Influence of chemical activation of a 35% hydrogen peroxide bleaching gel on its penetration and efficacy—In vitro study

Effect of a brush tip on in-office bleaching gels in an attachable syringe: Hydrogen peroxide penetration, bleaching efficacy and amount of gel expended

OBJECTIVE

Evaluate the penetration of hydrogen peroxide (HP) into the pulp chamber, bleaching efficacy (BE) and amount of gel expended during in-office bleaching using an applicator brush tip and conventional tip from different commercial brands.

MATERIALS AND METHODS

104 human premolars were randomly distributed into thirteen groups (n = 8) according to the commercial brand: DSP White Clinic 35 % Calcium (DW), Nano White 35 % (NW), Total Blanc One-Step 35 % (TS), Whiteness HP Blue 35 % (WB), Potenza Bianco Pro SS 38 % (PB), Opalescence XTra Boost 40 % (OB), no bleaching (negative control), and application method: applicator brush tip and conventional tip for all groups. Initial HP concentration (%) was determined via titration and pH was measured with digital pH meter. Concentration (µg/mL) of HP into the pulp chamber was measured using UV-Vis spectrophotometry, the BE (ΔE*ab, ΔE00 and ΔWID) was evaluated with a digital spectrophotometer, and the amount of gel expended was evaluated using a precision analytical digital balance. Statistical analysis included two-way ANOVA, Tukey's, and Dunnett's test. Comparison between HP into the pulp chamber vs BE was performed with Person's correlation (α = 0.05).

RESULTS

Brush tip demonstrated a low amount of HP in the pulp chamber compared to the conventional method for all bleaching gels (p < 0.0003), as well as lower amount of gel expended (p < 0.002). The brush tip did not result in a significant difference in BE compared to the conventional (p > 0.05). No correlations were found between both factors (p > 0.05).

CONCLUSION

Brush tip showed lower penetration of HP in the pulp chamber and a reduced volume of spent gel when compared to the conventional tip, for all commercial brands.

CLINICAL RELEVANCE

Brush tip is recommended for bleaching gels in an attachable syringe due to its ability to reduce the penetration of HP into the pulp chamber and minimize the amount of bleaching gel used.

Whitening toothpastes with hydrogen peroxide concentrations vs. at-home bleaching

OBJECTIVES

To evaluate the effect of whitening toothpastes with different hydrogen peroxide (HP) concentrations on HP permeability, color change, and physicochemical properties, compared to at-home bleaching treatment.

MATERIALS AND METHODS

Forty-nine premolars were randomized into seven groups (n = 7): untreated (control); at-home bleaching with 10% carbamide peroxide gel (AH; 10% CP) with 14 and 28 applications of 180 min each (AH [14 × 180 min] and AH [28 × 180 min]); three whitening toothpastes (3% HP; 4% HP and 5% HP) and 10% CP brushed 28 times for 90 s each (TB [28 × 90 s]). HP permeability was measured using a UV-VIS spectrophotometer and color change by a digital spectrophotometer (ΔEab, ΔE00, and ΔWID). Initial concentration, pH, and viscosity were measured through titration, digital pH meter, and rheometer, respectively. Statistical analysis included one-way ANOVA, Tukey's test, and Dunnett's test (α = 0.05).

RESULTS

4% HP group showed acidic pH, the lowest viscosity and the highest HP concentration into the pulp chamber (p < 0.05). The 10% CP groups had lower HP in the pulp chamber and greater color change than other groups (p < 0.05), except the 5% HP group in ΔEab and ΔE00. For ΔWID, the 10% CP AH groups showed greater whitening than other groups (p < 0.05).

CONCLUSIONS

Whitening toothpaste with up to 5% HP resulted in higher HP permeability and less color change compared to 10% CP. Higher HP commercial concentrations in toothpaste increased whitening effect; however, acidic pH toothpastes exhibited greater HP permeability.

CLINICAL RELEVANCE

Whitening toothpastes with high hydrogen peroxide concentrations were less effective than at-home bleaching, resulting in less color change and greater permeability of hydrogen peroxide, potentially increasing the risk of tooth sensitivity.

The effect of photobiomodulation therapy associated with casein phosphopeptide-amorphous calcium phosphate fluoride paste on the treatment of posthome whitening tooth sensitivity and color change: A randomized clinical trial

OBJECTIVE

This study assessed whether combining photobiomodulation therapy (PBMT) with casein phosphopeptide-amorphous calcium phosphate fluoride (CPP-ACPF) paste can effectively reduce post-home whitening tooth sensitivity (TS) without compromising shade change.

METHODS

Fifty participants were selected and assigned to one of four groups: (1) PLACEBO group-received a placebo paste and PBMT simulation; (2) PBMT group-received a placebo paste + PBMT; (3) CPP-ACPF group-received CPP-ACPF paste and PBMT simulation; (4) CPP-ACPF + PBMT group-received both CPP-ACPF paste and PBMT. The participants used whitening trays containing 22% carbamide peroxide for 2 h a day for 21 days. TS was measured daily using a visual analog scale, while shade change was assessed using a spectrophotometer: before bleaching treatment (T0), after the first (T1), second (T2), and third (T3) weeks of treatment, and 30 days (T4) after completing the whitening treatment.

RESULTS

Intragroup analysis revealed that the PLACEBO group had the highest increase in sensitivity during the whitening treatment. The CPP-ACPF and PBMT groups showed no significant difference tooth whitening (TW) between weeks regarding aesthetic change. The CPP-ACPF and PBMT group exhibited a significant reduction in TS between the first and third and between the second and third weeks TW, but not between the first and second. Conversely, the PLACEBO group showed a higher sensitivity than the other groups (p < .05). The CPP-ACPF and PBMT groups did not differ from each other. Furthermore, the CPP-ACPF and PBMT group showed a greater decrease in sensitivity than the PLACEBO group at T1, T2, and T3 (p < .01), and was significantly differed from CPP-ACPF and PBMT groups only at T2 and T3. All groups confirmed TW effectiveness. Student's and paired t-test did not reveal any significant difference between groups (p > .05).

CONCLUSION

Therefore, PBMT associated with CPP-ACPF paste can reduce TS without compromising the efficacy of TW.

Feasibility and Safety of Adopting a New Approach in Delivering a 450 nm Blue Laser with a Flattop Beam Profile in Vital Tooth Whitening. A Clinical Case Series with an 8-Month Follow-Up

A prospective observational case series included six patients who presented with discoloured upper and lower teeth extending from the right second premolar to the left second premolar. The photoactivation dosimetry and treatment protocol were as follows: λ 450 nm, 1 W, CW; flattop beam profile; 1 cm2; 15 J/spot; 10 irradiated spots; an irradiation time of 15 s/spot; three whitening cycles in a single session. Blanc One ULTRA+ was the bleaching agent. A visual analogue scale (VAS) was utilised to evaluate the pain intensity and dental hypersensitivity during treatment immediately after complete treatment (T1), 24 h (T2), and 8 h (T3) postoperatively, and at an 8-month follow-up timepoint (T4), whereas the dental colour shade change was assessed using the VITA colour shade guide pre-treatment (T0), T1, and T4. The Gingival index and modified Wong Baker faces scale were utilised to evaluate gingival inflammation and patients' treatment satisfaction, respectively. Our findings revealed a reduction in the dental colour shade of the six cases between 2 and 10- fold (average of 3.5-fold) at T1 and maintained at T4, indicating significant improvement in the colour shade change with optimal outcomes. The percentage of this improvement for all the patients was ranged between 16.6% and 33.3%. At all timepoints, a "0" score was provided for pain intensity, dental hypersensitivity, and gingival inflammation. Our study demonstrates the feasibility and safety of a λ 450 nm laser delivered with a flattop handpiece to achieve optimal whitening outcomes without adverse effects. This offers a useful guide for dental clinicians for vital in-office tooth whitening. Extensive clinical studies with large data are warranted to validate our study protocol.

Reactive oxygen species for therapeutic application: Role of piezoelectric materials

This perspective article emphasizes the significant role of reactive oxygen species (ROS) in in vivo remedial therapy of various diseases and complications, capitalizing on their potential reactivity. Among the various influencers, herein, piezoelectric materials driven ROS generation activity is primarily considered. Intrinsic non-centrosymmetry of piezoelectric materials makes them suitable for distinct dipole formation in the presence of external mechanical stimuli. Such characteristics prompt the positioning of opposite charged carriers to execute associated redox transformations that effectively participate to generate ROS in the aqueous media of the cell cytoplasm, organelles and nucleus. The immense reactivity of piezoelectric material driven ROS is fostered to terminate cellular toxicity or curtail tumor cell growth, due to their higher specificity. This perspective considers the conjugated performance of piezoelectric materials and ultrasound which can remotely generate electrical charges that promote ROS production for therapeutic application. In particular, a substantial synopsis is provided for the remedial activity of numerous piezocatalytic materials in tumor cell apoptosis, antibacterial treatment, dental care and neurological disorders. Subsequently, the report precisely demonstrates the methods involving various spectrophotometric approaches for the analysis of the ROS. Finally, the key challenges of piezoelectric material-based therapy are discussed and systematic future progress is outlined.

Effect of an In-Office Bleaching Agent with Surface Pre-Reacted Glass-Ionomer Filler on the Enamel Surface: A In-Vitro Study

In-office bleaching with high concentrations of hydrogen peroxide (H₂O₂) agents causes undesirable alterations in the enamel. Surface pre-reacted glass-ionomer (S-PRG) filler is a functional material known for its acid-neutralizing and demineralization-inhibition properties. This study evaluates the effect of S-PRG filler incorporation in H₂O₂-based bleaching on the enamel surface. Bovine enamel surfaces were bleached using a bleaching paste formulated with a liquid (35% H₂O₂) and a powder containing 5% or 10% S-PRG filler. The surface roughness and the Vickers microhardness of the treated enamel surfaces were evaluated. The enamel surfaces were observed under a scanning electron microscope (SEM) and analyzed using energy dispersive X-ray (EDX) technology. The surfaces were challenged by citric acid and observed by SEM. The specimens bleached with the paste containing the S-PRG filler showed lower enamel surface roughness and higher microhardness values than did those bleached with the plain paste (0% S-PRG filler); meanwhile, there were no significant differences between the 5% or 10% S-PRG filler groups. The S-PRG filler groups showed enamel surface morphologies similar to those of the non-bleached enamel, according to SEM observation, and EDX analysis detected the presence of fluoride and strontium ions. The S-PRG filler groups showed a higher resistance to erosion. The S-PRG filler mitigated the detrimental effects of bleaching agents on the enamel surface and provided resistance to erosion.

Synthesis, Characterization, and Investigation of Novel Ionic Liquid-Based Tooth Bleaching Gels: A Step towards Safer and Cost-Effective Cosmetic Dentistry

The objective of this study was to synthesize a novel choline hydroxide ionic liquid-based tooth bleaching gel. Ionic liquid-based gels were synthesized and characterized using FTIR along with pH testing. Tooth sample preparation was carried out in line with ISO 28399:2020. The effects of synthesized gels on tooth samples were tested. Tooth samples were stained and grouped into three experimental groups: EAI (22% choline hydroxide gel), EAII (44% choline hydroxide gel), and EB (choline citrate gel) and two control groups: CA (commercial at-home 16% carbamide peroxide gel) and CB (deionized water). The tooth color analysis, which included shade matching with the Vitapan shade guide (n = 2), and digital colorimetric analysis (n = 2) were evaluated. The surface characteristics and hardness were analyzed with 3D optical profilometry, Scanning Electron Microscopy (SEM), Energy Dispersive X-ray Spectroscopy (EDX), and Microhardness testing (n = 3), respectively. The tooth color analysis (Vitapan shade guide) revealed that all the tooth samples treated with synthesized choline citrate gel (EB) showed an A1 shade as compared to the other four groups, giving a range of shades. An analysis of the ΔE values from digital colorimetry; EAI, EAII, CA, and CB showed ΔE values in a range that was clinically perceptible at a glance. However, EB showed the highest value of ΔE. The mean microhardness values for the five groups showed that the effects of three experimental gels i.e., 44% choline hydroxide, 22% choline hydroxide, and choline citrate, on the microhardness of the tooth samples were similar to that of the positive control, which comprised commercial at-home 16% carbamide peroxide gel. SEM with EDX of three tested subgroups was closely related in surface profile, elemental composition, and Ca/P ratio. The roughness average values from optical profilometry of four tested subgroups lie within approximately a similar range, showing a statistically insignificant difference (p > 0.05) between the tested subgroups. The synthesized novel experimental tooth bleaching gels displayed similar tooth bleaching actions without any deleterious effects on the surface characteristics and microhardness of the treated tooth samples when compared with the commercial at-home tooth bleaching gel.

Application Tip and Concentration of a Self-mixing Bleach: Hydrogen Peroxide Inside the Pulp Chamber, Color Change, and Amount of Bleaching Gel Used

PURPOSE

The objective of this study was to evaluate if the application method (tip with brush or tip without brush) and hydrogen peroxide (HP) concentration (6% or 35% self-mixing) of in-office bleaching gel influences the penetration of HP into the pulp chamber, color change, and the amount of bleaching gel used.

METHODS

Forty healthy premolars were randomly divided into the following five groups (n=8): no treatment; HP6% using a tip with a brush, HP6% using a tip without a brush, HP35% using a tip with a brush, and HP35% using a tip without a brush. After treatments, the HP concentration (μg/mL) within the pulp chamber was determined using UV-Vis spectrophotometry. The color change (ΔEab, ΔE00, and ΔWID) was evaluated using a digital spectrophotometer. The amount of gel used (g) in each group was measured using a precision analytical balance. Data from each test were submitted to parametric tests (α=0.05).

RESULTS

The tip with a brush resulted in a lower amount of HP inside the pulp chamber and less gel used when compared with the tip without a brush, regardless of HP concentration (p<0.05). However, regarding the tip used, although no significant difference was observed when HP35% was used (p>0.05), a higher whitening effect was observed when the 6% HP was applied without a brush as opposed to with a tip brush (p<0.05).

CONCLUSIONS

The use of a tip with a brush, regardless of the in-office bleaching gel concentration (6% or 35% self-mixing), presented a lower penetration and lower volume of spent gel when compared to a tip without brush. However, the whitening effect depended on the concentration of HP used.

A new approach for professional dental bleaching using a polymeric catalyst primer

OBJECTIVE

Evaluate the influence of a polymeric catalyst primer (PCP) on esthetic efficacy (EE), degradation kinetics of hydrogen peroxide (H₂ O₂ ), and trans-amelodentinal cytotoxicity (TC) of bleaching gels.

MATERIALS AND METHODS

The following groups were established: G1: No treatment (NC, negative control); G2: PCP; G3: 10% H₂ O₂ ; G4: PCP + 10% H₂ O₂ ; G5: 20% H₂ O₂ ; G6: PCP + 20% H₂ O₂ ; G7: 35% H₂ O₂ (positive control); G8: PCP + 35% H₂ O₂ . To determine EE, enamel/dentin discs (E/DDs) were stained and subjected or not to bleaching protocols for 45 min. To assess TC, the E/DDs were adapted to artificial pulp chambers. The extracts (culture medium + gel components diffused through E/DDs) were applied to odontoblast-like MDPC-23 cells. The viability (VB), oxidative stress (OxS), morphology (SEM), amount of H₂ O₂ diffused and the production of hydroxyl radical (OH^• ) were assessed (two-way ANOVA/Tukey/paired Student t-test; p < 0.05).

RESULTS

The highest EE was found in G8 (p < 0.05), and G4, G6, and G7 did not differ statistically (p > 0.05). In G4, the limited H₂ O₂ diffusion reduced OxS and increased cell VB (p < 0.05).

CONCLUSIONS

Coating the enamel with PCP containing 10 mg/ml of manganese oxide before applying the 10% H₂ O₂ bleaching gel maintains the EE of conventional in-office bleaching and minimizes the toxic effects of this esthetic therapy.

CLINICAL SIGNIFICANCE

Coating the enamel with a PCP before applying the bleaching gel may potentiate the EE of the conventional in-office tooth bleaching and reduce the toxicity of this professional therapy to the dental pulp.

Improved esthetic efficacy and reduced cytotoxicity are achieved with a violet LED irradiation of manganese oxide-enriched bleaching gels

Gels with high concentrations of hydrogen peroxide (H2O2) have been associated with cytotoxicity and consequent post-bleaching tooth sensitivity. This study assessed the bleaching efficacy (BE) and cytotoxicity (CT) of bleaching gels with low concentrations of H2O2 containing manganese oxide (MnO2) and photocatalyzed with violet LED (LEDv). The following groups were established: G1: no treatment (negative control, NC); G2: 35% H2O2 (positive control, PC); G3: LEDv; G4: 10% H2O2; G5: 6% H2O2; G6: 10% H2O2 + MnO2 + LEDv; G7: 6% H2O2 + MnO2 + LEDv. To analyze BE, standardized enamel/dentin discs (E/DDs) were subjected to the bleaching procedures for 45 min (1 session). The color change was determined before and after performing the bleaching protocols (ΔE00; ΔWI). To analyze CT, the E/DDs were adapted to artificial pulp chambers, and the extracts (culture medium + diffused gel components) were applied to cultured odontoblast-like MDPC-23 cells. Then, the cells were assessed concerning their viability (VB), oxidative stress (OxS), and Live/Dead. The amount of H2O2 diffused was also determined (ANOVA/Tukey; p < 0.05). Cell viability decreased in all bleached groups compared to G1 (NC; p < 0.05). The cells in G6 and G7 presented higher viability than in G2, G4, and G5 (p < 0.05). The BE in G7 was similar to G2 (PC; p < 0.05). The lowest OxS and H2O2 diffusion values were found in G6 and G7, compared to the other bleached groups (G2, G4, and G5; p < 0.05). The 6% H2O2 bleaching gel (G7) submitted to both methods of catalysis (MnO2 + LEDv) caused only a mild cytotoxicity and maintained the excellent esthetic outcome promoted by in-office conventional tooth bleaching.

Influence of Manganese Oxide on the Esthetic Efficacy and Toxicity Caused by Conventional In-office Tooth Bleaching Therapy

OBJECTIVE

This study aimed to evaluate the esthetic efficacy, cytotoxicity, and kinetics of decomposition of hydrogen peroxide (H2O2) present in a commercial bleaching gel with 35% H2O2 (BG35%) chemically activated with manganese oxide (MnO2).

METHODS AND MATERIALS

After incorporating 2 mg/mL, 6 mg/mL, and 10 mg/mL of MnO2 into BG35%, the stability of pH and temperature of the products were analyzed. To assess the esthetic efficacy (ΔE and ΔWI), the BG35%s with MnO2 were applied for 45 minutes on enamel/dentin discs (DiE/D). BG35% or no treatment were used as positive (PC) and negative (NC) controls, respectively. To analyze the cell viability (CV) and oxidative stress (OXS), the same bleaching protocols were performed on DiE/D adapted to artificial pulp chambers. The extracts (culture medium + gel components that diffused through the discs) were applied to pulp cells and submitted to H2O2 quantification. BG35% with MnO2 that showed the best results was evaluated relative to kinetic decomposition of H2O2, with consequent generation of free radicals (FR) and hydroxyl radicals (OH•). The data were submitted to the one-way analysis of variance complemented by Tukey post-test (α=0.05). Data on kinetics of H2O2 decomposition were submitted to the Student's-t test (α=0.05).

RESULTS

All the BG35%s with MnO2 showed stability of pH and temperature, and the gel with 10 mg/mL of this activator had an esthetic efficacy 31% higher than that of the PC (p<0.05). Reduction in OXS and trans-amelodentinal diffusion of H2O2 occurred when all the BG35%s with MnO2 were used. The addition of 6 and 10 mg/mL of MnO2 to BG35% increased the CV in comparison with PC, confirmed by the cell morphology analysis. An increase in FR and OH• formation was observed when 10 mg/mL of MnO2 was added to BG35%.

CONCLUSION

Catalysis of BG35% with MnO2 minimized the trans-amelodentinal diffusion of H2O2 and toxicity of the product to pulp cells. BG35% containing 10 mg/mL of MnO2 potentiated the decomposition of H2O2, enhancing the generation of FR and OH•, as well as the efficacy of the in-office tooth therapy.

Influence of Viscosity and Thickener on the Effects of Bleaching Gels

OBJECTIVE

This study investigated the influence of the viscosity and kind of thickener of 35% hydrogen peroxide bleaching gels on the tooth (color change, demineralization of enamel, and permeation) and on the gel [reactive oxygen species (ROS), pH, and peroxide concentration].

METHODS AND MATERIALS

Two hundred forty specimens were divided into groups of bleaching gels with different thickeners (CAR, carbomer; ASE, alkali swellable emulsion; MSA, modified sulfonic acid polymer; SSP, semisynthetic polysaccharide; PAC, particulate colloids) in three viscosities (low: 50,000 cP; medium: 250,000 cP; high: 1,000,000 cP). Color change (ΔEab), demineralization of enamel by Knoop microhardness (KHN) reduction analysis, and peroxide permeation (PP) were analyzed in the specimens, while pH, peroxide concentration (PC), and ROS were evaluated in the gels. Data were analyzed by two-way ANOVA (α=0.05).

RESULTS

The higher viscosity gels reduced ΔEab, PP, enamel softening, and ROS in relation to the lower viscosity gels. However, the drop in pH and PC were higher in the more viscous gels. Gels with MSA produced higher ΔEab compared with SSP and ASE. The PP was higher for PAC, and smaller for SSP and CAR. The KHN reduction was higher for CAR and smaller for PAC. The higher pH reduction was seen for ASE and CAR, and the smaller for SSP. The PC reduction was higher for SSP and smaller for CAR. More ROS were observed for MSA and fewer for ASE.

CONCLUSIONS

Increased gel viscosity was associated with reduced color change, permeation, demineralization of enamel, and ROS, and led to increased peroxide decomposition and pH alteration during the treatment. The kind of thickener significantly interfered with the treatment effects.

Evaluation of Tooth Sensitivity of In-office Bleaching with Different Light Activation Sources: A Systematic Review and a Network Meta-analysis

OBJECTIVES

A systematic review and network meta-analysis were performed to answer the following research question: Are there differences in the risk and the intensity of tooth sensitivity (TS) among eight light activation systems for in-office bleaching in adults?

METHODS

Randomized controlled trials (RCTs) that compared at least two different in-office bleaching light activations were included. The risk of bias (RoB) was evaluated with the RoB tool version 1.0 from the Cochrane Collaboration tool. A random-effects Bayesian mixed treatment comparison (MTC) model was used independently for high- and low-concentration hydrogen peroxide. The certainty of the evidence was evaluated using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach. A comprehensive search was performed in PubMed, Bridge Base Online (BBO), Latin American and Caribbean Health Sciences Literature database (LILACS), Cochrane Library, Scopus, Web of Science, and grey literature without date and language restrictions on April 23, 2017 (updated on September 26, 2019). Dissertations and theses, unpublished and ongoing trials registries, and IADR (International Association for Dental Research) abstracts (2001-2019) were also searched.

RESULTS

After title and abstract screening and the removal of duplicates, 32 studies remained. Six were considered to be at low RoB, three had high RoB, and the remaining had an unclear RoB. The MTC analysis showed no significant differences among the treatments in each network. In general, the certainty of the evidence was graded as low due to unclear RoB and imprecision.

CONCLUSION

There is no evidence that the risk and intensity of TS are affected by light activation during in-office bleaching.

Comparison of the Effect of Agitation on Whitening and Tooth Sensitivity of In-Office Bleaching: A Randomized Clinical Trial

OBJECTIVE

This single-blind, split-mouth, randomized trial was aimed at evaluating the bleaching efficacy (BE) and tooth sensitivity (TS) of a 20% hydrogen peroxide (HP) bleaching agent used under active or passive application.

METHODS AND MATERIALS

Twenty-two patients with canines darker than C2 were selected. Teeth were bleached in two sessions, with a one-week interval between treatments. The bleaching agent was applied using active (HPactive) or passive (HPpassive) application. Each tooth in the HPactive-allocated hemiarch received bleaching gel with sonic activation after 10 and 30 minutes from the start of treatment, with rounded movements all over the buccal surface. The color changes were evaluated by subjective (Vita Classical and Vita Bleachedguide) and objective (VITA Easyshade Spectrophotometer) methods at baseline and 30 days after the second session. TS was recorded up to 48 hours after treatment using a 0-10 visual analog scale. Color change in shade guide units (SGUs) and ΔE was analyzed using a Wilcoxon test (α=0.05). The absolute risk and intensity of TS were evaluated using McNemar test and a Wilcoxon test, respectively (α=0.05).

RESULTS

Significant whitening was observed in both groups after 30 days of clinical evaluation. The activation did not significantly influence BE (ΔSGU HPpassive=5.6 and HPActive=5.8; p=0.98; and ΔE HPpassive=10.6 and HPactive=10.3; p=0.83). Absolute risk of TS (HPactive=36.4% and HPpassive=31.8%; p=0.94) was similar for both groups (Fisher exact test). TS intensity (visual analogue scale) was higher during the bleaching sessions and up to 24 hours thereafter for both groups, with no differences between groups (twoway analysis of variance and Tukey).

CONCLUSION

The active application of a 20% HP gel did not improve BE and TS.

Whitening effect of 35% hydrogen peroxide in simulation of tooth with orthodontic bracket

OBJECTIVE

To evaluate the color change and tooth whitening perception in 2 and 3 mm dental specimens simulating the orthodontic bracket for a 14-day period.

MATERIALS AND METHODS

Forty bovine tooth fragments (8 × 7 mm) of 2 mm (G2, n = 20) and 3 mm (G3, n = 20) were divided into Control (C: without bracket simulation and whitening) and Experimental (E: with composite resin simulating orthodontic bracket cementation area). Analyses of color change (ΔE₀₀ ) and perception of tooth whitening (WI_D ) were performed before (T₀ ) and after (T₁ ) the first bleaching session; before (T₂ ) and after (T₃ ) the second bleaching session; and after 7 days of the second bleaching session (T₄ ).

RESULTS

After 14 days (T4), ΔE₀₀ and WI_D showed similarity results, except for G2C and G3E_. The thickness did not influence the ΔE₀₀ and WI_D (G2C = G3C and G2E = G3E). The presence of orthodontic bracket did not interfere in the color change or tooth whitening perception after 14 days, except for comparison of G2C and G3E. Additionally, dentin thickness did not influence the color change.

CLINICAL SIGNIFICANCE

Teeth with orthodontic brackets showed similar color change and whitening perception to teeth without orthodontic bracket, but it is not influenced by dentin thickness.

Effects of different remineralizing agents on color stability and surface characteristics of the teeth following vital bleaching

The aim of the study was to investigate the effects of various remineralizing agents on the color stability and surface characteristics of the teeth after vital bleaching. The extracted 96 human incisors were used for the study. Initially, the samples were randomly divided into two groups and exposed to in-office and at-home bleaching agents. Then, the groups were divided into six subgroups (n = 8), including the control group did not undergo remineralization after bleaching, according to five remineralizing agents (Gelato APF Gel, Remin Pro, Tooth Mousse, MI Paste Plus, Curodont Protect). Surface roughness was assessed at baseline, after bleaching and remineralization procedures. Color measurements of the samples were obtained at baseline, after bleaching and then after immersion in the staining solution following remineralization process. Scanning electron microscopy and atomic force microscopy (AFM) analyzes were carried out in order to examine the morphological changes on the surface of the enamel. The independent t-test, paired-samples t-test, and one-way ANOVA was used to compare the data and post-hoc LSD test to compare the difference among the study groups (α = .05). Surface roughness increased following in-office and at-home bleaching in all groups, and reduced after application of remineralizing agents in all groups. Significant differences were found among the groups with respect to changes in surface roughness and color values following treatment with remineralizing agents (p <.05). AFM analyses revealed increased surface roughness after bleaching and a reduction of rough surfaces following treatment with remineralizing agents. Remineralizing agents can be used to reduce postbleaching increase in surface roughness and to maintain color stability after bleaching.

In-office bleaching with low/medium vs. high concentrate hydrogen peroxide: A systematic review and meta-analysis

OBJECTIVE

To answer the following research question: "Dolow/medium hydrogen peroxide (HP) concentrations used for in-office bleaching in patients with permanent dentition have similar color change and bleaching sensitivity (BS) to high HP concentrations?"

DATA

Randomized controlled trials that compared low/medium vs. high concentrate HP were included. The risk of bias (RoB) was evaluated using the Cochrane Collaboration tool. Meta-analyses were conducted for color change (ΔE*ab, ΔSGU/SGU), risk, and intensity of BS, using the random-effects model. Heterogeneity was assessed with the Cochrane Q test, I² statistics, and prediction interval. The GRADE assessed the certainty of the evidence.

SOURCES

Search was performed in PubMed, Cochrane Library, BBO, LILACS, Scopus, Web of Science and grey literature on 15th September 2018 (updated on 13th May 2020).

STUDY SELECTION

25 studies remained. Five were at low RoB; thirteen were at unclear RoB, and seven were at high RoB. The risk of having BS was, on average, 33 % lower (RR = 0.67; 95 % CI 0.51 to 0.86) for low/medium concentrate HP than high HP. No significant difference in color change was detected among groups, except from the subgroup low vs. high HP for the immediate color change, but this difference is not clinically relevant. The certainty of evidence for color change was low and very low, and moderate for the BS.

CONCLUSIONS

Low and medium hydrogen peroxide concentrate products for in-office bleaching have lower risk and intensity of bleaching sensitivity than the high concentrate hydrogen peroxide group, with no difference in color change efficacy.

CLINICAL SIGNIFICANCE

The use of low concentrate hydrogen peroxide products may produce the same color change efficacy with the bonus of having lower risk and intensity of bleaching sensitivity. However, the ideal concentration at which this occurs is yet unknown and deserves further investigations. No funding. PROSPERO CRD42018108266.

Assessment of Peroxide in Saliva During and After At-home Bleaching With 10% Carbamide and Hydrogen Peroxide Gels: A Clinical Crossover Trial

CLINICAL RELEVANCE

This study suggests that at-home bleaching systems are safe in relation to toxicity based on peroxide levels in saliva since the amount of peroxide potentially ingested is much lower than the estimated toxic dose.

SUMMARY

Alencar C, de Paula BLF, de A. Jassé FF, Araújo JLN, Silva CM. Photobiomodulation vs. Placebo on Post-Bleaching Sensitivity and Color Change: A Split-Mouth Clinical Study

Objective:

This study aimed to investigate the efficiency of Photobiomodulation (PBM) with low-level LASER therapy compared to placebo in post-bleaching sensitivity and color change during a three-week office bleaching treatment.

Methods:

A split-mouth model was used to evaluate 21 subjects. The right and left hemi-archs were randomized to one of two groups: GP (placebo): simulated LASER application followed by tooth bleaching with 35% hydrogen peroxide; and GL: treated with PBM followed by tooth bleaching with 35% hydrogen peroxide. A four-degree modified Visual Analog Scale (VAS) was used to assess tooth sensitivity after the application of an evaporative stimulus (stimulated pain). In addition, a daily questionnaire was used to measure unstimulated pain. The color change was measured using a spectrophotometer. The Friedman and Wilcoxon tests were used to analyze data sensitivity. Color results were statistically analyzed using Analysis Of Variance (ANOVA) followed by the Tukey post-hoc test.

Results:

There was no significant difference between GP and GL for stimulated pain evaluation (p> 0.05). However, there was a significant difference between the groups for unstimulated pain evaluation (p≤ 0.05). In addition, ΔE data did not reveal any significant difference in tooth color between groups at any time (p> 0.05).

Conclusion:

PBM prevented post-bleaching sensitivity compared to placebo, based on the daily pain assessment questionnaires. PBM did not compromise the quality of bleaching treatments.

Effect of Bleaching Gel Concentration on Tooth Color and Sensitivity: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate a high concentration of hydrogen peroxide (35%) regarding tooth sensitivity and color change in tooth bleaching in comparison to low concentrations (6% to 20%).

METHODS AND MATERIALS

This review was conducted using the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and is registered on the Prospective Register of Systematic Reviews (CRD42017064493). The PICO question was "Does a concentration of hydrogen peroxide ≥35% using in-office bleaching procedure contribute to greater tooth sensitivity?" A search was made in PubMed/MEDLINE, Scopus, and the Cochrane Library.

RESULTS

Fourteen studies were selected for the qualitative analysis and seven for quantitative analysis. A total of 649 patients were evaluated (mean age: 36.32 years; range: 13.9 to 31 years), and the follow-up period ranged from one week to 12 months. The meta-analysis demonstrated that tooth sensitivity was higher in the patients submitted to treatment involving a high concentration of hydrogen peroxide (0.67; 95% confidence interval [CI]: 0.44 to 1.03; p=0.04; I ² : 56%), and a significant difference was found regarding objective color ΔE (1.53; 95% CI: 2.99 to 0.08; p<0.0001; I ² : 82%) but no significant difference was found regarding subjective color ΔSGU (0.24; CI: 0.75 to 1.23; p<0.00001; I ² : 89%).

CONCLUSIONS

This study indicated that a lower concentration of hydrogen peroxide causes less tooth sensitivity and better effectiveness in objective color change (ΔE); however, there is no difference between them related to subjective color (ΔSGU).

Effect of Remineralizing Agents on Tooth Color after Home Bleaching

Objectives:

The purpose was to investigate the effect of casein phosphopeptide-amorphous calcium phosphate fluoride (CPP-ACPF) paste, Remin Pro paste, and 0.05% sodium fluoride (NaF) mouthwash on teeth discoloration after home bleaching.

Materials and Methods:

In this in-vitro study, 48 intact and unstained human incisors were divided into four groups (n=12): control (Group 1), CPP-ACPF paste (Group 2), Remin Pro paste (Group 3), and 0.05% NaF mouthwash (Group 4). The specimens were bleached using 20% carbamide peroxide gel for 21 days and were subjected to pH cycling and surface treatment with remineralizing agents for one month. The color of the specimens was determined according to the CIELAB color space at baseline, after bleaching, and after surface treatment. Data were analyzed using one-way analysis of variance (ANOVA), post-hoc least significant difference (LSD) test, and one-sample t-test (P=0.05).

Results:

ANOVA showed a significant difference in the mean ΔE of the four groups after surface treatment (P<0.05). Post-hoc LSD test showed a significant difference between the mean ΔE of the control group and those of the treatment groups (P<0.05) with no significant difference between the treatment groups, except for Remin Pro. The mean ΔE and ΔL of the Remin Pro group showed less change than those of the CPP-ACPF and NaF groups, indicating that Remin Pro has the lowest potential for post-bleaching tooth discoloration.

Conclusion:

CPP-ACPF paste, Remin Pro paste, and 0.05% NaF mouthwash cause noticeable teeth discoloration immediately after bleaching. Remin Pro has less effect on tooth color than the other two products.

The effect of oral anti-inflammatory drugs on reducing tooth sensitivity due to in-office dental bleaching: A systematic review and meta-analysis

BACKGROUND

The authors' aim was to evaluate the effectiveness of anti-inflammatory drugs on tooth sensitivity (TS) during and after in-office dental bleaching procedures.

TYPES OF STUDIES REVIEWED

The authors selected randomized controlled trials in which the investigators compared anti-inflammatory drugs with a placebo to evaluate in-office dental bleaching TS. The authors performed an electronic search by using PubMed, ScienceDirect, and Embase. In addition, the authors searched other Web sites, such as ClinicalTrials.gov, to identify ongoing studies.

RESULTS

The authors included 7 randomized controlled trials (324 adults) in the review. According to the extracted data, the authors performed the meta-analysis by using risk ratios and their 95% confidence intervals or by using the mean difference with a 95% confidence interval. The authors used the Cochrane Collaboration's tool to assess study quality. After the evaluation, the authors considered 6 studies to be high quality and a single study to be low quality. The overall results of the evaluation process revealed the absence of a clinically significant effect of anti-inflammatory drugs.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

The results of this analytic process indicated that anti-inflammatory drugs have no clinically significant effect on the TS that occurs due to in-office bleaching. Readers must analyze these results carefully given the limitations of this review, such as the small samples size and the heterogeneity among the studies in some stages of the evaluation process. The results of this analytical study highlight the need for more clinical studies to reach a significant conclusion because TS is one of the most important reasons for the cessation of bleaching treatment.

Increased whitening efficacy and reduced cytotoxicity are achieved by the chemical activation of a highly concentrated hydrogen peroxide bleaching gel

OBJECTIVE

This study was designed for the chemical activation of a 35% hydrogen peroxide (H2O2) bleaching gel to increase its whitening effectiveness and reduce its toxicity.

METHODOLOGY

First, the bleaching gel - associated or not with ferrous sulfate (FS), manganese chloride (MC), peroxidase (PR), or catalase (CT) - was applied (3x 15 min) to enamel/dentin discs adapted to artificial pulp chambers. Then, odontoblast-like MDPC-23 cells were exposed for 1 h to the extracts (culture medium + components released from the product), for the assessment of viability (MTT assay) and oxidative stress (H2DCFDA). Residual H2O2 and bleaching effectiveness (DE) were also evaluated. Data were analyzed with one-way ANOVA complemented with Tukey's test (n=8. p<0.05).

RESULTS

All chemically activated groups minimized MDPC-23 oxidative stress generation; however, significantly higher cell viability was detected for MC, PR, and CT than for plain 35% H2O2 gel. Nevertheless, FS, MC, PR, and CT reduced the amount of residual H2O2 and increased bleaching effectiveness.

CONCLUSION

Chemical activation of 35% H2O2 gel with MC, PR, and CT minimized residual H2O2 and pulp cell toxicity; but PR duplicated the whitening potential of the bleaching gel after a single 45-minute session.

Effects of Enzymatic Activation of Bleaching Gels on Hydrogen Peroxide Degradation Rates, Bleaching Effectiveness, and Cytotoxicity

Objectives:

The aim of this study was to evaluate the effect of horseradish peroxidase (HRP) on the release of free radicals, bleaching effectiveness, and indirect cytotoxicity of a 35% hydrogen peroxide (HP) bleaching gel.

Methods and Materials:

First, HP degradation rates and free radical release were evaluated for 35% HP in contact or not with HRP (10 mg/mL). The bleaching gel associated or not with HRP was then applied (3 × 15 minutes) to enamel/dentin discs adapted to artificial pulp chambers, and the culture medium in contact with dentin surfaces (extract) was collected and exposed to cultured odontoblast-like cells. Membrane damage and viability of cells as well as oxidative stress were evaluated. Residual HP/free radical diffusion was quantified, and bleaching effectiveness (ΔE) was assessed. Unbleached discs served as negative controls.

Results:

The addition of HRP to the 35% HP bleaching gel enhanced the release of free radicals in comparison with plain HP gel. The 35% HP-mediated cytotoxicity significantly decreased with HRP in the bleaching gel and was associated with reduced HP/free radical diffusion through the enamel/dentin discs. ΔE values increased every bleaching session for HRP-containing gel relative to positive control, accelerating the whitening outcome.

Conclusion:

The enzymatic activation of a 35% HP bleaching gel with HRP accelerated HP degradation mediated by intensification of free radical release. This effect optimized whitening outcome as well as minimized residual HP and free radical diffusion through enamel and dentin, decreasing the harmful effects on odontoblast-like cells.

Effect of Calcium and Fluoride Addition to Hydrogen Peroxide Bleaching Gel On Tooth Diffusion, Color, and Microhardness

Objectives:

The aim of this study was to evaluate the effect of calcium and fluoride addition to a 35% hydrogen peroxide (HP) bleaching gel with regard to its diffusion through the tooth structure, enamel microhardness, and bleaching efficacy.

Methods and Materials:

Eighty specimens (6 mm in diameter and 2 mm in height; 1 mm/enamel and 1 mm/dentin) were obtained from bovine incisors that were polished and divided into four groups (n=20) according to the remineralizing agent added to the gel: Ca = 0.5% calcium gluconate; F = 0.2% sodium fluoride; Ca+F = 0.5% calcium gluconate and 0.2% sodium fluoride; and control = no agent. Initial microhardness and color were assessed. The samples were positioned over simulated pulpal chambers filled with acetate buffer solution to capture the HP. Gels were applied over enamel for 30 minutes, and HP diffusion was assessed by spectrophotometry two hours after bleaching. Microhardness was measured immediately after bleaching and then the specimens were immersed into artificial saliva for seven days for final color assessment. Data were analyzed by one-way analysis of variance followed by Tukey test.

Results:

Bleaching reduced microhardness for all groups (p=0.0001), but the Ca+F and F groups showed lower reductions after bleaching. The addition of Ca, F, and Ca+F decreased the peroxide penetration through the tooth structure (p=0.0001), but there were no differences in color change for ΔL (p=0.357), Δa (p=0.061), Δb (p=0.823), and ΔE (p=0.581).

Conclusion:

The addition of calcium and fluoride in the gel did not affect bleaching efficacy, but it was able to reduce both the peroxide diffusion and the bleached enamel microhardness loss.

Effect of low-level laser therapy combined with 5000 parts per million fluoride dentifrice on postbleaching sensitivity: A clinical, randomized, and double-blind study

OBJECTIVE

The aim of this double-blind, randomized, controlled clinical study was to assess the efficacy of low-level laser therapy (LLLT) combined with 5000 ppm fluoride dentifrice on postbleaching sensitivity in teeth exposed to 35% hydrogen peroxide for four weeks.

MATERIALS AND METHODS

Twenty-five volunteers were evaluated using the split-mouth model in which the right and left maxillary/mandibular quadrants were randomized and allocated to one of two groups: GPLACEBO, in which the laser tip was positioned without the emission of light (placebo effect) + 5000 ppm sodium fluoride, or GLASER, which comprised LLLT + 5000 ppm sodium fluoride. For both groups, LLLT and placebo were used before bleaching, whereas fluoride was applied after bleaching. LLLT was applied at two points: on the central cervical and medial regions of the incisors, canines, and premolars in the corresponding hemi-arch. At each point, 60 J/cm² was applied for 16 seconds with an irradiance of 3.75 W/cm² using the therapeutic infrared device. To assess tooth sensitivity, a modified visual analogue scale was used after an evaporative stimulus, and a daily pain questionnaire was also applied.

RESULTS

The Wilcoxon and Friedman tests demonstrated a significant difference in the incidence of sensitivity pain between GPLACEBO and GLASER (P ≤ .05), with different evaluation times.

CONCLUSION

Teeth treated with laser therapy in combination with the topical use of sodium fluoride at each bleaching session demonstrated less sensitivity compared with the application of sodium fluoride only.

CLINICAL SIGNIFICANCE

The use of a low-level laser therapy in combination with topical use of sodium fluoride improves symptoms of dentin sensitivity at each bleaching session.

Effectiveness of Light Sources on In-Office Dental Bleaching: A Systematic Review and Meta-Analyses

OBJECTIVE

A systematic review and meta-analyses were performed to evaluate the efficacy of tooth color change and sensitivity of teeth following in-office bleaching with and without light gel activation in adult patients.

METHODS

This review was registered at PROSPERO (CRD 42017060574) and is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Electronic systematic searches of PubMed/MEDLINE, Web of Science, and the Cochrane Library were conducted for published articles. Only randomized clinical trials among adults that compared in-office bleaching with and without light activation with the same bleaching gel concentrations were selected. The outcomes were tooth color change and tooth sensitivity prevalence and intensity.

RESULTS

Twenty-three articles from 1054 data sources met the eligibility criteria. After title and abstract screening, 39 studies remained. Sixteen studies were further excluded. Twenty-three studies remained for qualitative analyses and 20 for meta-analyses of primary and secondary outcomes. No significant differences in tooth color change or tooth sensitivity incidence were found between the compared groups; however, tooth sensitivity intensity decreased when light sources were applied.

CONCLUSION

The use of light sources for in-office bleaching is not imperative to achieve esthetic clinical results.

Effect of pH on whitening efficacy of 35% hydrogen peroxide and enamel microhardness

OBJECTIVE

This study aimed to evaluate the effect of 35% hydrogen peroxide at different pH values and the degree of tooth staining on whitening efficacy and enamel microhardness.

MATERIALS AND METHODS

90 enamel-dentin specimens were obtained from bovine incisors. They were randomly divided into 2 groups (n = 45), 1 group was immersed in a staining broth for 14 days, and another group was not stained and kept in distilled water at 37°C. Twenty-four hours after the staining procedure, each group was distributed into 3 subgroups that were whitened by 35% hydrogen peroxide with different pH values (5, 7, and 8.4) for 30 minutes. The color was measured at baseline and 7 days after whitening. Microhardness was measured at baseline, immediate, 24 hours, and 1 month after the whitening procedure. Data were submitted to 2-way analysis of variance (ANOVA) and the Tukey test for multiple comparisons for color analysis. Repeated measures ANOVA and the Tukey test were used to analyze microhardness data.

RESULTS

The color change of the stained groups (ΔE₀₀  = 4.6) was significantly higher than that of the nonstained groups (ΔE₀₀  = 3.7). Microhardness value decreased significantly immediately after whitening for all subgroups and did not return to initial values. For each measurement time, microhardness was not significantly different among subgroups with different pH values.

CONCLUSIONS

Despite the effectiveness of 35% hydrogen peroxide, changes on gel pH did not affect the whitening efficacy, and the enamel was superficially demineralized, regardless of pH values.

CLINICAL SIGNIFICANCE

Independently of the pH value of whitening gel, enamel undergoes superficial demineralization and with a reduction in superficial microhardness that does not return to the initial values. However, using hydrogen peroxide with different pH values does not alter the whitening effect.

Evaluation of the Effect of Different Laser Activated Bleaching Methods on Enamel Susceptibility to Caries; An In Vitro Mode

Introduction: Today, bleaching is a routine noninvasive alternative for treatment of discolored teeth. The aim of this study was to determine whether conventional or laser activated bleaching predispose teeth to develop caries or not. Methods: Sixty human molars were mounted on acrylic cylinders and their Knoop microhardness (KHN) as well as DIAGNOdent (DD) values were recorded. They were divided into 4 experimental groups; G1) conventional bleaching with 40% hydrogen peroxide gel, G2) Diode laser assisted bleaching with same gel, G3) Nd:YAG laser assisted bleaching with the same gel, G4) control group. After bleaching, all samples were subjected to a three day pH cycling regimen and then, KHN and DD values were measured. Results: All groups had significant reduction in KHN values. It seems that there is no statistically meaningful difference between changes in enamel microhardness of the sample groups and all groups have changed in a similar amount. Reduction of DD scores were significant in Diode laser and conventional groups, however changes in Nd:YAG laser and control groups were not significant. Changes in DD values have followed a similar pattern among groups, except in G1- G4 and G2-G4 couples. Conventional and diode laser groups had a meaningful difference in reduction of DD values in comparison with the control group. Conclusion: It can be concluded that bleaching whether conventional or laser activated, does not make teeth vulnerable to develop carious lesions.

Randomized clinical trial of the effect of NovaMin and CPP-ACPF in combination with dental bleaching

OBJECTIVE

This randomized, controlled, double-blind clinical study evaluated the effect of calcium sodium phosphosilicate (NovaMin) and casein phosphopeptide-amorphous calcium phosphate with fluoride (CPP-ACPF) on the prevention of post-operative sensitivity and on the effects of clinical bleaching treatment.

MATERIAL AND METHODS

Sixty volunteers were selected according to inclusion and exclusion criteria and were randomly assigned into three groups (n=20): CG (control group) patients, who were treated with 35% hydrogen peroxide; NOVAG (NovaMin group) patients, who were treated with 35% hydrogen peroxide followed by the application of NovaMin; and CPPG (CPP group) patients, who were treated with 35% hydrogen peroxide followed by the application of CPP-ACPF. Both bioactive agents were applied for five minutes. An evaporative stimulus associated with a modified visual scale was used to analyze sensitivity 24 hours after each bleaching session. The color evaluation was performed on the maxillary central incisors using a spectrophotometer. Associations between the intervention group, bleaching session, and reported sensitivity were tested using Chi-square partitioning.

RESULTS

Color change values (ΔE) were analyzed using analysis of variance (ANOVA). The significance level used for both tests was 5%. In the intragroup assessment, the Friedman test showed that only the CPP-ACPF group showed no statistically significant difference (p<0.05) between baseline and first bleaching session. In the intergroup assessment, the Kruskal-Wallis test showed that the CPPG had less postoperative sensitivity after the first session, when compared to the other groups (p<0.05). Color change analysis (ΔE) showed a significant difference between the means obtained in the different bleaching sessions in all groups (p<0.05).

CONCLUSIONS

This study showed that the combination of CPP-ACPF with 35% hydrogen peroxide significantly reduced post-operative sensitivity in the first session, compared with the other evaluated treatments. The association of CPP-ACPF and NovaMin did not affect the color change induced by tooth bleaching.

Color stability of resin used for caries infiltration after exposure to different staining solutions

PURPOSE : The aim of this study was to investigate the staining behavior of demineralized enamel infiltrated by low-viscosity resin. METHODS AND MATERIALS : Bovine enamel/dentin cylindrical samples (3 × 2 mm) were assigned into four groups (n=45) according to the enamel treatment: sound enamel (control), demineralization + artificial saliva, demineralization + daily application of 0.05% NaF, demineralization + resin infiltration (Icon, DMG). Artificial white spot lesions were produced in groups with demineralization. After the treatments, color was assessed by spectrophotometry, using the CIE L*a*b* system. The specimens (n=15) were then immersed in deionized water, red wine, or coffee for 10 minutes daily for eight days. Color was measured again, and the specimens were repolished with sandpaper discs. The final color was assessed. Data were analyzed by two-way analysis of variance and Tukey tests (α=0.05). A paired t-test was used for comparison between staining and repolishing conditions. RESULTS : There were significant differences for surface treatment and dye after staining and repolishing. Immersion in wine and coffee resulted in significantly increased color alteration (ΔE) compared with water (p=0.001). The resin-infiltrated group exhibited the highest staining values (p=0.001). The repolishing procedures resulted in significantly decreased color change.

CONCLUSION

The exposure of specimens to colored solutions resulted in significant color alteration. The demineralized enamel treated with resin infiltration showed significantly higher staining than all other tested groups; however, the repolishing of the specimens minimized the staining effect.

Influence of Different Types and Concentrations of Chemical Catalysts on Dental Bleaching Efficiency

The objective of this study was to evaluate the effects of different types and concentrations of chemical catalysts on the efficiency of 35% hydrogen peroxide gel on dental bleaching. Enamel-dentin disks were obtained from bovine incisors and the initial color was assessed. The groups were divided according to the type and concentration of catalyst added to an experimental gel: ferrous sulphate (FS) (0.001, 0.002 and 0.003%); ferrous gluconate (Fg) (0.01, 0.02 and 0.03%); ferric chloride (FC) (0.01, 0.02 and 0.03%); manganese gluconate (MG) (0.01, 0.02 and 0.03%); and manganese chloride (MC) (0.01, 0.02 and 0.03%). The positive control (PC) group received the bleaching gel without any catalyst, while in the negative control (NC) the specimens remained in artificial saliva. Three applications of the bleaching gels were performed for 10 minutes each, repeated after 7 days. Color assessments were performed 7 days after the first session and 7 days after the second. The specimens were stored in artificial saliva and assessed again after 1 year. The data were analyzed by parametric analysis of variance and Tukey's test. Some of the chemical catalysts tested were effective in reducing the yellowish color of the samples in relation to the positive control group after 1 and 2 applications and diminished the color relapse over time. After 1 year, the FS was the most effective catalyst tested. We concluded that some chemical catalysts increased the efficiency of dental bleaching.

Analysis of the Color and Fluorescence Alterations of Enamel and Dentin Treated With Hydrogen Peroxide

Abstract: The aim of this study was to evaluate the effect of hydrogen peroxide whitening on fluorescence and color of bovine enamel and dentin. Twenty five dentin discs and 25 enamel discs, with 6 mm diameter and 1 mm thick, were obtained. Direct fluorescence (spectrofluorophotometry) and color (spectrophotometry) were assessed. After fluorescence and color baseline measurements, specimens were immersed in a 35% hydrogen peroxide (HP) solution for 1 h. This procedure was repeated after 7 days. Final fluorescence and color measurements were performed after the second immersion. Chemical characterization of 5 additional specimens was also performed. Data were submitted to repeated analysis of variance and Tukey´s test for fluorescence and unpaired t-test for color and chemical components (p<0.05). Fluorescence decreased significantly in dentin specimens after whitening. Enamel presented lower fluorescence than dentin at baseline, but this parameter did not decrease after whitening. Color changes were observed for both substrates, with significantly greater whitening effect in dentin (ΔE=10.37) (p<0.001). Whitening by hydrogen peroxide induced significant decrease in fluorescence of tooth dentin and promoted significant color changes in dentin and enamel with more accentuated outcomes in dentin.

Effect of in-office bleaching with 35% hydrogen peroxide with and without addition of calcium on the enamel surface

This study aimed to evaluate effectiveness and effects of bleaching with 35% hydrogen peroxide with and without calcium on color, micromorphology, and the replacement of calcium and phosphate on the enamel surface. Thirty bovine enamel blocks (5.0 × 5.0 mm) were placed into the following groups: G1: artificial saliva (control); G2: 35% hydrogen peroxide gel without calcium (Whiteness HP Maxx-FGM); and G3: 35% hydrogen peroxide gel with calcium (Whiteness HP Blue-FGM). Three color measurements were performed with a spectrophotometer: untreated (baseline), after performing staining, and after application of bleaching agents. Calcium deposition on the enamel was evaluated before and after the application of bleaching agents using energy-dispersive X-ray spectrometry. The enamel surface micromorphology was observed under scanning electron microscopy. The pH of each product was measured. The data were subjected to one-factor analysis of variance (ANOVA), and any differences were analyzed using Tukey's test (P < 0.05). G3 showed greater variation in total color after the experiment than G2 and G1; there was no significant difference in calcium or phosphorus concentration before and after the experimental procedures; morphological changes were observed only in G2 and G3; and the pH values of the Whiteness HP Maxx and Whiteness HP Blue bleaching agents were 5.77 and 7.79, respectively. The 35% hydrogen peroxide with calcium showed greater bleaching potential, but the addition of calcium had no effect in terms of reducing morphological changes or increasing the calcium concentration on the enamel surface.

Effects of the concentration and composition of in-office bleaching gels on hydrogen peroxide penetration into the pulp chamber

In tooth whitening, the hydrogen peroxide (HP) diffuses in the enamel and dentin, reaching the pulp. This in vitro study aimed to quantify the penetration of HP in the pulp chamber in teeth submitted to bleaching agents of different concentrations of HP without calcium (HP 20% [20CF], HP 35% [35CF]) and with calcium (HP 20% [20CC], HP 35% [35CC]).

METHOD

Fifty human premolars were sectioned 3 mm from the cemento-enamel junction and the pulp tissue was removed. The teeth were divided into five groups according to treatment and with a control group (n=10). An acetate buffer solution was placed in the pulp chamber of all teeth. The control group was exposed only to distilled water, while the other groups were treated with a bleaching procedure, according to the manufacturer's recommendations. After treatment, the acetate buffer solution was transferred to a glass tube in which leuco-crystal violet and peroxidase solutions were added, resulting in a blue solution. The optical density of this blue solution was determined spectrophotometrically and converted into micrograms equivalent to the HP. Data were analyzed using analysis of variance and Tukey tests (α=0.05).

RESULTS

The HP concentration did not affect the HP inside the pulp chamber, but the presence of calcium significantly reduced it (p<0.0001).

CONCLUSION

The amount of HP that reaches the pulp chamber depends on the bleaching protocol and the product employed, and it seems to be less affected by HP concentration.

Influence of pH on the Effectiveness of Hydrogen Peroxide Whitening

Objective

To evaluate the influence of pH on the bleaching effect of hydrogen peroxide on chromogen agents.

Method

Hydrogen peroxide 50% was mixed with red wine or with an alcoholic solution of tobacco in glass cuvettes, resulting in final peroxide concentrations of 16.97% and 21.12%, respectively. The pH of this mixture was measured and adjusted with 3.3 M HCl solution or 2.5 M NaOH solution to obtain the final pH values of 3.0, 4.0, 5.0, 6.0, 7.0, 8.0, and 9.0. After mixing, the color of these solutions was evaluated in a reflectance spectrophotometer; readings were repeated after 10 minutes for the wine solution and 20 minutes for the tobacco solution. Ten samples were prepared for each solution at each pH. Color changes (Delta E) were calculated. The data were statistically analyzed using analysis of variance one-way and Tukey tests, with a significance level of 5%.

Results

There were significant differences among the different pH values for the wine and tobacco solutions (p=0.0001). The Tukey test showed that for both solutions, pH 9.0 resulted in a significantly greater bleaching effect than the other values tested.

Conclusion

The efficacy of hydrogen peroxide bleaching is directly proportional to the increase in its pH.

Effect of hydrogen peroxide concentration on enamel color and microhardness

OBJECTIVES

The aim of this study was to investigate the effect of hydrogen peroxide gels with different concentrations (20%, 25%, 30%, and 35%) on enamel Knoop microhardness (KNH) as well as on changes in dental color (C).

METHODS

Cylindrical specimens of enamel/dentin (3-mm diameter and 2-mm thickness) were obtained from bovine incisors and randomly divided into six groups (n=20), according to the concentration of the whitening gel (20%, 25%, 30%, 35%, control, thickener). After polishing, initial values of KNH0 and color measurement, assessed by spectrophotometry using the CIE L*a*b* system, were taken from the enamel surface. The gels were applied on the enamel surface for 30 minutes, and immediate values of KNHi were taken. After seven days of being stored in artificial saliva, new measures of KNH7 and color (L7* a7* b7*, for calculating ΔE, ΔL, and Δb) were made. Data were submitted to statistical analysis of variance, followed by Tukey test (p<0.05).

RESULTS

Differences in gel concentration and time did not influence the microhardness (p=0.54 and p=0.29, respectively). In relation to color changes, ΔE data showed that the 35% gel presented a higher color alteration than the 20% gel did (p=0.006).

CONCLUSION

Bleaching with 35% hydrogen peroxide gel was more effective than with the 20% gel, without promoting significant adverse effects on enamel surface microhardness.

Influence of Simulated Pulpal Pressure on Efficacy of Bleaching Gels

Aim

The aim of this study was to investigate the influence of simulated pulpal pressure on efficacy of bleaching gels.

Materials and methods

Cylindrical enamel-dentin specimens from bovine teeth (3 mm diameter, enamel and dentin layer each 1 mm thick) were divided into 4 groups, according to the bleaching treatment: negative control (non-bleached), bleached with 10% carbamide peroxide (CP), bleached with 7.5% hydrogen peroxide (HP) and bleached with 35% hydrogen peroxide. Ten percent CP gel was applied for 8 h/day and 7.5% HP for 1 h/day, during 14 days. For 35% HP treatment, two sessions of 45 minutes each were employed. In intermediate periods specimens were stored in artificial saliva. Experimental groups (n = 19) were subdivided according to the simulation of pulpal pressure (25 mm Hg) during bleaching treatment. Initial color measurement and after bleaching treatment were assessed by spectrophotometry, using CIE L*a*b* system. The data were statistically analyzed by ANOVA and Dunnett's posthoc tests (p < 0.05).

Results

There was significant difference of ∆E for all experimental groups compared to negative control group, according to Dunnett's test (p < 0.0001). There were no significant difference for total color variation (∆E) among experimental groups (p > 0.05).

Conclusion

It was concluded that all bleaching gels showed bleaching efficacy compared to non-bleached group and that the simulated pulpal pressure did not influence the bleaching outcomes of the tested gels.

Clinical significance

Although numerous in vitro studies investigating the efficacy of bleaching agents have been performed, they do not properly simulate the pulpal pressure. In order to make these studies closer to clinical conditions, it is important to reproduce these conditions in laboratory, so the results can be more reliable. This in vitro study was performed under simulated pulpal pressure, aiming to investigate its influence on dental bleaching outcomes.

How to cite this article

Borges AB, Batista GR, Arantes PT, Wiegand A, Attin T, Torres CRG. Influence of Simulated Pulpal Pressure on Efficacy of Bleaching Gels. J Contemp Dent Pract 2014;15(4):407-412.

Bleaching effectiveness, hydrogen peroxide diffusion, and cytotoxicity of a chemically activated bleaching gel

OBJECTIVES

The objective of this study was to evaluate the bleaching effectiveness, hydrogen peroxide diffusion (H2O2), and cytotoxicity of a bleaching gel with 35 % H2O2 either associated with ferrous sulfate (FeSO4) or not.

MATERIALS AND METHODS

Enamel/dentin discs adapted to artificial pulp chambers were placed in compartments containing a culture medium (Dulbecco's Modified Eagle's Medium (DMEM)) and distributed into the following groups: G1-no treatment (negative control), G2-10 % carbamide peroxide (one application for 4 h), G3-35 % H2O2 (three applications for 15 min), and G4-35 % H2O2 + 0.004 g FeSO4 (three applications for 15 min). After treatments, the extracts (DMEM + bleaching components that diffused across enamel and dentin) were applied on human dental pulp cells (HDPCs) and odontoblast-like cells (MDPC-23). Cell viability (MTT assay, Kruskal-Wallis and Mann-Whitney, α = 5 %), quantification of H2O2 diffusion, and color change of the enamel/dentin discs (Commission Internationale de I'Eclairage L*a*b* system) were assessed (analysis of variance and Tukey's tests, α = 5 %).

RESULTS

For both cells, a significant reduction in cell viability was observed for G3 and G4 compared with G1 and G2. No statistical difference was observed between G3 and G4. The rate of H2O2 diffusion was significantly higher in G3 compared with that in G2 and G4. The ΔE value for G4 was statistically higher than that of the other groups.

CONCLUSIONS

Chemical activation of H2O2 by FeSO4 improves the bleaching effectiveness. However, this metal ion has no significant protective effect against pulp cell cytotoxicity.

CLINICAL RELEVANCE

Although the chemical activation of H2O2 by adding FeSO4 to the bleaching agent improved the bleaching effectiveness, this metal ion has no significant protective effect against pulp cell cytotoxicity.

Effective tooth-bleaching protocols capable of reducing H(2)O(2) diffusion through enamel and dentine

OBJECTIVES

To evaluate the effects of experimental protocols on bleaching effectiveness and hydrogen peroxide (HP) diffusion through enamel and dentine.

METHODS

Enamel/dentine discs were subjected to six bleaching sessions, consisting of 1 or 3 applications of 17.5% or 35%-HP gel for 5/15min, or 37% carbamide peroxide (CP) gel for 10/20min. Discs undergoing the regular protocol (35%-HP; 3×15min) constituted the positive control group. Colour change (ΔE) was assessed (CIE L*a*b* system) after each session. HP diffusion was quantified (sessions 1, 3, and 6) in enamel/dentine discs adapted to artificial pulp chambers. Data were analysed by Pillai's Trace and Bonferroni test, or by one-way ANOVA and SNK/Tamhane's test (α=5%).

RESULTS

All tooth-bleaching protocols significantly increased the ΔE values. A reduction in HP diffusion and no significant difference in ΔE compared with the positive control were observed for the following bleaching protocols: 17.5%-HP 3×15min, at the 4th session; and 35%-HP 1×15 and 3×5min, at the 5th session. HP diffusion in the 37%-CP 3×20min bleaching protocol was statistically similar to that in the positive control. The other experimental bleaching protocols significantly decreased HP diffusion through enamel/dentine discs, but the ΔE values were statistically lower than those observed in the positive control, in all sessions.

CONCLUSION

Shortening the contact time of a 35%-HP gel or reducing its concentration produces gradual tooth colour change and reduced HP diffusion through enamel and dentine.

CLINICAL SIGNIFICANCE

A reduction in HP concentration, from 35% to 17.5%, in a bleaching gel or shortening its application time on enamel provides a significant tooth-bleaching improvement associated with decreased HP diffusion across hard dental tissues. Therefore, these protocols may be an interesting alternative to be tested in the clinical situation.

Influence of concentration and activation on hydrogen peroxide diffusion through dental tissues in vitro

This study evaluated the effect of physical and chemical activation on the diffusion time of different concentrations of hydrogen peroxide (HP) bleaching agents through enamel and dentin. One hundred and twenty bovine cylindrical specimens were divided into six groups (n = 20): 20% HP; 20% HP with light activation; 20% HP with manganese gluconate; 35% HP; 35% HP with light activation; and 35% HP with manganese gluconate. The specimens were fixed over transparent epoxy wells with internal cavities to simulate a pulpal chamber. This chamber was filled with an enzymatic reagent to simulate pulpal fluid. The bleaching gels were applied on enamel surface and the image of the pulpal fluid was captured by a video camera to monitor the time of peroxide penetration in each specimen. ANOVA analysis showed that concentration and type of activation of bleaching gel significantly influenced the diffusion time of HP (P < 0.05). 35% HP showed the lowest diffusion times compared to the groups with 20% HP gel. The light activation of HP decreased significantly the diffusion time compared to chemical activation. The highest diffusion time was obtained with 20% HP chemically activated. The diffusion time of HP was dependent on activation and concentration of HP. The higher concentration of HP diffused through dental tissues more quickly.

In vitro evaluation of halogen light-activated vs chemically activated in-office bleaching systems

OBJECTIVES

To compare the tooth whitening efficacy, temperature and HP concentration changes induced by halogen light-activated and chemically activated in-office bleaching systems.

MATERIALS AND METHODS

Twenty-four extracted premolars were randomly divided into two groups (n = 12): Group BL (35% HP with halogen light activation) and Group OP (38% HP with chemical activation). Tooth color was measured by a spectrophotometer according to the CIE L*a*b* color space system. Temperatures of bleaching gels and pulp chambers during the bleaching process were monitored and recorded by a digital multimeter with K-type thermocouple. HP concentrations were tested before and after treatments by iodometry. ANOVA and paired t-test were used for statistical analyses at the significance of p < 0.05.

RESULTS

Tooth whitening resulted in the increase of ΔL* and ΔE and reduction of Δb*. Paired t-tests revealed groups BL had greater ΔE than group OP, however, there was no statistically significant difference in ΔE between them after 3 weeks post-treatment. Maximal temperature rise (ΔT) was found only in group BL, showing the increment of 2.55 and 2.02°C for bleaching gels and pulp chambers, respectively. HP concentrations were higher than baseline values for group OP (p < 0.001) rather than group BL.

CONCLUSIONS

Halogen light and chemically activated in-office bleaching systems were both effective for tooth whitening, but halogen light activation could improve the immediate whitening effect. In contrast, chemical activation was a more conservative method due to the little temperature rise in pulp chambers.

Effects of light activation, agent concentration, and tooth thickness on dental sensitivity after bleaching

Examining three bleaching systems, this in vivo clinical trial evaluated the relationship among tooth sensitivity, light activation, and agent concentration, and it correlated dental sensitivity with tooth thickness.

MATERIALS AND METHODS

Eighty-seven volunteer patients were included. Inclusion criteria were the presence of anterior teeth without restorations as well as the absence of a previous bleaching experience and absence of noncarious cervical lesions or dental pain. Exclusion criteria included pregnancy or breastfeeding, a maximum of TF3 hypoplasia, tetracycline-fluorosis stains, malpositioned teeth, orthodontic treatment, periodontal disease, and/or analgesic/anti-inflammatory intake. Patients were randomly assigned to three bleaching groups: Group A (n=25) was treated with 15% H2O2 and nitrogenous-titanium-dioxide and was light activated (Lase Peroxide Lite, DMC, SaoCarlos, Sao Paulo, Brazil); Group B (n=27) was treated with 35% H2O2 and was light activated (Lase Peroxide Sensy, DMC); and Group C (n=35) was treated with 35% H2O2 (White Gold Office, Dentsply, 38West Clark Ave., Milford, USA) without light activation. Tooth sensitivity (TS) was self-reported by the patients using the visual analog scale (VAS) at baseline (TS0), immediately after treatment (TSI), and at seven days after treatment (TS7). In 46 patients, tooth thickness was determined by computed tomography. TS0, TSI, and TS7 were compared between the A and B groups to determine the effect of concentration and between the B and C groups to determine the effect of light using analysis of covariance. The correlation between tooth thickness and TSI was determined by Spearman Rho test (SPSS 15).

RESULTS

Eighty-seven patients were evaluated at baseline, and 61 were evaluated at seven days. Separated by groups, tooth sensitivity, expressed as VAS value at the time points TS0, TSI, and TS7, respectively, were as follows: Group A: 13.76 ± 13.53, 24.40 ± 25.24, and 5.94 ± 5.5; Group B: 15.07 ± 18.14, 42.4 ± 31.78, and 8.68 ± 17.99; and Group C: 10.80 ± 14.83, 31.51 ± 29.34, and 7.24 ± 9.2. Group A showed significantly lower tooth sensitivity than group B at TSI (p=0.032). No differences were observed in the tooth sensitivities between groups B and C. No correlation was encountered between tooth thickness and tooth sensitivity immediately after treatment (Rho=-0.088, p=0.563). The median tooth thickness was 2.78 ± 0.21 mm.

CONCLUSIONS

Increases in the concentration of bleaching agents directly affect tooth sensitivity, and LED/laser activation and tooth thickness are not correlated with tooth sensitivity after dental bleaching.

The effects of light on bleaching and tooth sensitivity during in-office vital bleaching: a systematic review and meta-analysis

OBJECTIVE

To evaluate the influence of light on bleaching efficacy and tooth sensitivity during in-office vital bleaching.

DATA SOURCES

We performed a literature search using Medline, EMBASE and Cochrane Central up to September 2011.

STUDY SELECTION

All randomised controlled trials (RCTs) or quasi-RCTs comparing the light-activated bleaching system with non-activation bleaching system were included. Reports without clinical data concerning bleaching efficacy or tooth sensitivity were excluded.

RESULTS

Eleven studies were included in the meta-analysis. A light-activated system produced better immediate bleaching effects than a non-light system when lower concentrations of hydrogen peroxide (15-20% HP) were used (mean difference [MD], -1.78; 95% confidence interval [CI]: [-2.30, -1.26]; P<0.00001). When high concentrations of HP (25-35%) were employed, there was no difference in the immediate bleaching effect (MD, -0.39; 95% CI: [-1.15, 0.37]; P=0.32) or short-term bleaching effect (MD, 0.25; 95% CI: [-0.47, 0.96]; P=0.50) between the light-activated system and the non-light system. However, the light-activated system produced a higher percentage of tooth sensitivity (odds ratio [OR], 3.53; 95% CI: [1.37, 9.10]; P=0.009) than the non-light system during in-office bleaching.

CONCLUSIONS

Light increases the risk of tooth sensitivity during in-office bleaching, and light may not improve the bleaching effect when high concentrations of HP (25-35%) are employed. Therefore, dentists should use the light-activated system with great caution or avoid its use altogether. Further rigorous studies are, however, needed to explore the advantages of this light-activated system when lower concentrations of HP (15-20%) are used.