Effect of 35% hydrogen peroxide on in-office bleaching against changes in tooth enamel hardness: Literature review Corresponding author: Asy-Syifa Brillian Avicenna brillianavicenna@gmail.com South East Asia Nursing Research, Vol 4 No 1, March 2022 ISSN:2685-032X DOI: https://doi.org/10.26714/seanr.4.1.2022.47-50 Review Article Effect of 35% hydrogen peroxide on in-office bleaching against changes in tooth enamel hardness: Literature review Asy-Syifa Brillian Avicenna1, Christina Mahardika1, Lira Wiet Jayanti1 1 Faculty of Dentistry, Universitas Muhammadiyah Semarang, Indonesia Article Info Abstract Article History: Submitted: Feb 14th 2022 Accepted: March 5th 2022 Published: March 29th 2022 Keywords: hydrogen peroxide; bleaching; enamel hardness Teeth bleaching is one of the treatments for teeth discolouration. Teeth bleaching can do in-home or in-office. The material for that use in-office bleaching is 35% hydrogen peroxide. Hydrogen peroxide is a chemical compound that is tough and has a micro molecule that can easily penetrate enamel tissue and dentin tissue. Bleaching with hydrogen peroxide in-office is now more attractive because can be faster to see the result. Bleaching with hydrogen peroxide when done repeat will make teeth more sensitive, and damage enamel tissue and dentin tissue. The objective of this study is to know the influence of in-office bleaching using 35% hydrogen peroxide on microhardness enamel. This research is made with a literature review with search engine google scholar, PubMed, and science direct. The results of 10 articles show the effectiveness of teeth discolouration after bleaching using 35% hydrogen peroxide in-office. The reduction in enamel microhardness seen using SEM, knob and Vickers is visible although not significant. Based on the literature review research that has been carried out, it can be concluded that there is a reduction in enamel hardness after the in-office bleaching process by using 35% hydrogen peroxide. INTRODUCTION Teeth discoloration is part of the aesthetic problem in society. Teeth discoloration can be caused by intrinsic factors (the incorporation of substances inside enamel and dentin such as tetracyclin, imperfect dentinogenesis, fluorosis, dental trauma and drugs) and extrinsic factors caused by agents that cause changes in enamel (cigarettes, tea, and coffee).1 Teeth bleaching is one of the measures taken to deal with tooth discoloration. The material commonly used for in-office bleaching is hydrogen peroxide.2 Hydrogen proxide has the ability to dissociate into reactive oxygen species (ROS) which is widely used in tooth bleaching. Hydrogen peroxide is used for in-office bleaching because of its stronger properties than carbamide peroxide.3 The bleaching process occurs when low- molecular hydrogen peroxide diffuses through enamel and dentin, then releases reactive oxygen species (ROS) that react or bind to other weak substances. The penetration of oxidative agents in the tooth structure will damage the dye molecules so that it will give a brighter result to the tooth. https://jurnal.unimus.ac.id/index.php/SEANR/index https://jurnal.unimus.ac.id/index.php/SEANR/index https://jurnal.unimus.ac.id/index.php/SEANR/index https://crossmark.crossref.org/dialog/?doi=10.26714/seanr.4.1.2022.47-50&domain=pdf&date_stamp=2022-03-29 South East Asia Nursing Research, Vol 4 No 1, March 2022/ page 47-50 48 Asy-Syifa Brillian Avicenna / Effect of 35% hydrogen peroxide on in-office bleaching against changes in tooth enamel hardness: Literature review This process is usually called a redox3 reaction. The high peroxide content makes the pH level of the teeth decrease so that it can cause changes in the enamel including increased roughness, decreased micro hardness of enamel, decreased strength of enamel and changes in the composition of enamel.4 Hydrogen peroxide used in dentistry is between 5% to 38%. The process of bleaching teeth produces the effect of reducing the hardness of enamel, increasing tooth sensitivity and erosion.5 Research conducted in 2015 by De Paula using 35% hydrogen peroxide in in-office bleaching, teeth in contact with saliva can cause demineralization and dehydration processes after a few days post-bleaching.6 In in-office bleaching, the duration of contact with bleaching agents has a greater effect than the concentration of bleaching agents. One of the effects that appears after bleaching teeth is a decrease in the level of micro-hardness in enamel.7 Enamel hardness can be tested with Knoop or Vickers, SEM (Scanning Electron Microscopy), and EDS (Energydispersive X- ray Spectroscopy).8 METHOD The research is in the form of literature review by collecting a number of data on 35% hydrogen peroxide in in-office bleaching related to changes in enamel hardness that have been carried out in previous studies. The research results listed were obtained using keywords in each database (google scholar, PubMed. And science direct) according to the problem of the research problem. The results of all databe obtained 489 articles which were then screened according to the inclusion and exclusion criteria from 2011-2021, accessible ful text, in the form of research articles and using English and Indonesian. Furthermore, an assessment of the feasibility of a copy of the ful text is carried out where a review of the entire article is carried out and then it is calculated with a critical appraisal to find out whether the relevant article is used to answer research problems that have been formulated in accordance with the research objectives. The article was analyzed for research problems and then concluded. RESULT Based on the search results of 3 databases, namely Google scholar, PubMed, and science direct, there are 10 articles related to 35% hydrogen peroxide. The results of 10 articles show the effectiveness of teeth discoloration after bleaching using 35% hydrogen peroxide in-office. The reduction in enamel micro hardness seen using SEM, knob and Vickers is visible although not significant. The reduction of enamel micro hardness can be caused by several things. DISCUSSION The in-office bleaching process on teeth has been carried out in the past 100 years ago. The in-office bleaching method is currently widely practiced because of its advantages such as, it does not require a long time, and can minimize taboos in food consumption. A commonly used material for in-office bleaching is usually hydrogen peroxide. Some also use non-additives in the bleaching process.9 Hydrogen peroxide is a strong oxidizing agent and can cause the formation of other highly effective bleaching agents such as perihydroxyl anions (HO) and hydroxyl radicals (OH-). Hydrogen peroxide material can cause burns or irritation to the gingiva if it accidentally hits soft tissues, because hydrogen peroxide has unstable and hard properties.10 In the redox reaction process, hydrogen peroxide which has small molecules can easily diffuse into the enamel matrix layer. The free radicals then interact with organic molecules to achieve stability. The South East Asia Nursing Research, Vol 4 No 1, March 2022/ page 47-50 49 Asy-Syifa Brillian Avicenna / Effect of 35% hydrogen peroxide on in-office bleaching against changes in tooth enamel hardness: Literature review effectiveness of bleaching is influenced by several things such as stains on teeth, pH, length of application time, temperature, hydrogen peroxide concentration, additives (rsa enhancing agents), and other factors (age and gender).11 Hydrogen peroxide is active at an alkaline pH. However, a high pH can cause damage to the surface of tooth enamel.5 The temperature setting in the in-office bleaching process has an effect on removing ROS so that hydrogen peroxide performance increases up to 2x.5 Teeth bleaching with pH 5, pH 7, pH 8, pH 9, and pH 10 resulted in, teeth bleaching with pH 10 visible results were very significant, but side effects that appeared such as a significant decrease in enamel surface hardness were also.12 The length of time of application also affects the bleaching process. Teeth repeated 3x15 minutes using 35% hydrogen peroxide produce a brighter tooth color than using 40% hydrogen peroxide once repeated.13 Some of the effects arising from the bleaching process using 35% hydrogen peroxide include increasing tooth sensitivity, erosion, changing the hardness of enamel, hard tissue structure, and reducing micro hardness in enamel. The change is due to the demineraly process caused by redox reactions.14 The reduction in enamel hardness seen using the vickers tool, the presentation of micro hardness in enamel ranges from 22.1 to 0.4 values. The use of 35% hydrogen peroxide in in-office bleaching results in a change in the structure of enamel hardness seen using SEM. Side effects of bleaching can be minimized by using desensiting materials. The use of LEDs in applications can also minimize side effects that occur in teeth.15 The bleaching process begins with a subjective and objective examination and then determines the diagnosis of treatment and documentation before treatment. The patient is explained to be the cost and time of treatment, then the patient is instructed to fill in the informed concent. The installation of a check rectractor is done to protect the lips and as a marker to facilitate the part to be treated. Prosilaxis actions using brushes and pumice are performed on the teeth to be bleached. This action is useful for removing debris or dirt that is still attached to the teeth. The initial color of the teeth is assessed First use the Vita Shade Guide and the patient is educated to keep the mouth open during the procedure. Cotton rollers are applied along the tooth fomix to be bleached. The application of opal dam green is 4-6 mm long and 1.5-2 mm thick on the gingiva of the cervical part of the tooth to be bleached. Irradiation with light curing is carried out for 20 seconds in each jaw. Bleaching material is applied to teeth 0.5-1 mm thick on the labial surface then incisal. Apply for 20 minutes until the desired color is reached.16 The bleaching material is cleaned by disuction and using cotton pellets, after which the patient is instructed to gargle with warm water. After all the procedures are performed, the color of the teeth is checked again using the vita shade guide and documentation is carried out again after bleaching.16 CONCLUSION Based on the literature review research that has been carried out, it can be concluded that there is a reduction in enamel hardness after the in-office bleaching process by using 35% hydrogen peroxide which is influenced by several factors, namely, the pH level of the hydrogen peroxide content, the size of the hydrogen peroxide presentation content, the length of application time, the number of repetitions and temperature. ACKNOWLEDGMENTS The author would like to thank all those who have helped and supported the review process and writing this research article. South East Asia Nursing Research, Vol 4 No 1, March 2022/ page 47-50 50 Asy-Syifa Brillian Avicenna / Effect of 35% hydrogen peroxide on in-office bleaching against changes in tooth enamel hardness: Literature review REFERENCES 1. 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