Ó

Operative Dentistry, 2012, 37-5, 464-473

Clinical Research

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
RT Basting  FLB Amaral  FMG França
FM Flório

Clinical Relevance
For the in-office technique, lower prevalence of tooth sensitivity may be expected when
using in-office 38% hydrogen peroxide (HP) agent when compared with the 35% HP agent,
which may be related to the presence, type, and concentration of desensitizing agents in
the bleaching agents. The use of 10% carbamide peroxide (CP) or 20% CP home-use and
35% HP or 38% HP in-office treatments may have the same effectiveness in bleaching
teeth.

SUMMARY
*Roberta Tarkany Basting, PhD, professor, Restorative
Dentistry, Leopoldo Mandic School of Dentistry, Campinas,
São Paulo, Brazil The aim of this study was to compare the
Flávia Lucisano Botelho do Amaral, PhD, MS, Restorative effectiveness of and tooth sensitivity to 10%
Dentistry, São Leopoldo Mandic School of Dentistry, Campi- and 20% carbamide peroxide (CP) home-use
nas, São Paulo, Brazil bleaching agents and 35% and 38% hydrogen
Fabiana Mantovani Gomes França, PhD, Restorative Dentist- peroxide (HP) in-office bleaching agents, all of
ry, São Leopoldo Mandic School of Dentistry, Campinas, São
*Corresponding author: Rua José Rocha Junqueira, 13,
Paulo, Brazil
Campinas, São Paulo 13045–755 Brazil; e-mail: rbasting@
Flávia Martão Flório, PhD, Restorative Dentistry, São yahoo.com
Leopoldo Mandic School of Dentistry, Campinas, São Paulo,
DOI: 10.2341/11-337-C
Brazil
Basting & Others: Bleaching Materials Containing Desensitizing Agents 465

which contain desensitizing agents, in a clin- final color shade results among the treatments
ical trial. Four agents were evaluated: 10% CP (Kruskal-Wallis, p,0.05). This study showed
and 20% CP (Opalescence PF 10% and Opales- that 43.2% of all the volunteers experienced
cence PF 20%, Ultradent, both with 0.5% potas- mild or moderate tooth sensitivity during the
sium nitrate and 0.11% fluoride ions), 38% HP treatment with bleaching agents. A higher
(Opalescence Boost PF, Ultradent, with 3% prevalence of tooth sensitivity was observed
potassium nitrate and 1.1% fluoride ions), and for 71.4% of the volunteers who used the 20%
35% HP (Pola Office, SDI, with potassium CP home-use bleaching agent, which may be
nitrate). The initial screening procedure in- ascribed to the peroxide concentration and/or
cluded 100 volunteers, aged 18 to 42, with no the time/length the agent was in contact with
previous sensitivity or bleaching treatment the dental structures.
and with any tooth shade. Volunteers were
randomly assigned among the technique/ INTRODUCTION
bleaching agent groups. A run-in period was
Tooth bleaching is an increasingly requested dental
performed 1 week before the beginning of the
treatment because it is considered to be a more
bleaching treatment. For the home-use bleach-
conservative approach to improve the color of teeth
ing technique, each volunteer was instructed
without invasive procedures such as crowns or
to dispense gel (10% CP or 20% CP) into the
laminated veneers. Carbamide peroxide (CP) is a
trays and then insert them into his or her
well-accepted agent for home-use bleaching super-
mouth for at least two hours per night for
vised by a dentist; the gel is applied to the external
three weeks. For the in-office bleaching tech-
surfaces of the teeth using a customized tray.1 In the
nique, the bleaching agents (38% HP or 35%
past, a 10% CP was considered as the standard
HP) were prepared and used following the
product for the home-use bleaching technique.2 In an
manufacturer’s instructions, with three appli-
attempt to increase the efficacy of the bleaching
cations performed in each session. Three ses-
agents, higher concentrations of CP were used,3–7 as
sions were carried out with an interval of
well as different concentrations of hydrogen peroxide
seven days between each session. The partici-
(HP), ranging from 3% to 10%.6,8 The main advan-
pants were evaluated before, at one week, two
tages of the home-use technique are the ease of use,
weeks, and three weeks after the beginning of
reduced chair time, and a low incidence of tooth
the bleaching treatment, and again one and
sensitivity and gingival irritation.9–12 Also, some
two weeks after the bleaching treatment end-
home-use agents include fluoride and/or other
ed. A shade guide (Vita Classical, Vita) was
desensitizing products, such as potassium nitrate,
used by a blinded examiner to perform shade
in formulations that may reduce tooth sensitivity.11
evaluations before bleaching and two weeks
However, the in-office technique has emerged as
after the end of bleaching. At the time of the
more popular than home use because highly concen-
shade evaluations, tooth sensitivity was also
trated products may promote faster tooth whitening
recorded by asking the volunteers to classify
(the higher the bleaching solution concentration, the
the sensitivity during bleaching treatment as
absent, mild, moderate, or severe. The present more quickly a shade change will occur).
study found that 13.8% of the volunteers with- The in-office systems typically use a high concen-
drew from the study due to tooth sensitivity, tration of HP (15% to 38%) and make possible the
and 43.2% of the participants experienced use of light-activation devices (eg, plasma arc, light-
some type of sensitivity during bleaching emitting diodes, diode laser, and xenon halogen
treatment. The v2 test showed that there was lamps) with the purpose of accelerating the whiten-
a significant prevalence of tooth sensitivity ing process. However, the use of light sources for in-
during bleaching treatment using the home- office tooth whitening is still controversial.13–15 The
use 20% CP agent, with 71.4% of volunteers dentist is in complete control of the process through-
reporting any level of tooth sensitivity out the treatment and has the option to end the
(p=0.0032). A low prevalence of tooth sensitiv- treatment at any time. Usually the color change
ity was observed for volunteers who used the results can be observed after a single visit. Despite
in-office 38% HP agent (15.0%). The Wilcoxon the advantage of the in-office method to quickly
test (p,0.05) showed that all of the bleaching achieve tooth whitening, tooth sensitivity is usually
treatments were effective in bleaching teeth reported.13–19 As in the home-use agents, some
and that there were no differences between the manufacturers have incorporated fluoride or desen-
466 Operative Dentistry

sitizing products into the in-office gel formulas to people with active caries, periodontal disease,
decrease tooth sensitivity. However, there is no previous hypersensitivity, tetracycline-stained
information about the addition of these products teeth, and who had received a prior bleaching
regarding the decrease in tooth sensitivity and treatment. The study required each participant to
effectiveness in bleaching. have six upper and six lower anterior teeth with no
A number of clinical trials have compared the more than one-sixth of each buccal surface covered
performance of high- and low-concentration agents with a restorative material. The study included
used for home-use or in-office tooth bleaching, and volunteers of either gender, aged 18 to 42 years,
some have shown a similar whitening effect regard- and with any tooth shade. The bleaching technique
less of the concentrations and techniques and concentration of the agent to be used (Table 1)
used.9,12,20,21 Nevertheless, the incidence of tooth were randomly attributed to the volunteers in an
sensitivity or irritation gingival is more common attempt to obtain an equal number (25) of volun-
when the agent concentration19,21,22 or bleaching teers per bleaching agent group by the use of a
time5,23,24 is increased. randomization table to allocate the participants to
each study group. However, 94 volunteers (76
However, due to the different techniques available women and 18 men) were accepted to participate
for bleaching teeth (home use or in office), various in this study after signing the informed consent
concentrations of bleaching agents available in the form and meeting the inclusion/exclusion criteria of
market, and the addition of fluoride or desensitizing the study.
products in bleaching agents, it may be difficult for
the dentist to choose the technique and agent that A shade guide (Vitapan Classical, Vita, Bad
will prove to be the most effective for and least Säkingen, Germany) was used to perform initial
sensitive to the patients. Therefore, the purpose of baseline shade selection of the middle third of the
this study was to compare the effectiveness of and central incisor. The researcher who evaluated the
the dental sensitivity to 10% and 20% CP home-use tooth shade did not know the technique or bleaching
bleaching agents and 35% and 38% HP in-office agent each volunteer used. No attempt was made to
bleaching materials containing desensitizing agents exclude participants with a lighter tooth shade of the
in a clinical trial. The null hypothesis tested was central incisors (shade A1, for example) except the
that there are no differences in efficacy and dental lightest one (B1), because other teeth would be
sensitivity with the use of these bleaching gels, darker than the shade presented by tooth 11 and the
regardless of their concentration, the technique used participant may require a bleaching treatment to
(home use or in office), or the presence of desensi- improve the color of all teeth. At this moment, a
tizing agents. statistical analysis was applied to detect whether
there were differences in color shade of the volun-
MATERIALS AND METHODS teers among groups. The Fisher exact test showed
that there was a homogeneous distribution of initial
Ethics, Sample Size, Eligibility Criteria, tooth shade color of volunteers among the technique
Randomization, and Blinding and bleaching agents groups (p=0.113).
The protocol was reviewed and approved by the
Research Ethical Committee of São Leopoldo Mandic Bleaching Procedure
School of Dentistry, Campinas, São Paulo, Brazil, One week before starting treatment, a run-in period
prior to the start of the study. A total of 100 was performed for all participants to standardize the
participants took part in this study. All participants toothbrush (Oral B Classic, Procter & Gamble, São
signed an approved human informed consent form. Paulo, SP, Brazil) and 1500 ppm fluoride dentifrice
It was determined that a sample size of 80 (Colgate Máxima Proteção Anticáries, Colgate-Pal-
volunteers would be necessary, with 20 volunteers molive, São Berbardo do Campo, SP, Brazil) used.
per group. The sample size was increased to 25 For the home-use bleaching techniques, alginate
volunteers per group to account for potential loss of impressions (Jeltrate, Dentsply International, Mil-
participants or their refusal to participate. ford, DE, USA) of both arches of each participant
The initial screening procedure included an were obtained to prepare stone molds (Gesso pedra,
anamnesis, an intraoral assessment, and a medical Vigodent S/A Ind. Com., Rio de Janeiro, RJ, Brazil).
history form to determine the eligibility of each No preparations with reservoirs were made because
volunteer to enter the study. The study excluded no differences in effectiveness25 and no higher rates
pregnant and breast-feeding women, as well as and intensity of gingival inflammation26 have been
Basting & Others: Bleaching Materials Containing Desensitizing Agents 467

Table 1: Bleaching Techniques, Bleaching Agents, Composition, Manufacturer, pH Measure, and Lot Number of the Agents
Used in the Study

Bleaching Bleaching Compositiona Manufacturer pH Measured Lot Number

Techniques Agents

Home-use Opalescence PF 10% 10% carbamide peroxide, 0.5% Ultradent 7.1 B51JR
bleaching potassium nitrate, and 0.11% Products, South
technique fluoride ions (1000 ppm); pH ;6.5 Jordan, UT,
USA

Opalescence PF 20% 20% carbamide peroxide, 0.5% Ultradent 7.2 B3NVC

potassium nitrate, and 0.11% Products, South
fluoride ions (1000 ppm); pH ;6.5 Jordan, UT,
USA

In-office Opalescence Boost PF 38% hydrogen peroxide, 3% Ultradent 6.6 B3VFR; B563J
bleaching 38% potassium nitrate, and 1.1% fluoride Products, South
technique ions (10000 ppm); pH ;7.0 Jordan, UT,
USA

Pola Office 35% Liquid: 35% hydrogen peroxide, SDI Limited, 2.6 083011; 082776;
distilled water, and stabilizers. Bayswater, 082547
Powder: thickener, catalyst, Victoria,
pigments, and potassium nitrate Australia
(unknown concentration); pH ;7.0
a
The exact percentage of these additives is proprietary.

found. All teeth of both arches were to be bleached minutes. No heat or special lamps were used to
and thus were included in the trays. The trays and complete the process. The agent was removed using
three bleaching gel tubes were given to each suction and gauze only for a new application. After
volunteer with instructions to dispense the gel into the last application, teeth were rinsed with water
both trays and then insert them into the mouth for at and the gingival isolation and lip retractor were
least two hours per night for three weeks.12 removed. A total of three applications were complet-
For the in-office bleaching technique, the bleach- ed in each session. There were three sessions with an
ing agent was prepared and used following the interval time of seven days between each session.
manufacturer’s instructions. The gingivae of all All participants were advised to avoid darkened
teeth to be bleached were isolated with either foods and beverages during bleaching as much as
OpalDam (Ultradent, South Jordan, UT, USA) light possible and to not use any kind of mouth rinses. For
cured resin (for Opalescence Xtra Boost/ Ultradent, the home-use bleaching group of volunteers, written
South Jordan, UT, USA) or Gingival Barrier (SDI instructions concerning the proper use of the
Limited, Bayswater, Victoria, Australia) (for Pola bleaching agent were given. Instructions were also
Office/ SDI Limited, Bayswater, Victoria, Australia). given to call the main researcher or to cease using
To prevent saliva from flowing through embrasures the treatment solutions if tooth sensitivity or
of anterior teeth, a saliva ejector and cotton rolls gingival irritation was perceived as too great to
were used in the sublingual region. An expanded lip tolerate.
retractor was used to protect lips. At one, two, and three weeks after the beginning of
For Opalescence Boost PF, the activator was the bleaching treatment, the participants of the
mixed into the bleaching agent using the proper home-use bleaching were assessed; at the same time,
syringe. For Pola Office, the powder was mixed into participants of the in-office technique were receiving
the liquid using a brush applicator to obtain a their bleaching treatments. All participants were
homogeneous gel. For both products, the mixture also evaluated one and two weeks after the end of the
was then applied 1–2 mm thick on the buccal bleaching treatment. At the final evaluation ap-
surfaces of the teeth (second premolar to second pointment, the blinded researcher determined tooth
premolar) of both arches and remained on for eight shade by following the same protocol used at
468 Operative Dentistry

Table 2: Prevalence of Tooth Sensitivity Reported by

Wallis test. The associations among variables were
Volunteers (Absolute and Percentage) During analyzed by the v2 test (Bioestat 5.0 statistical
Bleaching Treatment According to Technique/ program, Mamirauá Maintainable Development In-
Bleaching Agent a stitute, Belém, Brazil) or the Fisher exact test
(Release 9.2, SAS Institute Inc, Cary, NC, USA)
Absence Presence Total when at least one of the variables was less than 5.
The significance level was 5%.
n % n % n
RESULTS
Home-use 10% CP 12 63.2 7 36.8 19
There was a homogeneous distribution of volunteers
among the technique and agent bleaching groups,
Home-use 20% CP 6 28.6 15 71.4 21
with 25 volunteers for 20% CP, 24 volunteers for 10%
CP, 24 volunteers for 35% HP, and 21 volunteers for
In-office 35% HP 11 52.4 10 47.6 21
38% HP. Some volunteers withdrew from the
experiment due to extreme sensitivity during the
In-office 38% HP 17 85.0 3 15.0 20
bleaching treatment. A total of 13.8% of the
volunteers withdrew from the study: five from 10%
Total 46 56.8 35 43.2 81 CP, four from 20% CP, three from 35% HP, and one
a
v2 test, p = 0.0032. from 38% HP.
There was a significant prevalence of tooth
baseline. Tooth sensitivity also was recorded at this sensitivity during the bleaching treatment with
time by the same blinded researcher asking the the home-use 20% CP agent, with 71.4% of the
volunteers to classify the sensitivity during bleach- volunteers reporting any level of tooth sensitivity
ing treatment as absent, mild, moderate, or severe. If (p=0.0032). A low prevalence of tooth sensitivity
the sensitivity was severe enough that the volunteer was observed for volunteers who used the in-office
stopped using the bleaching agent, the volunteer was 38% HP agent (15.0%). The present study found
withdrawn from the study. that 43.2% of the participants experienced some
type of sensitivity during the bleaching treatment
Although the manufacturers stated the pH of the
(Table 2).
agents, an evaluation was made by using a fresh
portion of each agent either extruded by the syringe When tooth sensitivity was reported (Table 3),
(home-use agents) or recently mixed (in-office there was mild sensitivity when volunteers used the
agents). A measurement in triplicate was performed 10% CP home-use agent (85.7%). Severe sensitivity
using a pHmeter (MS Tecnopon Equipamentos that did not compromise the continuity of the
Especiais Ltda, Piracicaba, SP, Brazil) (Table 1). bleaching treatment was reported by volunteers
who used 20% CP home-use agent (6.7%) and 35%
Statistical Analysis HP in-office agent (10.0%).

The data were tabulated in an Excel program for There were no significant differences among groups
each volunteer according to bleaching technique/ in tooth color shade of volunteers after the end of the
concentration, gender, tooth sensitivity, and tooth treatments among technique/bleaching agents groups
shade of the right central upper incisor and (Table 4). All volunteers obtained a lighter shade
submitted to exploratory analysis. The selected tab color after the bleaching treatment, showing its
in the shade guide was converted to previously effectiveness (Table 5). All the technique/bleaching
established numeric values9,13,21 ranging from 1 (B1) agents had the same effectiveness (Table 6).
to 16 (C4) in decreasing order of value: B1, A1, B2,
D2, A2, C1, C2, D4, A3, D3, B3, A3.5, B4, C3, A4, and DISCUSSION
C4. The smaller the numeric value, the lighter the Tooth sensitivity is the most common adverse side
tooth. The comparison between shade color before effect of bleaching. It is related to the increase in
and after each treatment was analyzed by the enamel and dentin permeability and the consequent
Wilcoxon nonparametric test. The comparisons of easy passage of the peroxide through the enamel and
shade color between volunteers among the technique dentin to the pulp.23,27,28 Although the great major-
and bleaching agents groups before and after the ity of people are able to tolerate tooth whitening,
bleaching treatments were analyzed by the Kruskal- sensitivity related to tooth whitening is a critical
Basting & Others: Bleaching Materials Containing Desensitizing Agents 469

Table 3: Intensity of Perceived Tooth Sensitivity Reported Table 5: Prevalence of Volunteers Who Showed Color
by Volunteers (Absolute and Percentage) During Change According to Vita Shade Guide Scalea
Bleaching Treatment According to Technique/
Bleaching Agent Initial Shade Final Shade Color Tooth
Color Tooth
Mild Moderate Severe B1 A1 A2 C2 B3

n % N % n % A1 9 (–) (–) (–) (–)

Home-use 10% CP 6 85.7 1 14.3 0 0.0 B2 3 2 (–) (–) (–)

Home-use 20% CP 10 66.7 4 26.6 1 6.7 A2 16 12 (–) (–) (–)

In-office 35% HP 6 60.0 3 30.0 1 10.0 A3 5 12 3 (–) (–)

In-office 38% HP 2 66.7 1 33.3 0 0.0 B3 (–) 1 (–) (–) (–)

Total 24 68.7 9 25.6 2 5.7 A3.5 1 3 5 (–) (–)

B4 1 (–) (–) (–) (–)

problem. Studies have shown that the prevalence of
sensitivity during home-use or in-office bleaching
C3 (–) (–) (–) 2 (–)
treatments varies from 0% to 100% of partici-
pants.9,10,13,20,21,23,29,30 Bernardon and others21 re-
A4 (–) (–) 2 (–) 1
ported a higher rate of tooth sensitivity for the in-
a
office bleaching treatment compared with the home- Fisher exact test, p = 0.7291.

use technique, although other studies showed sim-

ilar levels of tooth sensitivity when comparing both person.10 In this study, 43.2% of volunteers experi-
techniques.9,19,20,31 This suggests that tooth sensi- enced some sensitivity during the treatment with
tivity is not only related to the high peroxide bleaching agents. With home-use bleaching agents,
concentration used in the in-office techniques but is 71.4% who used 20% CP experienced tooth sensitiv-
also a symptom that may vary greatly from person to ity vs 15% of volunteers who used the in-office 38%

Table 4: Prevalence of Color Shade in Volunteers (Absolute and Percentage) at the End of Bleaching Treatment According to
Technique/Bleaching Agent a

Shade Home-use 10% CP Home-use 20% CP In-office 35% HP In-office 38% HP Total

n % n % n % n % n %

B1 10 28.6 14 40.0 4 11.4 7 20.0 35 44.8

A1 5 16.7 5 16.7 13 43.3 7 23.3 30 38.5

A2 3 30.0 1 10.0 3 30.0 3 30.0 10 12.8

C2 1 50.0 0 0.0 0 0.0 1 50.0 2 2.6

B3 0 0.0 0 0.0 0 0.0 1 100.0 1 1.3

Total 24 30.8 25 32.1 24 30.8 21 26.9 78 100

a
Fisher exact test, p = 0.0501.
470 Operative Dentistry

Table 6: Median, Minimum, and Maximum Values of Shade Color Tooth Before and After Bleaching Treatments and the
Comparison by Wilcoxon Test

Technique/Bleaching Agent Before After

Mediana Minimum Maximum Median Minimum Maximum

Home-use 10% CP 5 Aab 2 15 1 Ba 1 7

Home-use 20% CP 5 Ab 2 12 1 Ba 1 2

In-office 35% HP 9 Aa 5 15 2 Ba 1 5

In-office 38% HP 5 Aab 3 15 2 Ba 1 11

a
Medians followed by different letters (capital letters in rows and lowercase in columns) are different by Wilcoxon (p,0.05) and Kruskal-Wallis (p,0.05) tests,
respectively.

HP. This also shows that sensitivity may not only be potassium nitrate, sodium fluoride, or amorphous
related to the peroxide concentration but most likely calcium phosphate.33 Dentists have done their part
is related to the time/length the application is in by using different techniques prior to or in associa-
contact with the dental structure (higher for home- tion with the bleaching treatment, such as using of
use agents), as well as to the presence, type, and fluorides as desensitizing agents on a tray, or
concentration of desensitizing agents in the compo- prescribing these products as mouth rinses or
sition. Thus, the null hypothesis regarding dental dentifrices, or topically applying them on the
sensitivity response was rejected. Moreover, the external surfaces of the teeth.30,32,34,35
tooth sensitivity was considered mild or moderate,
The home-use agents evaluated in this study
and only 13.8% of the participants in both techniques
contain potassium nitrate and sodium fluoride,
experienced enough extreme sensitivity to force
which have been shown to efficiently and signifi-
them to withdraw from the study. Schulte and
cantly reduce postoperative sensitivity.11 It is be-
others29 found that sensitivity was severe enough
lieved that potassium nitrate reduces dental
to cause 14% of the participants to discontinue the
sensitivity by decreasing the ability of nerve fibers
home-use bleaching 10% CP agent, although other
in the dental pulp to repolarize after an initial
studies showed no volunteers who withdrew from
depolarization due to pain sensation. Fluoride may
the study when using the home-use agents.10,20 In
be added to the bleaching agent’s composition
this study 13.8% of the volunteers declined continu-
because it also may decrease sensitivity by blocking
ing the treatment due to sensitivity: 9.5% from the
the dentin tubules, thus reducing fluid flow to the
home-use treatment and 4.3% from the in-office
pulp chamber.36 Some studies showed that the use of
bleaching treatment.
10% CP with potassium nitrate and fluoride37 or the
Although tooth sensitivity is generally reported use of 16% CP with amorphous calcium phosphate38
immediately after the application of the in-office significantly reduced the amount of sensitivity. Also,
agents13 or during the first few days of using the Matis and others33 found no differences in sensitiv-
home-use bleaching treatment,10 these events are ity when comparing 15% CP containing potassium
generally mild and resolved during or on completion nitrate and fluoride with 16% CP containing amor-
of the treatment.16,32 In this study, tooth sensitivity phous calcium phosphate. Although the same con-
records were reported at the end of the treatment as centration of desensitizing agents (0.5% potassium
a way to evaluate the volunteer’s perception of the nitrate and 0.11% sodium fluoride) were formulated
bleaching technique used. for different concentrations of the home-use bleach-
In an attempt to decrease or limit the side effects ing agents (10% and 20% CP), a significantly higher
of dental sensitivity during bleaching, manufactur- sensitivity was experienced by the volunteers who
ers have introduced different desensitizing agents used the 20% CP (71.4%) than by those who used the
into the composition of the bleaching agent, such as 10% CP (36.8%) (Table 2), using the same protocol
Basting & Others: Bleaching Materials Containing Desensitizing Agents 471

for both. For the group of volunteers who used the studies that used both evaluation methods,9,13,21
20% CP agent, there was a higher prevalence of showing that the subjective method is a reliable,
moderate or severe sensitivity than for those who practical, and useful method to evaluate color
used the 10% CP (Table 3). Thus, in comparing the changes.
home-use products, it can be suggested that a high The effectiveness of the bleaching treatment is one
concentration of CP may be related to a higher of the major factors to be considered when choosing a
prevalence of tooth sensitivity.19,21,22 bleaching technique or agent, but longevity, safety,
For the in-office bleaching treatments, a higher and the patient’s convenience should also play an
prevalence of tooth sensitivity was experienced by important role in selecting the bleaching treatment.
those volunteers who used the 35% HP agent than This study found no clinically significant differences
by those who used the 38% HP agent (47.6% and in bleaching, which corroborates Giachetti and
15%, respectively, reporting some level of tooth others,31 who performed a clinical trial comparing
sensitivity). Although the manufacturer of 35% HP at-home bleaching treatments with in-office bleach-
does not mention the concentration of potassium ing treatments. Meireles and others22 and Giachetti
nitrate contained in the formula, the results of a and others31 showed that a higher CP concentration
lower prevalence of tooth sensitivity for 38% HP does not increase the longevity of the whitening
may be related to the type and concentration of the effect of home-use tooth-bleaching agents. Da Costa
desensitizing agents (3% potassium nitrate and and others19 also verified that subjects preferred,
1.1% fluoride ions). This corroborates Al Shethri and would recommend, the home-use bleaching
and others17 who found no differences in tooth technique over the in-office technique.
sensitivity when comparing 35% HP with 38% HP The results of this study indicate that 10% CP or
in-office agents. Thus, for the in-office bleaching 20% CP home-use treatments and 35% HP or 38%
agents, tooth sensitivity may not be related to the HP in-office treatments are effective bleaching
concentration of the bleaching agent used, as procedures to whiten teeth. However, the 20% CP
opposed to what was found for the at-home agents, home-use treatment was found to produce more
but to the type and concentration of desensitizing sensitivity than other techniques/agents, even
agents used. though desensitizing agents were incorporated into
This study also confirmed that low-concentration the product. The technique preference of the dentist
bleaching agents can provide effects similar to those and patient, composition and concentration of the
obtained with high concentrations, as shown by Kihn bleaching agents, side effects involved (such as tooth
and others,4 Matis and others,5 Braun and others,7 sensitivity), and effectiveness must be taken into
and Leonard and others.23 Therefore, the null consideration when choosing the safest bleaching
hypothesis, when considering the efficacy of bleach- treatment for the patient.
ing, was accepted. A meta-analysis of seven clinical
studies indicated a significant mean change from CONCLUSION
baseline of 6.4 shade-guide units, according to the This study showed that 43.2% of the volunteers
Vitapan guide scale (Vita), by the use of tray-based experienced mild or moderate tooth sensitivity
bleaching systems using 10% CP gels.39 In this during the treatment with bleaching agents. A
study, a median change from baseline of 4 to 7 shade- higher prevalence of tooth sensitivity was observed
guide units was observed for all techniques, con- for 71.4% of the volunteers who used the 20% CP
firming that all bleaching treatments were effective, home-use bleaching agent. This may be ascribed to
without any differences of final color shade obtained the peroxide concentration and the time/length
with all treatments. Also, regardless of the initial application of the agents in contact with the dental
color shade of the upper central incisors, 83% of the structure. For the in-office technique, a low preva-
volunteers obtained the lighter shade colors (B1 or lence of tooth sensitivity was observed for the
A1) of the Vita guide scale after treatment. In this volunteers who used the 38% HP agent when
study, the shade color was evaluated with a compared with those who used the 35% HP agent.
subjective method: visual examination with the aid This may be related to the presence, type, and
of the shade guide. Although an objective method concentration of the desensitizing agents in the
(such as the use of a spectrophotometer) would be composition. The use of the 10% CP or 20% CP
more precise and without the influence of the home-use and the 35% HP or 38% HP in-office
examiner and illumination conditions, similar re- treatments have the same effectiveness in bleaching
sults regarding color change were observed in teeth.
472 Operative Dentistry

Acknowledgements randomized clinical trial Operative Dentistry 33(6)

606-612.
We would like to thank Fundação de Amparo à Pesquisa do
Estado de São Paulo (FAPESP) for its financial aid (Grants 13. Marson FC, Sensi LG, Vieira LC, & Araújo E Clinical
2008/00979–9) and Fernanda Rezende Gonçalves, who helped evaluation of in-office dental bleaching treatments with
with the bleaching treatments. and without the use of light-activation sources Operative
Dentistry 33(1) 15-22.

Conflict of Interest 14. Lima DA, Aguiar FH, Liporoni PC, Munin E, Ambrosano
GM, & Lovadino JR (2009) In vitro evaluation of the
The authors of this manuscript certify that they have no effectiveness of bleaching agents activated by different
proprietary, financial, or other personal interest of any nature light sources Journal of Prosthodontics 18(3) 249-254.
or kind in any product, service, and/or company that is
presented in this article. 15. Torres CR, Barcellos DC, Batista GR, Borges AB,
Cassiano KV, & Pucci CR (2011) Assessment of the
(Accepted 22 November 2011) effectiveness of light-emitting diode and diode laser
hybrid light sources to intensify dental bleaching treat-
ment Acta Odontologica Scandinavica 69(3) 176-181.

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