FGM. In more than 16 years in the market, FGM became a dental bleaching leader not only in Brazil but in all Latin America. Besides dominating 80% of the national market share, FGM exports around 450 thousand items per year to more than 70 countries. FGM has support bleaching millions of smiles all over the world with the Whiteness line of products. Count on FGM to spread clear and wide open smiles around the world. Trust dental products developed by the country that is an expert in beauty and trust the leading Company in dental esthetic products in Brazil. Learn more about the 250 items developed with top notch technology to support the daily routine of practioners and maximize results to patients: www. fgm.ind.br/en

1 Only behind USA and Japan. Source: ABIHPEC 2009. 2 Only behind USA. Source: Folha de São Paulo Journal, 2010. 3 According to Newsweek.com, 2011. 4 According to Newsweek.com, 2011.

Index 1. The Dental Bleaching

1.1 History

1.2 Treatment initial considerations

1.3 Indications for Dental Bleaching

1.4 Types of dental staining

1.5 Bleaching Substances and Mechanisms of Action

1.6 Initial Examination and Bleaching Techniques x Products Available

1.7 Safety in Dental Bleaching

1.7.1 Clinical examination

1.7.2 Follow-up and Professional Instructions

1.7.3 Dental hypersensitivity

1.7.4 Soft tissue irritation

1.7.5 Effects of Bleaching Gel on Tooth Structure

1.7.6 Recommendations to patients during Dental Bleaching

1.7.7 Quality of FGM products

1.8 Trends and Innovations in Dental Bleaching 2. Dental Bleaching Techniques

13 14

2.1 Previous Procedures to various Dental Bleaching Techniques

2.2 Home Bleaching Technique | Whiteness Perfect and White Class Protocol

2.2.1 Manufacturing individual trays for at-home dental bleaching

2.2.2 Whiteness Perfect

2.2.3 White Class

2.3 In-office Bleaching Technique | Whiteness HP and Whiteness HP Maxx Protocol

2.3.1 Whiteness HP

2.3.2 Whiteness HP Maxx

2.4 In-office Bleaching Technique | Whiteness HP Blue Protocol 2.4.1Whiteness HP Blue

36 40

2.5 Bleaching Technique for non-vital Teeth (walking bleach technique) Whiteness Super-endo and Whiteness Perborato Protocol

2.5.1 Whiteness Super-endo

2.5.2 Whiteness Perborato

2.6 Dental Microabrasion Technique | Whiteness RM Protocol 2.6.1 Whiteness RM 2.7 Combined Dental Bleaching Technique 2.7.1 Clinical Case | Combined Dental Bleaching Technique Free of hypersensitivity References

50 54 56 57 64

The growing evolution of communication media and knowledge diffusion allows for a progressive decrease of oral diseases such as caries, gingivitis and periodontitis. As population is getting more and more aware of the treatments and technologies available, the demand of patients looking for prevention and esthetical improvements is getting higher, and dental bleaching is one of the most desired esthetic treatments of all. Dental bleaching consists of a conservative procedure9,

13, 14

that allows patients to have

whiter teeth, disregarding the need for a restorative

prosthetic

approach.

The

treatment is basically based on two versions: in-office or at-home supervised bleaching. Both are easy to use and provide excellent results; however both have specific characteristics that influence on the indication according to each case. The present material consists of a dental bleaching manual and approaches the subject introductorily. Mainly to briefly elucidate some of the most important topics regarding dental bleaching, such as the indications of different methods, substances available, mechanisms of actions, directions, etc. FGM is proud to share quality information and hopes that the content herein available may support the spreading and awareness of safety guidelines which will enable professionals to enhance their skills to perform both comfortable and safe dental bleaching procedures.

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Dental Bleaching

1.1 History

Demand for dental bleaching is not recent. The first dental bleaching procedure was reported in 1860 in vital and non-vital teeth with the combination of several products based on chloride, sulfur dioxide and oxalic acid and heat by means of heated instruments, performed exclusively in-office. Home use dental bleaching sessions first took place in the 80Â´s, when one observed that patients under treatment with carbamide peroxide as an oral antiseptic resulted in whiter teeth. Nowadays bleaching has greatly evolved, being performed in vital and non-vital teeth both in-office and athome, available in different concentrations and with products that guarantee safety and comfort.

1.2 Treatment initial considerations Dental bleaching is a noninvasive procedure that has already presented scientific evidences of safe clinical application1,2,3,4,5,6. It is a method that relates the application of chemical substances on teeth aiming to obtain wither teeth coloration, improving the esthetics of the smile. Since esthetics has been widely spread and desired by patients, the search for less invasive dental bleaching procedures has become object of studies and researches leading to great improvement throughout the years. Nowadays, the treatment is also an initial step for patients who search for restorative and prosthetic treatments. Along the modernization of techniques and materials, it is possible to offer patients different means to obtain outstanding results, taking into account clinical conditions and even daily routine resulting in a safe and comfortable treatment.

1.3 Indications for Dental Bleaching The type of bleaching treatment and bleaching products depends directly on the type of tooth discoloration diagnosed; that may be yellowish or darkened teeth due to adverse conditions (traumas, diet rich in pigments, etc.). Basically, the cases bellow can be considered as indications6,7,8:

Manual of Dental Bleaching FGM

Teeth darkened by aging; Naturally yellow teeth; Teeth darkened by substances of cigar; Teeth pigmented for a diet rich in pigments; Teeth that may receive restorative/prosthetic rehabilitation, aiming to balance the shade of the smile; Non vital teeth that suffered shade alteration; Teeth affected by staining due to tetracycline use or its derivatives*; Teeth affected by fluorosis*. *in case of mild levels.

1.4 Types of Dental Staining Dental darkening can be determined by extrinsic and intrinsic factors. Extrinsic pigments are related to formation and deposition of pigmented substances on dental surface that may penetrate tooth through enamel and dentin. Normally these stains are caused by food that are pigmented, tar and nicotine (in smoking patients), some dental materials (eugenol, metallic alloys, etc.), mouthwashes such as clorhexidine and also accumulation of bacterial biofilm. On the other hand, intrinsic pigmentations are frequently related to pulp alterations (internal bleeding, necrosis and dystrophic calcification) and the use of drugs such as tetracycline and its derivatives8. The undue ingestion of fluoride in the dental development ages may also result in fluorosis, which compromises correct formation of enamel in different levels and generally results in intrinsic staining. Pigments inside the dental structure are also known as cromophores, they have long and complex molecular chains that cause higher light absorption and consequently confer a visual aspect of darkened teeth7.

1.5 Bleaching Substances and Mechanisms of Action The main bleaching agent used for tooth dental bleaching is Hydrogen Peroxide â&#x20AC;&#x201C; in concentrations normally ranging from 3 to 35% - and Carbamide Peroxide â&#x20AC;&#x201C; ranging from 10 to 37%8. The carbamide peroxide acts as carrier for Hydrogen Peroxide - which is in fact the active agent responsible for bleaching - so it provides a slower action. During its decomposition it releases Hydrogen Peroxide and other subproducts such as urea and ammonia that take part on the bleaching process. In general, 3% carbamide approximately equals 1% hydrogen peroxide that will be decomposed by oxygen and water. Hydrogen peroxide and Carbamide peroxide are applied in different protocols according to each concentration. The substances are indicated for different treatments; however, they act through a common mechanism: action of hydrogen peroxide. These powerful oxidizing agents dissociate by releasing reactive oxygen radicals that, due to their low molecular weight and to the permeability of the tooth structure, penetrate the tooth and reach pigmented areas such as enamel and dentin. Through an oxidizing process, these reactive radicals break the molecular chains of the chromophores (chemical groups responsible for color) into smaller chains that are more soluble and mainly colorless, which can be eventually eliminated by diffusion. Peroxide diffusion and breaking of pigments depend on conditions such as nature of dental structure, levels of permeability of tissues, exposed surface, thickness of the dentin tissue, power/concentration of the bleaching agent, length of product application, among others.

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Mechanism of Action of the Hydrogen Peroxide on dental bleaching process Gel

Dentin

After

During

Before

Chromophore

Peroxide Ename

Oxidation of chromophores

Bleached Tooth

Different individuals may react differently to treatment results, what can be justified partially by the topics presented previously. The professional in charge will appoint the techniques available, taking into account the patient’s profile. Maximizing results safely is a continuous goal for professionals that look for to excellence.

1.6 Initial Examination and Bleaching Techniques x Products Available Dentists must always perform an accurate initial clinical examination3 similarly to any other dental procedure in order to evaluate the viability of dental bleaching for that specific patient. It is important to gather information such as general health, medical records and use of drugs. During oral examinations dentists should make sure that the patient is free of caries or unadapted/infiltrated restorations, dental fracture exposing dentin, periodontal disease, receding gums or cervical lesions (abfraction, erosion or abrasion). If any of the mentioned problems is diagnosed, they should be treated prior to the bleaching process (by means of provisional restorations, prophilaxys, periodontal treatment, etc.). Radiographic examination such as periapical and/or interproximal radiographs are also important to provide further details of oral health. Another important tool is the thermal testing of dental vitality, indicated when there might be signs of pulp alterations. Dentist can estimate the level of dental hypersensitivity by asking patients about eventual sintoms on daily routine and by applying air blast on cervical third of teeth. In regards of anamnesis, professional must be aware of patient’s daily routine, eating habits, any particularities such as excess of acid drinks ingestions, parafunctional or smoking habits. The patient’s profile must be identified to allow the best selection of bleaching technique, in order to prescribe the ideal concentration and dosage for ones specific needs. Another important step is registering the patient´s initial teeth shade. That type of record may be accomplished by using a shade guide unit taking notes on the most evident teeth (central incisors and cuspids). Intraoral photographs are also good tools to reveal results. Regarding bleaching techniques, there are four different modalities: a) at-home bleaching with individual tray; b) in-office bleaching; c) combined technique – starting in-office and complementing with at-home use; and d) walking bleach technique – specific for non-vital teeth.

Manual of Dental Bleaching FGM

a) At-home bleaching (with individual tray): This technique requires a mold of each dental arch and posterior manufacturing of custom trays that are made by the lab technician. These trays are loaded with bleaching gel (one small drop in each tooth cavity of the tray) and then worn for a specific period, according to the concentration and version of the gel. FGM provides Carbamide Peroxide at 10%, 16% or 22% (Whiteness Perfect and Whiteness Simple) and Hydrogen Peroxide 4%, 6%, 7,5% and 10% (White Class with Calcium). The dosage varies according to the concentration, and the length of time to wear the tray goes from 30 minutes to 4 hours daily or even overnight, for two to three weeks. At-home bleaching is considered the most conservative one due to lower concentrations of peroxides and therefore is one of the most widely prescribed and object of studies since the first bleaching protocol has been described. Nowadaysit is known as effective, safe and long lasting3,9.

b) In-office bleaching: Without the use of trays, this technique consists of coating the teeth with higher concentration bleaching gels in sessions that last for about an hour. FGM provides hydrogen peroxide gels in the following concentrations: 20% (Whiteness HP Blue 20%) and 35% (Whiteness HP Blue 35%, Whiteness HP and Whiteness HP Maxx). For patients more prone to hypersensitivity, it is important to combine the use of desensitizing agents before bleaching sessions and therefore monitor the patient assiduously. Professionals might associate the use of external light sources aiming to accelerate oxygen liberation, in an attempt to shorten sessions or increase efficiency. However, studies show that depending on the type of energy source and the how long the exposure time is, to, the use of light may increase the tooth temperature what could lead to pulp irritation and dental hypersensitivity10,11. Comparing the efficiency between the techniques performed with or without light source, most of the studies show that there are no additional benefits conferred to light source application during in-office bleaching sessions10-25, or the difference is not clinically noticeable, only when electronic equipment is used on in vitro studies16. Thus, the use of light is up to the professional, who may build his own concept about the subject by reading consistent literature and acquiring experience with different methodologies. Light source for bleaching acceleration is not recommend by FGM, although some of its products present adequate properties to support light use â&#x20AC;&#x201C; such as Whiteness HP Maxx that contains a heat blocker, to reduce teeth heating. The in-office technique is frequently used in patients who want faster results in shorter periods of time and dislike wearing dental trays.

c) Combined Techniques: Another effective technique commonly used is the combination of both techniques â&#x20AC;&#x201C; in-office and at-home in a single treatment. Basically it consists of performing one or two sessions in office and then complementing the treatment by using the gel in custom made trays for about one week. It is an interesting alternative for more resistant cases and when a shorter treatment is needed7. This technique combines greater initial speed and provides evident and long lasting results, obtained in an intermediate time if compared to the techniques performed separately.

d) Walking Bleach Technique: This technique is performed on devitalized darkened teeth that present itÂ´s conduit properly treated and good periodontal health. The professional accesses the pulp chamber, creates the cervical barrier and then the bleaching agent is placed into the pulp chamber. The cavity is sealed provisionally for a period of about five days, and then the patient returns to the office for a revaluation. FGM bleaching line has two products for that purpose; Whiteness Perborato (Sodium Perborate) and Whiteness Super-Endo (Carbamide Peroxide at 37%). For non-vital teeth, one can even associate walking bleaching technique to the conventional in-office technique by applying Hydrogen Peroxide in-office. PS: more details will be provided on the following pages regarding this technique.

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Choosing the proper technique involves the combination of several factors such as probable origin of the discoloration (higher or lower complexity), patientâ&#x20AC;&#x2122;s oral health and particular characteristics, the commitment of the patient to the treatment, length of treatment and his expectations. Professionals must ensure that the treatment elapses safely and comfortably. In order to optimize results, professionals must obtain an accurate patient profile, characteristics and potential result from different techniques, as well as identify eventual side effects and itÂ´s correct treatment. (bear in mind to prioritize the prevention of discomfort than treat side effects).

1.7 Safety in Dental Bleaching Dental bleaching has become popular and been performed with the same protocol since 1989, when Dr. Haywood and Heymann published an article about at-home dental bleaching7. Since then, the treatment has been studied exhaustively in order to assess safety and effects on dental tissues. Nowadays, after more than twenty years of clinical practice, dental bleaching can be considered a safe, conservative and effective procedure once the professional observes some basic aspects.

1.7.1 Clinical examination The first step and one of the most important is the first clinical examination that should be conducted carefully to establish a correct treatment plan. There are some clinical situations that may be corrected before the bleaching procedure takes place (according to item 1.6) to assure the safety of the process. The bleaching must only be conducted when the oral and systemic condition of the patient is totally clarified. If required, professionals should call for a periapical or interproximal radiographs to elucidate the diagnosis.

1.7.2 Follow-up and professional instructions Once the patient is able to undergo the treatment, the professional must follow the case on periodic appointments. Professional must provide patients with clear instructions and directions of the product as well as eventual restrictions during treatment such as having acid food/drink, heavily colored food/drink, cigar, etc. During treatment, patients must look for the professional in case of any eventual side effect is sensed. The dentist is responsible for ensuring safety throughout the treatment and must recognize and treat any side effect that the patient may present. Performing a comfortable bleaching session increases patientâ&#x20AC;&#x2122;s satisfaction and corroborates to a positive image of the professional.

Manual of Dental Bleaching FGM

1.7.3 Dental Hypersensitivity That is the most common side effect observed during and post treatment in vital teeth. When it is sensed, most of the cases are usually mild and easily controlled with simple maneuvers and should disappear without reoccurrences after the end of the treatment. The discomfort mechanism is not totally cleared yet, however it is known that the permeation of Hydrogen Peroxide by enamel and dentin is responsible for reversible pulp reactions. In cases of higher hypersensitivity (rarer), that reaction could lead to local arterial vasodilatation, increase of capillary hydrostatic pressure, increase of pulp tissue pressure, etc., leading to higher hypersensitivity, but still controllable. As the incidence, the intensity of hypersensitivity varies from patient to patient and depends on factors such as pain tolerance, volume of the pulp chamber and presence of important cracks or unadapted restorations. In cases of moderate hypersensitivity, the discomfort may last for one or two days after the beginning of home bleaching, regressing as the treatments progresses. When the hypersensitivity occurs after in-office bleaching, it generally lasts for four to six hours after gel applications. It is known that the level of hypersensitivity is influenced by the concentration of the gel and thus it is more frequent in the in-office technique. Whenever the discomfort persists becoming a major hindrance, the professional should evaluate the patient clinically by searching for any factor that was not previously detected (cracks, wear, recession, caries, etc.). In case nothing is found, the following guidelines are suggested: a) At-home bleaching: Discontinue treatment for 24h; Apply desensitizing agent Desensibilize KF 0,2% for 10 minutes daily on the custom tray, for as many days as needed or when symptoms are reduced. Using Desensibilize prior to the bleaching reduces the level and incidence of hypersensitivity; Reduce the concentration of the gel; Perform the bleaching alternating days; In extreme cases, consider prescribing specific drugs and discontinue treatment.

b) In-office technique: Apply Desensibilize KF 2% in-office for ten minutes just before coating the teeth with the bleaching gel. Using a desensitizing agent is advisable37 to maximize comfort during treatment; Discontinue use of light sources that may heat teeth, in case it is being used; Reduce the concentration of the gel; FGM offers hydrogen peroxide at 20% (Whiteness HP Blue), which minimizes hypersensitivity; Consider changing techniques: at-home bleaching may be more comfortable to the patient due to the concentration of the gel; In extreme cases, consider prescribing specific drugs and discontinue treatment.

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1.7.4 Soft tissue irritation While home bleaching, mild level of irritation may be eventually observed due to the hydrogen peroxide contact with oral soft tissues. That side effect manifests by slightly burning and redness, generally on the gingival margin. It is a transitory effect (normally regresses and disappears after discontinuing the treatment) and it is generally associated to unadapted tray (that hurts gingiva), the presence of pre-existing gingival irritation and excess of gel disposed on the tray. In that case, instruct the patient to follow the directions precisely – avoiding excess that may overflow the tray – and perform new clinical examination to identify any gingival problem as well as correct the fit of the tray, that must be free of shavings, with rounded corners and covering one millimeter of the gingival margin. See more details on the step-by-step section “Manufacturing individual trays for at-home dental bleaching” (page 20). For the in-office technique (that prescribes more concentrated gels) one can expect more severe reactions and even swelling in case of prolonged gel contact with the soft tissues. In such cases, it is recommended to immediately coat the affected area with Neutralize (stabilized catalase enzyme that comes with the FGM inoffice bleaching kit) and follow up the case closely. On the most severe cases the lesion may present edema and ulceration, and if there is no improvement after some days, medical assistance is recommended. To avoid that kind of side effect, a gingival barrier Top Dam should be used correctly (see Whiteness HP, Whiteness HP Maxx and Whiteness HP Blue protocols) as well as the bleaching gel should be handled carefully. Also, to allow better access to the teeth, the use of an adequate lip retractor Arcflex is advisable.

1.7.5 Effects of Bleaching Gel on the Tooth Structure Studies show that bleaching agents may affect enamel microhardness and surface roughness, depending on the type of bleaching agent, concentration and length of sessions. Reduction of enamel microhardness and increase of enamel roughness should be considered as temporary effects and are easily reverted by the action of saliva and by polishing the teeth with felt disks, respectively. FGM offers bleaching gels that contain fluoride, which may support the mineral recovery of the enamel and consequently accelerate recovery of the microhardness. There is also a line of products that contains calcium gluconate (Whiteness HP Blue and White Class), which reduces mineral loss of teeth during bleaching procedures (GIANNINI, M., 2008).

1.7.6 Recommendations to patients During Dental Bleaching There are some important directions that must be informed to patients: Avoid acid food or drinks that may increase dental hypersensitivity; Avoid food saturated in pigments (soft drinks, sauces, red wine, etc.); Avoid smoking; In case of hypersensitivity, patients must seek for dentist advice. Guidelines for patients under at-home treatment: Brush the teeth thirty minutes prior to applications; Apply the right amount (small drop) of gel on the tray as indicated by the professional; Remove the excess of gel that overflows the tray with the finger or toothbrush; Trays are to be worn according to the directions on each product; After use, wash mouth abundantly with water; Store the tray clean, in a dry and airy place; Attend the dental visits weekly for supervision.

Manual of Dental Bleaching FGM

Tetric Ceram

(Ivoclar Vivadent)

Aelite

(Bisco)

Venus

(Heraus Kulzer)

4Seasons

Estelite Sigma

(Ivoclar Vivadent) (Tokuyama)

a 1.7.7 Quality of FGM Products Opallis + Tecnologia (FGM)

0,0

0,2

0,4

0,6

0,8

1,0

1,2

1,4

de Color FGM is uniquely committed toVariacíon developing high(∆E) quality products, as a result of over 20 years of experience

and research on dental bleaching. The company concerns about every single characteristic of the bleaching gels to offer dentists a top quality product. 1400

Liberación de Fluoruro (µg/cm3)

a) Incorporation of Potassium Nitrate and Fluoride: results in more comfort to patient 1200

Maxxion C Vidrion C

Potassium in the dentin, and therefore reduces potential hypersensitivity. Ionomaster C 1000Nitrate desensitizes nerve fibers VitroCem Likewise the fluoride acts through a mechanism of tubules obliteration to offer a more comfortable 800 process to patient. 600

b) Incorporation of calcium: preserves dental microhardness 400 The calcium gluconate added to the formulas of the Whiteness HP Blue (in-office use) and White 200 Class (at-home use) provides a dental remineralizing effect that was observed in microhardness tests 0 (GIANNINI, M., 2008) which attested that calcium containing gels reduce up to three times the decrease 0 5 10 15 20 25 of microhardness during bleaching sessions. Días Observe that calcium preserved the integrity of enamel by reducing the loss of mineral:

Decrease of Microhardness (%)

Redução da microdureza (%) -18

Without Calcium

-16

With Calcium

-14 -12 -10

-8

-6 -4 -2 0

White Class 6% Whiteness HP Blue 35% Source: Prof. Dr. Marcelo Gianinni – Unicamp – SP/Brasil.

c) High water content Resistencia de Unión por microtracción (MPa)

The Whiteness60line of at-home bleaching agents contains high water content in its composition, which A despite acting50 as a vehicle for and balancing the viscosity of the gel, maintains tooth a a other substances hydrated throughout bleaching treatments. A,B B,C d) pH stability

Dental bleaching gels present non-acid pH39, which prevents demineralizing effect on dental structures. In C b 20gels, the product is ready to use presenting a neutral pH. For in-office bleaching, FGM at-home bleaching 10

Immediato

provides formulas separated into two phases in order to maintain the long term stability of20.000 the product. The Trás ciclos térmicos Peroxide phase is 0maintained in acid pH (more stable) and should be mixed with the Thickener phase to Competidor A Competidor B Competidor C obtain an adequate neutralÁmbar pH gel to then be coated onto the structure of the tooth. (FGM)

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Complementary products to convey more comfort: a) Neutralize: more safety for users of higher concentrated Peroxides Neutralize is a Catalyze enzyme solution that comes with the in-office bleaching kits. Catalyzes Hydrogen Peroxide decomposition and neutralizes its action in eventual soft tissue contact during bleaching session. It is important to observe that Neutralize must be applied as soon as an undue contact is observed, since it might only work on Peroxide that is still active not reversing the irritatory effect. Very easy to apply and confer safety to procedure. b) Desensibilize KF: Desensitizing agents aim to provide more comfort to patients during bleaching processes and consequently increase patientâ&#x20AC;&#x2122;s satisfaction. FGM offers Desensibilize KF 0,2% and 2% for at-home and in-office use, respectively. The product is based on 5% potassium nitrate and 0,2% or 2% sodium fluoride depending on the version. The use of a desensitizing agent for ten minutes just before bleaching sessions reduces dental hypersensitivity26 and it is recommended as part of the protocol, mainly to patients who have previously reported dental hypersensitivity.

1.8 Trends and Innovations in Dental Bleaching The current unbelief in external energy sources has lead to the development of products that use other mechanisms to accelerate the bleaching process. They are called self-catalyzed and consist of products that do not advocate the use of light. Searching for more practical processes, new formulations are now available in packages of bleaching-gelsyringes that allow direct coating of the product on the teeth, under protocols that eliminate recoating of gel during session (single application per session). In order to protect the structure of enamel, calcium has been incorporated to formulations to minimize the decrease of superficial microhardness. To maximize comfort and safety when using in-office techniques, professionals have been searching for lower concentrated Hydrogen Peroxides (Whiteness HP Blue 20%). Studies show that if used for bit longer periods, the bleaching level is comparable to concentrations at 35%, with lower levels of hypersensitivity. In order to reduce hypersensitivity, Desensibilize KF 2% should be used prior to bleaching process. Studies also demonstrate that no detrimental effect is conferred to the speed of the process and increase of comfort is very significant. The search for scientific information as well as professional development must be continuous, since world dentistry has incessantly chased scientific evidences in order to contribute for a safer, efficient and healthy treatment to patients.

Manual of Dental Bleaching FGM

Dental Bleaching Techniques

2.1 Previous procedures to various dental bleaching techniques As previously read, prior to the bleaching treatment, professionals must make some clinical maneuvers to ensure that the treatment will be conducted safely. Bellow there are some initial steps that should be commonly adopted to every patient who are considering a dental bleaching.

1st Step | Anamnesis First perform anamnesis, by identifying: a) Medical history Patients should be questioned about current use of any medication, existing systemic diseases such as diabetes and if they are pregnant or lactating. Note: in order to prescribe a bleaching treatment for a diabetic patient, under most circumstances it would be prudent to obtain medical clearance prior to performing any extensive dental therapy, therefore patients should be aware. b) Oral condition Patients must be questioned whether fluoride was unduly ingested in childhood, if encountered dental trauma or previously had a dental bleaching. Dental hypersensitivity on daily routine must also be identified prior to exposing patients to treatments. c) Diet Patients must be questioned on the frequency of ingestions of coffee, tea, soft drinks, red wine and other heavily colored substances. d) Habits Patients must be questioned if are smokers, suffer from onychophagy (nail biting), bruxism, etc.

2nd Step | Clinical exam Patients considering the treatment should be free of oral health problems, in case of any; they must be detected and treated prior to dental bleaching procedures. Professionals must basically search for:

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a) Dental biofilm or calculus. Enhance gel contact to the surface with a prophylaxis.

b) Caries lesions. Remove affected tissue and restore tooth with temporary or permanent material*.

c) Unadapted restorations. Change restoration with temporary or permanent material*.

d) Gingivitis or periodontitis. Diagnose causes and treat the disease previously.

e) Receding gingiva. Itâ&#x20AC;&#x2122;s indicated to cover exposed areas with temporary or permanent material*.

Manual of Dental Bleaching FGM

f) Pulp alterations. Teeth with affected pulp must be treated previously and may require specific bleaching.

g) Dental cracks or fractures. According to the level of commitment and dentin exposure, it is suggested to restore tooth with temporary or permanent material*.

h) Enamel hypoplasia. Spots may become more evident after bleaching, eventually consider restorative approach after bleaching.

i) Fluorosis staining. According to the level of staining, microabrasion treatment prior to bleaching may be suggested.

j) Tetracycline staining. Treatment may differ according to the level of the staining; in some cases bleaching can be held for longer periods than in other diagnosis.

*When choosing for restoration with permanent dental material, be aware that the material is not bleached as teeth are, which may lead to substitution of the restoration material post treatment.

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3rd Step | Radiograph examination Performing radiograph exam to complement clinical information is advisable. The professional may execute periapical or interproximal radiographs to elucidate the case and then confer more safety to the procedure.

4th Step | Prophylaxis It consists of eliminating superficial staining that cannot be removed under normal brushing. The sodium bicarbonate jet polishing may be used, as well as polishing with rubber cup or Robinson brush. For patients who present pigmentation of interproximal areas, use fine grain sandpapers strips below contact point. However, it is necessary to observe if the patient needs previous periodontal treatment. Note: in case the prophylaxis or tooth scaling shall hurt gingiva, a break must be considered prior to bleachings with custom trays. Sore gingiva may be irritated easily by the Peroxides.

5th Step | Initial color registration To obtain reference to color changes during treatment, it is essential to register initial shade with the aid of a shade guide. Always consider cuspids and incisors separately, since cuspids may present a more saturated color. Patients should follow the whole procedure with a mirror.

Manual of Dental Bleaching FGM

2.2 Home Bleaching Technique

Whiteness Perfect and White Class Protocol

Prior to initiating the technique read item 2.1 “Previous procedures for various dental bleaching techniques”. The technique described next suggests a basic protocol used for at-home bleaching with Whiteness Perfect and White Class, based on carbamide Peroxide and Hydrogen Peroxide respectively. The procedure is a guide and can be complemented with any other additional step according to the experience of the professional. Also, read carefully the instructions manual of each product in order to learn about specific characteristics.

1st Step | Manufacturing the custom tray For more information on how to proceed, please see the “Step-by-Step: Manufacturing individual trays for at-home dental bleaching” on page 20.

2nd Step | Instructions on how to apply the gel on tray Patients should apply a small amount of gel on the spaces corresponding to the buccal surface of teeth on the tray and then fit it onto the dental arch with moderate pressure so that the gel is distributed all over the buccal surface of the teeth. If needed, remove excess of gel that overflows from the tray with the aid of a brush or finger.

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3rd Step | Orientation about daily wear time of the tray Loaded with gel, the tray must be fitted onto the teeth and remain still during the whole time estimated by the dentist. The recommended period of time is based on the type of gel used and its concentration. The application time and the concentration of the gel can be changed in case of hypersensitivity, special need or if requested by the patient. Daily wear time varies from 1 to 4 hours according to each protocol (White Class or Whiteness Perfect). The gel can also be used alternately or fractionated in daily periods. In these conditions the average time of treatment may be longer, however the outcome will be the same. After wearing, the tray must be washed, dried and stored in the tray case. It is important that patients return on regular basis to appointments throughout the treatment so that dentists can evaluate the development of the treatment, diagnose and treat any side effect.

4th Step | Final shade registration At the end of the treatment, it is important to register the final shade of all bleached teeth and compare with the initial shade (with the aid of a shade guide) to ensure that patients are aware of the results and that optimum shade has been reached.

Before

After

Manual of Dental Bleaching FGM

2.2.1 Manufacturing individual trays for at-home dental bleaching Molding technique 1st Step Before molding, perform dental prophylaxis. Then, place the patient in an adequate position to allow the dental arch to be molded parallel to the ground.

2nd Step Select an impression tray that has a free space to the teeth of the arch to be molded (Fig. 1). The tray must completely involve all teeth, if total coverage is not reached, place increments of wax to increase the height of the tray.

Figure 1: Selection of the impression tray

3rd Step The material of choice is alginate. Dispense the correct proportion of water/powder according to the manufacturerÂ´s instructions. Add powder to water in a bowl and manipulate it until a smooth and homogeneous mix is obtained (Fig. 2).

Figure 2: Correct homogenization of alginate

4th Step Place the mixed alginate in the selected impression tray, spreading the material all over the surface (Fig. 3).

Figure 3: Loading the impression tray with alginate

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5th Step Place the loaded tray into the patient’s mouth deepening from posterior to anterior, aligning the central part of the tray to the midline of the patient (Fig. 4). Make moderate pressure and be sure the tray does not contact teeth.

Figure 4: Placing the tray onto the patient´s dental arch

6th Step Keep the impression trays static stabilizing it with two fingers (Fig. 5) until the complete gelification of the alginate. When ready, remove the tray.

Figure 5: Molding of the arch

7th Step Before casting the mold with plaster, disinfect the alginate impression with antimicrobial agents (i.e. Clorhexidina S – FGM) for ten minutes. Ideally the mold should be casted with plaster right after obtaining the mold. When it is not possible, keep it inside a closed recipient until casting. Search for specific directions on your material´s instructions manual.

Making of the model 8th Step The material of choice to cast the mold must be type III plaster, prepared in a proportion of 30ml of water to 100g of powder. Pour water into a bowl and then add the powder, mixing both vigorously for about 45 seconds until homogenization is complete (Fig. 6).

Figure 6: Mixing of the plaster

Manual of Dental Bleaching FGM

9th Step After mixing the plaster, proceed to the casting aided by a spatula or brush. If possible, use a vibrating device for better flowing (Fig. 7 and 8).

Figure 7: Casting the mold aided by spatula

Figure 8: Vibration device for better flowing

10th Step Wait until complete set of plaster. Remove the model on an interval of 30 to 60 minutes after casting.

11th Step Trim the model by using an adequate dental plaster trimmer, removing excess and leveling the base (Fig. 9). The model should be shaped as a horseshoe to allow for the vacuum forming of the custom tray.

Figure 9: Trimming of the model

12th Step After trimming the models, dry it vigorously (Fig. 10). Relieves on buccal surface of the model are not required (Matos IC, Borges MAP, Oliveira LC. The influence of making relieves on buccal surfaces of models on the final result of dental home bleaching. J Dent Res 84 (Spec Iss A): 2005.).

Figure 10: Models trimmed in the shape of horseshoe

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13th Step Place de model on the vacuum forming device, under the vinyl tray sheet (Fig. 11). Turn on the equipment to start heating the sheet. When it shows a bulging of about one inch, rapidly pull down the sheet over the model and turn the vacuum on for about ten seconds.

Figure 11: Model on the vacuum forming device. Observe the bulging of the vinyl tray sheet showing the correct time to lower it down over the model

14th Step The tray sheet must adjust to the contours of the model, mainly the ones close to the gingiva since the tray should form a rounded edge to hold the gel into the custom tray (Fig. 12).

Figure 12: Correct adaptation of the vinyl sheet to the model

15th Step After cooling of the tray, trim it in order to keep its contour 1mm above the gingival margin (Fig. 13).

Figure 13: Trim of the tray respecting the cervical contour and 1mm margin

Manual of Dental Bleaching FGM

Whiteness Perfect

Dentist-supervised at-home bleaching available in 10%, 16% and 22% carbamide peroxide.

Leader in Sales Whiteness Perfect is a carbamide peroxide-based gel available in three versions (10%, 16% and 22%) for at-home use supervised by a professional. The product is known for its high quality and safety standards and is a market leader in Brazil and Latin America, present in over 70 countries.

SAFETY AND COMFORT • Contains desensitizing agents. The potassium nitrate and fluoride that provide comfort to patients while the fluorine that prevents enamel demineralization. • With high water content that prevents enamel dehydration.

CONVENIENCE • The product is available in different versions and broader wearing time ranging from 4 hours to only 1 hour and a half allowing patients to easily fit treatment to daily schedules. • The kit comes with a tray case to store individual trays.

VERSATILE • Perfect for combined bleaching technique, since it is available in different concentrations. • Syringes last longer, the kit provides enough gel to perform a full treatment for one patient.

EUROPEAN UNION REFERENCE

PRODUCT

CONCENTRATION

Whiteness Perfect

10% Carbamide Peroxide

Whiteness Perfect

16% Carbamide Peroxide

Whiteness Perfect

22% Carbamide Peroxide

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COSMETIC

MEDICAL

Kit Whiteness Perfect 10% and 16% 5 3g syringes of gel 5 application tips 2 vinyl tray sheets of 1mm of thickness for making of the custom trays 1 tray case Instructions for professional and patient

Kit Whiteness Perfect 22% 4 3g syringes of gel 4 application tips 2 vinyl tray sheets of 1mm of thickness for making of the custom trays 1 tray case Instructions for professional and patient

Mini kit Whiteness Perfect 10% and 16% 3 3g syringes of gel 3 application tips Instructions for professional and patient

Bulk Whiteness Perfect 10%, 16% and 22% 50 3g syringes of gel Instructions for professional and patient

Manual of Dental Bleaching FGM

White Class

Dentist-supervised at-home bleaching available in 4%, 6%, 7½% and 10% hydrogen peroxide.

Effective and safe Available in 4 concentrations (4%, 6%, 7½% and 10%), the product meets the most demanding needs ofpatients, require shorter daily wearing time and faster results compared to carbamide peroxide-based gels. Contains calcium which ensures safety and prevents enamel demineralization.

SAFETY • Double desensitizing action: potassium nitrate and sodium fluoride • Does not interfere on microhybrid or nanohybrid restorations microhardness28. • Cutting edge technology that supports high gel stability.

EFFECTIVENESS • Effectiveness equivalent to carbamide peroxide gels, however peroxide provides faster visible results.

CONVENIENCE • The product is available in different versions and broader wearing time ranging from 2 hours to 30 minutes allowing patients to easily fit the treatment to daily schedules. • The kit comes with a designed tray case to easily accommodate and transport a tray and a bleaching gel syringe.

VERSATILE • Syringes last longer, the kit provides enough gel to perform a full treatment for one patient.

EUROPEAN UNION REFERENCE

PRODUCT

CONCENTRATION

White Class

4% Hydrogen Peroxide

White Class

6% Hydrogen Peroxide

White Class

7,5% Hydrogen Peroxide

White Class

10% Hydrogen Peroxide

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COSMETIC

MEDICAL

individual syringes 4%, 6%, 7 ½% and 10%. 1 3g syringes of bleaching gel 1 application tip Instructions for professional and patient

Kit White Class 4%, 6%, 7½% and 10% 4 3g syringes of gel 4 application tips 1 tray case 1 next visit card Instructions for professional and patient

Bulk White Class 4%, 6%, 7½% and 10% 50 3g syringes of gel Instructions for professional and patient

Manual of Dental Bleaching FGM

2.3 In-office Bleaching Technique

Whiteness HP and Whiteness HP Maxx Protocol

Prior to initiating the technique read item 2.1 “Previous procedures for various dental bleaching techniques”. The following bleaching technique describes the basic protocol for in-office bleaching with Whiteness HP, however the same protocol can be used for Whiteness HP Maxx, both based on Hydrogen Peroxide at 35%. The procedure is a guide and can be complemented with any other additional steps according to each professional´s experience. Also, read carefully the instructions manual of each product in order to learn more about each particular characteristics.

1st Step | Exposure of smile line with the aid of ArcFlex (FGM) lip retractor Besides providing lip and cheek retraction, tongue control and bite rest, ArcFlex provides comfort to the patient throughout the sessions.

2nd Step | Application of desensitizing agent Desensibilize KF2% For more comfort to patient during and after treatment, apply desensitizing agent Desensibilize KF2% for 10 minutes. That will reduce/avoid eventual dental hypersensitivity. After application, remove the gel with a saliva ejector and then wash and dry the teeth.

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3rd Step | Gingival protection with Top Dam Apply the gingival barrier Top Dam on the gingival margin so that the surface is totally covered and protected. The resin should be light cured for 20 to 30 seconds. To observe if the dam is correctly in place, use a dental mirror and look at the incisal to cervical direction; if there is any uncovered gap, apply small amounts of Top Dam to correct and light cure it again.

4th Step | Mixing of the gel Shake the thickener flask to obtain complete homogenization. Hold the flasks of thickener and Hydrogen Peroxide vertically to dispense drops.The correct proportion is 3 drops of Peroxide to 1 of thickener; for both dental arches an amount of 21:7 should be enough, although that quantity may be modified according to the case. Manipulate vigorously until a viscous and firm gel is formed.

5th Step | Coating of the buccal surface of the teeth with bleaching gel Coat a thin layer of gel onto the full area of teeth. The application can be done with the spatula included in the kit or with any other type of process desired by the professional. Generally, the gel is applied on the teeth that compose the â&#x20AC;&#x153;smile lineâ&#x20AC;?, from second premolar to another (same arch).

Manual of Dental Bleaching FGM

6th Step | Gel removal and reapplication The gel must be removed and the teeth must be recoated with gel every 15 minutes up to 3 times in one session. If required this protocol can be reduced to 1 or 2 applications per session, although an increase on the number of sessions may be necessary to achieve the final result. During each application it is recommended that the dentist move the gel a bit with an instrument in order to release any oxygen bubbles, renewing gel contact to the tooth. At the end of each 15 minutes application, remove the gel with a saliva ejector (endodontic or surgical tip). When finishing the third application in a single session, rinse teeth very well before removing the gingival barrier. Note: the total number of sessions depends on each specific case, generally it is recommended to perform 3 sessions of 3 applications each (45 minutes total in one session).

7th Step | Removal of Top Dam gingival barrier Remove the gingival barrier, detaching it by pulling it forward with a rounded instrument. The barrier must detach entirely or in big pieces.

8th Step | Final polishing of teeth Perform the polish of enamel with felt disk (Diamond Flex â&#x20AC;&#x201C; FGM) and polishing paste (Diamond Excel â&#x20AC;&#x201C; FGM). .

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9h Step | Final registration of teeth shade Make sure to register the final shade and show it to the patient by using of a shade guide to compare the final to the initial result and to ensure that the optimum shade has been reached.

Before

After

Manual of Dental Bleaching FGM

Whiteness HP In-office bleaching available in 35% Hydrogen Peroxide.

Trust and leadership Whiteness HP is a 35% hydrogen peroxide in-office bleaching gel that can be light activated or not. With a drop by drop system that allows for specific dosage based on the number of teeth that will be bleached, avoiding wastes. Suitable for vital and non-vital teeth (internal bleaching gel applied during sessions), a simple product to use that provides great results.

SAFETY • Safe protocol: reapplication of gel during bleaching sessions maintains the pH gel safe which prevents enamel demineralization. • Comes with Neutralize: stabilized catalase enzyme accompanies the bleaching kit, suitable for application in mucosa that eventually contacts the bleaching gel.

EFFECTIVENESS • Great performance if light activated or not.

CONVENIENCE • Suitable for vital and non-vital teeth. The drop by drop system dispenses the right amount of product as required which prevents wastes. Available in kits and mini kits.

COMFORT • Whiteness HP may be used with desensitizing agents before and after bleaching sessions, without damaging bleaching results 29,30.

EUROPEAN UNION REFERENCE

PRODUCT

CONCENTRATION

Whiteness HP

35% Hydrogen Peroxide

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COSMETIC

MEDICAL

Kit up to 18 applications with Top Dam 1 bottle with 10g of Hydrogen Peroxide 1 bottle with 5g of thickener 1 bottle with 2g of Peroxide Neutralizing Solution (Neutralize) 1 spatula 1 plate for gel preparation 1 syringe of gingival isolation Top Dam with 2g and 6 tips Instructions for professional

Kit up to 18 applications without Top Dam 1 bottle with 10g of Hydrogen Peroxide 1 bottle with 5g of thickener 1 bottle with 2g of Peroxide Neutralizing Solution (Neutralize) 1 spatula 1 plate for gel preparation Instructions for professional

Mini kit up to 6 applications 1 bottle with 4g of Hydrogen Peroxide 1 bottle with 2g of thickener 1 bottle with 2g of Peroxide Neutralizing Solution (Neutralize) 1 spatula 1 plate for gel preparation Instructions for professional

Manual of Dental Bleaching FGM

Whiteness HP Maxx In-office bleaching available in 35% Hydrogen Peroxide.

Comfort, security and satisfaction to your patient! Whiteness HP Maxx is a 35% hydrogen peroxide in-office bleaching gel, that can be light activated or not. Contains heat blocker that prevents teeth from being overheated when exposed to warm light source. A cutting edge product, safe, effective and easy to apply. With a drop by drop system that allows for specific dosage based on each case, avoiding wastes. Suitable for vital and non-vital teeth (internal bleaching gel applied during sessions), a product known for being safe and effective.

SAFETY • Heat blocker: prevents teeth from being overheated when exposed to warm light source. • Safe protocol: reapplication of gel during bleaching sessions maintains the pH safe which prevents enamel demineralization. • Comes with Neutralize: stabilized catalase enzyme accompanies the bleaching kit, suitable for application in mucosa that eventually contacts the bleaching gel.

EFFECTIVENESS • Great performance if light activated or not31,32.

CONVENIENCE • Suitable for vital and non-vital teeth. The drop by drop system dispenses the right amount of product based on each requirement, preventing wastes. Available in kits and mini kits.

EUROPEAN UNION REFERENCE PRODUCT Whiteness HP Maxx

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CONCENTRATION 35% Hydrogen Peroxide

COSMETIC

MEDICAL

Kit up to 18 applications 1 bottle with 10g of Hydrogen Peroxide 1 bottle with 5g of thickener 1 bottle with 2g of Peroxide Neutralizing Solution (Neutralize) 1 spatula 1 plate for gel preparation 1 Top Dam with 2g and 6 tips Instructions for professional

Kit up to 6 applications 1 bottle with 4g of Hydrogen Peroxide 1 bottle with 2g of thickener 1 bottle with 2g of Peroxide Neutralizing Solution (Neutralize) 1 spatula 1 plate for gel preparation 1 Top Dam with 1g and 2 tips Instructions for professional

Manual of Dental Bleaching FGM

2.4 In-office Bleaching Technique Whiteness HP Blue Protocol

Prior to initiating the bleaching technique read the item 2.1 “Previous procedures to various dental bleaching techniques”. The following bleaching technique describes the basic protocol used for in-office bleaching with Whiteness HP Blue, based on Hydrogen Peroxide at 20% and 35%. The procedure is a guide and can be complemented with any other additional steps according to each professional´s experience. Also, read carefully the instructions manual of each product in order to learn about each particular characteristics.

1st Step | Expose the smile line with the aid of Arcflex lip retractor Besides providing lip and cheek retraction, tongue control and bite rest, Arcflex enhances comfort to the patients throughout sessions.

2nd Step | Application of desensitizing agent Desensibilize KF2% Provide more comfort to patients pre and post treatment, by using desensitizing agent Desensibilize KF2% for 10 minutes. This will reduce/avoid eventual dental hypersensitivity. After application, remove the gel with a saliva ejector and then wash and dry the teeth.

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3rd Step | Gingival protection with Top Dam Apply the gingival barrier Top Dam on the gingival margin so that surface is totally covered and protected. The resin should be light cured for 20 to 30 seconds. To observe if the dam was correctly applied, use a dental mirror and look at the incisal to cervical direction; if there is any uncovered gap, apply small amounts of top dam to correct and light cure it again.

4th Step | Manipulation of the gel Prepare the gel by mixing both phases, attach the syringes, push the plungers alternatively for 8 times, then transfer the mixed content to the transparent syringe in order to observe homogenization and to dose the quantity applied during session.

5th Step | Coating of the buccal surface of teeth with gel Attach an application tip to the syringe that contains the mixed gel and coat a thin layer of it on the teeth. The mixed content is enough to coat a â&#x20AC;&#x153;smile lineâ&#x20AC;?; from second premolar to another.

Manual of Dental Bleaching FGM

6th Step | Action of the gel on the tooth surface The gel should remain on the teeth for at least 40 minutes when the Whiteness HP Blue 35% is selected and for 50 minutes when the Whiteness HP Blue 20% is selected. The gel should be applied once per session for both versions. With the aid of a disposable microaplicator (Cavibrush â&#x20AC;&#x201C; FGM), move the gel on teeth frequently (from 5 to 10 minutes) to release oxygen bubbles and renew the gel contact to the tooth. Application length may be reduced in case of dental hypersensitivity or specific needs. In these conditions, the total number of sessions might be increased in order to obtain the optimum shade. Note: the total number of sessions may vary according to each case, generally 2 to 3 sessions of 40 or 50 minutes each are recommended.

7th Step | Removal of the gel When the application is over, remove it with saliva ejector and rinse teeth abundantly.

8th Step | Removal of Top Dam gingival barrier To remove the gingival barrier, simply detach it by pulling it forward with the aid of an instrument. The barrier must come out entirely or in big pieces.

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9th Step | Final polishing of teeth Polish the enamel with felt disk (Diamond Flex â&#x20AC;&#x201C; FGM) and polishing paste (Diamond Excel â&#x20AC;&#x201C; FGM).

10th Step | Final register of teeth shade Make sure to register the final shade and show it to the patient using shade guide to compare the final to the initial result.

Before

After

Manual of Dental Bleaching FGM

Whiteness HP Blue In-office bleaching available in 20% or 35% Hydrogen Peroxide.

Simple to use and effective Whiteness HP Blue is designed to allow in-office procedures to be more convenient and comfortable, providing the usual quality and effectiveness of the Whiteness line of products. The product is available in two versions, 20% and 35% hydrogen peroxide, available in two phases, separated by syringes that are coupled and mixed prior to applications. The contents of the syringes are pre-dosed, enough product to bleach both arches per sessions, no gel reapplication is required during sessions. By having calcium and a neutral pH provides safe treatments. SAFETY • With Calcium: gels containing calcium prevent demineralization and reduce hypersensitivity33. • Stable pH: proven stability and pH control throughout gel application (one application per session)34. • Comes with Neutralize: stabilized catalase enzyme accompanies the bleaching kit, suitable for application in mucosa that eventually contacts the bleaching gel.

EFFECTIVENESS • Great performance if light activated or not.

VERSATILE • Available in two versions: 35% and 20% hydrogen peroxide. • Kit lasts up to 6 applications (20 teeth each) or spare syringes for one application.

CONVENIENCE • Easy to mix: the coupled syringes (thickener and peroxide) allows both phases to be effectively and safely mixed. • Pre-dosed portions: prevents waste of material. • One application per session: no gel reapplication required.

COMFORT • Whiteness HP Blue 20% version provides low hypersensitivity. • Low incidence of hypersensitivity even with short intervals among sessions36.

EUROPEAN UNION REFERENCE

PRODUCT

CONCENTRATION

Whiteness HP Blue

20% Hydrogen Peroxide

Whiteness HP Blue

35% Hydrogen Peroxide

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COSMETIC

MEDICAL

Kit Whiteness HP Blue 20% and 35% (6 complete applications) 6 syringe set (1,2g each, total of 7,2g) 1 bottle with 2g of Neutralize 1 syringe of Top Dam with 2g and 6 tips 6 syringes attachment appliances 6 tips up to application of gel Instructions for professional use

Whiteness HP Blue 20% and 35% (Unique application) 1 syringe set (1,2g each, total of 2,4g) 1 syringe attachment appliances 6 tips up to application of gel Instructions for professional use

Manual of Dental Bleaching FGM

2.5 Bleaching technique for non-vital teeth (walking bleach technique)

Whiteness Super-endo and Whiteness Perborato Protocol Photos gently provided by Dr. Carlos Augusto de Oliveira Fernandes, Dr. Marília Mota Silva and Dr. Patrícia Maria Soares Lima Thé

Prior to initiating the bleaching technique read the item 2.1 “Previous procedures to various dental bleaching techniques”. The technique described next suggests a basic protocol used for in-office bleaching with Whiteness Perborato (Sodium Perborate and Hydrogen Peroxide at 20%), however its protocol is the same used for Whiteness Super-Endo (Carbamide Peroxide at 37%). The procedure is a guide and can be complemented with any other additional steps according to each professional´s experience. Also, read carefully the instructions manual of each product in order to learn about each particular characteristics.

1st Step | Case evaluation Before initiating bleaching treatment, make sure that the tooth has undergone an endodontic root treatment by means of clinical and radiograph examination. Register initial shade of the tooth by using a shade guide and photograph if possible.

2nd Step | Access to pulp chamber Access the pulp chamber and clean it completely by removing all of the restorative material.

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3rd Step | Buccal surface measure Measure the buccal surface to define length of the root conduit for deobturation by calculating 3mm above the cervical margin. Once the length is established, prepare a Largo drill.

4th Step | Partial removal of root filling Remove guta-percha according to the previous measurement.

5th Step | Cervical sealing Make a 3mm thick cervical sealing by using a glass ionomer (Maxxion R â&#x20AC;&#x201C; FGM), flowable resin (Opallis Flow â&#x20AC;&#x201C; FGM) or zinc phosphate cement. This maneuver intends to prevent bleaching gel from reaching the periodontium through the root conduit and consists of a critical step, so it must be accomplished perfectly.

Manual of Dental Bleaching FGM

6th Step | Material preparation The preparation of the material varies according to the selected bleaching agent: Whiteness Super-Endo: No preparation required, product is ready to apply Whiteness Perborato: : If a more fluid paste is desired, the appropriate proportion should be 1:1 Note: As an alternative, the liquid phase (Hydrogen Peroxide at 20%) may be replaced by water or saline while mixing, that may lead to a slightly slower action, however the final result remains the same, and besides confers certain benefits such as an even higher pH. If a more dense mix is desired, the proportion should be 2:1 (powder : liquid)

7th Step | Insertion of the bleaching agent in the pulp chamber Apply the product inside the pulp chamber until two thirds of its volume is filled.

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8th Step | Sealing of the cavity In between sessions, seal the cavity provisionally with restorative material following adhesive protocol (Opallis or Opallis Flow – FGM) or with glass ionomer (Maxxion R – FGM). Verify the patient´s tooth contact in protrusion and laterality movements. Premature contact may break the provisional restoration or even the tooth.

9th Step | Reevaluating and finishing the case Evaluate the case after 3 to 4 days, if required repeat applications respecting the time frame of 3 to 4 days. The number of applications may go up to 8 times, according to each case. When concluding the treatment, a one- week break should be respected prior to final restoration.

Before

After

Manual of Dental Bleaching FGM

Whiteness Super-Endo 37% Carbamide Peroxide for non-vital discolored.

Whiteness super endo Whiteness Super Endo is a dental bleaching gel based on (carbamide peroxide 37% for non-vital discolored teeth). The product is ready for use and should be applied according to the walking bleach technique inside the pulp chamber. With proper viscosity, the product is easy to use and provides high wettability, intensively interacting with dentin.

CONVENIENCE • Ready for use, no need for tooling. Product available in gel and syringes ready for use, suitable for procedures. • The syringe comes with tips that allow easy insertion into pulp cavity. • Hydrophilic gel: bleaching gel that is easily removed with water when changing the gel.

VERSATILE • Whiteness Super Endo may be combined with in-office or at-home bleaching for vital teeth.

LASTS LONGER • Since Whiteness Super Endo lasts longer several cases may be performed with one syringe.

EUROPEAN UNION REFERENCE

PRODUCT

CONCENTRATION

Whiteness Super-Endo

37% Carbamide Peroxide

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COSMETIC

MEDICAL

Whiteness Super-Endo 1 syringe with 3g 15 syringes tips of gel Instructions for professional use

Manual of Dental Bleaching FGM

Whiteness Perborato

Sodium perborate and hydrogen peroxide 20% for internal bleaching of discolored non-vital teeth.

Effective and safe Whiteness perborate is a dental bleaching gel based on sodium perborate and hydrogen peroxide 20%. The product should be applied in non-vital discolored teeth, according to the walking bleach protocol inside the pulp chamber. Available in powder and liquid in separate phases, the product provides two different viscosities suitable for each professional demand.

SAFETY • Neutral pH: when mixing the phases (sodium perborate + hydrogen peroxide 20%), the product has a neutral pH, which can be raised by a basic mixture of sodium perborate in distilled water or saline solution, that provides more safety to procedures.

CONVENIENCE • Mixing is easier since the product is available in fine-grained powder. • Walking bleach technique: easily inserted into pulp cavity offering two viscosities according to each case.

VERSATILE • May be mixed in two ratios: 2:1 or 1:1 (powder: liquid). Allows more viscous mixtures which are suitable for bonding less retentive cavities. May be combined with in-office or at-home bleaching for vital teeth.

LASTS LONGER • Since the product lasts longer several cases may be performed with just one kit.

EUROPEAN UNION REFERENCE

PRODUCT

CONCENTRATION

Whiteness Perborato

20% Hydrogen Peroxide

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COSMETIC

MEDICAL

Whiteness Perborato 1 bottle with 10g powder (Sodium Perborate) 1 bottle with 8g liquid (20% Hydrogen Peroxide) 1 powder dosing spoon Instructions for professional

Manual of Dental Bleaching FGM

2.6 Dental Microabrasion Technique Whiteness RM Protocol

The microabrasion technique is effective in superficial staining of enamel. If puzzled by depth of the staining (spots), professional should perform diagnosis through transillumination. Deep spots committing dentin are not removed by microabrasion. The transillumination is not an acknowledged method; however professionals are starting to prescribe it more and more also as a proximal caries diagnoses. It consists of a light emitting device – usually optic fiber – which is placed on the palatal/lingual surface of the stained tooth. When looking through the buccal surface, if the spot presents smoky aspect and contours cannot be easily defined, the lesion is extended to the dentin. Otherwise, if the lesion shows crisp contours and it is clearly visible it might be more superficial, on enamel only – and therefore microabrasion procedure could be adopted. Also read the product user manual for further details.

1st Step | Dental dam isolation It is mandatory to use dental dam isolation to protect soft tissues and prevent swallowing of the product.

2nd Step | Application of the product Apply small amount of the product on the surface to be abraded. Use the spatula that comes with the kit or a rubber cup in a low rotation speed and abrade the product against the spots for 10 seconds.

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3rd Step | Reapplication of the product Wash teeth abundantly with water after applying the paste. In order to analyze whether more product should be applied, the enamel must always be wet. Microabrasion can be repeated for up to 15 times in the same session, according to each case. In case of doubts in regards of the deepness of the spot during the procedure, observe if the shape and size of the spot changes. If not, it is a deeper spot and the technique will not suit such diagnostic. In that case, consider restoring the area.

Manual of Dental Bleaching FGM

4th Step | Fluoride application After rinsing and drying the teeth, apply neutral sodium fluoride (Fluor Care – FGM) for 1 minute.

5th Step | Final polishing of teeth Polish the enamel with felt disk (Diamond Flex – FGM) and polishing paste (Diamond Excel – FGM). 5th Step | Final polishing of teeth

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6th Step | Reevaluating and finishing the case Reevaluate the case to check the outcome of the treatment. It is important to make sure patients are aware of the outcome. Note: if necessary perform dental bleaching to optimize results.

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After

Manual of Dental Bleaching FGM

Whiteness RM 6% Hydrochloric Acid and Silicon Carbide for enamel stain removal

Safety and effectiveness in stain removal Whiteness RM is the evolution in pumice stone use as it comes ready for use as paste that combines the cutting power of abrasive grains with a balanced acid concentration for maximum efficiency. Suitable for removing surface stains on enamel, the product is easy to use and highly effective for conservative treatment.

SAFETY AND EFFECTIVENESS • Conservative technique and yet highly effective for stain removal on enamel without changing the overall dentin structure 37,38. • Removes stains permanently.

CONVENIENCE • Product ready for use. Includes spatula for application on teeth and tips that allow proper control of applications.

COMFORT • Minimally invasive procedure that prevent sensitivity.

VERSATILE • Whiteness RM may be combined with dental bleaching, especially in cases of dental fluorosis.

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Whiteness RM 1 syringe with 2g of Whiteness RM 1 spatula 10 syringes tips Instructions for professional use

Manual of Dental Bleaching FGM

2.7 Combined Dental Bleaching Technique

The dental bleaching success is reached by planning and executing the treatment following the clinical protocol strictly. According to each clinical situation and the patient´s profile, a combined bleaching technique could be selected, which will speed up results and provide long lasting results. Professional supervised home bleaching is known as an efficient bleaching technique and presents lower risk of hypersensitivity; however results are slowly evidenced. Besides that, many patients cannot or do not wish to wear custom trays for 3 weeks or more. On the other hand, in-office bleaching does not demand the use of custom trays, although it requires more chair time and is more costly. Choosing the most suitable bleaching technique requires taking into consideration many factors such as patients´ history, age, teeth shade, discipline, hypersensitivity, expectations towards the length of treatment, and besides that clinical and radiograph exams.

“The combination of techniques provides fast results; it is effective and meets patients´ expectation mainly by showing fast alterations which are highly expected in in-office technique.” Carlos Kose Specialist in Dentistry – ABO/Ponta Grossa/PR/Brazil; MSc in Dentistry – UEPG/PR/Brazil; PhD in Dentistry – UEPG/PR/Brazil; Professor of Specialization and Perfectioning Courses in Dentistry in EAP-ABO/Ponta Grossa/PR/Brazil.

“The in-office bleaching technique, in spite of providing fast results due to high concentrated Peroxides (from 15% to 38%), is limited since it shows less durability of results over the months of therapy. That is proven by literature and especially by the Dr. Didier Diertschi´s article, published on (Quintessence Journal, October 2006) an excellent scientific article that proves the effectiveness of in-office technique mainly in enamel. However in dentin, probably due to the short time the gel contacts teeth, it results in limited dentin bleach. That may be bypassed by combining the use of home bleaching with in-office bleaching, providing a more uniform bleaching involving enamel and dentin.”

Carlos Francci Graduated by the University of Dentistry of São Paulo (FOUSP); MSc, PhD and Professor of Dental Materials by FOUSP; Coordinator of Specialization and Upgrade in Dentistry of EAP/ Central APCD and of ABO/Pouso Alegre/MG/Brazil; Coordinator of GFree (Francci Group of Esthetics Study)

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2.7.1 CLINICAL CASE Combined dental bleaching technique free of hypersensitivity

Case gently provided by Prof. Dr. Américo Mendes Carneiro Junior, MSc and PhD in Dentistry by the University of São Paulo/Brazil; Specialist in Implantology by CIODONTO University; Didactic and Scientific Coordinator of Specialization Courses in Implantology of INGÁ University/Palmas/TO/Brazil; Ministering national and international courses.

The case A patient is considering dental bleaching to be accomplished in one week due to important event that is coming up. As the treatment must be concluded quickly, the best choice was performing in-office bleaching followed by the at-home technique, by using individual tray. The in-office bleaching provides a final result similar to the at-home bleaching, although its long-term result stability tends to be smaller. The home technique with custom tray is accomplished in 2 to 6 weeks, so both techniques allow fast procedures enhancing stability.

1. Initial aspect of the smile.

Manual of Dental Bleaching FGM

2. Prophylaxis

3. Initial shade registration.

4. Placement of lip retractor (ArcFlex-FGM).

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5. Covering of gingival margins with Top Dam FGM.

6. Light curing of Top Dam.

7. Aspect after complete installation of Top Dam.

Manual of Dental Bleaching FGM

The solutions used When combining bleaching technique protocol, Whiteness HP Blue at 35% is selected for in-office procedures since it is easy to use, once it is pre-dosed and application lasts up to 40 minutes without requiring recoating throughout sessions. Also, another benefit is that no light activation is required. After removing the product, I give the bleaching agent for the patient; White Class 7Â˝ % with Calcium, advising to use twice a day for one hour during three days. Still in-office, I load the patientÂ´s custom trays with Desensibilize KF 2% and ask him/her to wear it for 30 minutes. This conduct virtually eliminates eventual discomfort during the procedure, improving comfort to patients and professionals.

8. Application of 35% Whiteness HP Blue coating all buccal surfaces of the teeth.

9. Application of the gel on the 2nd premolar to another in both dental arches.

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10. After 40 minutes, gel is removed with the saliva ejector. 11. Gingival barrier detaches easily with the aid of a clinical probe.

12. Checking shade after session.

13. Application of desensitizing agent while the patient receives instructions on the combined technique.

Manual of Dental Bleaching FGM

14. Using a desensitizing gel.

15. Polishing with felt disk (Diamond Flex) and diamond paste (Diamond Excel) at the end of the treatment.

16. Result after one session in-office and three days of consecutive use of White Class at 7Â˝ %.

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The result After three days of home bleaching, patient shall return to clinic to evaluate the result and have teeth polished with Diamond Excel paste and Diamond Flex felt disk. This procedure increases the luminosity and brightness of the tooth. The entire procedure was very successful and the patient is very pleased.

*Solutions used according to Prof. Dr. AmĂŠrico Mendes Carneiro JuniorÂ´s protocol.

18 e 19. Comparing initial stage to results accomplished after 6 months of the end of the treatment.

Manual of Dental Bleaching FGM

References 1 - FUGARO, J.O.; NORDAHL, I.; FUGARO, O.J.; MATIS, B.A.; MJÖR, I.A. Pulp reaction to vital bleaching. Operative Dentistry, v. 29, n. 4, p. 363-368, 2004. 2 - HAYWOOD, V.B. Frequently asked questions about bleaching. Compendium, v. 24, n. 4A, p. 324-337, abr. 2003. 3 - HAYWOOD, V.B. Nightguard vital bleaching: indications and limitations. US DENTISTRY, p. 2-8, 2006. 4 - COLLINS, L.Z.; MAGGIO, B.; GALLAGHER, A.; YORK, M.; SCHÄFER, F. Safety evaluation of a novel whitening gel, containing 6% hydrogen peroxide and a commercially available whitening gel containing 18% carbamide peroxide in an exaggerated use clinical study. Journal of Dentistry, v. 32, p. 47-50, 2004. 5 - GIANNINI, M.; SILVA, A.P.; CAVALLI, V.; PAES LEME, A.F. Effect of carbamide peroxide-based bleaching agents containing fluoride or calcium on tensile strength of human enamel. J Appl Oral Sci., v. 14, n. 2, p. 82-87, 2006. 6 - HIRATA, R. et al. Tips: dicas em odontologia estética. São Paulo: Artes Médicas, 2011. 576p. (1) 7 - NOCCHI, E. et al. Restaurações estéticas: compósitos, cerâmicas e implantes. Porto Alegre: Artmed, 2005. 308p. (3) 8 - VASCONCELOS, B.C.E.; GUSMÃO, E.S.; VIEIRA, L.T. et al. Odontologia clínica: 18º congresso pernambucano de odontologia. Recife: EDUPE, 2006. 294p. (2) 9 - MARSON, F.C.; SENSI, L.G.; ARAUJO, F.O.; MONTEIRO JUNIOR, S.; ARAÚJO, E. Avaliação clínica do clareamento dental pela técnica caseira. R Dental Press Estét, v. 2, n. 4, p. 84-90, out./nov./dez. 2005. 10 - BAIK, J.W.; RUEGGEBERG, F.A.; LIEWEHR, F.R. Effect of light-enchanced bleaching on in vitro surface and intrapulpal temperature rise. J Esthet Rest Dent, v. 13, p. 370-378, 2001. 11 - BUCHALLA, W.; ATTIN, T. External bleaching therapy with activation by heat, light or laser – a systematic review. Dent Mater., v. 23, p. 586-596, 2007. 12 - BUCHALLA, W.; ATTIN, T. External bleaching therapy with activation by heat, light or laser - a systematic review. Dent Mater., v. 23, n. 5, p. 586-596, mai. 2007 13 - GOMES, R.S.; SOUZA, F.B.; LACERDA, C.M.; BRAMBILLA, C.F.F.; PASCOTTO, R.C. Avaliação clínica da eficiência do uso do sistema LED-laser, LED e luz halógena na ativação do agente clareador em dentes vitalizados. R Dental Press Estét, v.5, n. 2, p. 72-77, abr./mai./ jun. 2008. 14 - GURGAN, S.; CAKIR, F.Y.; YAZICI, E. Different light-activated in-office bleaching systems: a clinical evaluation. Lasers Med Sci, v. 25, p. 817-822, 2010. 15 - HEIN, D. K.; PLOEGER, B. J.; HARTUP, J. K.; WAGSTAFF, R. S.; PALMER, T. M.; HANSEN, L. D. In-office vital tooth bleaching-what do lights add? Compend. Contin. educ. Dent., Jamesburg, v. 24, n. 4A, p. 340-52, abr. 2003. 16 - KUGEL, G.; PAPATHANASIOU, A.; WILLIAMS, A.J. 3rd, ANDERSON, C.; FERREIRA, S. Clinical evaluation of chemical and lightactivated tooth whitening systems. Compend Contin Educ Dent, v. 27, p. 54-62, 2006. 17 - LIEBENBERG, W. Another white lie? J. esthet. Restor. Dent., v. 18, n. 3, p. 155-160, 2006. 18 - LUK, K.; TAM, L.; HUBERT, M. Effect of light energy on peroxide tooth bleaching. JADA, v. 135, p. 194-201, fev. 2004. 19 - MARON, F.C.; SENSI, L.G. Clareação de dentes vitalizados através da técnica de consultório e a necessidade da utilização de fontes de luz. R Dental Press Estét, v. 4, n. 3, p. 41-53, jul./ago./set. 2007. 20 - MARSON, F. C. Avaliação clínica do efeito de diferentes unidades de ativação sobre o clareamento dental. 2006. 132f. Tese (Doutorado na área de concentração Dentística) – Programa de Pós-graduação em Odontologia, Universidade Federal de Santa Catarina, Florianópolis. 21 - MARSON, F. C.; SENSI, L. G.; ARAÚJO, F. O.; ANDRADA, M. A. C.; ARAÚJO, E. Na era do clareamento dentário a laser ainda existe espaço para o clareamento caseiro? R Dental Press Estét, v. 3, n. 1, p. 135-144, jan./fev./mar. 2006.

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22 - MARSON, F.C.; SENSI, L.G.; VIEIRA, L.C.C.; ARAÚJO, E. Avaliação clínica do clareamento dental pela técnica no consultório. R Dental Press Estét, v. 4, n. 4, p. 50-60, out./nov./dez. 2007. 23 - PAPATHANASIOU, A.; KASTALI, S.; PERRY, R. D.; KUGEL, G. Clinical evaluation of a 35% hydrogen peroxide in-office whitening system. Compend. Contin. educ. Dent., v. 23, n. 4, p. 335-338, abr. 2002. 24 - RIEHL, H.; NUNES, E. As fontes de energia luminosa são necessárias na terapia de clareamento dental?. Jubileu de Ouro www. ciosp.com.br/anais/Capitulos/Cap07 _alta Janeiro 2007. 25 - ZEKONIS, R.; MATIS, B. A.; COCHRAN, M. A.; AL SHETRI, S. E.; ECKERT, G. J.; CARLSON, T. J. Clinical evaluation of in-office and at-home bleaching treatments. Oper. Dent., Seattle, v. 28, n. 2, p. 114 -121, mar./abr. 2003. 26 - TAY, L.Y.; KOSE, C.; LOGUERCIO, A.D.; REIS, A. Assessing the effect of a desensitizing agent used before in-office tooth bleaching. J Am Dent Assoc., v. 140, n. 10, p. 1245-1251, 2009. (4) 27 - At-home Bleaching: Color Alteration and H2O2 Penetration, L.C.A.G. DE ALMEIDA, A.L.F. BRISO, M.O. GALLINARI, F.A. DE AZEVEDO, P.H. DOS SANTOS, and C.A.D.S. COSTA, J Dent Res 91 (Spec Iss B): 407, 2012 (www.dentalresearch.org). 28 - Effect of Home Bleaching Agents on Microhardness of Composite Resins, L.M. RUIZ, G.M. GOMES, M.R. AZEVEDO, G.C. MARTINS, O.M.M. GOMES, J.C. GOMES, and A.L. CALIXTO, J Dent Res 90 (Spec Iss A ): 2021, 2011 (www.dentalresearch.org). 29 - in - Office Bleaching: Effect of Preliminary Use of a Desensitizing Agent, E.A. PAULA, G.C. MARTINS, S.K. PEREIRA, O.M. GOMES, A. LOGERCIO, and A. REIS, J Dent Res 90(Spec Iss A): 559,2011 (www.deantalresearch.org) 30 - TAY, Lidia Yileag et al. Assessing the effect of a desensitizing agent used before in-office tooth bleaching. The journal of the American Dental Associatin, v. 140, n. 10, p. 1245-1251, 2009. 31 - D’ARCE, M. B. et al. Evaluation of ultrasound and light sources as bleaching catalysts-an in vitro study. The European journal of esthetic dentistry: official journal of the European Academy of Esthetic Dentistry, v. 7, n. 2, p. 176, 2012. 32 - KOSSATZ, S. et al. Effect of light activation on tooth sensitivity after in-office bleaching. Operative Dentistry, v. 36, n. 3, p. 251-257, 2011. 33 - Tooth sensitivity and bleaching effectiveness of calcium-containing in-office bleaching gel, S.K. PEREIRA, G.C. MARTINS, L.Y. TAY, A.D. LOGUERCIO, and A. REIS, J Dent Res 90(Spec Iss A): 2543, 2011 (www.dentalresearch.org). 34 - Variation Of pH Bleaching Gels And Roughness On Bovine Enamel, A.C. TRENTINO, R.F.L. MONDELLI, L.M. AZEVEDO, L. WANG, S.K. ISHIKIRIAMA, and M.T. ATTA, J Dent Res 90(Spec Iss A): 2038, 2011 (www.dentalresearch.org). 35 - Effect of Hydrogen Peroxide Concentration on Bleaching, G. NASCIMENTO, A.R. FRAZÃO, C.M. SILVA, D.M. GUIMARÃES, L.M. RODRIGUES, and E.B. ALVES, J Dent Res 89(Spec Iss A): 834, 2010 (www.dentalresearch.org). 36 - In-office Bleaching with a 2-day Interval Between Sessions: Tooth Sensitivity, E.A. DE PAULA, C. ROSSO, N. JÉSSICA, S. KOSSATZ, A.D. LOGUERCIO, and A. REIS, J Dent Res 92(Spec Iss A): 3114, 2013 (www.dentalresearch.org). 37- RODRIGUES, Marcela Charantola et al. Minimal alterations on the enamel surface by micro-abrasion: in vitro roughness and wear assessments. Journal of Applied Oral Science, v. 21, n. 2, p. 112-117, 2013. 38 - Evaluation of Enamel After Microabrasion, Polishing and Storage in Saliva, L.S.M. FRAGOSO, D.A.N.L. LIMA, R.S. DE ALEXANDRE, G.M.B. AMBROSANO, F.H.B. AGUIAR, and J.R. LOVADINO, J Dent Res 91(Spec Iss B): 1061, 2012 (www.dentalresearch.org). 39 - POZZOBON, R.T.; DINELLI, W., CANDIDO, M.S.M. Avaliação do pH de diferentes agentes clareadores dentais. Revista Dentística on line, v. 3, n. 7, jan./fev./mar./abr./mai./jun. 2003. 40 - ALVES, E.A.; ALVES, F.K.A.; CAMPOS, E.J.; MATHIAS, P. Susceptibility to carieslike lesions after dental bleaching with different techniques. Quintessence International, v. 38, n. 7, p. 404-409, jul./ago. 2007. 41 - BARATIERI, L.N.; et al. Dentística restauradora: fundamentos e possibilidades. São Paulo: Ed Santos, 2001, cap. 17, p. 675-722. 42 - COLLINS, L.Z.; MAGGIO, B.; LIEBMAN, J.; BLANCK, M.; LEFORT, S.; WATERFIELD, P.; LITTLEWOOD, D.; NAEENI, M.; SCHÄFER, F. Clinical evaluation of a novel whitening gel, containing 6% hydrogen peroxide and a standard fluoride toothpaste. Journal of Dentistry, v. 32, p. 13-17, 2004. 43 - DIETSCHI, D.; ROSSIER, S.; KREJCI, I. In vitro colorimetric evaluation of the efficacy of various bleaching methods and products. Quintessence International, v. 37, n. 7, p. 515-526, jul./ago. 2006. 44 - HAYWOOD, V.B.; HOUCK, V.M.; HEYMANN, H.O. Nightguard vital bleaching: effects of various solutions on enamel surface texture and color. Quintessence Int, v. 22, n. 10, p. 775-782, out. 1991. 45 - JOINER, A. The bleaching of teeth: a review of the literature. Journal of Dentistry, v. 34, p. 412-419, 2006. 46 - LEE, K.H.; KIM, H.I.; KIM, K.H.; KWON, Y.H. Mineral loss from bovine enamel by a 30% hydrogen peroxide solution. Journal of Oral Reahabilitation, v. 33, p. 229-233, 2006. 47 - LOPES, G.C.; et al. Effect of bleaching agents on the hardness and morphology of enamel. J Esthet Restor Dent, v. 13, n. 6, p. 132139, nov./dez. 2001. 48 - MATIS, B.A.; HAMDAN, Y.S.; COCHRAN, M.A.; ECKERT, G.J. A clinical evaluation of a bleaching agent used with and without reservoirs. Operative Dentistry, v. 27, p. 5-11, 2002.

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49 - MATIS, B.A.; MOUSA, H.N.; COCHRAN, M.A.; ECKERT, G.J. Clinical evaluation of bleaching agents of different concentrations. Quintessence Int, v. 31, n. 5, p. 303-310, mai. 2000. 50 - RODRIGUES, J.A.; OLIVEIRA, G.P.F.; AMARAL, C.M. Avaliação “in vitro” da efetividade de diferentes sistemas clareadores caseiros. Arquivos em Odontologia, v. 41, n. 1, p. 001-104, jan./mar. 2005. 51 - SULIEMAN, M. An overview of bleaching techniques: history, chemistry, safety and legal aspects. Dental Update, v. 31, p. 608-616, 2004. 52 - WOOLVERTON, C.J.; HAYWOOD, V.B.; HEYMANN, H. A toxicologic screen of two carbamide peroxide tooth whiteners. J Dent Res, v. 70, 1991. 53 - At-home Bleaching: Color Alteration and H2O2 Penetration, L.C.A.G. DE ALMEIDA, A.L.F. BRISO, M.O. GALLINARI, F.A. DE AZEVEDO, P.H. DOS SANTOS, and C.A.D.S. COSTA, J Dent Res 91 (Spec Iss B): 407, 2012 (www.dentalresearch.org). 54 - Effect of Home Bleaching Agents on Microhardness of Composite Resins, L.M. RUIZ, G.M. GOMES, M.R. AZEVEDO, G.C. MARTINS, O.M.M. GOMES, J.C. GOMES, and A.L. CALIXTO, J Dent Res 90 (Spec Iss A ): 2021, 2011 (www.dentalresearch.org). 55 - Colorimetric Analysis of the Influence of Calcium in Tooth Bleaching, A.F.S. CRUZ, M. SOBRAL, L.D. ALEXANDRINO, Y. GOMES, C.M. SILVA, and E.B. ALVES, J Dent Res 91(Spec Iss B): 420, 2012 (www.dentalresearch.org). 56 - Effectiveness of Calcium-containing Bleaching Gels and Hydrogen Peroxide Enamel/dentin Diffusion, D.G.S. SOARES, F.S. VARGAS, A.P. RIBEIRO, E.C.V. PONTES, J. HEBLING, and C.A. DE SOUZA COSTA, J Dent Res 91(Spec Iss B): 410, 2012 (www.dentalresearch. org). 57 - Effect of Bleaching on Staining Susceptibility of a Composite Resin, O.M.M. GOMES, R. ALEIXO, B.F. BITTENCOURT, R. FICINSKI, G.C. MARTINS, G.M. GOMES, and P.A. FARHAT, J Dent Res 92 (Spec Iss A): 1140, 2013 (www.dentalresearch.org). 58 - D’AMARIO, M. et al. Effect of hydrogen peroxide topical applications on enamel and composite resin surfaces. Dental Materials, v. 26, p. e24-e25, 2010.

The bleaching guide was developed aiming to instruct professionals on performing dental bleaching. The manufacturer is not to be held account for any damage that may occur to patients who undergo treatment in disagreement to the content herein published. The company strongly recommends reading the instructions of each product prior to executing the protocol in patients. The content of this guide is of exclusive and particular use of FGM Dental Products, and therefore no copies or reproductions are allowed without previous authorization.