Tooth whitening today DAVID C.

SARRETT J Am Dent Assoc 2002;133;1535-1538

The following resources related to this article are available online at jada.ada.org ( this information is current as of January 11, 2010 ):
Downloaded from jada.ada.org on January 11, 2010 Updated information and services including high-resolution figures, can be found in the online version of this article at:
http://jada.ada.org/cgi/content/full/133/11/1535

This article appears in the following subject collections: Esthestics http://jada.ada.org/cgi/collection/esthestics Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at:
http://www.ada.org/prof/resources/pubs/jada/permissions.asp

2010 American Dental Association. The sponsor and its products are not endorsed by the ADA.

P R A C T I C A L

S C I E N C E

ABSTRACT
Background. Methods to improve the esthetics of the dentition by tooth whitening are of A D A J interest to dentists, their patients and the public. In the past 20 years, research on bleaching and N C U other methods of A ING EDU 4 RT removing tooth discolICLE orations has dramatically increased. Dentist-supervised and over-thecounter products now are available to solve a variety of tooth discoloration problems without restorative intervention. The indications for appropriate use of toothwhitening methods and products are dependent on correct diagnosis of the discoloration. Overview. Tooth-whitening methods include the use of peroxide bleaching agents to remove internal discolorations or abrasive products to remove external stains. Peroxide bleaching procedures are completed by the dentist in single or multiple appointments, or by the patient over a period of weeks to months using custom trays loaded with a bleaching agent. Both methods are safe and effective when supervised by the dentist. Microabrasion is indicated for the removal of isolated discolorations that often are associated with fluorosis. Whitening toothpastes remove surface stains only through the polishing effect of the abrasives they contain. Conclusions and Practice Implications. Tooth whitening is a form of dental treatment and should be completed as part of a comprehensive treatment plan developed by a dentist after an oral examination. When used appropriately, tooth-whitening methods are safe and effective.
A
T

DAVID C. SARRETT, D.M.D., M.S.

ince the introduction of the tooth-whitening technique that uses custom bleaching trays loaded with 10 percent carbamide peroxide gel 13 years ago,1 the demand for information on tooth bleaching and whitening has increased dramatically. When I conducted an online search of the National Library of Medicines MEDLINE database2 from 1969 to 1978 using the search terms tooth AND (bleaching OR whitening), I found 38 references. When I conducted similar searches for 1979 to 1988, 1989 to 1998, and 1999 to the present, I found 111, 456 and 225 references, respectively. Frazier and Haywood3 reported that 92 percent of dental schools now are teaching the custom tray bleaching technique. The safety and efficacy of this tooth-whitening method have been welldocumented in clinical studies, and the ADA Seal of Acceptance has been Tooth awarded to tooth-whitening products. whitening is, If you visit the oral health care section of your pharmacy, you will become aware and should remain, dental of the marketing of and assumed public demand for over-the-counter, or OTC, care that tooth-whitening products. This array of must be products includes toothpastes, professionally mouthrinses and bleaching agents that supervised. make claims about their ability to whiten teeth. Dental professionals likely are able to evaluate the various claims made by these products. The average consumer, however, more likely will walk away confused or may purchase an ineffective product or a product that is not appropriate for and is potentially harmful to his or her tooth discoloration problem. The increased availability of these products indicates that they are being purchased and used by the public. Patients need to decide between using OTC whitening products and seeking professionally supervised toothwhitening treatment from dentists. A new option is to go to a tooth-whitening center at which tooth whitening is the primary service being delivered. Some patients may choose to continue receiving regular dental care from their general dentists, while using a tooth-whitening

IO N

Tooth whitening today

center for their dentist-supervised bleaching treatments. The fact that patients may be receiving both OTC and dentistsupervised tooth-whitening treatments that are not part of a comprehensive oral health treatment plan raises concerns. Tooth whitening is, and should
JADA, Vol. 133, November 2002 1535

CON

Downloaded from jada.ada.org on January 11, 2010

P R A C T I C A L

TABLE

TOOTH-WHITENING METHODS, INDICATIONS FOR USE AND ADVERSE EFFECTS.

TYPE OF PRODUCT OR METHOD ACTIVE AGENTS INDICATIONS FOR USE POTENTIAL ADVERSE EFFECTS Root resorption Transient tooth sensitivity and gingival irritation Sensitivity of teeth during bleaching

Internal BleachingIn-Office or Walking External BleachingIn-Office One to Three Visits

35 percent hydrogen peroxide 30 percent to 38 percent hydrogen peroxide, alone or with heat or light 10 percent carbamide peroxide

Endodontically treated teeth Single or multiple discolored teeth

Custom Bleaching Trays Worn by Patient Daily for Two to Six Weeks

Multiple teeth and entire arches, most effective for yellow or brown discoloration; may be effective for tetracycline staining with longer use Surface staining Isolated brown or white discolorations of shallow depth in enamel White discoloration on yellowish teeth

Brushing With Whitening Toothpaste Microabrasion Followed by Neutral Sodium Fluoride Applications Microabrasion Followed by Custom Tray Bleaching

Abrasives Abrasives and acid

None None

Downloaded from jada.ada.org on January 11, 2010

Abrasives and acid; 10 percent carbamide peroxide

Sensitivity of teeth during bleaching

remain, dental care that must be professionally supervised. Tooth whitening should be part of a comprehensive treatment plan developed by a dentist after an oral examination. In this article, I review the tooth-whitening options available to patients and discuss what is known about the safety and efficacy of toothwhitening methods and products. The table summarizes the indications for use and the adverse effects of tooth-whitening methods.
TOOTH-BLEACHING OPTIONS

Before the introduction of dentist-supervised home tooth whitening using custom trays and whiteners containing 10 percent carbamide peroxide agents, nonrestorative treatment of discolored teeth was performed using 35 percent hydrogen peroxide applied either internally or externally.4 Internal bleaching. Internal application is limited to endodontically treated teeth. The socalled walking bleach involves sealing the bleaching agent inside the endodontic access cavity. The patient returns to the dentist to have the bleaching agent renewed until the desired shade change or maximum effect is achieved. Root resorption is a known potential adverse effect and can lead to the loss of the tooth.5 External bleaching. Dentists perform
1536 JADA, Vol. 133, November 2002

external bleaching with 30 to 38 percent hydrogen peroxide by isolating gingival tissues and applying the bleaching gel to the tooth surface. This process may be used with or without heat or light during the bleaching treatment.4 The side effects for vital teeth include transient tooth sensitivity and gingival irritation. Both internal and external bleaching are effective in whitening discolored teeth and are indicated primarily for treatment of one or two teeth rather than entire arches. Custom tray bleaching. For patients seeking to whiten multiple teeth or entire arches, using a custom tray loaded with 10 percent carbamide peroxide gel generally is the method of choice. This treatment is most effective for whitening teeth with moderate yellow discoloration, moderate brown discoloration or both. Generally, a noticeable whitening effect will be achieved after a daily bleaching for two to six weeks, although the amount of color lightening may vary among people.6,7 The shade change appears to be stable for six to 12 months or longer for some patients,8 at which time patients may consider whether to bleach the teeth again for several days to regain the original effect. The research data on this treatment are quite extensive and indicate that this method is safe and effective when supervised by dentists.

P R A C T I C A L

The most common side effect of using a custom caries and stained restorations can cause other tray for bleaching is transient tooth sensitivity problems. Since bleaching will not correct these that can be managed by having the patient bleach discolorations, users of OTC bleaching products on alternate days, reduce the bleaching time of may overuse the products when trying to correct each application or both.6,9 The sensitivity disaptheir discolorations. The consequences of undiagpears once the bleaching is ceased. Although rare, nosed caries are obvious. patients who experience severe sensitivity that TOOTH SURFACE DISCOLORATION cannot be managed by altering the bleaching REMOVAL OPTIONS regimen should discontinue use of this toothwhitening method. Gingival irritation also is Toothpastes. Toothpastes that make claims that reported by patients and most often is caused by they whiten teeth do so primarily by polishing an improperly fabricated tray.9 For patients away stains on the surface of the teeth. Some seeking to whiten only one or two teeth, this toothpastes also contain peroxide bleaching method also is effective when the dentist modifies agents. There is no evidence that these tooththe tray and instructs the patient to pastes are effective in whitening only place bleach in the tray in the teeth with internal discoloration. area of the teeth to be whitened. Toothpastes that have received the Because there are Tetracycline staining has proven ADA Seal have been shown to be many causes of tooth to be difficult or impossible to effective at removing stain through discoloration, a remove through traditional polishing while also reducing caries bleaching methods. A recent via fluoride. comprehensive oral report10 indicates that using 10 perThe Centers for Disease Control examination by a cent carbamide peroxide in custom and Prevention recently released dentist is required to trays for three to six months can be its recommendations for using fluoensure that patients effective in removing tetracycline ride to control caries.15 It is evident are using the most staining. The adverse effects of that fluoridated water and tootheffective toothlong-term bleaching are not wellpaste are the fluoride delivery established; however, if the only mechanisms that contribute the whitening treatment. alternative to bleaching is restoring majority of caries-reduction benethe teeth with ceramic veneers or fits. The release of active fluoride crowns, it seems reasonable to during brushing is not a simple attempt bleaching first. The patient should be manner of having the toothpaste contain a fluomonitored closely, and only two to six weeks ride ingredient, as other components such as the supply of bleach should be dispensed at one time. abrasive, flavorings and vehicle can render the OTC bleaching. OTC products that use carfluoride ineffective.16,17 We must continue to bamide peroxide and prefabricated or userencourage the public and patients to use fluoridemodified trays are available,11 and some of these containing toothpastes that have been proven products appear to be equivalent in peroxide coneffective at reducing caries. tent to similar products sold only to dentists. Microabrasion. Isolated brown or white areas Other OTC products deliver peroxide to the teeth of enamel discoloration on otherwise normal using strips that patients apply to their teeth.12 teeth, which often are attributed to fluorosis, can There are very few published reports on the safety be treated with microabrasion if the discoloration and efficacy of these products compared with the is less than a few tenths of a millimeter deep.18 published research on dentist-dispensed whiteners Microabrasion is performed by applying an abracontaining 10 percent carbamide peroxide. sive slurry of silicon carbide and hydrochloric acid There are considerable concerns that the unsuusing a manual or handpiece-driven rubbing pervised use of these products can lead to adverse action. This slow removal of enamel is easier to effects. Significant damage to enamel as the control than that performed using rotary instruresult of using OTC products has been ments. The depth of the discoloration cannot be reported.13,14 The long-term, repeated use of inapknown until attempts are made to remove it. If propriate products may lead to irreversible the discoloration is too deep, it cannot be removed damage to tooth enamel. Patients who choose to using microabrasion, and a restorative solution bleach discolorations caused by undiagnosed should be considered.
JADA, Vol. 133, November 2002 1537

Downloaded from jada.ada.org on January 11, 2010

P R A C T I C A L

The mechanism of color improvement appears to be the removal of discolored surface enamel and the creation of a highly reflective enamel surface that may mask any remaining Dr. Sarrett is a prodiscoloration.19 The combined fessor and assistant benefits of enamel microabradean, Academic Affairs, Virginia Commonwealth sion followed by home tooth University School of whitening using carbamide perDentistry, and is a oxide have been reported in case member, ADA Council on Scientific Affairs. studies.20-22 The combined regiAddress reprint men is reported to be most effec- requests to Dr. Sarrett at P.O. Box 980566, tive in patients who have promi- Richmond, Va. 23298-0566, e-mail nent white areas on teeth that dsarrett@ucu.edu. are yellowish or that have darkened with age. In vitro results support the application of neutral sodium fluoride after microabrasion is completed to create enamel that is significantly more resistant to demineralization than untreated enamel.23
CONCLUSION

There are many safe and effective toothwhitening methods. For most patients, the methods described in this article should be used to correct discolored teeth before restorative intervention in undertaken. Because there are many causes of tooth discoloration, a comprehensive oral examination by a dentist is required to ensure that patients are using the most effective tooth-whitening treatment for their tooth discoloration problems. s
1. Haywood VB, Heymann HO. Nightguard vital bleaching. Quintessence Int 1989;20:173-6.

2. National Library of Medicine. PubMed. Available at: www.ncbi.nlm.nih.gov/entrez/query.fcgi. Accessed Sept. 30, 2002. 3. Frazier KB, Haywood VB. Teaching nightguard bleaching and other tooth-whitening procedures in North American dental schools. J Dent Educ 2000;64(5):357-64. 4. Goldstein RE. In-office bleaching: where we came from, where we are today. JADA 1997;128:11S-8S. 5. Goon WW, Cohen S, Borer RF. External cervical root resorption following bleaching. J Endod 1986;12:414-8. 6. Haywood VB. Current status of nightguard vital bleaching. Compendium 2000;21(supplement 28):S10-S7. 7. Matis BA, Mousa HN, Cochran MA, Eckert GJ. Clinical evaluation of bleaching agents of different concentrations. Quintessence Int 2000;31:303-10. 8. Leonard RH. Efficacy, longevity, side effects, and patient perceptions of nightguard vital bleaching. Compendium 1998;19:766-81. 9. Li Y. Tooth bleaching using peroxide-containing agents: current status of safety issues. Compendium 1998;19:783-96. 10. Leonard RH. Nightguard vital bleaching: dark stains and longterm results. Compendium 2000;21(supplement 28):S18-27. 11. Li Y. Biological properties of peroxide-containing tooth whiteners. Food Chem Toxicol 1996;34:887-904. 12. Gerlach RW, Gibb RD, Sagel PA. A randomized clinical trial comparing a novel 5.3 percent hydrogen peroxide whitening strip to 10 percent, 15 percent, and 20 percent carbamide peroxide tray-based bleaching systems. Compendium 2000;21(supplement 29):S22-S8. 13. Cubbon T, Ore D. Hard tissue and home tooth whiteners. CDS Rev 1991;84(5):32-5. 14. Hammel S. Do-it-yourself tooth whitening is risky. U.S. News and World Report. April 20, 1998:66. 15. Center for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR 2001;50:1-42. 16. Stookey GK. Are all fluoride dentifrices the same? In: Wei SH, ed. Clinical uses of fluorides. Philadelphia: Lea & Febiger; 1985. 17. Hattab FN. The state of fluorides in toothpaste. J Dent 1989;17:47-54. 18. Croll TP. Enamel microabrasion: observations after 10 years. JADA 1997;128(supplement):45S-50S. 19. Donly KJ, ONeill MO, Croll TP. Enamel microabrasion: a microscopic evaluation of the abrosion effect. Quintessence Int 1992;23:175-9. 20. Cvitko E, Swift EJ, Denehy GE. Improved esthetics with a combined bleaching technique: a case report. Quintessence Int 1992;23: 91-3. 21. Killian CM. Conservative color improvement for teeth with fluorosis-type stain. JADA 1993;124:72-4. 22. Croll TP. Esthetic correction for teeth with fluorosis and fluorosislike enamel dysmineralization. J Esthet Dent 1998;10:21-9. 23. Segura A, Dunly KJ, Wefel JS. The effects of microabrasion on demineralization inhibition of enamel surfaces. Quintessence Int 1997;28:463-6.

Downloaded from jada.ada.org on January 11, 2010

1538

JADA, Vol. 133, November 2002