Application of the Remineralizing Therapy During At-Home Vital Teeth Whitening
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Application of the Remineralizing Therapy During At-Home
Vital Teeth Whitening
Zheleznyy P.A., M.D., professor
Bazin А.К., Candidate of Medical Science, associate professor
Zheleznaya Y.K., Candidate of Medical Science, associate professor
Rusakova E.Y., Candidate of Medical Science, associate professor
Zheleznaya А.P., Perminov А.S., Shashkova О.V.
Childhood dentistry department of the Novosibirsk state medical university, Regional dentists’ association of
Novosibirsk
Matelo S.K. Group of Companies DRC, Moscow
INTRODUCTION
In the course of the last decade one can observe an increase in the aesthetic requirements
of patients caused by various reasons including the impact of foreign mass media promoting
natural beauty of healthy teeth [1, 2].
The idea of tooth whitening attracts many patients. When they come to a dentist’s room
for medical advice regarding this procedure, in most cases they question about safety. [3, 8, 16].
Quite often dentists do not possess information that could be considered sufficiently objective
because Russia as well as other countries of the whole globe feel the deficiency of scientific data
about influence of the bleaching systems upon human teeth.
In the year of 2006 H. Hasson and his co-auth. published an analytical survey of clinical
investigations of the dental bleaching procedure carried out at the home place.
Having analyzed 416 articles devoted to teeth whitening, it was found out that just 25
works included data, which could be analyzed by using statistical methods. The inclusion criteria
had been met only in these 25 cases as well. All analyzed works included information about the
dental whitening results, which were received immediately after this procedure completion,
while data obtained 1-2 weeks later after the investigation of the medical course had been
finished, were given just in 13 papers. The follow-up results (1 month later and more) of the
investigation were registered just in 6 works. It is significant that all the researches had been
sponsored by the dental bleaching system manufacturers. The authors of the analytical survey
drew a conclusion that information about the influence of whitening methods upon the oral
cavity organs was fragmentary and chaotic and there was a strong necessity to conduct
independent clinical researches that would include the assessment of the stability of the aesthetic
treatment results and long-term consequences [14].
Enamel hyperesthesia (14—78% of the cases) and irritation of soft tissues (that is why it
is recommended to thoroughly isolate gums from contact with the peroxide gel) are the most
wide-spread side effects [24]. Tooth hyperesthesia can be a result of the demineralization of the
dental hard tissues. The demineralization effect can be caused not only by peroxidates but also
by the components of the base. This point of view can be confirmed by information provided by
Jorgensen M.G., Carroll W.B. According to their data almost 30% of the patients, who were
using the placebo gel, noticed light forms of hyperesthesia after 3 weeks of use [15]. It is well-
known that in the majority of cases of at-home teeth whitening the increased dental sensitivity is
caused by the carbopol polymer based whitening systems, which are more viscous in contrast to
preparations that are less viscous [23]. There are evidences proving that protracted applications
of carbopol can also result in the enamel demineralization [20]. The data proving the facts of
demineralization of tooth hard tissues during the whitening procedure are not of rare occurrence
nowadays [9, 12, 17, 22, 11, 13]. As the methods of investigations are being constantly improved
they helped obtain evidences regarding morphological changes in the surface layer of the
enamel. For instance, enamel porosity starts developing, which is a result of the disappearance of
the aprismatic mineral layer [17, 25]. Using the method of microtomography, the registered
depth of the enamel demineralization area is equal to 50 micrometers [12]. Moreover, in recent
years a whole array of works has been published that describe changes in the mechanical
qualities of the demineralized tissues. As a result of dental whitening procedure , in such
demineralized tissues one can observe a significant decrease in their microhardness [9, 17, 20],
in the strength (Young’s Modulus) of the nontubular dentin and enamel [9], values of the filling
material adhesion [21] and in other indicators that characterize the biomechanical status of teeth.
We are uncertain about the viewpoint, according to which there is no increased risk of the
development/progression of erosions and dental caries [19, 7], especially if to take into
consideration the fact that authors make their conclusions upon the basis of in vitro
investigations. Virtually no literature work contains information that would describe the
dynamics of biochemical characteristics of saliva during the teeth bleaching procedure [3, 5, 18].
In spite of the high prevalence of this method, up till now many Russian specialists still
regard dental bleaching as a procedure that damages teeth rather significantly. Analogous fears
are expressed by western specialists referring to cases from their clinical practice [10, 12]. On
the other hand, the question of follow-up results of such exposure has not been studied properly
yet. The problem of the increased risk of the formation of caries and other pathologies of tooth
hard tissues still remains unclear and requires more accurate information [14].
MATERIALS AND METHODS
Among the patients complaining about the change in their teeth colour 78 people aged
from 25 to 35 years old with indications for at-home whitening of vital teeth located in front
sections of the lower and upper jaws were selected.
Prior to the whitening procedure all the patients had a satisfactory hygienic state of their
oral cavities (OHI-S did not exceed 1,6), a healthy periodontium or a light degree of
inflammation of the gingival margin. The dental caries intensity was assessed using the DMF
index (decayed, missing, filled teeth). All patients had an average level of dental caries intensity.
Oral cavity sanation and professional hygienic treatment were fulfilled prior to the teeth
bleaching procedure. Personal hygienic care, diet and habits were corrected before dental
whitening as well. All patients gave their written consent for their teeth to be bleached. Before
the whitening procedure the initial tooth colour was determined in all the patients by using the
standard Vita scale (table 1).
Table 1. METHOD OF TOOTH COLOUR CHANGES ASSESSMENT WITH VITA SCALE
ORDER OF SHADES FROM LIGHT TO DARK
Shade on the scale B1 A1 C1 B2 A2 D2 A3 D3 B3 D4 C2 C3 B4 C4 A3.5 A4
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Assigned number
Patients were divided into 3 equivalent groups. Treatment was carried out in conformity
with the schemes given in table 2.
Table 2. IMPLEMENTATED SCHEMES OF DENTAL BLEACHING
Group Correction of Professional Whitening Remineralizing therapy
hygienic hygienic
habits treatment
and sanation
1 (28 yes yes At home during 1 No
people) month. Applications:
once a day for 20 min.
2 (27 yes yes At home during 1 At home, after the whitening procedures,
people) month. Applications: once a day for 20 min.
once a day for 20 min.
3 (23 yes yes At home during 1 In ambulatory conditions. Every other day.
people) month. Applications: Applications of 5% calcium
once a day for 20 min. glycerophosphate solution for 10 minutes. 3
minutes’ oral rinsing with 0,2 % NaF
solution.
Tooth whitening was carried out by at-home method using an individual mouth-piece
together with commercial samples of the gel containing 10% of carbamide peroxide. The dental
bleaching course lasted for one month. Applications of peroxide gel were made daily, one time a
day for 20 minutes. Remineralizing therapy was carried out using two schemes. In group 2 a
commercial composition, “R.O.C.S. Medical Minerals” gel was used. The patients were given
this remineralizing gel to be used at home as 20 minutes’ applications immediately after the
whitening gel has been used. Patients from group 3 followed a standard methodology of the
remineralizing therapy, which implied the use of the 5% calcium glycerophosphate solution
applications in the course of 10 minutes and oral rinsing (mouth bath) with 0,2% sodium
fluoride solution in the course of 3 minutes. The remineralizing procedures were started one day
later after the whitening course had begun and were carried out every other day in the course of
one month (all in all, 14 remineralizing procedures were made).
Hyperesthesia prevalence in the groups of patients was determined in the percent
correlation and its presence or absence was taken as a basis. Classification by Fedorov Yu.A. [6]
was used for diagnosing the hyperesthesia of the tooth hard tissues. According to this
classification in case of the first degree of severity the teeth react to temperature irritants (cold,
hot); in case of the second degree of severity they react to chemical irritants (sweet, sour) while
in case of the third degree they react to all irritant types (temperature, chemical and tactile).
Then, the following characteristics were under control in the course of one year:
1. Tooth colour
2. Hyperesthesia presence
3. Dental caries intensity according to DMF index (decayed, missing, filled teeth)
4. Calcium content in the oral cavity fluid
The received results of the clinical investigations underwent the statistical treatment with
the determination of the average arithmetical value (М), the average quadratic deviation (у), the
average quadratic mistake (m) and the validation criterion (t). Taking this criterion as a basis the
reliability of the studied characteristic (P) was determined using the Student’s table. The
differences were considered to be trustworthy in case of pRESULTS AND DISCUSSION
Efficacy of the aesthetic treatment
The scheme of the peroxide gel use was in conformance with the manufacturer’s
recommendations and made it possible to improve the tooth colour. On the average, the tooth
colour improvement equaled 2,09 points of Vita scale. Better results were registered in the
groups, in which at-home bleaching methods and remineralizing therapy were combined. The
results in group 2 and group 3 amounted to 3,45 and 3,41 points, respectively. In average, the
combination of methods of dental whitening with the peroxide gel and remineralizing therapy
with calcium and phosphorus salts ensured 65% rise in the aesthetical treatment effectiveness
(pic. 1).
Unstable achieved results are one of the most serious problems arising after the
aesthetical treatment by using the dental whitening method. Continuance of the aesthetical
results is dependent upon the hygienic regime, dietary preferences and harmful habits. In our
investigation the monitoring of the groups was fulfilled in the course of one year and this
characteristic was assessed three months and one year later after the dental bleaching course had
been finished. In group 1 the average values of the tooth colour became worse after 3 months
(the average value was equal to 7,21±0,35) and one year later they virtually returned to the initial
state (prior to the whitening course) with the average value of 8,07±0,41. In groups 2 and 3,
where the patients were using whitening methods together with the remineralizing therapy, valid
changes in tooth colour were not registered during the whole year. The result achieved duringthe course of the aesthetic treatment was successfully maintained during the whole period of
observation.
Increased tooth sensibility
In some patients tooth sensibility appears after the first whitening procedure and it is
worth mentioning that it does not appear immediately after the procedure completion but only a
day later. In our investigation the increased tooth sensibility appearing one day later after the
very first whitening manipulation was registered just in group 1. The maximum number of the
patients take notice of the dental hyperesthesia at the end of the first week of the at-home dental
bleaching procedure. In group 1 we observed the increase in the number of cases of tooth
sensibility: after a day the dental hyperesthesia was registered in 32% of the patients while one
week later it was found in 61% of them. One month later after the whitening course completion
the hyperesthesia prevalence in group 1 dropped to the level of 36%, which is 3,3 times higher
prior to whitening (pic. 2).
In groups 2 and 3 the number of cases of the increased tooth sensibility dropped during
whitening treatment and the hyperesthesia prevalence was below the initial level during the
whole period of observation.
Dental caries
All the patient undergoing the dental bleaching procedure had either a high or average
degree of the enamel resistance to the carious process (the average DMF value amounted to
12,35 in the groups under investigation. No demineralization foci were found).While assessing the degree of the dental
caries intensity in patients from group 1, this
index value rose and amounted to 14,26 ±0,03,
which corresponded to the high degree of the
caries intensity. In patients from group 2 DMF
index was equal to 12,47±0,07 one year later.
In patients from group 3 the average value of
DMF index equaled to 12,67±0,07 after one
year. It means that group 1 had the maximum
annual increment of the dental caries intensity,
which amounted to 1,91 and was authentically
higher in contrast to groups 2 and 3 (pic.3).
The minimum rate of dental caries
increase was registered in group 2, where the
remineralizing therapy was implied through the
use of “R.O.C.S. Medical Minerals” gel.
Calcium content in saliva
Despite the fact that the analysis of the calcium content in the oral cavity fluid did not
detect any reliable differences in the groups of patients during the whole investigation period,
this question is of indisputable interest (pic. 4).From our view point, this phenomenon can be explained in such a way: in groups 2 and 3
the calcium content was replenished at the cost of remineralizing preparations while in group 1 it
was “washed out” from the dental enamel, which was clinically proved by the high increment of
the DMF index together with high level of dental hyperesthesia occurrence in this group. In the
current clinical investigation they used calcium glycerophosphate as a source of calcium and
phosphorus for tooth remineralization. It is common knowledge that the dental remineralization
process is supported by enzymes. To be precise, the inclusion of phosphates and calcium into the
dental enamel gets significantly activated under the influence of phosphatases. Calcium
glycerophosphate is a substrate for the alkaline and acid phosphatases. As a result of hydrolysis
of calcium glycerophosphate as well as enzyme impact ions of calcium and phosphate are
released. The energy, which is also released during hydrolysis, is believed to be used for ion
transference into the dental enamel. Investigations with the use of immobilized alkaline
phosphatase conducted at the Central research institute of dentistry demonstrated that in
comparison with other calcium-phosphate substrates it is glycerophosphate that contributes to the
ultimate success of the dental remineralization [4].
Application of R.O.C.S. Medical Minerals gel for tooth remineralization is more
comfortable both for a dentist and a patient as the gel is a finished form suitable for home and
ambulatory conditions. The classical scheme of remineralizing therapy, which received its
implementation in group 3, requires attending the dentist’s room at a regular basis, which is not
convenient for many modern patients. The absence of age and ecological limits that could
influence upon the regular and prolonged use of this gel can be undoubtedly regarded as an
important advantage of the product.CONCLUSIONS
The analysis of the results obtained during the current clinical investigation demonstrates
that while conducting the at-home dental bleaching manipulations it is reasonable to supplement
the aesthetic treatment algorithm with renewing procedures, where the enamel and dentine
remineralization with a help of calcium and phosphate, basic elements of hydroxyapatite, is the
most essential one. The combination of dental bleaching methods and the remineralizing therapy
ensured the following:
Improvement of results of the at-home tooth whitening by 65% on average with these results
remaining unchanged for not less than a year.
Elimination of the risk of dental hyperesthesia appearance, which is the most widespread
complication after tooth bleaching.
83% drop in the risk of dental caries development. The use of R.O.C.S. Medical Minerals
gel as a remedy for the remineralizing therapy decreases the caries risk by 93%.You can also read
