Lupine Publishers | The Applied Importance of Pediatric Dentistry (An Overview)

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Today, with the promotion of community awareness, fortunately, the importance of oral health and maintenance of primary teeth for parents is clear. Due to the important roles of primary teeth in the oral system, these teeth should be maintained until the eruption of the permanent teeth. For this reason, it seems the parent’s perspective has changed, and children’s dentistry is now a priority for most families. Pediatric dentists should be specialized in different fields of pediatric dentistry. They will be training in the fields of pediatric psychology, child anesthesia and sedation, and age-appropriate behavior management so that they can manage children’s treatments in the best way. This group of dentists is specialized in eliminating child concerns and anxiety too. They can distract children’s minds by talking to them from what they plan to do. This friendship makes the child’s fears go away and the treatments are accomplished positively so that the child would not feel any bad dental experiences at all. Pediatric dentists provide the parents with the necessary training information to protect their children’s teeth from the very beginning of their childhood.

Keywords: Pediatric dentists; pediatric psychology; child anesthesia; sedations; elimination of anxiety; child behavioral management

Introduction

Pediatric Dentistry is one of the branches of dentistry in which the dentist works with children and adolescents. In 1909, Minnie Evangeline Jordon established the first dental practice in the United States devoted only to pediatric patients [1]. This discipline was first recognized by the American Dental Association in the United States [2] and subsequently graded in other countries as a separate specialty. In general, for a general dentist to receive a child’s specialty, he must complete two to three years of special training. In this area, the dentist not only focuses on oral and dental health, but he will also be interlinked with children and the psychological behavior of the children. Children have their mental characteristics and do not tolerate oral examination and dental treatments; consequently, they may not cooperate well with the general dentist. In pediatric dentistry, the dental practitioner thoroughly performs examination and treatment with the use of applied techniques, so that the child will become fully cooperative. To ease the process of dental treatment, they will use the appropriate and fun tools for the child to accept the dental procedures. The dental office environment is also one of the factors that can be effective in improving the treatment in the child [3]. Entertaining the child before and during treatment with toys and cartoons is one of the things that play significant effects [3-5]. The pediatric dentist offers a range of therapeutic approaches that can help the improvement of the oral health status of the child. The pediatric dental specialization has given special attention to dentistry in children from birth to adolescence. Due to the importance of pediatric dentistry, a pediatric dentist must have the experience, expertise, and the ability to maintain the health of teeth, gums. In general, the oral conditions of children can be monitored by a pediatric dentist at different stages of the child’s development [4]. If oral health is neglected, the likelihood of developing dental caries and other illnesses that cause permanent complications for the teeth of the baby will be very high.

Pediatric Dentistry Features

In this article, we intend to introduce some of the most important features of pediatric dentistry.

Oral health education

Tooth decay, as well as non-compliance with health in children, reduce their school performances and create poor social relationships [6-9]. Children’s dentistry with providing a pleasant and educational environment for children and adolescents not only reducing their stress but also can greatly increase the awareness of children and prevent the occurrence of various types of oral and dental diseases [7].

Specialized children’s dental services

Primary teeth are very important in childhood and adolescence, which plays an important role in their correct chewing of foods. Not only does this contribute to the health of children, but it also helps children to speak the words correctly. All services such as primary teeth restoration, pulpotomy and pulpectomy procedures, SS crowns, fluoride therapy, and permanent teeth services in children are provided by children’s dentistry.

General anesthesia

One of the causes that prevent children from visiting the dentist is the fear and anxiety in referring to pediatric dentistry [5,10]. This fear causes the child to suffer from oral and dental illness due to a lack of regular referral. In a general dental office, due to a lack of knowledge of the psychology of the child, it is not possible to provide a warm and comfortable environment for children. Referring the child to the pediatric dentist, in addition to addressing the problems caused by the child’s lack of health, allows the child to address the dental and oral problems in a happy and intimate environment. Today, for children with anxiety and fear of referring to dentistry, general anesthesia is used during examination and dental procedures to increase the accuracy and quality of the work of the pediatric dentist.

Application of Hypnosis (artificial sleep)

Oral and dental hygiene is one of the things parents should consider from childhood. Since children are sensitive and fearful of the dental problem, many solutions have been proposed to counteract it. Sometimes children’s dental conditions are in a special situation where pediatricians turn to the use of hypnosis in children’s dentistry [11]. Dissatisfied children with a weak collaboration attitude could delay the treatment in most cases. This artificial sleep in dentistry is done by an anesthetist and is one of the newest dental care services. Although artificial sleep does not make the child feel unfamiliar with the office environment the advantage is the dental work is accomplished while they are sleeping.

Promoting the right habits

While a child may not need a dentist at the age of two, it is important to start training oral hygiene habits as soon as possible [12-14]. During dental examinations, the pedodontist can help the child learn how to use a toothbrush, or how to use dental floss to prevent dental caries and dental diseases. Considering that good habits can be formed from childhood and adolescence, so constant referral to the dentist can enhance that.

Features of Pedodontist

a) Pediatric dentists must be an expert in child psychology and know how to deal with children; they have to able to get the patient’s confidence in the shortest possible time [4].
b) Pediatric dentist should be able to interact with the parents; should not speak harshly and should not blame parents for the delayed treatment processes [4].
c) Because the child’s patience is very limited, the dentist should be on time, and the patient should not wait for a long time in the waiting room [4].
d) During the examination, the Pedodontist must show a high degree of accuracy and focus on the problem [4].
e) During the dental procedure, he has to avoid talking about things that are not suitable for a child’s age [4].
f) Treating adolescents like adults, should be another critical criterion that a Pedodontist must pay close attention to that.

Benefits of Pediatric Dentistry

Perhaps some parents think about what the difference between dentists is. All dentists are informed about dentistry, so they can refer to any dentist for treatment. But parents may not be fully aware of the benefits of pediatric dentistry. We review these advantages.

Maintaining oral and dental health

Perhaps one of the most important benefits of pediatric dentistry is that these professionals try to keep the child’s mouth clean and healthy by using the best training and educational tools, special features, and appropriate accessories. Constant and ongoing periodic examinations can help parents alleviate the child’s oral and dental illnesses, as well as help them to take care of regularly, and identify potential problems that may appear in the future.

Preventing early teeth loss

When parents think of the health of kids’ teeth, it is better to start their job right now! Pediatric dental care ensures that the child’s teeth will be healthy, free from decay and other dental diseases in the future. Dental caries is the most common chronic infectious disease of childhood [15]. Streptococcus Mutans, Lactobacilli, Actinomyces spp. and some other anaerobic bacteria are the most primary etiologic agents of dental caries [16]. Dental services and periodic examinations of children regularly can help prevent this complication and other types of other diseases of the mouth, teeth, and gums. Diagnosis of cavities in the teeth of a child is a critical issue insomuch as the lack of continuous care and periodic examinations can lead to more acute problems, such as tooth loss shortly.

Gaining awareness of the important issues of oral health of children

Oral health has to be started at the very beginning of the baby’s birth. Even if mothers are nursing or feeding with a bottle of milk, it is necessary to start a good oral hygiene program from the very beginning and as soon as possible. Before teething, mothers should keep the gums clean with soft and wet cloth. When teeth begin to erupt, they should also be cleaned. It is essential to use the right toolset for this daily work. For example, it is necessary to buy a special toothbrush for a baby that is more suitable for his little mouth. A Pedodontist keeps them healthy by removing microbial plaques and impacted food which may be stuck in between the teeth in a routine dental examination. This is an important part of pediatric dental care because it prevents the growth of bacteria that can lead to dental diseases such as tooth decay or inflammation of the gum tissue.

Children’s dentistry and dental care

The most important background for children’s dentistry is the prevention of dental decay and intensive care for their teeth. This care should be continued under the supervision of a pediatric dentist which starts at the age of one when the baby’s teeth begin to erupt and gradually would be replaced with permanent teeth until the age of ten to twelve. It is best to take the child to a pedodontist at the earliest age and repeat this procedure every six months. This prompts not only make the child become familiar with the dental environment but also it causes the child’s fears to diminish. More importantly, in both childhood and early youth, the kid’s oral health will be under the supervision of the pediatric dentist.

The Importance of Referring to the Pediatric Dentist

Oral health is an important part of public health that plays a significant role in the quality of life of people in society, especially children. Unfortunately, the frequency of teeth decay is often high due to the lack of attention paid by both parents and children. One of the most effective measures to improve the oral and dental health of children is conducting examinations by pediatric dentists [4,12]. To refer to a pedodontist office, parents should not wait for the pain and dental problems of the child because this delay can cause more severe problems. The primary teeth are very important and depend on the evolutionary stages necessary for the health of the children’s permanent teeth. Pedodontist can help parents to provide the necessary health care for children’s oral health and give them the necessary advice. A pediatric dentist has some special skills in oral health and dental care from childhood to adolescence. He has the expertise and experience to protect and maintain and treat the teeth, gums, and oral tissues of a child of all ages. Since the first teeth have erupted, regular consultation with a pedodontist is mandatory. This visit should be done every six months. These referrals help both parents get the right information and advice on how to protect the health of the child’s teeth. Furthermore, the child will get familiar with the office environment and its staff, and get some pleasant dental experience before having caries, pain, or dental abscesses. In this case, the child will be more cooperative in future treatment sessions.

Why are Periodic Dental Referrals Essential?

Nowadays, parents should be aware of the need for periodic examinations before further destruction of children’s teeth is taken into consideration. Regarding the principle of the existence of a problem, faster treatment will ensure longer teeth life. Moreover, it will increase the function of the teeth and will include a lower cost. Because if they close their eyes to the problems, those problems will get worse every day, and these will not ever stop. Problems can be accumulated and result in tooth loss, fabricating of space maintainers and apace retainers for the edentulous area, troublous and costly orthodontic treatments, implant-prone treatments, and so on. In other words, if parents fail to take the advantage of these referrals, they will be damaging to their children’s oral health which is hard to compensate and consequently, its effects remain until the end of their lives. Effects that are being handled on time definitely would be crucial in terms of cost, pain, and the length of the period of recovery for their parents and their children.

Conclusion

Pediatric dentistry is a branch of dentistry which concerns with dental and oral health in children. Since oral and tooth injuries start in childhood and adolescence ‘prevention and treatment of these injuries are very important in this period. For this reason, pediatric dentists not only can increase the level of knowledge of children and adolescents in oral health but also can prevent many abnormalities in the mouth and teeth. On the other hand, a pedodontist in addition to knowledge of dentistry has learned the principles of behavioral control of children. The dentist will provide attractive and pain-free behavioral therapy techniques for children. It is interesting to know that some dentists manage the treatment of children with cerebral palsy, mentally retarded, or even autism. The difference between children’s dentistry and other branches of dentistry is how to deal with children.

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Lupine Publishers | The Challenges of Pediatric Dentistry in the 21st Century

 Lupine Publishers | Journal of Pediatric Dentistry

Editorial

According to the information available on the prevalence of early childhood caries in the United States and other industrialized societies and given the focus of this disease on poor children and minorities, pediatric dentistry has been focused on it. A pediatric dentist should be aware of the new challenges in keeping children free from dental caries in childhood. Today, we believe that on one hand the dental diseases, and on the other hand their prevention and control, are highly influenced by factors that are beyond the biological bacterial, sugars, and tooth factors in the Keyes interaction model. These factors include the impact of society, the system of life, and families that are not the primary biological factors. This means that the pediatric dentist should consider different factors that merely include the child, his family, and the child’s oral health. Preventive dentistry involves recognizing the effect of external factors and non-biological factors on the onset and progress of caries, especially in poor and heterogeneous societies. Nowadays, the most important considerations in childcare are as follows:

a) The importance of oral health for children as the best opportunity for preventing early childhood caries by providing preventive information to families and the role of the collaboration of general dentists and families as non-specialists in the field of dentistry.
b) The techniques of fissure sealants and composite resins, and their positions in children’s dentistry, as well as the considerations of the lifespan of these treatments in comparison with other treatments, and also concerns about dental toxicity.
c) Dentistry for disabled patients and other children with special care needs, which today have a longer lifespan thanks to medical advances, but usually dental treatments, require medication considerations, body health, and medical needs.
d) Early diagnosis and treatment of orthodontics, which is important in guiding the development of occlusion and reducing long-term future treatments. e) Complex treatments, such as sedation techniques, to control pain and anxiety of the patient, and the need for knowledge and mastery of the guidelines for the safe and practical use of these techniques.
f) The problem of developing fluorosis, due to the presence of fluoride in the environment and the need to change the therapies of fluoride therapy and their dose.
g) Obesity and other eating disorders, their effects on oral health, and the need for patient care in the dental office.
h) Extensive and complex radiographic techniques such as digital radiography and 3D imaging, providing better diagnostic information, as well as simultaneous concerns about radiation doses during childhood.
i) Substance abuse, such as painless tobacco, recreational drugs used in adolescents and pre-puberty, and misuse of prescription drugs that have become epidemic in many societies.
j) Digitization of health information, management, and ability to move them, as well as the role and the position of today’s electronic world.
k) Promote public health support activities, including the participation of dentists in health committees, school sports teams, health program counselors, and other out-of-office roles that require oral health care expertise.

Children’s dentistry is the key to health and prevention, and social macroeconomic planning at such an age can be used in a large community to reduce the teeth decays, periodontal diseases, the prevention of orthodontic treatment, the promotion of the national culture and health, and finally cost reduction of the family per capita. If prevention dentistry would be a national priority, then surely the dental insurance companies that usually do not cover the dental treatments, they will be persuaded to provide public health after a decade. This can happen only by eliminating the dangers of dental crisis which shows the importance of childhood preventive dentistry.

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Lupine Publishers | Impact in Oral Cavity due to the Use of Hydrogen Peroxyde in Dental Treatment

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Background: Chemicals agents are commonly found in people activities. It has a big role, especially in the oral cavity. The adverse effects that have been reported in cellular, animal and human studies include: chemical burn, cervical root resorption associated with non-vital bleaching; increased tooth sensitivity associated with vital bleaching; alteration in the surface topography of enamel; reduction in bond strength of resin based materials and the possibility that H₂O₂ may have carcinogenic or tumor promoting capabilities Chemical agents are often used by people. But the chemical agents can cause the damage in human body such as oral cavity.

Objectives: To know the association between dental treatment and chemical burns in oral cavity. Problem statement: In dental treatment, chemical agents are often used by dentist due to its function. But chemical agents can cause the damage in oral mucosa.

Discussion: One of the chemicals that is often found can cause chemical burn in oral mucosa is hydrogen peroxide. Hydrogen peroxides or H₂O₂ is used to decrease plaque formation and to control pyorrhea (gum inflammation). The mechanism of antimicrobial action is due to the release of nascent oxygen which is detrimental to anaerobes. It acts on both Gram positive and Gram-negative organism. H₂O₂ solutions usually do not result in severe toxicity but may cause vomiting; mild irritation to mucosa; and burns in the mouth, throat, oesophagus, and stomach. Ingestion of higher concentrations (>10%) can result in more dangerous sequelae, such as burns to mucus membranes and gut mucosa.

Conclusion: The use of chemical agents in dental treatment can cause the chemical burns in oral cavity. So, the patients need to listen more towards the dentist about the instruction after treatment so the materials cannot cause the irritation in oral mucosa.

Keywords:Oral cavity, chemical burn, dental treatment, hydrogen peroxide

Introduction

Chemicals agents are commonly found in people activities. It has a big role, especially in the oral cavity. Chemical agents are often used by people. But the chemical agents can cause the damage in human body such as oral cavity. Mucosal damage in the oral cavity can be iatrogenic during dental procedures, misuse or improper application of medicine and non-pharmaceutical substances by the patients. Chemicals that are often used in the oral cavity when dental care such as bleaching, restorations for restoration to dentures [1]. The practice of dentistry is very closely related to the use of chemicals. Inappropriate or excessive use of chemicals can cause damage to the oral mucosa. Clinical presentation of the chemical injuries might differ according to the composition and concentration, the pH of the substance, the quantity applied, the manner and duration of tissue contact, and the extent of penetration into tissue. These oral mucosal changes can vary from diffuse erosive lesions ranging from simple mucosal sloughing to complete mucosal detachment with extensions into the submucosa [2]. Dental treatments which were provided by dentists cannot be separated from chemical agents that actually have an impact on the body, but the dentists use them as needed so that often it does not have an impact on the oral mucosa. One of the chemicals that is often found can cause chemical burn in oral mucosa is hydrogen peroxide [3].

Hydrogen peroxide (H₂O₂) is a colorless liquid with a bitter taste and is highly soluble in water to give an acidic solution. H₂O₂ is an oxidizing agent with a wide number of industrial applications in for example, bleaching or deodorizing textiles, wood pulp, hair, fur and foods, in the treatment of water and sewage, as a seed disinfectant and neutralizing agent in wine distillation. Low concentrations of H2O2 have been found in rain and surface water, in human and plant tissues, in foods and beverages and in bacteria. Hydrogen peroxide is a reactive oxygen species, along with superoxide (O₂-), hydroxyl (HO), peroxyl (ROO) and alkoxyl (RO). In human tissue, intrinsic sources of H₂O₂ are organelles (especially mitochondria), salivary cells, microorganisms, and the lungs. Hydrogen peroxide production can be followed by the liberation of highly reactive oxygen species in the body via enzymatic and spontaneous redox reactions that often involve interaction with transitional metals such as iron or copper [4]. Enzymes such as catalase, glutathione peroxidase and superoxide dismutase catalyze the decomposition of H₂O₂ into water and oxygen. Reactive oxygen radicals are a potential source of cell damage through causing DNA strand breaks, genotoxicity, and cytotoxicity, but these radicals tend neither to cross biological membranes nor travel large distances within a cell. Antioxidants provide a source of electrons that reduce hydroxyl radicals to water. However, when exogenous H₂O₂ levels overwhelm cellular protective mechanisms, H₂O₂ presents a health hazard. Individuals with catalase lack catalase activity, leading to high endogenous H₂O₂ levels causing necrosis and ulceration of soft and hard tissues [5]. Hydrogen peroxides or H₂O₂ is used to decrease plaque formation and to control pyorrhea (gum inflammation). The mechanism of antimicrobial action is due to the release of nascent oxygen which is detrimental to anaerobes. It acts on both Gram positive and Gram-negative organism. The other mechanism of antimicrobial property is the effect of H₂O₂ on debridement of bacterial cell walls [6]. It is widely used professional and self‑administered dental product. The most common applications of H₂O₂ include Mouth rinse (1%–3%) and bleaching agent (3%–5%). As patients' needs for aesthetic dental treatment shift from traditional treatment including caries and dentures to esthetic treatment, an increasing number of people are visiting the dental office with hopes for whiter teeth. Over the counter (OTC) bleaching products are sold as cosmetics and are freely available through stores, pharmacies, and the Internet. Although in-office bleaching is a particularly popular method for bleaching, the bleaching agent may sometimes come into contact with the patient's gingiva or oral mucosa during the in-office bleaching procedure, even if the gingiva is protected with a light-cured resin or rubber dam and bleaching is performed by an experienced dentist. This may result in temporary whitening and pain in the gingiva or oral mucosa, but the pain subsides within a few hours and the whitened spot eventually regains its original color. This has also been reported with at-home bleaching [7,8] (Table 1).

Table 1: Exposure to Hydrogen Peroxide.

A study investigate the toxicity of in-office bleaching agents on gingiva, Hydrogen peroxide can be toxic in high concentrations and with exposures of prolonged duration, concentrated (30-35 per cent) hydrogen peroxide solutions have been used for in-office bleaching treatments with had adverse soft and hard tissue effects observed clinically, one of them might be chemical burn. Nevertheless, there have been occasions when accidental ingestion of hydrogen peroxide products in the home has led to hospitalization and adverse health outcomes, and this should be kept in mind when assessing the relative safety of hydrogen peroxide-containing products for home (unsupervised) use. Concerns have been expressed over the potential adverse effects of the use of H₂O₂ in dental treatment. The adverse effects that have been reported in cellular, animal and human studies include: chemical burn, cervical root resorption associated with non-vital bleaching; increased tooth sensitivity associated with vital bleaching; alteration in the surface topography of enamel; reduction in bond strength of resin based materials and the possibility that H₂O₂ may have carcinogenic or tumor promoting capabilities [9,10]. Aim of this article is to know the association between dental treatment and chemical burns in oral cavity due to chemical agents used especially impact H₂O₂.

Discussion

The response of mammalian cells to H₂O₂ is highly variable, dependent on factors such as catalase concentration and DNA repair activity. In one study, H₂O₂ induced a dose-dependent increase of hypoxanthine guanine phosphoribosyl transferase (HPRT) mutations in vitro in human T lymphocytes, most mutations being of the same kind as observed in T cells in vivo. Another study, using human lymphocytes, assessing genotoxicity showed the main event induced by extracellular application of H₂O₂ to be necrosis and not micronucleus formation [10,11].

Stomatitis

Oral ingestion of 3% H₂O₂ solutions usually do not result in severe toxicity but may cause vomiting; mild irritation to mucosa; and burns in the mouth, throat, oesophagus, and stomach. Ingestion of higher concentrations (>10%) can result in more dangerous sequelae, such as burns to mucus membranes and gut mucosa. It shows a dose‑dependent reaction where at high concentration eugenol causes adverse effect on fibroblast‑.and osteoblasts‑like cells. This leads to localized necrosis and compromised healing. In lower concentration, it causes localized hypersensitivity reactions to oral mucosa called “contact stomatitis” and on dermis causes “contact dermatitis,” possibly because it can react directly with proteins to form conjugates and reactive happens [5,11] (Figure 1). Study before found that almost no cytotoxicity from H₂O₂ was seen in the low-concentration stimulation group (1.5 × 10−3% or less) at any duration other than 60 minutes. However, 60-minute stimulation resulted in cytotoxicity at all concentrations. Stimulation at 15% H₂O₂, which is similar to the concentration used in clinical practice, showed marked cytotoxicity, lowering cell survival by half at 90 seconds (p<0.05), which is the shortest time period examined. Using the same stimulation samples as in the section above, microarray was used to analyze the gene clusters that were suppressed from the addition of vitamin E among the gene cluster induced by H₂O₂ stimulation. The results confirmed that H₂O₂ stimulation induced the expression of genes associated with the proinflammatory cytokine TNF-α cascade. Expression of these genes was suppressed with vitamin E addition. These results demonstrate that H₂O₂ stimulation response includes triggering the proinflammatory cytokine TNF-α cascade and that addition of vitamin E suppresses the response of this cascade [12,13].

Figure 1: Concentration of H₂O₂ and its absorbance.

Gingival inflammation

Study in vitro examinations of signs such as whitening of the gingiva and pain that may result from tooth whitening. No studies to this effect in HGFs have been reported from at-home bleaching agents but mostly result from in-office bleaching agents and OTC products. Many studies have been carried out on tooth hypersensitivity from in-office or at-home bleaching agents. From in vitro studies, it has been concluded that whitening agents histologically penetrate the dentin and do not damage the pulp.  In current dental practice, pain incurred during the procedure is generally treated with medication or fluoride or by stopping the procedure. Several studies examining plaque control as an index have shown that whitening agents reduce plaque on the gingiva and reduce gingival inflammation.  Hydrogen peroxide and carbamide peroxide have been used for debridement during endodontic therapy, in mouth rinses to reduce plaque in individuals with gingivitis, and for treatment of periodontal diseases [13,14]. Gingival fibroblasts are known to be affected by H₂O₂.However, studies have shown that fibroblasts in other parts of the body are more strongly affected.  In the present study, highly concentrated H₂O₂ caused inflammation in gingival fibroblasts and had toxic effects, with marked changes in cell morphology. One study found that higher concentrations of H₂O₂ caused senescence-like changes in cells. It has long been known from in vivo animal experiments that H₂O₂ causes acute inflammation and even edema in skin. Simon and other  have shown H₂O₂ to cause necrosis in human fibroblasts. Cells are protected by various types of enzymes and other substances and manage the immune system that responds to inflammation. Inferring from the above studies, it is possible that H₂O₂ penetrates the cell membrane to cause damage, so that enzymes cannot do their job [15,16].

Chemical burn

Recent studies have reported gingival irritation and chemical burn after at-home bleaching. Kirsten and others reported that patients experienced gingival irritation from at-home bleaching both immediately after the procedure and up to 45 days following treatment. Another study reported that hypersensitivity and gingival irritation disappeared within two days after in-office bleaching. Previous investigations have shown that 15% of patients reported gingival irritation after in-office bleaching, but it was possible to safely control contact of the bleaching gel with the gingival margin by using light-cured gingival dams [17,18]. Among the human genes listed in Table 2, TNFSF10 belongs to the tumor necrosis factor (TNF)–α ligand superfamily. TNFRSF4 and TNFRSF19 belong to the TNF-α receptor superfamily (TNFRSF). Other authors have examined the gingiva and proinflammatory cytokines. Two types of in-office were examined for bleaching agent and one type of at-home bleaching agent. Found that interleukin (IL)–1β expression increased with in-office bleaching but that there was no change in the expression of IL-10. In inflamed tissue, macrophages and other cells of the innate immune system synthesize TNF-α, a proinflammatory cytokine, to fight off infection and treat tissue damage. This TNF-α then binds to cell surface receptors and induces the production of other cytokines, triggering and maintaining inflammation. It is possible that H2O2 came into contact with the gingiva triggered a cellular response through the inflammatory cascade via TNF-α resulting in chemical burn [19,20].

Table 2: Correlation between H₂O₂ and its impact to human gene.

Carcinoma potential

Another study also reported that using hydrogen peroxide and alcohol on a daily/weekly basis encourages the promotion of malignant neoplasm in the oral mucosa. Alcohol, for instance, potentiates in 50 times the harm caused by tobacco. Mouth washing with hydrogen peroxide, using products made with alcohol or drinking alcohol everyday may lead to the risk of oral chemical carcinogenesis. Also known as urea peroxide, sodium perborate, carbamide peroxide or other less common names, the hydrogen peroxide may have deleterious effects on the enamel, dentin, cementum, pulp and gingiva [6]. These names vary according to the presentation and formulation of the product. However, if both formulation and presentation of the product are controlled, and if the product is properly applied by a professional who takes the appropriate compensatory measures, its use is safe. In the oral mucosa, hydrogen peroxide potentiates the effect of many other carcinogenic agents found in patient's mouth. These carcinogenic agents may originate from food, cosmetics, hygiene products, pesticides, herbicides, tobacco, alcohol, virus, among others. Such potentiation happens due to the fact that these products are promoting agents of oral chemical carcinogenesis [21]. In mice low doses of hydrogen peroxide (0.1% and 0.4%) administered in drinking water caused adenomas or adenocarcinomas in the duodenum. These findings have been questioned and it has been proposed that the most likely cause of the lesions observed were the decreased water consumption of the mice and resultant abrasion of the luminal lining on ingestion of pelleted dry rodent food. Another animal study suggested that a known tobacco carcinogen 9, 10-dimethyl-1, 2-benzanthracene (DMBA) could be augmented in producing carcinogenesis in the buccal epithelium of hamsters by 3% H₂O₂.These results have been disputed due to the small number of animals studied. Further studies in hampsters given up to 70mg/kg of H₂O₂ by oral intubation for up to six months or up to 3% H₂O₂ in combination with DMBA applied five times daily for 16-20 weeks on the buccal epithelium did not show any sign of carcinogenesis. Further studies on skin have concluded that H₂O₂ is inactive as a tumour promoter or carcinogen [22,23].

Impact in root resorption and tooth sensitivity

An adverse effect that has been reported following internal tooth bleaching is cervical root resorption (an inflammatory-mediated external resorption of the root). Summarizes the available data to support a correlation between internal tooth bleaching and cervical root resorption. In these cases, it is very difficult to distinguish if the root resorption noted was due to the effect of the bleach or the trauma [21,24]. A high concentration of hydrogen peroxide in combination with heating seems to promote cervical root resorption. The underlying mechanism for this effect is unclear, but it has been suggested that the bleaching agent reaches the periodontal tissues through the dentinal tubules and initiates an inflammatory reaction.  In vitro studies using extracted teeth showed that  hydrogen peroxide placed in the pulp chamber penetrated the dentine, that heat increased the penetration and that the penetration is greater in teeth with cervical cemental defects. Intracorneal bleaching with 30% hydrogen peroxide reduces the micro-hardness of dentine and enamel  and mechanically weakens the dentine [5,19].

Case reports and small clinical studies have confirmed that a 10% carbamide peroxide gel used in a bleaching tray at night, (the so-called nightguard vital bleaching technique), produces predictable tooth whitening as do H₂O₂ strips and 'power bleaching' using 35% H₂O₂ with or without light and/or heat activation. Tooth sensitivity is a common adverse effect of external tooth bleaching. Data from various studies of 10% carbamide peroxide indicate that from 15-65% of patients reported increased tooth sensitivity. Higher incidences of tooth sensitivity (from 67-78%) were reported after bleaching with H₂O₂ in combination with heat [22,25]. There are many carcinogenic products available for sale, for instance: alcoholic beverages, cigarettes, ground tobacco, medicines, insecticides and others. These products are sold directly to the consumer after warnings and awareness campaigns had been carried out. That is how democracy works; products are sold directly to the consumers, but with a wide range of awareness, classification and explanatory campaigns stating that these products are carcinogenic. Hydrogen peroxide reddens the mucosa and gingiva by wounding them with tissue dissolution and inflammation. Hydrogen peroxide burns and may lead to necrosis of gingival papillae. It completely cleans the teeth because it demineralizes the enamel and also removes dirt or pigments. The enamel becomes porous and food stains it even more, increasing the need for mouth washing. Enamel becomes thicker every day. Should there be any restoration, it will induce microleakage through its interface with the tooth, causing the enamel to come out easily while eating [22,26].

If burning the mucosa and demineralizing the enamel were the biggest problems, we could think about using hydrogen peroxide with moderation. However, the biggest problem is that hydrogen peroxide is a promoting agent. In other words: it potentiates the effect of inducers of oral, throat, esophagus, stomach, and intestine cancer. Pesticides, tobacco products, alcohol, HPV and other oncogenic viruses, sunray and chemicals found in industrialized food are potentiated by hydrogen peroxide. Many doctoral dissertations, master's thesis, research and books confirm what the literature has already proved by means of different methodologies. In vivo chemical carcinogenesis experiments prove the carcinogenic effect of hydrogen peroxide on the mucosa that receives tooth bleaching products, antiseptics, and toothpaste [20,27]. Dental bleaching is based on the ability of H₂O₂ to penetrate through tooth structure and produce free radicals to oxidize the colored organic molecules. There are many reports investigated the effect of dose and exposure time of H₂O₂ to the pulpal tissues as the bleaching agents penetrated through the tooth structure.  The safety of H₂O₂ tooth bleaching is still controversial: its genotoxicity and carcinogenicity are under active discussion. Diaz-Llera et al. showed that 0.34–1.35 μM of H₂O₂ induced hypoxanthine guanine phosphoribosyl transferase (HPRT) mutation both in vitro and in vivo. High-dose H₂O₂ was reported to be mildly carcinogenic for the duodenum of catalase-deficient mice. In another report, 1% H₂O₂ (~ 0.3 M) in drinking water induced forestomach tumors in rats. These reports showed that exposure to high-dose H₂O₂ for a sustained period induces oxidative stress that leads to DNA damage in mammalian cells [26,27].

Conclusions

The use of chemical agents in dental treatment can cause the chemical burns in oral cavity. So, the patients need to listen more towards the dentist about the instruction after treatment so the materials cannot cause the irritation in oral mucosa.

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