CRITICAL APPRAISAL

In-Office Tooth Whitening: Pulpal Effects and Tooth

Sensitivity Issues
Author
SO RAN KWON, DDS, MS, PhD, MS*
Associate Editor
EDWARD J. SWIFT, JR., DMD, MS

Tooth whitening is a popular method for improving the appearance of discolored teeth. The wide range of techniques
availablein-oce whitening, dentist-supervised at-home whitening, and over-the-counter whiteningreects its
popularity. The ecacy and side eects are dependent on the technique, with tooth sensitivity being the most commonly
reported side eect associated with all of the approaches. Sensitivity issues related to at-home whitening have been
reviewed in previous appraisals (Swift, JERD 2006; 18:2258 and 3015). Therefore, the current Critical Appraisal
focuses on the incidence of sensitivity, pulpal responses, and prevention of sensitivity during in-oce whitening
treatments.

Efficacy, Side-Effects and Patients Acceptance of Different Bleaching Techniques (OTC,

In-Office, At-Home)
T.M. AUSCHILL, E. HELLWIG, S. SCHMIDALE, A. SCULEAN, N.B. ARWEILER
Operative Dentistry 2005 (30:15663)

Materials and Methods: The study involved 39 subjects

who ranged in age from 21 to 68 years and whose right
upper canine was unrestored and of shade A3 or
darker. Subjects with poor dental health or known
hypersensitivity were excluded.

shade guide. The over-the-counter (OTC) group

received 5.3% hydrogen peroxide strips (Whitestrips,
Procter & Gamble Technical Centres Ltd, Egham, UK)
to be worn for 30 minutes twice a day (one cycle = 30
minutes). The at-home group was asked to wear a
custom-fabricated tray lled with the whitening gel
(Opalescence PF, 10% carbamide peroxide, Ultradent
Products, South Jordan, UT, USA) for 8 hours per night
(one cycle = 8 hours). For the in-oce group, teeth
were isolated using a conventional dam and the
whitening gel (Opalescence Xtra Boost, 38% hydrogen
peroxide, Ultradent) was applied to the labial surface of
the teeth for 15 minutes (one cycle = 15 minutes).

Whitening ecacy was based on the time required to

achieve six grades of whitening on a value-oriented Vita
Classic (Vita Zahnfabrik, Bad Sckingen, Germany)

Participants were asked to record tooth sensitivity,

gingival irritation, and their acceptance of the treatment
based on a visual analog scale (VAS) ranging from 0 to

ABSTRACT
Objective: This was a randomized, examiner-blinded
clinical trial to determine the ecacy of three
whitening techniques and the occurrence of side eects
such as tooth sensitivity, gingival irritation, and
potential changes to the enamel surface.

*Associate Professor, Department of Operative Dentistry, University of Iowa College of Dentistry, Iowa City, IA, USA
Contact for editorial questions: soran-kwon@uiowa.edu

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CRITICAL APPRAISAL Kwon and Swift

10, 7 days after treatment. Changes to the enamel

surface were evaluated by comparing scanning electron
microscopy images taken before and after treatment on
epoxy resin casts of the upper canine.
Results: All participants completed the study and all
three techniques were eective in whitening the teeth.
The mean treatment cycles to achieve the dened shade
were 31.85 6.63, 7.15 1.86, and 3.15 0.55 for OTC,
at-home, and in-oce, respectively, demonstrating
signicant dierences in treatment cycles related to the
whitening method. Tooth sensitivity was mild, transient,
and reversible in all groups; the VAS scores of
2.62 1.46 (OTC), 2.85 1.41 (in-oce), and
3.38 1.66 (at-home) did not dier signicantly.
Moreover, none of the techniques produced detectable
changes to the enamel surface.
Conclusions: All three techniques eectively whitened
teeth. When the manufacturers instructions are
followed, 16 days of OTC whitening are comparable to
7 days of at-home and 1 day of in-oce whitening. Side
eects were minimal and reversible in all cases.

COMMENTARY
This study is one of the very few to compare the
ecacy and side eects of three distinct whitening
techniques. It provides valuable information on the
relative time needed to achieve a dened dierence in
shade with each technique. Dierences in the level of
sensitivity experienced were not signicant, consistent

with ndings from Bizhang and colleagues, who

compared three whitening methods and found that
sensitivity was minor and disappeared spontaneously.1
Notably, however, other literature describes a higher
incidence (6778% versus 1565%) as well as an
increased level of sensitivity (moderate to severe versus
mild) for in-oce whitening versus at-home whitening
techniques.2,3 These apparent discrepancies may be
partly attributed to the following factors. First, the
studies may have used dierent inclusion criteria for
preexisting tooth sensitivity, which is the best predictor
of tooth sensitivity with whitening. Second, the in-oce
whitening protocols diered with respect to the
concentration of the whitening agent, the length of time
for which the agent was applied, and the frequency with
which the agent was applied. Third, the regimen for
reporting sensitivity may have diered (on a daily basis
versus several days after treatment). Fourth, the
measurement of sensitivity in clinical trials is not
standardized, with VAS ranges of 0 to 10 or 100 having
been used or scales of 0 to 3 or 4 being used.

REFERENCES
1. Bizhang M, Chun Y-HP, Damerau K, et al. Comparative
clinical study of the eectiveness of three dierent
bleaching methods. Oper Dent 2009;34:63541.
2. Tay LY, Kose C, Herrera DR, et al. Long-term ecacy of
in-oce and at-home bleaching: a 2-year double-blind
randomized clinical trial. Am J Dent 2012;25:199204.
3. Nathanson D, Parra C. Bleaching vital teeth: a review and
clinical study. Compendium 1987;8:4907.

Assessing the Effect of a Desensitizing Agent Used before In-Office Tooth Bleaching
L.Y. TAY, C. KOSE, A.D. LOGUERCIO, A. REIS
Journal of American Dental Association 2009 (140:124551)

prevented by pre-treatment with a desensitizing

agent.

ABSTRACT
Objective: The purpose of this double-blind randomized
clinical trial was to determine whether tooth sensitivity
arising from in-oce whitening can be

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Materials and Methods: This study involved 30

undergraduate students with six caries-free maxillary

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CRITICAL APPRAISAL Kwon and Swift

anterior teeth of shade C2 or darker. Participants were

randomly divided into an experimental or placebo
group. The experimental group was pre-treated with a
desensitizer containing 5% potassium nitrate and 2%
sodium uoride (Desensibilize KF 2%, FGM Dental
Products, Joinville, Santa Catarina, Brazil) for 10
minutes, as specied by the manufacturer. In-oce
whitening with a 35% hydrogen peroxide gel
(Whiteness HP, FGM Dental Products) was then
performed for 45 minutes. This procedure was repeated
after 1 week. The placebo group was subjected to the
same protocol, with the exception that the
pre-treatment gel did not contain any active ingredient
(potassium nitrate or sodium uoride).
Two calibrated evaluators were used to measure the
tooth color before and immediately after the rst and
second whitening. Tooth shades were determined
according to a value-oriented Vita Classic shade guide.
Participants were asked to record the occurrence of
tooth sensitivity on a daily basis, using a 0 to 4 scale
corresponding to no, mild, moderate, considerable, and
severe sensitivity, respectively.
Results: All 30 participants completed the study. There
was no signicant dierence in color change between
the two groups. The incidence of tooth sensitivity was
higher in the placebo group (86.7%) versus the
experimental group (46.7%). In the placebo group, the
predominant sensitivity level was considerable
whereas that in the experimental group was mild.
Conclusions: The application of a desensitizing gel
containing 5% potassium nitrate and 2% sodium
uoride before in-oce whitening did not aect
whitening ecacy but reduced the incidence and
severity of tooth sensitivity.

COMMENTARY

hydrodynamic theory. The rst is to occlude the

permeability of the dentinal tubules using agents such
as uoride and amorphous calcium salts. Another is to
reduce the excitability of dental nerve bers by applying
potassium salts. The main dierence between whitening
sensitivity and dentinal hypersensitivity (e.g., following
periodontal surgery) is that pain can be provoked in the
absence of prolonged stimulation and is not necessarily
associated with exposed dentin. Thus, it has been
suggested that the latter approachto reduce nerve
excitabilityshould be more eective than the dentinal
tubule occlusion method for whitening sensitivity.
The study highlighted here is one of several conrming
that the use of these desensitizers reduces not only the
incidence, but also the severity of tooth sensitivity
associated with in-oce whitening. This study is also
important in demonstrating that the use of
desensitizers does not aect the whitening outcome.

SUGGESTED READING
Pal M, Mayoral JR, Llopis J, et al. Evaluation of the
eectiveness of an in-oce bleaching system and the eect
of potassium nitrate as a desensitizing agent. Odontology
2013. DOI 10.1007/s10266-013-0132-3.
Paula E, Kossatz S, Fernandes D, et al. The eect of ibuprofen
use on tooth sensitivity caused by in-oce bleaching. Oper
Dent 2013;38:6018.
Kossatz S, Martins G, Loguercio AD, Reis A. Tooth sensitivity
and bleaching eectiveness associated with use of a
calcium-containing in-oce bleaching gel. J Am Dent
Assoc 2012;143:e81e87.
He LB, Shao MY, Tan K, et al. The eects of light on
bleaching and tooth sensitivity during in-oce vital
bleaching: a systematic review and meta-analysis. J Dent
2012;40:64453.
Markowitz K. Pretty painful: why does tooth bleaching hurt?
Med Hypotheses 2010;74:83540.

Tooth sensitivity related to whitening has been

addressed using a variety of approaches based on the

2014 Wiley Periodicals, Inc.

DOI 10.1111/jerd.12121

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Human Pulp Responses to In-Office Tooth Bleaching

C.A.S. COSTA, H. RIEHL, J.F. KINA, N.T. SACONO, J. HEBLING
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010 (109:e59e64)

ABSTRACT

COMMENTARY

Objective: This study evaluated and compared the

histological changes of human incisor and premolar
pulps in response to in-oce whitening with a 38%
hydrogen peroxide gel.

The pulpal response to whitening is an important

consideration when evaluating the safety of tooth
whitening with various concentrations of material.
Previous studies on dentist-supervised at-home
whitening with 10% carbamide peroxide indicated that
pulpal responses were minimal and noticeably
diminished by 2 weeks after treatment, supporting the
notion that at-home whitening is safe. The results
reported in this article are important in that they
strongly caution against the use of highly concentrated
whitening materials on lower incisors. However, this
study should be extended in the future to more clearly
assess the safety of in-oce whitening with respect to
pulpal health.

Materials and Methods: Sixteen caries-free teeth to be

extracted for orthodontic purposes were selected from
patients who were, on average, 16.2 years of age. These
teeth were divided into four groups: whitened lower
premolars (n = 6), whitened lower incisors (n = 4),
non-whitened premolars (n = 3), and non-whitened
incisors (n = 3). In the case of teeth in the whitened
groups, a 38% hydrogen peroxide gel (Opalescence Xtra
Boost) was applied to the buccal surface three times for
15 minutes per application. The non-whitened control
teeth were treated with a rubber/pumice prophylaxis.
All teeth were extracted 2 days after the in-oce
whitening procedure and were processed for histologic
evaluation. Analysis by microscopy evaluated three
histopathologic events: the inammatory cell response,
tissue disorganization, and reactionary dentin
formation.
Results: No histopathologic events were detected in the
non-whitened incisors and premolars and the whitened
premolars. However, the whitened incisors presented
with changes in the pulp, most notably a large zone of
coagulative necrosis in the coronal area. In addition, the
radicular pulp was characterized by mild inammatory
changes, with mononuclear cells accumulating around
congested and dilated blood vessels. Deposition of
reactionary dentin was also observed in the whitened
incisors.
Conclusions: Whitening with 38% hydrogen peroxide for
45 minutes causes pulpal damage in mandibular
incisors, but not to that of the premolars.

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Limitations of this study include the following. First,

although the study assessed 16 teeth, it did not specify
how many subjects these teeth came from or how teeth
and/or subjects were allocated to the experimental or
control group. Second, the baseline status of the teeth
was described as sound, but neither the denition of
sound nor the methods employed to test pulp vitality
were described. Third, the teeth were extracted 2 days
after whitening, and no other time period was
evaluated. A future study including a longer follow-up
period between whitening and extraction might provide
more reliable results on the long-term pulpal response.

SUGGESTED READING
Kina JF, Huck C, Riehl H, et al. Response of human pulps
after professionally applied vital tooth bleaching. Int Endod
J 2010;43:57280.
Fugaro JO, Nordahl I, Fugaro OJ, et al. Pulp reactions to vital
bleaching. Oper Dent 2004;29:3638.

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The Effect of Tooth Bleaching on Substance P Expression in Human Dental Pulp

J. CAVIEDES-BUCHELI, G. ARIZA-GARCA, S. RESTREPO-MNDEZ, N. ROS-OSORIO, N. LOMBANA, H.R.
MUOZ
Journal of Endodontics 2008 (34:14625)

ABSTRACT

COMMENTARY

Objective: This study evaluated the eects of dierent

in-oce whitening protocols on the expression of
Substance P (SP) in healthy human dental pulps.

Substance P is a neuropeptide that triggers an increase

in blood ow (due to vasodilation) and the movement
of inammatory cells and mediators to sites of damage.
It is one of the bodys natural defense mechanisms, and
exposure to it may account for post-whitening
symptoms such as tooth sensitivity.

Materials and Methods: This study involved 40

caries-free teeth to be extracted for orthodontic
purposes and were obtained from healthy, non-smoking
participants ranging in age from 18 to 27 years. The
teeth were divided into four groups (n = 10). The three
experimental groups received (1) 38% hydrogen
peroxide (Opalescence Xtra Boost) applied for 15
minutes, (2) 35% hydrogen peroxide (Lase Peroxide,
DMC, So Paulo, Brazil) activated with an infrared
diode laser (Biolux, BioArt, So Paulo, Brazil) for 3
minutes, and (3) Zoom light-activated 25% hydrogen
peroxide (Discus Dental, Culver City, CA, USA) for 20
minutes. The control group received no treatment.
Immediately after whitening, the teeth were
anesthetized, extracted, and processed for
radioimmunoassay.

This study demonstrated increased expression of SP

with light/laser-activated in-oce systems. It is
interesting to note that Fugaro and collegues study
evaluating substance P expression after whitening with
10% carbamide peroxide found no signicant increase
in neuropeptide levels compared with the non-whitened
control group. Future studies on the correlation of SP
expression levels and occurrence of tooth sensitivity
related to dierent whitening methods may suggest new
avenues for developing improved whitening protocols.

SUGGESTED READING
Results: SP was expressed in all pulp samples.
Expression was highest in the case of the Zoom
light-activated group, followed by the laser-activated
group, and then the 38% hydrogen peroxide group.
Lowest values were observed in the control group.
Conclusions: Light-activated and laser-activated in-oce
bleaching induced increased SP expression.

2014 Wiley Periodicals, Inc.

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Fugaro OJ, Fugaro JO, Matis BA, et al. The dental pulp:
inammatory markers and vital bleaching. Am J Dent
2005;18:22932.
Sawada Y, Hosokawa H, Matsumura K, Kobayashi S.
Activation of transient receptor potential ankyrin 1 by
hydrogen peroxide. Eur J Neurosci 2008;27:113142.

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THE BOTTOM LINE

358

In-office bleaching is an effective method for whitening teeth. Tooth sensitivity associated with in-office whitening is
reversible and may range from mild to considerable.

The incidence and severity of tooth sensitivity can be reduced by pretreatment with a desensitizer such as
potassium nitrate.

Histologic studies and clinical studies on long-term pulpal effects are lacking to definitively support the safety of
in-office tooth whitening.

Future studies on the etiology of tooth sensitivity related to whitening might greatly improve the means of
preventing and managing this side effect.

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2014 Wiley Periodicals, Inc.

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