ArticlePDF AvailableLiterature Review

Abstract

Hydrogen peroxide (H(2)O(2)) is a powerful oxidising agent. It gives rise to agents known to be effective bleaching agents. The mechanisms of bleaching involve the degradation of the extracellular matrix and oxidation of chromophores located within enamel and dentin. However, H(2)O(2) produces also local undesirable effects on tooth structures and oral mucosa. In clinical conditions, the daily low-level doses used to produce tooth whitening never generate general acute and sub-acute toxic effects. Genotoxicity and carcinogenicity only occur at concentrations that are never reached during dental treatments. Some transient adverse effects have been reported on the oral mucosa and the digestive tract if the product is swallowed. Local effects may occur on the oral mucosa and dental tissues during whitening, namely, pulp sensitivity, cervical resorption, release of selected components of dental restorative materials, and alteration of the enamel surface. Most of the local effects are dependent of the technique and concentration of the product so far used, but as the results of bleaching obtained are not stable, repeated treatments add to the adverse effects. The informed decision to administer or not and the control of bleaching effects should stand in the hand of dental surgeons and certainly not as it appears at present, as cosmetics sold without any restriction despite the potential health hazards of peroxides.
REVIEW
Undesirable and adverse effects of tooth-whitening products:
a review
Michel Goldberg &Martin Grootveld &Edward Lynch
Received: 6 February 2009 /Accepted: 8 June 2009 / Published online: 20 June 2009
#Springer-Verlag 2009
Abstract Hydrogen peroxide (H
2
O
2
) is a powerful oxidis-
ing agent. It gives rise to agents known to be effective
bleaching agents. The mechanisms of bleaching involve the
degradation of the extracellular matrix and oxidation of
chromophores located within enamel and dentin. However,
H
2
O
2
produces also local undesirable effects on tooth
structures and oral mucosa. In clinical conditions, the daily
low-level doses used to produce tooth whitening never
generate general acute and sub-acute toxic effects. Geno-
toxicity and carcinogenicity only occur at concentrations
that are never reached during dental treatments. Some
transient adverse effects have been reported on the oral
mucosa and the digestive tract if the product is swallowed.
Local effects may occur on the oral mucosa and dental
tissues during whitening, namely, pulp sensitivity, cervical
resorption, release of selected components of dental
restorative materials, and alteration of the enamel surface.
Most of the local effects are dependent of the technique and
concentration of the product so far used, but as the results
of bleaching obtained are not stable, repeated treatments
add to the adverse effects. The informed decision to
administer or not and the control of bleaching effects
should stand in the hand of dental surgeons and certainly
not as it appears at present, as cosmetics sold without any
restriction despite the potential health hazards of peroxides.
Keywords Tooth whitening .Hydrogen peroxide .
Cytotoxic effects .Genotoxicity .Carcinogenicity .
Resorptions .Hypersensitivity .Enamel surface
Introductory remarks
Genetic diseases such as dentinogenesis imperfecta,or
dentine dysplasia or some forms of amelogenesis imper-
fecta, some acquired foetal and post-natal pathologies
occurring during tooth formation such as medical diseases
(i.e., icterus, congenital erythropoietic porphyria, chole-
stasis, and renal diseases), treatments with tetracycline, or
chronic ingestion of fluoride during childhood, may
induce unacceptable levels of intrinsic tooth staining that
should be included in the list of handicaps. In such cases,
there is a real need for bleaching, mostly for psychological
reasons and also for an improved social life of the patient
[19,22,49]. Bleaching procedures are effective and
certainly less destructive than any full or partial prosthetic
restoration.
However, there is currently a wide range of bleaching
techniques used for aesthetic reasons, and in many cases,
such treatments are not necessary. As a consequence, the
wide diffusion of whitening methods have to be
controlled because it is well known that there is no
therapy without high or small risks. When these methods
are used correctly, there are only minor consequences
and, therefore, a clinical tolerability. In contrast, abuses
approach the limits of risks and this should be taken into
Clin Oral Invest (2010) 14:110
DOI 10.1007/s00784-009-0302-4
M. Goldberg (*)
EA2496, Faculté de Chirurgie Dentaire,
Université Paris Descartes,
1, rue Maurice Arnoux,
92120 Montrouge, France
e-mail: mgoldod@aol.com
e-mail: michel.goldberg@parisdescartes.fr
M. Grootveld
Department of Applied Science, London South Bank University,
London, UK
E. Lynch
School of Dentistry, Queens University,
Belfast, Ireland
consideration or better documented prior to taking a
clinical decision.
Tooth-whitening treatments are carried out either at
the chair-side by dental surgeons (in-office)orby
staff-supervised in-office bleaching,orasat-home
dentist-supervised treatments, or bleaching devices are
sold over-the-counter (OTC) to patients and may be used
without any control of dental practitioners [11,19]. Each
method is effective for most staining but needs different
periods of time to obtain the expected result. When strips
are used as typical OTC treatments, 31.85 cycles of
15 min are necessary to obtain some whitening; whereas,
at-home dentist-supervised bleaching needs 7.15 cycles
and in-office treatment needs 3.15 cycles [11].
In many countries, no final decision has yet been taken
by state agencies for sanitary security to classify the
bleaching agents as medical devices or cosmetic products,
or both, depending on the final concentration of the gel.
Whatever the decision will be in this matter, up to now, the
active compounds are, in general, the same although the
doses administered can differ substantially. Between 1918
[1] and the 1990s [66], sporadically, a few publications
reported that bleaching could be obtained clinically, but
most studies were published in the last 20 years [9,69].
Bleaching effects are mostly based on the effects of
carbamide peroxide, releasing about 33% of their content
as hydrogen peroxide (H
2
O
2
). H
2
O
2
can act as a powerful
oxidising agent and can give rise to agents known to be
effective bleaching agents (i.e., its corresponding mono-
anion (HO
2
) and hydroxyl radical (OH)). In addition,
carbamide peroxide also releases urea, which is rapidly
decomposed into carbon dioxide and ammonia [22,41].
Chemical reaction of the two reagents with the organic
extracellular matrix components (ECM), including pig-
ments or chromophores, constitutes the chemical basis of
tooth whitening.
It is well documented that urea degrades the organic
matrix located in the enamel [8,31,32]. The organic matrix
constitutes 0.6% in weight and 4% in volume of the total
human adult enamel. Urea and ammonium ions (NH
4
)
+
act
on the hydrogen bounds that are crucial regarding the
secondary, tertiary, and quaternary structures of matrix
proteins. After the initial alteration, the degraded proteins
are further split into small peptides, released, and finally
eliminated from the mature enamel [8,31,32,41,57]. The
same applies to most non-collagenous dentin matrix
components. The empty minute spaces that are rendered
accessible by urea allow the diffusion of hydrogen peroxide
throughout the whole thickness of enamel up to the
dentino-enamel junction (DEJ).
Bleaching agents cross the DEJ and interact in the
subjacent dentin with the chromophores, pigments, and ions
that are now recognised to be responsible for tooth staining.
The removal of ECM is not homogeneous. In enamel, it is
mostly detectable in some rods and not apparently
associated with inter-rods [31,32]. The removal of matrix
components is associated with the loss of some hydroxy-
apatite crystals, bound at specific areas where there is a
local accumulation of matrix components. Consequently,
minute craters form at the enamel surface as a reaction to an
efficient peroxide treatment [24,60,62,93]. The balance
between the need for treatment that is judged necessary by
the practitioner and the risk induced by the therapy has to
reach a valuable equilibrium. It is clear that many efforts of
the industry were carried out in order to minimise the
noxious effects of bleaching products. However, there is
clearly a compromise between efficiency and safety that
cannot be ignored [11,19].
Adverse effects of bleaching agents have been reported
after the treatment of non-vital teeth [69]. When applied to
vital teeth, tooth sensitivities, the alteration of enamel
surfaces, and the consequences arising from the release of
some components of restorative materials have been
reported [22] and are important phenomena to consider.
The effects on the oral mucosa are controversial and depend
on the technique that has been employed. It is also the case
that the effects of bleaching agents on the digestive tracts of
both animals and humans have to be considered in detail.
The conclusions of in vitro and animal studies should be
adapted to the human situation. Finally, general toxicity,
genotoxicity, and carcinogenicity are also important con-
siderations that have to be taken into account in the frame
of safety or tolerability [57,82,85].
A review of the potential effects of bleaching agents is
not facile, largely because of the many divergent reports
that have been published on a range of important aspects
of this area. There are multiple reasons for these
conflicting reports. In some cases, what has been
published arises more from the marketing and advertise-
ment of products rather than that from unbiased scientific
investigations, and it is not always a simple process to
decide what has to be kept on the list of reputable
references. In many cases, however, diverging published
data are mostly attributable to differences between the
concentrations of the bleaching reagent that was used,
the reagent itself, and even the carrier, which may also
play an important role in the reaction (or lack of it). In
any case, taking into account the many excellent reports
that are available, it is necessary to consider the limit
above which there is a risk of undesirable side effects.
An excellent review article has been published in 2003,
and we have to acknowledge that it constitutes one of the
major references in the field [22]. However, since the last
67 years, new experimental results were obtained and
new products were put on the market. These additional
data are incorporated in this review.
2 Clin Oral Invest (2010) 14:110
General and local toxic effects of hydrogen peroxide
Allergic sensitivity
No allergic sensitivity has yet been reported for carbamide
or hydrogen peroxides, or for alternative peroxo-adducts, in
contrast to the acute and sub-acute effects that are well
documented.
Acute cytotoxic effects
Acute cytotoxic effects appear at doses over 5 g/kg/day for
a product containing 10% (w/w) carbamide peroxide [44,
88]. This corresponds to a 0.3 to 1.8 mg/kg (body weight)/
day H
2
O
2
. Force-feeding rats directly into the stomach with
5, 15, and 50 mg of carbamide peroxide/kilogramme, or its
equivalent in tooth-whitening products, induce dose-
dependent ulcerations of the mucosa, easily detectable 1 h
after feedings; however, these heal after 24 h. This reaction
is not observed for doses lower than 15 mg/kg. The gel
associated with peroxides in a commercially available
product seems to enhance the toxic effects. No adverse
effect has been detected in the kidney or liver [21].
From these data, assuming a threshold of toxicity of
15 mg of carbamide peroxide/kilogramme and a security
factor of 100, it is apparent that at a carbamide peroxide
concentration of 10 mg (equivalent to 3.6% (w/v)H
2
O
2
),
we are at the limit of systemic effects for a 70-kg man [21].
In this context, it has been reported that a 16-month-old
child died after ingestion of a 3% (w/v)H
2
O
2
solution.
However, this accident was at the lowest doses so far
reported. From the available data, we can conclude that the
everyday doses used during whitening procedures is close
to a level where adverse systemic effects might occur.
Sub-acute toxic effects
There are no effects or, at least, no reported effects in
humans. In animals, the daily critical doses should be
lower than 30 mg/kg/day for the rat and 26 mg/kg/day
for the mouse.
After topical application to humans, °OH radical
derived from electron transfer to H
2
O
2
can, in principle,
induce lipid peroxidation, and also DNA alteration
followed by cell lysis and death [41,57]. Anti-oxidants
and iron chelators may prevent such reactions, the former
by scavenging °OH or lipid peroxyl radicals (LOO°), the
latter by complexing Fe(II) and attenuating its ability to
participate in Fenton-type reactions. The enzyme catalase
inhibits these reactions via its capacity to directly consume
H
2
O
2
; whereas, the lipid-soluble antioxidant vitamin E
(α-tocopherol) blocks such damage by scavenging LOO°
radicals [57,82].
H
2
O
2
induces squamous metaplasia on tracheal explants
at concentrations of 50100 μmol/l; whereas, cytotoxic
effects appear at a concentration 500 μmol/l [71]. At
700 μmol/l, H
2
O
2
induces embryonic fibroblast necrosis;
whereas, at 150 μmol/l, apoptotic effects are induced [34].
In another report, it is shown that when 35% (w/v)
carbamide peroxide is used, the percentage of viable cells
is decreased to 60% in comparison with control cells
(FM3A cell line). This value falls down to 43% with a 20%
(w/w) carbamide peroxide gel. The level of toxicity is 50
and 40 μg/ml, respectively. An extrapolation to a 70-kg
individual suggests that in order to remain below the risk
doses and avoid any toxic effects, the daily dose used
should be 10 mg carbamide peroxide, or its 3.3 mg H
2
O
2
equivalent [7].
Genotoxicity and carcinogenicity
International Agency on Research on Cancer data [44] do not
refer to any mutation or cancer risk attributable to profes-
sional exposure. However, in animal models, adenoma and
duodenum carcinoma have been detected experimentally
after oral administration of H
2
O
2
. In the mouse, hyperplasia
appears in the gastric mucosa in 2042% and duodenum
hyperplasia in 4062% of the experimental animals 8 weeks
subsequent to the ingestion of 0.10% or 0.40% (w/v)H
2
O
2
solutions. These reactions are more substantial in the
duodenum than the stomach. In addition to gastric mucosal
ulcerations after force-feeding with 15 mg/kg carbamide
peroxide, adenoma and carcinoma were observed. This
pathological transformation seems to be strain-dependent
and linked specifically to the catalase activity of the different
groups of mice [4547]. Critical analysis of the experimental
situation leads to conclude that hydrogen peroxide is not a
carcinogenic thread, at least for the digestive tract [23].
It seems unlikely that H
2
O
2
may induce cutaneous cancers
[13,52]. In the oral cavity, repeated applications of 30%
(w/w)H
2
O
2
produce hyperkeratosis, hyperplasia, and dyspla-
sia with weak intensity after 22 weeks [71,89]However,no
tumours were detectable with H
2
O
2
alone. This is not the case
when a carcinogenetic agent is co-administered with H
2
O
2
[89]. However, it is documented that H
2
O
2
inhibits gap
junctional intercellular communication in glutathione-
sufficient but not in glutathione-deficient cells, and an
aberrant intercellular junctional communication has been
implicated in tumour promotion, neuropathy, and teratogen-
esis. This sheds light on potential dangers and on some
genetic aspects of the reaction [87].
H
2
O
2
has been shown to be mutagenic in a number of
strains including Salmonella typhimurium and Escherichia
coli [2]. In some cell cultures, H
2
O
2
treatment induces
DNA strand breakage and is mutagenic, especially toward
cells from the L5178Y murine lymphoma subline. For
Clin Oral Invest (2010) 14:110 3
example, at 37°C, LY-R are 3.6 times more sensitive to the
killing effects than LY-S cells; whereas, at 4°C, they were
11 times more sensitive [53]. Mutagenicity has also been
reported in V79 Chinese hamster cells, and the reaction is
concentration dependent. Ziegler-Skylakakis and Andrae
[94] concluded from their investigations that at a solution
level of 4 mM H
2
O
2
, the mutation frequency increased
sixfold above the controls, and the extent of survival was
reduced by 50%. DNA fragmentation has also been
observed in human lymphocyte cultures and epithelial cells
of the respiratory tract.
Following the use of hydrogen peroxide at a concentra-
tion of (10 μmol/L), Timblin et al. [84] observed the
overexpression of the proto-oncogen c-jun, a process which
leads to cell proliferation.
It should be added that despite all the potential risks
inherent with the use of peroxides, up to now there is no
report of human cases where carcinogenic effects are
actually established [23,57]. However, two recent publica-
tions pointed out that hydrogen peroxide used in long-term
treatment and at a high concentration might act as a
promoter of oral mucosal damage and, moreover, have
genotoxic and carcinogenic effects [65,85].
Local effects of bleaching agents on dental tissues
and oral mucosa
The whitening effects of hydrogen peroxide on teeth
and oral mucosa are well documented [11,18,49,55,
67]. However, in a limited number of cases, undesirable
effects such as hypersensitivity (2.623.38%) and gingival
irritation (0.230.85%) have been reported [11,54].
Changes in enamel microhardness, micromorphological
defects due to demineralization, and effects on restorative
materials have also been reported [17,24,43,60,62,64,
68,77,80,81,9093].
Effects on non-vital teeth (internal and/or external treatment):
internal and external resorptions
Some time after a root canal treatment, the colour of the
treated tooth changes and gradually becomes unaesthetic
[74]. This is very often the case for incisors after a local
trauma. Darker or brown-grey teeth may be subjected to a
whitening treatment that removes less dental tissue than
the preparation of a jacket crown or a veneer. In most
studies, however, no adverse reaction has been observed
after such treatments. Indeed, no resorption was detected
in a series of 100 and 250 patients, respectively, that have
been treated and recalled for a follow-up [6,42]. However,
external resorptions have also been reported in a further
series of patients. About 7% of the teeth displayed
resorptions in 58 cases, monitored during an 8-year period
[26]. The frequency of resorption is certainly dependent
on the bleaching method that has been utilised. A mixture
of sodium perborate and 3% hydrogen peroxide was
shown to induce delayed outer resorptions, which
appeared 12 years after the treatment. Heating the
bleaching solution enhances the number of resorptions
that are induced [69].
Exactly why such external resorptions are occurring is
poorly understood. They seem to be dependent on the pH,
the trauma, and the heating procedure that was used. They
appear a few years after the bleaching treatment, and we
are still unable to control them. The origin of the
pathology could be an enhancement of bacterial penetra-
tion inside dentine tubules [40]. This invading pathway
may be also related to some structural defects or patholog-
ical alterations of the cementum that favour such bacterial
penetration [74]. Apparently, no correlation was found
between the mechanism of action of sodium perborate and
the adhesive properties of macrophages. It seems that these
cells do not play a role in the resorption process [48].
Tissue permeability in the cervical area of the tooth may be
implicated in the initiation of such resorptions. However,
there is no predictable evidence from clinical examination
that such lesions will form. Therefore, before taking the
decision to administer a whitening treatment on non-vital
teeth, it is important to consider that resorption may be
induced. The final outcome of such cervical resorption is
the fracture of the crown, when the lesion reaches a certain
volume. This, unfortunately, leads to a residual root that
cannot be employed for a prosthetic device and, hence, has
to be extracted.
Effects of external treatments on vital teeth
Post-treatment hypersensitivity and pulp alteration
When a 10% (w/w) carbamide peroxide treatment is
conducted, between 15% and 65% of the patients receiving
it display sensitivities of the treated teeth within the next
4 days [38,54,78], far less for other authors (2.623.38%)
depending on the bleaching product and the concentration
used [11]. The sensitivity is higher with H
2
O
2
combined with
the thermo-catalytic enhancement at some point following
the chair-side treatments [69]. This sensitivity may last up to
39 days and, in some cases, is so painful that it leads to
treatment interruption. It is well documented that H
2
O
2
diffuses throughout the enamel layer and dentine, even in
vital teeth. In vitro studies demonstrate peroxide penetration
into the pulp with most bleaching agents and methods,
including whitening strips that presumably would excerpt
mild effects [2830]. This phenomenon results from both the
osmotic and vascular pressures [35]. The physiopathological
4 Clin Oral Invest (2010) 14:110
mechanisms of sensitivity or pain are however not fully
understood. Nerve endings are undetectable in enamel.
Contemporarily, it is well documented that nerve endings
are present in the inner dentin in an area near the
periphery of the pulp (150 μm thick), visualised either by
radioautography [15] or by immunocytochemistry [58]. The
absence of nerve endings in the outer dentine and at the DEJ
clearly does not assist us in interpreting the phenomenon.
The hydrodynamic hypothesis developed by Brännström
[14] may apply here, i.e., backward and forward movement
of the dentinal lymphmay be transmitted to odontoblast
processes located inside tubules and then to cell bodies
where a direct anatomical link occurs between odontoblasts
and nerve endings in what is known as the sub-odontoblastic
plexus. Bleaching agents containing H
2
O
2
in high concen-
tration may favour bacterial penetration through dentinal
tubules [40]. In view of the mild irritative process,
reactionary dentine is formed which gradually reduces the
hypersensitivity. Alternatively, there is peritubular dentine
formation after such stimulation, resulting in an eventual
reduction of diameter of the lumen of the tubules. The two
processes may be interdependent.
Diverging results have been published with respect to
the consequences of the influence of whitening treatments
on pulp. According to Seale et al. [79], a 35% (w/v)
hydrogen peroxide gel used for 30 min induces severe pulp
reactions in dog teeth. The odontoblast layer is reduced and
even disappears in the area facing the treated part of the
tooth. The predentine is missing. Inflammatory cells are
present at the pulp surface, and internal resorbing processes
may be observed 4 days after the treatment. The inflam-
matory reaction is present for a period of 15 days, together
with the dilation of blood vessels, vascular thrombus, and
haemorrhages. Fortunately, these alterations disappear after
2 months. Another report reveals translocation of odonto-
blast nuclei in dentinal tubules in 32% to 53% of treated
human teeth, without any pulp reaction [20]. The differ-
ences between these two reports do not appear to be
ascribable to compositional differences between the two
bleaching agents which were used, since they both
contained 35% (w/w)H
2
O
2
coupled with thermal enhance-
ment. A more recent study provides evidence for a
moderate reaction with 10% (w/w) carbamide peroxide
[5]. Moreover, it should be noted that bleaching methods
induce an increase of endogenous pulp peroxide (mean
value, 0.44 mM). However, this was 3,000 less than that
which can induce acute pulp damages arising from enzyme
release [50]. In any case, tooth sensitivity resumes
gradually, without any long-term adverse effects.
Sensitivity can be prevented or decreased by treating the
teeth 30 min prior to whitening by desensitising agents
containing 3% potassium nitrate and 0.11% per weight
fluoride [56].
Alteration of enamel surface: consequences on bacterial
plaque adhesion and cariogenicity
In this area, reports on the effects of whitening gels are also
divergent. Some researchers have reported either no effect
on or only minor changes to the enamel surface or the
subsurface [18,37,50,51,64,9092]. In contrast, others
have shown moderate to severe enamel surface modifica-
tions [24,27,60,62,80,93]. Again, it is difficult to have a
clear-cut idea on the actual situation. The divergent results
that were obtained are mainly attributable to differences in
the protocols, the chemicals that were used and their
concentrations, and also may be influenced by the method
used to visualise the effects. In some case, the reliability of
the results is related also to the scientific independency of
the researcher and is also apparently linked to the scientific
quality of the journal where the report is published.
Although some authors have pointed out that tooth
bleaching with selected commercial H
2
O
2
or carbamide
peroxide do not produce modifications in surface morphol-
ogy [8183], another group of reports found that bleaching
agents create some enamel porosity [21,54,56,84]. For
example, Ruse et al. [77] have shown that in bleached
enamel, the calcium/phosphate ratio is altered by a 35%
H
2
O
2
treatment. According to Seghi and Denry [80],
enamel treated with a 10% (w/w) carbamide peroxide gel
displays a reduction in apparent fracture toughness (ca.
30%), with no significant changes in surface hardness. Data
acquired indicate small but significant decreases in abrasion
resistance. To explain these findings, the authors hypoth-
esised that the chemical action of H
2
O
2
induced an
alteration of the organic matrix of enamel. Differences
between these published reports may arise from a variation
in the concentration of chemical bleaching agents, e.g., a
concentration of 35% (w/w) carbamide peroxide (1112%
H
2
O
2
) affects the structure of enamel; whereas, 10% or
16% (w/w) have no effect [68]. From the published
literature, it could be concluded that bleaching treatments
induce changes in surface roughness and consequently
influence the formation of supra- and sub-gingival plaque
[70]. Therefore, the adhesion of Streptococcus mutans to
enamel is increased [43]. This is also the case for
Streptococcus sobrinus, but not for Actinomyces viscosus
[63]. Such undesirable effect may have some implication on
future developments regarding the carious decay. However,
to the best of our knowledge, it should be recognised that
up to now, there are no clinical report available on the
potential development of caries from a broad series of
whitening treatments. However, it may be assumed that
with the development of such methods, we may face such
consequences in the near future.
An investigation performed with the atomic force
microscope revealed that commercial bleaching agents as
Clin Oral Invest (2010) 14:110 5
well as a 30% (w/v)H
2
O
2
solution enhanced groves present
at the surface of enamel and also act on its inner structure
[39]. Hence, it may be concluded that most bleaching
agents (even those containing 10% (w/v) carbamide
peroxide), induce slight to moderate alterations of the
enamel surface and a decreased enamel microhardness,
variations between the bleaching agents employed were
clearly notable [73]. These microlesions are of much lesser
importance than those arising from etching with phosphoric
acid. From some reports, it appears that minor defects are
also induced in the subsurface. These defects might
interfere with the adhesive properties of restorative materials.
After some time, the porosities are gradually reduced. In view
of enamel abrasion, and also as a result of ion re-precipitation
controlled by some salivary proteins and/or by the bacterial
plaque, calcium-phosphate precipitation occurs inside the
porous enamel, a phenomenon that leads eventually to re-
hardening and furthermore contributes to a return to the
normal situation.
Therefore, the concept that in-officebleaching is a
non-destructive cosmetic procedure should be reconsidered,
and this apply also to the other whitening procedures. It
should be considered that enamel demineralization is an
undesirable effect resulting from bleaching agents, related
to their concentration and to the time necessary to obtain
teeth whitening. Along this line, strips may have less
destructive effects, although peroxide release in saliva is
higher by using some strips in comparison with trays
charged with gels [36]. Remineralization due to saliva may
restore gradually the mineral charge of enamel surfaces, but
the specific organic matrix is definitively degraded, and this
alteration may interfere with enamel repair. Attempts to
reduce the loss of mineral and the formation of micro-
defects on enamel surface were carried out with fluoride-
containing bleaching agents shown to induce less enamel
surface demineralization and altered microhardness [17].
Effects of tooth-whitening peroxides on the oral and gastric
mucosa
When the dental surgeon at the chair-side applies H
2
O
2
or
alternative peroxo-adducts, there is a clinical control of the
risk factor for developing gingival irritation. This is not
always the case with nightguard, i.e., dentist-prescribed
home-applied bleaching methods. The situation may be
even worse when patients without any control of a dental
surgeon are using whitening methods. Carefully adapted
trays are mandatory if the dental practitioner wishes to
prevent or suppress gingival irritations.
H
2
O
2
, together with lauroyl and benzoyl peroxides, all
represent compounds with the potential to generate free
radical species. They are not carcinogenic when applied
topically to the mouse skin, but they are potent skin
irritants. Notable modifications induced by peroxides in
skin are epidermal hyperplasia and the induction of dark
keratinocytes: 15% or 30% (w/v)H
2
O
2
gave rise to an
extensive epidermolysis, inflammation, and vascular injury
in rodents. This was found to be followed by a rapid
regeneration and epidermal hyperplasia [52]. After topical
application of 10% (w/v) carbamide peroxide, an increase in
the quantity of cells located in the basal layer of the oral
mucosa revealed by proliferating cell nuclear antigen
(PCNA) staining was noted [3]. However, by immunode-
tection of cyclin D and p16 (representing a proliferation
marker and a negative regulator of cell proliferation,
respectively, the alteration of which are considered as
markers of an initial cancer formation), studies carried out
on the oral mucosa failed to indicate any significant
alteration [33]. In contrast, using the PCNA as a marker,
the same researchers have shown a transient proliferation
after topical application of carbamide peroxide to the basal
and suprabasal epithelial oral border [3]. Therefore, the
controversy is not yet solved.
In fact, temporary burnings of the tissue arising from
H
2
O
2
have been reported. In the hamster pouch, severe
inflammatory processes are now well identified. During
the treatment of periodontal diseases, the bacteriostatic
properties of H
2
O
2
have been widely used, and in this
context, cell lysis has been reported at a concentration as
low as 1% [61].
Carefully adapted plastic trays or nightguards may
reduce the amount of whitening agent that is expelled onto
the oral mucosa when the patient overfills the tray. Strips
and painted lacquers reduce the risk. The ingestion of
bleaching gel may produce gastric pain, although the
repeated ingestion of peroxide-containing gels does not
seem to have severe consequences.
Effects on restorative materials: the release of mercury
and silver from amalgams and adverse effects
on the adhesive properties and on the margin
of composites fillings
Bleaching agents have well-established effects on dental
fillings [4,10]. After treatment of silver amalgam with a
gel containing 10% (w/w) carbamide peroxide, an increased
level of mercury and silver was found near the surface of
silver amalgam; whereas, tin and copper levels therein were
diminished [75,76]. In vitro, carbamide peroxide favours the
release of mercury from silver amalgams. However, in vivo,
the reaction is limited by the dental biofilm [83]. Mercury
can be released up to 80 h after whitening treatment [72].
Such effects have been reported exclusively for silver
amalgam fillings. These effects are not clinically detectable
but have been reported from in vitro studies for other
materials used in restorative dentistry. There are nowadays
6 Clin Oral Invest (2010) 14:110
convincing evidences that bleaching agents may influence
bacterial adhesion, modify the surface roughness of
polyacid-modified resin-based composites and resin-
modified glass ionomer cements (see for review [10]).
The interfacial fracture toughness of dentin/resin composite
adhesive is affected, with significant reductions observed at
16% and 21% (w/w) carbamide peroxide concentrations,
after 42 h [25]. The marginal leakage of resin composite
restorations is increased after bleaching with 10% (w/w)
carbamide peroxide, but not amalgam restorations [86].
Penetration of the pulp chamber by bleaching agents is
common with resin-modified glass ionomer cement fillings;
whereas, the lowest pulpal peroxide penetration is detected
with the resin composite materials [28]. A 6% (w/w)H
2
O
2
does not cause significant surface dissolution of glass
ionomer, but the authors did not investigate the dentin-glass
ionomer cement (GIC) interface [59].
Altogether, these data suggest that whitening treatments
may induce alterations of the restorative material itself,
impairs the conversion of dental adhesives after dentin
whitening, or modify the interface between the biomaterial
and dentine to the detriment of adhesive properties [10,16].
Moreover, if the restorative material is present in the
bleached surfaces, a significant reduction in the resin
composite shear bond strength can be observed [12,81].
The long-term effects of such methods are questionable
in terms of public health costs, especially when they are
used without the control of a dental surgeon.
Stability of tooth-whitening treatments and acquired
exogenous staining
It is now well established that bleaching methods are
efficient. After a few days or appointments at the chair-side,
teeth lost one or two colour divisions on a tooth shade
device, and patients are generally satisfied from the gain
that is obtained. However, after some time, the initial
staining colour returns, or in view of dental enamel
permeability, a renewed level of exogenous staining agents
penetrates and diffuses throughout enamel and even reaches
dentine [19]. This is the case for tobacco smoke, tea, coffee,
jams, and many other potential staining agents. As long as
dental surgeons control the process, it is not an acute
problem. However, when identified by the patient, the
staining instability may lead to uncontrolled multiple
treatments and, hence, the repeated re-exposure of enamel
and gingiva to peroxo derivatives. It is also clear that the
patients conception of white teeth is mentally mediated and
related more to social and sexual concepts rather than to a
reality, but the end-point will be that some individuals will
unnecessarily over-use whitening devices. As a conse-
quence, demineralisations and local severe structural alter-
ations may occur as a long-term effect of repeated
bleaching, and sub-toxic or toxic doses may be inadver-
tently attained. The percentage of such patients is not
known at present. Another open question is that on
treatment with 10% to 15% (w/w) carbamide peroxide,
efficient whitening results are easily and rapidly obtained.
To be equivalent to a process involving 1015% (w/w)
carbamide peroxide for 2 weeks, a treatment conducted
with a lower concentration such as 5% (w/w) should be
performable for ca. 3 weeks. Although in the latter
treatment the dose of peroxide is lowered, the time required
to reach a whitening effect is of course extended.
Consequently, lower doses will involve longer treatments,
although it could be argued that noxious effects may be
similar [11,55].
Finally, in order to match the colour of previously
placed restorative material with the shade obtained after
bleaching on natural teeth, fillings have to be replaced.
Because tooth whitening is not stable, the colour of the
fillings differs gradually from the frontal teeth and they
need again to be renewed [19]. We reach here the limits
of what can be acceptable between a dentistry primarily
oriented on cosmetology and the biomedical clinical
practise.
Conclusions
Despite the rather contradictory conclusions arising from an
analysis of the literature, it appears that the chemical
mechanisms of bleaching agent actions involve alteration
or destruction of the enamel organic matrix, a phenomenon
that allows the diffusion of peroxides throughout enamel
toward dentin where the chromophores are oxidatively
decolourised. From an analysis of the available data, we can
conclude that
1. Bleaching causes small defects at the surface and
subsurface of enamel.
2. Dentin permeability is probably modified and, as a
consequence, post-treatment transient tooth sensitivity
is observed in many cases.
3. The effects on pulp are more controversial and may be
inconsistent. Nevertheless, chronic treatment with
peroxides may be not safe, and this could be the case
when such treatments are carried out in the absence of
a sufficient level of control by dental surgeons.
4. Effects observed regarding dental restorations are well
recognised, there is a release of mercury from
amalgam fillings, and bleaching methods alter the
interface between dental tissues and glass ionomer
cements or resin composites.
5. The bleaching of non-vital teeth may induce resorp-
tion in the cervical area in an unpredictable manner.
Clin Oral Invest (2010) 14:110 7
6. The long-term effect of bleaching on the development
of carious decay has not yet been demonstrated but
cannot be ignored.
7. Gingival lesions appear in relation to the uncontrolled
applications of whitening gels. Again, the cellular and
tissular mechanisms of peroxide damage are well
elucidated, and again there is a critical requirement for
qualified control in order to avoid long-term gingival
tissue damage.
8. The ingestion of peroxide may occur when poorly
adapted trays are employed.
9. At the doses that are administered, it is clear that up
until now, there is no indication of any effects in terms
of general toxicity, genotoxicity, and carcinogenicity
in human. Therefore, there is a clinical tolerability. It
is also clear that below a 3.6% (w/w)H
2
O
2
concen-
tration (10% (w/w) carbamide peroxide), there is
apparently no toxic or sub-toxic risk.
10. Taking into account the possibility that chronic treat-
ments might be applied as cosmetic products that are
sold OTC, the higher concentrations utilised should
perhaps be revised.
Altogether, all these local effects have to be taken into
consideration prior to deciding if a whitening treatment is
necessary or, for that matter, safe. Potential patients should
be warned. There is a balance between the effects that may
or may not appear and the real need for bleaching. In many
cases, it seems rather an artificial cosmetic fashion
requirement than a deserving cause. Finally, the informed
and appropriate decision to administer or not, and the
control of bleaching effects should stand in the hand of
dental surgeons (or at least be under their control), and
certainly not as it appears at present, as cosmetics sold
without any restriction despite the potential health hazards
of peroxides.
Conflicts of interest We have no conflict of interest.
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10 Clin Oral Invest (2010) 14:110
... Enamel and dentin behave as semi-permeable membranes allowing the diffusion of HP according to Fick's second law [5] reaching the pulp in minutes [6]. For CP, the urea groups degrade the organic parts of the enamel, leaving empty spaces that favour the diffusion of hydrogen peroxide throughout the whole enamel thickness [7]. Higher concentrations and longer application times are associated with better results [8], but also with a higher incidence of side effects like hypersensitivity (the most common secondary effect of dental whitening) [9] and pulp damage [5], tooth demineralization (leading to changes in roughness and hardness) and gingival irritation [7]. ...
... For CP, the urea groups degrade the organic parts of the enamel, leaving empty spaces that favour the diffusion of hydrogen peroxide throughout the whole enamel thickness [7]. Higher concentrations and longer application times are associated with better results [8], but also with a higher incidence of side effects like hypersensitivity (the most common secondary effect of dental whitening) [9] and pulp damage [5], tooth demineralization (leading to changes in roughness and hardness) and gingival irritation [7]. Besides, the need to apply these products for hours, either at the dentist or at home, is not convenient for the user. ...
... At basic pH, HAP dissolution should not occur, but protein degradation in the tooth organic matrix might be happening. Indeed, the urea in CP along with the ammonium ions (NH 4 + ) formed in contact with water act on the hydrogen bonds of the proteins weakening their structure [7]. Since the components of the organic matter form a support structure that stabilizes the crystalline enamel layer [47], any change in the organic matter could cause an effect in the reflectance in the first 30 µm, as observed in PC1. ...
Article
Objectives To compare the side effects of typical whitening treatments (by means of oxidation) compared to the new treatment developed by the authors through reduction. The aim is to provide information about the chemical interactions of the encapsulated reductant agent (metabisulfite, MBS) with the enamel structure compared with carbamide peroxide (CP) and to study their penetration in the hydroxyapatite (HAP) and the changes produced in the mineral and its hardness. Methods Chemical imaging is performed by synchrotron-based micro Fourier transformed infrared spectroscopy (SR-µFTIR). Continuous Stiffness Measurements (CSM) were used to determine the depth reached by the treatments in order to delimitate the area of study. Results The SR-µFTIR studies showed that MBS treatments softened the first 10 µm of enamel, as happens in the initial stages of tooth decay. Principal component analysis (PCA) showed that the main differences between treatments were found in the intensity of the ν3 PO4³⁻ peak related to tooth demineralization. CP and MBS promoted different changes in the HAP mineral, observed as opposite shifts of the peak: CP shortened the P-O bond while MBS seemed to elongate it. Moreover, MBS promoted the loss of carbonates while CP did not, which is probably related to the solution’s pH. When comparing MBS and MBS Liposomes, it was observed how liposomes favoured the diffusion of MBS to inner layers, since the effects of MBS were observed in deeper enamel. Thus, the encapsulated MBS whitening effect is highly improved in terms of time when compared to MBS alone or CP. Significance The obtained results indicated that using oxidizing (CP) or reducing (MBS) treatments, promote different HAP mineral changes, and that liposomes favour the diffusion of MBS into the enamel. It is the first time that synchrotron light is used to map the bovine incisor’s enamel chemically, and to determine the effect of a whitening treatment in terms of chemical HAP modifications, and the extent in deep of these effects.
... Bu radikaller eşleşmemiş elektronlara sahip oldukları için aşırı derecede elektrofiliktirler. 22 Ozon da kararsız bir moleküldür. Ozon gazı ayrışması sonucu oksijen molekülü ve bir serbest radikal olan eşleşmemiş elektronlara sahip oksijen anyonu ortaya çıkar. ...
... Ozon gazının ayrışmasından sadece oksijen anyonu oluşurken hidrojen peroksitin ayrışmasından oksijen anyonu, perhidroksil, hidroksil ve süperoksit serbest radikali oluşur. 17,22 Bu serbest radikaller arasından hidroksil radikali en güçlü serbest radikaldir. 23 Ağartma işleminde hidrojen peroksitin daha etkili olması oluşturduğu serbest radikal türlerine ve çeşitliliğine bağlı olabilir. ...
... Peroksit içeren kimyasal ağartma maddelerinin diş sert dokularının kaybı, periodontal dokularda olası hasar, diş hassasiyeti ve rezin içerikli restoratif materyallerin bağlanma kuvvetini azaltması gibi çeşitli yan etkilere sahip olduğu bilinmektedir. 22 Ozonun dental ve periodontal dokular üzerindeki önemli yan etkileri henüz çalışmalarda bildirilmemiştir. Aksine oral patolojilerin tedavisinde, minimal girişimsel diş hekimliğinde remineralizasyon terapilerinde kullanımı doğrulanmış ve ozonun rezin içerikli malzemelerin bağlanma gücü üzerinde olumsuz bir etkisi olmadığı bildirilmiştir. ...
... Whereas dental ceramics are completely inorganic, enamel includes organic component which constitute the matrix of the structure. 22 Tooth surface can adsorbe limited amount of bleaching agent owing to the prismatic nature of enamel. Existence of agents in dentinoenamel junction, dentine and even pulp chamber after 5 to 15 minute bleaching sessions was reported by previous researches. ...
... Existence of agents in dentinoenamel junction, dentine and even pulp chamber after 5 to 15 minute bleaching sessions was reported by previous researches. 17,[19][20][21][22] The cause of the unexpected change in ΔL* values is thought to be the lack of the chromogen accumulation on none of the samples in this study. Therefore the research design is quite different from the in vivo studies that evaluated color previously. ...
... They are considered as safe, but dental sensitivity and mucosal irritations may occur due to their use (Goldberg et al., 2010). ...
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This study aimed to explore the public's perception on the use of over-the-counter tooth whitening (OCTW) from the analysis of videos deposited in a social media service. A cross-sectional, qualitative, and quantitative study was developed using YouTube TM as a search platform. Videos with personal reviews on the use of OCTW products (toothpaste [WT], strips [WS], whitening pens [WP], and charcoal-based products [WC]) were selected, visualized, and transcribed in verbatim. Transcriptions were analyzed using a content analysis model including seven thematic categories: perceptions of results, adverse effects, using aspects, financial aspects, sensorial perceptions, expectations, and truthfulness in video production. Variables related to engagement and features of the videos were collected and descriptively analyzed. In total, 104 videos were included in the study. Videos about WS (43.9%), followed by WT (22.7%) and WC (16.0%) were the most viewed on the platform. Tooth sensitivity was frequently reported for WS (57.1%) and WT (18.2%). Periodontal tissue disorders were specially noticed in WC and WS videos (16% and 14.3%, respectively). WC showed the highest level of satisfaction in the results (88.8%) and sponsorship for its use. In conclusion, OCTW products can be marketing influenced and applied without professional counselling and they may cause adverse effects. This fact points out the importance of qualified recommendations specially informing the buyer about undesirable or harmful effects to the dental and periodontal tissues. 2 Resumo Este estudo teve como objetivo explorar a percepção do público sobre o uso do clareamento dentário sem prescrição (CDSP) a partir da análise de vídeos depositados em um serviço de mídia social. Foi desenvolvido um estudo transversal, qualitativo e quantitativo, utilizando o YouTubeTM como plataforma de busca. Vídeos com comentários pessoais sobre o uso de produtos de CDSP (creme dental clareador [CDC], tiras [TC], canetas clareadoras [CC] e produtos à base de carvão [PC]) foram selecionados, visualizados e transcritos na íntegra. As transcrições foram analisadas por meio de um modelo de análise de conteúdo que incluiu sete categorias temáticas: percepções de resultados, efeitos adversos, aspectos de uso, aspectos financeiros, percepções sensoriais, expectativas e veracidade na produção do vídeo. Variáveis relacionadas ao engajamento e características dos vídeos foram coletadas e analisadas descritivamente. No total, 104 vídeos foram incluídos no estudo. Os vídeos sobre TC (43,9%), seguidos de CDC (22,7%) e PC (16,0%) foram os mais vistos na plataforma. A sensibilidade dentária foi frequentemente relatada para TC (57,1%) e CDC (18,2%). Distúrbios do tecido periodontal foram especialmente notados nos vídeos de PC e TC (16% e 14,3%, respectivamente). O PC apresentou o maior nível de satisfação nos resultados (88,8%) e patrocínio para sua utilização. Em conclusão, os produtos de CDSP podem ser influenciados pelo marketing e aplicados sem aconselhamento profissional e podem causar efeitos adversos. Este fato ressalta a importância de recomendações qualificadas, especialmente informando o comprador sobre efeitos indesejáveis ou prejudiciais aos tecidos dentários e periodontais. Palavras-chave: Clareamento dental; Mídias sociais; Internet; Medidas de resultados relatados pelo paciente. Resumen Este estudio tuvo como objetivo explorar la percepción del público sobre el uso de blanqueamiento dental de venta libre (BDVL) a partir del análisis de videos depositados en un servicio de redes sociales. Se desarrolló un estudio transversal, cualitativo y cuantitativo utilizando YouTube TM como plataforma de búsqueda. Se seleccionaron, visualizaron y transcribieron textualmente videos con reseñas personales sobre el uso de los productos BDVL (pasta de dientes [PD], tiras [TB], bolígrafos blanqueadores [BB] y productos a base de carbón [PC]). Las transcripciones fueron analizadas utilizando un modelo de análisis de contenido que incluye siete categorías temáticas: percepciones de resultados, efectos adversos, aspectos de uso, aspectos financieros, percepciones sensoriales, expectativas y veracidad en la producción de videos. Se recopilaron y analizaron descriptivamente variables relacionadas con el compromiso y las características de los videos. En total, se incluyeron en el estudio 104 videos. Los videos sobre TB (43,9 %), seguidos de PD (22,7 %) y PC (16,0 %) fueron los más vistos en la plataforma. La sensibilidad dental se informó con frecuencia para TB (57,1%) y PD (18,2%). Los trastornos del tejido periodontal se notaron especialmente en los videos PC y TB (16% y 14,3%, respectivamente). PC mostró el mayor nivel de satisfacción en los resultados (88,8%) y patrocinio para su uso. En conclusión, los productos BDVL pueden verse influenciados por la comercialización y aplicarse sin asesoramiento profesional y pueden causar efectos adversos. Este hecho destaca la importancia de recomendaciones cualificadas que informen especialmente al comprador sobre efectos indeseables o nocivos para los tejidos dentales y periodontales. Palabras clave: Blanqueadores dentales; Medios de comunicación sociales; Internet; Medición de resultados informados por el paciente.
... In response, over-the-counter (OTC) bleaching products soon became popular when they were introduced in the market at the beginning of the 2000s. 1 Hydrogen peroxide, the active agent in the OTC bleaching products, has potential adverse effects such as post-bleaching hypersensitivity, gingival irritation, alteration in enamel microhardness, and even genotoxicity and carcinogenicity. [2][3][4] Concerning those adverse effects, the EU Council Directive 2011/84/EU stated that only the products containing up to 0.1% of hydrogen peroxide were safe and could be sold as cosmetics to consumers without the supervision of dentists on 31 October 2012. However, this concentration might be too low to have a satisfying tooth-whitening effect. ...
Article
Purpose: To investigate the tooth-whitening effects of mouthrinses containing different sizes of hydroxyapatite (HAP) particles after prolonged application time and compare them with a commercial whitening mouthrinse. Methods: 50 bovine incisors were stained and randomly distributed into five groups: the HAP groups with 3 µm, 200 nm and 50 nm particle size, the commercial whitening mouthrinse group and the distilled water group. The teeth underwent prolonged mouthrinse applications that were equivalent to simulated 3- and 6-month mouthrinsing. Tooth color was measured and calculated before and after mouthrinsing. The group and application time effects were analyzed with a nonparametric analysis of longitudinal data using the nparLD package in R and ANOVA-type statistic was reported. Pairwise Wilcoxon rank-sum tests with BH correction were performed to compare the tooth color changes of individual groups. The mouthrinse-treated enamel was observed by SEM. Results: The whitening effect of HAP mouthrinses after the prolonged application time was confirmed. The HAP mouthrinses exhibited similar whitening effects to the commercial mouthrinses. The particle size and application time could significantly affect the whitening performance of HAP mouthrinses. The 50 nm HAP group exhibited significantly higher ΔE values than the 3 µm group after the 6-month-equivalent application (P= 0.024). A longer period of application increased significantly the ΔE and ΔL values (P< 0.05). The HAP-treated enamel surfaces were entirely covered with HAP after the 6-month-equivalent application. Clinical significance: The HAP nanoparticles showed better tooth-whitening performance after a longer period of mouthrinsing than the microsized HAP particles. This should be taken into consideration by dental manufacturers for optimizing the particle size for their HAP-containing products. To achieve a better outcome in tooth-whitening, the patients should apply the mouthrinse regularly for an extended period of time.
... These results corroborate the results of Wang and Chisini [18,19] study, which demonstrated that the shape and storage temperature directly influence the stability of HP. Hydrogen peroxide is an oxidizing agent whose action is enhanced by temperature [18][19][20]. Therefore, high temperature and humidity cause a change in the chemical balance among the components of the bleaching gel, initiating the degradation of carbamide peroxide (CP), resulting in the formation of water that is capable of further dissolving CP [21,22]; we found a reduction in values of HP quantification. ...
Article
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Objective To evaluate the physical–chemical (weight, pH, quantification of hydrogen peroxide) and mechanical (texture profile and rheology tests) properties of the experimental bleaching gel based on the bioadhesive polymer Aristoflex® AVC, after accelerated stability testing. Materials and methods A total of 300 syringes of bleaching gels were divided into 5 groups (n = 60): Whiteness Perfect® 10%—FGM (WP); carbamide peroxide 10% with aristoflex (CPa); carbamide peroxide 10% with Carbopol (CPc); aristoflex thickener (A); and Carbopol thickener (C). According to the following requirements and time, the accelerated stability test was performed: in an incubator at 40 °C and 75% humidity per 1, 3, and 6 months, and baseline (refrigerator at 5 °C and 25% humidity). The variables were analyzed following the statistical tests: Two-way ANOVA and Tukey’s test were applied to pH; weight data were analyzed using a mixed model for repeated measurements over time and the Tukey–Kramer test; one-way ANOVA and Tukey’s test analyzed the rheology test; generalized linear models were used to quantify the peroxide amount and texture profile data. A significance level of 5% was considered. Results The experimental bleaches CPa and CPc had the highest pH values when compared to the others in 6 months. Thickeners A and C did not change the pH, weight, and active content over the accelerated stability times (p > 0.05). Furthermore, there was weight loss after 3 months of storage for CPa and CPc (p < 0.05). In the quantification of hydrogen peroxide, the WP group showed the highest values over time (p < 0.0001), only showing a significant loss after the 3rd month. Meanwhile, CPa and CPc showed a reduction in quantification from the 1st month. Conclusions Temperature and humidity directly influenced the active content and properties of bleaching gels. In addition, the presence of components regardless of thickeners, such as stabilizers, in the commercial gel allowed for greater stability over time. Clinical relevance The development of experimental bleaching gels for clinical use requires careful testing. Therefore, accelerated stability testing represents a valuable tool in the development and evaluation of cosmetic formulations.
... The rough surface will be more susceptible to retain stains, and color rebound will occur. (14)(15)(16) Another concern is the post bleaching hypersensitivity which is the most prevalent drawback of in-office bleaching technique. (17) Although being the most prevalent drawback, the etiology of post bleaching hypersensitivity is not yet fully understood. ...
... Tooth bleaching products are still a concern due to their adverse effects [6]. Thus, tooth bleaching products have been developed to overcome the side effects of bleaching treatments. ...
Article
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Objectives The objectives of this study were to develop a novel bleaching material containing hydrated calcium silicate (hCS) particles and investigate the effects of hCS on the bleaching efficacy, microhardness, and surface morphology of bovine enamel.Materials and methodsTo prepare the hCS particles, white Portland cement was mixed with distilled water and ground into a fine powder. The particles in various proportions were then mixed with 35% hydrogen peroxide solution (HP), while HP without hCS was used as a control (HP), and teeth whitening gel was used as a commercial control (CC). Following the thrice application of experimental and control solutions on the discolored bovine enamel surface for 15 min, color change (n = 10), microhardness (n = 10), and micromorphology (n = 2) of the enamel surface were analyzed.ResultsThe Δ E* of the enamel surface treated with the experimental solution containing hCS was significantly higher than that of the CC, but there were no significant differences between the different hCS contents. The experimental solution containing hCS reduced the percentage of microhardness loss on the enamel surface, and the percentage of microhardness loss significantly decreased as the content of hCS increased (p < 0.05). The erosion pattern was only observed on enamel surfaces treated with HP and CC.Conclusions This study suggests that HP containing hCS is effective in bleaching efficacy. In addition, hCS could also minimize the microhardness loss of tooth structure caused by HP and maintain enamel surface morphology.Clinical relevance.This novel bleaching material is promising for inhibiting demineralization and promoting the remineralization of teeth during bleaching treatment in dental clinics.
Preprint
Background The aim of this study was to evaluate the postbrushing tooth-whitening effect of toothpaste containing hydroxyapatite nanoparticles (nano-HAPs). The impact of the concentration on the whitening performance of nano-HAP toothpaste was also investigated. Methods Two concentrations of nano-HAP (10 wt% and 1 wt%) were incorporated in nonabrasive toothpastes. Forty bovine incisors were randomly assigned into four groups: 10 wt% nano-HAP, 1 wt% nano-HAP, toothpaste without nano-HAP as a negative control and water as a blank control. Each tooth was treated with the toothpaste three times and hydrodynamic shear force (HSF) once. The nano-HAP-treated enamel was observed by SEM after each application. Tooth color ( L *, a * and b * values) was measured by a spectrophotometer, and color changes (△ E , △ L, △ a and △ b values ) were calculated. Two-way mixed ANOVA was performed to evaluate the influence of the concentration and repeated application on the tooth-whitening effect of nano-HAP. Results We found that nano-HAP-treated enamel exhibited higher L* values and lower a * and b * values than the control groups ( P <0.05). The 10 wt% nano-HAP group showed significantly higher △ E values than the 1 wt% nano-HAP group ( P <0.05). After three applications, the △ E mean value of the 10 wt% nano-HAP group was 4.47. The △ E and △ L values were slightly reduced after HSF ( P <0.05). For both nano-HAP groups, HAP single crystallites and agglomerates were identified, and their sizes grew with nano-HAP reapplication. Conclusion In conclusion, nano-HAP toothpaste has a satisfying postbrushing whitening effect and good resistance to mechanical forces. The whitening effect seemed to be concentration-dependent.
Article
Background The authors aimed to evaluate the effect of a novel radiofrequency (RF) toothbrush on tooth stains and shades compared with a sonic vibrating toothbrush (CVS Health SmileSonic Pro Advanced Clean Sonic Toothbrush, Ranir) that earned the American Dental Association Seal of Acceptance. Methods The authors conducted a single-blind prospective study over 6 weeks. Participants were randomized to 1 of 2 study groups to receive either an RF toothbrush (ToothWave, Home Skinovations [test]) or a sonic vibrating toothbrush (SmileSonic powered toothbrush, Ranir [control]) and performed twice-daily toothbrushing with fluoridated toothpaste (Crest Cavity Protection, Procter & Gamble) for 6 weeks. Tooth stains and shades were assessed using the Lobene Stain Index and VITA Bleachedguide 3D-MASTER shade guide (VITA North America) at baseline and after 4 and 6 weeks of toothbrushing. In addition, the VITA Easyshade Advance 4.0 spectrophotometer (VITA North America) was used for shade evaluation. Safety was evaluated by means of oral soft-tissue examinations at each visit. Percentage reduction from baseline was compared between the groups. Statistical analyses were conducted using Mann-Whitney nonparametric model. Results Eighty-six participants (43 in each group) completed the study with fully evaluable data. At baseline, the groups did not differ significantly in mean measurement scores. Percentage reductions of the measured scores were significantly greater (more extrinsic stain removal and whitening) in the test group than in the control group (P < .001). Both toothbrushes were well-tolerated, and no device-related adverse events were reported during the study. Conclusions The RF toothbrush produced substantial benefits in the reduction of tooth stains and whitening of tooth shade compared with a powered toothbrush (CVS Health SmileSonic Pro Advanced Clean Sonic Toothbrush, Ranir) that earned the American Dental Association Seal of Acceptance. Practical Implications The novel RF toothbrush is a safe and effective tool for stain removal and tooth whitening and can serve as an alternative to other whitening agents. This clinical trial was registered at ClinicalTrials.gov. The registration number is NCT03885609.
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Over the last decade, much research has focused on the potential health benefits of antioxidants and indeed many synthetic and natural compounds have been evaluated for their antioxidant profile. However, in several studies only a limited number of assays, often poorly validated, are used and the techniques available frequently lack specificity. These limitations may incorrectly influence the results. This review will therefore focus on several pitfalls that may emerge in vitro and in vivo antioxidant research. First, different in vitro techniques to determine antioxidant potential are discussed, including radical scavenging assays and fingerprinting methods. As a rule, a panel of different assays is indispensable to characterize and establish in vitro antioxidant activity. Furthermore, as problems of absorption, distribution, metabolism and excretion are only accounted for by in vivo studies, the need for in vivo antioxidant research is pointed out. Several methods to characterize the in vivo activity of antioxidants, including major drawbacks and pitfalls of some assays, have been discussed. The availability of both a representative “oxidative stress” animal model and a battery of well-validated assays to assess the broad diversity of oxidative damage and antioxidative defence parameters, are crucial for antioxidant research in vivo.
Article
The purpose of this in vitro study was to determine the effects of three commercially available 10% carbatnide peroxide solutions and a 1.5% hydrogen peroxide solution on enamel surfaces and color. The crowns of forty freshly extracted human teeth were sectioned in half incisogingivally One half ivas bleached for 250 hours total treatment title. The other half of each looth was subjected to the same profoeol in distilled water solutiotis. The eolor of both the treated and eontrol halves was determined using a colorimeter There was no significant difference between any of the control groups, and each treated group was significantly lighter than its corresponding control group. The control and treated halves of samples of each group were then sputter eoated and examined for differences in surface morphology and were compared to enamel etched with 31% phosphoric acid. No significant differences in enamel surface texture were detected between the treated and control enamel surfaces of the teeth in any of the groups. However, the enamel surfaees in all groups differed significantly from conventionally etched enamel.
Article
Carbamide peroxide is the active ingredient in many at-home patient-applied tooth whiteners. The cytotoxicity of carbamide peroxide, as related to oxidative stress, was evaluated in vitro with several human cell lines, including Smulow-Glickman (S-G) gingival epithelial cells. The potency of carbamide peroxide was related to its hydrogen peroxide component rather than to carbamide, was eliminated in the presence of exogenous catalase, and was enhanced in the presence of aminotriazole, an inhibitor of cellular catalase. The intracellular level of glutathione, a scavanger of toxic oxygen metabolites, was decreased in cells exposed to carbamide peroxide; at higher concentrations of carbamide peroxide, leakage of lactic acid dehydrogenase was also evident. Cells pretreated with the glutathione-depleting agents, buthionine sulfoximine, chlorodinitrobenzene, and bis(chloroethyl) nitrosourea, were hypersensitive to subsequent challenge with carbamide peroxide. Conversely, pretreatment with the iron chelator, deferoxamine, protected the cells against subsequent exposure to carbamide peroxide.
Article
Fifty-eight bleached pulpless teeth were re-examined after periods of 1–8 years. Recall examination included recording of the esthetic results, clinical findings and radiographs. External root resorption was found in 4 of the cases (6.9%), and was progressive in 2 cases and arrested in 2 cases. There had not been any pre- or postoperative trauma in any of the 4 cases. The occurrence of resorption was not related to the bleaching technique used. Resorptive lesions were found to have been initiated apical to and not at the cemento-enamel junction. Esthetically, the bleaching was considered successful in only 50% of the cases, acceptable in 29% and failed in 21%. These results caution against indiscriminate use of bleaching with hydrogen peroxide, and emphasize the importance of preventive measures and postoperative follow-up of bleached pulpless teeth.
Article
Replicas of unerupted and erupted human enamel submitted to protein-disrupting solutions showed: (1) an inequal distribution of porosities in the subsurface; (2) such porosities were restricted gradually in each enamel subunit (enamel segments limited by two perikymata). First the whole surface was covered by a network, reduced at a later stage to half of the surface and ultimately the porosities were present only in the perikymata. This paper confirms the occurrence of a late maturation at stage where cells are no longer active and details the time-dependent involution of these porosities.
Article
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.
Article
We have used the autoradiographic method to locate trigeminal nerve endings in monkey teeth. The nerve endings were labeled in two adult female Macaca fascicularis by 20 hours of axonal transport of radioactive protein (3H-L-proline). We found a few labeled axons in contralateral mandibular central incisors and one mandibular canine. In ipsilateral teeth, numerous myelinated and unmyelinated axons were labeled; they formed a few terminal branches in the roots but primarily branched in the crown to form the peripheral plexus of Raschkow and to terminate as free endings in the odontoblast layer, predentin, and as far as 120 μm into dentinal tubules. Electron microscopic autoradiography showed that the radioactive axonally transported protein was confined to sensory axons and endings; odontoblasts and dentin matrix were not significantly labeled. Labeled free nerve endings were closely apposed to odontoblasts in dentin but did not form distinctive junctions with them.Nerve endings were most numerous in the regular tubular dentin of the crown adjacent to the tip of the pulp horn, occurring in at least half of the dentinal tubules there. Reparative dentin was poorly innervated, even near the tip of the crown, and it had a different tubular structure and adjacent pulpal structure from the innervated dentin. Radicular dentin was not innervated in most areas but did contain a few labeled axons where the predentin was wide and the odontoblasts were columnar, as at the buccal and lingual poles of some roots.Our results show that dentinal sensory nerve endings in primate teeth can be profuse, sparse, or absent depending on the location and structure of dentin and its adjacent pulp. When dentin was innervated, the tubules were straight and contained odontoblast processes, the predentin was wide, the odontoblast cell bodies were relatively columnar, and there was an adjacent cell-free zone and pulpal nerve plexus.
Article
The chemical reactions that take place at the amalgam surface when exposed to bleaching agents are not well-understood. It is known, however, that mercury ions are released from dental amalgam when bleached. We hypothesized that increasing concentrations of hydrogen peroxide are more effective than water at increasing mercury ion release from dental amalgam. We prepared dental amalgam discs (n = 65) by packing amalgam into cylindrical plastic molds and divided them into 13 equal groups of 5 discs each. The discs in each group were individually immersed in either 0%, 3.6%, 6%, or 30% (w/v) hydrogen peroxide at exposure periods of 1, 8, 48, and 168 hrs. Samples were taken for mercury ion release determination by inductively coupled plasma mass spectrometry. There were significant increases in mercury release between control and all other hydrogen peroxide concentrations at all exposure times (p < 0.05).