available at www.jstage.jst.go.

jp/browse/islsm ORIGINAL ARTICLES

The efficacy of laser-assisted in-office bleaching and

home bleaching on sound and demineralized enamel

Farzaneh Ahrari 1, Majid Akbari 2, Sakineh Mohammadpour 3, Maryam Forghani 4

1: Dental Research Center, Department of Orthodontics, School of Dentistry,

Mashhad University of Medical Sciences, Mashhad, Iran
2: Dental Research Center, Department of Operative dentistry, School of Dentistry,
Mashhad University of Medical Sciences, Mashhad, Iran
3: Postgraduate Dental Student, Department of Periodontics, School of Dentistry,
Babol University of Medical Sciences, Babol, Iran
4: Dental Materials Research Center, Department of Endodontics, School of Dentistry,
Mashhad University of Medical Sciences, Mashhad, Iran

Aims: This study investigated the effectiveness of laser-assisted in-office bleaching and home-
bleaching in sound and demineralized enamel.
Materials and Methods: The sample consisted of 120 freshly-extracted bovine incisors. Half of the
specimens were stored in a demineralizing solution to induce white spot lesions. Following expo-
sure to a tea solution for 7.5 days, the specimens were randomly assigned to 4 groups of 30
according to the type of enamel and the bleaching procedure employed. Groups 1 and 2 consisted
of demineralized teeth subjected to in–office bleaching and home bleaching, whereas in groups 3
and 4, sound teeth were subjected to in-office and home bleaching, respectively. A diode laser
(810 nm, 2 W, continuous wave, four times for 15 seconds each) was employed for assisting the
in-office process. The color of the specimens was measured before (T1) and after (T2) staining and
during (T3) and after (T4) the bleaching procedures using a spectrophotometer. The color change
(DE) between different treatments stages was compared among the groups.
Results: There were significant differences in the color change between T2 and T3 (DE T2-T3) and
T2 and T4 (DE T2-T4) stages among the study groups (p<0.05). Pairwise comparison by Duncan
test revealed that both DET2-T3 and DET2-T4 were significantly greater in demineralized teeth sub-
mitted to laser-assisted in-office bleaching (group 1) as compared to the other groups (P< 0.05).
Conclusion: Laser-assisted in-office bleaching could provide faster and greater whitening effect
than home bleaching on stained demineralized enamel, but both procedures produced comparable
results on sound teeth.

Key words: In office bleaching • home bleaching • demineralized enamel • white spot lesion •

laser-spectrophotometry • Diode • Tooth color

Introduction such as those undergoing fixed orthodontic therapy. 1)

These spots are the first clinical signs of demineraliza-
Demineralization areas called “white spots” are fre- tion and are characterized by their opacity compared
quently observed in subjects with high risk of caries to healthy enamel. 2) The milky color of white spots
may impair the appearance of the teeth and make the
Addressee for Correspondence: patients unsatisfied with the results of esthetic dental
First Corresponding Author: treatments. 3) Different approaches have been used for
Maryam Forghani
Dental Materials Research Center, School of Dentistry, managing white spot lesions including the application
Mashhad University of Medical Sciences, Vakilabad of products containing fluoride or casein phosphopep-
Boulevard, Mashhad, Iran
Phone: +98-513-8829501 Fax: 05138829500 tide-amorphous calcium phosphate (CPP-ACP),
E-mail: forghaniradm@mums.ac.ir microabrasion, bleaching and restorative treatments.
forghanirad_m@yahoo.com 4,5) Bleaching has been employed as a minimally inva-
Second Corresponding Author:
Farzaneh Ahrari Received date: April 9h, 2015
E-mail: Ahrarif@mums.ac.ir Accepted date: August 18th, 2015
©2015 JMLL, Tokyo, Japan Laser Therapy 24.4: 257-264 257
 ORIGINAL ARTICLES available at www.jstage.jst.go.jp/browse/islsm

sive technique to mask the lesions by achieving a more bleaching and home-bleaching in sound and deminer-
uniform appearance throughout the dentition. It has alized enamel.
been demonstrated that white spots match better with
the remaining tooth structure following the bleaching Materials and Methods
procedures. 5-8) Knosel et al. 8) found that bleaching
could satisfactorily camouflage white spot lesions The sample consisted of 120 freshly-extracted bovine
observable following fixed orthodontic therapy. The incisors without visible caries or structural defects on
bleaching treatment may have additional advantages in the enamel surface. The teeth were immersed in a
orthodontically treated subjects as they are usually 0.1% thymol solution for 1 week at room temperature,
affected with various degrees of discoloration in followed by storage in distilled water until the time of
healthy and demineralized parts of the dentition. the experiment. The teeth were cleaned with pumice
There are two main methods of professional den- slurry and brush. Then, half of the specimens were
tal bleaching; home applied and in-office procedures. individually immersed in 5 ml of a demineralizing solu-
Home bleaching involves the application of bleaching tion for 12 weeks to create artificial caries. The dem-
agents that liberate low levels of hydrogen peroxide ineralizing solution consisted of 2.2 mM CaCl2, 2.2 mM
(HP) over a long period of time. In contrast, in-office NaH2Po4 and 50 mM acetic acid, with pH adjusted at
bleaching employs much higher levels of HP (up to 4.8 using potassium hydroxide (KOH). 17) This solution
55%) for short durations. 9) The use of home-bleaching was refreshed weekly. The sample was then randomly
is associated with several advantages such as less HP divided into 4 groups of 30 according to the type of
concentration, lower cost and taking less time in the enamel and the bleaching procedure employed as fol-
dental office, 10, 11) but in this procedure, there is lack lows.
of control on the use of bleaching agents and trays by
the patients. The main advantages of in-office bleach- Group 1 consisted of demineralized teeth subjected to
ing include dental practitioner control on the bleaching in–office procedure.
process, prevention of soft-tissue exposure or material Group 2 consisted of demineralized teeth underwent
ingestion, reduced treatment time and immediate home bleaching.
results that enhance patient’s satisfaction with dental Group 3 consisted of sound teeth subjected to in–office
treatment. 12) procedure.
The in-office procedures could be accelerated by Group 4 consisted of sound teeth underwent home
the application of light or heat to activate the bleaching bleaching.
agent. Several types of activation devices are available
to be used in combination with bleaching materials
Color change measurement
such as halogen curing lamps, plasma arc lamps, light-
emitting diodes (LEDs) and lasers. Laser radiation Before bleaching, all the specimens were artificially
assists the release of free radicals in the bleaching stained using a tea solution. The tea solution was pre-
agents, leading to a faster whitening process. pared by boiling 2 g of tea in 100 ml of distilled water
Furthermore, it has been demonstrated that laser irradi- for 5 min followed by filtering through gauze to
ation could minimize hypersensitivity of the teeth dur- remove the tea from the infusion. 18) Each tooth was
ing the bleaching process. 13, 14) One important con- immersed in 10 ml of this solution for 7.5 days and
cern about using the peroxide-based formulations is then rinsed thoroughly under tap water.
alteration in surface micromorphology and reduction in A spectrophotometer (Easyshade; Vita Zahnfabrik,
microhardness and calcium content of enamel. 14, 15) It Bad Säckingen, Germany) was used to measure the
has been claimed that diode laser activation of HP dur- color of the specimens according to the CIELAB
ing the bleaching process not only increases the (Commission International de l’Eclairage L*a* and b*)
whitening effect but also protects the change in enam- color space system. In this system, the L axis indicates
el structure compared to that occurs with gel treatment the value or degree of lightness (ranges from 0: black
alone. 16) to 100: white), whereas the a plane represents the
There are a few studies regarding comparison of degree of red/green (+a: red, -a: green) and the b
the two professional bleaching techniques on manag- plane corresponds with the degree of yellow/blue (+
ing discolored white spot lesions. The present study b: yellow, - b: blue) within the sample. The color of
aimed to evaluate, through the spectrophotometric the teeth was assessed before (T1, baseline examina-
analysis, the effectiveness of laser-assisted in-office tion) and after (T2) the staining procedure. The middle

258 F Ahrari et al
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part of the tooth was considered for color measure- The artificial saliva was replaced daily. The specimens
ment. were subjected to color assessment on day 1 following
the second (T3) and third (T4) in-office bleaching ses-
The Laser-assisted in-office bleaching process
sions.
The in-office bleaching consisted of the application of
The home bleaching procedure
a 40% hydrogen peroxide gel (Opalescence Xtra Boost;
Ultradent Products Inc., South Jordan, UT, USA) fol- To make custom trays for the home bleaching proce-
lowed by laser irradiation for further activation of the dure, every 6-8 teeth were mounted in plaster so that
bleaching agent. The gel was prepared according to an ovoid arch was formed, resembling upper dentition
the manufacturer’s instructions and was applied at a (Fig 1). The undercuts were filled out by pink wax
thickness of 1-2 mm on the buccal enamel surface. The (Fig 1). The arch was then covered by a layer of pink
apparatus employed was a gallium-aluminum-arsenide wax to allow making a special tray. An alginate
(GaAlAs) diode laser with a wavelength of 810 nm impression was then taken and a bleaching tray was
(ARC Laser GmbH, Nuremberg, Germany). The laser made for each dentition.
was held manually at an approximate distance of 1 A 15% carbamide peroxide gel (Opalescence
mm from the gel and perpendicular to the enamel sur- 15%; Ultradent Products Inc.,South Jordan, UT, USA)
face, and the irradiation was performed at power of 2 was used for home bleaching. The gel was applied on
W and continuous wave (CW) mode, using a non-con- the enamel surface of each specimen at a thickness of
tact bleaching handpiece. 1-2 mm, and then the custom-made tray was placed
The in-office bleaching was performed for 3 ses- over the arch. The plaster models were kept at 37°c
sions every seven days, in 15 days. In every session, and 100% humidity. After 8 hours, the gel was thor-
the bleaching gel remained in contact with the speci- oughly rinsed off the enamel surface, and the speci-
men for a total period of 10 minutes, and the laser was mens were kept in refreshed artificial saliva for the
irradiated four times for 15 seconds each at intervals of remaining hours of the day. The whitening process
2 minutes between irradiations. The total irradiation was repeated daily over a period of 15 days.
time was 60 seconds per tooth and the first laser irradi- The specimens in the home bleaching groups
ation was performed after 1 minute of placing gel on were subjected to color assessments at days 8 (T3) and
the enamel surface. After the bleaching process, the 16 (T4) after starting the process.
teeth were thoroughly rinsed under tap water and All measurements were performed twice by the
stored in Fuzayama Meyer artificial saliva solution. This same operator and the mean value was calculated. The
solution consisted of KCl (0.4 g/l), NaCl (0.4 g/l), total color change (DE) between different treatments
CaCl₂.2H₂O (0.906 g/l), NaH₂PO₄.2H₂O (0.690 g/l), stages was determined using the following formula:
Na₂S.9H₂O (0.005 g/l) and urea (1 g/l) with pH=7.03. DE= [(DL)2 + (Da)2 + (Db)2]0.5

Statistical analysis
The Kolmogrov-Smirnov test confirmed the nor-
mal distribution of the data. One way analysis of vari-
ance (ANOVA) was conducted to compare the color
change (DE) obtained from the two measurements at
T1 to T4 time points among the experimental groups,
followed by Duncan post hoc test for pairwise compar-
isons. The data were analyzed by SPSS (Statistical
Package for the Social Sciences, version 16.0, SPSS Inc,
IL, USA) software and the significance level was prede-
termined at p<0.05.

Results

Figures 2 to 4 present changes in L*, a* and b* values

Fig. 1: Mounting the teeth in plaster for making in the study groups over the course of the experiment.
custom trays. The undercuts have been Following staining (T2), the lightness value dropped
filled out by wax. (shifted to the dark domain) and then increased during

Efficacy of laser bleaching and home bleaching 259

 ORIGINAL ARTICLES available at www.jstage.jst.go.jp/browse/islsm

T3 and T4 stages (Fig 2). The L value of all groups

(except group 2) was greater at the end of the treat-
ment (T4) than that of the baseline examination (T1).
The a* and b* values increased after staining (color
shift to red and yellow directions, respectively) and
then decreased during the bleaching therapy in most
groups (Figs 3 and 4).
Table 1 indicates the descriptive statistics and the
results of ANOVA and Duncan test regarding the color
change (DE) between different stages in the experi-
mental groups. No significant differences were found
Fig. 2: A line chart indicating changes in “L” parameter
in the color change between T1 and T2 (DET1–T2), T1
in the study groups over the experiment.
(Group 1 demineralized teeth subjected to in– and T3 (DET1–T3), T1 and T4 (DET1-T4) and T3 and
office bleaching, Group 2 demineralized teeth T4 (DET3–T4) time points (p>0.05; Table 2) among the
exposed to home bleaching, Group 3 sound study groups. The experimental groups, however
teeth subjected to in–office procedure, Group 4 exhibited statistically significant differences in the color
sound teeth exposed to home bleaching) change between T2 and T3 (DET2–T3) and T2 and T4
(DET2-T4) intervals (p<0.05; Table 2). Pairwise com-
parison by Duncan test (Table 1) revealed that both
DET2-T3 and DET2-T4 were significantly greater in
demineralized teeth submitted to laser-assisted in-office
bleaching (group 1) as compared to the other experi-
mental groups (P< 0.05).

Discussion

Tooth bleaching has been considered as a part of mini-

mally invasive treatments for white spot lesions 5, 7)
Fig. 3: A line chart indicating changes in “a” parameter which could mask the lesions and lead to a more per-
in the study groups over the experiment. fect appearance and esthetic smile. In this study, a
(Group 1 demineralized teeth subjected to in– GaAlAs diode laser was used for in-office bleaching
office bleaching, Group 2 demineralized teeth and its effect on sound and demineralized bovine teeth
exposed to home bleaching, Group 3 sound was compared with that of home bleaching, using
teeth subjected to in–office procedure, Group 4 color measurements. Bovine teeth are the most widely
sound teeth exposed to home bleaching)
used substitute for human teeth in dental research 23)
because of their close chemical composition and
micro-morphological characteristics to human enamel
and dentin 24, 25). Since the presence of white spot
lesions is usually associated with enamel discoloration
at the end of the orthodontic treatment, a staining pro-
cedure was employed in this experiment. It is believed
that color change values exceeding 3.3 units are clini-
cally visible in any site by independent observers. 19)
In the present study, the color change after staining
(DET1-T2) was greater than 3.3 units in the study
groups, indicating that the staining stage produced
Fig. 4: A line chart indicating changes in “b” parameter observable discoloration in all the specimens.
in the study groups over the experiment.
In the present study, the L value decreased and
(Group 1 demineralized teeth subjected to in–
office bleaching, Group 2 demineralized teeth the a and b values increased in all groups after immer-
exposed to home bleaching, Group 3 sound sion of the specimens in tea solution (T2). The degree
teeth subjected to in–office procedure, Group 4 of reduction in L parameter and the degree of increase
sound teeth exposed to home bleaching) in a parameter were greater in demineralized than

260 F Ahrari et al
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Table 1: Mean and standard deviation (SD) and the results of statistical analysis for comparison of color differ-
ences (DE) between different treatment stages among the study groups (Group 1 demineralized teeth
subjected to in–office bleaching, Group 2 demineralized teeth exposed to home bleaching, Group 3
sound teeth subjected to in–office procedure, Group 4 sound teeth exposed to home bleaching)
T1 T2 T3 T4
Groups CIE
Mean SD Mean SD Mean SD Mean SD
L 90.55 3.38 80.68 4.33 87.41 17.30 92.83 3.07
1 a -0.24 0.86 3.09 2.07 -0.64 0.67 -0.52 1.26
b 23.03 4.11 34.28 3.44 19.81 3.35 19.66 3.20
L 92.95 3.54 84.19 12.62 92.95 3.35 91.80 12.91
2 a -0.20 1.05 2.30 2.0 -1.11 1.15 -3.88 11.31
b 22.20 3.55 25.64 6.04 20.12 4.12 23.01 4.19
L 92.63 2.83 86.08 8.14 90.50 16.37 95.05 4.30
3 a -0.30 1.05 0.75 2.41 -0.70 1.66 -0.74 1.60
b 18.51 3.33 27.86 7.01 19.33 4.81 17.89 4.04
L 92.76 2.66 87.75 2.75 91.25 12.90 95.06 2.35
4 a -0.58 0.90 0.30 0.97 -2.07 1.09 -2.22 1.14
b 19.04 2.87 27.07 5.19 19.91 4.96 18.90 5.41

Table 2: Mean and standard deviation (SD) and the results of statistical analysis for comparison of color differ-
ences (DE) between different treatment stages among the study groups (Group 1 demineralized teeth
subjected to in–office bleaching, Group 2 demineralized teeth exposed to home bleaching, Group 3
sound teeth subjected to in–office procedure, Group 4 sound teeth exposed to home bleaching)

DE T1-T2 DE T1-T3 DE T1-T4 DE T2-T3 DE T2-T4 DE T3-T4

Groups
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
1 15.52 5.04 8.01 5.04 4.61 2.23 21.26 12.41 19.57 3.83 6.42 18.12
2 10.65 12.60 4.96 12.60 8.65 16.64 12.09 12.03 15.31 18.97 7.14 16.83
3 12.44 8.89 8.36 8.89 6.00 3.83 14.45 14.55 13.97 7.11 5.37 16.63
4 10.76 6.31 7.31 6.31 6.03 3.47 12.69 10.75 12.66 5.53 5.32 12.41
P value 0.23 0.732 0.449 0.049 0.017 0.966

healthy teeth. This indicates that the demineralized completion of the bleaching treatments. The color
enamel is possibly more susceptible to absorb external changes between T1-T3, T1-T4, and T3-T4 stages were
stains than sound enamel. However, the difference in not significantly different among the study groups.
DET1-T2 was not statistically significant among the However, the color change between T2 and T3 stages
study groups. as well as the color change between T2 and T4 time
Following the bleaching, all the test groups dis- points were significantly greater in demineralized teeth
played color improvement. The third color assessment submitted to laser-assisted in-office bleaching (group 1)
(T3) was performed on the 8th day after starting home as compared to the other study groups. It is believed
bleaching procedure and following 2 sessions of laser- that HP diffuses through the enamel and dentin, pro-
assisted in-office bleaching, whereas the final color ducing free radicals that react with pigment molecules.
measurement (T4) was accomplished one day after 26) White spot lesions have a subsurface porosity in the

Efficacy of laser bleaching and home bleaching 261

 ORIGINAL ARTICLES available at www.jstage.jst.go.jp/browse/islsm

enamel below the well mineralized surface layer. 27-29) achieved with negligible increase in the pulp tempera-
This porosity may induce increased diffusion of oxidiz- ture. Luk et al. 33) and Suleiman et al. 34) proved that
ing agents and more whitening effect on demineralized the application of different light sources and laser sys-
than sound teeth. The greater concentration of HP as tems for activating the bleaching agent improved the
employed in power bleaching could help to achieve a success of overall tooth whitening. Gurgan et al. 35)
quicker and greater whitening effect on demineralized indicated that in-office bleaching systems with or with-
teeth compared to that occurs with home bleaching out light activation improved tooth color but bleaching
process. with diode laser had the additional advantage of reduc-
In the present study, the efficacy of both laser- ing tooth and gingival sensitivity. In contrast, Calatayud
assisted in-office bleaching and home bleaching was et al. 36) concluded that the use of diode laser negligi-
similar on stained sound enamel. In contrast, the laser- bly improved the whitening efficacy of a 35% HP gel.
assisted in-office procedure was more effective than Strobl et al. 37) and Marcondes et al. 38) indicated that
home bleaching in whitening demineralized enamel. It the additional activation of the HP-containing agent
is difficult to compare the results of this study with that with a Nd:YAG laser was not associated with an
of previous investigations as most studies compared enhanced bleaching performance. In a clinical study
the whitening efficacy of different methods on healthy with a split-mouth design, Hein et al. 39) displayed that
enamel. The findings of this study corroborate the the three bleaching lights tested had no additional
results of some previous authors 16) who found that effect over the bleaching gel alone.
both professional bleaching procedures were effective Clinically, lasers should be used with great care
in whitening healthy teeth. In a clinical study, Mondelli to prevent excessive increase in the pulp temperature.
et al. 30) concluded that LED/Diode laser activation of In this study, 2 W power was selected according to the
the bleaching agent can produce effective results in recommendations of the manufacturer and the results
less time, compared to home-bleaching or in-office of previous authors. 14) A 2 minute interval between
bleaching without light activation. The outcomes of laser exposures was designed to prevent from thermal
this study, however, contradict the results of Zekonis et damage to the pulp tissue. Another option is to use the
al. 31) who showed that the home applied procedure laser in pulsed instead of continuous wave mode in
produced significantly more whitening effect than in- order to allow tooth structures to cool down between
office process during all active-treatment periods and irradiations and thus prevent from heat accumulation
follow-up visits. in the underlying tissues. 40) Other factors may also
The goal of power bleaching is to whiten the influence the temperature of the dental surface during
teeth efficiently, while minimizing any adverse effects laser-assisted bleaching such as the thickness of the
on tooth structures. It is assumed that irradiation from bleaching gel, the duration of laser application, the dis-
a diode laser light source heats the HP, thereby accel- tance between laser tip and tooth surface and the color
erating the decomposition of hydrogen peroxide and of the bleaching gel. 41) A limitation of this study was
formation of hydroxyl and oxygen free radicals 19, 20) that the effect of conventional in-office bleaching was
and in this way leads to reduced treatment time and not compared with that of laser-assisted in-office
possibly enhances treatment results. The results of this bleaching in order to test any benefit of laser treatment
study indicated faster and greater whitening effect on in the whitening process. Future studies should focus
stained demineralized teeth by using the laser-assisted on evaluating the temperature of the tooth and pulp
in-office bleaching compared to that of the home tissue using different laser powers and modes of irradi-
bleaching technique. Many patients are interested in ation. Further clinical studies are also warranted to
obtaining whiter teeth quickly, thus laser-assisted in- compare the efficacy and long-term stability of laser-
office bleaching could be recommend for them. assisted in-office bleaching with that of home bleach-
There is some controversy regarding the benefits ing and power bleaching using other light sources for
of power bleaching compared to that of in-office treatment of white spot lesions.
bleaching without light activation. Son et al. 16) found
that the diode laser irradiation improved the whitening Conclusion
effect of HP. Dominguez et al. 32) believed that for
effective tooth whitening, the light source is more Under the conditions used in this study:
important than the bleaching agent. They found that 1- The laser-assisted in-office bleaching produced
activation with a LED light source should be consid- faster and greater whitening effect on stained
ered the best option as a great color change was white spot lesions compared to that of the home

262 F Ahrari et al
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bleaching technique and thus it could be recom- 2- The laser-assisted in-office bleaching and home
mended for patients with discolored demineral- bleaching displayed similar efficacy in stained
ized teeth. sound enamel.

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[Acknowledgements]
This article is based on an undergraduate thesis (No. 2586). The authors would like to thank the vice chancellor for
research of Mashhad University of Medical Sciences for technical and financial support of this project.

[Conflict of interest]
The authors deny any conflict of interest.

264 F Ahrari et al