Modern concepts of teeth whitening – a narrative review

Abstract

Whitening has been known since Biblical times. Nowadays, in the developed world, patients are placing a stronger interest in the aesthetic appearance of their teeth. As a result, public demand for aesthetic dentistry, including tooth whitening, has recently increased. Aesthetics of the teeth is of great importance to many patients. The aim is to summarise and discuss the teeth whitening procedure, tools, materials, and methods, as well as its efficacy and safety. In addition, the paper aims to provide full and comprehensive information for dentists and their patients about the merits and perils of whitening. Methods. Relevant literature from Scopus published in English was selected using the following search criteria "tooth OR teeth AND whitening OR bleaching" by 2022. In total, there were found 3840 papers. Then, we applied the inclusion and exclusion criteria to the selected scientific papers to choose the relevant ones. Results. A comprehensive study of the available information related to means and products for teeth whitening was carried out. Whitening may be accomplished by the physical removal of the stain or a chemical reaction to lighten the tooth colour. The indications for appropriate use of tooth-whitening methods and products depend on the correct diagnosis of the discolouration. When used appropriately, tooth-whitening methods are safe and effective. Conclusions. Tooth whitening is a form of dental treatment and should be completed as part of a comprehensive treatment plan developed by a dentist after an oral examination.

Full text

Original Research Article:
review article
(2022), «EUREKA: Health Sciences»
Number 6
31
Medicine and Dentistry
MODERN CONCEPTS OF TEETH WHITENING – A NARR ATIVE REVIEW
Svitlana Boitsaniuk1
Orest Kochan
Department of Measuring Information Technology
Lviv Polytechnic National University
12 Stepana Bandery str, 12, Lviv, Ukraine, 79013
Mariana Levkiv1
levkiv@tdmu.edu.ua
1Department of Dental Therapy
I. Horbachevsky Ternopil National Medical University
1 Voli ave, Ternopil, Ukraine, 46001
Corresponding author
Abstract
Whitening has been known since Biblical times. Nowadays, in the developed world, patients are placing a stron-
ger interest in the aesthetic appearance of their teeth. As a result, public demand for aesthetic dentistry, including tooth
whitening, has recently increased. Aesthetics of the teeth is of great importance to many patients.
The aim is to summarise and discuss the teeth whitening procedure, tools, materials, and methods, as well as
its efficacy and safety. In addition, the paper aims to provide full and comprehensive information for dentists and their
patients about the merits and perils of whitening.
Methods. Relevant literature from Scopus published in English was selected using the following search criteria
“tooth OR teeth AND whitening OR bleaching” by 2022. In total, there were found 3840 papers. Then, we applied the
inclusion and exclusion criteria to the selected scientific papers to choose the relevant ones.
Results. A comprehensive study of the available information related to means and products for teeth whitening
was carried out. Whitening may be accomplished by the physical removal of the stain or a chemical reaction to lighten
the tooth colour. The indications for appropriate use of tooth-whitening methods and products depend on the correct
diagnosis of the discolouration. When used appropriately, tooth-whitening methods are safe and effective.
Conclusions. Tooth whitening is a form of dental treatment and should be completed as part of a comprehensive
treatment plan developed by a dentist after an oral examination.
Keywords: abrasives, bleaching, dental floss, esthetics, hydrogen peroxide, mouthwash, toothpaste, teeth, tooth
discolouration, whitening.
DOI: 10.21303/2504-5679.2022.002690
1. Introduction
A snow-white smile is an important detail of the image, which probably everyone has
dreamed of at least once. The desire of patients to have an aesthetically perfect smile has led to the
active development of such a direction in aesthetic dentistry as teeth whitening or bleaching [1–4].
Methods to improve the esthetics of dentition by tooth whitening are of interest to dentists,
their patients, and the public. As the population’s dental awareness has grown, so has its demand
for a natural (or preferably supernatural) smile. The inescapable fact is that patients are eager to
have whiter and brighter smiles. The desire for whiter teeth is the strongest driving force in people’s
quest for dental treatment [5–9].
A whitening process for teeth describes restoring the natural colour of teeth by removing
stains from the tooth surface. Whiteners are cleaning agents found in some toothpaste and mouth
rinses. Bleaching teeth refers to whitening teeth beyond their natural colour. While the ADA has
defined the differences between teeth whitening and teeth bleaching, often, these terms are used
interchangeably [10].

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2. Materials and methods
For this review article, a narrative review style was performed using a comprehensive liter-
ature search within the Scopus database to identify any studies for whitening/bleaching techniques
in dentistry. The search considered works published in Scopus from 3840 until 2022 (included)
using the keywords ‘tooth OR teeth AND whitening OR bleaching’.
Only relevant literature from the electronic search was selected for the present review. The whit-
ening/bleaching techniques of teeth, items, and strategies were interesting. The inclusion criteria are
as follows: (i) use of existing commercial materials or their modifications in dental praxis; (ii) use of
bleaching/whitening agents in esthetic dentistry; (iii) full-text journal articles indexed in Scopus written
in English ; (iv) books and book chapters written in English; (v) books and book chapters of highly rated
publishers (Wiley, Elsevier and Springer) which appear in the references of the materials which meet
our criteria but are not indexed in Scopus; (vi) case reports (clinical trials); (vii) randomised controlled
studies. The exclusion criteria are as follows: (i) scientific papers written in a native language (not En-
glish); (ii) conference papers; (iii) articles with obsolete methods and tools from the modern point of
view; (iv) editorials.
(1) The search was carried out in the Scopus database using the keywords ‘tooth OR teeth
AND whitening OR bleaching’. In total, 3840 records were found.
(2) Three co-authors analysed 3840 records for compliance with the inclusion and exclusion
criteria. In total, 3769 records were deleted, i.e., 71 records remained.
(3) In the reference lists of these 71 articles, we found 2 relevant books and sections of books
by highly rated publishers (Wiley, Elsevier, and Springer or affiliated with them).
(4) To the 71 records from Scopus, we added 2 books and chapters of books. That is 73 re-
cords in total. All selected records were distributed among all authors for reading the full-text
articles and preparing the manuscript. The procedure is shown in Fig. 1 in the PRISMA flowchart.
Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram

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3. Result
3. 1. History of clinical development and evolution of the procedure
Ancient civilisations and teeth whitening
The desire for whiter teeth is not completely a recent phenomenon. Even Biblical times,
white dentition was considered attractive, youthful, and desirable. In third-century bc Greece, The-
ophrastus wrote that it was ″considered a virtue to shave frequently and have white teeth″.
The ancient Egyptian culture placed a strong emphasis on personal appearance. Pharaohs
were fascinated by the idea of achieving white teeth, and they used a special toothpaste that con-
tained wine vinegar, pumice stone, and ground oxen hooves. While this abrasive and acidic mix-
ture may have whitened teeth, it likely caused serious damage to the tooth enamel [7, 10].
The ancient Romans also loved white smiles. They used chew sticks to get rid of plaque on
their teeth. There are even documents to indicate that they used urine (due to its ammonia content)
to keep dental stains at bay (Fig. 2) [11–15].
Fig. 2. The evolution of modern whitening techniques
3. 2. Classification of whitening procedures
Bleaching procedures can be classif ied as follows:
Internal (or nonvital) bleaching. The active agent is placed within the pulp chamber by the
dentist (in-off ice bleaching) and can be left in its place between appointments (“walking bleach-
ing”) as well. [16–19].
External (or vital) bleaching. The active agent is placed in contact with the tooth surface.
Despite its name, vital bleaching can be performed only on endodontic-treated teeth. Vital bleach-
ing can be further divided into at-home bleaching (with self-application of the bleaching agent by
the patient as instructed by the dentist) and in-office bleaching (in which the dental team performs
the bleaching procedure at the dental chair) [20–23].
Bleaching with over-the-counter products [24, 25].
Table 1 Summarises the indications for use and the adverse effects of tooth-whitening
methods [26].
Despite the large number of techniques described in the literature concerning the external
bleaching of vital teeth, all are based on the direct use of hydrogen peroxide (H2O2) or its precursor,
carbamide peroxide (CH6 N2O3) [27].
Whitening occurs through the process of chemical degradation of chromogens. Therefore,
the success of the teeth whitening technique is directly related to the ability of peroxides to pene-
trate or diffuse into the enamel and dentin.

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Most bleaching systems use either hydrogen peroxide or carbamide peroxide (or, more
recently, both in combination). The chemistry is similar since carbamide peroxide, or urea per-
oxide degrades into urea and hydrogen peroxide in the presence of water. By weight, carbamide
peroxide contains 33 % hydrogen peroxide, so a bleaching gel with 10 % carbamide peroxide
contains a similar activity level as one with 3.3 % hydrogen peroxide (Fig. 3) [28, 29].
Tab le 1
Tooth-whitening methods, indications for use and adverse effects
Type of product or method Active agents Indications for use Potential adverse effects
Internal bleaching − in- off ice
or walking
35 per cent hydrogen per-
oxide
Endodontically treated
teeth Root resor ption
External bleaching − in-of-
fice one to three visits
30 per cent to 38 per cent
hydrogen peroxide, alone or
with heat or light
Single or multiple disco-
loured teeth
Transient tooth sensitivity and
gingival irritation
Custom bleaching trays are
worn by the patient daily for
two to six weeks
10 per cent carbamide
perox ide
Multiple teeth and entire
arches, most effective for
yellow or brown disco-
louration; may be effective
for tet racycline stai ning
with longer use.
Sensitivity of teeth during bleach-
ing
Brushing with whitening
toothpaste Abrasives Surface staining None
Microabrasion followed
by neutral sodium f luoride
applications
Abrasives and acid
Isolated brown or white
discolourations of the shal-
low depth in enamel
None
Microabrasion followed by
custom tray bleaching
Abrasives and acid; 10 per
cent carbamide peroxide
White discolouration on
yellowish teeth
Sensitivity of teeth during bleach-
ing
Fig. 3. Structure of bleaching agents
Tooth-whitening methods include using peroxide bleaching agents to remove internal dis-
colourations and abrasive products to remove external stains. Both methods are safe and effective
when supervised by the dentist. Micro-abrasion is indicated for removing isolated discolourations
that are often associated with fluorosis. Whitening toothpaste removes surface stains only through
the polishing effect of the abrasives they contain (Fig. 4) [30].

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Fig. 4. Varieties of teeth enamel bleaching methods
3. 3. Types of stains/discolourations/ comparative diagnosis of stains
Many types of teeth discolourations may affect the appearance of teeth, and the causes of
these problems vary, as does the speed with which they may be removed.
Distinguishing between the quality and the cause of stains has more than just academic
interest. Knowing the reason for tooth staining allows the dentist to plan the whitening technique
better and provide a more accurate prediction of the result. Many factors can cause staining and
discolouration of teeth. Traditionally, tooth discolourations are divided into extrinsic and intrin-
sic (Tabl e 2).
Tab le 2
Types of tooth discolouration
Reasons
Extrinsic stains
Intrinsic stains
Discolourations developed
before teeth erupt ion (folli-
cle development)
Discoloration developed
after teeth eruption
– Tobacco
– Food and beverages
– Medicines
– Amelogenesis imperfecta
– Dentinogenesis imperfecta
– Endemic f luorosis
– Porphyria
– Sickle cell anaemia
– Staining with tet racycline
– Age
– Dental metals
– Food, drink and habits such
as smoking
– Idiopathic pulp recession
– Dental material
– Traumatic injury

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Intrinsic stains are localised inside the tooth, either in the enamel or the underlying dentin.
They can result from systemic causes are 1) drug-related (tetracycline); 2) metabolic: dystrophic
calcification, f luorosis; and 3) genetic: congenital erythropoietic por phyria, cystic fibrosis of the
pancreas, hyperbilirubinemia, amelogenesis imperfecta, and dentinogenesis imperfecta [31, 32].
Intrinsic staining of teeth happens prior to tooth eruption during tooth development. However,
intrinsic staining can also occur after tooth eruption. Mainly pulpal hemorrhagic products follow-
ing trauma may lead to intrinsic discolouration by blood penetration into the dentin tubuli. Dental
procedures like amalgam f illings or endodontic treatments can also cause them. Deeper internal
stains or enamel defects usually cause intrinsic stains.
Extrinsic stains usually result from the accumulation of chromatogenic substances on the ex-
ternal tooth surface [14, 33]. Colouring compounds – chromophores – are of organic and inorganic
origin. Chromophores absorb light in the visible range and ref lect mainly a complementary colour,
usually yellow or brownish, recognised by the human eye. Organic chromophores are small organic
molecules, such as tannins or furfural, found in tea, coffee, red wine or fruits. Chromophores can
also be formed by chemical processes (e.g., oxidation) of initially colourless compounds. Coloured
tin sulfide, SnS, may result from the chemical reaction of stannous fluoride, SnF2, from toothpaste
with volatile sulfur compounds produced by oral bacteria [34].
The causes of tooth staining must be carefully evaluated to predict better the rate and extent
to which whitening will improve tooth colour, as some stains are more sensitive to the process than
others. The indications for appropriate use of tooth-whitening methods and products depend on the
correct diagnosis of the discolouration. Several approaches are available for measuring changes in
tooth colour. These include visual measurements by trained clinicians and instrumental measure-
ments using spectrophotometry, chromameters and digital image analysis [34, 35].
3. 4. In-office treatments
In-office bleaching (“powerful bleaching”) is done with concentrated solutions of H2O2 in
water (typically 15 %, 30 %, 35 wt %) for about 20-30 min. However, care must be taken because a
concentrated hydrogen peroxide solution is highly oxidising and harmful to soft tissue. Therefore, the
gingiva and tongue must be protected by suitable means (e.g. rubber dam). Furthermore, peroxides
are antibacterial agents that may lead to an imbalance (dysbiosis) of the oral microbiome [36–40].
Some professional whitening procedures employ light sources. The following types of light
are the most frequently used: LED, plasma arc and halogen. From a chemical viewpoint, this irra-
diation should not change the oxidative effect of hydrogen peroxide, but it may enhance the reaction
rate due to local temperature increases [41–46].
Over night (″nightguard″) bleaching is accomplished by the application of a 10-20 % car-
bamide peroxide-containing gel (see below) in a patient-specific mouthguard [47, 48]. A 10 %
carbamide gel has been approved by the American Dental Association for home bleaching. Due
to the lower concentration of hydrogen peroxide, several overnight treatments are necessary to
achieve visible effects. The whitening effect of both power bleaching and nightguard bleaching was
reported to persist for several years after treatment. Other bleaching options are paint-on gels and
whitening strips based on peroxides [49–51].
3. 5. Over-the-counter teeth whitening products
Whitening toothpaste
Whitening toothpaste often (but not always) contain harder abrasives in greater amounts
than standard toothpaste. Abrasives with such quality and in such amount are included in tooth-
paste to achieve sufficient removal of external stains [33, 52–54]. Therefore, abrasives are the most
important ingredients in toothpaste formulations for effective stain removal.
To achieve teeth whitening, many different agents are used, e. g., in commercially available
toothpaste (Table 3).
Common abrasives are hydrated silica, SiO2·n H2O, calcium carbonate, CaCO3, and alumina,
Al2O3 (Table 4). These abrasives may also differ in particle size, morphology and hardness [33, 54].

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Especially the properties of silica abrasives strongly depend on parameters such as water content,
cross-linking, particle shape and particle size [55].
Tab le 3
Examples of commonly used whitening agents in products for home and professional use (in
alphabetical order; the most efficient whitening agents are given in the example) [52, 55]
Whitening Agent Mode of Action
Abrasives (e. g., hydrated silica, perlite, alumina)
 Mechanical removal of extrinsic stains
Antiredeposition agents (e. g., polyphosphates, sodium citrate) Prevention of the deposition of chromophores and inhibition of
calculus formation where external stains could be incor porated
Calcium phosphates (e. g., hydroxyapatite)
Adhesion of white calcium phosphate particles on the tooth
surface and prevention of bacterial attachment/plaque forma-
tion on the teeth
Colourants (e. g., blue covarine) Shifting colour absor ption and reflection spectra from yellow
to blue
Enzymes/proteases (e. g., papain, bromelain) Support stain removal due to degradation of proteins (hydroly-
sis of peptide bonds)
Peroxides (e. g., hydrogen peroxide, calcium peroxide) Oxidation of organic chromophores
Polyaspartate (e. g., sodium polyaspartate) Inhibition of plaque-formation
Surfactants (e. g., sodium lauryl sulfate) Removal of hydrophobic compounds from the tooth surface
Tab le 4
Overview of commonly used abrasives in toothpaste [54]
Name (INC I*) Chemical Formula Relative Hardness Expected Stain Removal
Sodium bicarbonate NaHCO3Soft Low
Dicalcium phosphate dihydrate (brushite) CaHPO4  H2OSoft Low
Calcium carbonate CaCO3Soft Low
Calcium pyrophosphate Ca2P2O7Medium hard Medium
Hydroxyapatite Ca5(PO4)3(OH) Medium hard Medium
Hydrated silica SiO2nH2O Medium hard Medium
Perlite A mineral silicate Hard High
Alumina Al2O3Hard High
Note: *INCI: International Nomenclature of Cosmetic Ingredients
Whitening compounds in whitening toothpaste are also based on peroxide. However, due to
the chemical instability of hydrogen peroxide, other compounds are used, such as calcium perox-
ide, sodium percarbonate and magnesium peroxide, surfactants, anti-fouling agents, dyes, enzymes
and poly-aspartate [53, 55–57] (Tabl e 5).
Tab le 5
Bleaching agents that are frequently used and contained in-home or in-office whitening products
Bleaching agent Mechanism of act ion
Abrasive substances (hydrated silica or silicon dioxide, perlite,
alum ina) Mechanical removal of external stains
Abrasive substances (hydrated silica or silicon dioxide, perlite,
alum ina)
Agents preventing the precipitation of chromophores (polyphos-
phates, sodium citrate)
They prevent the deposition of chromophores and in hibit the
formation of hard dental deposits
Calcium phosphates (hydroxyapatite) Adhesion of white calcium phosphate particles on tooth surfac-
es and prevention of bacterial attachment/biofilm formation
Dyes (covarin blue) Change in the absorption spectrum and colour ref lection from
yellow to blue

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In addition to whitening toothpaste, whitening mouthwashes, whitening strips, whitening
floss, and whitening chewing gums have been reported in the literature. Whitening mouthwashes
containing a low concentration of hydrogen peroxide (1.5 %) and sodium hexametaphosphate have
been used with moderate success [51, 58, 59].
Whitening mouthwashes
Whitening oral rinses fight the formation of plaque and tartar. Whitening mouthwashes
have a low concentration of HP and sodium hexametaphosphate, potassium pyrophosphate, and
sodium citrate. These ingredients work to whiten teeth either by bleaching or removing and con-
trolling stains. Hydrogen peroxide diffuses through the organic matrix of the tooth and produces
free radicals that lead to successful whitening. However, the efficacy of whitening mouthwashes
may be decreased by the fact that they are in contact with the teeth for a short period compared with
bleaching gel for use at home [60, 61].
After using such means, the teeth become cleaner and whiter, and plaque accumulates on
them more slowly. However, frequent use of oral whitening rinses can lead to irritation of the mu-
cous membrane and increased sensitivity of the teeth [62–64].
Whitening strips
In addition to whitening toothpaste, whitening strips, dental f loss, and chewing gums have
been reported in the literature [65, 66].
Peroxide gels are used in tooth strips. They contain urea and hydrogen peroxide. As
soon as you remove the protective sticker from the strip, the gel is activated: it produces per-
oxide ions of oxygen in an active form, which, in turn, have pronounced oxidising properties.
Ions penetrate into the deepest layers of tooth tissue and destroy pigments (organic) to ordi-
nary water and carbon dioxide. As a result of these processes, tooth enamel is also brighten-
ed [51, 67].
Whitening dental f loss has been brought to the market (coated with abrasive silica), but up
to 2009, no clinical report was published. Whitening chewing gum containing sodium hexameta-
phosphate did not perform better than normal chewing gum [30, 51, 68].
3. 6. Side Effects, Risks and Hazards
The most commonly reported side effects are tooth sensitivity and gingival or mucosal
irritation [69–73].
Almost always, the sensitivity that occurs during bleaching is short-termed and disap-
pears after the bleaching is stopped. Patients usually experience sensitivity during both home
and dental office whitening. There are several simple and complex reasons for tooth sensitivity
during whitening:
Possible causes of tooth sensitivity and gingival irritation
– Addition of Carbopol and other thickening agents.
– Age of the patient (patients younger than 40 experience more side effects).
– Anhydrous-based whitening products.
– Chemical byproducts of carbamide peroxide.
– Chemical interaction of the tray.
– The concentration of the whitening solution.
– Dissolving media.
– Exposure time.
– Flavours were added to the whitening solution.
– Frequency of application.
– Inherent patient sensitivity.
– Medical status of the patient.
– The pH of the whitening solution.
– Sex of the patient (women appear to experience more side effects than men).

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– Tray material used.
– Tray rigidity.
Two methods to consider for treating sensitivity during whitening treatment are the passive
method and the active method.
Passive method:
– Altering the whitening time.
– Changing the frequency.
– Reducing concentration to find a comfortable solution for the patient.
– Allowing the patient to skip a night of whitening.
– Using less whitening gel in the tray.
– Trimming back the whitening tray so it does not impinge on the gingival margins.
Active method:
– In the active method, desensitising materials are applied either directly onto the teeth or
inside the whitening tray.
– Products used are f luoride or potassium nitrate applied in the tray as a pretreatment, at the
onset of symptoms, or after a course of treatment.
– The use of f luoride and potassium nitrate to treat whitening sensitivity has been clinically
researched and works well.
Typically, the gingival or mucosal irritation is related to improperly fitted trays, improper or
excess application of the gel, and the use of the gel longer than prescribed. The soft tissue irritation
noted is usually mild and transient and is resolved shortly after the treatment has ended.
Peroxides harm the adhesion of composite resins to dental tissues owing to oxygen supersat-
uration in the recently bleached enamel.
As we know, oxygen is a strong inhibitor of composite material polymerisation. The excess
oxygen, however, is depleted in approximately 2 weeks. Therefore, the rule of thumb is to wait 3
weeks after completion of at-home bleaching before placing composite restorations.
4. Conclusions
Teeth whitening and bleaching are great ways to improve your smile and make you feel more
confident.
Teeth whitening/bleaching is a form of dental treatment and should be done as part of a com-
prehensive treatment plan developed by a dentist after an oral checkup. When used appropriately,
tooth-whitening methods are safe and effective.
Patients should be informed of the risks associated with tooth whitening and instructed on
identifying adverse occurrences so that they may seek professional help as needed.
Conflict of interests
The authors declare no conflict of interest.
Funding
The study was performed without financial support.
Acknowledgements
The authors are grateful to the publishing company and journal team “EUREKA: Health
Sciences” for the kind support of Ukrainian scientists and Estonia for supporting Ukraine in
struggling against the russian invasive war. As well we are thankful to the Ukrainian Armed
forces. This work has become possible only because of the resilience and courage of the
Ukrainian Army.

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© The Author(s) 2022
This is an open access article
under the Creative Commons CC BY license
Received date 04.10.2022
Acc epted date 22.11.2022
Published date 30.11.2022
How to cite: Boitsaniuk, S., Kochan, O., Levkiv, M. (2022). Modern concepts of teeth whitening – a narrative review. EUREKA:
Health Sciences, 6, 31–43. doi: http://doi.org/10.21303/2504-5679.2022.002690