ESTHETIC DENTISTRY

Clinical effects of the exposure to red wine during at-home

bleaching
Lucas Lage Menezes, DDS, MS/Suellen Nogueira Linares Lima, DDS, MS/Etevaldo Matos Maia-Filho,
DDS, MS, PhD/Elizabeth Soares Fernandes, PhD/Saulo Jose Figueredo Mendes, PhD/Leticia Machado
Gonçalves, DDS, MS, PhD/Matheus Coelho Bandeca, DDS, MS, PhD/Alessandra Reis, DDS, MS, PhD/
Alessandro D. Loguercio, DDS, MS, PhD/Rudys Rodolfo De Jesus Tavarez, DDS, MS, PhD

Objectives: This clinical trial evaluated the effects of red wine sensitivity were compared by the Fisher exact test. Tooth sensi-
exposure on the effectiveness of at-home bleaching with 10% tivity intensity data sets for both the visual analog scale and the
carbamide peroxide, degree of tooth sensitivity, and levels of numeric rating scale were compared using the Wilcoxon signed
periodontal inflammatory markers. Method and materials: rank test (α = .05). Repeated measures and two-way ANOVA fol-
Eighty participants were assigned to two groups, namely, those lowed by the Bonferroni test were used to assess time-course
who drank red wine (experimental group), and those who did and differences between groups in NO production. Results: The
not drink red wine (control group). The experimental group par- bleaching technique was effective regardless of wine consump-
ticipants rinsed their mouths with 25 mL of red wine four times a tion (P > .05). Tooth sensitivity was classified as mild, with no dif-
f
day during the bleaching period. Shade evaluation was assessed ferences between groups (P > .05). Red wine reduced both the
visually by using the Vita Classical and Vita Easyshade techniques. gingival crevicular fluid and salivary levels of NO (P < .05). Con-
Tooth sensitivity was evaluated by the numeric and visual analog clusion: Red wine does not interfere with the effectiveness and
scales, and the salivary and gingival crevicular fluids were col- sensitivity of at-home teeth bleaching with 10% carbamide per-
lected for assessment of nitric oxide (NO) levels, a marker of in- oxide and protects against bleaching-induced inflammation.
flammation. Differences in color change were analyzed by one- (Quintessence Int 2022;53:48–57; doi: 10.3290/j.qi.b1864313)
way analysis of variance (ANOVA). The absolute risks of tooth

Key words: at-home bleaching, carbamide peroxide, crevicular gingival fluid, nitric oxide, tooth sensitivity

Among all available options of cosmetic procedures in den- support this hypothesis. Indeed, it was shown that exposure to
tistry, dental bleaching is certainly the most sought-after pro- coffee and tea during bleaching does not have a negative im-
cedure. It can be done at home by using low-concentrated pact on color change.6,7 Also, the consumption of coke during
hydrogen peroxide (H2O2) or carbamide peroxide gels, or in the in-office bleaching treatment did not affect color change8;
office using higher concentrations of these bleaching agents.1 hence, pigment-containing diets may not have any detrimental
Regardless of the bleaching protocol employed, clinicians effects on color change.9
often ask patients to stop drinking coffee, red wine, coke, or any However, it is uncertain if other types of colored diet compo-
type of pigmented foods and beverages. This caution has been nents can affect bleaching results. Red wine is an acidic drink
taken as some in vitro studies have suggested that the concom- largely consumed worldwide. It gained popularity after the iden-
itant exposure of this colored diet may jeopardize bleaching tification of anti-inflammatory and antioxidant compounds, such
efficacy.2-5 On the other hand, the available clinical trials do not as polyphenols, in its composition.10 These are suggested to pro-

48 QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022

 Menezes et al

tect against cardiovascular and inflammatory bowel diseases.11,12 Pregnant or lactating women, smokers, and participants suf- f
Red wine extracts were also found to have antimicrobial activi- fering from bruxism were excluded from the study. Participants
ties against periodontal pathogens13 and to decrease macro- with poor oral hygiene, who had undergone teeth-whitening
phage-mediated inflammatory responses.14,15 Interestingly, it treatment, with maxillary anterior teeth with endodontic treat-
was demonstrated that tooth bleaching agents can induce ment, visible enamel cracks, gingival recessions, cervical lesions or
crevicular inflammation and damage, a response largely associ- fractures, spontaneous TS, severe internal discoloration, and used
ated with nitric oxide (NO) synthesis and leukocyte activation.16 fixed orthodontic appliances were also excluded from the study.
Therefore, this clinical trial aimed to investigate whether
red wine exposure affects the effectiveness of bleaching with
Sample size calculation
10% carbamide peroxide, as well as the degree of tooth sensi-
tivity (TS) and periodontal inflammation. The primary outcome of this study was bleaching efficacy. A
whitening degree (ΔE, CIEL*a*b*, 1978)18 of approximately
7.4 ± 3.0 was previously observed for a 10% carbamide per-
Method and materials
oxide gel.19,20 Thus, a minimal sample size of 32 participants
per group was required to have a 90% chance of detecting an
Ethics approval and protocol registration
equivalence limit of 2.5 units between the control and experi-
The study protocol was conducted in full accordance with the mental groups. The equivalence limit was determined by the
World Medical Association Declaration of Helsinki, approved by 50:50% acceptability limit for ΔE76.21 Finally, 30% more patients
the Committee for the Protection of Human Participants of the were added to compensate for any dropout.
local university (protocol number: 2.271.693), and registered in
the Brazilian Clinical Trials Registry (REBEC number RBR-3x9m5j).
Sequence generation and allocation concealment
The report of this study followed the Consolidated Standards of
Reporting Trials (CONSORT) statement.17 Patients who met the inclusion criteria were asked about their
daily wine consumption. Those who did not drink wine were
allocated to the control group. No other dietary restrictions
Trial design, settings, and locations of data collection
were placed on the participants in the control group. The par-
This study was a controlled trial with a parallel design in which ticipants that reported drinking wine were placed in the exper-
the evaluator was masked to group assignments. All participants imental group. Participants in both groups were instructed not
were informed about the nature and objectives of the study. The to eat pigmented foods or drinks such as coffee, soft drinks, red
study was performed from October 2018 to June 2019 in the sauces, grape juice, and beets, in order to produce a better sce-
Clinics of the School of Dentistry from the State University of nario to evaluate only the effect of wine. To ensure that this
Ponta Grossa, PR, Brazil. recommendation was followed, the patients filled a diet diary,
in which they reported all food consumption.

Recruitment
Blinding
Recruitment was performed by posting written advertisements
on the university walls. All volunteers signed an informed con- This was evaluator-blind (SNLL) for the clinical trial, and evalu-
sent form before being enrolled in the study. ator-blind (SJFM) for levels of periodontal inflammatory mark-
ers, but the patient and operator (LLM) were not masked to the
group assignments. However, the evaluator who assessed color
Eligibility criteria
changes throughout the bleaching protocol was blinded to the
Participants were 18 to 40 years old and presented with good group assignments.
general and oral health (without need of restorative, periodontal,
endodontic, and surgical treatments). Participants were required
Study intervention
to have anterior teeth without cavities, restorations, or periodon-
tal disease, and maxillary incisors of shade A2 or darker as deter- A total of 80 participants were divided in to two groups (con-
mined by the Vita Classical Shade Guide (VITA Zahnfabrik). trol, n = 40, and experimental, n = 40). Alginate impressions of

QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022 49

 ESTHETIC DENTISTRY

1 2

Fig 1 Silicone guide with the tip of the Vita Easyshade Fig 2 Strip inserted in the groove at a depth of 1–2 mm to collect
spectrophotometer to standardize color selection. gingival crevicular fluid.

each subject’s maxillary and mandibular arch were made and as continuous and linear variables as performed in previous
these were filled with dental stone. No block-out material was controlled trials.23 Color changes were calculated from the start
applied to the labial surfaces of the stone model teeth. A 1-mm of the active phase to each individual time-point assessed by
soft vinyl material provided by the manufacturer (FGM Dental calculating the change in the number of shade guide units
Products) was used to make custom-fitted bleaching trays, (ΔSGU) that occurred towards the lighter end of the value-ori-
which were trimmed 1-mm beyond the gingival margin. ented list of shade-tabs.
Participants in the control group performed dentist-super- For the Vita Easyshade spectrophotometry, an impression of
vised at-home dental bleaching with 10% carbamide peroxide the maxillary incisors was taken with dense silicone (Coltoflax
(Whiteness Perfect, FGM) for 4 hours daily for 3 weeks. All patients and Perfil Cub Kit, Vigodent) and a 6-mm window was created
used the tray during the day (in the morning or in the afternoon) in the middle third area of the maxillary right central incisor
to guarantee that the bleaching procedure was not interrupted. (Fig 1). The tip of the Vita Easyshade spectrophotometer device
The experimental group consisted of subjects who re- was then inserted into the silicone guide and the L*, a*, and b*
ported drinking at least one bottle of red wine per week and parameters of color were obtained from the CIELab space. The
were considered moderate consumers.22 They were subjected L* value represents the luminosity (value from 0 [black] to 100
to the same bleaching procedure and were asked to rinse their [white]), a* value represents the measurement along the red-
mouths with 25 mL of red wine (Grand Expedition Merlot, green axis, and b* value represents the measurement along the
Bento Gonçalves, 11.5% vol.) for 30 seconds four times a day, at yellow-blue axis. The color change (ΔE) before (baseline) and
approximately 4-hour intervals. after each assessment period was calculated using the follow-
ing CIELab formula: ΔE = [(ΔL*)2 + (Δa*)2 + (Δb*)2]1/2.
Before start the color measures of each patient, the Vita Easy-
Measurement of the study outcomes
shade system was always calibrated. One calibrated evaluator
Primary outcome: color change recorded the color of each patient’s teeth at baseline and at all
Color changes were assessed by the subjective method Vita experimental time-points. In case of disagreements, they were
Classical (Vita Zahnfabrik), and objectively by Vita Easyshade asked to reach a consensus before the patient was dismissed.
spectrophotometry (Vident) at baseline, once a week for the
first 3 weeks of bleaching, and 4 weeks after the end of the
Secondary outcomes
bleaching procedure. The Vita Classical scale was arranged in
16 tabs from the highest (B1) to the lowest (C4) values: B1, A1, Tooth sensitivity evaluation
B2, D2, A2, C1, C2, D4, A3, D3, B3, A3.5, B4, C3, A4, and C4. Participants were asked to keep a daily record of whether they
Although this scale is not linear, color changes were considered experienced sensitivity. They were instructed to register imme-

50 QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022

 Menezes et al

diately after the occurrence of TS. For this purpose the five- cubated for another 30 minutes at 37°C. Absorbance was read
point verbal numeric rating scale (NRS) and the visual analog at 550 nm. The absorbance of each sample was subtracted by
scale (VAS) were used at all evaluation times. The NRS com- the blank sample absorbance and compared against a stan-
prises the following criteria: dard curve (0 to 300 μmol/L sodium nitrite) and expressed as
■ 0 = none NO levels in μmol/L.
■ 1 = mild
■ 2 = moderate
Statistical analysis
■ 3 = considerable
■ 4 = severe. The analysis followed the intent-to-treat protocol and involved
all participants, who were divided in two groups. Two one-
The VAS scale employs a 10-cm horizontal line with the words “no sided t tests for independent samples (TOST) were used to test
pain” at one end and “worst pain” at the opposite end. The length in the equivalence of the study groups at the different assess-
mm from the marked point to the zero end (no pain) was measured ment points (baseline vs 1 week, baseline vs 2 weeks, baseline
with a millimeter ruler, and allowed us to determine pain thresh- vs 3 weeks, and baseline vs 1 month post-bleaching).
olds and it was used as index of TS intensity during treatment. Such an approach includes a right-sided test for the lower
If the participant scored 0 (no sensitivity) at all time points, margin of the equivalence limit and a left-sided test for the
this subject was considered to be insensitive to the bleaching upper margin using one-sided .025 significance levels. The
protocol. In all other circumstances, the participants were consid- overall P value is considered to be the larger of the two P values
ered to have bleaching-induced TS. This dichotomization allowed obtained from the lower and upper tests. A P value lower than
us to calculate the absolute risk of TS, which is the percentage of the critical .05 significant level meant that equivalence could
patients who reported TS at least once during treatment. be claimed. Mean difference and 95% confidence interval (CI)
were calculated between groups at each time assessment.
Collection of gingival crevicular fluid and saliva samples For ΔE, if both treatments differed by more than 2.5 units in
Gingival crevicular fluid (GCF) samples were collected (at base- either direction, then equivalence would not hold. Although
line and different time-points following bleaching) as described not powered for, equivalence was similarly evaluated for color
by Lima et al.24 Following isolation, teeth were air-dried. Sam- change in SGU (defined as a change in 1.0 SGU). A traditional
ples were then, randomly collected from three maxillary sites repeated-measures one-way ANOVA was employed for each
per patient with a standard paper strip (Perio-paper; IDE Inter- color change instrument to detect color changes over time.
state). The strips were inserted in the sulcus to the depth of 1 to The absolute risks of TS of both groups were compared by
2 mm for 15 seconds (Fig 2). After removal, blood-free strips (01 means of Fisher exact test. The relative risk as well as the CI for
from each tooth) were placed in to Eppendorf tubes and kept the effect size was also calculated. The TS intensity data set for
at −80°C for further analysis. In parallel, non-stimulated salivary both the VAS and NRS scales were plotted in histograms and
samples were collected in a 15-mL tube for 5 minutes. Then, inspected for normal distributions. As data did not have normal
samples were centrifuged at 2,000 rpm for 10 minutes and the distribution, the groups were compared using the Wilcoxon
supernatant was collected and kept at −80°C for analysis. signed rank test (α = .05) at each time assessment. The statis-
tical program used for statistical analysis was SPSS 23.0 (IBM).
Nitric oxide (NO) levels Finally, repeated-measures and two-way ANOVA followed by
On the day of analysis, the strips containing GCF were eluted in the Bonferroni test was used for analysis of effects on NO levels.
200 μL of sterile phosphate-buffered saline (PBS), vortexed, and
centrifuged at 10,000 rpm for 10 minutes. The strips were
Results
discarded and the resulting samples were used in the assay.
NO3− content was reduced to NO2− by incubating 80 μL of each
Characteristics of included participants
saliva and GCF sample with 20 μL of 1 U/mL nitrate reductase
(Sigma-Aldrich) and 10 μL of 1 mol/L NADPH (Sigma-Aldrich) A total of 113 participants were examined according to the in-
for 30 minutes at 37°C.25 Then, 100 μL of Griess reagent (5% v/v clusion and exclusion criteria, but only 80 participants re-
H3PO4 containing 1% w/v sulfanilic acid and 0.1% w/v N-1- mained for the clinical trial. The reasons for exclusion are de-
napthylethylenediamine; Sigma-Aldrich) and samples were in- scribed in Fig 3. All participants attended the follow-up visits

QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022 51

 ESTHETIC DENTISTRY

Fig 3 Flow chart of the different

Enrollment Assessed for eligibility (n = 113)
phases of the study. NCCL,
non-carious cervical lesion.

Excluded (n = 9)
• Shade not A2 or darker (n = 10)
• Presence of restorations (n = 15)
• Presence of NCCLs (n = 9)

Randomized (n = 80)

Allocation

Allocated to intervervention (n = 40) Allocated to intervervention (n = 40)

• Received allocated intervention (n = 40) • Received allocated intervention (n = 40)

Follow-up

Lost to follow-up (n = 0) Lost to follow-up (n = 0)

Analysis

Analyzed (n = 40) Analyzed (n = 40)

3

Table 1 Characteristics of participants Equivalence was claimed in most of the time-points assessed,
except for ΔSGU obtained after the first week of bleaching.
Characteristic Control Experimental
Age (years; mean ± SD) 24.8 ± 6.0 26.4 ± 5.4
Tooth sensitivity
Baseline color (SGU; mean ± SD)* 8.3 ± 3.0 8.2 ± 2.4
*Vita Classical (Vita Zahnfabrik). Table 3 shows the absolute and relative risk of TS during the
bleaching protocol for both groups. Most of the participants,
above 92%, from both groups experienced TS at least once
during the bleaching protocol and none quit the treatment. during the study. No significant differences between groups
Usually, the dietary recommendation was followed for the ma- were detected (Fisher test, P value > .05).
jority of patients. Figure 3 depicts the participant flow diagram The mean and SD values of TS in both pain scales (NRS and
in the different phases of the study design. The initial tooth col- VAS) at the different assessment times are depicted in Table 4.
ors of both groups was assessed by the Vita Classical Shade No significant differences between groups were observed at
Guide (VITA Zahnfabrik). Baseline measures were of 8.3 ± 3.0 any time-points (P > .05).
and 8.2 ± 2.4 SGU (mean ± standard deviation [SD]), for the
control and experimental groups, respectively. The mean age
Nitric oxide (NO) levels
was around 25 years old (Table 1).
Data depicted in Fig 4 demonstrate the salivary and GCF levels
of NO of patients undergoing tooth bleaching. Prior to bleach-
Color change
ing, all subjects exhibited similar GCF and salivary levels of NO
The means and SDs of color change in ΔSGU and ΔE for the con- (Fig 4). A significant increase of NO was observed for GCF sam-
trol and experimental groups are presented in Table 2. In both ples of control patients at the first week of bleaching (Fig 4a;
groups, a whitening of approximately 9.5 units of ΔE and 7.0 P < .05). The same subjects exhibited elevated levels of salivary
units of ΔSGU (P < .05) at the end of the treatment was observed. NO from the second week of bleaching (Fig 4b; P < .05). The sal-

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 Menezes et al

Table 2 Color change in ΔE and ΔSGU (means, SDs, and mean difference) for both groups and the lowest P value from the two TOST statistics

Color Time Greater of the two

instrument assessment Experimental Control Mean difference (95% CI) one-sided P values Equivalent?
ΔSGU Vita Baseline vs. 1 week 4.8 ± 2.2 3.9 ± 1.9 0.9 (−0.02 to 1.82) .436 No
classical
Baseline vs. 2 weeks 6.1 ± 2.2 6.1 ± 2.2 0.0 (−0.82 to 0.82) .02 Yes
Baseline vs. 3 weeks 7.0 ± 2.4 6.9 ± 2.7 0.05 (−0.9 to 1.0) .05 Yes
Baseline vs. 4 weeks 7.0 ± 2.4 7.0 ± 2.7 0.03 (−0.92 to 0.97) .046 Yes
post-bleaching
ΔE Baseline vs. 1 week 6.0 ± 3.2 5.8 ± 3.3 0.2 (−0.98 to 1.4) .001 Yes
Baseline vs. 2 weeks 8.4 ± 3.7 8.3 ± 3.6 0.13 (−1.2 to 1.5) .002 Yes
Baseline vs. 3 weeks 9.8 ± 4.6 10.0 ± 4.1 −0.2 (− 1.8 to 1.4) .01 Yes
Baseline vs. 4 weeks 8.9 ± 4.6 9.9 ± 4.5 −1.0 (−2.5. to 0.62) .049 Yes
post-bleaching

Table 3 Absolute and relative risk of tooth sensitivity during bleaching

Group Number of patients with TS Absolute risk of TS (95% CI) Relative risk of TS (95% CI)
Experimental (n = 40) 37 92.5 (80.1 to 97.4) 0.94 (0.85 to 1.04)
Control (n = 40) 39 97.5 (87.1 to 99.5)
Fisher test; P value = .615

Table 4 Sensitivity values in the NRS and VAS scales according to the time of evaluation

Color instrument Time assessment Experimental Control Mean difference (95% CI) P value
NRS During 1st week 1.1 ± 0.8 1.1 ± 0.9 0.0 (−0.4 to 0.4) .833
During 2nd week 1.1 ± 0.8 1.2 ± 1.0 0.0 (−0.4 to 0.4) .775
During 3rd week 1.1 ± 0.8 1.4 ± 1.0 0.3 (−0.1 to 0.7) .151
VAS 0–10 During 1st week 1.3 ± 1.4 1.4 ± 2.1 0.1 (−0.7 to 0.9) .732
During 2nd week 1.3 ± 1.4 1.3 ± 1.5 0.0 (−0.7 to 0.7) .768
During 3rd week 1.2 ± 1.3 1.6 ± 1.8 0.4 (−0.3 to 1.1) .598

ivary levels of NO remained elevated in these individuals at teeth following red wine consumption is a matter of concern
4 weeks post-bleaching (Fig 4b; P < .05). On the other hand, for some people. This can be verified through a simple Google
those who rinsed their mouths with red wine presented with search, which yields several tips to avoid this particular form of
attenuated NO production at both crevicular and salivary sites dental staining. In line with this concern, there are wine wipes
(Fig 4; P > .05). available on the market, which claim to wipe wine stains off of
the teeth without interfering with the wine’s taste.
This concern is especially relevant for patients who un-
Discussion
dergo tooth bleaching. Alterations in tooth enamel occur
Pigments like anthocyanins, present in the skin of grapes, during bleaching due to the acidic nature of the great majority
which give red wine its dusky red color, can easily bind to the of bleaching agents on the market for this procedure.26 De-
dental structure of some patients. The reddish appearance of mineralization is an expected enamel alteration after bleach-

QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022 53

 ESTHETIC DENTISTRY

Baseline 3rd week Baseline 3rd week

1st week 4 weeks p
post-bleaching
g 1st week 4 weeks p
post-bleaching
g
2nd week 2nd week

500 # #
2500
*

Salivary NO levels (μm)

400
GCF NO levels (μm)

2000

300 1500

200 1000
*
100 500 *
*
*
0 0

4a Control Experimental 4b Control Experimental

Figs 4a and 4b Effects of wine rinse on the gingival crevicular fluid (GCF) and salivary nitric oxide (NO) levels in individuals undergoing
bleaching with carbamide peroxide. NO levels in (a) GCF and (b) salivary samples of individuals undergoing carbamide peroxide. Wine (25 mL)
was rinsed four times a day for 30 s, with intervals of approximately 4 hr between each rinse. *P < .05, differs from baseline; #P < .05, differs from
the control group.

ing, which could make the substrate more susceptible to stain- duction, this was not observed in in situ studies. Additionally,
ing by wine.10 when contact between teeth and saliva occurs during all at-
Some interesting alternatives have been evaluated to de- home bleaching procedures, no significant problems in terms
crease enamel demineralization or even help improve the re- of demineralization are observed.31,32
mineralization process. For instance, laser irradiation, either It is also important to mention that the pigments present in
alone or in combination with fluoride, causes a significant in- coffee, wine, and other colored drinks and foods are composed
crease in enamel erosion resistance.27,28 Further, Zirk et al29 of macromolecular chains that cannot easily penetrate the
observed a higher potential of remineralization of artificial dental structure within the short period of time they are in con-
enamel caries lesions when applied to novel nanoscaled metal tact with the enamel during the bleaching protocol.33 Similarly,
fluorides with relatively low free fluoride concentrations. There- an equivalent color change was observed for smokers and non-
fore, future studies should evaluate the potential of alternative smokers undergoing tooth bleaching.34
therapies, such as laser irradiation and nanoscaled metal fluor- TS is one of the main adverse effects of tooth whitening and
ides, to decrease enamel demineralization due to tooth bleach- may be responsible for patients’ discontinuation of the proced-
ing, or even help improve the remineralization process. ure.35 Findings from previous studies36-38 indicate that the
However, the present investigation showed equivalent mechanisms that lead to TS are not fully established, although
color changes after bleaching, both in those who did and did it is believed that they are associated with bleaching-induced
not rinse their mouths with red wine. Nonetheless, the extrinsic permeability of the enamel and dentin, which allows the chem-
staining potential of red wine on the dental surface cannot be ical to penetrate the dental structure, causing sensitization of
denied, as reported earlier, although it should be noted that the nerve endings present in the dentin, resulting in discomfort
this is temporary and easily reversible by the effect of saliva.10 to the patient.32
In this context, it is worth stating that saliva is able to reverse Other studies39,40 have also correlated TS with the concen-
tooth demineralization by replacing the minerals lost during tration of the bleaching product used, with reports demon-
bleaching.30 This is proven to be somewhat true when in vitro strating higher levels of sensitivity during in-office bleaching
and in situ studies that evaluated morphologic alterations after than at-home bleaching; however, it is not uncommon for sen-
at-home bleaching are compared. While in vitro studies showed sitivity to be related to patients’ pain threshold and not only the
some demineralization pattern or enamel microhardness re- concentration of the product.39

54 QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022

 Menezes et al

In the present study, it was observed that approximately trudes 1-mm beyond the gingival margin and could, therefore,
92% of patients presented TS at some point during the bleach- present a danger to the gingival margin. However, recent clin-
ing procedure. This finding corroborates the literature that sug- ical studies showed that no significant increase in the gingival
gests a considerable proportion of patients experience sensi- aggression was observed when the extent of the tray reservoir
tivity during and after the bleaching treatment.23,41,42 It should was evaluated during at-home bleaching.43-45
be noted that bleaching-induced TS is transitory, and this may Among the limitations of the study, a very narrow age
be due to the continuous presence and protective effects of range was selected in the present study (18 to 30 years old).
saliva, as well as the correct dosage of the product, which both Thus, the current findings need to be extrapolated to other age
ensure the conservation of the characteristics of the surface of groups with caution. Overall, the evidence gathered here indi-
the dental enamel and promote its constant remineralization.31 cates that there is no need for patients to refrain from drinking
Findings also revealed that H2O2-based tooth bleaching colored beverages such as red wine in order to undergo tooth
agents are suggested to cause tissue damage, a response that bleaching. Data also suggest that small amounts of red wine
was associated with reduction of GCF NO levels from days 1 to may be beneficial as it reduces bleaching-induced NO-depen-
7 following bleaching.16 In the present study, NO was increased dent inflammation in the oral cavity.
in samples of control patients from T1 (7 days post bleaching),
indicating that local inflammation, first detected in the GCF and
Conclusion
later in in the saliva samples, was active. Differences between
the studies may be due to the nature of the bleaching agents, The consumption of red wine during at-home teeth bleaching
as the speed of the release of H2O2 varies between them. does not interfere with bleaching effectiveness or TS. In addi-
Despite not affecting pain thresholds, the present data indi- tion, the results indicate that patient exposure to red wine
cate that a red wine rinse is not only safe with regards to bleaching reduces the production of periodontal inflammatory mediators
efficacy, but also reduces GCF and salivary NO levels in patients such as nitric oxide in the oral cavity.
undergoing carbamide peroxide bleaching. Therefore, a wine
rinse may be an interesting approach to attenuate bleaching-in-
Acknowledgments
duced inflammation. This hypothesis is supported by previous
data indicating that red wine extracts are anti-inflammatory.14,15 The authors thank FGM Dental Products for the donation of the
It is worth mentioning that bleaching was not performed materials used in this investigation. This study was partially
with a reservoir in the tray, and the tray was designed 1-mm supported by the National Council for Scientific and Technolog-
beyond the gingival margin. In fact, some clinicians could pre- ical Development (CNPq) under grants 303332/2017-4 and
dict that, without a reservoir, the bleaching gel could be imme- 308286/2019-7 and Coordenação de Aperfeiçoamento de Pes-
diately pressed out of the tray toward the gingival margin, soal de Nível Superior – Brasil (CAPES) – Finance Code 001. The
causing some gingival irritation. In the same way, the tray pro- authors declare no conflicts of interest.

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56 QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022

 Menezes et al

Lucas Lage Menezes Elizabeth Soares Fernandes Professor, Instituto de Pesquisa

Pelé Pequeno Príncipe, Curitiba – PR, Brazil
Saulo Jose Figueredo Mendes MS student, Programa de Pós
Graduação em Microbiologia, Universidade Ceuma, SaŰo Luís,
MaranhaŰo, Brazil
Leticia Machado Gonçalves Professor, Departamento Odont-
ologia I, Universidade Federal do Maranhão, SaŰo Luís, MaranhaŰo,
Brazil
Matheus Coelho Bandeca Professor, Programa de Pós Gradu-
ação em Odontologia, Universidade Ceuma, SaŰo Luís, MaranhaŰo,
Brazil
Lucas Lage Menezes PhD student, Programa de Pós Graduação
Alessandra Reis Professor, Programa de Pós Graduação em
em Odontologia, Universidade Ceuma, Luís, MaranhaŰo, Brazil
Odontologia, Universidade Estadual Ponta Grossa, Uvaranas, Ponta
Grossa, ParanaŮ, Brazil
Suellen Nogueira Linares Lima PhD student, Programa de Pós
Graduação em Odontologia, Universidade Ceuma, SaŰo Luís, Alessandro Dourado Loguercio Professor, Programa de Pós
MaranhaŰo, Brazil Graduação em Odontologia, Universidade Estadual Ponta Grossa,
Uvaranas, Ponta Grossa, ParanaŮ, Brazil
Etevaldo Matos Maia-Filho Professor, Programa de Pós Gradu- Rudys Rodolfo De Jesus Tavarez Professor, Programa de Pós
ação em Odontologia, Universidade Ceuma, SaŰo Luís, MaranhaŰo, Graduação em Odontologia, Universidade Ceuma, SaŰo Luís,
Brazil MaranhaŰo, Brazil

Correspondence: Prof Dr Alessandro D. Loguercio, School of Dentistry, Dept REstorative Dentistry, State University of Ponta Grossa. Rua
Carlos Cavalcanti, 4748 Bloco M, Sala 64-A, Uvaranas, Ponta Grossa, Paraná, Brazil 84030-900. Email: aloguercio@hotmail.com

QUINTESSENCE INTERNATIONAL | volume 53 • number 1 • January 2022 57

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