ARTÍCULOS ORIGINALES

Post-bleaching sensitivity in patients with sickle cell disease

 

Guacyra M. Lisboa¹, Verônica L. Guedes², Maria do R. M. L. Luna³, Américo M. Carneiro-Jr⁴, Roberto C. Stegun⁵

¹ Department of Dentistry, Hemocentro de Alagoas, Brazil.
² Department of Hematology, Hemocentro de Alagoas, Brazil.
³ Department of Dentistry, Laboratório Central de Saúde Pública de Alagoas, Brazil.
⁴ Department of Dentistry, Instituto de Atendimento e Estudos Odontológicos do Nordeste, Alagoas, Brazil.
⁵ Department of Dental Prosthesis, School of Dentistry, University of São Paulo, Brasil.

CORRESPONDENCE Dr. Guacyra Machado Lisboa Rua Desembargador Tenorio, 225/1503 - Farol 57050-050 - Maceio, AL, Brazil gmlgat@uol.com.br

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ABSTRACT

Sickle cell disease (SCD) is a monogenic disease that affects millions of people worldwide. This study analyzed the effectiveness of bleaching and tooth sensitivity after in-office bleaching in patients with SCD. Forty volunteers were randomly assigned to four groups of 10 patients each (five with the SCD and five healthy controls) and treated using in-office bleaching with 35% hydrogen peroxide and different light activation protocols. No statistically significant difference was observed with relation to presence of tooth sensitivity, with or without use of a source of light for peroxide activation, and all bleaching therapies were effective, regardless of the technique employed and the presence/absence of sickle cell disease. The data showed that in-office dental bleaching is a viable alternative for improvement of oral esthetics for patients with SCD.

Key words: Esthetics; Hydrogen peroxide; Tooth bleaching.

RESUMO

Sensibilidade dentária pós-clareamento em pacientes com doença falciforme

A doença falciforme (DF) é a doença monogênica e afeta milhões de pessoas em todo o mundo. Este estudo analisou a eficácia do clareamento e a presença de sensibilidade dentinária após clareamento dental em portadores de DF. Quarenta voluntários distribuídos aleatoriamente em quatro grupos com diferentes fontes de luz foram submetidos à técnica de clareamento em consultório, utilizando peróxido de hidrogênio a 35%. Não foram encontradas diferenças estatisticamente significativas em relação á presença de sensibilidade, com ou sem a utilização de uma fonte de luz para acelerar a ativação do peróxido e todos os clareamentos foram efetivos, independentemente da técnica utilizada e da presença/ausência de DF. Os dados mostraram que o clareamento dental em consultório, utilizando peróxido de hidrogênio a 35% é uma alternativa viável para melhoria da estética em pacientes com DF.

Palavras-chave: Clareamento dental; Estética; Peróxido de hidrogênio.

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INTRODUCTION

Sickle cell disease (SCD) is the most common monogenic disease in the world¹, affecting millions of people. In Brazil, 20,000 to 30,000 people are estimated to have sickle cell disease, which tends to increase as a result of the high degree of miscegenation^2,3. The disease is caused by the replacement of glutamic acid with valine in the sixth position of the β-globin chain, resulting in abnormal cells referred to as hemoglobins S (HbS, as in sickle). When oxygen is absent or low, HbS molecules are polyme rized and lose their normal round morphology, shortening the mean life of red blood cells, causing vessel occlusion and infarction, and consequently leading to ischemia, pain, necrosis, dysfunction, permanent damage to tissues and organs, and chronic hemolysis^4,5. In 1973, life expectancy of patients with sickle cell disease was 14 years; at present, in patients under strict medical monitoring, life expectancy can reach approximately 70 years⁶.
As a result of the peculiarities of sickle cell disease, these patients require special attention during treatment and clinical management, requiring pre- established protocols for procedures considered routine in dental practice⁷. Tooth bleaching is a conservative method for dental structures and is therefore widely sought for the improvement of oral esthetics. Tooth sensitivity after bleaching is the side-effect most frequently reported by patients who have undergone bleaching⁸. This study analyzed the effectiveness of bleaching, and tooth sensitivity after in-office bleaching, in patients with SCD. It was motivated by the growing interest in dental bleaching among patients with sickle cell disease and the scarcity of studies on bleaching efficacy and the behavior in this specific population regarding the procedure.

MATERIALS AND METHODS

Ethical considerations
This study was approved by the Research Ethics Committee of Universidade Estadual de Ciencias da Saude de Alagoas (protocol no. 949/08) and written informed consent was obtained from all study participants.

Selection of subjects
This study enrolled forty volunteers aged 18 to 45 years, of both genders, with no caries, with vital teeth in the gap between first premolars of the maxilla and mandible and good periodontal health, who agreed to participate in the study and signed informed consent. Exclusion criteria were patients who had used any bleaching agents within the past year, had deficient restorations, reported any tooth sensitivity, spontaneous or triggered by air spray, had taken any kind of analgesic or anti-inflammatory drugs within one month before bleaching, smokers and pregnant or lactating women. Volunteers were randomly assigned to four groups of 10 patients each: five with sickle cell disease and five healthy controls.

Data collection
All participants underwent in-office bleaching with 35% hydrogen peroxide (Whiteness HP Maxx, FGM Dental Products, Joinville, Brazil). The bleaching agent was applied three times, each session lasting 15 minutes. Before the bleaching procedures, they received prophylaxis with pumice and water in a rubber cup. Group 1 was treated with a halogen light unit (photopolymerizer CL-K220, Kondortech, Sao Carlos, Brazil), and the bleaching agent was activated on each individual tooth for 30 seconds per tooth. In Group 2, a light emitting diode (LED) unit was used (Easy Bleach, Clean Line, Taubate, Brazil), and activation also took place on each individual tooth, for 30 seconds per tooth. In Group 3, a LED/laser unit was used (Easy Bleach, Clean Line, Taubate, Brazil), and peroxide was activated simultaneously on both arches, for 3 minutes. In Group 4, no light source was used to activate the bleaching agent. Bleaching treatment efficacy was assessed using the Vitapan Classical shade guide (Vita- Zahnfabrik, Bad Sackingen, Germany). In this guide the colors are organized from B1 (lighter) to C4 (darker) and numbered from 1 (B1) to 16 (C4)⁹. The area for color matching was the middle third of the buccal surface of the central upper left incisor and it was evaluated by a duly calibrated examiner. Color was determined before and after bleaching. Absence of tooth sensitivity was evaluated at the following times: during the first 5 hours, at 6-12 hours, 13-24 hours, 25-72 hours (2-3 days), 73-192 hours (4-8 days), and 193-240 hours (8-10 days). Each patient was also asked to describe whether tooth sensitivity was spontaneous or provoked. If provoked, patients were asked to report the factor that triggered sensitivity: heat, cold, speaking or other.

Statistical analysis
Statistical analysis was performed using the BioEstat software, version 5.0 (Optical Digital Technology, Belem, Brazil). Tooth sensitivity data were analyzed by Fisher's exact test and effecti - veness of bleaching data was analyzed by paired t test. Significance level was set at 5% (p < 0.05).

RESULTS

All bleaching therapies were effective, regardless of the technique employed and the presence/ absence of sickle cell disease (Table 1, Fig. 1). Provoked and/or spontaneous sensitivity were experienced by 72.5% (29 out of 40) of the volunteers. However, it was absent in the following periods: 73-192 hours (4-8 days) and 193-240 hours (8-10 days). The way in which sensitivity developed varied among volunteers. Five volunteers reported only spontaneous sensitivity; twenty-four reported provoked sensitivity, of whom seventeen also reported spontaneous sensitivity. The factor that triggered sensitivity also differed among volunteers, with the factor most often mentioned being SPEAKING, which was cited by 50% of volunteers (Table 2).

Table 1: Analytical results for color determined before and after in-office dental bleaching with 35% hydrogen peroxide.

Table 2: How sensitivity developed in 40 volunteers (20 with and 20 without sickle cell disease) after in-office dental bleaching, according to technique employed.

Fig. 1: Tooth color before and after in-office bleaching with 35% hydrogen peroxide, (A) volunteer with SCD (B) volunteer without SCD.

Only two participants mentioned others factors, both associated with SPEAKING that triggered tooth sensitivity: when brushing teeth and when smiling. Whether or not a light source was used to activate hydrogen peroxide did not produce statistically significant differences in terms of tooth sensitivity, regardless of the presence or absence of sickle cell disease (Table 3).

Table 3: P values obtained for presence of sensitivity in 40 volunteers (20 with and 20 without sickle cell disease) after in-office dental bleaching according to technique employed.

DISCUSSION

Pain is the most frequent symptom in patients with sickle cell disease. The frequency and severity of painful episodes vary among patients. Some patients feel pain on a daily basis; others only occasionally ^10,11 . Dehydration, infection, stress and cold temperatures are some of the factors that may trigger painful episodes¹². Painful crisis duration may range from some hours to weeks¹⁰. An esthetically pleasing appearance contributes to increasing self-esteem and wellbeing. In this scenario, tooth bleaching has become a popular treatment, because it preserves tooth structure and improves appearance without any major adverse effects¹³.
Approximately 67.5% of patients with sickle cell disease exhibit intrinsic opacity related to organic matrix hypocalcification during the mineralization phase^14,15. Because of the increased levels of opacity observed in these patients, Okafor et al.¹⁵ suggested that they should undergo treatment by bleaching or capping of the teeth, depending on the severity of the problem or esthetic compromise. Almeida et al.¹⁶ and Mondelli et al.¹⁷ evaluated 40 and 48 patients respectively. Both demonstrated that all bleaching techniques tested were equally effective with or without light. They concluded that light sources were unnecessary to bleach teeth. These results are compatible with the findings of our study, where bleaching was effective in all groups, regardless of whether or not a light source was used to activate the hydrogen peroxide. For sensitivity triggers, the data show that HEAT alone did not trigger sensitivity, being mentioned only when associated with SPEAKING, which in this case might have been a confounding factor. Presence of sensitivity and whether or not a light source was used to accelerate the hydrogen peroxide treatment showed no statistically significant diffe rence in patients with or without sickle cell disease. Almeida et al.¹⁸ and Bernardon et al.¹⁹ found similar results in their studies. However, these findings differ from those reported by Kossatz et al.²⁰, who observed more persistent and higher sensitivity levels 24 hours after treatment in the group treated with light activation. Similarly, He et al.²¹ observed that the light-activated system produced a higher percentage of tooth sensitivity than the non-light-activated system during in-office bleaching.
Tooth sensitivity was reported by 72.5% of the patients and lasted 3 days or less. Tang and Millar²², also reported that 85.2% of the patients experienced tooth sensitivity at some point following the bleaching procedures. Despite the fact that in-office bleaching is a lengthy procedure, where the patient spends about an hour motionless, in a situation that can easily cause stress, none of the volunteers with SCD reported a painful crisis after the procedure, suggesting that there is no need for specific protocols to perform in-office dental bleaching with 35% hydrogen peroxide in these patients. However, due to the peculiarities of SCD, the most appropriate time to perform the procedure should be selected in conjunction with the medical staff in charge of the patient. No statistically significant difference was observed in relation to presence of tooth sensitivity among patients with and without sickle cell disease, regardless of whether or not a source of light was used for peroxide activation. On the other hand, our data showed a significant statistical difference for bleaching effectiveness, proving that the purpose of the procedure was achieved. Teeth were bleached in both groups assessed, showing that in-office dental bleaching is a viable alternative for improvement of oral esthetics for patients with SCD.

ACKNOWLEDGEMENTS

The authors are grateful to FGM Dental Products, which donated the bleaching kits used in the study. We thank Sidney Santos and Elifabiana Araujo for assistance with recruitment of study participants, and Taynah and Gyulia Rabelo for all the help provided during the study.

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