Toothwhitening: An Overview

Fiona Collins BDS, MBA, MA, FPFA

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Toothwhitening: An Overview

Civilizations throughout history have made efforts to whiten their teeth. Toothwhitening (bleaching) in modern times has become one of the most frequently requested and performed esthetic procedures in dentistry.1A history of toothwhitening. Available at: https://www.seattletimes.com/seattle-news/health/a-history-of-tooth-whitening/.,2American Dental Association, ADA Council on Scientific Affairs. Tooth whitening/bleaching: Treatment considerations for dentists and their patients. 2009, revised 2010. Available at: https://www.ada.org/~/media/ADA/About%20the%20ADA/Files/ada_house_of_delegates_whitening_report.ashx According to one survey, the majority of people believe a brighter smile leads to a happier, more successful life.3American Academy of Cosmetic Dentistry. 2012 Whitening Survey. Available at: https://aacd.com/proxy/files/Publications%20and%20Resources/Whitening%20Survey_Aug12(1).pdf. Whiter teeth also results in more positive perceptions of an individual’s intellect, appeal and relationships, and a positive psychosocial impact and effect on patients’ self-perception of their smiles.4Joiner A, Luo W. Tooth colour and whiteness: A review. J Dent 2017;67S:S3-10.,5Lajnert V, Kovacevic Pavicic D, Pavlic A, Pokrajac-Bulian A, Spalj S. Smile Aesthetics Satisfaction Scale: development and validation of a new brief five-item measure of satisfaction with smile aesthetics in adults and the elderly. Int Dent J 2018;68(3):162-70.,6Angel P, Bersezio C, Estay J, Werner A, Retamal H, Araya C, Martin J, Fernández E. Color stability, psychosocial impact, and effect on self-perception of esthetics of tooth whitening using low-concentration (6%) hydrogen peroxide. Quintessence Int 2018;49(7):557-66.

Toothwhitening has a positive effect on patients’ self-perception.

While extrinsic stain at the tooth surface and in the pellicle can be removed with prophylaxis and while brushing with toothpaste, intrinsic stain (IS) present within the dental hard tissue cannot and may instead be treated by toothwhitening.7Watts A, Addy M. Tooth discolouration and staining: a review of the literature. Br Dent J 2001;190:309-16. IS can result from internalized extrinsic stain, fluorosis, hereditary conditions, systemic diseases, enamel hypoplasia, medications, trauma and dental materials.7Watts A, Addy M. Tooth discolouration and staining: a review of the literature. Br Dent J 2001;190:309-16. (Figure 1) In addition, aging results in a yellowed appearance and changes in tooth surface morphology can reduce light refraction and reflection, making teeth appear darker.8Ten Bosch JJ, Coops CC. Tooth color and reflectance as related to light scattering and enamel hardness. J Dent Res 1995;74:374-80.

Figure 1. Tetracycline staining

Image courtesy of Dr. Joyce Bassett

Treatment options

In-office and at-home whitening (IO; AH) can be performed with gels containing hydrogen peroxide (HP), or carbamide peroxide (CP) which breaks down into HP and urea (e.g., 20% CP breaks down into 6% HP and 14% urea). Other options include the use of enzymes, a varnish, and laser whitening. IO is typically performed with 25% to 40% HP gels and may be assisted by light, lasers or ionic technology. Home-use products contain lower concentrations, typically ranging from 10% to 33% CP and 6% to 14% HP. These include dentist-supervised take-home toothwhitening kits and unit-dose disposable trays; ionic technology; store- and internet-sourced gels, strips, pens and disposable trays; and whitening kiosks/spas.9Pinto MM, Gonçalves ML, Mota AC, Deana AM, Olivan SR, Bortoletto C, Godoy CH, Vergilio KL, Altavista OM, Motta LJ, Bussadori SK. Controlled clinical trial addressing teeth whitening with hydrogen peroxide in adolescents: a 12-month follow-up. Clinics (Sao Paulo) 2017;72(3):161-70. ,10Carlos NR, Bridi EC, Amaral F, França F, Turssi CP, Basting RT. Efficacy of home-use bleaching agents delivered in customized or prefilled disposable trays: A randomized clinical trial. Oper Dent 2017;42(1):30-40. (Table 1)

Table 1. In-office and Home-use Whitening Options

In-Office Options Home-use Options
25% to 40% HP 10% to 33% CP
Light-activation 5% to 14% HP
Use of enzymes Dentist-supervised kits with trays; unit dose disposable trays
Laser whitening Gels, strips, pens, disposable trays
Ionic technology Ionic technology
Whitening varnish Whitening kiosks/spas

IO and AH are safe when properly performed, routinely provided for adults and can benefit children and adolescents.2American Dental Association, ADA Council on Scientific Affairs. Tooth whitening/bleaching: Treatment considerations for dentists and their patients. 2009, revised 2010. Available at: https://www.ada.org/~/media/ADA/About%20the%20ADA/Files/ada_house_of_delegates_whitening_report.ashx,11American Association of Pediatric Dentists. Council on Clinical Affairs. Policy on the use of dental bleaching for child and adolescent patients. Revised 2019. Available at: https://www.aapd.org/media/Policies_Guidelines/P_Bleaching.pdf Toothwhitening is not recommended for the primary or mixed dentition, and young patients should be supervised.11American Association of Pediatric Dentists. Council on Clinical Affairs. Policy on the use of dental bleaching for child and adolescent patients. Revised 2019. Available at: https://www.aapd.org/media/Policies_Guidelines/P_Bleaching.pdf Dentist-supervised toothwhitening is recommended as part of an overall treatment plan, and enables the management of any side effects.2American Dental Association, ADA Council on Scientific Affairs. Tooth whitening/bleaching: Treatment considerations for dentists and their patients. 2009, revised 2010. Available at: https://www.ada.org/~/media/ADA/About%20the%20ADA/Files/ada_house_of_delegates_whitening_report.ashx,11American Association of Pediatric Dentists. Council on Clinical Affairs. Policy on the use of dental bleaching for child and adolescent patients. Revised 2019. Available at: https://www.aapd.org/media/Policies_Guidelines/P_Bleaching.pdf Defective restorations and dental caries should be treated prior to whitening. The stain’s etiology, prognosis, treatment efficacy, patient preference, cost and predicted compliance are considerations in determining how to treat a patient.

Toothwhitening is not recommended for the primary or mixed dentition, and young patients should be supervised by an adult.

Mechanism of action

Stain molecules contain chromophores bonded together by carbon double bonds.10Carlos NR, Bridi EC, Amaral F, França F, Turssi CP, Basting RT. Efficacy of home-use bleaching agents delivered in customized or prefilled disposable trays: A randomized clinical trial. Oper Dent 2017;42(1):30-40. During toothwhitening, HP diffuses into tooth structure through enamel nanopores approximately 2 to 6 nanometers in diameter and then interacts with stain molecules.12Kwon SR, Wertz PW. Review of the mechanism of tooth whitening. J Esthet Restor Dent 2015;27(5):240-57. ,13Peng C, Park S, de Sousa FB, Gan H, Lee SJ, Wang W, Lavender S, Pilch S, Han J. Enhanced teeth whitening by nanofluidic transport of hydrogen peroxide into enamel with electrokinetic flows. Dent Mater 2019 Sep 19. doi: 10.1016/j.dental.2019.08.118. HP breaks down, producing free radicals that break the double bonds in stain molecules, thereby altering the absorption and reflection of light, and rendering teeth whiter in appearance. HP oxidizes organic material changing it into more opaque and whiter material.14Rezende M, Loguercio AD, Kossatz S, Reis A. Predictive factors on the efficacy and risk/intensity of tooth sensitivity of dental bleaching: A multi regression and logistic analysis. J Dent 2016;45:1-6.

During toothwhitening, HP diffuses into tooth structure through enamel nanopores approximately 2 to 6 nanometers in diameter.

Efficacy of toothwhitening

IO, or a combination of IO and AH, are generally faster than AH alone. (Figures 2, 3) A mean shade change of 3 is reported for one 45-minute treatment with 35% HP.14Rezende M, Loguercio AD, Kossatz S, Reis A. Predictive factors on the efficacy and risk/intensity of tooth sensitivity of dental bleaching: A multi regression and logistic analysis. J Dent 2016;45:1-6. IO, AH and combination treatments are equally effective in achieving the end result. In a randomized controlled trial with 75 subjects, treatment effect was the same for AH with 10% HP used one hour/day for 15 days, IO with 40% HP used 40 minutes daily for 3 days, and one IO session of 30 minutes followed by 15 days of AH.15Dourado Pinto AV, Carlos NR, Amaral FLBD, França FMG, Turssi CP, Basting RT. At-home, in-office and combined dental bleaching techniques using hydrogen peroxide: Randomized clinical trial evaluation of effectiveness, clinical parameters and enamel mineral content. Am J Dent 2019;32(3):124-32. The combination treatment was the fastest. In another study, no between-treatment differences in color change were observed for 35% and 38% HP and 10% and 20% CP gels.16Basting RT, Amaral FL, França FM, Flório FM. Clinical comparative study of the effectiveness of and tooth sensitivity to 10% and 20% carbamide peroxide home-use and 35% and 38% hydrogen peroxide in-office bleaching materials containing desensitizing agents. Oper Dent 2012;37(5):464-73. Other studies corroborate these findings.17de Geus JL, Wambier LM, Kossatz S, Loguercio AD, Reis A. At-home vs in-office bleaching: A systematic review and meta-analysis. Oper Dent 2016;41(4):341-56.,18Vaez SC, Correia A, Santana TR, Santana M, Peixoto AC, Leal PC, Faria-E-Silva AL. Is a single preliminary session of in-office bleaching beneficial for the effectiveness of at-home tooth bleaching? A randomized controlled clinical trial. Oper Dent 2019;44(4):E180-89. Studies comparing light-activated and light-free toothwhitening are heterogeneous. Greater efficacy has been reported for light-activated whitening.13Peng C, Park S, de Sousa FB, Gan H, Lee SJ, Wang W, Lavender S, Pilch S, Han J. Enhanced teeth whitening by nanofluidic transport of hydrogen peroxide into enamel with electrokinetic flows. Dent Mater 2019 Sep 19. doi: 10.1016/j.dental.2019.08.118. ,19Park S, Kwon SR, Qian F, Wertz PW. The effect of delivery system and light activation on tooth whitening efficacy and hydrogen peroxide penetration. J Esthet Restor Dent 2016;28(5):313-20. However, in several systematic reviews, no differences in color change or in the rate of whitening were found for light-activated and light-free whitening.20Maran BM, Burey A, de Paris Matos T, Loguercio AD, Reis A. In-office dental bleaching with light vs. without light: A systematic review and meta-analysis. J Dent 2018;70:1-13.,21Maran BM, Ziegelmann PK, Burey A, de Paris Matos T, Loguercio AD, Reis A. Different light-activation systems associated with dental bleaching: a systematic review and a network meta-analysis. Clin Oral Investig 2019;23(4):1499-1512.,22SoutoMaior JR, de Moraes S, Lemos C, Vasconcelos BDE, Montes M, Pellizzer EP. Effectiveness of light sources on in-office dental bleaching: A systematic review and meta-analyses. Oper Dent 2019;44(3):E105-17.

Figure 2. Pre-treatment with isolation dam in position

Figure 3. Shade before and after in-office toothwhitening

In recent research, electrokinetic energy was shown to drive HP gel into enamel nanopores to a greater depth than through standard diffusion-based infiltration.13Peng C, Park S, de Sousa FB, Gan H, Lee SJ, Wang W, Lavender S, Pilch S, Han J. Enhanced teeth whitening by nanofluidic transport of hydrogen peroxide into enamel with electrokinetic flows. Dent Mater 2019 Sep 19. doi: 10.1016/j.dental.2019.08.118. This method uses 35% and 9% HP for IO and AH, respectively. A conducting gel is placed on the occlusal and lingual surfaces of the proprietary tray and the based and catalyst HP gel is mixed in the syringe and placed in the tray on the facial aspect. All gel has to be in contact with the teeth. After switching it on, the device is operated for 30 minutes. It was found that the same shade changes occurred in vitro in 1 hour using this ionic technology as with 3 hours of whitening using a standard technique.

Electrokinetic energy drives HP gel into enamel nanopores to a greater depth than with standard diffusion and increased the rate of whitening.

A two-layer varnish whitening system has also been investigated and introduced. This system consists of an inner layer of 20% HP varnish and an outer sealing layer that holds the HP at the site. The varnish was compared to standard IO with a 25% HP gel with and without light-activation.23Park S, Kwon SR, Qian F, Wertz PW. The effect of delivery system and light activation on tooth whitening efficacy and hydrogen peroxide penetration. J Esthet Restor Dent 2016;28(5):313-20. Three whitening sessions of 30 minutes each occurred 3 to 5 days apart and the gels were replaced at 15 minutes in accordance with the manufacturer’s instructions for use. Using a calibrated intraoral spectrophotometer, it was found that the two-layer varnish and 25% HP gel without light-activation produced equivalent shade changes.

A two-layer varnish whitening technique has been found to produce shade changes equivalent to use of 25% HP gel without light-activation.

Measuring and Communicating Shade Changes

Options for measuring shade (color and whiteness) prior to, during and at the conclusion of toothwhitening include shade guides, spectrophotometers, colorimeters, spectroradiometers and digital imaging systems.4Joiner A, Luo W. Tooth colour and whiteness: A review. J Dent 2017;67S:S3-10. A Vita Classical shade guide is often used in the dental office with the 16 shades rearranged, or a Vita Bleachedguide 3D-MASTER with 29 shades may be used. (Figures 4,5)

Figure 4. Vita Classic rearranged for whitening assessment

Figure 5. Vita Bleachedguide 3D-MASTER

Keeping a record of the baseline shade as well as an image with the patient smiling and a pre-whitening intraoral image allows for comparison with post-whitening images. Patients may no longer remember the original shade/think there has not been much change. Taking before and after images and showing these on a computer/tablet/iPad lets patients see the difference side-by-side, in turn helping to manage patient satisfaction.

Taking before and after images and showing these side-by-side lets patients see the difference, helping to manage patient satisfaction.

Potential side effects

Dental sensitivity is reported to occur in from 8% to 66% of patients receiving toothwhitening.11American Association of Pediatric Dentists. Council on Clinical Affairs. Policy on the use of dental bleaching for child and adolescent patients. Revised 2019. Available at: https://www.aapd.org/media/Policies_Guidelines/P_Bleaching.pdf The risk is greater for longer contact time and younger age.14Rezende M, Loguercio AD, Kossatz S, Reis A. Predictive factors on the efficacy and risk/intensity of tooth sensitivity of dental bleaching: A multi regression and logistic analysis. J Dent 2016;45:1-6. Systematic reviews have confirmed that higher-concentration gels can result in greater risk for sensitivity. However, in a third review no differences in risk were found for high- and low-concentration gels.14Rezende M, Loguercio AD, Kossatz S, Reis A. Predictive factors on the efficacy and risk/intensity of tooth sensitivity of dental bleaching: A multi regression and logistic analysis. J Dent 2016;45:1-6. ,17de Geus JL, Wambier LM, Kossatz S, Loguercio AD, Reis A. At-home vs in-office bleaching: A systematic review and meta-analysis. Oper Dent 2016;41(4):341-56.,20Maran BM, Burey A, de Paris Matos T, Loguercio AD, Reis A. In-office dental bleaching with light vs. without light: A systematic review and meta-analysis. J Dent 2018;70:1-13. Results of a review of laser-activated whitening were equivocal.24Kikly A, Jaâfoura S, Sahtout S. Vital laser-activated teeth bleaching and postoperative sensitivity: A systematic review. J Esthet Restor Dent 2019 Apr 16. doi: 10.1111/jerd.12482. [Epub ahead of print] Study heterogeneity and small sample sizes can confound findings. In a review with a narrower range of variables, the risk of sensitivity was 51% for AH and 62.9% for IO, respectively, and lower for teeth with darker shades at baseline.14Rezende M, Loguercio AD, Kossatz S, Reis A. Predictive factors on the efficacy and risk/intensity of tooth sensitivity of dental bleaching: A multi regression and logistic analysis. J Dent 2016;45:1-6.

Options for managing sensitivity include reducing contact time, reducing gel concentration and increasing the interval between whitening sessions. Each of these increases the duration of treatment to achieve the final result using standard techniques. Other methods to reduce the risk of, and manage, sensitivity include pre-treatment with amorphous calcium phosphate (ACP), using a gel that incorporates a desensitizer, and using a desensitizer or low-level laser therapy. IO with 30% HP followed by AH with 10% CP and use of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) for 15 days was effective in reducing sensitivity in one study.25Oldoini G, Bruno A, Genovesi AM, Parisi L. Effects of amorphous calcium phosphate administration on dental sensitivity during in-office and at-home interventions. Dent J (Basel) 2018;6(4). pii: E52. doi: 10.3390/dj6040052. Pre-treatment with 10% ACP and IO with 30% HP followed by AH with 10% CP containing 15% ACP for 15 days, and a combination of low-level laser therapy and 5,000 ppm fluoride have also been found to be effective.25Oldoini G, Bruno A, Genovesi AM, Parisi L. Effects of amorphous calcium phosphate administration on dental sensitivity during in-office and at-home interventions. Dent J (Basel) 2018;6(4). pii: E52. doi: 10.3390/dj6040052.,26Alencar CM, De Paula BLF, Araújo JLN, Alves EB, De Albuquerque Jassé FF, Silva CM. Effect of low-level laser therapy combined with 5000 parts per million fluoride dentifrice on postbleaching sensitivity: A clinical, randomized, and double-blind study. J Esthet Restor Dent 2018;30(4):352-9. (Table 2) In a recent systematic review with 11 studies, it was concluded that pre-treatment with anti-inflammatory and analgesic drugs was ineffective for the prevention of sensitivity associated with in-office tooth whitening.27Santana MLC, Leal PC, Reis A, Faria-e-Silva AL. Effect of anti-inflammatory and analgesic drugs for the prevention of bleaching-induced tooth sensitivity. A systematic review and meta-analysis. J Am Dent Assoc 2019;150(10):818-29.e4

Table 2. Prevention and Management of Sensitivity Associated with Toothwhitening
Reduce concentration of HP/CP
Reduce wear time
Increase interval between applications
Pre-treatment with amorphous calcium phosphate
Incorporation of a desensitizer into whitening gel
Use of a desensitizing paste/gel after whitening sessions
Low-level laser therapy
Low-level laser therapy together with 5,000 ppm fluoride

Gingival irritation may occur as a result of tray impingement on the gingival tissues or leakage of HP or CP from poorly-fitting whitening trays.28Haywood VB. Nightguard vital bleaching: Current concepts and research. J Am Dent Assoc 1997;127(suppl):19S-25S. Isolation dams must be carefully applied prior to IO and trays for AH must fit well.

Effect on Tooth Structure

In a review of 55 studies, conflicting results were found for the effect of toothwhitening on tooth structure.29Attin T, Schmidlin PR, Wegehaupt F, Wiegand A. Influence of study design on the impact of bleaching agents on dental enamel microhardness: a review. Dent Mater 2009;25(2):143-57. Immediately after whitening 51% of treatments resulted in reduced enamel hardness, while after a post-treatment interval reduced enamel hardness was not present for 71% of treatments. In recent in vitro studies, reduced microhardness was also found.30Fukuyama M, Kawamoto C, Saikaew P, Matsuda Y, Carvalho RM, Selimovic D, Sano H. Effect of topical fluoride application on enamel after in-office bleaching, as evaluated using a novel hardness tester and a transverse microradiography method. Eur J Oral Sci 2017;125(6):471-8. ,31Coceska E, Gjorgievska E, Coleman NJ, Gabric D, Slipper IJ, Stevanovic M, Nicholson JW. Enamel alteration following tooth bleaching and remineralization. J Microsc 2016;262(3):232-44.,32Crastechini E, Borges AB, Torres C. Effect of remineralizing gels on microhardness, color and wear susceptibility of bleached enamel. Oper Dent 2019;44(1):76-87. In contrast, in another study no changes in enamel topography were found with scanning electron microscopy.33Farawati FAL, Hsu SM, O'Neill E, Neal D, Clark A, Esquivel-Upshaw J. Effect of carbamide peroxide bleaching on enamel characteristics and susceptibility to further discoloration. J Prosthet Dent 2019;121(2):340-6. Under conditions similar to the intra-oral environment, i.e., using human saliva and with exposure to fluorides, fewer treatments result in reduced microhardness.29Attin T, Schmidlin PR, Wegehaupt F, Wiegand A. Influence of study design on the impact of bleaching agents on dental enamel microhardness: a review. Dent Mater 2009;25(2):143-57. Additionally, these changes can be prevented or reversed with exposure to fluorides or calcium-based technologies, and were also prevented with use of arginine carbonate and bioactive glass.34Hauss Monteiro DD, Valentim PT, Elias DC, Moreira AN, Machado Cornacchia TP, Magalhães CS. Effect of surface treatments on staining and roughness of bleached enamel. Indian J Dent Res 2019;30(3):393-8.,35Torres C, Zanatta RF, Silva TJ, Borges AB. Effect of calcium and fluoride addition to hydrogen peroxide bleaching gel on tooth diffusion, color, and microhardness. Oper Dent 2019;44(4):424-32.,36Vieira-Junior WF, Ferraz LN, Pini N, Ambrosano G, Aguiar F, Tabchoury C, Lima D. Effect of toothpaste use against mineral loss promoted by dental bleaching. Oper Dent 2018;43(2):190-200. Enamel surface alterations with white circular areas observed immediately after whitening resolved within a week in a recent in vivo study with two 20-minute applications of 35% HP one week apart.37De Rosa A, Di Stasio D, Lauritano D, Santoro R, Marotta A, Itro A, Lucchese A. Non-invasive analysis of bleaching effect of hydrogen peroxide on enamel by reflectance confocal microscopy (RCM): study of series of cases. Odontology 2019;107(3):285-90. It is generally recommended that enamel bonding procedures be avoided for a short period after toothwhitening due to the risk of reduced bond strength.38Cheng YL, Musonda J, Cheng H, Attin T, Zheng M, Yu H. Effect of surface removal following bleaching on the bond strength of enamel. BMC Oral Health 2019;19(1):50. While toothwhitening is both safe and effective, overzealous and excessive toothwhitening can damage tooth structure.11American Association of Pediatric Dentists. Council on Clinical Affairs. Policy on the use of dental bleaching for child and adolescent patients. Revised 2019. Available at: https://www.aapd.org/media/Policies_Guidelines/P_Bleaching.pdf With respect to stain, three recent in vitro studies found no increase in stain propensity for teeth immersed in tea, coffee, wine, beet dye or other natural or artificial dyes after standard toothwhitening procedures.33Farawati FAL, Hsu SM, O'Neill E, Neal D, Clark A, Esquivel-Upshaw J. Effect of carbamide peroxide bleaching on enamel characteristics and susceptibility to further discoloration. J Prosthet Dent 2019;121(2):340-6.,39Monteiro D, Moreira A, Cornacchia T, Magalhães C. Evaluation of the effect of different enamel surface treatments and waiting times on the staining prevention after bleaching. J Clin Exp Dent 2017;9(5):e677-81.,40Rezende M, Kapuchczinski AC, Vochikovski L, Demiate IM, Loguercio AD, Kossatz S. Staining power of natural and artificial dyes after at-home dental bleaching. J Contemp Dent Pract 2019;20(4):424-7.

Reductions in enamel microhardness may occur during toothwhitening. This can be prevented or reversed with fluorides, calcium-based technologies, arginine carbonate and bioactive glass.

Patient Education, Expectations and Satisfaction

Given its popularity and patient demand, toothwhitening contributes to practice building. Simply asking patients on the medical history form if they are interested, or asking during an appointment if they have a special event that they are going to can result in patients requesting this minimally invasive and esthetically pleasing treatment. Dental hygienists can advise patients on toothwhitening during routine prophylaxis and discuss options, how long each will take and outcomes.

Expectations must be managed, and misconceptions dispelled to avoid patient dissatisfaction. Tooth color varies by individual and some dentitions whiten more than others.4Joiner A, Luo W. Tooth colour and whiteness: A review. J Dent 2017;67S:S3-10. Generally, greater whitening has been observed for teeth that are darker at baseline and for younger patients.14Rezende M, Loguercio AD, Kossatz S, Reis A. Predictive factors on the efficacy and risk/intensity of tooth sensitivity of dental bleaching: A multi regression and logistic analysis. J Dent 2016;45:1-6. Promising an improvement based on a specific number of shades is ill-advised. In addition, extended toothwhitening over a period of months may be required for patients with resistant IS, such as tetracycline stains.41Botelho MG, Chan AWK, Newsome PRH, McGrath CP, Lam WYH. A randomized controlled trial of home bleaching of tetracycline-stained teeth. J Dent 2017;67:29-35. Treatment options and their efficacy, the potential duration of treatment, cost, shade mismatch of pre-existing tooth-colored restorations after whitening, side effects and their prevention and management should be discussed. Considerations include other treatment indicated based on the findings of the comprehensive examination, and whether this can best be performed before, during or after toothwhitening.12Kwon SR, Wertz PW. Review of the mechanism of tooth whitening. J Esthet Restor Dent 2015;27(5):240-57. Patients should be aware that relapse occurs over time and can reversed with additional whitening.42Tay LY, Kose C, Herrera DR, Reis A, Loguercio AD. Long-term efficacy of in-office and at-home bleaching: a 2-year double-blind randomized clinical trial. Am J Dent 2012;25(4):199-204. Lastly, oral hygiene instruction including avoidance of stain-inducing foods, drinks and habits will help to maintain a healthy, attractive smile after treatment.

Conclusions

Dentist-supervised treatment is recommended as part of an overall treatment plan and may include IO, AH, both or include the use of adjunctive technology. Dental hygienists can play an important role in explaining toothwhitening to patients and in practice building. Patient satisfaction is enhanced when expectations are managed, and patients understand the variables and choices in treatment. Toothwhitening has proven to be safe and effective and continues to be a requested and popular minimally invasive treatment with high levels of patient satisfaction.

References

  • 1.A history of toothwhitening. Available at: https://www.seattletimes.com/seattle-news/health/a-history-of-tooth-whitening/.
  • 2.American Dental Association, ADA Council on Scientific Affairs. Tooth whitening/bleaching: Treatment considerations for dentists and their patients. 2009, revised 2010. Available at: https://www.ada.org/~/media/ADA/About%20the%20ADA/Files/ada_house_of_delegates_whitening_report.ashx
  • 3.American Academy of Cosmetic Dentistry. 2012 Whitening Survey. Available at: https://aacd.com/proxy/files/Publications%20and%20Resources/Whitening%20Survey_Aug12(1).pdf.
  • 4.Joiner A, Luo W. Tooth colour and whiteness: A review. J Dent 2017;67S:S3-10.
  • 5.Lajnert V, Kovacevic Pavicic D, Pavlic A, Pokrajac-Bulian A, Spalj S. Smile Aesthetics Satisfaction Scale: development and validation of a new brief five-item measure of satisfaction with smile aesthetics in adults and the elderly. Int Dent J 2018;68(3):162-70.
  • 6.Angel P, Bersezio C, Estay J, Werner A, Retamal H, Araya C, Martin J, Fernández E. Color stability, psychosocial impact, and effect on self-perception of esthetics of tooth whitening using low-concentration (6%) hydrogen peroxide. Quintessence Int 2018;49(7):557-66.
  • 7.Watts A, Addy M. Tooth discolouration and staining: a review of the literature. Br Dent J 2001;190:309-16.
  • 8.Ten Bosch JJ, Coops CC. Tooth color and reflectance as related to light scattering and enamel hardness. J Dent Res 1995;74:374-80.
  • 9.Pinto MM, Gonçalves ML, Mota AC, Deana AM, Olivan SR, Bortoletto C, Godoy CH, Vergilio KL, Altavista OM, Motta LJ, Bussadori SK. Controlled clinical trial addressing teeth whitening with hydrogen peroxide in adolescents: a 12-month follow-up. Clinics (Sao Paulo) 2017;72(3):161-70.
  • 10.Carlos NR, Bridi EC, Amaral F, França F, Turssi CP, Basting RT. Efficacy of home-use bleaching agents delivered in customized or prefilled disposable trays: A randomized clinical trial. Oper Dent 2017;42(1):30-40.
  • 11.American Association of Pediatric Dentists. Council on Clinical Affairs. Policy on the use of dental bleaching for child and adolescent patients. Revised 2019. Available at: https://www.aapd.org/media/Policies_Guidelines/P_Bleaching.pdf
  • 12.Kwon SR, Wertz PW. Review of the mechanism of tooth whitening. J Esthet Restor Dent 2015;27(5):240-57.
  • 13.Peng C, Park S, de Sousa FB, Gan H, Lee SJ, Wang W, Lavender S, Pilch S, Han J. Enhanced teeth whitening by nanofluidic transport of hydrogen peroxide into enamel with electrokinetic flows. Dent Mater 2019 Sep 19. doi: 10.1016/j.dental.2019.08.118.
  • 14.Rezende M, Loguercio AD, Kossatz S, Reis A. Predictive factors on the efficacy and risk/intensity of tooth sensitivity of dental bleaching: A multi regression and logistic analysis. J Dent 2016;45:1-6.
  • 15.Dourado Pinto AV, Carlos NR, Amaral FLBD, França FMG, Turssi CP, Basting RT. At-home, in-office and combined dental bleaching techniques using hydrogen peroxide: Randomized clinical trial evaluation of effectiveness, clinical parameters and enamel mineral content. Am J Dent 2019;32(3):124-32.
  • 16.Basting RT, Amaral FL, França FM, Flório FM. Clinical comparative study of the effectiveness of and tooth sensitivity to 10% and 20% carbamide peroxide home-use and 35% and 38% hydrogen peroxide in-office bleaching materials containing desensitizing agents. Oper Dent 2012;37(5):464-73.
  • 17.de Geus JL, Wambier LM, Kossatz S, Loguercio AD, Reis A. At-home vs in-office bleaching: A systematic review and meta-analysis. Oper Dent 2016;41(4):341-56.
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