Dental Materials Journal 2010; 29(1): 47–52

Can intra-coronally bleached teeth be bonded safely after antioxidant

treatment?
Tancan UYSAL1, Huseyin ERTAS2, Burak SAGSEN2, Hakan BULUT3, Ozgur ER2 and Ayca USTDAL1
1
Department of Orthodontics, Faculty of Dentistry, Erciyes University, Erciyes Universitesi, Diş Hekimliği Fakültesi, 38039, Melikgazi, Kayseri,
Turkey
2
Department of Conservative Dentistry and Endodontics, Faculty of Dentistry, Erciyes University, Erciyes Universitesi, Diş Hekimliği Fakültesi, 38039,
Melikgazi, Kayseri, Turkey
3
Department of Orthodontics, Faculty of Dentistry, Ege University, Ege Universitesi, Diş Hekimliği Fakültesi, Bornova, Izmir, Turkey
Corresponding author, Tancan UYSAL; E-mail: [email protected]

The aim of this study was to compare the effects of antioxidant treatment and delayed bonding, following intra-coronal bleaching, on
the shear bond strength (SBS) and bond failure site of brackets bonded to enamel. Eighty mandibular incisors were divided into four
equal groups. After root canal filling, specimens in Group 1 were used as control and not bleached. For experimental groups 2 to 4,
bleaching agent was placed into the rest of the cavity for a four-day period and this bleaching treatment was performed two times. In
Group 2, specimens were bonded immediately after bleaching; in Group 3, specimens were bleached and then immersed in artificial
saliva for 30 days before bonding; in Group 4, specimens were bleached, treated with an antioxidant agent, and then bonded. The
SBS values of bonded brackets were measured in megapascal (MPa), while adhesive remnant index (ARI) scores were determined
after the brackets failed. The SBS values of Group 1 (mean: 20.3±7.1 MPa) and Group 4 (mean: 18.2±6.1 MPa) were significantly
higher (p>0.001) than those of Group 2 (mean: 4.9±3.2 MPa) and Group 3 (mean: 8.7±4.9 MPa). No significant differences in SBS were
found between Groups 1 and 4, and between Groups 2 and 3.

Keywords: Intra-coronal bleaching, Antioxidant, Bonding

Received Jul 29, 2009: Accepted Sep 18, 2009

agent immediately before bonding significantly reduced

INTRODUCTION
the SBS of orthodontic self-etching primer systems.
Discoloration of non-vital teeth can be caused by both It has become increasingly common that patients
intrinsic and extrinsic factors. Besides invasive who have received orthodontic treatment also desire to
therapies such as crowning or the placement of veneers, have their endodontically treated teeth bleached.
tooth bleaching has emerged as a simpler, viable Against this backdrop of an increasing trend in post-
treatment alternative1). In view of the increasing endodontic intra-coronal bleaching of teeth, it thus
popularity of non-vital bleaching, there arises in seems necessary and important to determine whether
tandem an increasing need for effective treatment of such a procedure would significantly influence the bond
discolored teeth with non-vital pulps using bleaching strength of orthodontic bracket bonded to the enamel
agents2). surface13). To the best of the authors’ knowledge, only
In restorative dentistry, a number of researches one study13) in published literature has investigated the
have evaluated the shear bond strength (SBS) of effect of intra-coronal bleaching treatment on the SBS
composite resins on enamel and dentin after intra- of metallic brackets. It was concluded in that study13)
coronal bleaching treatment, but there is still no that such a treatment adversely affected the SBS and
consensus on its effects on bond strength3-5). Some changed the failure site during debonding when the
studies showed that the bond strength with enamel bonding procedure was performed immediately or at
decreased after intra-coronal bleaching with carbamide 30days after bleaching13).
peroxide at varying concentrations3,4), whereas some Several preventive methods have been suggested
concluded that the permanent restoration can be to overcome the clinical problems related to
accomplished immediately after intra-coronal compromised bond strength after bleaching. Some of
bleaching5). the proposed methods included removal of the
As for the effects of extra-coronal bleaching on the superficial layer of enamel14), pretreatment of bleached
SBS of orthodontic brackets6-12), different study designs enamel with alcohol15), or use of adhesives containing
have been undertaken. Cacciafesta et al.9) evaluated organic solvents16). However, a widely made suggestion
the effects of bleaching treatment on the SBS of a is to delay the bonding procedure after bleaching since
resin-modified glass ionomer cement (RMGIC), Fuji the reduction in composite resin bond strength to
Ortho LC, which was used to bond stainless steel freshly bleached enamel has been shown to be
brackets. It was found in that study9) that bleaching temporary17). As such, the bonding procedure is
before bonding significantly lowered the SBS of generally recommended to be rescheduled at a later
RMGIC. In a recent study, Uysal and Sisman10) also date subsequent to the bleaching treatment, ranging
found that the use of a carbamide peroxide bleaching from 24 hours to 4 weeks after bleaching6,9,11,12,17).
48 Dent Mater J 2010; 29(1): 47–52

On the bleaching agents used, carbamide peroxide were cleaned and polished with a rubber cup and a
— which is a biological oxidant — is commonly used in slurry of pumice in water, followed by rinsing with a
bleaching treatments. It actualizes the bleaching water spray and drying with compressed air.
process by oxidizing the macromolecules of stains Endodontic access cavities were prepared using
quickly and breaks them into smaller fragments, ISO 12 round diamond bur (Diatech, Coltene
consequently diffusing them across dental surfaces18). If Whaledent, Altstatten, Switzerland) with a high-speed
the bond strength decreases on enamel treated with handpiece under water cooling. The root canals were
carbamide peroxide as a result of the oxidizing action, instrumented using ProTaper Ni-Ti rotary instruments
it may be reversed by applying a biocompatible and (Dentsply-Maillefer, Ballaigues, Switzerland), and 1 ml
neutral antioxidant before applying the resin of 2.5% NaOCl irrigation was provided between each
composite11,12). In an in vitro study by Lai et al.19), it was file. Final irrigation was performed with a saline
found that when an antioxidant agent was applied to solution and the root canals were dried with sterile
enamel for 3 hours after bleaching with carbamide paper points. By means of a cold lateral condensation
peroxide, the reduced SBS of the composite was technique, the canals were filled with an epoxy-resin
reversed. Similarly, in a study by Bulut et al.11) which root canal sealer named AH 26 (Dentsply De Trey,
investigated the effect of antioxidant treatment on the Konstanz, Germany) and gutta-percha (SPI Dental
SBS of metal brackets bonded to human enamel after Mfg. Inc., Inchon, Korea). Then, the root fillings were
bleaching with carbamide peroxide, it was found that removed at 2 mm apical to the cementoenamel junction
treating the bleached enamel surface with 10% sodium followed by placing a light-cured glass ionomer base
ascorbate or delayed bonding by 1 week reversed bond (Vitrebond, 3M ESPE, St. Paul, Minnesota, USA) of
strength reduction. In another recent study, Bulut et approximately 2 mm thickness.
al.12) showed that treatment with an antioxidant
immediately after bleaching was effective in reversing Experimental groups
the reduced tensile bond strength of brackets. As listed in Table 1, all tooth samples were prepared
The aim of this in vitro study was to compare the according to the procedure of each experimental group
effects of antioxidant treatment and delayed bonding described below.
after intra-coronal bleaching with 16% carbamide Group 1 (Control): Access cavity was rinsed with
peroxide on the SBS and bond failure site of metal distilled water and dried, and the final composite
brackets bonded with a composite resin to human restoration was placed. A 37% phosphoric acid gel (3M
enamel. Dental Products, St. Paul, Minnesota, USA) was used
for the acid-etching of 20 incisors for 15 seconds. Tooth
samples were then rinsed with water from a 3-in-1
MATERIALS AND METHODS
syringe for 30 seconds and dried with an oil-free source
Preparation of tooth samples for 20 seconds.
Eighty non-carious, freshly extracted, single-rooted Group 2: Intra-coronal bleaching was performed
mandibular incisors were used in this study. Teeth according to the manufacturer’s instructions. A 16%
with hypoplastic areas, cracks, or gross irregularities of carbamide peroxide bleaching agent (Whiteness Perfect,
the enamel structure were excluded. The criteria for FGM Dental Products, Joinville, Brazil) was placed
tooth selection dictated no pretreatment with a into the rest of the cavity and the latter was sealed by
chemical agent such as alcohol, formalin, or hydrogen a temporary filling material (Cavit, 3M ESPE AG,
peroxide, or any other form of bleaching. Seefeld, Germany). After 4 days, this bleaching
The teeth were stored in distilled water (for a treatment was repeated to simulate the clinical
maximum of 1 month), and the water was changed conditions whereby two bleaching sequences are
weekly to avoid bacterial growth. The tooth samples needed. As per a routine procedure, the temporary
were randomly divided into four equal groups. All filling material was removed after 4 days and in order
teeth were mounted vertically in a self-cure acrylic so to neutralize the bleaching agent, calcium hydroxide
that the crowns were exposed. The buccal surfaces was placed for one more week. Then, the access cavity

Table 1 Experimental groups and their treatment methods

Group Bleaching Treatment Method
Group 1 − Bracket bonding without bleaching

Group 2 Intra-coronal 16% carbamide peroxide bleaching + bracket bonding

Group 3 Intra-coronal 16% carbamide peroxide bleaching + immersion in artificial saliva

solution for 30 days + bracket bonding

Group 4 Intra-coronal 16% carbamide peroxide bleaching + 10% sodium ascorbate

antioxidant treatment + bracket bonding
 Dent Mater J 2010; 29(1): 47–52 49

was rinsed with distilled water and final composite crosshead speed of 0.5 mm/min was used, and the
restoration was placed. In preparation for bracket maximum load necessary to debond the bracket was
bonding, the bracket bonding area was etched with recorded. The force required to remove the brackets
37% phosphoric acid gel for 30 seconds. was measured in Newtons (N), and the corresponding
Group 3: Bleaching protocol for this group was the SBS (1 megapascal (MPa) = 1 N/mm2) was calculated
same as that for Group 2. However, after bleaching by dividing the force value by the bracket base area
and before etching, the teeth were stored in artificial (6.82 mm2).
saliva for 30 days at room temperature. The artificial
saliva storage medium was changed daily. Adhesive remnant index (ARI) evaluation
Group 4: Bleaching protocol for this group was the After debonding, all teeth and brackets were examined
same as that for Group 2. However, after bleaching under a stereomicroscope at ×10 magnificatio (SZ 40,
and the placement of final composite restoration, an Olympus, Tokyo, Japan). Any adhesive remaining
antioxidant — 10 mL of 10% sodium ascorbate — was after bracket removal was assessed using the adhesive
applied to the enamel surfaces as an irrigating solution remnant index (ARI)20) and scored according to the
for 10 minutes with a flow rate of 1 mL per minute amount of resin adhering to the enamel surface. The
under continuous agitation. The enamel surfaces were range of ARI scores is as follows: 5 – no composite
then thoroughly rinsed with distilled water for 30 remained on the tooth; 4 – less than 10% of the
seconds, and the brackets subsequently bonded to the composite remained on the tooth; 3 – more than 10%
prepared enamel surfaces. but less than 90% remained on the tooth; 2 – more
than 90% of the composite remained on the tooth; and
Bracket bonding procedure 1 – all the composite remained on the tooth, along with
Eighty stainless steel mandibular incisor brackets the impression of the bracket base.
(Product No: 017-660, ZeroBase Orthodontics, 3M
Unitek, Monrovia, California, USA) with a base surface Statistical analysis
area of 6.82 mm2 were used for all the experimental All statistical analyses were performed using the
groups in this study. Information on the mean base Statistical Package for Social Sciences software package
surface area of the brackets was provided by the (SPSS for Windows 13.0, SPSS, Chicago, Illinois, USA).
manufacturer. Descriptive statistics, including the mean, standard
Following surface preparation, the liquid primer of deviation, minimum and maximum values, were
Transbond XT was applied to the etched surfaces and calculated for all the four groups of teeth tested. The
the brackets were bonded on mandibular incisors with mean values of SBS were statistically analyzed using
Transbond XT (3M Unitek). Any excess resin was one-way analysis of variance (ANOVA) and Tukey’s
removed with an explorer before curing. Then, a light multiple comparison test at p<0.05. For the ARI
emitting diode curing light (Elipar Freelight-2, 3M scores, the chi-square test was used to determine any
ESPE, Seefeld, Germany) was used to cure the significant differences among the four experimental
adhesive resin for 20 seconds. groups.

Debonding procedure
RESULTS
Immediately after bracket bonding, the embedded
samples were secured in a jig attached to the base Table 2 lists the descriptive statistics and statistical
plate of a universal testing machine (Hounsfield Test comparison results for the SBS values of the four
Equipment, Salford, Lancashire, UK). A chisel-edge groups tested in this study. Statistical analysis by
plunger was mounted in the movable crosshead of the ANOVA revealed significant differences among the four
testing machine and positioned such that the leading groups tested (F=35.923, p=0.000). Tukey’s test showed
edge was aimed at the enamel-adhesive interface. A that the SBS values of Group 1 (no bleaching control;

Table 2 Descriptive statistics and results of ANOVA and Tukey’s test comparing the shear bond strengths of the four
experimental groups
Bond strength (MPa)
Groups tested N F-value p-value Tukey*
Mean SD Minimum Maximum
Group 1 (Control) 20 20.3 7.1 9.0 31.0 A
Group 2 (B-O) 20 4.9 3.2 1.0 10.0 B
35. 923 0.000
Group 3 (B-30) 20 8.7 4.9 2.0 17.0 B
Group 4 (AO) 20 18.2 6.1 11.0 33.0 A
SD: standard deviation; N: sample size; B-O: bonded immediately after bleaching; B-30: bonded at 30 days after
bleaching; AO: antioxidant treatment after bleaching.
*Groups with different letters are significantly different from each other.
50 Dent Mater J 2010; 29(1): 47–52

Table 3 Frequency of distributions and comparison of ARI scores (%)

ARI Scores* Multiple Comparison
Chi- p-
Group Group Group Group
ARI=1 ARI=2 ARI=3 ARI=4 ARI=5 N square value
2 3 4
Group 1 (Control) 0 (0%) 10 (50%) 6 (30%) 4 (20%) 0 (0%) 20 *** *** NS
Group 2 (B-O) 0 (0%) 0 (0%) 0 (0%) 10 (50%) 10 (50%) 20 NS ***
37. 666 0.000
Group 3 (B-30) 0 (0%) 0 (0%) 0 (0%) 5 (25%) 15 (75%) 20 ***
Group 4 (AO) 4 (20%) 10 (50%) 2 (10%) 2 (10%) 2 (10%) 20
SD: standard deviation; N: sample size; B-O: bonded immediately after bleaching; B-30: bonded at 30 days after
bleaching; AO: antioxidant treatment after bleaching.
*ARI scores, where 1: all the composite, with impression of bracket base, remained on tooth; 2: more than 90% of
composite remained on tooth; 3: more than 10% but less than 90% of composite remained on tooth; 4: less than 10% of
composite remained on tooth; 5: no composite remained on tooth
NS: not significant; ***: p<0.001

mean: 20.3±7.1 MPa) and Group 4 (antioxidant In search of a possible explanation for the
treatment; mean: 18.2±6.1 MPa) were significantly decreased bond strength after bleaching with carbamide
higher (p>0.001) than that of Group 2 (bleaching peroxide1), several studies have focused on the physical
immediately before bonding; mean: 4.9±3.2 MPa) and alterations that occurred after the bleaching
Group 3 (bleaching at 30 days before bonding: mean: treatments. Some authors suggested poor bonding
8.7±4.9 MPa). No statistically significant differences surfaces due to changes in the enamel structure, a
were found between Groups 1 and 4, and between result of increased porosity as manifested by an over-
Groups 2 and 3 (p<0.05). etched appearance with loss of prismatic form21).
Table 3 lists the frequency distribution and results Besides, other important factors that could have
of chi-square analysis of ARI scores. Statistical contributed to the decreased bond strength included
analysis revealed significant differences among the four loss of calcium, decrease in microhardness, and
groups tested (χ2=37.667, p=0.000). In Group 1, there alterations in the organic substance22). Consistent with
was a higher frequency of ARI scores of 2–4, indicating these suggested explanations, results of the current
cohesive failures within the resin. In Groups 2 and 3, study demonstrated statistically significant reduction
the failures were mostly adhesive at the resin-enamel in the SBS of brackets bonded to teeth immediately
interface (Scores 4 and 5). In Group 4, the failures after intra-coronal bleaching when compared with the
were of both adhesive (at resin-bracket interface) and control.
cohesive types (Scores 1 and 2). Similar to the SBS On the effect of delayed bonding after bleaching,
results, it was determined that there were no Uysal et al.6) and Uysal and Sisman10) investigated this
statistically significant differences in ARI scores effect by storing their samples in artificial saliva for 30
between Groups 1 and 4, and between Groups 2 and 3 days and suggested that delayed bonding by a
(p>0.05). minimum of 2 to 3 weeks might be beneficial for extra-
coronal bleaching. However, present findings in the
context of intra-coronal bleaching did not strongly
DISCUSSION
support these results6,10) which showed that immersion
Effect of delayed bonding toward the reversal of reduced of bleached teeth in distilled water or artificial saliva
bond strength after bleaching resulted in a reversal of the reduced enamel bond
Pertaining to the effects of extra-coronal bleaching on strength6,7,9-12,17).
the SBS of orthodontic brackets, different bleaching With intra-coronal bleaching, Uysal et al.13) showed
agents have been investigated and at varying that immersion of bleached tooth samples in artificial
concentrations. Some researchers investigated the saliva for 30 days increased the SBS of orthodontic
effects of 25–35% hydrogen peroxide6,8,9) on the SBS of brackets, but not up to the level obtained for the
brackets, whilst some investigations were carried out control. This could be because in the case of extra-
using 10–16% carbamide peroxide7,10-13). On the effect coronal bleaching, reversal of compromised bond
of intra-coronal bleaching on the SBS of orthodontic strength might be due to residual oxygen from the
brackets, only one such study was carried out by Uysal bleaching material being removed from the enamel
et al.13). In that study13), it was shown that intra- surface by the immersion process11). However, this
coronal bleaching with carbamide peroxide adversely phenomenon might behave differently for intra-coronal
affected the SBS and changed the bond failure site bleaching. On the recommended time intervals for
when the bonding procedure was performed delayed bonding after bleaching, studies on extra-
immediately or at 30 days after bleaching. coronal bleaching have proposed a wide-ranging time
 Dent Mater J 2010; 29(1): 47–52 51

interval from 24 hours to 30 days. In light of the result scores after bleaching6,8-13,17), some studies6,17) reported
obtained in this study, we proposed a delay of at least that cohesive failures were prevalent, whereas another
4 weeks after intra-coronal bleaching for the tooth study reported that failures occurred at the enamel-
structure to regain its pre-bleaching adhesive adhesive interface9).
properties. In the current study, a comparison of the ARI
scores indicated that there were significant differences
Effect of antioxidant treatment toward the reversal of among the four groups tested. In Group 1, there was a
reduced bond strength after bleaching higher frequency of cohesive failures within the
In pursuit of identifying other factors that may account composite resin. In Groups 2 and 3, the failures were
for the reduced bond strength after bleaching, it has mostly adhesive at the resin-enamel interface. In Group
been proposed that residual oxygen from the bleaching 4, both adhesive (at resin-bracket interface) and
agent inhibited resin polymerization23). As such, recent cohesive failures occurred. Results of this study showed
studies have devoted much attention to neutralizing that after bleaching, antioxidant treatment with 10%
the oxygen species with antioxidant agents. Amongst sodium ascorbate led to a shift in bond failure site to
which, some in vitro studies have demonstrated the be similar to that in unbleached enamel. Bleached
protective effects of ascorbic acid salts against hydrogen teeth had more adhesive failures (at resin-enamel
peroxide11,12). interface), whereas unbleached or antioxidant-treated
On the effect of antioxidant treatment after intra- teeth after bleaching had more cohesive failures (within
coronal bleaching on the SBS of metal brackets bonded the resin). Therefore, frequency distributions of the
to human enamel, a survey of the published literature failure sites in this study clearly revealed differences in
indicated that no such investigations have been carried the quality of the bond formed among the four
out. At this juncture, it must be emphasized that it is experimental groups.
important to test the efficacy of this preventive method
against the negative effects of bleaching for intra-
CONCLUSIONS
coronal bleaching, chiefly because the results and
conclusions obtained for extra-coronal bleaching should Within the limitations of this study, the following
not be applied indiscriminately for intra-coronal conclusions were drawn:
bleaching. 1. Intra-coronal bleaching with carbamide peroxide
With extra-coronal bleaching, Bulut et al.11,12) found adversely affected the SBS of orthodontic
that treating the bleached enamel surface with an brackets when bonding was performed
antioxidant agent before bonding reversed the immediately after bleaching.
compromised bond strength of composite resin. They 2. Immersion in artificial saliva for 30 days after
thus suggested that the antioxidant treatment could be intra-coronal bleaching slightly improved the
an alternative to the delayed bonding method, thereby SBS of brackets, but not up to the level obtained
eliminating the need to reschedule bracket bonding to for the unbleached samples.
a later date in clinical situations. In the case of intra- 3. Treating the bleached enamel surface with an
coronal bleaching, Uysal et al.13) reported that a 30-day antioxidant agent reversed the compromised SBS
immersion of tooth specimens in artificial saliva (used of orthodontic brackets.
to mimic the salivary antioxidant effect) after bleaching 4. Intra-coronal bleaching significantly altered the
did not reverse bond strength reduction. In the present bond failure site when compared to the
study, the antioxidant treatment favorably reversed the unbleached samples. However, the antioxidant
reduction in SBS values after intra-coronal bleaching; treatment — instead of delayed bonding after
similarly, immersion in artificial saliva did not reverse bleaching — shifted the bond failure site to be
the reduced enamel bond strength. similar to that of unbleached enamel.
Reynolds24) suggested that a minimum bond
strength of 5.9 to 7.8 MPa was adequate for most
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