ArticlePDF AvailableLiterature Review

Abstract

Clinical Relevance Tooth whitening is observable with all methods of bleaching. Dentist-prescribed overnight bleaching was shown to be the most effective method of bleaching.
©Operative Dentistry, 2009, 34-2, 230-235
Review of the
Effectiveness of Various
Tooth Whitening Systems
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Review of the
Effectiveness of Various
Tooth Whitening Systems
©Operative Dentistry, 2009, 34-2, 230-235
BA Matis • MA Cochran • G Eckert
Clinical Relevance
Tooth whitening is observable with all methods of bleaching. Dentist-prescribed overnight
bleaching was shown to be the most effective method of bleaching.
SUMMARY
This review compares nine published studies
conducted at the Indiana University School of
Dentistry. Twenty-five products in four different
systems were evaluated using the Trubyte
Bioform Color Ordered Shade Guide and a
Chroma Meter. The dentist-prescribed overnight
bleaching delta mean shade guide value (DSGV)
10 weeks post-bleaching was 13.2 and delta E
value (DEV) 4.7; dentist-prescribed daytime
bleaching DSGV 10 weeks post-bleaching was
10.5 and DEV 3.4; in-office bleaching DSGV 10
weeks post-bleaching was 6.7 and DEV was 2.1;
over-the-counter bleaching DSGV two weeks
post-bleaching was 7.2 and DEV was 4.1. A color
difference of Delta E 2.6 is perceivable. Tooth
whitening is observable with all methods of
bleaching. Dentist-prescribed overnight bleach-
ing was shown to be the most effective method of
bleaching.
INTRODUCTION
“Doctor, I want a whiter, brighter smile. What kind of
bleaching works best?” Today’s dentist is acutely aware
of the value of tooth bleaching to his or her practice and
patients, but they want to provide treatment based on
reliable evidence. The challenge for dentists is to deter-
mine the effectiveness of various tooth-whitening sys-
tems, while keeping patients’ safety paramount. This
has become more and more difficult, as manufacturers
continue to provide new products that purport to be
superior to others currently on the market. Numerous
claims are made based on higher concentrations of an
active agent, the addition of desensitizing agents, better
*Bruce A Matis, DDS, MSD, professor, director of Clinical
Research Section, Indiana University School of Dentistry,
Department of Restorative Dentistry, Indianapolis, IN, USA
Michael A Cochran, DDS, MSD, professor, director of Graduate
Operative Dentistry Program, Indiana University School of
Dentistry, Department of Restorative Dentistry, Indianapolis,
IN, USA
George Eckert, MAS, biostatistician, Indiana University School
of Medicine, Division of Biostatistics, Indianapolis, IN, USA
*Reprint request: 1121 West Michigan Street, Indianapolis, IN
46202, USA; e-mail: bmatis@iupui.edu
DOI: 10.2341/08-74
Literature Review
formulations or the use of lights or other innovations,
although it is a well known fact that dental bleaching is
primarily time- and concentration-dependent.1
While many studies have been published detailing
the effectiveness of various bleaching agents, there are
only a few that have looked at both in-office and at-
home systems.2-3 It is also very difficult to make valid
comparisons between research accomplished at differ-
ent sites using diverse instruments and techniques.
Most published studies use the Vitapan classical Shade
Guide (Vita Zahnfabrik, Bad Sackingen, Germany) for
subjective evaluation, but it has not been demonstrat-
ed that the shade tabs are actually linear in color meas-
urement.4The Trubyte Bioform Color Ordered Shade
Guide is grouped according to the Munsell Color
Notation (each tab identified by hue, chroma and value)
and has a wider spectrum of shades, but this shade
guide still cannot be interpreted as absolute. A new
shade guide has recently been introduced with more
equal color spaces and an extended tooth-whitening
range.5Several different color-measuring instruments
are being used for objective evaluation, but their values
cannot currently be compared. In addition, the skill of
the evaluator and lighting variables are other factors
that need to be addressed and are challenging to con-
trol.
The American Dental Association (ADA) has recently
revised its criteria for the Seal of Acceptance program
with dentist-prescribed at-home,6in-office7and over-
the-counter8products, certifying the safety and efficacy
of those products to a certain measurable standard.
Only one dentist-prescribed at-home product has been
awarded the ADA Seal of Acceptance at this time.9Even
though the guidelines for ADA acceptance have recent-
ly been revised for the efficacy of products, the biologi-
cal safety criteria have not been changed since they
were established in 1994.10
In an attempt to provide an evidence-base for the den-
tal practitioner, the purpose of this review article is to
compare the effectiveness of various methods of tooth
whitening by evaluating articles where most of the
objective and all of the subjective evaluations were con-
ducted using the same instruments. All study protocols
were approved by the IUPUI Institutional Review
Board, Indianapolis, IN, USA, and informed consent
statements were signed by the subjects in the nine ref-
erenced studies.
COMPARABLE STUDIES
All of the studies cited in this review of tooth whiten-
ing agents:
used the Trubyte Bioform Color Ordered
Shade guide (Style A, Dentsply/York Division,
Dentsply International Inc, York, PA, USA) as
the subjective color evaluation instrument.
were evaluated by the same person (except for
one11) who has lectured to dental students on
color and shade evaluation for more than 25
years.
used the Chroma Meter CR 321 (Minolta
Corporation, Ramsey, NJ, USA)12 with the
exception of two; one used the Chroma Meter
CR 121,11 and the other used the ShadeEye
(Shofu Inc, Kyoto, Japan).13 Each subject was
evaluated for color using the Chroma Meter
and utilized a customized cone that was disin-
fected between uses, while those evaluated
with ShadeEye had a disposable cone used for
each evaluation.
were carried out in an area that had color-cor-
rected lighting and were not influenced by out-
side light.
used subjects who were enrolled with the same
Inclusion/Exclusion criteria (Table 1), except
for the study using over-the-counter products.13
Smoking was not an exclusion factor in that
study.
The data used in this review represent values from
the time dental bleaching was discontinued, as it
would not be appropriate to begin when the studies
were initiated. The in-office products would be two
weeks ahead in the reversal of color when compared
with those products that have one or two weeks of
bleaching before reversal of color would begin.
Some of the reported studies were carried out for a
much longer period than other studies. The data for
this comparison were carried out to only 10 weeks for
those studies that go longer, so that products could be
compared.
Due to space limitations, only E and shade guide val-
ues are presented in this review; however, L*, a* and
b* values are available from the referenced articles.
The ADA states in the guidelines for acceptance of
tooth bleaching products that the E value specified
must be due to higher L* and lower b* values.6-8 E val-
ues are included in the current review, because they
come closest to the ability of the human eye to perceive
color.
Each study was accomplished for a specific research
objective. Six studies in this meta analysis were split-
mouth design studies, where different sides of the
mouth used a different formula, different times or con-
centrations. This is the most effective way to conduct
clinical research on products, because, if all teeth are
vital, then the potential for whitening of the contralat-
eral teeth will be similar. It has been reported that
crossover has not influenced color changes,14 if trays
are made carefully and excess gel is not dispensed into
the trays at the time of testing. One of the split mouth
231
Matis, Cochran & Eckert: Review of the Effectiveness of Various Tooth Whitening Systems
232
Operative Dentistry
design studies compared the efficacy of a 10%
CP vs a 15% CP.14 Another study compared the
sensitivity reduction that occurs using a 15% CP
product containing potassium nitrate and fluo-
ride (PF) compared with another 15% CP prod-
uct containing amorphous calcium phosphate
(ACP).15 The objective of another study was to
determine whether the use of reservoirs during
daytime bleaching made a difference in the
effectiveness of a product,16 while another study
tested the null hypothesis that there was no dif-
ference between using the same equivalent con-
centrations of HP in agents containing HP and
CP17 and the last split mouth study that com-
pared the use of at-home vs in-office tooth-
whitening agents.3
Three studies in this meta analysis were not
accomplished as split-mouth design studies, but
on different cells of subjects. Included are two
studies where the authors tested the null
hypothesis that there are no differences
between the effectiveness of different in-office
products.18-19 The null hypothesis that there was
no difference between the efficacy of using
whitening strips compared with whitening
Figure 1. Mean delta shade of products evaluated at the Clinical Research Section of
the Indiana University School of Dentistry. Baseline assessments were made two
weeks before the end of bleaching for at-home night time and at-home daytime prod-
ucts one week before the end of bleaching for OTC products and approximately two
hours before the end of bleaching for in-office products.
Study # Products Concentration N Bleaching Time of Bleach Post-Bleaching Length of
Study
3 Opalescence 10% CP 20 2 Weeks Overnight 10 Weeks 12 Weeks
StarBrite 35% HP 20 2 Weeks 2-3 x 10 Minutes 10 Weeks 12 Weeks
11 Opalescence 10% CP 30 2 Weeks Overnight 22 Weeks 24 Weeks
Placebo 0% CP 30 2 Weeks Overnight 22 Weeks 24 Weeks
13 Whitestrip Supreme 10% HP 25 1 Week 2 x 30 Minutes 2 Weeks 3 Weeks
Ranir Wrap 8% HP 26 1 Week 2 x 30 Minutes 2 Weeks 3 Weeks
Ranir Wrap 8% HP 25 1 Week 30 Minutes 2 Weeks 3 Weeks
14 Opalescence 10% CP 25 2 Weeks Overnight 4 Weeks 6 Weeks
Opalescence 15% CP 25 2 Weeks Overnight 4 Weeks 6 Weeks
15 Opalescence 15% CP + PF 32 2 Weeks Overnight 10 Weeks 12 Weeks
Nite White 16% CP +ACP 32 2 Weeks Overnight 10 Weeks 12 Weeks
16 Rembrandt Xtra 16% CP 27 2 Weeks 2 Hours 10 Weeks 12 Weeks
Rembrandt Xtra 16% CP 27 2 Weeks 2 Hours 10 Weeks 12 Weeks
17 Opalescence 20% CP 24 2 Weeks 2 x 60 Minutes 10 Weeks 12 Weeks
Day White 7.5% HP 24 2 Weeks 2 x 60 Minutes 10 Weeks 12 Weeks
18 StarBrite 35% HP 20 1 Hour In chair 11 Weeks 11 Weeks
Opalescence Xtra B 38% HP 20 1 Hour In chair 11 Weeks 11 Weeks
19 Accelerated 40% HP 4 15 Minutes In chair 6 Weeks 6 Weeks
ArcBrite 30% HP 4 1 Hour In chair 6 Weeks 6 Weeks
BriteSmile 15% HP 4 1 Hour In chair 6 Weeks 6 Weeks
Illumine 15% HP 4 1 Hour In chair 6 Weeks 6 Weeks
Niveous 27% HP 4 45 Minutes In chair 6 Weeks 6 Weeks
One-Hour Smile 35% HP 4 45 Minutes In chair 6 Weeks 6 Weeks
PolaOffice 35% HP 4 36 Minutes In chair 6 Weeks 6 Weeks
Zoom! 25% HP 4 1 Hour In chair 6 Weeks 6 Weeks
Table 1: Products, concentration, subject number, bleaching, time of bleaching, post bleaching and length of studies.
233
Matis, Cochran & Eckert: Review of the Effectiveness of Various Tooth Whitening Systems
wraps was tested in one study.13 The last of the nine
studies was accomplished to determine the efficacy
and clinical safety of 10% CP and was accomplished
using a placebo vs 10% CP in separate subjects.11
All peer-reviewed published studies that were accom-
plished at the Clinical Research Section at the Indiana
University School of Dentistry are included in this
meta analysis. Table 1 identifies the studies, products
used, concentrations, number of subjects, bleaching
times and post-bleaching follow-up evaluations. These
studies had examinations at slightly different follow-
up times, so the data are summarized at the end of
bleaching, then at approximately 1, 2, 4, 6 and 10
weeks after completion of the bleaching. Because all
data from the individual studies was available, this
meta analysis was performed using an ANOVA. The
ANOVA included terms for week, tooth type and prod-
uct, as well as interactions among the three factors
and baseline measurements as covariates. Random
effects for study, subject, subject-by-week and subject-
by-tooth type were also included. Products were
grouped together to identify means, along with 95%
confidence intervals for the means, ranges and average
% loss from the end of bleaching (Table 2).
Dental Prescribed Overnight Bleaching
There are four studies in which a total of six products
were used overnight.3,11,14-15 Three of the studies used
10% CP,3,11,14 and another study used 15% and 16% CP.15
The mean delta of the shade guide values of the six
products was 16.3 immediately after bleaching and
13.2 ten weeks post-bleaching (Table 2, Figure 1). The
Group Weeks Mean 95% CI Min Max %Loss
Delta E At-home
Overnight 0 9.7 8.3 - 11.2 1.0 19.6
1 6.7 5.2 - 8.2 1.4 18.6 31%
4 4.9 3.5 - 6.4 0.4 15.9 49%
10 4.7 3.0 - 6.5 1.6 13.4 51%
At-home
Daytime 0 6.6 4.6 - 8.5 1.7 15.6
1 4.6 2.6 - 6.6 0.8 14.2 30%
4 3.4 1.5 - 5.4 0.8 6.8 48%
10 3.4 1.4 - 5.4 1.2 12.6 48%
In-office 0 5.4 3.2 - 7.5 1.2 11.1
1 3.0 0.4 - 5.5 0.9 9.8 45%
2 2.3 0.0 - 5.2 1.0 7.1 57%
4 2.0 0.0 - 4.1 0.7 6.1 63%
6 1.9 0.0 - 4.7 0.8 4.4 65%
10 2.1 0.0 - 4.3 1.2 6.3 60%
OTC 0 4.6 1.8 - 7.3 0.8 7.3
2 4.1 1.4 - 6.9 0.6 7.3 10%
Delta Shade At-home
Overnight 0 16.3 15.1 - 17.5 2.0 25.0
1 14.8 13.6 - 16.1 1.0 25.0 9%
4 13.6 12.3 - 14.8 0.0 22.0 17%
10 13.2 11.8 - 14.6 1.0 23.0 19%
At-home
Daytime 0 12.8 11.1 - 14.5 5.3 20.0
1 11.8 10.1 - 13.5 4.7 19.7 8%
4 11.1 9.4 - 12.8 4.3 18.3 13%
10 10.5 8.9 - 12.2 4.0 17.7 18%
In-office 0 9.6 7.6 - 11.5 -1.3 19.2
1 8.3 6.0 - 10.6 1.0 16.7 13%
2 7.0 4.5 - 9.6 -1.3 14.0 26%
4 6.3 4.3 - 8.2 -3.0 15.7 34%
6 5.9 3.3 - 8.4 -3.0 14.8 39%
10 6.7 4.8 - 8.5 -4.3 17.7 30%
OTC 0 7.8 5.7 - 9.9 0.0 16.0
2 7.2 5.2 - 9.3 0.0 16.0 7%
Table 2: Mean, 95% confidence interval for the mean, minimum, maximum and average percent loss of delta E and delta
shade guide for each tooth whitening system.
234
Operative Dentistry
mean delta of the E value was 9.7 immediately
after bleaching and 4.7 ten weeks post-bleach-
ing (Table 2, Figure 2).
Dental Prescribed Daytime Bleaching
There are two studies in which four products
were used during the day.16-17 One study used
16% CP, which was used for two hours once a
day16 either with or without reservoirs. The
other study used products containing 20% CP
and 7.5% HP. The products in that study were
used twice a day for one hour.17
The mean delta of the shade guide values of
the products was 12.8 immediately after bleach-
ing and 10.5 ten weeks post bleaching (Table 2,
Figure 1). The mean delta of the E value was 6.6
immediately after bleaching and 3.4 ten weeks
post bleaching (Table 2, Figure 2).
In-office Bleaching
There were three studies in which 11 in-office
products were used.3,18-19 One study used 35% HP,
which was placed three times for 10 minutes at
two different sittings.3The second study used
35% and 38% HP, which were placed three times
for 20 minutes each at the same sitting.18 The
third study used eight products containing any-
where from 15%-40% HP.19 The eight products were
used for various periods of time (Table 1).
The mean delta of the shade guide values of the 11
products was 9.6 immediately after bleaching and 6.7
ten weeks post-bleaching (Table 2, Figure 1). The mean
delta of the E value was 5.4 immediately after bleach-
ing and 2.1 ten weeks post-bleaching (Table 2, Figure 2).
Over-the-counter Bleaching
There is one study in which products were used three
different ways.13 One product contained 10% HP and
was used for 30 minutes twice a day for one week. Both
of the other agents contained 8% HP. One was used for
30 minutes once a day and the other for 30 minutes
twice a day for one week.
The mean delta of the shade guide values of the three
products was 7.8 immediately after bleaching and 7.2
two weeks post-bleaching (Table 2, Figure 1). The mean
delta of the E value was 4.6 immediately after bleach-
ing and 4.1 two weeks post-bleaching (Table 2, Figure 2).
DISCUSSION
All groups in the study had at least 20 subjects, with
the exception of one study, where eight products were
evaluated using 32 subjects. This was considered a pilot
study.19 Six of the studies were half-mouth design stud-
ies.3,14-18 This study design is the most valid study design
for tooth-whitening research. Each tooth in the half-
mouth responds to the agent that covers it. With well-
made reservoirs, it has been determined that crossover
effects, if there were any, are negligible.14
Manufacturer ’s recommendations were followed.
Where reservoirs were recommended, they were placed.
In the study of eight in-office products,19 invitations to
observe the procedures were extended to all of the man-
ufacturers whose products were used in the study. Four
of the eight manufacturers sent representatives to help
ensure their products were used according to their
instructions.
A study by Auschill and others evaluated the time it
took for tooth whitening agents from different systems
to reach six Vita shade guide tab changes.2These
authors determined that it took 31.85 cycles of 30 min-
utes using an over-the-counter product, 7.15 cycles of
using an at-home product overnight and 3.15 cycles of
using an in-office product to reach the shade tab change
desired.
The research center at Loma Linda University School
of Dentistry, Loma Linda, CA, USA, routinely uses a
colorimeter and Vitapan classical Shade Guide (Vita
Zahnfabrik) to measure changes in color. In their study
evaluating the effectiveness of three tooth-whitening
systems, Li and others reported that the overnight sys-
tem was the most effective of the three systems in a 21-
day study.20
Neither of the studies that looked at three different
systems carried out their evaluation periods past the
endpoint of bleaching. It is important to look at color
Figure 2. Mean delta E of products evaluated at the Clinical Research Section of the
Indiana University School of Dentistry. Baseline assessments were made two weeks
before the end of bleaching for at-home night time and at-home daytime products one
week before the end of bleaching for OTC products and approximately two hours
before the end of bleaching for in-office products.
235
Matis, Cochran & Eckert: Review of the Effectiveness of Various Tooth Whitening Systems
reversal for at least four weeks after completion of the
bleaching, so that the true endpoint can be identified,
instead of a false endpoint that does not indicate what
color patients can expect their teeth to remain for an
extended period of time.
There are only two in vivo studies that have deter-
mined the perceptibility of color using a colorimeter.21-22
In one study,21 it was found that a mean color of 3.7
Delta E units between composite veneers and sound
teeth was rated as a perfect match in the oral environ-
ment. In the other in vivo study,22 it was found that 50%
of the observers could perceive a color difference of 2.6
Delta E units with interchangeable right and left den-
ture teeth in a denture base.
The current study compared products used for a cer-
tain time period. Bleaching is time- and concentration-
dependent. The current study documents the relative
lightening that has been shown to occur where research
has been conducted with various systems according to
manufacturers’ recommendations.
CONCLUSIONS
Tooth whitening is most effective when bleaching gel is
placed in trays and the trays are used overnight. The
second most effective system is placing the tooth
whitening gel in a tray and using it during the daytime
for shorter periods of time.
In-office tooth whitening systems cause the teeth to
become light immediately after bleaching. However,
two weeks after completing the bleaching treatment,
over-the-counter tooth whitening was as effective as in-
office tooth whitening. For this reason, most in-office
systems recommend tray bleaching as a follow-up pro-
cedure to ensure long-term effectiveness.
(Received 29 May 2008)
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Purpose: The purpose of this study was to evaluate the effect of ultraviolet ray (UV) on tooth bleaching using titanium dioxide photo catalyst in vitro. Materials and Methods: Hematoporphyrin-stained paper (HSP) and artificially discolored bovine teeth (BT) were bleached by an in-office bleaching material containing low concertation of hydrogen peroxide and titanium dioxide photocatalyst. For the bleaching, light irradiation was performed at wavelengths of 265, 310, 365, 405, and 450 nm for HSP, and 265, 300, and 405+470 nm for BT. Before and after bleaching, color was measured to obtain CIE L*a*b* values. The color differences (ΔE) were calculated and were statistically analyzed. Results: In the HSP experiment, the 265 and 310 nm groups showed a remarkable bleaching effect and ΔE of the 310 nm group was statistically the highest (p < 0.05). In the BT experiment, ΔE of the 265 nm group was statistically the highest followed by 300 nm, then 405+470 nm groups (p < 0.05). Conclusion: UV-C (265 nm) and UV-B (300 and 310 nm) showed high bleaching effect with an in-office bleaching material containing low concentration of hydrogen peroxide and titanium dioxide photocatalyst.
... The perception of tooth sensitivity in the group that received athome treatment was statistically related to the higher average impact of OHRQoL after the bleaching procedure. Many factors are known to increase sensitivity, such as high concentrations of oxidative agents, high enamel permeability, prolonged use of bleaching agents, and differences in the structural morphology of enamel and dentin with pores, which facilitate the infiltration of bleaching [32,33]. Meireles et al. evaluated the impact of whitening treatment on the OHRQoL of Brazilian adults and observed that the tooth sensitivity was present in more than 40 % of the participants (41.3-10 % CP; 44.5-16 % CP), with negative impacts (pain and difficulty in cleaning) in patients who used vital whitening at home [14]. ...
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Objective To investigate the impact of tooth bleaching on oral health-related quality of life (OHRQoL) in adults using a randomised clinical trial comparing at-home and in-office bleaching. Method A total of 130 individuals were randomly allocated to two groups (n = 65) according to the type of treatment. At-home treatment was performed using 10 % carbamide peroxide (2 h/day; 3 weeks) and an in-office placebo, while 35 % hydrogen peroxide was used for in-office (1/week; 3 weeks) and an at-home placebo. Colour was assessed using the CIELAB system using a digital spectrophotometer. Objective and subjective colour change was estimated by calculating CIEDE2000 (ΔE00) and shade guide units (ΔSGU), respectively. The OHRQoL was measured using the Brazilian version of the Oral Health Impact Profile (OHIP-14). All assessments were performed at baseline and after 21 days. For bivariate analysis, the chi-square test, Student’s t-test, and Wilcoxon test were used. The effects of OHRQoL were assessed using distribution-based responsiveness. Results Objective colour change was observed at home (p = 0.033), in comparison to in-office (p = 0.429). Mean OHIP-14 scores were similar between groups at baseline (p = 0.368) and after treatment (p = 0.695). Bleaching had a moderate positive effect on the OHRQoL of adults, especially with respect to the psychological discomfort domains, social disability, and total OHIP-14 score. The perception of tooth sensitivity in the group that received at-home treatment was negatively associated with OHRQoL (p = 0.037). Conclusion The bleaching agents were highly effective and demonstrated a moderate influence on the patients’ aesthetic perception and psychosocial impact.
... The most used in day-by-day clinic is the shade guide. The other technique is using a spectrophotometer measurement, usually used in laboratorial experiments [2,4]. Tooth sensitivity during a bleaching treatment is classified in four stages, according to Marson:none, slight, moderate and severe. ...
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Background: Tooth discoloration varies in etiology, appearance, localization, severity and adherence to tooth structure. It may be
... The results mean that HP concentrations lower than the traditional 35 % for in-office bleach can whiten teeth just as effectively as higher HP concentration. Although there is a common belief that the higher the bleaching agent's concentration, the higher is the bleaching efficacy [90][91][92], this may be valid only to a certain extent. As pointed out by Mena-Serrano et al. 2016 [35], chemical reaction rates may be increased by raising the reactants' concentration, as this increases the number of collisions of reactants per unit time. ...
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Objective To answer the following research question: “Dolow/medium hydrogen peroxide (HP) concentrations used for in-office bleaching in patients with permanent dentition have similar color change and bleaching sensitivity (BS) to high HP concentrations?” Data Randomized controlled trials that compared low/medium vs. high concentrate HP were included. The risk of bias (RoB) was evaluated using the Cochrane Collaboration tool. Meta-analyses were conducted for color change (ΔE*ab, ΔSGU/SGU), risk, and intensity of BS, using the random-effects model. Heterogeneity was assessed with the Cochrane Q test, I² statistics, and prediction interval. The GRADE assessed the certainty of the evidence. Sources Search was performed in PubMed, Cochrane Library, BBO, LILACS, Scopus, Web of Science and grey literature on 15th September 2018 (updated on 13th May 2020). Study selection: 25 studies remained. Five were at low RoB; thirteen were at unclear RoB, and seven were at high RoB. The risk of having BS was, on average, 33 % lower (RR = 0.67; 95 % CI 0.51 to 0.86) for low/medium concentrate HP than high HP. No significant difference in color change was detected among groups, except from the subgroup low vs. high HP for the immediate color change, but this difference is not clinically relevant. The certainty of evidence for color change was low and very low, and moderate for the BS. Conclusions Low and medium hydrogen peroxide concentrate products for in-office bleaching have lower risk and intensity of bleaching sensitivity than the high concentrate hydrogen peroxide group, with no difference in color change efficacy. Clinical Significance The use of low concentrate hydrogen peroxide products may produce the same color change efficacy with the bonus of having lower risk and intensity of bleaching sensitivity. However, the ideal concentration at which this occurs is yet unknown and deserves further investigations. No funding. PROSPERO CRD42018108266.
... Reports have indicated that peroxide concentration and application time are the main factors to determine the efficacy of tooth bleaching (19,20). Gels with higher peroxide concentrations may be more effective, yielding bleaching in a shorter period of times, but may also result in greater side effects (21). ...
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Background: To evaluate the bleaching efficacy of at-home carbamide peroxide (CP) gels in two concentrations, containing or not a desensitizing agent. Material and methods: Forty incisors were divided into four groups (n=10), according to gel concentrations (10% or 22%), and presence or not of 3% potassium nitrate in the gel. A thin layer of gel was applied to the buccal surface of each tooth for 2h/day for 4 weeks. Bleaching efficacy was measured using a spectrophotometer, and ∆E*ab, ∆E00 and ∆WID were calculated. Measurements were performed at baseline, 7, 14, 21, 28, and 35 days following the first gel application. Data were analyzed by two-way RM-ANOVA and Tukey's test (α=0.05). Results: Regarding gel concentration or potassium nitrate inclusion, both gels resulted in color change above the perceptibility thresholds, which were similar between gels. Regarding time, significant differences were observed between color change values at 7 days and other time periods. ∆WID ranged from 3.8 to 9.6. Significant moderate to strong positive correlation was observed among the parameters. Conclusions: Nor the CP concentration, neither the inclusion of potassium nitrate in the gel, had influence on bleaching efficacy. All gels were effective and showed good results from the first weeks' application. Key words:Tooth bleaching, carbamide peroxide, desensitizer, potassium nitrate, color.
... It is generally used in high concentrations (35-40%) to provide short-term bleaching affects (nearly 1 hour). 3 Futhermore, activation of this agent with heat, light and lasers at different wavelengths are gaining popularity to achieve faster and more effective bleaching result. 4 Lasers are able to catalyze bleaching reaction by enhancing the formation of free oxygen radicals and by providing deeper penetration. ...
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This study investigated the effect of pH of bleaching agent, photo-irradiation time or application times on bleaching action using hematoporphyrin-stained papers (HSPs) and artificially stained bovine-teeth (BT). 23% H2O2 with pH 5.5, 6.0, 7.0, 8.0 and 9.0 were applied on the specimens. HSP was photo-irradiated for 1, 3 and 5 min. BT were photo-irradiated for 10 min and the bleaching was repeated ten times (n=10). CIE L*a*b* of the specimens were measured before and after the procedure. Data were analyzed by repeated-measures ANOVA followed by multiple comparisons with Bonferroni correction. For the HSP, longer irradiation time and higher pH yielded significantly higher color difference (ΔE). As for BT, increasing application times and higher pH resulted in higher ΔE. It was concluded that the pH of the bleaching agent significantly improved the bleaching effect with increased photo-irradiation time for HSP and with an increase of repeated application times for BT.
Article
The purpose of this clinical study was to evaluate the effect and safety of a new in-office bleaching material containing visible light activating titanium oxide photocatalyst (TiON in Office, GC). Anterior teeth of 72 patients were selected at the University Hospital of Dentistry, Tokyo Medical and Dental University or Aichi Gakuin University Dental Hospital with the permission of each Institutional Review Board. After informed consent, teeth were bleached with TiON in Office by three times of application and photo activation according to the manufacturer's instructions. The lightness of the tooth before and after bleaching was measured by a visual assessment using the Vitapan Classical Shade Guide (Vita, Germany). One of the teeth of each patient was selected as being representative for the evaluation. The obtained data was statistically analyzed by the Wilcoxon signed-rank test (p<0.05). Every adverse event during and after the bleaching procedure was recorded. Although the bleaching effects varied among the patients, the lightness of the bleached tooth was improved in all patients and a statistical difference was found between before and after bleaching. Thirteen adverse events were observed: 11 were whiteness of marginal gingival by accidental contact with the bleaching gel, which was not accompanied by any patient discomfort and had recovered by the time of the next visit; one was gingivitis which seemed to have no relationship with the bleaching procedure; and one was a slight disorder of the upper lip after bleaching, which could have been a side effect of the testing material. Spontaneous pain or postoperative sensitivity was not found during and after bleaching. It was concluded that TiON in Office is safe and effective for vital tooth bleaching.
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This in vivo study evaluated the variation of tray fabrication (trays constructed with or without reservoirs) on the degree of color change of teeth and sensitivities associated with using a 15% carbamide peroxide bleaching agent for two hours once daily for 14 days. Patients returned in one, two, three, six and 12 weeks. Color changes were evaluated by subjective shade matching, comparing clinical photographs and through measurements obtained using a color-measuring device. Subjects were asked to keep a daily record of any tooth and gingival sensitivity on the right and left side of their maxillary dental arch for three weeks. Colorimeter data showed that teeth lightened with agent with reservoirs were significantly lighter than teeth lightened with the same agent without reservoirs. However, the amount of lightening was below the threshold of visual differentiation. Shade guide and slide photography data showed no significant differences between teeth lightened with agent with reservoirs compared to teeth lightened with the same agent without reservoirs. In addition, no significant differences in tooth and gingival sensitivity were found between the tray side with reservoirs and those without reservoirs.
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This three-month, single-blind clinical study compared two whitening treatments, at-home with 10% carbamide peroxide and in-office with 35% hydrogen peroxide, for the degree of color change of teeth, color relapse and tooth and gum sensitivity. The degree of color change and color relapse was evaluated by using a colorimeter, shade guide and color slide photography. Teeth and gum sensitivity were self-evaluated by the subjects, who recorded daily the tooth and gum sensitivity they experienced during the two weeks of treatment and one week post-treatment. A 14-day at-home treatment was compared with 60 minutes of in-office treatment (two appointments, each with three 10-minute applications). The at-home treatment produced significantly lighter teeth than the in-office treatment during all active-treatment periods and follow-up visits according to all three-color evaluation methods. Color relapse for both treatments stabilized by six weeks. At-home treatment resulted in statistically significant higher gum sensitivity than in-office treatment during the latter part of the first week. For tooth sensitivity there were no significant differences between the treatments. Eighty four percent of the subjects reported at-home treatment to be more effective and 16% found no difference between the treatments. There were no subjects who reported the in-office treatment to be superior in tooth whitening to the at-home treatment.
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Nightguard vital bleaching, or at-home bleaching using a 10% carbamide peroxide material in a custom-fitted tray, has become the standard for tooth whitening. This article answers many of the questions associated with this process, and compares the procedure with other whitening options.
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Objective: A 6-month, double-blind study was undertaken to assess the efficacy and safety of a 10% carbamide peroxide gel designed for at-home tooth bleaching. Method and materials: Sixty patients were randomized into two equal subgroups balanced by age, gender, and oral health status. Shade guide measurements, color transparency photographs and colorimeter readings were taken and evaluated at baseline and 1, 2, 3, 6 12, and 24 weeks. The active phase of treatment lasted 14 days. Results: At 22 weeks postbleaching (week 24 of the study), patients receiving the active agent had a 14.1 rank order difference in the shade guide from baseline, and 66% had a clinically observable color change as determined by photographic assessment. They also had a measurable, statistically significant color change from baseline to 6 months of Delta E* = 5.0. The tooth color of maxillary incisors stabilized at week 6 and maxillary canines at week 12. The mean color change lost from weeks 2 to 24 was 45% (in Delta E*). Transient tissue and tooth sensitivity, noted in some patients, resolved after treatment was completed. Conclusion: The product tested is an effective and safe tooth-whitening agent.
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This clinical study compared the efficacy of three different bleaching techniques with respect to the bleaching times required in order to achieve six grades of whitening in human teeth. Any side effects that were noted and the patients' acceptance of the method were recorded by a visual analog scale ranging from 0 to 10. Moreover, epoxy casts from the study teeth were analyzed by scanning electron microscopy in order to detect any potential changes in the enamel surface due to treatments. Thirty-nine volunteers participated in the study and were allocated randomly to one of three different bleaching treatments: Group A (n=13) used Whitestrips (over-the-counter technique; one cycle=30 minutes), Group B (n=13) used Opalescence PF 10% (at-home bleaching technique; one cycle=8 hours) and Group C (n=13) used Opalescence Xtra Boost (in-office bleaching technique; one cycle=15 minutes) until a defined whitening of six tabs compared to the baseline were reached (assessed by the VITA shade guide). All three methods achieved six grades of whitening. The mean treatment time required to reach the defined level of whitening was 31.85 +/- 6.63 cycles in Group A, 7.15 +/- 1.86 cycles in Group B and 3.15 +/- 0.55 cycles in Group C. All products differed significantly from each other in terms of treatment cycles and required treatment time (p < 0.001 by ANOVA and Mann-Whitney-U-test). Using the VA scale, side effects noted within the three groups were minimal. Tooth hypersensitivity ranged from 2.62 (Whitestrips) to 3.38 (Opalescence PF), and gingival irritation ranged between 0.23 (Opalescence Xtra Boost) and 0.85 (Whitestrips). The most accepted method was the at-home bleaching technique. None of the teeth studied showed detectable enamel surface changes in the subsequent SEM analysis using 200x and 2000x magnification.
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Judgments of appearance matching by means of the visual criteria established by the United States Public Health Service (USPHS) and by means of an extended visual rating scale were determined for composite resin veneer restorations and their comparison teeth. Using a colorimeter of 45 degrees/0 degrees geometry and the CIELAB color order system we used the color of the restorations and comparison teeth to calculate a color difference for every visual rating. Statistically significant relationships were found between each of the two visual rating systems and the color differences. The average CIELAB color difference of those ratings judged a match by the USPHS criteria was found to be 3.7. However, the overlap in ranges of the color differences for those comparisons rated matches and mismatches indicates the importance of other factors in appearance matching, such as translucency and the effects of other surrounding visual stimuli. The extended visual rating scale offers no advantages to the more broadly defined criteria established by the USPHS.
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A 6-month, double-blind study was undertaken to assess the efficacy and safety of a 10% carbamide peroxide gel designed for at-home tooth bleaching. Sixty patients were randomized into two equal subgroups balanced by age, gender, and oral health status. Shade guide measurements, color transparency photographs, and colorimeter readings were taken and evaluated at baseline and 1, 2, 3, 6, 12, and 24 weeks. The active phase of treatment lasted 14 days. At 22 weeks postbleaching (week 24 of the study), patients receiving the active agent had a 14.1 rank order difference in the shade guide from baseline, and 66% had a clinically observable color change as determined by photographic assessment. They also had a measurable, statistically significant color change from baseline to 6 months of delta E* = 5.0. The tooth color of maxillary incisors stabilized at week 6 and maxillary canines at week 12. The mean color change lost from weeks 2 to 24 was 45% (in delta E*). Transient tissue and tooth sensitivity, noted in some patients, resolved after treatment was completed. The product tested is an effective and safe tooth-whitening agent.
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Vital tooth bleaching for esthetic reasons has gained in popularity during the last few years. However, few studies have investigated the efficacy of daytime bleaching products. The purpose of this double-blind in vivo study was to evaluate the efficacy of 20 percent carbamide peroxide, or CP, and 7.5 percent hydrogen peroxide, or HP, during daytime use. The degree of color change, any color relapse, and tooth or gingival sensitivity were evaluated. Twenty-four patients participated in this study. The bleaching gels were randomly applied to the right and left maxillary anterior teeth. Patients were shown how to place the two bleaching agents in a custom tray for one hour, twice a day for two weeks. Patients returned in one, two, three, six and 12 weeks for color evaluation with the colorimeter and shade guides as well as to have color slide photographs taken. The authors evaluated sensitivity by asking the patients to record daily for 21 days any tooth or gingival sensitivity they experienced. Use of the 20 percent CP resulted in significantly more lightness than the 7.5 percent HP during the first 14 days of the study, but at the end of the study, there was no significant difference between products with regard to tooth lightness. In addition, the authors found no statistically significant difference between products with regard to gingival or tooth sensitivity. Both CP and HP are effective at-home bleaching agents when daytime bleaching is preferred. Dentists who choose to use daytime bleaching can select either CP or HP.
Article
The purpose of this study was to evaluate the degree of color change, any rebound effect, and sensitivities associated with using 2 different concentrations of carbamide peroxide in vivo. Twenty-five subjects used 10% and 15% agents in trays for 14 days on different sides of their maxillary arches. Subjects returned in 3 days and at 1, 2, 3, and 6 weeks for evaluation of color change and rebound effect. Shade matching, photographic means, and a colorimeter were used for evaluation. Subjects self-reported gingival and tooth sensitivity on a scale of 1 (no sensitivity) to 5 (severe sensitivity). After 2 weeks, delta L*, delta a*, delta b*, delta E* and delta shade guide rank means for the 10% whitening agent were 6.50, -1.37, -4.63, 8.79, and -15.40, respectively; for the 15% agent, they were 8.72, -1.63, -5.90, 11.03, and -16.59, respectively. After 6 weeks, delta L*, delta a*, delta b*, delta E*, and delta shade guide rank means for the 10% whitening agent were 3.04, -0.99, -3.19, 5.13, and -13.13, respectively; for the 15% agent, they were 3.48, -1.01, -3.60, 5.58, and -13.65, respectively. Means for gingival sensitivity were 1.18 and 1.21 for the 10% and 15% agents, respectively; means for tooth sensitivity were 1.21 and 1.26 for the 10% and 15% agents, respectively. All 3 methods of evaluation revealed a significant difference in the tooth lightness achieved by 10% and 15% products at 2 weeks but no significant difference at 6 weeks. No statistically significant difference was found in gingival or tooth sensitivity.
Article
A three-cell, randomized, parallel, investigator-blinded clinical trial was conducted to compare the efficacy and safety of three professional at-home tooth whitening systems, including Crest Professional Whitestrips (6.5% H2O2), Day White 2 (7.5% H2O2) and Nite White Excel 2 (16% carbamide peroxide equivalent). Ninety subjects were randomly assigned to three groups (30/group). Subjects were instructed to use the assigned whitener following the manufacturers' instructions. Clinical examinations at baseline, and on days 3, 7, 14, and 18 (Day White), or 21 (Crest Professional Whitestrips and Nite White) included the following parameters: 1) oral tissues; 2) tooth shade by the Vitapan Classical shade guide; 3) tooth shade by a chromameter with a jig; and, 4) tooth sensitivity and gingival irritation. The results showed significant shade reductions with time in all three groups. Nite White resulted in significantly greater shade reductions in periods between days 7, 14, or 21 and baseline than did the other two systems. Tooth sensitivity and gingival irritation, which were mostly mild and transient, occurred in all groups. It is concluded that all three whitening systems evaluated are effective and safe. Nite White Excel is superior to the other two systems because it provides a greater whitening efficacy with comparable or lower incidence of tooth sensitivity and gingival irritation.