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

Chemicals agents are commonly found in people activities. It
has a big role, especially in the oral cavity. Chemical agents are often...


377
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 (H 2 O 2 ) is a colorless liquid with a bitter taste and is highly soluble in water to give an acidic solution. H 2 O 2 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 (O 2 -), hydroxyl (HO), peroxyl (ROO) and alkoxyl (RO). In human tissue, intrinsic sources of H 2 O 2 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 H 2 O 2 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 H 2 O 2 levels overwhelm cellular protective mechanisms, H 2 O 2 presents a health hazard. Individuals with catalase lack catalase activity, leading to high endogenous H 2 O 2 levels causing necrosis and ulceration of soft and hard tissues [5].
Hydrogen peroxides or H 2 O 2 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 H 2 O 2 on debridement of bacterial cell walls [6]. It is widely used professional and self-administered dental product. The most common applications of H 2 O 2 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).

Stomatitis
Oral ingestion of 3% H 2 O 2 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

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].  [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].

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 Further studies on skin have concluded that H 2 O 2 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 inflammatorymediated 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.
Case reports and small clinical studies have confirmed that a 10% carbamide peroxide gel used in a bleaching tray at night,

Volume 4 -Issue 5
Copyrights @ Nanda Rachmad Putra Gofur, et al. Inter Ped Dent Open Acc J 381 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 forestomach tumors in rats. These reports showed that exposure to high-dose H 2 O 2 for a sustained period induces oxidative stress that leads to DNA damage in mammalian cells [26,27].

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.